tumour (93%) than CT (53%) [52]. Endoscopic ultra- sound may also be used to stage pancreatic cancer but its accuracy needs further evaluation [2]. This technique is also highly accurate for localizing pancreatic neuroen- docrine tumours which are often not well seen by other methods (fig. 32.8) [6]. Endoscopic ultrasound-guided fine-needle aspiration biopsy is possible from lymph nodes and pancreatic lesions and in experienced hands is safe [75]. With the increased availability of this technique it is being used more frequently for the evaluation of patients with pancreatic tumours, in particular for biopsy and assessing resectability. It may also be valuable for patients with problematic biliary tract pain where MRCP and other scanning has been negative and ERCP unhelpful. Endoscopic ultrasound to look for tiny bile duct stones and for pancreatic disease may be clinically indicated in combination with endoscopic biliary manometry. Biliary scintigraphy The technetium-labelled iminodiacetic acid derivative (IDA) is cleared from the plasma by hepato-cellular organic anion transport and excreted in the bile (fig. 32.9a). Biliary radiopharmaceuticals have so improved that one of the newest, Iodida, is easily prepared and is taken up by the liver and excreted into bile efficiently with only 5% of the injected dose excreted in the urine. Effective concentration in the bile duct is achieved in patients with total serum bilirubin levels exceeding 340mmol/l (20mg/dl). Resolution is much less than with other forms of bile duct visualization and the role of cholescintigraphy is therefore limited. The method may be used to determine patency of the cystic duct in suspected acute cholecystitis (fig. 32.9b). The radio-activity is followed until it reaches the duodenum. If the gallbladder fails to visualize, despite common bile duct patency and intestinal visualization, the probability of acute cholecystitis is 99%. The gallbladder ejection fraction can be calculated from the loss of isotope from the gallbladder after a stan- dard infusion of sincalide (the C-terminal octapeptide of CCK) [78]. This technique can help to identify gallblad- der disease in some patients who have gallbladder-like pain but a normal ultrasound. Cholescintigraphy can show whether the bile duct is obstructed, but in most units US serves this role. In the more complicated patient, analysis of the pattern of uptake and hepatic clearance of radio-activity, or the combination of scintigraphy with US, can differentiate intra-hepatic cholestasis from bile duct obstruction — useful, for example, in the patient with a biliary stricture, who remains cholestatic despite insertion of a biliary endoprosthesis. Scintigraphy is also useful in assessing the patency of biliary-enteric anastomoses, and may show biliary leaks after cholecystectomy (fig. 32.9c) or liver transplantation [44]. Choledochal cysts can be diagnosed although ultra- sound CT and MRI scanning are just as satisfactory (see fig. 33.13). In the neonate, IDA scanning is used to differentiate between biliary atresia and neonatal hepatitis (fig. 32.9d). It may be combined with ultrasound. Functional obstruction of the sphincter of Oddi after cholecystectomy may be suggested by delayed and reduced excretion of activity with slower emptying of the biliary tree. Oral cholecystography Although oral cholecystography shows gallbladder stones with an accuracy of 85–90%, it is now rarely used because of the greater sensitivity and wide availability of transabdominal ultrasonography. In recent years it had a limited role in the evaluation of the gallbladder before oral bile acid therapy but this treatment has also become much less frequent with the development of laparo- scopic cholecystectomy. The contrast agents used were iodine containing, con- jugated with glucuronic acid by the liver, and excreted in bile. In the fasting patient contrast enters the gallbladder if the cystic duct is patent. There is reabsorption of water by the lining mucosa, concentration of contrast and gall- bladder opacification (fig. 32.10). Complications includ- ing hypersensitivity are extremely rare. Imaging of the Biliary Tract: Interventional Radiology and Endoscopy 567 Fig. 32.8. Endoscopic ultrasound in a patient with suspected neuroendocrine tumour in whom CT scan had shown no abnormality. 