Jaundice Interventions and
Malignant bile duct obstructions palliative and curative
Bile duct biopsies
US with colour doppler
- limited by bowel gas if present.
CT, MR, MRCP
1. ERCP often preferred;
- especially if coagulopathies, ascites, large liver cysts
2. PTC may be preferred to define complex liver ductal anatomy, for
3. May need both to define ducts above and below an injury.
4. PTC is the first step to PBD
- and the only absolute contraindication is coagulopathy.
- e.g. platelets <100,000 or INR >1.5.
- also avoid in hepatic infxs.
- ascites: should avoid chance of persistent leak around the tube;
Advance needle into liver, under fluoroscopic guidance
- will see bile push back contrast, then flush and light up biliary
Need to find a peripheral duct for a PBD catheter
Sometimes need to advance needle sub-xiphoid for left duct system
If pt is critically ill, placement of an external drainage catheter
would be effective.
- once stable, could return for conversion to internal / external
drainage / stent.
--> ultimate goal always to re-establish biliary-enteric
Loss of bile can lead to substantial electrolyte disturbances.
Biliary drainage catheters are generally flushed 1-2x day,
especially if viscous bile or infected.
--> sterile forward flushing, taking care not to draw forcefully
back into the syringe; else may drag GI bugs into the biliary
circulation causing sepsis.
May need periodic changing over a guidewire.
PTC --> Internal Drainage
Palliative biarly stenting.
Allows rapid treatment and reduces cost compared with catheter
Eithe rplastic or metal
- plastic are larger, require dilation; painful, theoretical risk of
- metal are smaller, but deploy larger so that more permanent; can't
Patency generally 6-12 months.
- covered devices may extend this.
Complications of PTC
Technical success is high and complications low (5=8%)
Major = hemobilia, haemorrhage, sepsis, biloma, peritonitis,
pancreatitis, pleural effusions; rarely, death.
Cholangitis is brief, often during catheter manipulation.
- usual sepsis management here.
Hemobilia / haemorrage is from injury to major vessels; generally
managed by repositioning or upsizing catheters
- arterial branch injury may need arteriography.
Pericatheter bile leakage may occur if luminal flow not free.
- occasionally ascites leaks around the tube; purse string suture
may fix it.
Over the wire cholangiogram first.
Sometimes performed via the nose
- allows measurement of bile volume and allows cholangiograms
- but more loss of bile salts, water, electrolytes, digestive
Plastic stents commonly used here due to low cost and ease of
- but migrate and occlude early, often last only 3-6m; get colonized
with a biofilm.
- larger lumens = better.
Metal stents now covered to prevent tumour ingrowth; long patency
- but higher risk of migration and pancreatitis.
Use in Choledocholithiasis
ERCP should be therapeutic and not diagnostic as less
invasive tests area available.
Note that US is insensitive for choledocholithiasis; sensitivity
- MRCP sensitivity >90%, but a little less when there are small
stones <5mm or biliary sludge.
CBD stones are found in about 15% of symptomatic gallstone patients.
Success of ERCP is ~90% at extraction
- balloon dilation of sphincter causes pancreatitis and is not
- stone are removed by sphincterotomy and extraction using a basket
- can trawl duct with a balloon to remove small stones and sludge
- removed 1 at a time to reduce complications of duct damage and
About 5-15% depending on who is doing it.
Pancreatitis is most common; 2-7%
- higher in SOO dysfunction, females, younger pts, recurrent
Bleeding and perforation serious but 1% or so.
- higher bleeding if coagulopathy (always should be checked),
Used here for both tissue sampling and palliation.
Most patients have inoperable lesions, many that are operable should
go straight to surgery if bilirubin level allows it.
Palliation is best with stenting; less long term issues but better
morbidity, mortality and stay.
Success rates are 95%
- lower for hilar lesions; may end up needing PTC
Structures; complex area and specialist territory.
Dilate the stricture, maintain patency of the duct, e.g. by
- plastic stents more common here as can be changed easily.
High success rate 90%, but only with stent use.
Lap chole responsible for 80%.
Endoscopic treatment of biliary structure has 75% success rate and
65% of these patent at 70months.
Sequential ERCPs, increased number and diameter of stents until
complete removal at 12months is first line approach.
Associated biliary stricture rate high.
Accounts for 10% of bile duct strictures.
Multiple plastic stents has high long term success rate and should
be first line.
Primary Sclerosing Cholangitis
Stricture dilating and stenting; see notes.