Cholangiography in the jaundiced patient

Percutaneous transhepatic biliary drainage in patients with postsurgical bile leakage and nondilated intrahepatic bile ducts

OBJECTIVE AND BACKGROUND

Bile leakage is a serious postoperative complication and percutaneous transhepatic biliary drainage (PTBD) may be an option when endoscopic treatment is not feasible. In this retrospective study, we established technical and clinical success rates as well as the complication rates of PTBD in a large group of patients with postoperative bile leakage.

METHODS

Data on all patients with nondilated intrahepatic bile ducts who underwent a PTBD procedure for the treatment of bile leakage between January 2000 and August 2012 were retrospectively assessed. Data included type of surgery, site of bile leak, previous attempts of bile leak repair, interval between surgery and PTBD placement. Outcome measures were the technical and clinical success rates, the procedure-related complications, and mortality rate.

RESULTS

A total of 63 patients were identified; PTBD placement was technically successful in 90.5% (57/63) after one to three attempts. The clinical success rate was 69.8% (44/63). Four major complications were documented (4/63; 6.3%): liver laceration, pneumothorax, pleural empyema, and prolonged hemobilia. One minor complication involved pain.

CONCLUSIONS

PTBD is an effective treatment with low complication rates for the management of postsurgical bile leaks in patients with nondilated bile ducts.

Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts compared with patients with dilated intrahepatic bile ducts

OBJECTIVE

The purpose of this article is to compare the technical success and guidance of percutaneous transhepatic biliary drainage (PTBD) in patients with nondilated and dilated bile duct systems using different techniques to supplement the conventional approach.

MATERIALS AND METHODS

Between 2006 and 2008, 71 patients (mean age, 66.6 years) underwent PTBD with 97 interventions. According to sonographic evaluation of bile duct morphology, patients were divided into two groups: 50 patients with dilated and 21 patients with nondilated bile ducts. In a retrospective analysis, both groups were compared for technical success, fluoroscopy time, complications, and medical indications. The use of interventional guidance (deviations from the standard protocol) in patients with nondilated bile ducts was recorded.

RESULTS

The technical success rate was 90% in patients with dilated bile ducts versus 81% in patients with nondilated ducts, with no significant difference (p = 0.36). The greater complexity of the intervention in patients with nondilated bile ducts resulted in longer fluoroscopy times (p = 0.04). Complication rates were not different between the two groups. The main indication for PTBD was relief of a compressed biliary system in patients with dilated ducts and postoperative management of complications or prevention of tumor-associated bile duct obstruction in patients with nondilated ducts. T-drainage, additional CT-guided puncture, and temporary gallbladder drainage were performed in 16 of 21 interventions for patients with nondilated bile ducts, resulting in a 100% success rate, versus a success rate of 60% in the five PTBDs of nondilated ducts performed in the conventional manner.

CONCLUSION

T-drainage, additional CT-guided puncture, and temporary gallbladder drainage improve the technical success of PTBD when used in patients with nondilated bile ducts. With these measures, technical success and complication rates in patients with nondilated ducts are comparable to those for PTBD of dilated bile ducts.

Transhepatic cholangiography in patients with suspected biliary disease and nondilated intrahepatic bile ducts

Transhepatic cholangiography (THC) was performed in 107 patients who had nondilated intrahepatic bile ducts on computed tomography (CT) or ultrasound. The cholangiogram was diagnostic in 72 patients (67%). Thirty-one (43%) of the 72 diagnostic studies were abnormal and showed poor emptying, stones, or strictures. Twenty-three (21%) complications occurred, including two deaths. Sixteen patients experienced acute pain, requiring additional narcotics. There was one case of peritonitis and pancreatitis, and two of bacteremia. We compared our success and complication rates to those of endoscopic retrograde cholangiography (ERC) reported in the literature. We conclude that when a bile duct abnormality is clinically suspected, the incidence of pathology is sufficiently high to warrant direct visualization of the ducts in order to make an anatomic diagnosis, even if the intrahepatic ducts are not dilated. However, ERC has a better success rate and fewer complications than THC and it should be the initial invasive procedure.

