Aust. RadioI. (1979),23, 113
A Huge Bile Cyst - An Unusual Complication of Percutaneous Transhepatic Cholangiography (PTC) IVAN VUJIC, M.D. Assistant Professor o f Radiology, Medical University of South Carolina HUBERTC. MEREDITH,M.B.B.S., M.R.A.C.R. Assistant Professor of Radiology, Medical University of South Carolina MARION C. ANDERSON, M.D. Professor and Chairman of Department of Surgery, Medical University of South Carolina
INTRODUCTION Leakage of bile from the liver is a well described complication of PTC. It usually occurs into the peritoneal cavity (Juler, et a[, 1977) (Okuda, et al, 1974) (Lang, 1974) (Zinberg and Berk, 1965) (Ariyama, et al, 1978). Bile collecting in the subcapsular space following the procedure has
FIGURE la. -PTC (Early Film). Lateral insertion of the needle (open arrow). Several of the intrahepatic ducts to the right lobe are slightly dilated. The left intrahepatic ducts have not filled. There hasbeen marked extravasation of contrast material around the CHD. N o filing of the extrahepatic ducts is shown. -
REP IUNTS: Hubert C. Meredith, M.D. Department of Radiology, Medical University of South Carolina, 17 1 Ashley Avenue, Charleston, South Carolina 29403.
Australasian Radiology, VoL XXIII, No. 2, July, I979
been described only once previously (Lawson, 1974). Apatient with obstructivejaundice, thought to be caused by a cholangiocarcinoma, is described below. Following PTC, he developed complete obstruction of the common hepatic duct (CHD) and massive leakage of bile into the subcapsular space.
FIGURE 1b.-PTC (Later fdm). The needle has been withdrawn. The CDH and CBD are now W e d with contrast material and appear to be normal. There is free flow of contrast material into the duodenum. Subcapsular extravasation of contrast material is shown (open arrows). Right intrahepatic bile ducts are shown (arrowheads) but again there is no f f i g of the left ducts. No gallstones are visible and the gallbladder is normal. G - Gallbladder H - Hepatic flexure containing barium.
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FIGURE 2. -Transverse sonographic image (9 cm above the umbilicus with the patient supine) demonstrates a huge sonolucent mass in the right upper quadrant, displacing the liver markedly to the left. Intrahepatic bile ducts are grossly dilated. S - Spine. D - Bile ducts C -- Bile cyst A - Aorta L - Liver
CASE REPORT A 54 year old white male was admitted t o another hospital with a clinical picture of obstructive jaundice of several weeks' duration. Apart from mild jaundice, physical examination was normal but he rapidly became deeply jaundiced. PTC was carried out from the lateral approach with a 20 gauge Teflon-sheathed needle. Details of the procedure were not available but the films (Figures la, b) showed slight dilatation of the right intrahepatic biliary ducts without filling of the left ducts. The extrahepatic ducts were not obstructed or dilated, the gallbladder was normal and gallstones were not shown. There was marked extravasation of contrast material into the tissues surrounding the CHD. At laparotomy, two days later, the surface of the liver was bile stained without intraperitoneal or subcapsular bile leakage. An operative cholangiogram was described as showing free flow of contrast material into the duodenum but despite compression of the common bile duct (CBD), there was no retrograde filling of 114
the intrahepatic ducts. The abdomen was closed after cholecystectomy without drainage of the bile ducts. Pathological examination of the gallbladder showed chronic cholecystitis and a liver biopsy showed changes consistent with chronic biliary obstruction. The immediate post-operative period was uneventful with decreasing jaundice but in the second post operative week, the patient was transferred t o our institution because of increasing jaundice. At the time of admission, he was described as being jaundiced but in no distress. The abdomen was distended and the liver percussible to 14 cm below the right costal margin. In the ensuing three weeks, he began t o experience pain in his right side, jaundice increased slightly, his abdomen became more distended, his ankles became edematous and he developed a small right pleural effusion. An upper gastrointestinal examination showed a huge mass in the right upper abdomen which displaced the stomach anteriorly. ERCP was unsuccessful but ultrasound examination showed Australasian Radiology, VoI. XXIII, No. 2, July, I979
