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DOI: 10.1055/s-0039-3401327
Imaging in Obstructive Jaundice: What a Radiologist Needs to Know before Doing a Percutaneous Transhepatic Biliary Drainage
- Abstract
- Introduction
- Causes of Obstructive Jaundice
- Indications for PTBD
- Role of Imaging before PTBD
- Conclusion
- References
Abstract
Percutaneous transhepatic biliary drainage (PTBD) is one of the commonly performed biliary interventions. In patients with obstructive jaundice, PTBD may be a lifesaving emergency procedure or may serve as an alternative intervention in patients who fail to undergo endoscopic drainage or those who are too sick to be considered for endoscopic drainage. The key factor in technical and clinical success of PTBD is a thorough preprocedure imaging evaluation. In this review, we highlight the imaging aspects that should be evaluated and reported by a radiologist when evaluating a patient planned for biliary drainage.
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Introduction
Obstructive jaundice is a type of jaundice which occurs due to a mechanical obstruction in the biliary drainage pathways.[1] It is not a disease per se but is the manifestation of some underlying disease process. It can present with acute symptoms or gradually progressive indolent course depending upon the underlying cause.[2] Percutaneous transhepatic biliary drainage (PTBD) is a minimally invasive procedure for drainage of the biliary system.[3] PTBD is preferred as the primary procedure in patients who have had prior bilio-enteric anastomosis, or those who are unsuitable for endoscopic retrograde cholangiopancreatography (ERCP) due to other reasons. Imaging plays an essential role in the diagnosis of underlying etiology and provides a road map for the procedures.[4] Imaging modalities for evaluation of biliary tree are ultrasonography (US), endoscopic ultrasound (EUS), computed tomography (CT), and magnetic resonance imaging (MRI)/MR cholangiopancreatography (MRCP).[5] In this review article, we highlight the important imaging aspects that should be evaluated by a radiologist in a patient being planned for biliary drainage.
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Causes of Obstructive Jaundice
Any obstruction starting from the level of intrahepatic biliary radicles till the ampulla of Vater either intrinsic or extrinsic can cause obstructive jaundice. These can be divided into congenital causes like a choledochal cyst, postoperative strictures, and inflammatory causes like post inflammatory ampullary stricture, choledocholithiasis, neoplastic etiologies like carcinoma gallbladder, periampullary carcinoma, etc., and traumatic etiologies. It has been observed that the most common causes of surgical obstructive jaundice are malignant lesions.[1] [2] [Table 1] highlights the various important causes of obstructive jaundice.
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Indications for PTBD
Percutaneous transhepatic biliary drainage (PTBD) may be performed for both benign and malignant causes.[3] It can be used as a palliative procedure in nonoperable patients, a bridging procedure for further biliary stenting, or as an emergency procedure for clinically unstable patients presenting with acute severe cholangitis. [Table 2] highlights the indications for PTBD.
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Role of Imaging before PTBD
Specific questions that a radiologist should answer on imaging prior to PTBD include:
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Is there obstruction?
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Which modality is the best to ascertain biliary obstruction?
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What is the level of obstruction?
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What is the cause of obstruction?
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What is the extent of disease?
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Is PTBD amenable?
Besides, imaging also helps in planning the procedure by addressing:
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Variants of bile ductal anatomy.
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Postoperative appearances that are relevant to PTBD.
Is there Obstruction?
Benign strictures have a broad spectrum of presentation ranging from subclinical disease to jaundice, pruritus, and cholangitis· Imaging diagnosis of biliary obstruction is straightforward in most cases. The normal intrahepatic bile ducts may measure up to 2 mm or less than 40% of the diameter of the accompanying portal vein branch.[6] In certain situations, particularly postcholecystectomy and hepaticojejunostomy (HJ) strictures, there may be minimal biliary dilatation ([Fig. 1]). Additionally, in patients with HJ strictures, the presence of pneumobilia may preclude a comprehensive evaluation of biliary tree on ultrasound (US). The clinical features may be much more pronounced compared with imaging findings. In these situations, biliary dilatation may not be detected on US and computed tomography (CT). Although MRCP has a higher sensitivity for detection of biliary dilatation, in the presence of pneumobilia may render the evaluation of biliary system difficult.[7] In most of the patients with malignant extra hepatic biliary obstructive (EHBO), the diagnosis of biliary obstruction is easily made on US.[6] However, in patients who have undergone ERCP and stenting or EUS-biliary drainage, the evaluation may be challenging due to the presence of pneumobilia.[7]
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Which Modality is the Best to Ascertain Biliary Obstruction?