Primary biliary cirrhosis

Primary biliary cirrhosis is a chronic liver disease of unknown etiology characterized by slowly progressive intrahepatic cholestasis due to an inflammatory destruction of small intrahepatic bile ducts. The clinical course of PBC is variable ranging from a few years in rapidly progressive cases to a normal life-expectancy in a proportion of asymptomatic cases. The typical patient is a middle-aged woman who may present with pruritus, increasing pigmentation of the skin, and eventually jaundice. The level of serum alkaline phosphatase is almost invariably elevated, serum mitochondrial antibodies are present in more than 90 per cent, and an elevated serum IgM is usually present. PBC is associated with many immunologic abnormalities and appears to be a classic autoimmune disease. Some of the immune defects may be epiphenomena; others such as a marked defect in suppressor T cell function seem to be related to the pathogenesis of the disease. All drug therapy that is aimed at slowing the disease process is experimental. A place for immunosuppressive drugs in the management of PBC would be anticipated. However, no drug has to date been definitively shown to have a beneficial effect on the disease. Currently, the main treatments used are aimed at preventing or correcting the complications of intractable cholestasis. Patients with PBC and evidence of hepatic decompensation and/or poor quality of life make good candidates for liver transplantation. The current aim of therapy is to find an effective regime of immunosuppression that will make hepatic transplantation redundant for this disease.

Laser lithotripsy: animal studies of safety and efficacy

The safety and efficacy of pulsed tunable dye laser fragmentation of common bile duct stones was assessed in pigs. Laser pulses were conducted through a flexible quartz fiber that was in direct contact with stones that had been surgically implanted into the common bile duct. All calculi were rapidly fragmented into small pieces without significant damage to the common bile duct. The immediate and delayed effects of pulsed lasers on the common bile duct were also evaluated. The common bile duct demonstrated a high tolerance to laser-induced damage even when the laser was discharged directly into the bile duct wall. These results suggest that laser lithotripsy can be performed in humans with a high degree of safety and efficacy.

Fragmentation of biliary calculi with tunable dye lasers

The feasibility of using lasers to fragment biliary calculi was examined in vitro. Flashlamp-pumped tunable dye lasers were coupled to small-diameter flexible quartz fibers that were placed in direct contact with biliary calculi. The minimum laser energy necessary to damage a calculus was measured for wavelengths between 450 and 700 nm and for pulse durations between 0.8 and 360 microseconds. This threshold energy increased with increasing wavelength but was not significantly affected by pulse duration. Cholesterol stones had uniformly higher thresholds than pigmented ones. When a repetitively pulsed laser was used, complete fragmentation required fewer than 500 pulses and fragments were predominantly less than 2 mm. The pulsed dye laser can effectively fragment biliary calculi when transmitted through a small-diameter quartz fiber and may be useful as a tool for fragmenting retained common duct stones.

Percutaneous transhepatic cholangiography: Ibadan experience

Our experience using the teflon method in carrying out transhepatic cholangiography is described. A teflon needle (20 gauge) was used instead of the conventional Chiba needle. The number of successful examinations and their complication rate are comparable with examination carried out with Chiba needle. The ease of the procedure with the teflon needle and its relative cheapness make this technique preferable, although not without risks, especially in the developing countries where inadequate funds are available for health care.

Hepatobiliary imaging using Tc-pyridoxylideneglutamate in the diagnosis of obstructive jaundice

In 77 of 114 consecutive patients with suspected hepatobiliary disease undergoing cholescintigraphy a firm clinical or operative diagnosis was possible. These patients were classified as normal, or as having extra-hepatic biliary obstruction (partial or complete) or hepatocellular disease. On a double-blind basis cholescintigraphy correctly interpreted 18 of 20 (90%) normal controls, 12 of 14 (86%) of those with partial obstruction, 16 of 16 (100%) of those with complete obstruction and 23 of 27 (85%) of those with hepatocellular disease giving an overall diagnostic accuracy of 69 of 77 (90%). There were no complications or toxic reactions. Ninety-three percent of patients with biliary obstruction (sensitivity) and 87% of those without biliary obstruction (specificity) were correctly diagnosed. Cholescintigraphy is a non-invasive, cheap and reliable investigation which can be used in the presence of icterus to discriminate between patients with and without extra-hepatic biliary obstruction. In contrast to grey scale ultrasonography the production and interpretation of scans are simple. Moreover cholescintigraphy adds a functional element to the investigation of liver disease.

