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Background and Aims: Accurately differentiating malignant strictures from benign ones is of significant importance and remains a major clinical problem.This study investigated the diagnostic yield of endoscopic retrograde cholangiography/intraductal ultrasound (ERC/IDUS) in distinguishing biliary strictures, and assessed some image findings from ERC/IDUS which might be useful in differentiation.Methods: From January 2008 to January 2015, patients who underwent ERC/IDUS for biliary strictures of unknown etiology were enrolled.Patient's ERC/IDUS diagnosis was compared with the final diagnosis determined by pathologic findings and/or clinical outcome of follow-up.Results: 193 patients with biliary strictures were included.IDUS correctly identified 94 of 97 malignant strictures and 76 of 96 benign strictures with sensitivity,specificity and accuracy rate of 96.91%, 79.17% and 88.08%, respectively.Additionally, the accuracy rate of IDUS for diagnosis of proximal biliary strictures was higher than that of distal biliary strictures (98.08% VS.82.73%, p=0.006).Besides, there was a significant difference in the length of stricture between benign and malignant strictures(13.76mrn±7.37mm vs.19.97mm± 11.37mm;p<0.001) as well as thickness of bile duct wall at the site of stricture(3.06mm±0.92mm vs.7.03mm±3.70mm, p=0.008).Biliary wall thickness>7mm without extrinsic compression had a positive predictive value (PPV)of 100% for including malignancy while length of stricture ≥ 20mm demonstrated a PPV of 93.44%.Conclusions: ERC/IDUS is effective in differentiating biliary strictures with undetermined etiology thus helping in further clinical management.