2.5cm diameter mass shown in head of pancreas PD, pancreatic duct; SV, superior mesenteric vein. (Courtesy of Dr Steve Pereira.) When this method is used three X-ray films are necessary; control, fasting after oral contrast, and after gallbladder contraction by fat stimulation or CCK. The gallbladder is seen in 85% of patients. Films are taken erect and prone. Normal visualization without stones gives a 95% probability that the gallbladder is normal. The technique is not valuable if the bilirubin is greater than twice the upper limit of normal be- cause of failure of efficient secretion of contrast by the liver. Oral cholecystography is of value in showing lesions of the gallbladder wall, for example adenomyomatosis [47]. This is seen as small fundal outpouchings. Rokitan- sky–Aschoff sinuses are seen as a dotted second contour around the gallbladder lumen. Anomalies of the gall- bladder may be visualized by oral cholecystography. Intravenous cholangiography The contrast (meglumine iotroxate; biliscopin) is concen- trated by the liver so that hepatic and common bile ducts are demonstrated. Tomography is used. However, intravenous cholangiography had become obsolete because of its poor diagnostic accuracy, its mor- bidity and the advent of MRCP. Endoscopic retrograde cholangiopancreatography [18] The ampulla of Vater is visualized endoscopically, the common bile duct or pancreatic duct is cannulated and contrast material injected (fig. 32.11). Patients with suspected biliary obstruction, a history of cholangitis or a pancreatic pseudocyst are at risk of procedure-related sepsis, and require antibiotic premedication [66]. The elderly are also at greater risk. Micro-organisms responsible include colonic flora (Escherichia coli, Klebsiella, Proteus, Pseudomonas, Strepto- coccus faecalis) and the antibiotic choice should reflect this and the hospital antimicrobial policy. Oral ciprofloxacin is as effective as intravenous cefuroxime, and more cost-effective [66]. The patient is starved for 6h. The procedure is done under sedation with a benzodiazepine (diazepam, midazolam) with an opiate as necessary. At ERCP, diseases of the oesophagus, stomach, duode- num, pancreas and biliary tract including duodenal diverticula and fistulae may be diagnosed. Manometry of the sphincter area is possible. Immediate treatment may be instituted, for example sphincterotomy for common duct stones. However, endoscopes are costly and the technique demands an experienced team. Usually the patient must be under observation for 24h 568 Chapter 32 Fig. 32.9. Cholescintigraphy ( 99m Tc Iodida). (a) Normal scan. At 30min the gallbladder (g) has filled. Isotope has already entered the bowel (B). (b) Acute cholecystitis. Gallbladder has not filled by 60min (c) Post- cholecystectomy bile leak. Isotope tracks laterally from gallbladder bed (short arrow) and T-tube track (long arrow). (d) Two-week-old infant with severe jaundice. Radio-activity is concentrated in the liver (L) and did not enter the bowel. Biliary atresia was confirmed. B, bladder. (a) (c) (b) (d) after the procedure. However, outpatient ERCP may be done for selected patients, although around 25% may need admission for complications or observation after a therapeutic procedure [36]. After sphincterotomy obser- vation for 6h or overnight may reduce the need for readmission [30]. The side-viewing duodenoscope is passed. The stomach and duodenum are inspected and biopsy and cytology specimens taken if indicated. The papilla is identified. Duodenal ileus is maintained by intermittent intravenous hyoscine N-butylbromide (Buscopan) or glucagon. The cannula is then introduced under direct vision into the papilla and contrast (e.g. iopromide) injected under fluoroscopic control. Preferential catheter- ization of bile duct and pancreatic duct is helped by directing the catheter towards 11 and 12 o’clock, respec- tively, with the ampullary area en face seen as a clock face. Use of a dual channel sphincterotome allows selective bile duct cannulation or cannulation after failure with a standard catheter. The intra-hepatic biliary tree, cystic and common bile ducts and gallbladder are filled (fig. 32.11). Changes in the position of the patient and tilting of the screening table after injection encourage distribution of contrast material throughout the duct system. In difficult cases, such as after sphincterotomy, a balloon catheter in the duct may be used to prevent reflux of contrast into the duodenum and so obtain better bile duct filling. The pancreatic duct is similarly cannulated and X-ray films