Updated: Dec 02, 2022
Author: Mohammad Wehbi, MD; Chief Editor: Kurt E Roberts, MD 



Cholangioscopy is a noninvasive endoscopic method used for both direct visual diagnostic evaluation and simultaneous therapeutic intervention of the bile ducts.[1]  Peroral cholangioscopy overcomes some of the limitations of endoscopic retrograde cholangiopancreatography (ERCP). Pancreatoscopy is the direct visual evaluation of the pancreatic ducts.

Although cholangioscopy has been in limited use since the 1950s, it has only comapratively recently matured as a noninvasive technique. In the 1970s, Rosch et al[2]  and Urakami[3]  independently described two different endoscopic methods for peroral cholangioscopy. Since that time, peroral cholangioscopy has been refined largely through advances in endoscopic technique, scope design, and functionality. However, widespread adoption of peroral cholangioscopy was hampered by technologic hurdles until relatively recently.[4]

Early cholangioscopes[2, 3, 5]  had several limitations: they were very fragile and could break up; required two endoscopists; had only a two-way steering mechanism, which severely limited negotiation of ducts; and lacked working channels and irrigation ports.[6]  Thus, in the absence of more modern endoscopic technologies, this procedure was restricted to a few specialized centers worldwide for very specific indications. However, the SpyGlass cholangioscopes (Boston Scientific, Marlborough, MA) overcame many of the limitations posed by these earlier cholangioscopes.

The introduction of a sophisticated cholangioscope system for cholangiopancreatoscopy has led many experts to believe that peroral cholangioscopy will become a universally adopted technique for the evaluation and treatment of biliary tract diseases. Indeed, SpyGlass cholangiopancreatoscopy showed promising results in a multicenter international study[4]  and was approved by the US Food and Drug Administration for diagnostic and therapeutic applications during endoscopic procedures in the pancreaticobiliary system.[7]

Cholangioscopy has been shown to be an effective diagnostic and therapeutic tool. Studies have evaluated clinical efficacy of peroral cholangioscopy in characterizing benign versus malignant natures of biliary strictures, diagnosing intraductal tumors, better defining unknown biliary pathologies, and treating biliary stones.[8, 9, 10, 11, 12]

Direct cholangioscopy (DC) using ultraslim gastroscopes was developed as an alternative to mother-and-baby cholangioscopes. DC provides superior imaging, achieves shorter total procedure time, and has a wider working channel for adequate tissue sampling.[13, 14]

In addition, Itoi et al[15]  tested a novel multibending prototype peroral direct cholangioscope (PDCS). This study showed that a cholangioscope passed over a guide wire or anchoring balloon had a high diagnostic and therapeutic success rate. However, results were not appealing with the free-hand insertion technique.

Pohl et al[16]  showed that a short-access mother-and-baby scope (SAMBA) is better than DC with regard to intraductal stability and accessibility of the intrahepatic bile ducts. Mori et al[17]  suggested duodenal balloon-assisted cholangioscopy as an alternative technique in cases of failure with conventional ERCP. A digital version of a SpyGlass cholangioscope is being developed and evaluated.[13, 18]

Image enhancement of endoscopically visualized tissue can be performed by dye, autofluorescence, narrowband image, or probe-based confocal fluorescence (PCLE) microscopy. Cholangioscopy, with the addition of these enhancing methods, helps to distinguish benign from malignant biliary strictures.[19]  PCLE provides microscopic information in real time, incorporating dynamic information such as blood flow, cellular architecture, contrast uptake, and leakage. Initial observational studies reported a good sensitivity and negative predictive value of the PCLE findings in diagnosing malignancy. However, evaluation in prospective, randomized studies is needed.[20]

Diagnostic applications are as follows:

  • Virtual or optic chromoscopy [13]
  • Confocal laser endomicroscopy
  • Precise mapping and delineation of intraductal tumor spread before resection

Therapeutic applications are as follows[13] :

  • Endoscopic tumor ablation therapy
  • Migrating stent removal
  • Endoscopic biliary drainage
  • Endoscopic nasobiliary drainage
  • Plastic stent placement
  • Endoscopic resection
  • Hot biopsy
  • Snare resection

