49 The distinction between a dominant stricture and CCA is difficult; the diagnosis of CCA is discussed below in this guideline. The goal of an endoscopic or percutaneous therapeutic approach to the management of patients with PSC is to relieve biliary obstruction. The stricturing disease of PSC may OTX015 concentration cause extrahepatic ductal obstruction and therefore lead to symptoms and decompensation of liver function. Some 15%–20% of patients will experience obstruction from

discrete areas of narrowing within the extrahepatic biliary tree.24, 50, 51 It is generally agreed that patients with symptoms from dominant strictures such as cholangitis, jaundice, pruritus, right upper quadrant pain or worsening biochemical indices, are appropriate candidates for therapy. The percutaneous approach is associated with increased morbidity but similar efficacy as the endoscopic PD0332991 purchase approach and is reserved for patients who have proximal dominant strictures with a failed endoscopic approach.52, 53 Before

any attempt at endoscopic therapy, brush cytology and/or endoscopic biopsy should be obtained to help exclude a superimposed malignancy. The best therapeutic endoscopic approach is still debated; multiple techniques have been utilized such as sphincterotomy, catheter or balloon dilatation, and stent placement.51–54 Of these, only endoscopic biliary sphincterotomy and balloon dilatation with or without stent placement have been found to be of value.51–59 Because injecting contrast agent into an

obstructed duct may precipitate cholangitis, perioperative antibiotics should be administered. Sphincterotomy alone has been performed in small subsets of patients, usually when stent placement was unsuccessful. In these small uncontrolled groups, bilirubin and alkaline phosphatase levels did improve.54 Indeed, the biliary sphincter of Oddi may be involved by the sclerosing process and therefore contribute to biliary obstruction. Nevertheless, sphincterotomy is rarely used alone, but rather to facilitate balloon dilatation, stent placement or stone extraction.55 Stricture dilatation can be accomplished through balloons or coaxial dilators. Balloon dilatation has been shown to be effective alone.52, 56, 57 It may be performed Venetoclax concentration periodically with or without stenting. However, biliary stenting has been shown to be associated with increased complications when compared to endoscopic dilatation only and should be reserved for strictures that are refractory to dilatation.52–57 At this time there has not been a randomized controlled study to evaluate the effectiveness of endoscopic therapy. Still, much indirect evidence by large retrospective studies, suggest that endoscopic therapy results in clinical improvement and prolonged survival. Baluyut et al.