Cli#.Radiol. (1979) 30, 507-512
combined Fine Needle Percutaneous Transhepatic Cholangiography and Hypotonic Duodenography in Obstructive Jaundice N. C. GOURTSOYIANNIS and D. J. NOLAN*
Department o f Radiology, The Radcliffe Infirmary, Oxford The information obtained at percutaneous transhepatic cholangiography in patients with obstructive jaundice is not always conclusive about the nature of the obstructing lesion. Hypotonic duodenography performed ~mediately after transhepatic cholangiography may assist in such cases by demonstrating the presence or absence of duodenal involvement. This ensures that the appropriate surgical procedure can be planned before operation. Our experience using the combined techniques in nine patients is reported.
The introduction of the fine Chiba needle has led to a more widespread use of percutaneous transhepatic ch01angiography. The ability of the fine needle technique to outline the bile ducts successfully makes it an extremely valuable examination in the diagnosis of cholestasis. Percutaneous transhepatic cholangiography prevents unnecessary exploration of the jaundiced patient with primary liver parenchymal disease and is a most useful potential source of practical information if laparotomy is necessary in biliary tract obstruction (Kittredge and Baer, 1975). In patients with extrahepatic biliary dbstruction, evaluation of the level of the block is important, because it gives a clue to the underlying lesion and it helps the surgeon decide the best way to proceed. The information given by the percutaneous transhepatic cholangiogram is not always conclusive about the nature o f the obstructive lesion. In our experience hypotonic duodenography carried out immediately after percutaneous transhepatic cholangiography is very important in establishing the correct diagnosis in many cases. The barium study of the duodenal loop is helpful in identifying local pathology in the duodenal wall and the ampulla of Vater. We report on nine jaundiced patients who were examined by hypotonic du0denography immediately following percutaneous transhepatic cholangiography.
TECHNIQUE Percutaneous transhepatic cholangiography is performed using the fine Chiba needle in the usual way (Okuda et al., 1974; Redeker et al., 1975; Ferrucci *Reprints from Dr D. J. Nolan, Department of Radiology, The Radcliffe Infirmary, Oxford OX2 6HE.
et al.,
1976; Pereiras et al., 1976; Nolan, 1977; Ariyama et al., 1978; Fraser et al., 1978). When the point o f obstruction is outlined films are taken. If the cause of the obstruction is obvious at this stage, for example, calculi, the examination is terminated. On the other hand, if there is complete obstruction of the common bile duct, the fine needle is withdrawn and hypotonic duodenography is immediately performed. The hypotonic duodenogram is carried out in a similar manner to that described by Jacquemet and his colleagues (1965) and Eaton and Ferrucci (1973). However, we use a 12 French radiopaque catheter which is a modification of the Bilbao Dotter tube (Bilbao et al., 1968) and is suitable for rapid duodenal intubation (Nolan, 1979). Hypotonia is induced with 0 . 2 - 0 . 2 5 m g o f glucagon (Miller et al., 1978). CASE REPORTS Case 1. Mrs F.W., aged 80, presented with a short history of colicky abdominal pain followed by itching, diarrhoea, jaundice and weight loss. On examination the liver was enlarged. The total serum bilirubin varied around 121~mol/ litre. Ultrasound was performed and dilated intrahepatic bile ducts were seen together with an irregular low echo area in the region of the pancreas. Percutaneous transhepatic cholangiography was performed and showed dilated intrahepatic bile ducts and complete occlusion of the distal common hepatic duct with a 'rat-tail' configuration (Fig. la). A hypotonic duodenogram, performed immediately after percutaneous transhepatic cholangiography, showed a mass effect and a double contour in the descending part of the duodenum (Fig. lb). A preoperative diagnosis of an advanced carcinoma of the head of the pancreas was made. At surgery the findings were confirmed and choledocho-duodenostomy was performed. Case 2. Mr W.M, aged 64, had a two-month history of abdominal pain, poor appetite, weight loss and jaundice. His
508
CLINICAL RADIOLOGY
(a)
Fig. 1 - Case 1. Advanced carcinoma o f the head o f the pancreas. (a) Dilated bile ducts are outlined with contrast m e d i u m . There is complete occlusion of the distal part of t h e c o m m o n hepatic duct where there is a 'rat-tail' configuration. (b) A mass effect and double contour of the medical border in the descending part o f the d u o d e n u m are seen. Contrast m e d i u m can be seen in the occluded c o m m o n hepatic duct.