Itoi et al evaluated the efficacy of cholangioscopy in IgG4-related sclerosing cholangitis (IgG4 SC).[21]  Their results suggested that cholangioscopy was effective in differentiating IgG4-SC from primary sclerosing cholangitis. Proliferative vessels on cholangioscopy was suggested to be useful to differentiating IgG4-SC from cholangiocarcinoma. Moreover, Suyigama et al showed peroral cholangioscopy to be useful as a preoperative examination modality for assessing tumor extension in cholangiocarcinoma patients.[22, 9, 10]


Indications for cholangiopancreatoscopy in biliary disease include the following[23, 4, 6, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43] :

  • Biopsy of indeterminate strictures [44] in patients without  primary sclerosing cholangitis
  • Exclusion of malignant stricture in  primary sclerosing cholangitis by providing visual-guided biopsy [45]
  • Diagnosing  cholangiocarcinoma
  • Indeterminate filling defect of bile ducts seen on imaging or ERCP
  • Nondiagnostic ERCP findings for biopsy
  • Precise preoperative location of biliary and pancreatic intraductal tumors
  • Visual evaluation and biopsy to evaluate posttransplantation biliary issues, intraductal mucinous neoplasm, and eosinophilic cholangitis
  • Evaluation for  cytomegalovirus, fungal, and parasitic infections
  • Hemobilia

Therapeutic indications for cholangiopancreatoscopy in biliary disease include the following:

  • Cystic duct stent placement
  • Photodynamic therapy of cholangiocarcinoma (potential indication)
  • Argon photocoagulation of intraductal mucinous neoplasm (potential indication)
  • Alternative to surgery in patients with Mirizzi syndrome type II (potential indication)
  • Biliary stone extraction [46] and dissolution using mechanical, electrohydraulic, or laser lithotripsy (see the image below)
Cholangioscopic view of (A) bile duct stone and (B Cholangioscopic view of (A) bile duct stone and (B) electrohydraulic lithotripsylithotripsy.

Diagnostic and therapeutic indications for cholangiopancreatoscopy in pancreatic disease include the following:

  • Pancreatic stones
  • Pancreatic duct tumors
  • Potential role in autoimmune pancreatitis

Some studies have demonstrated the efficacy of peroral cholangioscopy in comparison to ERCP for evaluating many biliary disorders. Kawakami et al[47]  showed that ERCP diagnosed intraepithelial tumor spread in only 22% of cases, whereas peroral cholangioscopy was successful in 77% of cases. Further, peroral cholangioscopy with concomitant biopsy accurately diagnosed 100% of cases.

A study by Fukuda et al[48]  showed that the sensitivity of combined ERCP/peroral cholangioscopy in diagnosing biliary lesions was 93% compared with only 58% for ERCP alone. The same study showed the superiority of cholangioscopy with biopsy in differentiating benign from malignant lesions with an accuracy of 100%.

Additionally, cholangioscopy was useful in evaluating indeterminate filling defects seen on ERCP. A study by Tischendorf et al[49]  showed that cholangioscopy significantly improves the ability to differentiate between benign and malignant biliary stenosis in patients with primary sclerosing cholangitis.

Siddique et al[50]  reported additional unexpected diagnostic information was provided by cholangioscopy for 18 of 61 patients. In seven of 61 patients, cholangioscopy revealed normal results when standard cholangiography suggested abnormal findings. This study also showed a role for cholangioscopy in biliary strictures in patients after liver transplantation and patients with hemobilia. (See the image below.)

Cholangioscopic view of normal intrahepatic biliar Cholangioscopic view of normal intrahepatic biliary mucosa.

A study by Awadallah et al[51]  reported that peroral cholangioscopy-guided biopsy was able to exclude malignancy in 31 patients with primary sclerosing cholangitis who had a prior finding of a dominant biliary stricture. A study by Itoi et al[52]  found that cholangioscopy with biopsy can diagnose benign and malignant lesions with a sensitivity of 99% and specificity of 95.8%.

Peroral cholangioscopy has also been evaluated as an effective tool for evaluation of pancreatic ducts. A study by Yamaguchi et al[24]  reported improved ability to diagnose intraductal papillary mucinous neoplasms of the pancreas by pancreatic cytology using mother-baby cholangioscopes. This study also concluded that there is no diagnostic value with pancreatic juice cytology in diagnosing pancreatic carcinoma.