Ultrasound is the initial imaging test of choice for evaluation of biliary system as it is widely available, relatively inexpensive, and has high sensitivity and specificity for detection of biliary dilatation[8] ([Fig. 2]). Additionally, it is highly accurate in the evaluation of gallbladder abnormalities, including cholelithiasis.[9] The disadvantages are the user dependence, difficulty in evaluation of obese patients, inability to evaluate the lower end of common bile duct (CBD), and the periampullary region.[10] EUS has high accuracy in the assessment of the lower end of the CBD and the periampullary region[11] ([Fig. 3]). CT has a high sensitivity and specificity in the local staging of malignant disease involving the biliary tree[12] ([Fig. 4]). However, it is not accurate in differentiation of malignant from benign strictures.[11] MRCP is highly accurate in assigning the level of obstruction[10] ([Fig. 5]). Contrast-enhanced MRI and diffusion-weighted MRI increase the confidence of differentiation of benign from malignant biliary strictures[13] ([Fig. 6]). When appropriately utilized, the imaging modalities discussed above provide a road map to decide the feasibility and approach to perform the biliary drainage.
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What is the Level of Obstruction?
All the previous imaging available with the patient should be reviewed. The aim is to classify the location of biliary obstruction as proximal or distal. This will help in deciding the preferred access for biliary drainage. In general, for distal biliary obstruction (beyond the hilum), ERCP is preferred.[14] For proximal biliary obstruction, PTBD is preferred.[14] In case of proximal obstruction, the documentation of patency of the primary confluence is also essential as separation of right and left hepatic ducts may mandate a bilateral PTBD in certain situations. The patency of the confluence will also affect the technique of biliary stenting. Patients with obstruction following biliary-enteric anastomosis are also suitable for PTBD. [Figs. 7] [8] [9] [10] highlight the classification of benign and malignant strictures based on the site of involvement.
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What is the Cause of Obstruction?
It is essential to differentiate between benign and malignant causes of biliary obstruction. Benign causes like Mirrizzi’s syndrome are best treated with surgical intervention. Benign periampullary strictures such as those caused by pancreatitis are suitable for sphincterotomy rather than percutaneous drainage. Strictures in the setting of biliary-enteric anastomosis and proximal benign strictures are candidates for percutaneous drainage if surgical resection is not possible. Certain imaging features favor malignant etiology, although this may be challenging and may require more comprehensive evaluation ([Table 3]).[15] [16]
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What is the Extent of Disease?
It is essential to stage the malignancy and ascertain the resectability of the disease. Patients amenable for resection should be considered for surgical interventions first unless these have been complicated by cholangitis. Although a matter of debate, according to a recent review, preoperative biliary drainage is not usually indicated for middle–distal obstruction.[14] On the other hand, proximal obstruction in patients who are potential candidates for major liver resection requires preoperative drainage in most of the cases.[14] Patients with unresectable or metastatic disease are considered for palliative biliary drainage and metallic stenting. The local extent of the disease may also affect the decision. If the secondary confluences are involved, then the contralateral side should be preferred. The decision to perform drainage in patients with involvement of bilateral secondary confluence should be made per case basis. The ductal system draining the maximum volume of functional residual liver should be preferred as more than 25% of the liver should be drained to relieve jaundice and pruritis.[6] The right anterior ducts provide easier route for internalization and stenting.
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Is PTBD Amenable?
PTBD requires dilatation of the ductal system for the intervention radiologist to puncture the duct. For routine purposes, peripheral ductal dilatation of more than 2 mm is desirable. However, under expert hands, nondilated or minimally dilated systems can also be punctured using micropuncture sets and other techniques (opacification of the ductal system through an indwelling T-tube, use of the T-tube tract, computed tomography (CT) guidance, and percutaneous cholecystotomy).[17] [18] The presence of moderate to gross ascites has been reported to increase the risk of bleeding and biliary peritonitis.[19] [20] [21] The presence of a distended gallbladder should be recorded as in some situations when all attempts to drain the biliary radicles have failed, and drainage may be achieved via percutaneous cholecystostomy.[22]
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Planning for Intervention: Variant Biliary Anatomy
It is not uncommon to find variant biliary ductal anatomy ([Fig. 11]). MRCP is the imaging method of choice for evaluating biliary anatomy. The preoperative assessment of biliary anatomy helps in deciding the routes of drainage.[23] This information is also helpful in guiding internalization, particularly in difficult cases.
