Percutaneous Cholangiography Research Articles

Liver disease complicating bone marrow transplantation: A clinical audit

Hepatic dysfunction following bone marrow transplantation (BMT) may present complex management issues. The incidence and aetiology of abnormal liver function following allogeneic and autologous BMT was reviewed over a 2 year period in Royal Perth Hospital and these findings were related to management decisions and patient outcome. Abnormal serum liver biochemistry during the first 12 post-transplant months occurred in all allogeneic (n = 31) and 14 of 23 (61%) autologous transplant patients; 13 (41%) allogeneic and three (13%) autologous patients developed severe hepatic dysfunction. In allogeneic transplants, the most common causes of liver disease were graft-versus-host disease (33%), drug hepatotoxicity (19%) and posttransplant viral hepatitis (15%); in autologous patients, disease recurrence (28%) and sepsis (17%) were the most frequent identifiable cause of abnormal liver function. The aetiology of abnormal liver biochemistry was not determined in 13 instances, but this did not adversely affect patient outcome. Percutaneous liver biopsy or endoscopic cholangiography were only required in three patients. Liver disease contributed to death in two allogeneic patients with multiple causes for liver dysfunction, and in one patient with refractory severe hepatic graft-versus-host disease. It was concluded that hepatic dysfunction is common after BMT, the cause of which can be determined in many cases with simple non-invasive tests used in conjunction with the clinical setting. Specific treatment, where necessary, is then able to be commenced in a majority of patients without the need for invasive investigation.

Complications after laparoscopic cholecystectomy

The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic cholecystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical approach were assessed. From April 1991 to October 1993, 23 patients were observed. Seven patients had biliary strictures, five had biliary lesions, five presented with retained common bile duct (CBD) stones, and one had a minor cystic duct leak. Five patients had miscellaneous abdominal fluid collections; in addition, biloma or bile ascites were present in 10/23 cases. Correct definition of iatrogenic lesions was mainly made by endoscopic retrograde cholangiography (ERCP) (n = 15), associated in six cases also with percutaneous cholangiography (PTC). "Minimally invasive" treatment included the full range of endoscopic and interventional radiological procedures. Six patients with biliary strictures, one patient with a biliary lesion, all five patients with residual CBD stones, and four patients with abdominal collections were treated by "minimally invasive" techniques: Therefore, laparotomy was avoided in 70% of cases (16/23 patients). Open surgery was necessary in 7/23 patients (30%), because of ductal lesion (n = 4), ductal stricture by endoloop (n = 1), iliac artery injury (n = 1), and phlegmon of gallbladder bed (n = 1). It appears that careful assessment of complications after LC is mandatory and often requires the combined use of ERCP/PTC and cross-sectional imaging.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of percutaneous transphepatic cholangiography (PTC) in biliary tract obstructions

Evaluation of percutaneous transphepatic cholangiography (PTC) in biliary tract obstructions

Biliary anastomosis after liver transplantation does not benefit from T tube splintage.

T tubes are commonly used to splint biliary anastomoses after liver transplantation. Although several advantages are claimed for this approach, there is undoubtedly some iatrogenic morbidity associated with the use of T tubes in this situation. We have evaluated 120 consecutive biliary reconstructions after liver transplant, the majority of which were unsplinted end to end bile duct anastomoses. We have shown that biliary leakage and stricture rates are not significantly affected by T tubes. We have also shown that endoscopic retrograde cholangiopancreatography and percutaneous cholangiography are reliable posttransplant methods for cholangiography and stricture dilatation. Routine T tube splintage of post-liver transplant biliary anastomoses is unjustified.

True single-stage percutaneous insertion of Wallstent biliary endoprostheses

SummaryIt is standard practice to leave a temporary external catheter in place for 24–48 h after biliary Wallstent placement. We aimed to establish the safety and effectiveness of a true single-stage procedure. Twenty-two patients underwent Wallstent insertion for palliation of malignant obstruction of the biliary tract. Following percutaneous cholangiography and balloon dilatation of the stricture, 10 mm Wallstent endoprostheses were inserted extending from the upper common hepatic duct to the duodenum. The introducer was then exchanged for a catheter and a cholangiogram performed. In 11 cases the catheter was removed, in the remaining cases it was not removed until after a satisfactory cholangiogram at 24–48 h. All of the patients from whom the catheter was removed made a good recovery with no procedure-related complications; in particular no early stent obstruction or leakage of bile was observed. Right flank pain was minimized and mobilization accelerated by the absence of an external catheter. We fee...

