Patients: All patients with biliary strictures referred to the Division of Gastroenterology at the University of Alberta Hospitals for investigation between January 1, 1995 and De­cember 31, 1995 were prospectively entered into the trial. The inclusion criteria were age 16 years or older and noncal- culus biliary obstruction. Patients were excluded if subse­quent evaluation did not show a stricture. Ethics committee approval was obtained.

Protocol: The following information was obtained:

  • Clinical history and careful physical examination.
  • Blood tests including serum bilirubin, alkaline phosphatase (AP), alanine transaminase (ALT), aspartate transaminase (AST), gamma glutamyl transpeptidase (GGT) and serum bile acids (BA) (Sigma Diagnostics, St Louis, Missouri).
  • Abdominal ultrasound examination with particular attention to intrahepatic biliary dilation, extrahepatic duct calibre, presence or absence of gallbladder and other relevant pathology such as tumour mass or ductal stones.
  • Disida scan. Patients were examined after a 4 h fast. Opiates were withheld for the proceeding 24 h. In addition to the standard scan, data were collected for deconvolutional analysis to determine hepatic extraction fraction and time activity curve so that the half-life of biliary excretion and time to peak activity could be analyzed.
  • Cholangiography. ERCP was attempted first in all patients with failures proceeding to PTC. Cefazoline 1 g was administered intravenously 30 to 60 mins before cholangiography. The biliary system was filled as completely as possible using 50% Conray 60 (Mallenchrodt, St Louis, Missouri) contrast injected under low pressure. The information obtained from each cholangiogram included site of stricture, multiplicity, character (smoothly tapered versus irregular or shouldered), stricture(s) length, minimal stricture width, maximal proximal biliary dilation and other information (ampullary mass, primary sclerosing cholangitis, cancer of the pancreas).

All data were to be collected within five working days so that the different imaging modalities tested would be compa­rable. All imaging studies were interpreted by radiologists blinded to the results of the patients’ other diagnostic stud­ies. The ERCP data were obtained last so that a biliary stent could be inserted if indicated. The cholangiographic meas­urements were confirmed by two independent observers. Stricture etiology was defined by cytology or biopsy histology or by clinical outcome after one year.
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