Endoscopic Management and Therapy of Primary Sclerosing Cholangitis

Primary sclerosing cholangitis (PSC) is a chronic progressive liver disease resulting in stricturing and destruction of the intra-and extrahepatic bile ducts and associated with cholangiocarcinoma (CCA) in 10-15% of patients. The pathogenesis of PSC remains unknown and there are currently no universally agreed upon medical therapies for treatment, with liver transplant representing the only available cure. Endoscopic therapy has proven vital in both diagnosis and management of the disease. A strategy of surveillance is recommended to enhance early detection of CCA to improve the possibility of resection and/or liver transplant, ultimately leading to increased survival. The combined use of magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and newer modalities such as fluorescence in situ hybridization (FISH) have increased the sensitivity of detected CCA. Advances in cholangioscopy, endoscopic ultrasound (EUS), fine needle aspiration (FNA), and ancillary cytologic testing will further improve our ability to detect CCA at an early stage.