Endoscopy 2008; 40(7): 563-571
DOI: 10.1055/s-2007-995688
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Methylene blue-aided cholangioscopy in patients with biliary strictures: feasibility and outcome analysis

A.  Hoffman1 , R.  Kiesslich1 , F.  Bittinger2 , P.  R.  Galle1 , M.  F.  Neurath1
  • 1Medical Clinic I, Johannes Gutenberg University of Mainz, Germany
  • 2Department of Pathology, Johannes Gutenberg University of Mainz, Germany
Further Information

Publication History

submitted 21 August 2007

accepted after revision 23 January 2008

Publication Date:
11 April 2008 (online)

Background and study aims: Chromoendoscopy using methylene blue is employed in the gastrointestinal tract to delineate neoplastic lesions. We tested the value of chromoendoscopy during choledochoscopy for characterization of local inflammation, neoplasias, and other alterations in patients with biliary strictures.

Methods: Patients with suspected biliary lesions were scheduled for endoscopic retrograde cholangiography with subsequent cholangioscopy. After initial inspection of the bile duct, 15 ml methylene blue (0.1 %) was administered via the working channel of the cholangioscope. Newly appearing circumscribed or unstained lesions were judged according to their macroscopic type and staining features. Methylene-blue-aided diagnosis was compared with either clinical follow-up of the patients or, in some cases, with the results of targeted biopsies.

Results: A total of 55 patients [biliary stenosis/cholestasis of unknown origin (n = 24), stenosis after orthotopic liver transplantation (n = 11), primary sclerosing cholangitis (n = 20)] were included. Methylene blue unmasked subtle mucosal changes and permitted macroscopic characterization of circumscribed lesions. Characteristic surface staining patterns were seen in chronic inflammation, dysplasia, and ischemic-type biliary lesions. Nondysplastic mucosa appeared homogeneously stained, whereas scarred strictures showed a weak uptake of methylene blue.

Conclusion: In this prospective feasibility study, methylene-blue-aided cholangioscopy was used for the first time to define different staining patterns of the bile duct. The differences in staining patterns identified normal, dysplastic, and inflamed mucosa of the bile duct, as was proved by follow-up or, in some cases, histology. Whereas homogeneous staining predicted the presence of normal mucosa, absence of staining of circumscribed lesions, or diffused staining of such lesions, represented neoplastic changes or inflammation.