taken. An aseptic technique is maintained throughout. Endo- scopes are thoroughly cleansed with soap and water and disinfected with activated glutaraldehyde. The danger of introducing infection is shown by a single endoscope which, although cleaned in an automatic machine, remained contaminated with Pseudomonas aeruginosa so resulting in biliary infection in 10 patients, with one fatality [3]. A history of minor reactions to intravenous contrast is not important but those who have had a major allergic reaction to iodinated contrast should be premedicated with corticosteroids and antihistamines [25]. The success rate for ERCP is 80–90% but depends on experience. Anatomical causes of failure include a peri- ampullary diverticulum or an ampullary tumour or stricture. Billroth II gastrectomy poses difficulties which may be overcome by an experienced endoscopist if necessary using a forward-viewing endoscope. Interpretation of the cholangiogram is not always easy. Contrast may obscure small stones. Air bubbles may cause confusion. Failure to fully fill the biliary tree, particularly in non-dependent parts, may add to the difficulty. Imaging of the Biliary Tract: Interventional Radiology and Endoscopy 569 Fig. 32.10. Oral cholecystogram showing gallbladder packed with stones. Fig. 32.11. ERCP, normal appearances. C, common bile duct; G, gallbladder; PD, pancreatic duct. Complications The complication rate is 2–3% and mortality 0.1–0.2%. Complications are directly related to the skill and experi- ence of the operator and to the presence of underlying pancreatic or biliary disease. Serum amylase levels rise considerably after ERCP and acute pancreatitis is the commonest complication. It almost always follows successful pancreatic cannulation and injection. The volume of contrast injected should be kept to a minimum. Non-ionic lower osmolarity contrast media have not been proven to carry a lower risk of acute pancreatitis. In most cases pancreatitis is clinically mild with recovery over a few days. For this and other reasons (duration of infusion required, cost-effectiveness) somatostatin or gabexate, both shown in randomized studies to reduce post-ERCP pancreatic injury, are not routinely used [4]. Pancreatic pseudocyst is a relative contraindication to ERCP. Cholangitis is the second most common compli- cation but the commonest cause of death. Bacteraemia is reported in 0–14% [66]. Pre-existing biliary infection and obstruction are important risk factors. Prophy- lactic antibiotics are important in prevention, together with early decompression of any biliary obstruction. In patients with primary sclerosing cholangitis and advanced disease, there may be deterioration after ERCP [10]. Indications ERCP adds to the speed of diagnosis of the jaundiced patient as it can be performed irrespective of depth of jaundice or state of liver function. It outlines the site of any biliary obstruction and in many instances indicates the cause. It can be used to show duct strictures, and gallbladder and common bile duct stones (figs 32.12, 32.13). It is of particular value in those with biliary disease and undi- lated intra-hepatic ducts. Diagnoses include primary sclerosing cholangitis, Caroli’s disease and other con- genital anomalies. ERCP may be performed after biliary surgery in the investigation of benign post-cholecystectomy symptoms or to define and treat more serious sequelae such as residual calculi, leaks and biliary strictures [22]. ERCP may be used to diagnose pancreatic disease, particularly in those with coincident hepato-biliary problems such as carcinoma of the pancreas and alco- holic pancreatitis with biliary obstruction. ERCP is occasionally used in the investigation of the patient with obscure epigastric pain. It allows visualiza- tion of stomach and duodenum as well as pancreatic and biliary ducts, all at one sitting. Pure bile or pancreatic juice may be obtained for culture, aspiration cytology or chemical analysis. Strictures may be brushed for cytology or biopsied [43]. Endoscopic sphincterotomy [18] Normal coagulation is a prerequisite for endoscopic 570 Chapter 32 Fig. 32.12. ERCP showing: (a) dilated bile duct above a stricture. The pancreatic duct comes to an abrupt halt in the head of the pancreas. Appearances are characteristic of carcinoma of the pancreas; (b) common bile duct filling as far as a hilar stricture due to a cholangiocarcinoma. (a) (b) sphincterotomy and the result of platelet