(b) total serum bilirubin was around 259 #mol/litre. Ultrasound examination of t h e upper a b d o m e n showed slightly dilated intrahepatic ducts, a dilated c o m m o n bile duct and sludge in the gallbladder. There was no evidence of gallstones or o f a lesion in the region of the pancreas. Percutaneous transhepatic cholangiography confirmed a dilated intrahepatic biliary tree and c o m m o n hepatic duct, a normal cystic d u c t and complete obstruction in the distal third o f the c o m m o n bile duct. H y p o t o n i c d u o d e n o g r a p h y followed and revealed an abnormal descending part o f the d u o d e n u m suggesting carcinoma o f the head of the pancreas. At surgery this diagnosis was confirmed and cholecysto-jejunostomy performed. Case 3. Mrs S.R., aged 70, w h o had had a pervious cholec y s t e c t o m y was admitted with a o n e - m o n t h history of n a u sea, vomiting, severe itching, dark urine, pale stools and recent jaundice. Her total serum bilirubin level was over 500 ~mol/litre. Ultrasound revealed dilated intrahepatic and c o m m o n bile ducts, b u t no evidence of gallstones_ Percutaneous transhepatic cholangiography confirmed the presence of a dilated biliary tree and showed a rather horizontally positioned c o m m o n bile duct with complete obstruction in its midpart. A h y p o t o n i c duodenogram was immediately performed. In this case it was impossible to keep t h e tip o f the catheter in the d u o d e n u m a n d as a result the d u o d e n u m could n o t be distended. As the duodenal loop appeared normal a diagnosis of a carcinoma of t h e c o m m o n bile d u c t was made. However at surgery a carcinoma of the head of t h e pancreas was f o u n d and choledocho--duodenostomy performed.
Case 4. Mr R.B., aged 66, presented with a one-week history o f painless jaundice. His total serum bilirubin was around 210/~mol/litre. Ultrasound showed a normal liver and no evidence of gallstones. A percutaneous transhepatic cholangiogram showed a normal billary tree and a welldefined gallbladder, b u t the c o m m o n bile duct was considerably narrowed and irregular in its distal third (Fig. 2a). The hypotonic duodenogram revealed a normal duodenum (Fig. 2b). A preoperative diagnosis of a carcinoma involving t h e distal c o m m o n bile duct was confirmed at surgery and an anastomosis o f the gallbladder to the proximal small intestine was performed. Case 5. Mr S.W., aged 85, was admitted with a three-week history o f deep jaundice, a dull ache in the epigastrium and weight loss. His total serum bilirubin was around 400 #tool/ litre. Ultrasound o f the upper a b d o m e n revealed a dilated c o m m o n bile duct, slight dilatation of the intrahepatic ducts and a transonic area in the region of the pancreas. Percutaneous transhepatic cholangiography showed dilated intrahepatic bile ducts, and a markedly dilated c o m m o n bile duct with complete occlusion in its distal part. A hypotonic duodenogram showed spiculation and distortion o f the folds of the inner border of the descending, transverse and ascending parts and also compression of the transverse part of the duod e n u m . At surgery an inoperable carcinoma of the head and b o d y of the pancreas was f o u n d and palliative decompression t h r o u g h the gallbladder was performed. Case 6. Mr H.T., aged 55, presented with an 18-month history o f epigastric, right hypochondrial and right subscapular pain, followed by a five-day history of deep jaun-
COMBINED
FINE NEEDLE PERCUTANEOUS
TRANSHEPATIC
CHOLANGIOGRAPHY
509
(b)
Fig. 2 - Case 4. Carcinoma of the c o m m o n bile duct. (a) Marked narrowing and irregularity of t h e distal c o m m o n bile duct is s h o w n at percutaneous transhepatic cholangiography. The remainder of t h e biliary tract is o f normal calibre. ( b ) Normal h y p o t o n i c duodenogram.