Studies evaluating the efficacy of the SpyGlass cholangioscopy system have reported that direct visualization improves the accuracy of cholangiographic findings and has good positive predictive value in evaluating patients with biliary obstructive symptoms of indeterminate origin.[4, 25, 26]  In one series, cholangioscopy-guided bile duct biopsies could be successfully performed in 89% of cases. Notably, the sensitivity of this technique for diagnosing intrinsic malignant strictures was higher than the transpapillary route.

An unanticipated benefit of the high sensitivity of cholangioscopy is that it has revealed previously unappreciated weaknesses in ERCP-mediated evaluation and diagnosis of biliary stones.

Parsi et al[25]  were able to diagnose at least 29% of ERCP-missed biliary stones by subsequent cholangioscopy, subsequently concluding that rates of missed stones on ERCP may be higher than previously thought. The same study reported a success rate of 92% in treatment of biliary stones using electrohydraulic or laser lithotripsy. Moon et al[27]  reported excellent success with lithotripsy with electrohydraulic or laser using ultraslim cholangioscopes.

In patients with difficult-to-treat stones, Arya et al[28]  described peroral cholangioscopy with electrohydraulic lithotripsy in 94 patients reporting a 96% fragmentation rate and 90% final stone clearance rate. Moreover, Hui et al[29]  demonstrated significantly less cholangitis and a decreased mortality with peroral cholangioscopy-guided lithotripsy as compared with biliary stenting alone in elderly patients.

Multiple other studies reported similar success rates in treatment of biliary stones using peroral cholangioscopy and electrohydraulic or laser therapy. Thus, when performed by experienced and well-trained personnel, peroral cholangioscopy can be a safe and highly effective technique for the management of difficult-to-treat biliary stones.


Contraindications for cholangioscopy include the following[53] :

  • Any condition that precludes patients from undergoing endoscopy
  • Acute pancreatitis excluding due to biliary stones
  • Uncorrected coagulopathy with a high bleeding risk
  • Altered upper gastrointestinal anatomy precluding access to the second portion of duodenum (eg, Roux-en-Y)

Technical Considerations

Procedural planning

Early communication has to be established with the institutional pathology department to alert them of a possible small biopsy specimen arrival from cholangioscopy. As the quantity of tissue sample acquired during cholangioscopy is very small, this communication will ensure optimal processing of the precious specimens.

Complication prevention

Cholangioscopy involves significant manipulation of the biliary ducts. Antibiotic prophylaxis is generally given before the procedure, with levaquin, ampicillin, and gentamicin being the most commonly used antibiotics.

Care must be taken to confirm that coagulation parameters are normal before the procedure so as to minimize bleeding risk.

Aggressive irrigation should be avoided when obstruction is visualized within the biliary duct so as to prevent cholangitis.


Periprocedural Care

Patient Education and Consent

Patients should be instructed to fast overnight before the procedure.

Informed consent must be obtained from the patient. The procedure to be performed and risks involved with the anesthesia and the procedure should be explained.

Preprocedural Planning

The procedure should be explained to the assisting staff.

All required equipment should be checked before the procedure begins.

Prophylactic antibiotics are usually administered 30 minutes before the procedure.


This section includes a few examples of cholangioscopes that have been introduced to date.[6, 54, 55, 53, 56, 36, 37, 38]

Two-operator systems: mother-and-baby scopes and miniscopes

These endoscopes use a large “mother” scope for duodenoscopy and then introduce a smaller “baby” scope to cannulate biliary ducts. When it was introduced, it was a revolutionary technology that provided successful visualization of bile ducts and pancreatic ducts. It also offered excellent diagnostic and therapeutic potential in the management of biliary disorders.

However, these systems are limited. They are fragile and cumbersome; require two endoscopists; are limited to two-way endoscopic steering; lack adequate working channels, widespread availability, and expertise; and have high maintenance costs.

Miniscopes were then developed. They were introduced into bile ducts through standard duodenoscopes. Earlier versions were fragile, did not have tip deflection, and lacked working channels.

Larger miniscopes were later developed to overcome the limitations of earlier, smaller miniscopes. Advantages include therapeutic capability from the instrumentation channel, but they were limited by the absence of separate air and water channels.