count and pro- thrombin time as well as haemoglobin should be known. Serum is taken for blood group analysis and saved in case transfusion is necessary. Premedication with anti- biotic is routine in most units. A skilled team is required with adequate equipment, in a hospital with facilities to treat any complication. After the diagnostic ERCP has shown a stone, the ampulla is catheterized with a dual-channel sphinctero- tome appropriate in length and design to the anatomy found. Fluoroscopy is used to establish that this has entered the bile duct. Aguide-wire is usually passed into the bile duct to stabilise the sphincterotome position during sphincterotomy. The sphincterotome is with- drawn leaving approximately 1cm of the wire within the ampulla, the wire is bowed and, under direct vision, a cut is made using a blend or cutting current from the cautery unit (fig. 32.14). The length of cut depends upon the anatomy of the ampulla and the supra-ampullary area, and the size of the stone. If sphincterotomy is being done as a preliminary to endoprosthesis insertion only a small cut is needed. For stones, the aim is to make a cut of sufficient length to allow removal. It may be necessary to cut through the biliary sphincter, shown by the release of bile. Air refluxes up the bile duct. For larger stones it is necessary to decide when to use a mechanical lithotripter and a moderate cut, rather than risk a larger, possibly complicated sphincterotomy. The success rate is above 90% [37], reaching 97% in an expert unit [70]. Causes of failure include a large peri- ampullary diverticulum, a Billroth II partial gastrectomy and an impacted stone at the ampulla. Related techniques which may be helpful include needle knife papillotomy [29], but this should only be used by experienced endoscopists. Complications [20, 31] These occur in about 10% and include haemorrhage, cholangitis, pancreatitis, duodenal perforation, Dormia basket impaction and Gram-negative shock. They are life threatening in 2–3%. Mortality is 0.4–0.6%. Prospective studies show pancreatitis in 8–10% of patients having an endoscopic sphincterotomy. The rate will be influenced by the technique used including selective catheterization of the biliary system using a sphinctertome. Pure cut electrocautery may reduce the risk [27]. Post-sphincterotomy pancreatitis is usually mild. Bleeding, usually from the retro-duodenal artery, is the most serious potential problem. It usually settles but, if not, surgery can be difficult. Treatment by arterial embolization may be successful. Bleeding is not always immediate and may be delayed several days after the procedure [30]. Imaging of the Biliary Tract: Interventional Radiology and Endoscopy 571 Fig. 32.13. ERCP showing common bile duct stone. A sphincterotome has been passed into the lower end of the bile duct. Fig. 32.14. Sphincterotome inserted into ampulla of Vater. The wire has been bowed and the sphincterotomy cut has begun. Cholangitis occurs if biliary decompression (stone removal) is unsuccessful. Prevention is by insertion of a naso-biliary tube or endoprosthesis. Late results of sphincterotomy show that two-thirds of patients have air in the biliary tract and free reflux of duodenal juice. Bacterial colonization of the bile is present whether or not there are symptoms; the signifi- cance of this is unknown. Late complications (5–10% over 5 years) include sphincter stenosis [13] and recur- rent stones. The long-term effects of loss of sphincter function are unresolved. In cirrhotic patients with choledocholithiasis endo- scopic sphincterotomy is effective and safe although coagulopathy must be corrected beforehand [58]. Indications Choledocholithiasis is the commonest indication. Emer- gency ERCP with endoscopic sphincterotomy is the treatment of choice for patients with acute suppurative obstructive cholangitis [45] which is almost always caused by a stone. Where there is acute cholangitis of lesser sever- ity elective ERCP is done after a period of antibiotic treatment. Whether or not the gallbladder is in place, sphincterotomy is the treatment of choice. In patients with common duct stones without cholangitis the choice depends on the clinical situation. For post- 572 Chapter 32 Fig. 32.15. (a) ERCP showing trawling of bile duct with balloon catheter to remove stones. (b) Removal of duct stone with basket. (c) Naso-biliary tube with stones in the common bile duct. (c) (a) (b) cholecystectomy retained