Combined approach to the differential diagnosis of cholestatic jaundice with endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, ultrasonography, and liver biopsy

A prospective study of 33 patients with cholestatic jaundice was performed with combined use of endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), ultrasonography, and liver biopsy. A higher rate of success with PTC in 25 cases of extrahepatic cholestasis was offset by the better score of ERCP in 8 cases of intrahepatic cholestasis and its wider diagnostic scope. The procedures were complementary in 10 cases. Ultrasonic imaging of intrahepatic bile ducts proved useful for selecting the first cholangiographic technique. Liver biopsy established etiology in intrahepatic cholestasis. Our combined approach allowed us to develop through objective criteria a diagnostic flow chart of cholestasis.

Ultrasound in the differential diagnosis of jaundice

Ultrasound examination was performed in 53 jaundiced patients; successful examination was accomplished in 48. Ultrasonography revealed mechanical biliary obstruction in 34 of 35 patients with obstructive jaundice. Dilatation of the intrahepatic or extrahepatic biliary ducts or the gallbladder was not present in any patient with non-obstructive jaundice. The value of ultrasound examination in the differential diagnosis of jaundice is emphasized.

The diagnosis of exocrine pancreatic disease: the present position reviewed

In this paper, recent advances in the diagnosis of pancreatic disease are reviewed, together with older methods currently in use. The clinical role of these techniques in the diagnosis of pancreatic disease is discussed with particular reference to symptomatology and prognosis of the various pancreatic disorders. Likely future developments in this field are considered.

Spontaneous closure of choledochoduodenostomy: diagnosis by endoscopy and ERCP

Choledochoduodenostomy has been recommended for the management of benign lower common bile duct obstruction, but opinion on this is still divided. Two cases are presented of recurrent cholangitis following choledochoduodenostomy, in which endoscopy and ERCP demonstrated closure of the choledochoduodenal anastomosis, continuing lower biliary obstruction and retained stones or debris. Persistent of recurrent symptoms following this operation may be due to stoma closure without adequate biliary drainage, and in these circumstances endoscopy with ERCP is proving most useful and in difficult cases may be the investigation of choice.

Acute cholangitis

The features of cholangitis were analyzed in 99 consecutive cases treated in the last ten years. The disease was severe and refractory in half the cases due to malignant stricture, and in 20% of those due to gallstones. Benign strictures, sclerosing cholangitis, and most cases of choledocholithiasis were associated with less severe cholangitis, which responded promptly to antibiotic therapy. High fever, a serum bilirubin level above 4 mg/dl, and hypotension characterized the most severe refractory cases in which emergency surgery was mandatory. Patients without manifestations were nearly always controlled successfully with antibiotics. We conclude that the term "suppurative cholangitis" is an unsatisfactory synonym for severe cholangitis, because the correlation between biliary suppuration and clinical manifestations in cholangitis is inexact; some patients with severe sepsis do not have pus in the bile duct, and a few patients with suppurative bile are only moderately ill.

The role of grey scale ultrasonography in the investigation of jaundice

Sixty-seven patients were prospectively studied using grey scale ultrasound (GSU) to assess its possible role as part of a jaundice investigation programme. All scans were performed by one radiologist, without clinical information. When intrahepatic ductal dilatation was found an attempt was made to establish the level and cause of obstruction. The calibre of the intrahepatic bile ducts was correctly reported in 66 patients (98 per cent). Forty-three proved to have extrahepatic cholestasis, 24 had intrahepatic cholestasis. No patient with intrahepatic cholestasis had dilated ducts seen on ultrasound. In 43 patients with obstructive jaundice, GSU accurately detected the level of obstruction in 28. This accuracy varied with the cause of obstruction. A direct indication of diagnosis was possible in 45 of the 67 patients. In a unit specializing in the management of complicated hepatobiliary problems, GSU has been shown to be accurate in differentiating extra- from intrahepatic jaundice. Being non-invasive, it appears ideally suited for use as a screening procedure, permitting selection of appropriate invasive investigations to provide complete preoperative imaging of the biliary tree. In patients with jaundice due to gallstones, GSU may be the only imaging technique required before surgery provided good operative cholangiography is available.

