Intrahepatic Rupture Secondary to Duct Exploration Demonstrated by Cholangiography 1

Diagnostic Radiology

Stanford M. Goldman, M.D., Arthur Diamond, M.D., and Julian O. Salik, M.D. Seven cases of iatrogenic rupture of the intrahepatic bile ducts were demonstrated on T-tube and/or operative cholangiography. This brings the total of documented case reports to 17. All patients had hepatic duct exploration with either the Fogarty balloon catheter and/or the biliary spoon and/or the biliary forceps and/or Bakes dilators. These extravasations usually occur from the right hepatic duct. The recognition of this entity is important because potentially serious complications may occur. Most of the previous cases of intrahepatic extravasation ascribed to excessive pressures of injection were probably surgically induced. INDEX TERMS: Biliary Ducts, calculi • Biliary Tract, calculi. Catheters and Catheterization, complications. Cholangiography. Cholecystography, complications

Radiology 118:13-17, January 1976



the past three years, 7 cases of intrahepatic parenchymal extravasation of contrast medium

from the hepatic ducts were diagnosed by operative and/or follow-up T-tube cholangiography. In each case,

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Fig. 1. CASE I. A. Normal operative cholangiogram. The patient then underwent common hepatic duct exploration (CHDE) with a Fogarty catheter. 8. T-tube study one week later with extravasation from the right hepatic duct. Note free flow of contrast agent into the duodenum. 1 From the Department of Radiology, Sinai Hospital of Baltimore, Inc. (S. M. G., Assistant Professor of Radiology; A. D., Instructor of Radiology; J. O. S., Associate Professor of Radiology, Johns Hopkins University School of Medicine), Baltimore, Md. Presented at the Sixty-first Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, 111., Nov. 30-Dec 5, 1975. shan

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were noted and a stone was visualized in the CBD at surgery. Subsequently, after a normal operative cholangiogram, the main hepatic and common bile ducts were explored with a Fogarty catheter. A Ttube was inserted and a cholangiogram obtained which now demonstrated intrahepatic extravasation from a peripheral branch of the right intrahepatic duct (Fig. 2). Again, free flow into the duodenum without obstruction was noted. The seven day follow-up T-tube was unchanged. CASE III. M. S., a 30-year-old woman, was admitted with right upper quadrant pain during the last trimester of pregnancy. Two weeks after delivery, an oral cholecystogram demonstrated stones. At surgery, 10 small stones were found in a normal-sized CBD. A biliary scoop was introduced in both dlrectlons, and an operative Ttube cholangiogram obtained. Extravasation of contrast agent from one of the major right hepatic duct tributaries was noted (Fig. 3) and again, contrast material passed readily into the duodenum. The patient made an unremarkable recovery. CASE IV. In H. W., a 45-year-old woman, the gallbladder failed to visualize adequately on oral cholecystography; opacification was poor and dilated ducts with at least one CBD stone were noted. At surgery, multiple gallbladder stones were found as well as two CBD stones lodged in a dilated duct. Following irrigation and use of a Fogarty balloon, the stones were removed, as demonstrated by an operative cholangiogram. Unfortunately, the hepar was not visible on the film. On the seventh postoperative day, a T-tube cholangiogram disclosed two pockets of extravasation from the right hepatic duct and also free flow into the duodenum (Fig. 4). The patient. made a satisfactory recovery.

Fig. 2. CASE II. Operative T-tube cholangiogram after CHDE (Fogarty catheter) shows extravasation from a right hepatic duct. A pre-CHDE was normal.

a different surgeon was involved. Case histories and experimental data are presented to support our belief that these extravasations occurred secondary to blind surgical instrumentation of the common hepatic duct. CASE REPORTS CASE I. M. J., a 69-year-old woman, was admitted with acute recurrent midepigastric pain of several months' duration and an oral cholecystogram demonstrated stones. The Sequential Multiple Analyzer-12 (S.M.A.-12) was not unusual and a cholecystectomy was performed. The operative cholecystogram was unremarkable, with a common bile duct (CBD) of normal width (Figure 1, A). A Fogarty biliary probe (6F) was introduced into the common hepatic duct (CHD), inflated with 1 ml of water, and then withdrawn. Seven days later, a T-tube cholangiogram disclosed a large extraductal collection arising from one of the right intrahepatic ducts. There was no fluoroscopic evidence of obstruction or spasm at the ampulla, with free passage of contrast substance into the duodenum (Fig. 1, B). The patient's recovery was uneventful and a repeat T-tube study was not performed. CASE II. A. R., a 70-year-old man, complained of right upper quadrant pain and jaundice of two days' duration. S.M.A.-12 showed an elevated bilirubin (4.1 mg/100 ml), elevated SGOT (5.5 I.U.) and alkaline phosphatase (250 I.U.). On abdominal films, opaque stones