bile duct stones sphincterotomy is clearly the best treatment in elderly frail patients and those with other medical problems. In this group of patients it is also the accepted treatment even when the gallbladder is still in situ. After removal of the common duct stone(s), the decision whether to proceed to chole- cystectomy depends upon clinical data, although when the patient is unfit for surgery conservative therapy without cholecystectomy is an option (Chapter 34). In younger, fit patients with retained stones after cholecystectomy, sphincterotomy is preferred to surgical bile duct exploration. With the gallbladder in place, however, it is not clear whether cholecystectomy should be preceded by endoscopic sphincterotomy or accompa- nied by duct exploration and stone removal at the time of surgery. The evolution of laparoscopic cholecystectomy and duct exploration adds to the therapeutic choice. Acute gallstone pancreatitis, particularly if severe and unresolving, is an indication for emergency ERCP and sphincterotomy if a stone is found (Chapter 34). Stone extraction is done with wire baskets or balloon catheters (fig. 32.15a,b). In 90% the common bile duct is successfully cleared of stones. If all the stones cannot be extracted from a patient with cholangitis a naso-biliary catheter or endoprosthesis must be left to drain the duct (fig. 32.15c). Stones larger than 15mm may be difficult to extract. Mechanical lithotripsy may be used to crush stones with success in 92% of patients [63]. Alternatively, an endoprosthesis may be inserted [50]. This prevents the stone obstructing the bile duct, and is a quicker pro- cedure than lithotripsy. Endoprosthesis insertion may be temporary until another attempt at stone removal, or used for long-term drainage. Administration of oral ursodeoxycholic acid while the endoprosthesis is in place appears to make later clearance of stones from the duct more successful [41]. Extracorporeal shock wave lithotripsy of common bile duct stones fragments them and allows them to pass through the sphincterotomy [26]. Laser lithotripsy is available in some specialist centres. Sphincterotomy is often done before endoscopic endo- prosthesis insertion. This was originally recommended to reduce the risk of pancreatic duct obstruction and pancreatitis, but carries the risk of bleeding and is not essential unless the os is particularly small or tight. Sphincterotomy at the main papilla may be used to treat the rare sump syndrome following choledocho- duodenostomy [14]. Papillary stenosis (Chapter 34) can also be treated by sphincterotomy. Stone removal without sphincterotomy Small stones (<8mm) may be removed through an intact ampulla, with or without balloon dilatation [51]. Larger stones have been removed using the combination of mechanical lithotripsy and balloon dilatation of the sphincter of Oddi. Pancreatitis is a complication in about 7%, but in a randomized trial was as frequent as with endoscopic sphincterotomy [9]. Naso-biliary drainage A sphincterotomy is not usually necessary. After ERCP, the common bile duct is cannulated and a guide-wire passed deep into an intra-hepatic duct. The cannula is removed and a 300-cm 5 French (Fr) pigtail catheter with multiple side holes is threaded over the wire which is then removed (fig. 32.15c). The catheter is re-routed through the nose. This technique allows decompression of the biliary tree. There are fewer complications than with percutaneous biliary drainage in terms of infection, bile leak and bleeding. Naso-biliary drainage can be used as a preliminary to later sphincterotomy in poor risk patients with choledo- cholithiasis and acute suppurative cholangitis, espe- cially if coagulation is abnormal. Anaso-biliary drain may be left in position when, after sphincterotomy, it has been impossible to clear all the stones from the common bile duct. Later cholangiogra- phy through the tube shows whether the stones have passed. Naso-biliary drainage may also be used to treat bile leaks after cholecystectomy or liver transplantation, although stent insertion is the first method of choice for both leaks and residual duct stones. Endoscopic biliary endoprostheses After catheterization of the ampulla and demonstration of the stricture by contrast, a guide-wire is passed through the catheter and an attempt is made to pass it through the stricture. At the first session this is possible in 60–70% of patients. Using a combination of an