(a) dice. His total serum bilirubin was around 245 vmol/litre. A pereutaneous transhepatic cholangiogram revealed slightly dilated intrahepatic bile ducts and a dilated c o m m o n bile duet with complete obstruction in its distal third (Fig. 3a). A hypotonic d u o d e n o g r a m showed a grossly irregular inner border of t h e descending d u o d e n u m (Fig. 3b). The preoperative diagnosis o f carcinoma of t h e head of t h e pancreas involving the distal c o m m o n bile duct was proved at surgery and a cholecysto-enterostomy was performed. Case 7. Mrs F.S., aged 78, with m a t u r i t y onset diabetes and a one-week history of severe itching, dark urine and jaundice was examined on admission and was f o u n d to have smooth heptomegaly. Biochemistry confirmed an obstructive type jaundice. A percutaneous transhepatlc cholangiogram revealed two segments of narrowing, one 2 cm in length, involving t h e c o m m o n hepatic duct and another 5 cm in length with irregular margins, involving the distal c o m m o n bile duct. In the h y p o t o n i c duodenogram which followed the duodenal loop appeared normal. On this basis a preoperative diagnosis of carcinoma o f the extrahepatic bile ducts was made. At operation a carcinoma of t h e extrahepatic bile ducts, mainly at the level of the porta hepatis, was found involving the left, right, c o m m o n hepatic and common bile ducts. Palliative decompression and drainage through a T-tube were carried out. Case 8. Mr G.R., aged 67, with a two-week history of painless jaundice had a total serum bilirubin o f around 236~mol/litre. Oesophago-gastro-duodenoscopy failed to reveal the cause of jaundice. A percutaneous transhepatic
cholangiogram combined with a h y p o t o n i c d u o d e n o g r a m showed a rounded filling defect with a s m o o t h outline in the distal end of a completely occluded c o m m o n bile duct and a mass indenting the d u o d e n u m at the site of the papilla o f Vater (Fig. 4a, b). The diagnosis o f a carcinoma of the head o f the pancreas was proved at surgery a n d a Whipple's operation was performed. Case 9. Mrs A.E., aged 72 presented with a six-week history of indigestion, nausea and painless jaundice. Her total serum bilirubin was around 580~mol/litre. An ultrasound examination of the liver showed dilated intrahepatic bile ducts and a dilated gallbladder with a gallstone in it. There was a large transonic structure that appeared to communicate with the gallbladder. A percutaneous transhepatic cholangiogram confirmed a dilated biliary tree with two gallstones in t h e gallbladder. There was marked dilatation o f the c o m m o n bile duct which was completely obstructed in its distal third and this accounted for t h e transonic structure. A h y p o t o n i c duodenogram at t h e end of the percutaneous transhepatic cholangiography showed an abnormal inner margin of the descending part o f the d u o d e n u m . The preoperative diagnosis o f carcinoma of the head o f the pancreas and cholelithiasis was confirmed at surgery. A cholecystect o m y and choledocho-jejunostomy were performed. DISCUSSION Percutaneous transhepatic cholangiography using t h e f i n e C h i b a n e e d l e is a u s e f u l a n d r e l i a b l e m e t h o d
510
CLINICAL RADIOLOGY
(a)
(b) Fig. 3 -- Case 6. Carcinoma o f the head o f the pancreas. (a) A percutaneous transhepatic eholangiogram shows a tight stricture and complete obstruction of t h e distal c o m m o n bile duct. Moderate dilatation o f the bile ducts is also shown.
(b) Marked irregularity and distortion o f the inner margin of the descending, transverse and ascending parts o f the duod e n u m is seen on t h e h y p o t o n i c duodenogram. The occluded c o m m o n bile duct is also seen.
in the diagnosis of obstructive jaundice. Important factors that must be adhered to during the procedure have been pointed out by Ferrucci and Wittenberg (1977) and include the use of a lateral approach, the injection-withdrawal manoeuvre and the avoidance of undue duct distension. Having confirmed a diagnosis of obstructive jaundice at fine needle cholangiography it may be difficult in some cases to locate the site of obstruction and its aetiology. The site of the obstruction can often be located following withdrawal of the needle if the patient is turned and the head of the fluoroscopic table is tilted upwards. However, in some cases with complete extrahepatic obstruction there may be no anatomical reference point for the surgeon to localise the lesion at laparotomy, especially if the obstruction is above the cystic duct. In addition the appearance of the totally occluded distal end of the common bile duct may not be characteristic of any particular
lesion; it is even possible for gallstones in the common bile duct to present as irregular filling defects suggestive of tumours or strictures. In order to obtain the maximum amount of information about lesions of the head of the pancreas and the papilla of Vater which cause obstructive jaundice, Raia (1966) decided to combine sheathed needle transhepatic cholangiography with duodenography. He performed gas-distension double-contrast duodenography using duodenal intubation (Raia and Kreel, 1966) as soon as percutaneous transhepatic cholangiography was finished. In 1968, Baum and Howe performed a combination of sheathed needle transhepatic cholangiography and hypotonic duodenography on four patients with obstructive jaundice due to carcinoma of the head of the pancreas. Okuda and Masahiro (1976) and Jaques and Bream (1978) found that visualisation of the anatomy of the porta hepatis and lower common bile duct was
COMBINED FINE NEEDLE PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY
511
(a) Fig. 4 - Case 8. Carcinoma of the head of the pancreas. (a) Dilatation and complete obstruction of the distal common bile duct by a smooth rounded fiUing defect. (b). There is a mass indenting the duodenum at the site of the papilla of Vaten The obstructed common bile duct is separated from the duodenum by the mass. improved by performing barium duodenography at the end of fine needle percutaneous transhepatic cholangiography. Hypotonic duodenography using a duodenal tube performed immediately following fine needle transhepatic cholangiography enabled a correct preoperative diagnosis of carcinoma of the head o f the pancreas to be made in six o f our patients. The duodenal loop was well distended and appeared normal in two other patients and diagnosis of carcinoma o f the bile ducts was confirmed at operation. We agree with Eaton and Ferrueci (1978) that consistently better results can be achieved with the tube m e t h o d of hypotonic duodenography than with the tubeless method or the simple gastrointestinal series. Duodenography was unsatisfactory and the diagnosis incorrect in the one patient in our series where it proved impossible to maintain the tube in the duodenum during the procedure. CONCLUSION Our experience with combined find needle percutaneous transhepatic cholangiography and h y p o t o n i c
duodenography shows that it is possible to localise precisely the site of biliary obstruction in relation to the duodenal loop and at the same time to get a clue to the nature o f the underlying lesion. In addition it often shows pathology involving the duodenal loop. The combined techniques help to define the limits of the lesion and so facilitate the planning of the appropriate operative procedure thus saving time and unnecessary dissection at operation.
