Dominant strictures in primary sclerosing cholangitis: A multicenter survey of clinical definitions and practices

Abstract

Dominant strictures (DSs) of the biliary tree occur in approximately 50% of patients with primary sclerosing cholangitis (PSC) and may cause significant morbidity. Nevertheless, the definition and management of DSs lacks consensus. We aimed to better understand current perceptions and practices regarding PSC‐associated DSs. We conducted an anonymous, 23‐question, survey‐based study wherein electronic surveys were distributed to 131 faculty in the Division of Gastroenterology and Hepatology at the three Mayo Clinic campuses (Rochester, Scottsdale, and Jacksonville) as well as the affiliated practice network. Responses were aggregated and compared, where applicable, to practice guidelines of the American Association for the Study of Liver Diseases and European Association for the Study of the Liver. A total of 54 faculty (41.2%) completed the survey, of whom 24 (44.4%) were hepatologists, 21 (38.9%) gastroenterologists, and 9 (16.7%) advanced endoscopists. One of the major study findings was that there was heterogeneity among participants' definition, evaluation, management, and follow‐up of DSs in PSC. The majority of participant responses were in accordance with societal practice guidelines, although considerable variation was noted. Conclusion: Despite the prevalence and morbidity of DSs in PSC, clinical perceptions and practices vary widely among hepatologists, gastroenterologists, and advanced endoscopists who manage these patients, even within a single health care system. Further studies are needed to address these variations, develop general and evidence‐based consensus, and increase adherence to societal guidelines. (Hepatology Communications 2018;2:836‐844)

Role of endoscopy in the management of primary sclerosing cholangitis

“…Dominant strictures are loosely defined as extrahepatic strictures of less than or equal to 1.5 mm or intrahepatic strictures greater than or equal to 1.0 mm in diameter (Figure 3)[24]. Published reports suggest that 40%-58% of patients with PSC will develop a dominant stricture during their lifetime[24-26]. This is of particular importance as patients with PSC who develop dominant strictures have a mean survival of 14 years compared to 27 years in patients who do not develop dominant strictures[27].…”

Inter-reader agreement of interpretation of radiological course of bile duct changes between serial follow-up magnetic resonance imaging/3D magnetic resonance cholangiopancreatography of patients with primary sclerosing cholangitis

“…Early detection of CCA is of utmost clinical importance in the follow-up of patients with PSC. Dominant stricture which is defined as a stricture with a diameter of less than 1.5 mm in common bile duct (CBD) or less than 1 mm in the left or right hepatic duct and in the common hepatic duct (CHD) [9][10][11] is associated with a higher risk of CCA in patients with PSC [12,13]. A dominant stricture, however, is defined at ERCP and there is a lack of consensus regarding the applicability of this term at MRCP.…”

Cancer risk in primary sclerosing cholangitis: Epidemiology, prevention, and surveillance strategies

“…However, early detection and tissue diagnosis of CCA have historically been challenging, limited treatment options are available if CCA is detected, and consequently, survival benefit of surveillance (until recently) has largely been unknown. Due to these limitations and others, unlike for GBC and CRC (Figure 2), there is currently no consensus, evidence-based societal guideline for CCA surveillance in PSC[32].…”