inner tube and pushing tube, an endoprosthesis is railroaded into position across the stricture. A 3.3-mm diameter (10Fr) tube requires an endoscope with a 4.2-mm chan- nel and provides effective decompression (fig. 32.16). Barbs on the endoprosthesis prevent it passing all the way up into the bile duct or subsequently back into the duodenum. Two endoprostheses may be used if necessary, for example to left and right hepatic ducts when there is a hilar stricture. Overall success rate of endoprosthesis insertion is 85–90% in skilled hands. Early complications include cholangitis and pancre- atitis. Sphincterotomy is not necessary before 10Fr stent insertion and may cause haemorrhage [48]. Sphinc- Imaging of the Biliary Tract: Interventional Radiology and Endoscopy 573 Fig. 32.16. ERCP: polyethylene stent inserted to relieve obstruction due to peri-ampullary tumour. terotomy may be needed if the ampulla is too tight to admit the stent or if catherization of the biliary system has been difficult so as to allow easy access on a subse- quent ERCP. Late complications include cholangitis and recurrent jaundice due to blockage of the tube, which can easily be removed and replaced endoscopically. Mesh metal endoprostheses are now available which, after insertion in compressed form, expand when released to a diameter of up to 1cm and remain patent for a longer period than conventional plastic stents (figs 32.17, 32.18). However, blockage still eventually occurs. Coated metal shunts may delay this [39]. Results and indications Endoscopic plastic endoprostheses successfully decom- press the bile duct and relieve symptoms in about 70–80% of patients. The method carries fewer complica- tions than the percutaneous route [65], and has a lower morbidity and mortality than surgical palliative bypass in patients with peri-ampullary carcinoma [64]. Blockage of polyethylene endoprostheses occurs in 25–30% at 3–6 months due to biliary sludge, containing bacteria. Antibiotic and ursodeoxycholic acid adminis- tration do not prevent this [33]. Tannenbaum stents made of Teflon do not have longer patency rates [28]. When expandable metal mesh endoprostheses block, obstruction is relieved by insertion of a plastic stent or another metal stent within the occluded endo- prosthesis [67]. However, the patency of expandable metal mesh endoprostheses is significantly longer than plastic types (fig. 32.18) [19, 42], but the metal type is more expensive. Present experience suggests that a plastic type be placed first, and when it blocks, a metal endoprosthesis is inserted in those patients who are progressing more slowly and are expected to survive longer [53]. Inoperable malignant biliary obstruction from carcinoma of pancreas, ampulla and hilum can be relieved. For a malignant hilar obstruction, drainage of only one lobe provides good palliation. A second endoprosthesis is only needed if cholestasis is not relieved sufficiently or there is sepsis in the undrained side [56]. Benign strictures, whether due to primary sclerosing cholangitis or post-cholecystectomy, can be treated in this way, although balloon dilatation is an alternative. Failed endoscopic removal of common duct stones. A stent may be introduced into the common bile duct where it 574 Chapter 32 Fig. 32.17. (a) ERCP showing malignant stricture (arrows) at lower end of bile duct. (b) Mesh metal stent (Wallstent) placed across the stricture. (Courtesy of Dr Kees Huibregtse.)(a) (b) has been impossible to remove all stones and when the patient is unfit for surgery. External biliary fistulas. Post-operative leaks from the cystic duct or gallbladder bed may be treated by intro- duction of a biliary stent. The leak usually seals making re-operation unnecessary. The stent is removed after a few weeks. Balloon dilatation Following endoscopic cholangiography, a balloon catheter may be introduced into the common bile duct and inflated. This may be used to dilate a benign stricture (fig. 32.19), whether traumatic or secondary to primary sclerosing cholangitis. It may be a useful preliminary step before insertion of an endoprosthesis. Per-oral cholangioscopy The bile duct interior can be inspected using a ‘baby’ endoscope introduced via a large channel (‘mother’) Imaging of the Biliary Tract: Interventional Radiology and Endoscopy 575 Polyethylene Metal 200 100 300 400 500 Time (days) Patency (%) 0 20 40 60 100 80 Fig. 32.18. Kaplan–Meier life table analysis of stent patency: randomized