Ayurveda Aetiology, Pathogenesis & Holistic Management of Inflammatory Bowel Disease
Head of Kayachikitsa (Ayurved medicine), Gujarat Ayurved University, India
Submission: August 09, 2018; Published: September 17, 2018
*Corresponding author: Nishant Shukla, Professor & Head of Kayachikitsa (Ayurved medicine), Shri V. M. Mehta Ayurveda College, Anandpar Rajkot, Ex. Head of Kayachikitsa Gulabkunverba Ayurved Mahavidyalaya, Anil 3 Patel Colony, Jamnagar, India, Tel: +91-9426984260;
How to cite this article: Nishant Shukla. Ayurveda Aetiology, Pathogenesis & Holistic Management of Inflammatory Bowel Disease. Adv Res Gastroentero Hepatol. 2018; 10(4): 555794. DOI: 10.19080/ARGH.2018.10.555794.
Keywords: Inflammation; Colon; Large intestine; Abdominal pain; Diarrhoeal disease
Abbrevations:MRCP: Magnetic Resonance Cholangiopancreatography; ERCP: Endoscopic Retrograde Cholangiopancreatography; DIA: Digital Image Technique; EUS: Endoscopic Ultrasonography; SOC: Single Operator Cholangioscopy; CT: Cross Section Imaging
HBiliary strictures are traditionally classified as ‘indeterminate’ when basic work up, including transabdominal imaging and endoscopic retrograde cholangiopancreatography (ERCP) with conventional brush cytology, is non-diagnostic for its etiology.
The clinical approach to the patient with indeterminate biliary stricture includes a thorough history and physical examination. By and large, strictures of the bile duct in patients with obstructive jaundice should be considered malignant unless a benign etiology is ascertained. The significance of biliary strictures without jaundice is less certain.
The most common biomarkers for suspected biliary
tract malignancies in clinical use are serum CA 19-9 and
carcinoembryonic antigen. In patients with PSC, using cut-off
value of 129U/ml, the sensitivity and specificity of CA 19-9 for the
diagnosis of cholangiocarcinoma are 79% and 98% respectively
. In patients without PSC, the sensitivity is only 53% with a
cutoff value 100 U/ml . Elevated serum carcinoembryonic
adenocarcinoma has also been shown to have a sensitivity of 33-
68% and specificity of 79-95% for cholangiocarcinoma.
Ultrasound is helpful in patients with biliary stricture by
demonstrating intrahepatic biliary radical dilatation and the
level of obstruction. However, the distal part of the common bile
duct is not properly evaluated because of the interference of
bowel gas. Moreover, it has a very low yield for actual detection
of strictures on biliary ductal masses . The development of
multi- detector helical scanners, used in conjunction with rapid
injection of contrast media, accurate depiction of extension of the
tumor, locoregional lymphadenopathy and encasement of blood
vessels to determine operability of the tumor can be picked up
Magnetic resonance cholangiopancreatography (MRCP) has
a high sensitivity for bile duct lesions and has got comparable
diagnostic accuracy in comparison to ERCP. Ductal features at
MRCP which may suggest malignancy include long (>10mm),
asymmetrical and irregular strictures. The presence of mass
lesion is highly suggestive of malignancy, especially in the
hilar region. Abrupt cut-off of the CBD in contrast to a smooth
tapering has traditionally been considered to be a sign of
malignancy (Figure 1). The sensitivity and specificity of MRCP
to differentiate malignant from benign strictures are reported to
be 38%-90% and 70%-85% respectively . MRCP is 88-96%
accurate in predicting the extent of involvement of the bile duct
ERCP remains the first line approach for tissue sampling
of biliary strictures. The reported sensitivity of conventional
brush cytology is 25% to 55% . Different techniques have
been employed to improve the sensitivity of conventional brush
cytology including novel brushes, biliary stricture dilation
with subsequent brushings and repeated brushings. The
pluricellular nature and submucosal pattern of tumor growth
in cholangicarcinoma or extrinsic malignancy involving the
bile ducts attributes to the low sensitivity of biliary brushings.
