Semierect

and Erect

Position

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ROBERT

in Percutaneous

F. LATSHAW’

AND

Percutaneous transhepatic cholangiography using a Chiba ‘skinny’ needle has proven to be a safe diagnostic procedure in the evaluation of intrahepatic and extrahepatic cholestasis [1-4]. The skinny needle technique was originally described in 1974 by Okuda et al. [1] of the Chiba University Hospital, Japan, and has been modified by others [2, 3]. The use of the semierect and erect position in transhepatic cholangiography has been ne‘

ported

twice

[1

5].

,

Ferrucci

et

al.

[5]

noted

on

its

no

improvement.

Liver

Report

function

tests

2 weeks

before

[1

at the

site

of obstruc-

tion, visualization of previously unopacified structures (gallbladder and cystic duct), and more precise localization of the site of obstruction using the semierect or erect position. The procedure was routinely performed Received

October

‘Department

18, 1977;

of Radiology,

accepted Milton

after

S. Hershey

revision

March

Medical

similar were

to Pereiras performed

et al. [2]. Semierect on

a standard

tilting

Unfortunately,

the

actual

angle

of the

plane

is shal-

,

4].

This

is

believed

to

be

related

to

the

elevated

intraductal pressures. Therefore, most authors stress that extreme cane be taken to avoid overdistension of the biliary tree. The recommended method in dilated systems is presently an equal volume exchange of contrast material for aspirated bile [1]. However, in our expenience and that of others [4], aspiration of bile through a Chiba needle may be difficult or impossible at times, even in obstructed systems. In these patients, morbidity may be minimized by reducing the total volume of contrast medium. We have found that use of the erect position allows limitation of the total quantity of contrast material to 20 ml or less and prevents the large volume exchanges which cause fluctuations in intraductal pres-

We have found that erect positioning has yielded additional diagnostic information in 13 of the last 15 patients with obstructed ductal systems undergoing skinny needle transhepatic cholangiography. We have opacification

views

low, and distal opacification is not always improved in the supine position. There is commonly stasis of viscous bile in the obstructed extrahepatic ducts as well as increased intraductal pressure. There may be poor mixing and poor flow of contrast medium distally in these ductal systems [4]. Kittnedge and Baer [8] reported that inspissated bile in the common bile duct may lead in inaccurate proximal localization of an obstructing lesion and indistinct definition at the site of an obstruction. Using erect positioning, contrast material will displace static bile slowly, and distal visualization will be significantly improved. A potential benefit of the erect position may be the limitation of the amount of contrast material required. It has been demonstrated that the morbidity associated with this procedure is higher in dilated biliary systems

Discussion

improved

a technique

erect

7].

admission revealed a total bilirubin of 18.5 mg/100 ml; alkaline phosphatase, 92 U/liter (normal, 30-1 10); and SGPT, 117 U/liter (normal, 5-30). The patient had lost about 11 kg in 10 weeks and was referred to our institution. Ultrasound examination on the day of admission revealed dilated intrahepatic and extrahepatic bile ducts. Skinny needle percutaneous transhepatic cholangiography was performed on the second hospital day. Radiography in standard supine, prone, lateral, and oblique views demonstrated a dilated biliary system but poor definition at the point of obstruction (fig. 1A). Erect positioning (90#{176})improved distal opacification and showed an obstructed common bile duct at the level of the ampulla of Vater with nodular defects at the point of obstruction (fig. 1B). Endoscopy revealed a nodular, friable, bleeding lesion of the ampulla. Multiple biopsies showed adenocarcinoma of the ampulla of Vater.

observed

ROHRER2

,

A 37-year-old white male developed prunitus, scieral icterus, dark urine, and light colored stools 2 months before admission. There was no history of blood transfusions, injections, drug abuse, shellfish ingestion, or known contact with hepatitis. The total bilirubin was 4 mg/100 ml (normal, 0.1-1.2) and the hepatitis B surface antigen screen negative. A liver biopsy was interpreted as “viral hepatitis,” and the patient was followed with

VICTOR

Cholangiography

radiognaphic-fluoroscopic table. In the past, when an anterior approach and a larger sheathed needle were used, the significant morbidity necessitated a standby surgery suite. There was a justifiable fear that excessive patient movement might increase the risks of bile peritonitis and hemorrhage. However, with the advent of the Chiba skinny needle, morbidity is low [1 2] and the incidence of bile peritonitis minimal (0.64%) [1]. The use of the erect position in our patients has not been associated with untoward effects, such as hypotension, vasovagal attacks, or more seniously, hemorrhage on bile peritonitis. The supine position should theoretically be ideal for visualization of the distal duct, since anatomically the extrahepatic ductal system slants in an arcuate curve anteriorly to posteriorly from porta hepatis to papilla [6,

importance in the face of obstruction. We feel the use of the erect position deserves emphasis and suggest its routine performance in the evaluation of obstructed biliary systems. Case

G.

using

‘

only

Transhepatic

8, 1978.

Center,

Pennsylvania

State

University.

Hershey,

Pennsylvania

17033.

Address

reprint

requests

to R. F. Latshaw. a Departments Am J Roentgenol © 1978 American

of Medicine

and Radiology.

131:171-172, July 1978 Roentgen Ray Society

Milton

S. Hershey

Medical

Center, 171

Pennsylvania

State University,

0361

Hershey,

Pennsylvania

-803X/78/0700

-

17033.

01 71 $00.00

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172

TECHNICAL

Fig. bile

1.-A,

duct

Left

is hazy

stagnant ampulla

posterior and

oblique

indistinct.

bile in distal common of Vater and nodularity

sures, prolong the time that the needle

view and

showing

there

intra-

is false

bile duct by contrast is apparent. Duodenum

study. and increase is within the hepatic

and

extrahepatic

proximal

biliary

ductal

dilitation

the amount parenchyma.

of

of

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grpahy.

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needle transhepatic cholangiography: a new approach to obstructive jaundice. Am J Roentgeno/ 127:403-407, 1976 6. Hatfield P, Wise R: Anatomic variation in the gallbladder and bile ducts. Semin Roentgenol 9: 157-164, 1976 7.

T. Kanda

H. Shimokawa

significance

2.

K.

K. Sumikoshi

distal

obstruction.

profil 1 . Okuda

and

B. Erect (90) view demonstrating displacement Visualization is significantly improved. Point of obstruction is accurately localized visualized and there is bile-contrast level in gallbladder.

localization

material. is now

NOTES

Duodenum.

Semin

Roentgeno/

Philadelphia,

Saunders,

1973