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Planning for Intervention: Postsurgical Biliary Anatomy
Biliary-enteric anastomosis is performed for a variety of benign and malignant diseases.[24] The most common type of biliary-enteric anastomosis is HJ. During HJ, usually a loop of jejunum is anastomosed to allow drainage of both right and left hepatic ducts. Less common, an anastomosis may be performed draining right and left ducts separately into the jejunal loop at two different sites ([Fig. 12]). Less common types of biliary-enteric anastomosis are choledochoduodenostomy, portojejunostomy, and cholecystoenteric bypass.[24]
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The performance of various imaging modalities in assessment of patients with EHBO has been compared in multiple studies ([Table 4]).[25] [26] [27] [28] [29] [30] It had been found that MRI/MRCP and EUS provide better diagnostic yield in terms of detection of obstruction and ascertaining the level of obstruction.
It is useful to follow a standard format for reporting imaging of patients presenting with obstructive jaundice ([Fig. 12]).
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Conclusion
In conclusion, detailed review of imaging is vital to the success of biliary drainage in patients with surgical obstructive jaundice. It plays an important role in deciding whether to undertake a percutaneous or endoscopic drainage and in patients undergoing PTBD; it helps in allowing adequate planning of the procedure.
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Conflicts of Interest
None declared.
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References
- 1 Selvasekaran R, Nagalakshmi G, Anandan H. Clinical spectrum of presentation of obstructive jaundice in inflammation, stone disease and malignancy. Int J Sci Stud 2017; 5: 10-14
- 2 Padhy B, Murmu D, Samal D, Jha S. Clinical study of surgical jaundice: an institutional experience. Int Surg J 2018; 5: 138-142
- 3 Yadav A, Condoti NK, Mukund A. et al. Percutaneous transhepatic biliary interventions. J Clin Interv Radiol ISVIR 2018; 2: 27-37
- 4 Patel NA, Parekh H, Vasavada DP, Mehta SG, Porecha MM, Shah J. A pictorial essay-imaging in surgical jaundice. Indian J Radiol Imaging 2006; 16 (01) 75-82
- 5 Katabathina VS, Dasyam AK, Dasyam N, Hosseinzadeh K. Adult bile duct strictures: role of MR imaging and MR cholangiopancreatography in characterization. Radiographics 2014; 34 (03) 565-586
- 6 Skoczylas K, Pawełas A. Ultrasound imaging of the liver and bile ducts - expectations of a clinician. J Ultrason 2015; 15 (62) 292-306
- 7 Irie H, Honda H, Kuroiwa T. et al. Pitfalls in MR cholangiopancreatographic interpretation. Radiographics 2001; 21 (01) 23-37
- 8 Yarmenitis SD. Ultrasound of the gallbladder and the biliary tree. Eur Radiol 2002; 12 (02) 270-282
- 9 Shea JA, Berlin JA, Escarce JJ. et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med 1994; 154 (22) 2573-2581
- 10 Yeh BM, Liu PS, Soto JA, Corvera CA, Hussain HK. MR imaging and CT of the biliary tract. Radiographics 2009; 29 (06) 1669-1688
- 11 McMahon CJ. The relative roles of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound in diagnosis of malignant common bile duct strictures: a critically appraised topic. Abdom Imaging 2008; 33 (01) 10-13
- 12 Singh A, Gelrud A, Agarwal B. Biliary strictures: diagnostic considerations and approach. Gastroenterol Rep (Oxf) 2015; 3 (01) 22-31
- 13 Cui XY, Chen HW. Role of diffusion-weighted magnetic resonance imaging in the diagnosis of extrahepatic cholangiocarcinoma. World J Gastroenterol 2010; 16 (25) 3196-3201
- 14 Iacono C, Ruzzenente A, Campagnaro T, Bortolasi L, Valdegamberi A, Guglielmi A. Role of preoperative biliary drainage in jaundiced patients who are candidates for pancreatoduodenectomy or hepatic resection: highlights and drawbacks. Ann Surg 2013; 257 (02) 191-204
- 15 Kim JY, Lee JM, Han JK. et al. Contrast-enhanced MRI combined with MR cholangiopancreatography for the evaluation of patients with biliary strictures: differentiation of malignant from benign bile duct strictures. J Magn Reson Imaging 2007; 26 (02) 304-312
- 16 Park MS, Kim TK, Kim KW. et al. Differentiation of extrahepatic bile duct cholangiocarcinoma from benign stricture: findings at MRCP versus ERCP. Radiology 2004; 233 (01) 234-240
- 17 Kühn JP, Busemann A, Lerch MM, Heidecke CD, Hosten N, Puls R. Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts compared with patients with dilated intrahepatic bile ducts. AJR Am J Roentgenol 2010; 195 (04) 851-857
- 18 Gupta P, Maralakunte M, Rathee S. et al. Percutaneous transhepatic biliary drainage in patients at high risk for adverse events: experience from a tertiary care referral centre. Abdom Radiol 2019; [epub ahead of print] DOI: 10.1007/s000261-091-02344-1.
