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Case 57
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History
▶ A68-Year-Old Male with Cholangiocarcinoma and Persistently Serum Bilirubin (Despite Endoscopic Stents)
Precluding Treatment with Gemcitibine. Are there other options to maximize biliary drainage?
Figure 57.1
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Case 57 Internal/External Biliary Drain
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Figure 57.2
Figure 57.3
Figure 57.4
Findings
▶ Coronal computed tomography (CT) reconstruction (Fig. 57.2) shows dilated intrahepatic bile ducts despite
the presence of an endoscopic plastic stent (arrow) placed through a self-expanding metallic stent (hollow
arrow).
▶ Color ow ultrasound of the le hemiliver (Fig. 57.3) demonstrates dilated bile ducts adjacent to portal vein
branches. Ultrasound was used to target a peripheral le bile duct.
▶ Adirectional catheter (arrow) has been advanced through the distal ange of the indwelling endoscopic stent
(Fig. 57.4). e catheter was then advanced, thereby displacing the plastic stent into the bowel (as seen in Fig.
57.5, hollow arrow).
▶ Aer the endoscopic stent was removed from the biliary tree, an internal external drain was placed draining
the le hemiliver (Fig. 57.4). ere is eective isolation of the right biliary tree due to a near complete
occlusion at the conuence of the le and right bile ducts.
Teaching Points
▶ Indications for biliary drainage include cholangitis, pruritus, biliary diversion, and lowering bilirubin for
chemotherapy or palliation of other symptoms, such as anorexia.
Figure 57.5
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▶ Endoscopic drainage is preferred in patients with low bile duct obstruction (i.e., below the conuence of the
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right and le hepatic ducts) because placement of a single stent will drain the entire biliary tree.
▶ Percutaneous biliary drainage is indicated for the treatment of high bile duct obstruction because a specic
ductal system may be targeted or when endoscopic drainage of low bile duct obstruction is unsuccessful or not
possible due to altered anatomy.
▶ e status of the portal vein, the presence of parenchymal atrophy or ascites, location of tumors, and the
presence of bile duct isolation should be considered when planning biliary drainage.
▶ e le hepatic duct is longer than the right, and the right biliary tree is therefore more susceptible to
isolation. Isolation can oen be anticipated based on preprocedure cross sectional imaging (CT, magnetic
resonance) but is not always accurate.
▶ Percutaneous biliary drainage is performed with uoroscopic guidance. Ultrasound may be used for the initial
puncture of the bile duct, and is particularly helpful in le-sided biliary drainage.
▶ External biliary catheters may be placed in the setting of sepsis to minimize manipulation, when the
obstruction cannot be crossed, or when high output from an internal/external drain causes dehydration or
electrolyte abnormalities. External biliary catheters are obligatory external drainage catheters because they are
generally placed above the obstruction.
▶ e Bismuth-Corlette classication of hilar cholangiocarcinoma has been used to describe the extent of high
bile duct obstruction:
Type 1 involves common hepatic duct but not the conuence.
Type 2 involves the conuence of the right and le hepatic ducts.
Type 3 extends to involve a right or le secondary conuence.
Type 4 involves both the right and le secondary duct conuence.
Management
▶ Catheter sideholes must be positioned both above and below the obstruction to provide adequate
drainage. All sideholes should be in the biliary tree (or bowel) because sideholes in the tract will cause
pericatheter leakage.
▶ Catheters should be ushed forward at least daily to retain patency. Routine exchange every 2–3months is
recommended to prevent occlusion.
Further Reading
Covey AM, Brown KT. Palliative percutaneous drainage in malignant biliary obstruction. Part1:indications and preprocedure
evaluation. J Support Oncol. 2006; 4(6):269–273.
Covey AM, Brown KT. Palliative percutaneous drainage in malignant biliary obstruction. Part2:Mechanisms and
postprocedure management. J Support Oncol. 2006; 4(7):329–335.
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Case 58
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History
▶ Resection of Cavernous Hepatic Hemangioma Complicated by Intrahepatic Abscess, Fever, and Leukocytosis
Aer drainage of the abscess (Fig.58.2) there is persistent bilious output from the catheter. What is the next step
in management?
Figure 58.1
Figure 58.2
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Case 58 Intrahepatic Biloma
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Figure 58.3
Figure 58.4
Figure 58.5
Figure 58.6
Findings
▶ Abdominal computed tomography (CT) scan demonstrates an intrahepatic collection with a thick wall in the
remnant right hemiliver (Fig. 58.3). On this axial image, a small part of a perihepatic drainage catheter is seen.
▶ Aer percutaneous drainage of the intraheptic abscess, contrast injection into the drainage catheter (Fig. 58.4)
demonstrates communication with the nondilated biliary tree (arrow). Again, note is made of the perihepatic
catheter previously placed in a separate collection (hollow arrow).
▶ Two weeks aer drainage of the biloma, a directional catheter was advanced from the abscess into the biliary
tree (Fig. 58.5), and an internal external biliary drain (Fig. 58.6) was placed via the biloma. Additional
sideholes were added to the catheter to provide ongoing decompression of the residual abscess cavity (arrow).
Teaching Points
▶ Biloma and abscess are in the dierential diagnosis for intrahepatic collections aer liver surgery. Bilomas
occur either because of iatrogenic injury to the biliary tree or secondary to downstream obstruction.
▶ Aer initial decompression of the abscess cavity, a change in the character of the output from purulent to
bilious conrms communication with the biliary tree.
▶ Other causes of liver abscess include hematogenous spread from gastrointestinal infection, including
appendicitis and diverticulitis. Hydatid (echinococcal) cyst is also in the dierential and is characterized by
septae and mural calcications.