REFERENCES
Ariyama, J., Shirakabe, M., Ohashi, K. & Roberts, G. M. (1978). Experience with percutaneous transhepatic cholangiography using the Japanese needle. Gastrointestinal Radiology, 2,359-365. Baum, M. & Howe, C. T. (1968). Hypotonic duodenography in the diagnosis of carcinoma of the pancreas and its further use when combined with percutaneous cholangiography and pancreatic scintiscanning. American Journal of Surgery, 115,519 525, Bilbao, M. K., Rosch, J., Feische, L. H. & Dotter, C. T. (1968). Hypotonic duodenography in the diagnosis of pancreatic disease. Seminars in Roentgenology, 3 , 2 8 0 287.
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CLINICAL R A D I O L O G Y
Eaton, S. B. & Ferrucci, J. T. (1973). The Radiology of the Pancreas and Duodenum, pp. 95-124. Saunders, Philadelphia_ Eaton, S. B. & Ferrucci, J. T. (1978). Commentary. Gastrointestinal Radiology, 13,233 -234. Ferrucci, J. T., Wittenberg, J., Sarno, R. A. & Dreyfuss, J. R. (1976). Fine needle transhepatie cholangiography: a new approach to obstructive jaundice. American Journal o f Roentgenology, 127, 403-407. Ferrueci, J. T. & Wittenberg, J. (1977). Refinements in Chiba needle transhepatic cholangiography. American Journal o f Roentgenology, 129, 11-16. Fraser, G_ M., Cruikshank, J. G., Sumerling, M. D. & Buist, T. A. S. (1978). Percutaneous transhepatic cholangiography with the Chiba needle. Clinical Radiology, 29, 101 112. Jacquemet, P., Liotta, D. & Mallet-Guy, P. (1965). The Early Radiologieal Diagnosis of Disease of the Pancreas and Ampulla of Vater: Elective Exploration of the Ampulla of Vater and the Head of the Pancreas by Hypotonic Duodenography. Charles C. Thomas, Springfield, I11. Jaques, P. F. & Bream, C. A. (1978). Barium duodenography as an adjunct to percutaneous transhepatic cholangiography. American Journal of Roentgenology, 130, 693 -696. Kittredge, R. & Baer, J. (1975). Percutaneous transhepatic eholangiography. Problems in interpretation. Radiology, 125, 35-46. Miller, R. E., Chernish, S. M., BruneUe, R. L. & Rosenak, B. D. (1978). Double-blind radiographic study of dose
response to intravenous glucagon for hypotonic dUoden° graphy. Radiology, 127, 55 -59. Nolan, D. J. (1977). Radiological aspec~ of bile duct surgery In Topics in Gastroenterology - 5, lruetove ~. C & t, ' " J-ee+ E. Blackwe 11 Scientific Publications, Oxford. ' Nolan, D. J. (1979). Rapid duodenal and jejunal intubation Clinical Radiology, 30, 183 -185. Okuda, K , Tanikawa, K , Emura, T., Karatomi, S. Jinnouc~. ' S., Urabe, K., Sumikoshi, T., Kanda, Y., Fukuyarna y/11~ Musha, H., Mori, H., Shimokawa, Y., Yakushiji, ~. Matsuura, Y. (1974). Non-surgical percutaneous trans. hepatic eholangiography - diagnostic significance in medical problems of the liver. American Journal of Digestive Diseases, 19, 21 - 36. Okuda, K. & Masahiro, I. (1976). Radiological Aspects of the Liver and Biliary Tract. Year Book Medical Publishers Chicago. Pereiras, R., White, P., Dusol, M., Jr, Irving, G., Hutson, 13., Lieberman, B. & Schiff, E. (1976). Percutaneous trans. hepatic cholangiography utilising the Chiba University needle. Radiology, 121,219-224. Raia, S. (1966). Percutaneous cholangiography and simultaneous duodenography. Surgery, 60, 1125 1128. Raia, S. & Kreel, L. (1966). Gas-distension, double-contrast duodenography using the Scott-Harden gastroduodenal tube. Gut, 7, 426. Redeker, A. G., Karvountzis, G. G., Richman, R. H. & Horisawa, M. (1975). Percutaneous transhepatic ehohn. giography: an improved technique. Journal of the American MedicalAssociation, 231,386- 387.
combined Fine Needle Percutaneous Transhepatic Cholangiography and Hypotonic Duodenography in Obstructive Jaundice N. C. GOURTSOYIANNIS and D. J. NOLAN*
Department o f Radiology, The Radcliffe Infirmary, Oxford The information obtained at percutaneous transhepatic cholangiography in patients with obstructive jaundice is not always conclusive about the nature of the obstructing lesion. Hypotonic duodenography performed ~mediately after transhepatic cholangiography may assist in such cases by demonstrating the presence or absence of duodenal involvement. This ensures that the appropriate surgical procedure can be planned before operation. Our experience using the combined techniques in nine patients is reported.