trial of metal vs. polyethylene stents. (From [19] with permission.) Fig. 32.19. Endoscopic balloon dilatation of bile duct stricture following liver transplantation. (a) Cholangiogram showing stricture. (b) Wire passed into intra-hepatic ducts. (c) Balloon dilatation to 8mm diameter. (d) Final cholangiogram with good result. (a) (b) (c) (d) six needle ‘passes’ are allowed before the procedure is abandoned. After successful injection into obstructed and dilated ducts the patient may need to be tilted so that the common bile duct has an opportunity to fill. If hilar obstruction prevents communication between the right and left hepatic duct, a percutaneous cholangiogram from both sides should be done. The technique is rela- tively safe so that surgery need not inevitably follow immediately. If dilated ducts are encountered, they should be catheterized and external or internal biliary drainage established. Trans-hepatically aspirated bile should be cultured. The patient must be observed care- fully in hospital. The technique is easy and the success rate is 100% if intra-hepatic bile ducts are dilated. With undilated ducts, such as in primary sclerosing cholangitis or with some cases of choledocholithiasis, the success rate drops to 90% but can rise to 95% in specially skilled hands. Complications The complication rate is less than 5% and includes bleed- ing, bile peritonitis and septicaemia (usually Gram- negative) in those with cholangitis or unsuspected bacteria in the bile. Indications For the majority of patients needing direct cholangiogra- phy, the percutaneous approach is the second choice used only after ERCP has failed. This practice is based less on the relative complication rates of the two diag- nostic procedures, and more on the greater therapeutic potential of ERCP, with a lower risk. Thus the endo- scopic approach allows sphincterotomy for stones, and safer stent insertion. Percutaneous cholangiography comes into its own, however, when endoscopic access is difficult or impossible (hepatico-enterostomy, Billroth II). It is also important in the work-up of hilar cholangiocarci- noma, where detail of both right- and left-sided duct systems is needed. Brush cytology and biliary biopsy may be performed by the percutaneous as well as endoscopic route. Percutaneous bile drainage Bile duct catheterization A sheathed needle is directed under antero-posterior and lateral fluoroscopy into a selected intra-hepatic duct already opacified by the ‘skinny’ needle cholangiogram. The needle is withdrawn and a guide-wire passed through the sheath into common bile duct or peripheral intra-hepatic duct. 576 Chapter 32 duodenoscope. This may provide additional informa- tion [61], but the thin scopes are fragile, the system expensive, and the technique requires two endoscopists. Percutaneous trans-hepatic cholangiography [74] Contrast is injected percutaneously into a bile duct within the liver (fig. 32.20). The procedure is done in the radiology department with intravenous sedation and under local anaesthesia. Antibiotic is given 0.5–1h before the procedure. The ‘skinny’ Chiba needle is 0.7mm (22 gauge) outside diameter. It is very flexible so that the patient is able to breathe normally with it in situ. The needle is introduced in the 7th, 8th or 9th right intercostal space at the point of maximal dullness to per- cussion in the mid-axillary line. Ultrasound guidance adds to the success. It is advanced parallel to the table top to about 2.5cm from the spine, bisecting a sagittal line between the dome of the diaphragm and the duode- nal cap identified by its gas shadow. Contrast is injected continuously as the needle is withdrawn. Bile ducts are identified by the persistence of contrast in tube-like branching structures. Portal and hepatic veins are recognized by the peripheral direction of flow and rapid disappearance of contrast medium. Lymphatics can be filled and the contrast takes 5–10min to be cleared. Up to Fig. 32.20. Diagnostic percutaneous trans-hepatic cholangiogram showing normal right and left intra-hepatic ducts and common bile duct, and free flow of contrast into duodenum. The gallbladder is beginning to fill. [...]