AN UNUSUAL COMPLICATION O F PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY closed. The patient made a satisfactory recovery and was discharged from hospital with the T-tube providing satisfactory bile drainage. DISCUSSION The complications of PTC, including bile leakage, tend t o occur in patients with obstructive biliary disease. The incidence is reported t o be higher in patients in whom the ducts are not drained during or following the procedure and in patients who have undergone previous cholecystectomy. It is also higher if the puncture was unsuccessful or if the extra-hepatic ducts were punctured during the procedure (Lang, 1974) (Lawson, 1974) (Jain et al, 1977) (Gothlin et al, 1973). A lower incidence of complications has been reported with the Chiba needle and with lateral puncture of the liver. (Okuda et al, 1974) (Aryama er al, 1978). Only one previous report of leakage of bile into the subcapsular space of the liver has been described following PTC (Lawson, 1974). The patient did not have obstructive jaundice and a small 35 ml collection of bile was FIGURE 3. -Operative cholangiogram showing complete obstruction at the level of the distal CHD with marked found in the region of the puncture site, four months following the procedure. dilatation of the intrahepatic ducts. In our patient, the clinical picture and the findings at PTC were compatible with partial obstruction of the CHD. Although histological markedly dilated intrahepatic biliary ducts and a confirmation is lacking, an underlying cholangiohuge cystic collection surrounding the right lobe carcinoma is strongly suspected. The patient of the liver (Figure 2). Liver-Spleen scan showed developed complete obstruction of the CHD moderate enlargement of the liver; the dynamic following PTC; the marked extravasation of flow study showing an avascular mass compressing contrast material in the region of the portathe liver laterally and superiorly. At angiography , hepatis during the procedure (Figures la. b) an avascular mass was seen adjacent t o the liver may have been a precipitating factor. Bile leakage and the capsular vessels were displaced away from was not observed at the time of laparotomy and the liver. An inferior venocavogram showed the cholecystectomy two days later and during this cava t o be obstructed and displaced t o the left in time, the puncture wound in the capsule healed. its upper part. Approximately one month after Because the bile ducts were not drained at operaadmission, the patient was reexplored surgically. tion increasing intrahepatic biliary pressure post A large subcapsular bile cyst, adherent t o the operatively caused bile t o leak from the puncture adjacent abdominal wall, was found bulging site in the liver into the subcapsular space. The forwards from the right lobe of the liver. It ex- partial resolution of the patient’s jaundice observed tended over the surfaces of the right lobe to the in the initial post-operative period can probably falciform ligament on the left and posteriorly into be attributed t o this. Jaundice recurred when the retroperitoneum, displacing the right kidney pressure build-up in the subcapsular space prevented forwards. Drainage of the cyst produced 4 litres further bile leakage from the liver. of bile. A puncture wound was found in the liver a t the site of the previous PTC. An operative ABSTRACT cholangiogram showed grossly dilated intrahepatic ducts with complete obstruction of the distal A huge subcapsular bile cyst. which formed CHD (Figure 3). The CBD and pancreas were over a period of six weeks following PTC, is normal. A biopsy of tissues in the porta hepatis described in a 54 year old male with obstructive showed inflammatory changes with no evidence jaundice. To our knowledge. this complication of tumor. A T-tube was placed retrograde through of PTC has been reported only once in the medical the stricture in the CHD and the abdomen was literature. Australasian Radiology, Vol. X X l l l ,
No. 2. July, 1 9 7 9
115
I. VUJIC, H. C. MEREDITH AND M. C. ANDERSON REFERENCES 1. Ariyama, J., Shirakabe, H., Ohashi, K. and Roberts, G. M. (1978): “Experience with percutaneous trans-
henatic cholaneiomauhv using the Jauanese needle.” G&trointest. RGdi&. 2 359. 2. Gothlin, J. and Transberg, K. G. (1973): “Complications of percutaneous transhepatic cholangiography.” Amer. J. RoentgenoL 117 : 426. 3. Jain, S. Long, R. G., Scott, J., Dick, R. and Sherlock, Sheila (1977): “Percutaneous transhepatic cholangiography using the Chiba needle - 80 cases.” Brit. J. Radiol. 50 : 175. 4. J u h (3. L., ConroY, R. M. and Fuefleman, R. w. (1977): “Bile leakage following percutaneous transhepatic cholangiograpy with the Chiba needle.” Arch. Surg. 1 1 2 : 954.
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5. Lang, E. K. (1974): “Percutaneous transhepatic cholangiography.” Radiology, 1 1 2 : 283. 6. Lawson, T. L. (1974): “Chronic subcapsular hepatic bile abscess: A rare complication of percutaneous transhepatic cholangiography.” Amer.. J. Gastroenterol. 61 : 383. I. Okuda, K., Tanikawa, K., Emura, T., Kuratomi, S., Jinnouchi, S., Urabe, K., Sumikoshi, T., Kanda, Y., Fukuyama, Y., Musha, H., Man, H., Shimokawa, Y., Yakushiji, F. and Matsuura, Y. (1974): “Nan-surgical percutaneous transhepatic cholangiography: Diagnostic significance in medical problems of the liver.” Amer. J. Digest. Dis. 19 : 2 1. 8. Zinberg, S. S., Berk, J. E. and Plasencia, H. (1965): “Percutaneous transhepatic cholangiography: Its use and limitations.” Amer. J. Digest. Dis. 10 : 154.