The introduction of the fine Chiba needle has led to a more widespread use of percutaneous transhepatic ch01angiography. The ability of the fine needle technique to outline the bile ducts successfully makes it an extremely valuable examination in the diagnosis of cholestasis. Percutaneous transhepatic cholangiography prevents unnecessary exploration of the jaundiced patient with primary liver parenchymal disease and is a most useful potential source of practical information if laparotomy is necessary in biliary tract obstruction (Kittredge and Baer, 1975). In patients with extrahepatic biliary dbstruction, evaluation of the level of the block is important, because it gives a clue to the underlying lesion and it helps the surgeon decide the best way to proceed. The information given by the percutaneous transhepatic cholangiogram is not always conclusive about the nature o f the obstructive lesion. In our experience hypotonic duodenography carried out immediately after percutaneous transhepatic cholangiography is very important in establishing the correct diagnosis in many cases. The barium study of the duodenal loop is helpful in identifying local pathology in the duodenal wall and the ampulla of Vater. We report on nine jaundiced patients who were examined by hypotonic du0denography immediately following percutaneous transhepatic cholangiography.
TECHNIQUE Percutaneous transhepatic cholangiography is performed using the fine Chiba needle in the usual way (Okuda et al., 1974; Redeker et al., 1975; Ferrucci *Reprints from Dr D. J. Nolan, Department of Radiology, The Radcliffe Infirmary, Oxford OX2 6HE.
et al.,
1976; Pereiras et al., 1976; Nolan, 1977; Ariyama et al., 1978; Fraser et al., 1978). When the point o f obstruction is outlined films are taken. If the cause of the obstruction is obvious at this stage, for example, calculi, the examination is terminated. On the other hand, if there is complete obstruction of the common bile duct, the fine needle is withdrawn and hypotonic duodenography is immediately performed. The hypotonic duodenogram is carried out in a similar manner to that described by Jacquemet and his colleagues (1965) and Eaton and Ferrucci (1973). However, we use a 12 French radiopaque catheter which is a modification of the Bilbao Dotter tube (Bilbao et al., 1968) and is suitable for rapid duodenal intubation (Nolan, 1979). Hypotonia is induced with 0 . 2 - 0 . 2 5 m g o f glucagon (Miller et al., 1978). CASE REPORTS Case 1. Mrs F.W., aged 80, presented with a short history of colicky abdominal pain followed by itching, diarrhoea, jaundice and weight loss. On examination the liver was enlarged. The total serum bilirubin varied around 121~mol/ litre. Ultrasound was performed and dilated intrahepatic bile ducts were seen together with an irregular low echo area in the region of the pancreas. Percutaneous transhepatic cholangiography was performed and showed dilated intrahepatic bile ducts and complete occlusion of the distal common hepatic duct with a 'rat-tail' configuration (Fig. la). A hypotonic duodenogram, performed immediately after percutaneous transhepatic cholangiography, showed a mass effect and a double contour in the descending part of the duodenum (Fig. lb). A preoperative diagnosis of an advanced carcinoma of the head of the pancreas was made. At surgery the findings were confirmed and choledocho-duodenostomy was performed. Case 2. Mr W.M, aged 64, had a two-month history of abdominal pain, poor appetite, weight loss and jaundice. His
508
CLINICAL RADIOLOGY
(a)
Fig. 1 - Case 1. Advanced carcinoma o f the head o f the pancreas. (a) Dilated bile ducts are outlined with contrast m e d i u m . There is complete occlusion of the distal part of t h e c o m m o n hepatic duct where there is a 'rat-tail' configuration. (b) A mass effect and double contour of the medical border in the descending part o f the d u o d e n u m are seen. Contrast m e d i u m can be seen in the occluded c o m m o n hepatic duct.