References

  • 1 Patel T. Cholangiocarcinoma.  Nat Clin Pract Gastroenterol Hepatol. 2006;  3 33-42
  • 2 Slattery J M, Sahani D V. What is the current state-of-the-art imaging for detection and staging of cholangiocarcinoma?.  Oncologist. 2006;  11 913-922
  • 3 Park M S, Kim T K, Kim K W. et al . Differentiation of extrahepatic bile duct cholangiocarcinoma from benign stricture: findings at MRCP versus ERCP.  Radiology. 2004;  233 234-240
  • 4 Selvaggi S M. Biliary brushing cytology.  Cytopathology. 2004;  15 74-79
  • 5 Singh V, Bhasin S, Nain C K. et al . Brush cytology in malignant biliary obstruction.  Indian J Pathol Microbiol. 2003;  46 197-200
  • 6 Singh P, Patel T. Advances in the diagnosis, evaluation and management of cholangiocarcinoma.  Curr Opin Gastroenterol. 2006;  22 294-299
  • 7 Kiesslich R, Fritsch J, Holtmann . et al . Methylene blue-aided chromoendoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis.  Gastroenterology. 2003;  124 880-888
  • 8 Jung M, Kiesslich R. Chromoendoscopy and intravital staining techniques.  Baillieres Best Pract Res Clin Gastroenterol. 1999;  13 11-19
  • 9 Hoffman A, Kiesslich R, Bittinger F. et al . Methylene blue aided cholangioscopy unravels the endoscopic features of ischemic type biliary lesions (ITBL) after liver transplantation.  Gastrointest Endosc. 2007;  66 1052-1058
  • 10 Wang H P, Chen J H, Wu M S. et al . Application of peroral cholangioscopy in an endemic area with high prevalence of hepatocellular carcinoma and choledocholithiasis.  Hepatogastroenterology. 2000;  47 1555-15 559
  • 11 Seo D W, Lee S K, Yoo K S. et al . Cholangioscopic findings in bile duct lesions.  Gastrointest Endosc. 2000;  52 630-634
  • 12 Fukuda Y, Tsuyuguchi T, Sakai Y. et al . Diagnostic utility of peroral cholangioscopy for various bile duct lesions.  Gastrointest Endosc. 2005;  62 374-382
  • 13 Zajaczek J E, Keberle M. Value of radiological methods in the diagnosis of biliary diseases.  Radiologe. 2005;  45 976-978, 980–986
  • 14 Ahmad N A, Shah J N, Kochman M L. Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography imaging for pancreaticobiliary pathology: the gastroenterologist’s perspective.  Radiol Clin North Am. 2002;  40 1377-1395
  • 15 Urakami Y, Seifert E, Butke H. Peroral direct cholangioscopy (PDCS) using routine straight-view endoscope: first report.  Endoscopy. 1977;  9 27-30
  • 16 Neuhaus H. Cholangioscopy.  Endoscopy. 1994;  26 120-125
  • 17 Neuhaus H, Schumacher B. Miniscopes.  Baillieres Best Pract Res Clin Gastroenterol. 1999;  13 33-48
  • 18 Tischendorf J J, Kruger M, Trautwein C. et al . Cholangioscopic characterization of dominant bile duct stenoses in patients with primary sclerosing cholangitis.  Endoscopy. 2006;  38 665-669
  • 19 Chen Y K, Pleskow D K. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study.  Gastrointest Endosc. 2007;  65 832-841
  • 20 Larghi A, Waxman I. Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study.  Gastrointest Endosc. 2006;  63 853-857
  • 21 Meenan J, Schoeman M, Rauws E. et al . A video baby cholangioscope.  Gastrointest Endosc. 1995;  42 584-585
  • 22 Nakajima M, Akasaka Y, Fukumoto K. et al . Peroral cholangiopancreaticoscopy under duodenoscopic guidance.  Am J Gastroenterol. 1976;  66 241-247
  • 23 Kodama T, Sato H, Horij Y. et al . Pancreatoscopy for the next generation: development of the peroral electronic pancreatoscope system.  Gastrointest Endosc. 1999;  49 366-371
  • 24 Fukuda Y, Tsuyuguchi T, Sakai Y. et al . Diagnostic utility of peroral cholangioscopy for various bile-duct lesions.  Gastrointest Endosc. 2005;  62 374-382
  • 25 Siddique I, Galati J, Ankoma-Sey V. et al . The role of choledochoscopy in the diagnosis and management of biliary tract diseases.  Gastrointest Endosc. 1999;  50 67-73
  • 26 Nimura Y, Shionoya S, Hayakawa N. et al . Value of percutaneous transhepatic cholangioscopy (PTCS).  Surg Endosc. 1988;  2 213-219
  • 27 Seo D W, Lee S K, Yoo K S. et al . Cholangioscopic findings in bile duct tumors.  Gastrointest Endosc. 2000;  52 630-634
  • 28 Nimura Y, Kamiya J, Hayakawa N. et al . Cholangioscopic differentiation of biliary strictures and polyps.  Endoscopy. 1989;  21 351-356
  • 29 Canto M I, Setrakian S, Petras R E. et al . Methylene blue selectively stains intestinal metaplasia in Barrett’s esophagus.  Gastrointest Endosc. 1996;  44 1-7
  • 30 Canto M, Setrakian S, Willis J. et al . Methylene blue staining of dysplastic and nondysplastic Barrett’s esophagus: an in vivo and ex vivo study.  Endoscopy. 2001;  33 391-400
  • 31 Seo D W, Lee S K, Yoo K S. et al . Cholangioscopic findings in bile duct lesions.  Gastrointest Endosc. 2000;  52 630-634
  • 32 Fukuda Y, Tsuyuguchi T, Sakai Y. et al . Diagnostic utility of peroral cholangioscopy for various bile duct lesions.  Gastrointest Endosc. 2005;  62 374-382
  • 33 Kim H J, Kim M H, Lee S K. et al . Tumor vessel: a valuable cholangioscopic clue of malignant biliary stricture.  Gastrointest Endosc. 2000;  52 635-638
  • 34 Sim C S, Neuhaus H, Tamada K. Direct cholangioscopy.  Endoscopy. 2003;  35 52-58

M. F. Neurath, MD

Medical Clinic I

University of Mainz

Langenbeckstr.1

55131 Mainz

Germany

Fax: +49-6131-175583

Email: neurath@1-med.klinik.uni-mainz.de