... congenital dilatation of liver lymphatics They are usually on the surface of the liver Biliary cystadenoma and cystadenocarcinoma are rare (Chapter 31) Malignant pseudocysts from degeneration 592 Chapter 33 and softening of secondary malignant growths also occur Congenital anomalies of the biliary tract The liver and biliary tract develop from a bud-like outpouching of the ventral wall of the primitive foregut... hepatectomy [ 29] of the serosal type The constancy of position of the fundus during contraction and the small size of the opening between the two parts indicate that this is probably a fixed, congenital malformation Diverticula of the gallbladder and ducts Diverticula of the body and neck may arise from persistent cysto-hepatic ducts which run in embryonic life between the gallbladder and the liver The fundal... anomaly the gallbladder lies under the left lobe of the liver, to the left of the falciform ligament This may be caused by the gallbladder migrating to a position under the left lobe of the liver (to the left of the round ligament) The path of the cystic duct is normal Alternatively a second gallbladder may develop directly from the left hepatic duct with failure of development or regression of the normal... lesser omentum The sheet may run from the common bile duct laterally over the gallbladder down to the duodenum, to the hepatic flexure of the colon and even to the right lobe of the liver, perhaps closing the foramen of Winslow In a milder form, a band of tissue runs from the lesser omentum across to the cystic duct and anterior to the gallbladder; or a loose veil forms a mesentery to the gallbladder... rare The extra duct is usually a subdivision of the right hepatic system and joins the common hepatic duct somewhere between the junction of the main right and left hepatic ducts and the entry of the cystic duct Floating gallbladder (fig 35.1c) It may, however, join the cystic duct, the gallbladder or the common bile duct Cholecysto-hepatic ducts are due to persistence of fetal connections between the. .. different parts of the solid gallbladder bud and spreading until the whole system is recanalized At 5 weeks the ductal communications of gallbladder, cystic duct and hepatic ducts are completed and at 3 months the fetal liver begins to secrete bile The majority of the congenital anomalies can be related to alterations in the original budding from the foregut or to failure of vacuolization of the solid... Functional similarities of hepatic cystic and biliary epithelium: studies of fluid constituents and in vivo secretion in response to secretin Hepatology 199 0; 11: 557 14 Farges O, Bismuth H Fenestration in the management of polycystic liver disease World J Surg 199 5; 19: 25 15 Freeze HH New diagnosis and treatment of congenital hepatic fibrosis J Pediatr Gastroenterol Nutr 199 9; 29: 104 16 Gabow PA Autosomal... gallbladder and the liver parenchyma with failure of re-canalization of the right and left hepatic ducts Continuity is maintained by the cystic duct entering a remaining hepatic duct or common hepatic duct or the duodenum directly Accessory ducts are of importance to the biliary and transplant surgeon as they may be inadvertently ligated or cut with resultant biliary stricture or fistula  594 Chapter 33 Left-sided... Because of the risk of subsequent adenocarcinoma or squamous cell carcinoma, excision is the method of Cysts and Congenital Biliary Abnormalities choice [22, 28] Biliary tract continuity is maintained by choledocho-jejunostomy with Roux-en-Y anastomosis Anastomosis of the cyst to the intestinal tract without excision is simpler but post-operative cholangitis and subsequent biliary stricturing and stone... 199 9; 49: 599 16 Chiverton SG, Inglis JA, Hudd C et al Percutaneous cholecystolithotomy: the first 60 patients Br Med J 199 0; 300: 1310 17 Citron SJ, Martin LG Benign biliary strictures: treatment with percutaneous cholangioplasty Radiology 199 1; 178: 3 39 18 Cotton PB, Williams CB 199 9 Practical Gastrointestinal Endoscopy, 4th edn Blackwell Science, Oxford 19 Davids PHP, Groen AK, Rauws EAJ et al Randomised . Prospective assess- ment of the utility of EUS in the evaluation of gallstone pan- creatitis. Gastrointest. Endosc. 199 9; 49: 599 . 16 Chiverton SG, Inglis JA, Hudd C et al. Percutaneous chole- cystolithotomy:. blend or cutting current from the cautery unit (fig. 32.14). The length of cut depends upon the anatomy of the ampulla and the supra-ampullary area, and the size of the stone. If sphincterotomy. Pseudomonas infection of the biliary system resulting from the use of a contami- nated endoscope. Gastroenterology 198 7; 92 : 7 59. 4 Andriulli A, Leandro G, Niro G et al. Pharmacologic treat- ment can prevent