True single stage percutaneous insertion of wallstent biliary endoprostheses

SummaryIt is standard practice to leave a temporary external catheter in place for 24–48 h after biliary Wallstent placement. We aimed to establish the safety and effectiveness of a true single-stage procedure. Twenty-two patients underwent Wallstent insertion for palliation of malignant obstruction of the biliary tract. Following percutaneous cholangiography and balloon dilatation of the stricture, 10 mm Wallstent endoprostheses were inserted extending from the upper common hepatic duct to the duodenum. The introducer was then exchanged for a catheter and a cholangiogram performed. In 11 cases the catheter was removed, in the remaining cases it was not removed until after a satisfactory cholangiogram at 24–48 h. All of the patients from whom the catheter was removed made a good recovery with no procedure-related complications; in particular no early stent obstruction or leakage of bile was observed. Right flank pain was minimized and mobilization accelerated by the absence of an external catheter. We fee...

Cholelithiasis in infancy: A study of 40 cases

During a 17-year period, 40 infants less than 1 year of age were investigated for cholelithiasis; 32 infants were seen within the past 10 years. Seventeen of them had no recognizable predisposing factors. In 6 infants, gallbladder lithiasis was a fortuitous finding on a plain radiograph or sonogram with no signs of common bile duct obstruction; under conservative management, no complications of lithiasis were observed on follow-up of 3 infants and spontaneous resolution occurred in 2 others. In the remaining 34 infants with lithiasis of the common duct or cystic duct or both, the initial symptoms were cholestatic jaundice in 21, acholic stools in 8, sepsis in 4, and abdominal pain in 1. Ultrasonography, performed in 33 of them, showed dilation of the biliary tract in 28, and stones in the gallbladder in 13 and in the bile ducts in 10. Percutaneous transhepatic cholangiography or operative cholangiography in 26 infants showed stones in the bile ducts in 23. In 3 infants, no lithiasis was visible, suggesting the spontaneous elimination of stones. Treatment was initially surgical in 9 infants, but starting in 1981 interventional radiologic procedures were attempted in 15 infants and were successful in 12. Spontaneous resolution of cholelithiasis occurred in 10 other infants with cholestasis. Recurrence of biliary stones was observed in 3 infants only after a follow-up of 7 months to 10 years. These results suggest that common bile duct lithiasis should be considered among the causes of cholestatic jaundice in infancy, and that some of the gallbladder calculi found in older children may have resulted from a lithogenic process that occurred during fetal life or shortly after birth. Percutaneous cholangiography with biliary drainage appears to be an effective means of treatment of infants with common bile duct obstruction; surgery can then be restricted to a limited number of cases, especially those with associated strictures of the bile ducts.

CT of intrahepatic lithiasis

Twenty out of 65 patients, submitted to percutaneous treatment for intrahepatic stones at our department since 1983, had ultrasound (US) and computed tomography (CT) performed before any treatment. CT visualised stones in 65% of patients while distribution of stones was assessed correctly in 40%. In 5 patients CT provided information useful for treatment: in one case extremely dilated bile ducts hindered cholangiographic evaluation of lithiasis while in the other four cases CT examinations showed stones in dilated bile ducts unrecognised on percutaneous or endoscopic retrograde cholangiography. It is concluded that CT is a useful tool in the diagnosis of bile duct lithiasis. It aids in treatment selection and, when the percutaneous approach is chosen, allows the interventional radiologist to select the ducts to be catheterised.