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Management
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▶ Placement of any drainage catheter into the liver should be planned to avoid the pleura if possible to eliminate
the risk of contamination of the chest. For collections high in the liver that contain air, access from a subcostal
approach can be performed using the air as the target under uoroscopy.
▶ Patients should be pretreated with antibiotics prior to drainage of a liver abscess, as the risk of sepsis related to
manipulation is high.
▶ Patients should be counseled that bile leaks can take several weeks to months to resolve. Bilomas may resolve
with long-term catheter drainage, but may require diversion of the bile ducts with either percutaneous or
endoscopic drainage. Occasionally, as in this case, eective drainage of both the infected biloma and the
biliary tree may be achieved from a single access.
Further Reading
Brown KT, Covey AM. Management of malignant biliary obstruction. Tech Vasc Interv Radiol. 2008; 11(1):43–50.
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Case 59
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History
▶ Cholangiocarcinoma With Intractable Pruritus. Based on the Cholangiogram in Figure59.2, What is the
Optimal Treatment Strategy for is Patient?
Figure 59.1
Figure 59.2
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Case 59 Primary Biliary Stent
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Figure 59.3
Figure 59.4
Figure 59.5
Findings
▶ Figure 59.3 is a single image from a contrast-enhanced computed tomography (CT) showing a central liver
mass and dilation of the intrahepatic bile ducts. Both the right and le (arrows) hepatic ducts appear to
converge on the mass, suggesting they are isolated from each other.
▶ Percutaneous cholangiogram from a right posterior approach shows a short-segment, high-grade obstruction
of the right hepatic duct (arrow, Fig. 59.4). Note there is no lling of le-sided ducts or the right anterior
ducts, representing complete isolation of the right posterior bile ducts.
▶ Aself-expanding metallic stent (SEMS) has been placed across the obstruction, allowing internal drainage of
the right posterior bile ducts, reestablishing enterohepatic circulation of bile (Fig. 59.5).
Teaching Points
▶ Eective drainage of a single liver segment will most oen relieve the symptom of pruritus.
▶ It is critical to obtain high-quality cross sectional imaging to appropriately plan for biliary intervention. Attention
should be taken to assess for any bile duct isolation, liver atrophy, the presence of ascites, and tumor location.
▶ When ductal systems are completely isolated, as in this case, the risk of contaminating the nonvisualized bile
ducts is very low. When bile ducts that are not adequately drained ll with contrast, cholangitis is common.
▶ e mean patency of uncovered SEMS in the biliary tree is 6–9months, and once placed, they cannot be
removed. erefore, they are used most oen to treat malignant bile duct obstruction.
▶ Stents placed across the papilla allow reux of small-bowel contents into the biliary tree while the stent is
patent. In this situation, if/when the stent occludes in the future patients oen present with cholangitis due to
obstruction of the contaminated biliary tree. When the stent can be placed above the papilla, as in this case,
integrity of the sphincter and sterility of the biliary tree are maintained making the chance of cholangitis in
the future low.
▶ To treat malignant biliary obstruction in the absence of cholangitis, stent placement is oen the best option
to minimize catheter-related complications, such as leaking, dislodgment, and the care that an exteriorized
device requires.
Management
▶ Placement of the stent eectively converts high bile duct obstruction to a situation that can be managed
endoscopically in the future if/when the stent occludes.
▶ When placed primarilary or within 1–2 weeks aer initial drainage, plugging of the access tract with gelfoam
may decrease the risk of bile leaking into the peritoneum.
Further Reading
Brown KT, Covey AM. Management of malignant biliary obstruction. Tech Vasc Interv Radiol. 2008;11(1):43–50.
ornton RH, Frank BS, Covey AM, etal. Catheter-free survival aer primary percutaneous stenting of malignant bile duct
obstruction. Am J Roentgenol. 2011; 197(3):W514–8.
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Case 60
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History
▶ Pancreatic Cancer With Right Upper Quadrant Pain, Fever, and Leukocytosis 10 Days aer Endoscopic Stent
Placement. What is the Diagnosis?
Figure 60.1
Figure 60.2
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Case 60 Biliary Stent Complicated by Cholecystitis
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Figure 60.3 Figure 60.4
Figure 60.5
Findings
▶ Coronal reconstruction and axial image from a contrast enhanced CT shows a metallic biliary stent in the
common hepatic duct (Figs. 60.3 and 60.4). ere is air in the intrahepatic bile ducts (Fig. 60.3, arrow), which
are nondilated, suggesting the stent is patent.
▶ e gallbladder (Fig. 60.4, arrow) is distended and thick walled with mural low density, suggesting gallbladder
wall edema. ese ndings are consistent with acute cholecystitis.
▶ In Figure 60.5, a percutaneous cholecystostomy catheter has been placed. Contrast injection aer
decompression shows an intact gallbladder. e proximal cystic duct is identied, but no contrast is seen
passing into the common hepatic duct. No intraluminal stones are identied.
Teaching Points
▶ Placement of even a bare (i.e., noncovered) metallic stent across the insertion of the cystic duct is complicated
by acute cholecystitis in a minority of patients. Similarly, stent placement across the pancreatic duct can result
in pancreatitis.
▶ Covered stents are more likely to result in cholangitis and pancreatitis, but to date there is no clear evidence of
improved patency compared to bare stents.
▶ Contrast injection at the time of initial cholecystostomy should only replace the volume of bile drained.
Overdistension of the gallbladder with contrast should be avoided to minimize the risk of sepsis secondary to
bacterial translocation.
▶ Percutaneous cholecystostomy is used to treat acalculous cholecystitis or for patients with calculus
cholecystitis who are poor candidates for operation due to comorbidities.
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