Australasian Radiology, Vol. XXIII, NO. 2, JUIY, I979
A Huge Bile Cyst - An Unusual Complication of Percutaneous Transhepatic Cholangiography (PTC) IVAN VUJIC, M.D. Assistant Professor o f Radiology, Medical University of South Carolina HUBERTC. MEREDITH,M.B.B.S., M.R.A.C.R. Assistant Professor of Radiology, Medical University of South Carolina MARION C. ANDERSON, M.D. Professor and Chairman of Department of Surgery, Medical University of South Carolina
INTRODUCTION Leakage of bile from the liver is a well described complication of PTC. It usually occurs into the peritoneal cavity (Juler, et a[, 1977) (Okuda, et al, 1974) (Lang, 1974) (Zinberg and Berk, 1965) (Ariyama, et al, 1978). Bile collecting in the subcapsular space following the procedure has
FIGURE la. -PTC (Early Film). Lateral insertion of the needle (open arrow). Several of the intrahepatic ducts to the right lobe are slightly dilated. The left intrahepatic ducts have not filled. There hasbeen marked extravasation of contrast material around the CHD. N o filing of the extrahepatic ducts is shown. -
REP IUNTS: Hubert C. Meredith, M.D. Department of Radiology, Medical University of South Carolina, 17 1 Ashley Avenue, Charleston, South Carolina 29403.
Australasian Radiology, VoL XXIII, No. 2, July, I979
been described only once previously (Lawson, 1974). Apatient with obstructivejaundice, thought to be caused by a cholangiocarcinoma, is described below. Following PTC, he developed complete obstruction of the common hepatic duct (CHD) and massive leakage of bile into the subcapsular space.
FIGURE 1b.-PTC (Later fdm). The needle has been withdrawn. The CDH and CBD are now W e d with contrast material and appear to be normal. There is free flow of contrast material into the duodenum. Subcapsular extravasation of contrast material is shown (open arrows). Right intrahepatic bile ducts are shown (arrowheads) but again there is no f f i g of the left ducts. No gallstones are visible and the gallbladder is normal. G - Gallbladder H - Hepatic flexure containing barium.
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FIGURE 2. -Transverse sonographic image (9 cm above the umbilicus with the patient supine) demonstrates a huge sonolucent mass in the right upper quadrant, displacing the liver markedly to the left. Intrahepatic bile ducts are grossly dilated. S - Spine. D - Bile ducts C -- Bile cyst A - Aorta L - Liver
CASE REPORT A 54 year old white male was admitted t o another hospital with a clinical picture of obstructive jaundice of several weeks' duration. Apart from mild jaundice, physical examination was normal but he rapidly became deeply jaundiced. PTC was carried out from the lateral approach with a 20 gauge Teflon-sheathed needle. Details of the procedure were not available but the films (Figures la, b) showed slight dilatation of the right intrahepatic biliary ducts without filling of the left ducts. The extrahepatic ducts were not obstructed or dilated, the gallbladder was normal and gallstones were not shown. There was marked extravasation of contrast material into the tissues surrounding the CHD. At laparotomy, two days later, the surface of the liver was bile stained without intraperitoneal or subcapsular bile leakage. An operative cholangiogram was described as showing free flow of contrast material into the duodenum but despite compression of the common bile duct (CBD), there was no retrograde filling of 114
the intrahepatic ducts. The abdomen was closed after cholecystectomy without drainage of the bile ducts. Pathological examination of the gallbladder showed chronic cholecystitis and a liver biopsy showed changes consistent with chronic biliary obstruction. The immediate post-operative period was uneventful with decreasing jaundice but in the second post operative week, the patient was transferred t o our institution because of increasing jaundice. At the time of admission, he was described as being jaundiced but in no distress. The abdomen was distended and the liver percussible to 14 cm below the right costal margin. In the ensuing three weeks, he began t o experience pain in his right side, jaundice increased slightly, his abdomen became more distended, his ankles became edematous and he developed a small right pleural effusion. An upper gastrointestinal examination showed a huge mass in the right upper abdomen which displaced the stomach anteriorly. ERCP was unsuccessful but ultrasound examination showed Australasian Radiology, VoI. XXIII, No. 2, July, I979