Single-operator system: SpyGlass cholangiopancreatoscopy

The initial clinical feasibility study for the SpyGlass cholangioscopy system (developed by Boston Scientific, Marlborough, MA) was described by Chen et al in 2007.[51]  This system was considered a major breakthrough in cholangioscope technology and overcame many limitations of earlier versions.

The SpyGlass cholangioscopy system is operated by a single endoscopist. It has four-way tip deflection, separate irrigation and working (instrumentation) channels, and a four-lumen single catheter. It allows for significantly decreased time under fluoroscopy and thus decreased radiation exposure. Multicenter international trials showed promising results in the diagnosis and treatment of many biliary and pancreatic diseases.

The SpyGlass cholangioscopy system[32]  consists of capital components and consumable devices (see in the image below).

Spyglass System and images from the biliary system Spyglass System and images from the biliary system.

Capital components include the following:

  • Component cart and three-joint arm
  • Light source and cable (300-W high intensity white light)
  • Camera and camera head (autoshutter camera with color image sensor)
  • Ocular-optical coupler that interfaces with the probe and camera head
  • Isolation transformer
  • Power cable pack
  • Irrigation pump
  • Video monitor

Regarding consumable devices, the system makes use of a disposable access and delivery catheter (10-French outer diameter), a reusable optical probe, and disposable biopsy forceps.

The SpyScope access and delivery catheter is a single-operator, disposable catheter used for introducing the SpyGlass system into the biliary system. It has a length of 230 cm and an outer diameter of 10 French. It consists of four lumina: one for the SpyGlass optical probe, one lumen for the SpyBite forceps, and two for electrohydraulic lithotripsy or laser probes. Two irrigation channels exit at the end of the catheter for irrigation of ducts. It is unique because it has a four-way tip deflection to help with navigation and better visualization of the biliary ducts.

The SpyGlass fiberoptic probe is a multiple-use device with a length of 231 cm that conducts light to biliary ducts and captures fiberoptic endoscopic images. It consists of a 6000-pixel image bundle surrounded by an approximately 225-light transmission bundle. A lens connected at the distal end of the image bundle captures a 70º field of view. Images captured are inferior to those captured by video cholangioscopes.

The SpyBite forceps is a single-use device that has a 286-cm working length. The forceps is introduced through the 1.2-mm working channel of the SpyScope catheter. The forceps jaw is designed with a central spike and has an outer diameter of 1 mm for obtaining small target biopsies under direct visualization.

The SpyGlass system is compatible with a few electrohydraulic lithotripsy and laser probe devices introduced through the working channel of the SpyScope catheter.

Direct cholangioscopy

Direct cholangioscopy has superior image quality. Equipment that has been used includes the following:

  • Olympus Gastroscope GIF-Q 180 with a diameter of 8.8 mm, preloaded with an 11.5-French balloon
  • Olympus Ultraslim upper endoscope GIF-XP 160 with a diameter of 5.9 mm and a 2-mm instrument channel

Lee et al evaluated the use of a third-generation multibending ultraslim cholangioscope (CHF-Y0010; Olympus Medical Systems, Tokyo, Japan), in 20 patients with difficult bile duct stones for whom previous attempts at conventional endoscopic stone removal had been unsuccessful.[57] Complete ductal clearance was achieved in 19 patients (95%). A median of 2 (range, 1-3) ERCP sessions were required for complete stone removal. One patient (5%) had an adverse event and was treated conservatively.

Patient Preparation


Cholangioscopy is a time-consuming and labor-intensive procedure. Deep sedation with parenteral midazolam/fentanyl by an anesthesiologist during the procedure is preferred. In few cases, general anesthesia may be required to perform the procedure. Protection of the airway is an important concern during a prolonged procedure such as cholangioscopy, which further emphasizes the need for an anesthesiologist.

The patient should be under continuous monitoring of blood pressure, heart rate, heart rhythm, respiratory rate, and pulse oximetry during the procedure.


Patients are generally placed in a prone position during cholangioscopy.



SpyGlass Cholangioscopy

Cholangioscopy using the SpyGlass cholangioscopy system[32, 53, 58, 59, 18]  can be performed by a single endoscopist. The SpyScope access and delivery catheter is attached to duodenoscope by a Silastic band below the working channel of the duodenoscope. The duodenoscope along with the SpyGlass cholangioscopy system is held by one hand of the endoscopist; the other hand is used for operating the deflection wheels of the duodenoscope and the SpyGlass system. The procedure is always performed in conjunction with endoscopic retrograde cholangiopancreatography (ERCP).