CASE V. S. M., a 21-year-old, mildly jaundiced woman (bilirubin 2.9 mg/100 ml), had an intravenous cholangiogram which showed a normal CBD and multiple gallbladder stones. After a normal needle cholangiogram, the biliary tree was explored in both directions using the spoon and Fogarty catheter. A T-tube was inserted and the subsequent cholangiogram revealed contrast agent extravasating from a branch of the right hepatic duct (Fig. 5). The patient's recovery was uneventful. CASE VI. L. R., a 66-year-old woman, was admitted with a diagnosis of obstructive jaundice (bilirubin 15 mg/1 00 ml) and ascending cholangitis. Nine days after the institution of Keflin therapy, the patient was afebrile with a bilirubin of 3.8 mg/1 00 rnl. An intravenous cholangiogram demonstrated a CBD stone partially obstructing the passage of the Cholografin into the duodenum. An initial needle cholangiogram showed a 17 X 15mm CBD stone but with free passage of contrast substance into the duodenum and no intrahepatic extravasation. After exploration of the duct in both directions with biliary forceps, an operative T-tube cholangiogram was obtained disclosing free passage of Hypaque into the duodenum, with multiple small areas of extravasation within the liver parenchyma from the right hepatic ducts. The patient recovered uneventfully. A second T-tube cholangiogram obtained on the seventh postoperative day showed no extraluminal contrast material. This is probably explained by the small size of the extravasations initially noted. CASE VII. V. S., a 79-year-old woman with intermlttent abdominal pain, was admitted with a poorly visualized gallbladder containing stones. A needle cholecystogram prior to duct exploration revealed a few small duct stones but no extravasation. A repeat cholangiogram obtained after hepatic duct exploration with Bakes dilators demonstrated a t-ern irregular area of extravasation from the right hepatic duct near the right superior lateral surface of the liver. This extravasation looked similar to the previous cases (particularly CASE II). Seven days later, a T-tube cholangiogram failed to disclose extravasation.

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Fig. 3. CASE III. A. Operative T-tube after CHDE (biliary spoon), showing intrahepatic extravasation. B. One week follow-up without change.

DISCUSSION

The usefulness of the operative cholangiogram and its complications have been adequately described (1-3). According to Whitehouse and Hoskins, the application of excessive pressure at the time of contrast injection will result in retrograde passage of contrast material into the hepatic sinuses (4). However, in our case reports, the etiology of the extravasation is thought to be secondary to iatrogenic damage caused by blind instrumentation of the hepatic ducts by the surgeon. In 1971, Henzel and colleagues reported 2 cases of intrahepatic disruption secondary to the use of the Fogarty catheter (5). Seven other cases have since been reported (6-9). Butsch has also seen this complication but does not mention the number of cases (10). Burhenne presented a case with multiple extravasations secondary to blind intrahepatic exploration (11) but the type of instrument was not mentioned. This report endeavors to present a comparatively large series of intrahepatic ruptures in 3 of which no Fogarty catheter was used. It appears that any intrahepatic duct exploration may lead to perforation and the balloon catheter is not the only causative agent. The latter probably causes damage when excessively inflated intrahepatically by rupturing the duct wall with consequent temporary extravasation. This was confirmed in cadav-

er studies where extravasations could be produced with as little as 0.5 ml of water (Fig. 6). We were also able to pass the Fogarty catheter in at least one autopsy specimen to within 1 or 2 em of the liver surface (Fig. 7) and are convinced that the surgeon is usually unaware of how far peripherally he is actually probing with the catheter, spoon, dilator, or forceps. It is interesting to note that in our series all extravasations occurred from the right intrahepatic duct. This was also true in all the published cases except 3 (9, 11). This finding has not been previously emphasized and can be explained on an anatomic basis since it is much easier for the probing instrument to enter the right hepatic duct. Free flow into the duodenum on the operative films and at fluoroscopy during postoperative cholangiography was demonstrated in all 7 of our patients. Furthermore, our autopsy cases also failed to demonstrate any obstruction before or during the time of intrahepatic extravasation. This leads one to assume that many of the previously described extravasations such as reported by Whitehouse were not due to excessive pressure of injection at all but were surgically induced. The recognition of this complication is of clinical significance and should be reported by the radiologist. It is stated that intraductal strictures, transient bleeding and

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Fig. 5. CASE V. Operative T-tube study post-CHDE (Fogarty and biliary spoon), revealing disruption of the right hepatic duct.