Grey-scale ultrasonography in cholestatic jaundice

Grey-scale ultrasonography was performed without access to detailed clinical information in a prospective study of 55 jaundiced patients. Forty-one were eventually proved to have an extrahepatic obstructive cause, and 14 had intrahepatic "medical" disease. Satisfactory ultrasound images were obtained in 54 patients, and the bile duct calibre was correctly reported in 53 (96%). All 14 medical cases were correctly identified. Two patients with gallstones (one with a normal sized duct) were incorrectly classified as medical. A specific and correct disease diagnosis was given in five of the 14 medical cases (one metastases, four cirrhosis), and in 23 of the 41 obstructive cases (12/14 pancreatic cancer, 5/15 gallstones), 5/5 bile duct compression, 1/3 bile duct cancer. Ultrasonography is safe, cheap, and acceptable to patients. It should be the first imaging investigation in jaundiced patients, providing remarkable diagnostic accuracy and important guidance for further management.

Endoscopic retrograde cholangiopancreatography. A review of the rewards and indications

Indications for endoscopic retrograde cholangiography (ERCP) have been poorly defined. We studied the symptoms in 161 patients who underwent ERCP and evaluated the results from four groups of indications: cholestasis, pancreatitis, suspected carcinoma of the pancreas, and pain of unknown etiology. The likelihood of finding abnormalities is discussed.

Computed tomography, ultrasound, and cholestatic jaundice

Computed tomography detected the presence of dilated ducts in 15 of 18 cases with extrahepatic obstructive jaundice and demonstrated the obstructing lesion in 18 out of 25. The cause of the obstruction was detected in the absence of duct dilatation, and calculi which were radiolucent on conventional radiographs were demonstrated. Ulstrasound detected dilated ducts in eight of 10 cases, but demonstrated the cause of the obstruction in only one of 13 cases. Both techniques are capable of demonstrating dilated ducts in the majority of cases, but computed tomography is better at detecting the cause of the obstruction.

A prospective study of the clinical value and accuracy of grey scale ultrasound in detecting gallstones

The accuracy and possible clinical value of grey scale ultrasonography in the detection of gallstones has been prospectively studied in 100 unselected patients presenting with recurrent biliary colic, acute cholecystitis or acute pancreatitis. Adequate visualization of the gallbladder was obtained in 79 cases, with 3 false positive and no false negative reports. Oral cholecystography remains the initial investigation of choice in patients presenting with recurrent biliary colic, but grey scale ultrasound has been shown in this study to be a reliable means of detecting gallstones in the 'acute' situation, when conventional contrast radiology is of limited value.

Prospective evaluation of endoscopic retrograde cholangiopancreatography in the diagnosis of periampullary cancers

In a prospective study of 112 patients suspected of periampullary cancer endoscopic retrograde cholangiopancreatography (ERCP) was successfully performed in 87 patients (78%). Technical failures were due to gastric outlet obstruction in four patients and inability to cannulate the ampulla of Vater in 21 patients. Successfully performed ERCP had both a high sensitivity (92%) and specificity (90%) for periampullary cancer. The few errors in pancreatogram interpretation were due to juxta-ductal cancers and difficulty in differentiating duct changes of cancer from those of chronic pancreatitis. Pancreatic cytology, performed in 21 patients, was reliable, diagnosed two pancreatic cancers when the pancreatogram failed and, if used routinely, assists interpretation of the pancreatogram. Retrograde cholangiography provided a correct diagnosis in six jaundiced patients with normal pancreatograms. Three complications of ERCP occurred in this series.

The early use of fine-needle percutaneous transhepatic cholangiography in an approach to the diagnosis of jaundice in a surgical unit

Fine-needle percutaneous transhepatic cholangiography (PTC) was performed in a series of 46 patients with jaundice or suspected biliary tract disease. The ductal system was successfully outlined in each of 20 patients with dilated intrahepatic ducts and in 19 of 26 patients with intrahepatic ducts of normal calibre. There were two episodes of septicaemia after PTC, one of them fatal. Valuable accurate diagnostic information was obtained in all cases with biliary tract obstruction. A programmed approach to diagnosis of suspected obstructive jaundice is outlined. Fine-needle PTC is an acceptably safe procedure and need not be followed by immediate laparotomy.

Endoscopic retrograde cholangiography in hepatic hydatid disease

Endoscopic retrograde cholangiography provides safe preoperative documentation of the relationship of hepatic hydatid cysts to the biliary ductal system and accurate distinction from coincident calculus disease.

Progress report. Ultrasound and gastroenterology

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ERCP

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Percutaneous transhipatic cholangiography

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