The SpyGlass direct visualization probe is inserted into the optical channel of the SpyGlass catheter.

Under direct vision, the duodenoscope is passed through the oral cavity and pharynx. Then, the esophagus is intubated and the duodenoscope is passed through the esophagus and stomach to reach the second portion of the duodenum to visualize the ampulla of Vater and the papillae.

A selective and deep cannulation of the biliary tree is performed. A guide wire is then introduced and positioned in the bile duct (or pancreatic duct) under fluoroscopy.

Sphincterotomy is usually performed for better access of the biliary tree.

The SpyScope catheter and the optical probe are introduced into the duodenoscope together as a unit and advanced into the biliary ducts for direct visualization. Once inside the common bile duct (CBD), the SpyGlass catheter is slowly advanced under fluoroscopic guidance. Once the SpyScope catheter is positioned in the CBD, the guide wire is removed.

The optical probe is then advanced beyond the tip of the SpyGlass catheter. Direct visualization of biliary ducts is performed by repeated advancing and withdrawal of the SpyScope catheter in the biliary duct. The four-way tip-deflection capability of the SpyScope catheter aids in achieving better visualization of the biliary ducts.

If a suspicious lesion is found in the biliary ducts, the SpyBite forceps are introduced through the operating channel for obtaining targeted small biopsies. If biliary stones are found, SpyGlass-directed electrohydraulic or laser lithotripsy is performed.

Irrigation of the biliary ducts is performed through the two irrigation ports built within the SpyScope catheter that exit at the tip of the catheter. This clears the debris in the bile ducts and provides better visual images throughout the procedure. Lack of a suction port is a drawback of this system, but manual suction can be achieved by attaching a syringe to the operating channel.

After completion of the procedure, patients are generally kept without oral intake until the next day.

Mother-and-Baby Scopes

Cholangioscopy using a mother duodenoscope and a baby cholangioscope requires two experienced endoscopists working together to complete the procedure.[56]

The procedure starts as a regular ERCP, with the introduction of a duodenoscope under direct visualization through the mouth. The scope is advanced to the second portion of the duodenum to visualize the ampulla of Vater.

Selective cannulation of the CBD is performed. A sphincterotomy is usually performed.

Cholangiography is then performed, and a guide wire is placed in the biliary system.

The cholangioscope is introduced into the working channel of the duodenoscope to cannulate the CBD. Under fluoroscopy, the cholangioscope is slowly advanced over the guide wire to the CBD.

Once the cholangioscope is within the CBD, the guide wire may be removed. The working channel available in the cholangioscope is used for diagnostic and therapeutic interventions. Targeted small biopsies can be obtained by introducing forceps through the working channel of the cholangioscope.

Electrohydraulic or laser lithotripsy also may be performed through the working channel of the cholangioscope.

Direct Cholangioscopy

Direct cholangioscopy is a relatively new technique with limited available data.[60, 54, 55, 61]  It is a technically difficult procedure that requires a larger sphincterotomy and a dilated bile duct, but the image quality is superior.

Direct cholangioscopy can be performed as either a wire-guided or a balloon-assisted procedure.

A standard therapeutic duodenoscope is advanced to the second portion of the duodenum, in much the same fashion as with previously mentioned methods for cholangioscopy.

A guide wire is then introduced into the bile ducts under fluoroscopic guidance.

The duodenoscope is removed, leaving the guide wire in the bile ducts.

An ultraslim endoscope is then back-loaded over the guide wire with the use of a standard ERCP cannula.

Under fluoroscopic guidance, an ultraslim endoscope is advanced into the bile ducts.

If a balloon-assisted method is used, a balloon is introduced and inflated in the common hepatic duct (CHD). This is used as an anchor to advance the ultraslim endoscope into the bile ducts.[62]


The potential complications associated with cholangioscopy are numerous and range from relatively mild sequelae to life-threatening conditions, including the following:

  • Cholangitis (most common complication)
  • Abdominal pain
  • Hypotension
  • Nausea
  • Radiculopathy
  • Perforation of bile duct (from the guide wire)
  • Elevated amylase and lipase without clinical pancreatitis
  • Inflammatory syndrome