Fig. 4. CASE IV. Operative T-tube CHDE (Fogarty catheter), showing two areas of intrahepatic rupture from the right duct.

possibly cholangitis can occur secondary to these ruptures. No apparent complications were seen in our series and no special therapeutic measures were instituted. The differential diagnosis includes the following important entities: 1. Multifocal, intrahepatic abscesses (12). These patients should be febrile. Most of our patients were not 2. Congenital hepatic fibrosis (13). This is a fatal disease due to massive intrahepatic fibrosis which causes portal hypertension and liver decomposition. In this disease, there are usually microscopic cysts which may enlarge and can occasionally communicate with the biliary tree. 3. Caroli's disease (14). This is a familial disease with segmental saccular dilatations of the intrahepatic ducts. No intrahepatic extravasatlons are noted. 4. Multiple biliary cysts (15). This rare anomaly demonstrates not only intrahepatic cysts but also pedunculated outpouchings of the extrahepatic biliary ducts.

Fig. 6. CASE VI. Autopsy specimen demonstrating extravasation. The Fogarty balloon was distended to only 0.5 ml of water.

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REFERENCES 1. Kakos GS, Tompkins RK, Turnipseed W, et al: Operative cholangiography during routine cholecystectomy: a review of 3,012 cases. Arch Surg 104:484-488, Apr 1972 2. Saltzstein EC, Evans SV, Mann RW: Routine operative cholangiography. Analysis of 506 consecutive cholecystectomies. Arch Surg 107:289-291, Aug 1973 3. Schulenberg CAR: Operative Cholangiography. London, Butterworth's, 1966 4. Whitehouse WM, Hoskins PA: Operative and post-operative cholangiography. [In] Margulis AR, Burhenne HJ, eds: Alimentary Tract Roentgenology. St. Louis, Mosby, 1967, pp 971-980 5. Henzel JH, Blessing WD, DeWeese MS: Intrahepatic biliary disruption. Report of two cases occurring during use of balloontipped biliary catheters. Arch Surg 102:218-220, Mar 1971 6. Henzel JH, DeWeese MS: Common duct exploration with and without balloon-tipped biliary catheters. Arch Surg 103: 199204, Aug 1971 . 7. Dainko EA: Complications of the use of the Fogarty balloon catheter. Arch Surg 105:79-82, Jul 1972 8. Van Way CW III, Sawyers JL: Damage to the intrahepatic biliary system from the use of the balloon-tipped catheter. Am J Surg 125:343-344, Mar 1973 9. Eaton SB, Wirtz RD, Ten Eyck JR, et al: Iatrogenic liver injury resulting from ductal instrumentation with the Fogarty biliary balloon catheter. Radiology 100:581-584, Sep 1971 10. Butsch JL: A technique for the prevention of hepatic duct disruption caused by the use of the Fogarty biliary catheter (letter). Arch Surg 108:381, Mar 1974 11. Burhenne HJ: Nonoperative retained biliary tract stone extraction. A new roentgenologic technique. Am J Roentgenol 117: 388-399, Feb 1973 12. Jelaso DV, Hirschfield JS: Multifocal intrahepatic abscesses demonstrated on percutaneous transhepatic cholangiogram. South Med J 67:310-311, Mar 1974 13. Leger L, Bouquien Y, Kerneis JP, et al: Dysgemesies conqenltales complexes des voies biliaires lntra-hepatlques au cours des cirrhoses juveniles avec hypertension portale, Presse Med 66: 1147 -1151, 25 Jun 1958 14. Majahed Z, Glenn F, Evans JA: Communicating cavernous

Fig. 7. CASE VII. Autopsy specimen (magnified).' Extravasation is shown after passage of a Fogarty catheter. The catheter passed easily to the periphery of the liver. Note how close the contrast material is to the surface of the liver (black arrow, right duct; white arrows, liver edge). ectasia of the intrahepatic ducts (Caroli's disease). Am J Roentgenol 113:21-26, Sep 1971 15. Arthur GW, Stewart JOR: Biliary cysts. Br J Surg 51:671675, Sep 1964 Julian O. Salik, M.D. Department of Radiology Sinai Hospital of Baltimore, Inc. Belvedere at Greenspring Avenues Baltimore, Md. 21215

Intrahepatic rupture secondary to duct exploration demonstrated by cholangiography.

Seven cases of iatrogenic rupture of the intrahepatic bile ducts were demonstrated on T-tube and/or operative cholangiography. This brings the total o...
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