(b) total serum bilirubin was around 259 #mol/litre. Ultrasound examination of t h e upper a b d o m e n showed slightly dilated intrahepatic ducts, a dilated c o m m o n bile duct and sludge in the gallbladder. There was no evidence of gallstones or o f a lesion in the region of the pancreas. Percutaneous transhepatic cholangiography confirmed a dilated intrahepatic biliary tree and c o m m o n hepatic duct, a normal cystic d u c t and complete obstruction in the distal third o f the c o m m o n bile duct. H y p o t o n i c d u o d e n o g r a p h y followed and revealed an abnormal descending part o f the d u o d e n u m suggesting carcinoma o f the head of the pancreas. At surgery this diagnosis was confirmed and cholecysto-jejunostomy performed. Case 3. Mrs S.R., aged 70, w h o had had a pervious cholec y s t e c t o m y was admitted with a o n e - m o n t h history of n a u sea, vomiting, severe itching, dark urine, pale stools and recent jaundice. Her total serum bilirubin level was over 500 ~mol/litre. Ultrasound revealed dilated intrahepatic and c o m m o n bile ducts, b u t no evidence of gallstones_ Percutaneous transhepatic cholangiography confirmed the presence of a dilated biliary tree and showed a rather horizontally positioned c o m m o n bile duct with complete obstruction in its midpart. A h y p o t o n i c duodenogram was immediately performed. In this case it was impossible to keep t h e tip o f the catheter in the d u o d e n u m a n d as a result the d u o d e n u m could n o t be distended. As the duodenal loop appeared normal a diagnosis of a carcinoma of t h e c o m m o n bile d u c t was made. However at surgery a carcinoma of the head of t h e pancreas was f o u n d and choledocho--duodenostomy performed.
Case 4. Mr R.B., aged 66, presented with a one-week history o f painless jaundice. His total serum bilirubin was around 210/~mol/litre. Ultrasound showed a normal liver and no evidence of gallstones. A percutaneous transhepatic cholangiogram showed a normal billary tree and a welldefined gallbladder, b u t the c o m m o n bile duct was considerably narrowed and irregular in its distal third (Fig. 2a). The hypotonic duodenogram revealed a normal duodenum (Fig. 2b). A preoperative diagnosis of a carcinoma involving t h e distal c o m m o n bile duct was confirmed at surgery and an anastomosis o f the gallbladder to the proximal small intestine was performed. Case 5. Mr S.W., aged 85, was admitted with a three-week history o f deep jaundice, a dull ache in the epigastrium and weight loss. His total serum bilirubin was around 400 #tool/ litre. Ultrasound o f the upper a b d o m e n revealed a dilated c o m m o n bile duct, slight dilatation of the intrahepatic ducts and a transonic area in the region of the pancreas. Percutaneous transhepatic cholangiography showed dilated intrahepatic bile ducts, and a markedly dilated c o m m o n bile duct with complete occlusion in its distal part. A hypotonic duodenogram showed spiculation and distortion o f the folds of the inner border of the descending, transverse and ascending parts and also compression of the transverse part of the duod e n u m . At surgery an inoperable carcinoma of the head and b o d y of the pancreas was f o u n d and palliative decompression t h r o u g h the gallbladder was performed. Case 6. Mr H.T., aged 55, presented with an 18-month history o f epigastric, right hypochondrial and right subscapular pain, followed by a five-day history of deep jaun-
COMBINED
FINE NEEDLE PERCUTANEOUS
TRANSHEPATIC
CHOLANGIOGRAPHY
509
(b)
Fig. 2 - Case 4. Carcinoma of the c o m m o n bile duct. (a) Marked narrowing and irregularity of t h e distal c o m m o n bile duct is s h o w n at percutaneous transhepatic cholangiography. The remainder of t h e biliary tract is o f normal calibre. ( b ) Normal h y p o t o n i c duodenogram.
