The role of SpyGlass Direct Visualization System on Patient with Indeterminate biliary strictures: A case report

Muhammad Miftahussurur, Manu Tandan, Dadang Makmun


Biliary strictures diagnosis has become a challenge where benign conditions could mimic a malignant process. Recently, SpyGlass DS overcame the limitations by allowing direct visualization of the biliary tree. A 65 years old Indian patient complaints of jaundice with total and direct bilirubin of 23.3 mg/dL and 16.2 mg/dL, respectively. Liver function test, gamma-glutamyltransferase and CA 19-9 were increased. Transabdominal ultrasound and abdominal CT supported dilatation of common bile duct (CBD) with abrupt narrowing showing periductal enhancement at supra pancreatic level and stricture. Endoscopic ultrasound showed intrahepatic CBD stricture with dilated proximal CBD and sludge ball. Endoscopic retrograde cholangiopancreatography showed mid CBD stricture. Although brush cytology results suggested low grade dysplasia and no definite evidence of malignancy, cholangioscopy using SpyGlass DS found nodularity with abnormal vascularity seen in mid of CBD suggesting malignancy, confirmed with histopathology as cholangiocarcinoma. We reported additional value of SpyGlass DS for detecting cholangiocarcinoma in an indeterminate biliary stricture patient.


Biliary stricture; cancer; SpyGlass DS; cholangiocarcinoma


Bowlus CL, Olson KA, Gershwin ME. Evaluation of indeterminate biliary strictures. Nat Rev Gastroenterol Hepatol. 2017;14(12):749.

Nguyen Canh H, Harada K. Adult bile duct strictures: differentiating benign biliary stenosis from cholangiocarcinoma. Med Mol Morphol. 2016;49(4):189-202.

Singh A, Gelrud A, Agarwal B. Biliary strictures: diagnostic considerations and approach. Gastroenterol Rep (Oxf). 2015;3(1):22-31.

Baillie J. Distinguishing malignant from benign biliary strictures: can confocal laser endomicroscopy close the gap? Gastrointest Endosc. 2015;81(2):291-293.

Xie C, Aloreidi K, Patel B, et al. Indeterminate biliary strictures: a simplified approach. Expert Rev Gastroenterol Hepatol. 2018;12(2):189-199.

Committee AT, Komanduri S, Thosani N, et al. Cholangiopancreatoscopy. Gastrointest Endosc. 2016;84(2):209-221.

Monga A, Ramchandani M, Reddy DN. Per-oral cholangioscopy. J Interv Gastroenterol. 2011;1(2):70-77.

Victor DW, Sherman S, Karakan T, Khashab MA. Current endoscopic approach to indeterminate biliary strictures. World J Gastroenterol. 2012;18(43):6197-6205.

Govil H, Reddy V, Kluskens L, et al. Brush cytology of the biliary tract: retrospective study of 278 cases with histopathologic correlation. Diagn Cytopathol. 2002;26(5):273-277.

Navaneethan U, Njei B, Lourdusamy V, Konjeti R, Vargo JJ, Parsi MA. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2015;81(1):168-176.

Shah RJ, Raijman I, Brauer B, Gumustop B, Pleskow DK. Performance of a fully disposable, digital, single-operator cholangiopancreatoscope. Endoscopy. 2017;49(7):651-658.

Navaneethan U, Hasan MK, Kommaraju K, et al. Digital, single-operator cholangiopancreatoscopy in the diagnosis and management of pancreatobiliary disorders: a multicenter clinical experience (with video). Gastrointest Endosc. 2016;84(4):649-655.

Hu B, Sun B, Cai Q, et al. Asia-Pacific consensus guidelines for endoscopic management of benign biliary strictures. Gastrointest Endosc. 2017;86(1):44-58.

Karagyozov P, Boeva I, Tishkov I. Role of digital single-operator cholangioscopy in the diagnosis and treatment of biliary disorders. World J Gastrointest Endosc. 2019;11(1):31-40.

Kim HJ, Kim MH, Lee SK, Yoo KS, Seo DW, Min YI. Tumor vessel: a valuable cholangioscopic clue of malignant biliary stricture. Gastrointest Endosc. 2000;52(5):635-638.

Varadarajulu S, Bang JY, Hasan MK, Navaneethan U, Hawes R, Hebert-Magee S. Improving the diagnostic yield of single-operator cholangioscopy-guided biopsy of indeterminate biliary strictures: ROSE to the rescue? (with video). Gastrointest Endosc. 2016;84(4):681-687.

Turowski F, Hugle U, Dormann A, et al. Diagnostic and therapeutic single-operator cholangiopancreatoscopy with SpyGlassDS: results of a multicenter retrospective cohort study. Surg Endosc. Sep 2018;32(9):3981-3988.

Altman A, Zangan SM. Benign Biliary Strictures. Semin Intervent Radiol. 2016;33(4):297-306.

Mizumoto R, Ogura Y, Kusuda T. Definition and diagnosis of early cancer of the biliary tract. Hepatogastroenterology. 1993;40(1):69-77.

Burnett AS, Bailey J, Oliver JB, Ahlawat S, Chokshi RJ. Sensitivity of alternative testing for pancreaticobiliary cancer: a 10-y review of the literature. J Surg Res. 2014;190(2):535-547.

Sethi A, Chen YK, Austin GL, et al. ERCP with cholangiopancreatoscopy may be associated with higher rates of complications than ERCP alone: a single-center experience. Gastrointest Endosc. 2011;73(2):251-256.

Sethi A, Doukides T, Sejpal DV, et al. Interobserver agreement for single operator choledochoscopy imaging: can we do better? Diagn Ther Endosc. 2014;2014:730731.

Full Text: PDF


  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.