Cholangiography in the jaundiced patient

Abstract

The differentiation between intrahepatic or 'medical' and extrahepatic or 'surgical' jaundice remains problematical in many patients. A diagnosis based only on the history, physical examination, laboratory tests, and noninvasive radiological studies may well be in error. Traditionally, an exploratory laparotomy was performed in patients whose condition showed no spontaneous resolution during a protracted period of observation. This meant considerable delay before the relief of surgical obstruction in some, whereas others with 'medical' jaundice would be subjected to the increased morbidity and mortality of laparotomy. A number of techniques have been developed which permit direct cholangiography when the intravenous technique is inadequate. All procedures have their pros and cons and each institution must select those which they regard as most suitable in view of the facilities and resources available, as well as the experience of the cholangiographer. Whichever technique or combination of techniques is chosen, the situation should be virtually eliminated whereby either 'surgical' jaundice is prolonged because of a lack of diagnosis, or where a patient with intrahepatic cholestasis is subjected to an unnecessary laparotomy. It seems reasonable to employ a minimum of percutaneous transhepatic cholangiography, and, ideally, this in combination with ERCP for preoperative cholangiography in patients with cholestatic jaundice. Few cases will defy both techniques. The morbidity is well known and if properly anticipated can be reduced to a minimum by judicious use of antibacterial agents and early surgical intervention when appropriate. Grey scale ultrasonography by indicating the diameter of the bile ducts enables one to select percutaneous transhepatic cholangiography for dilated ducts and ERCP for nondilated ducts with an almost 100% success rate for the former and only slightly less for the latter in experienced hands.