(a) dice. His total serum bilirubin was around 245 vmol/litre. A pereutaneous transhepatic cholangiogram revealed slightly dilated intrahepatic bile ducts and a dilated c o m m o n bile duet with complete obstruction in its distal third (Fig. 3a). A hypotonic d u o d e n o g r a m showed a grossly irregular inner border of t h e descending d u o d e n u m (Fig. 3b). The preoperative diagnosis o f carcinoma of t h e head of t h e pancreas involving the distal c o m m o n bile duct was proved at surgery and a cholecysto-enterostomy was performed. Case 7. Mrs F.S., aged 78, with m a t u r i t y onset diabetes and a one-week history of severe itching, dark urine and jaundice was examined on admission and was f o u n d to have smooth heptomegaly. Biochemistry confirmed an obstructive type jaundice. A percutaneous transhepatlc cholangiogram revealed two segments of narrowing, one 2 cm in length, involving t h e c o m m o n hepatic duct and another 5 cm in length with irregular margins, involving the distal c o m m o n bile duct. In the h y p o t o n i c duodenogram which followed the duodenal loop appeared normal. On this basis a preoperative diagnosis of carcinoma o f the extrahepatic bile ducts was made. At operation a carcinoma of t h e extrahepatic bile ducts, mainly at the level of the porta hepatis, was found involving the left, right, c o m m o n hepatic and common bile ducts. Palliative decompression and drainage through a T-tube were carried out. Case 8. Mr G.R., aged 67, with a two-week history of painless jaundice had a total serum bilirubin o f around 236~mol/litre. Oesophago-gastro-duodenoscopy failed to reveal the cause of jaundice. A percutaneous transhepatic
cholangiogram combined with a h y p o t o n i c d u o d e n o g r a m showed a rounded filling defect with a s m o o t h outline in the distal end of a completely occluded c o m m o n bile duct and a mass indenting the d u o d e n u m at the site of the papilla o f Vater (Fig. 4a, b). The diagnosis o f a carcinoma of the head o f the pancreas was proved at surgery a n d a Whipple's operation was performed. Case 9. Mrs A.E., aged 72 presented with a six-week history of indigestion, nausea and painless jaundice. Her total serum bilirubin was around 580~mol/litre. An ultrasound examination of the liver showed dilated intrahepatic bile ducts and a dilated gallbladder with a gallstone in it. There was a large transonic structure that appeared to communicate with the gallbladder. A percutaneous transhepatic cholangiogram confirmed a dilated biliary tree with two gallstones in t h e gallbladder. There was marked dilatation o f the c o m m o n bile duct which was completely obstructed in its distal third and this accounted for t h e transonic structure. A h y p o t o n i c duodenogram at t h e end of the percutaneous transhepatic cholangiography showed an abnormal inner margin of the descending part o f the d u o d e n u m . The preoperative diagnosis o f carcinoma of the head o f the pancreas and cholelithiasis was confirmed at surgery. A cholecystect o m y and choledocho-jejunostomy were performed. DISCUSSION Percutaneous transhepatic cholangiography using t h e f i n e C h i b a n e e d l e is a u s e f u l a n d r e l i a b l e m e t h o d
510
CLINICAL RADIOLOGY
(a)
(b) Fig. 3 -- Case 6. Carcinoma o f the head o f the pancreas. (a) A percutaneous transhepatic eholangiogram shows a tight stricture and complete obstruction of t h e distal c o m m o n bile duct. Moderate dilatation o f the bile ducts is also shown.
(b) Marked irregularity and distortion o f the inner margin of the descending, transverse and ascending parts o f the duod e n u m is seen on t h e h y p o t o n i c duodenogram. The occluded c o m m o n bile duct is also seen.
in the diagnosis of obstructive jaundice. Important factors that must be adhered to during the procedure have been pointed out by Ferrucci and Wittenberg (1977) and include the use of a lateral approach, the injection-withdrawal manoeuvre and the avoidance of undue duct distension. Having confirmed a diagnosis of obstructive jaundice at fine needle cholangiography it may be difficult in some cases to locate the site of obstruction and its aetiology. The site of the obstruction can often be located following withdrawal of the needle if the patient is turned and the head of the fluoroscopic table is tilted upwards. However, in some cases with complete extrahepatic obstruction there may be no anatomical reference point for the surgeon to localise the lesion at laparotomy, especially if the obstruction is above the cystic duct. In addition the appearance of the totally occluded distal end of the common bile duct may not be characteristic of any particular
lesion; it is even possible for gallstones in the common bile duct to present as irregular filling defects suggestive of tumours or strictures. In order to obtain the maximum amount of information about lesions of the head of the pancreas and the papilla of Vater which cause obstructive jaundice, Raia (1966) decided to combine sheathed needle transhepatic cholangiography with duodenography. He performed gas-distension double-contrast duodenography using duodenal intubation (Raia and Kreel, 1966) as soon as percutaneous transhepatic cholangiography was finished. In 1968, Baum and Howe performed a combination of sheathed needle transhepatic cholangiography and hypotonic duodenography on four patients with obstructive jaundice due to carcinoma of the head of the pancreas. Okuda and Masahiro (1976) and Jaques and Bream (1978) found that visualisation of the anatomy of the porta hepatis and lower common bile duct was
COMBINED FINE NEEDLE PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY
511
(a) Fig. 4 - Case 8. Carcinoma of the head of the pancreas. (a) Dilatation and complete obstruction of the distal common bile duct by a smooth rounded fiUing defect. (b). There is a mass indenting the duodenum at the site of the papilla of Vaten The obstructed common bile duct is separated from the duodenum by the mass. improved by performing barium duodenography at the end of fine needle percutaneous transhepatic cholangiography. Hypotonic duodenography using a duodenal tube performed immediately following fine needle transhepatic cholangiography enabled a correct preoperative diagnosis of carcinoma of the head o f the pancreas to be made in six o f our patients. The duodenal loop was well distended and appeared normal in two other patients and diagnosis of carcinoma o f the bile ducts was confirmed at operation. We agree with Eaton and Ferrueci (1978) that consistently better results can be achieved with the tube m e t h o d of hypotonic duodenography than with the tubeless method or the simple gastrointestinal series. Duodenography was unsatisfactory and the diagnosis incorrect in the one patient in our series where it proved impossible to maintain the tube in the duodenum during the procedure. CONCLUSION Our experience with combined find needle percutaneous transhepatic cholangiography and h y p o t o n i c
duodenography shows that it is possible to localise precisely the site of biliary obstruction in relation to the duodenal loop and at the same time to get a clue to the nature o f the underlying lesion. In addition it often shows pathology involving the duodenal loop. The combined techniques help to define the limits of the lesion and so facilitate the planning of the appropriate operative procedure thus saving time and unnecessary dissection at operation.