AN UNUSUAL COMPLICATION O F PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY closed. The patient made a satisfactory recovery and was discharged from hospital with the T-tube providing satisfactory bile drainage. DISCUSSION The complications of PTC, including bile leakage, tend t o occur in patients with obstructive biliary disease. The incidence is reported t o be higher in patients in whom the ducts are not drained during or following the procedure and in patients who have undergone previous cholecystectomy. It is also higher if the puncture was unsuccessful or if the extra-hepatic ducts were punctured during the procedure (Lang, 1974) (Lawson, 1974) (Jain et al, 1977) (Gothlin et al, 1973). A lower incidence of complications has been reported with the Chiba needle and with lateral puncture of the liver. (Okuda et al, 1974) (Aryama er al, 1978). Only one previous report of leakage of bile into the subcapsular space of the liver has been described following PTC (Lawson, 1974). The patient did not have obstructive jaundice and a small 35 ml collection of bile was FIGURE 3. -Operative cholangiogram showing complete obstruction at the level of the distal CHD with marked found in the region of the puncture site, four months following the procedure. dilatation of the intrahepatic ducts. In our patient, the clinical picture and the findings at PTC were compatible with partial obstruction of the CHD. Although histological markedly dilated intrahepatic biliary ducts and a confirmation is lacking, an underlying cholangiohuge cystic collection surrounding the right lobe carcinoma is strongly suspected. The patient of the liver (Figure 2). Liver-Spleen scan showed developed complete obstruction of the CHD moderate enlargement of the liver; the dynamic following PTC; the marked extravasation of flow study showing an avascular mass compressing contrast material in the region of the portathe liver laterally and superiorly. At angiography , hepatis during the procedure (Figures la. b) an avascular mass was seen adjacent t o the liver may have been a precipitating factor. Bile leakage and the capsular vessels were displaced away from was not observed at the time of laparotomy and the liver. An inferior venocavogram showed the cholecystectomy two days later and during this cava t o be obstructed and displaced t o the left in time, the puncture wound in the capsule healed. its upper part. Approximately one month after Because the bile ducts were not drained at operaadmission, the patient was reexplored surgically. tion increasing intrahepatic biliary pressure post A large subcapsular bile cyst, adherent t o the operatively caused bile t o leak from the puncture adjacent abdominal wall, was found bulging site in the liver into the subcapsular space. The forwards from the right lobe of the liver. It ex- partial resolution of the patient’s jaundice observed tended over the surfaces of the right lobe to the in the initial post-operative period can probably falciform ligament on the left and posteriorly into be attributed t o this. Jaundice recurred when the retroperitoneum, displacing the right kidney pressure build-up in the subcapsular space prevented forwards. Drainage of the cyst produced 4 litres further bile leakage from the liver. of bile. A puncture wound was found in the liver a t the site of the previous PTC. An operative ABSTRACT cholangiogram showed grossly dilated intrahepatic ducts with complete obstruction of the distal A huge subcapsular bile cyst. which formed CHD (Figure 3). The CBD and pancreas were over a period of six weeks following PTC, is normal. A biopsy of tissues in the porta hepatis described in a 54 year old male with obstructive showed inflammatory changes with no evidence jaundice. To our knowledge. this complication of tumor. A T-tube was placed retrograde through of PTC has been reported only once in the medical the stricture in the CHD and the abdomen was literature. Australasian Radiology, Vol. X X l l l ,
No. 2. July, 1 9 7 9
115
I. VUJIC, H. C. MEREDITH AND M. C. ANDERSON REFERENCES 1. Ariyama, J., Shirakabe, H., Ohashi, K. and Roberts, G. M. (1978): “Experience with percutaneous trans-
henatic cholaneiomauhv using the Jauanese needle.” G&trointest. RGdi&. 2 359. 2. Gothlin, J. and Transberg, K. G. (1973): “Complications of percutaneous transhepatic cholangiography.” Amer. J. RoentgenoL 117 : 426. 3. Jain, S. Long, R. G., Scott, J., Dick, R. and Sherlock, Sheila (1977): “Percutaneous transhepatic cholangiography using the Chiba needle - 80 cases.” Brit. J. Radiol. 50 : 175. 4. J u h (3. L., ConroY, R. M. and Fuefleman, R. w. (1977): “Bile leakage following percutaneous transhepatic cholangiograpy with the Chiba needle.” Arch. Surg. 1 1 2 : 954.
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116
5. Lang, E. K. (1974): “Percutaneous transhepatic cholangiography.” Radiology, 1 1 2 : 283. 6. Lawson, T. L. (1974): “Chronic subcapsular hepatic bile abscess: A rare complication of percutaneous transhepatic cholangiography.” Amer.. J. Gastroenterol. 61 : 383. I. Okuda, K., Tanikawa, K., Emura, T., Kuratomi, S., Jinnouchi, S., Urabe, K., Sumikoshi, T., Kanda, Y., Fukuyama, Y., Musha, H., Man, H., Shimokawa, Y., Yakushiji, F. and Matsuura, Y. (1974): “Nan-surgical percutaneous transhepatic cholangiography: Diagnostic significance in medical problems of the liver.” Amer. J. Digest. Dis. 19 : 2 1. 8. Zinberg, S. S., Berk, J. E. and Plasencia, H. (1965): “Percutaneous transhepatic cholangiography: Its use and limitations.” Amer. J. Digest. Dis. 10 : 154.
Australasian Radiology, Vol. XXIII, NO. 2, JUIY, I979