Endosonographic Evaluation of Biliary Tract Disease

Modem echoendoscopes visualize the papilla of Vater, the extraheptic bile ducts, and the gallbladder with great accuracy. Endosonography is helpful in preoperative staging of gallbladder and bile duct tumors and in the examination of patients with indeterminate biliary strictures. In patients with extrahepatic obstructive jaundice, the information obtained by endosonographic ultrasonography regarding the case, location, and extent of the obstructing lesion is superior to that obtained by conventional ultrasonography and computed tomography. Endosonographic ultrasonography is a useful complementary technique to endoscopic or percutaneous cholangiography.

Value of exfoliative cytology for investigating bile duct strictures.

The cause of a biliary tract stricture may be difficult to determine radiologically. Exfoliative biliary cytology was evaluated in 62 patients (median age 65 years, range 30-94) with biliary tract strictures presenting to the Hepatobiliary Unit between January 1984 and December 1989. Bile samples were taken during endoscopic retrograde cholangiopancreatography (ERCP) in 42 patients, percutaneous cholangiography in 14, and both in six. The site of stricturing was upper third of the bile duct in 43% (n = 27), middle third in 10% (n = six), and lower third in 47% (n = 29). Of the 47 patients with radiological appearances of a malignant stricture, 22 (47%) had histological confirmation by biopsy either under computed tomography guidance, at endoscopy, at operation, or at necropsy. Fourteen of the 47 patients had positive cytology (30%). In seven patients cytology alone established the presence of malignancy (15%) and in the other seven positive cytology was confirmed by histology. The addition of cytology to tissue biopsy therefore allowed malignancy to be confirmed in 29 of the 47 patients (62%). None of the 15 patients subsequently shown to have benign disease had positive cytology. Sensitivity of the technique was 30% and specificity 100%. Samples for exfoliative cytology are simple to obtain, the results are highly specific and should be a routine part of the investigation of biliary strictures.

Intraluminal biliary obstruction.

Jaundice caused by intraluminal bile duct obstruction in infancy is rare but may occur in association with biliary sludge, inspissated bile plugs, or gall stones. Nine boys (aged 2 weeks-6 months) with obstruction caused by inspissated bile (n = 7) or gall stones (n = 2) are presented. Haemolysis was not a factor in the patients' histories but an abnormal entry of the common bile duct into the third part of the duodenum was demonstrated in two and one had an asymptomatic haemangioma. Ultrasonography was the most useful investigation. Surgical removal of the bile duct obstruction was necessary in eight cases and included biliary tract drainage in six and cholecystectomy for changes of cholecystitis in four. Obstruction resolved spontaneously in one infant after percutaneous cholangiography. There were no postoperative complications.

Iatrogenic Chymobilia— A Disease of the Nineties?

The last two decades have seen a strong swing towards preservation of some of the sphincters of the alimentary tract, namely, the pyloric and anal sphincters, while at the same time there has been increasing vandalism of the sphincter at the distal end of the common bile duct. Endoscopic papillotomy, first introduced in 1974, is a very useful procedure in selected patients but too liberal use of the technique may result in a harvest of new problems in years to come. The intact sphincter of Oddi prevents the entry of duodenal contents into the biliary tree; its division allows their free reflux. By the term ’chymobilia’ we mean the presence of chyme in the biliary tree. The Greek word chyme (juice) is combined with the Latin word bilis (bile) in a manner similar to the term haemobilia introduced by Sandblom in 19481. Following endoscopic sphincterotomy reflux of duodenal chyme occurs in most patients; aerobilia is seen in half and bacterobilia in all2. The results of surgical sphincterotomy are similar. The majority of these patients with bacterobilia do not develop classical symptoms of ascending cholangitis, namely pain, pyrexia, rigors and jaundice but 20 per cent have bouts of upper abdominal pain and associated elevation of the serum Gamma glutamyltranspepside3. Following biliary-enteric anastomosis both aerobic and anaerobic bacteria are involved4. Bacterobilia may not be as innocent as was initially thought, and for patients with immunosuppression, the risk of cholangitis is markedly increased5. In addition the reflux of chyme may set up chemical changes with resultant inflammatory reaction in the duct epithelium and periductal area. The clinical syndrome of ascending cholangitis often indicates outflow obstruction usually of an incomplete nature due to residual or recurrent stones or restenosis. However we have seen cholangitis in patients following sphincterotomy and other types of biliary-enteric anastomosis where a free-flowing, unobstructed biliary tree was demonstrated by percutaneous cholangiography and by retrograde barium and air studies of the ductal system. Goldman and colleagues reported on six patientswho suffered repeated episodes of cholangitis despite widely patent biliary-enteric anastomoses6. Debris is frequently seen in the duct following fenestration whether it be choledochoduodenostomy where the sump syndrome can occur, or after simple surgical or endoscopic sphincterotomy. These ductal filling defects are sometimes referred to as false calculi images. Escourrou and colleagues found evidence of reflux from the duodenum into the biliary tree in 65 per cent of patients after endoscopic sphincterotomy but state that they never observed clinical symptoms related to

