A patient with primary sclerosing cholangitis (PSC) and ulcerative colitis develops a dominant stricture in the bile duct. Which feature on cholangiography MOST strongly suggests transition from PSC to cholangiocarcinoma rather than benign inflammatory stricture?
- A Multifocal strictures with skip lesions
- B New progressive stricture with upstream dilation not responding to balloon dilation ✓
- C Beaded appearance of intrahepatic ducts
- D Mural irregularity with inflammatory periductal enhancement on MRI
Explanation
In PSC, differentiating a dominant stricture from superimposed cholangiocarcinoma is critical. Features suggesting malignant transformation include: new or progressive stricture with marked upstream dilation, failure of balloon dilation to maintain patency, polypoid or mass-forming lesion, rapid clinical deterioration, and markedly elevated CA 19-9 (>129 U/mL in some studies). Multifocal skip lesions and beaded appearance are characteristic of PSC itself. Periductal enhancement with inflammation can occur in both conditions. ERCP with brush cytology, fluorescence in situ hybridization (FISH), or cholangioscopy-guided biopsy are used for tissue diagnosis.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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