Kaur, Jyotroop

Abstract Endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition is the cornerstone for assessment of suspected malignant biliary strictures. Conventional techniques, including biliary brush cytology and transpapillary forceps biopsy, are highly specific but are limited by modest sensitivity for detection of malignancy, often leaving a substantial proportion of individuals without a definitive diagnosis. To improve diagnostic sensitivity for cancer, several adjunctive approaches have been integrated into ERCP-based sampling. Peroral cholangioscopy (POC)-guided biopsies have become a reliable ERCP-based adjunctive modality, allowing direct visualization and targeted sampling, particularly in individuals with prior nondiagnostic procedures. Fluorescence in situ hybridization (FISH) is a technique used to improve diagnostic yield with biliary brushings by detecting chromosomal abnormalities, but is limited to specialized centers due to the need for specialized processing and training. Next-generation sequencing provides high sensitivity and can enable identification of actionable genomic alterations, while methylated DNA markers represent a promising, scalable molecular approach with strong diagnostic performance. Additional techniques include artificial intelligence–augmented direct visualization by POC and bile-based liquid biopsy. Current guidelines recommend multimodal ERCP-based sampling, combining at least two modalities where feasible, to optimize diagnostic accuracy. This review highlights the clinical performance, strengths, and limitations of established and emerging ERCP-guided techniques, emphasizing their evolving role in improving the diagnosis and management of malignant biliary strictures.

Background and Aims: Endoscopic ultrasound shear wave elastography (EUS-SWE) is a novel modality for liver stiffness measurement. The aims of this study are to evaluate the performance and reliability of EUS-SWE for detecting advanced liver disease in a prospective cohort. Methods: EUS-SWE measurements were prospectively obtained from patients undergoing EUS between August 2020 and March 2023. Liver stiffness measurements were compared between patients with and without advanced liver disease (ALD), defined as stage ≥3, to determine diagnostic accuracy for advanced fibrosis and portal hypertension. Logistic regression was performed to identify variables that impact the reliability of EUS-SWE readings. Select patients underwent paired magnetic resonance elastography (MRE) for liver fibrosis correlation. Results: Patients with ALD demonstrated higher liver stiffness compared to healthy controls (left lobe: 17.6 vs. 12.7 kPa, P <0.001; median right lobe: 24.8 vs. 11.0 kPa, P <0.001). The area under the receiver operator characteristic (AUROC) for the detection of ALD was 0.73 and 0.80 for left and right lobe measurements, respectively. General anesthesia was associated with reliable EUS-SWE liver readings (odds ratio: 2.73, 95% CI: 1.07-7.39, P =0.040). Left lobe measurements correlated significantly with MRE with an increase of 0.11 kPa (95% CI: 0.05-0.17 kPA) for every 1 kPa increase on EUS-SWE. D. Conclusions: SWE is a promising technology that can readily be incorporated into standard EUS examinations for the assessment of ALD.