Fifty three bile specimens from 42 patients were reviewed to assess the diagnostic role of the bile cytology and to define more reliable cytologic indicators of malignancy. Forty three bile specimens came from 34 patients with malignant biliary strictures and 10 bile specimens were from eight patients with benign conditions. There were no false positives. The diagnostic specificity of bile cytology was 100% while diagnostic sensitivity was 55.8%. Overall diagnostic accuracy was 64.2%. We identified four key criteria as cytologic indicators of malignancy among 20 variables by using multiple regression analysis: loss of honeycomb arrangement, hyperchromatism, increased N/C ratio, and coarse chromatin. When bile specimens with three or more of these four criteria are thought to represent malignancy, the sensitivity of diagnosis of malignancy was 65.2%, specificity was 90% and diagnostic accuracy was 69.8%.