Bilious Pleural Effusion following Liver Biopsy

Pleural effusions in patients with chronic liver disease are common and usually are of little consequence. Bilious pleural effusion can occur following percutaneous biopsy or cholangiography procedures if the pleura is traversed. This report emphasizes the role of biliary tract obstruction in the development of a bilious effusion and the importance of biliary tract decompression in treatment. We discuss the laboratory evidence supporting the diagnosis of bilious effusion and review the reported experience with this complication.

Endoscopic sphincterotomy - The basics

Endoscopic sphincterotomy refers to the incision of the terminal portion of the biliary or pancreatic ducts by a variety of techniques, depending on anatomic circumstances, goals and risks. Alternative methods include percutaneous transhepatic or surgical techniques. The initial Erlangen method - complete sphinccerotomy - carried an unavoidable risk of perforation and hemorrhage. Fractional incision or 'endoscopic papillotomy' - incision of the inferior sphincter - carries no risk of hemorrhage or perforation, done properly. Techniques of papillotomy including 'pull,' 'precut,' stent placement, infundibulotomy, percutaneous cholangiography, and internal spring wire are described, and general electrosurgical principles discussed.

Comparative Imaging of Gallbladder Cancer

We reviewed various imaging approaches in 22 patients with gallbladder cancer. Nineteen had had ultrasonography and nine computed tomography performed. A gallbladder mass or diffuse wall thickening was seen by ultrasonography in 42% and computed tomography in 33% of patients. A significant number of patients had no gallbladder wall abnormality detected by ultrasonography (37%) or computed tomography (56%). Performing both ultrasonography and computed tomography improved the diagnostic rate; in this subgroup the detection rate was 51%. Cholelithiasis, dilated biliary ducts, the liver metastases were associated findings. Percutaneous cholangiography in jaundiced patients revealed the level of bile duct occlusion and often suggested the diagnosis. Radionuclide hepatobiliary imaging simply revealed non-visualization of the gallbladder.

Ultrasound Guided Percutaneous Cholecystocholangiography for Early Differentiation of Cholestatic Liver Disease in Infants

SummaryDirect visualization of the extrahepatie biliary tree is difficult in infants and young children without resorting to an intraoperative cholangiogrum. Small size and lack of dilated intrahepatic ducts especially in infants with cholestatic jaundice often preclude using the techniques of percutaneous transhcpatic cholangiography or endoscopic retrograde cholangiopancreatography. We studied the feasibility of ultrasound‐guided percutaneous Cholecystocholangiography (US‐guided PCC) in differentiating extrahepatie from intrahepatic causes of cholestatic jaundice in four infants. Clinical, laboratory, radiographic, and histologic criteria had not conclusively excluded extrahepatie obstruction prior to the use of this technique. Four infants, between 4 and 10 weeks of age. were studied without complications. In one patient, biliary atresia was diagnosed at 4 weeks of age; in another, aspirated bile was cultured leading to a specific diagnosis of bacterial cholangitis; and, in two others, intrahepatic cholestasis was confirmed by the demonstrated patency of the extrahepatie biliary tree. In infants and young children in whom a gallbladder lumen can be seen, US‐guided PCC offers a potential rapid, nonoperative means of differentiating intrahepatic and extrahepatie causes of cholestatic jaundice, defining the anatomy of the extrahepatie biliary tree, and directly sampling gallbladder bile.

Abdominal sonography after hepatic transplantation: results in 36 patients.

