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Primary sclerosing cholangitis with dominant stricture — ESEGH MCQ

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HardPancreatico-biliary DiseasePrimary sclerosing cholangitis with dominant strictureESEGH

A 37-year-old man with long-standing ulcerative colitis develops worsening pruritus and weight loss. Liver tests show bilirubin 48 micromol/L, ALP 710 IU/L and ALT 96 IU/L. MRCP shows multifocal intrahepatic strictures and a new dominant hilar stricture. CA19-9 is elevated. What is the most appropriate investigation?

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Correct answer: A — ERCP with brush cytology and targeted sampling

A dominant stricture with systemic symptoms and rising cholestasis in PSC raises concern for cholangiocarcinoma, so ERCP with brushings or biopsy is appropriate. Colonoscopic surveillance is important in PSC-UC, but it does not evaluate the biliary stricture. Liver biopsy is more useful when small-duct PSC is suspected with a normal cholangiogram. The pearl is that new dominant strictures in PSC should be treated as malignant until assessed.

Reference: BSG PSC Guidance; EASL Sclerosing Cholangitis Guidance