Biliary strictures represent a major diagnostic challenge due to the difficulty in distinguishing benign from malignant etiologies.Endoscopic ultrasound (EUS) allows detailed exploration of the biliary and pancreatic ducts and enables targeted tissue sampling for diagnostic purposes.The aim of this study was to assess the diagnostic performance and clinical impact of EUS in the management of indeterminate biliary strictures.

This was a retrospective, single-center, descriptive study including all patients presenting with a biliary stricture suspected  on cholangio-MRI (MRCP) without evident mass, and subsequently explored by EUS over a six-year period (2019–2025).Collected data included clinical, biological, morphological, histological, and follow-up characteristics.

Twenty-five patients were included. The median age was 59 years (range 42–85), with a slight male predominance (14 men, 11 women).Clinically, all patients initially presented with cholestatic jaundice, with a mean total bilirubin (TB) level of 12,1 mg/dL.

The strictures were distal (common bile duct) in 83% of cases (20 patients) and hilar in 17% (5 patients).The median stricture length was 10 mm, and the appearance was predominantly malignant in 8 cases, and benign in 5 cases.

Fine-needle aspiration/biopsy (FNA/FNB) was performed in 64% of patients (16/25), using variable-caliber needles: mainly 22G (63%), followed by 20G (25%) and 19G (12%), according to lesion location and consistency.Histopathological analysis revealed malignant lesions in 13 cases (52 %), mainly cholangiocarcinomas (n=7) and pancreatic head adenocarcinomas (n=6).

Benign lesions were observed in 7 patients (28 %), including fibrotic Odditis, post-cholecystectomy biliary strictures, primary sclerosing cholangitis, and IgG4-related cholangitis.

A minor hemorrhagic complication post FNB/A was reported, with no other major adverse events.

Regarding therapeutic outcomes, 4 patients with malignant disease (16%) underwent curative surgical resection, and 4 others (16%) received palliative chemotherapy.

EUS enabled a definitive diagnosis in nearly 80 % of malignant cases, thereby guiding therapeutic management.It represents a key first-line diagnostic tool in the evaluation of biliary strictures, owing to its high-resolution imaging and ability to obtain targeted tissue samples.Further systematic histological correlation and prospective follow-up studies are warranted to refine the overall diagnostic performance of this technique.