Hepatic transplantation was performed in 46 patients over a 2-year period at the University of Minnesota. Thirty-six of these patients subsequently underwent 166 sonographic examinations of the upper abdomen. Forty-three examinations were performed within 2 weeks of transplantation, 47 between 2 and 8 weeks after transplantation, and 76 more than 8 weeks after transplantation. The sonograms were reviewed retrospectively and correlated with the available clinical and histopathologic data. Diffuse, nonspecific parenchymal abnormalities were seen in 27 patients. Focal regions of parenchymal abnormality seen in four patients were associated with abscess and infarction. Moderate to severe biliary dilatation was seen in seven patients with biliary obstruction diagnosed by percutaneous or T-tube cholangiography. Obstruction was seen most commonly in children who had undergone cholecystojejunostomy biliary reconstruction, and it required radiologic or surgical intervention. Routine sonographic assessment of the upper abdominal vasculature showed thrombosis of the portal vein in two cases, thrombosis of the inferior vena cava in one case, thrombosis of the donor aorta in three cases. Focal intraabdominal fluid collections were identified in 14 patients and represented hematomas in all but one. Free peritoneal fluid was detected in 19 patients. Sonography was used to guide percutaneous aspiration of abdominal fluid and to guide fine-needle puncture for percutaneous transhepatic cholangiography. Upper abdominal sonography provides a noninvasive means of evaluating and confirming a wide spectrum of complications that can follow hepatic transplantation. Because clinical and laboratory findings often are nonspecific in these patients, sonographic detection of focal parenchymal abnormalities, biliary dilatation, and vascular compromise is especially valuable.

Common bile duct obstruction: assessment by transcholecystic cholangiography.

Percutaneous transcholecystic cholangiography was performed in 20 patients. Fifteen patients had normal-sized bile ducts on sonograms and computed tomographic scans, and five had partial common bile duct obstruction. Gallbladder pressures were measured in 14 patients. In all cases the intrahepatic and extrahepatic bile ducts were well visualized. Only one clinically significant complication, bile peritonitis, occurred, and it was relieved by inserting a cholecystostomy catheter. Techniques as well as the potential indications for transcholecystic cholangiography are discussed. The authors believe the transcholecystic approach is a useful alternative to transhepatic cholangiography.

Resolution of diffuse granulomatous fibrosis of the liver with antituberculous chemotherapy

A 71-yr-old man with pulmonary tuberculosis developed jaundice, and an ultrasound examination suggested hepatolithiasis. The liver was markedly enlarged and of stony consistency. Two 2.5-cm biopsy specimens of the liver each disclosed diffuse fibrosis with giant cells; practically no normal parenchyma was seen. Ultrasonography and computed tomography disclosed multiple intrahepatic calcifications, and percutaneous cholangiography revealed stenosis of the right hepatic duct. One year after treatment with antituberculous drugs, liver biopsy specimens taken from the same areas of the liver showed nearly normal histology.

Pediatric liver transplantation. Part II. Diagnostic imaging in postoperative management.

The postoperative diagnostic imaging examinations of 44 children who underwent 59 orthotopic liver transplantations were reviewed. The imaging modalities used for the evaluation of suspected complications include plain roentgenography, ultrasonography (US), computed tomography (CT), nuclear scintigraphy, arteriography, percutaneous and operative cholangiography, and endoscopic retrograde cholangiopancreatography. The main postoperative complications included ischemia, thrombosis (hepatic artery and portal vein), infarction, obstruction or leakage of the biliary anastomosis, hepatic and perihepatic infection, and allograft rejection. US, the most frequently used abdominal imaging modality, was best suited for detection of biliary duct dilatation, fluid collections in or around the transplanted liver, and hepatic arterial, inferior vena caval, and portal vein thrombosis. CT was especially helpful in corroborating findings of infection and in locating abscesses. Technetium 99m sulfur colloid (early- and late-phase imaging) provided a sensitive, although nonspecific, means of assessing allograft vascularization and morphology. Angiography showed vascularity most clearly, and cholangiography was the most useful in the assessment of bile duct patency. A diagnostic imaging algorithm is proposed for evaluation of suspected complications.