Inadequate biliary cytology specimens are one of the main
reasons for non-diagnostic samples. This may be overcome by the
presence of an onsite cytopathologist. Several other strategies
include cutting the entire brush, creation of slides by the
endoscopy team and placing them in a fixative solution prior to
submission to pathology are being used to overcome inadequate
sampling. The fluorescence in situ hybridization analysis detects
chromosomal polysomy using fluorescent probes, whereas the
Digital Image Technique (DIA) quantifies nuclear DNA with
special stains to assess the presence of aneuploidy.
In patients with PSC these chromosomal abnormalities can
be seen without the presence of malignancy. Thus, the specificity
of FISH in this setting is lower than routine cytology. Thus, FISH
increases the sensitivity of brush cytology of indeterminate biliary
strictures without much improvement in the specificity. FISH
should be reserved for patients with high pre-test probability for
malignant strictures. Using endobiliary forceps, the malignancy
detection rates ranges from 44% to 89% for cholangiocarcinoma
and 33% to 71% for pancreatic cancer . Triple sampling with
brushing, transpapilary biopsy and endoluminal FNA has shown
the highest sensitivity. Risk of biliary ductal perforation after
endobiliary biopsy, however, remains a concern.
Endoscopic ultrasonography (EUS) has emerged as an
important method for evaluating indeterminate biliary stricture.
It provides an excellent alternative method for visualizing and
sampling the extra-hepatic biliary tree, hilar masses, gallbladder
and peri-hilar lymph nodes and vessels. Sensitivity is significantly
better in distal compared to proximally located tumors.
The technique has recently gained attention with the
development of a single operator cholangioscopy (SOC) system
known as the SpyGlass (Boston Scientific, Natick, MA, USA).
Visually directed biopsies can be obtained using biopsy forceps
(SpyBite). Overall sensitivity and specificity of SOC examination
for differentiating malignant and benign ductal abnormalities
have been seen to be 78% and 82% respectively, higher than
the 51% and 54% of ERCP alone . Among the cholangiscopic
features, the presence of abnormal tumor vessels due to
neovascularization within the biliary stricture is suggestive
of biliary malignancy. Intraductal nodules and masses can be
visualized during cholangiscopy and are indicative of malignancy
(Figure 2). Using these features, good concordance has been seen
between cholangioscopic appearance and histopathology.
ERCP with IDUS improves the diagnostic yield of biliary
strictures. A small and high-frequency ultrasound probe
provides high resolution images of ductal and periductal tissues.
IDUS features which suggest malignancy include eccentric
wall thickening with an irregular surface, a hypoechoic mass,
heterogenicity of the internal echo pattern, a papillary surface,
disruption of the normal three-layer sonographic structure of
the bile duct, presence of lymph nodes, and vascular invasion. It
is, however, not commonly available and expertise is needed for
a successful outcome.
For better characterization of biliary strictures, several
techniques have been employed during cholangioscopy. In
chromoendoscopy, different stains are topically applied to
the surface of the mucosa. Methylene blue can successfully
differentiate malignant lesions and ischemic strictures from
normal mucosa. Biliary narrow band imaging enhances
the vascular pattern of the mucosal surface and delineates
tumor extent effectively. Initial cholangioscopic studies with
autofluorescence have been less promising; poor specificity and
high rates of false positivity were observed .
Cellvizio is a probe-based CLE system which generates
optical biopsies, providing physicians with microscoping images
of tissue instantaneously and in a minimally invasive manner.
This technique produces specific patterns that correlate with
standard histology and differentiate between malignancy,
inflammation and normal mucosa. In a recent multicentre
study CLE was found to provide significantly higher diagnostic
accuracy for malignant biliary strictures than standard ERCP
(90% vs 73%) .
The Miami classification system has been proposed to
characterize pCLE findings for biliary strictures. The presence
of thick white bands (>20 micrometer), thick dark bands (>40
micrometer), dark clumps, epithelial structures and contrast
leakage were the factors which could differentiate malignant
from benign strictures . Another newer classification
system called the Paris classification was recently described.
This includes additional features such as vascular congestion,
dark glandular patterns, increased interglandular space and
thickened reticular structures .
The choice of diagnostic workup should be individualized,
depending to a great extent on local expertise and availability
of the particular technology. Cross section imaging (CT or MRI)
is useful to assess the respectability in patients with suspected
malignancy. Table 2 outlines differences between benign and