REFERENCES
Ariyama, J., Shirakabe, M., Ohashi, K. & Roberts, G. M. (1978). Experience with percutaneous transhepatic cholangiography using the Japanese needle. Gastrointestinal Radiology, 2,359-365. Baum, M. & Howe, C. T. (1968). Hypotonic duodenography in the diagnosis of carcinoma of the pancreas and its further use when combined with percutaneous cholangiography and pancreatic scintiscanning. American Journal of Surgery, 115,519 525, Bilbao, M. K., Rosch, J., Feische, L. H. & Dotter, C. T. (1968). Hypotonic duodenography in the diagnosis of pancreatic disease. Seminars in Roentgenology, 3 , 2 8 0 287.
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CLINICAL R A D I O L O G Y
Eaton, S. B. & Ferrucci, J. T. (1973). The Radiology of the Pancreas and Duodenum, pp. 95-124. Saunders, Philadelphia_ Eaton, S. B. & Ferrucci, J. T. (1978). Commentary. Gastrointestinal Radiology, 13,233 -234. Ferrucci, J. T., Wittenberg, J., Sarno, R. A. & Dreyfuss, J. R. (1976). Fine needle transhepatie cholangiography: a new approach to obstructive jaundice. American Journal o f Roentgenology, 127, 403-407. Ferrueci, J. T. & Wittenberg, J. (1977). Refinements in Chiba needle transhepatic cholangiography. American Journal o f Roentgenology, 129, 11-16. Fraser, G_ M., Cruikshank, J. G., Sumerling, M. D. & Buist, T. A. S. (1978). Percutaneous transhepatic cholangiography with the Chiba needle. Clinical Radiology, 29, 101 112. Jacquemet, P., Liotta, D. & Mallet-Guy, P. (1965). The Early Radiologieal Diagnosis of Disease of the Pancreas and Ampulla of Vater: Elective Exploration of the Ampulla of Vater and the Head of the Pancreas by Hypotonic Duodenography. Charles C. Thomas, Springfield, I11. Jaques, P. F. & Bream, C. A. (1978). Barium duodenography as an adjunct to percutaneous transhepatic cholangiography. American Journal of Roentgenology, 130, 693 -696. Kittredge, R. & Baer, J. (1975). Percutaneous transhepatic eholangiography. Problems in interpretation. Radiology, 125, 35-46. Miller, R. E., Chernish, S. M., BruneUe, R. L. & Rosenak, B. D. (1978). Double-blind radiographic study of dose
response to intravenous glucagon for hypotonic dUoden° graphy. Radiology, 127, 55 -59. Nolan, D. J. (1977). Radiological aspec~ of bile duct surgery In Topics in Gastroenterology - 5, lruetove ~. C & t, ' " J-ee+ E. Blackwe 11 Scientific Publications, Oxford. ' Nolan, D. J. (1979). Rapid duodenal and jejunal intubation Clinical Radiology, 30, 183 -185. Okuda, K , Tanikawa, K , Emura, T., Karatomi, S. Jinnouc~. ' S., Urabe, K., Sumikoshi, T., Kanda, Y., Fukuyarna y/11~ Musha, H., Mori, H., Shimokawa, Y., Yakushiji, ~. Matsuura, Y. (1974). Non-surgical percutaneous trans. hepatic eholangiography - diagnostic significance in medical problems of the liver. American Journal of Digestive Diseases, 19, 21 - 36. Okuda, K. & Masahiro, I. (1976). Radiological Aspects of the Liver and Biliary Tract. Year Book Medical Publishers Chicago. Pereiras, R., White, P., Dusol, M., Jr, Irving, G., Hutson, 13., Lieberman, B. & Schiff, E. (1976). Percutaneous trans. hepatic cholangiography utilising the Chiba University needle. Radiology, 121,219-224. Raia, S. (1966). Percutaneous cholangiography and simultaneous duodenography. Surgery, 60, 1125 1128. Raia, S. & Kreel, L. (1966). Gas-distension, double-contrast duodenography using the Scott-Harden gastroduodenal tube. Gut, 7, 426. Redeker, A. G., Karvountzis, G. G., Richman, R. H. & Horisawa, M. (1975). Percutaneous transhepatic ehohn. giography: an improved technique. Journal of the American MedicalAssociation, 231,386- 387.
