Percutaneous biliary intervention in patients with primary sclerosing cholangitis

Abstract

Magnetic resonance cholangiography (MRC) and endoscopic retrograde cholangiography (ERC) provide adequate cholangiographic assessment in most patients to diagnose primary sclerosing cholangitis (PSC) and demonstrate dominant strictures. Percutaneous transhepatic cholangiography (PTC) is reserved for cases in which these other less invasive diagnostic modalities are equivocal or not technically possible. There must be no contraindication to more invasive intervention and its possible associated complications. For treatment, percutaneous transhepatic drainage (PTD) may be necessary to control severe symptoms of cholestasis or to treat refractory cholangitis when endoscopic therapy fails. Endoscopic drainage is preferred in most instances due to the lack of an externalized drainage catheter and a lower procedural complication rate. Drainage improves the biochemical pattern and symptoms of PSC patients and decreases the frequency of cholangitic episodes. Results of PTD are thought to mirror endoscopic results, although prior failed endoscopy selects patients with advanced disease, particularly those with liver fibrosis or cirrhosis; diffuse, severe intra- and extrahepatic strictures; or cholangiocarcinoma (CCA). In patients with cancer, drainage may be preoperative or palliative.