- 19 Saad WE, Wallace MJ, Wojak JC, Kundu S, Cardella JF. Quality improvement guidelines for percutaneous transhepatic cholangiography, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv Radiol 2010; 21 (06) 789-795
- 20 Bonshock R, McLaughlin S, Duncan C. et al. Complication rates of percutaneous biliary drainage in the presence of ascites. J Vasc Interv Radiol 2017; 28: S54
- 21 Patel V, McLaughlin SW, Shlansky-Goldberg R. et al. Complication rates of percutaneous biliary drainage in the presence of ascites. Abdom Radiol (NY) 2019; 44 (05) 1901-1906
- 22 Gupta P, Kalra N, Kumar A, Kochhar R, Gupta V, Khandelwal N. Balloon dilatation of a benign biliary stricture through a T-tube tract. Indian J Radiol Imaging 2015; 25 (01) 21-24
- 23 Funaki B. Percutaneous biliary drainage. Semin Intervent Radiol 2007; 24 (02) 268-271
- 24 Boraschi P, Donati F. Biliary-enteric anastomoses: spectrum of findings on Gd-EOB-DTPA-enhanced MR cholangiography. Abdom Imaging 2013; 38 (06) 1351-1359
- 25 Romagnuolo J, Bardou M, Rahme E, Joseph L, Reinhold C, Barkun AN. Magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disease. Ann Intern Med 2003; 139 (07) 547-557
- 26 Morimoto K, Shimoi M, Shirakawa T. et al. Biliary obstruction: evaluation with three-dimensional MR cholangiography. Radiology 1992; 183 (02) 578-580
- 27 Dewbury KC, Joseph AE, Hayes S, Murray C. Ultrasound in the evaluation and diagnosis of jaundice. Br J Radiol 1979; 52 (616) 276-280
- 28 Chan YL, Chan AC, Lam WW. et al. Choledocholithiasis: comparison of MR cholangiography and endoscopic retrograde cholangiography. Radiology 1996; 200 (01) 85-89
- 29 Mendler MH, Bouillet P, Sautereau D. et al. Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases. Am J Gastroenterol 1998; 93 (12) 2482-2490
- 30 Ferrari FS, Fantozzi F, Tasciotti L, Vigni F, Scotto F, Frasci P. US, MRCP, CCT and ERCP: a comparative study in 131 patients with suspected biliary obstruction. Med Sci Monit 2005; 11 (03) MT8-MT18
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Publication History
Article published online:
04 February 2020
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References
- 1 Selvasekaran R, Nagalakshmi G, Anandan H. Clinical spectrum of presentation of obstructive jaundice in inflammation, stone disease and malignancy. Int J Sci Stud 2017; 5: 10-14
- 2 Padhy B, Murmu D, Samal D, Jha S. Clinical study of surgical jaundice: an institutional experience. Int Surg J 2018; 5: 138-142
- 3 Yadav A, Condoti NK, Mukund A. et al. Percutaneous transhepatic biliary interventions. J Clin Interv Radiol ISVIR 2018; 2: 27-37
- 4 Patel NA, Parekh H, Vasavada DP, Mehta SG, Porecha MM, Shah J. A pictorial essay-imaging in surgical jaundice. Indian J Radiol Imaging 2006; 16 (01) 75-82
- 5 Katabathina VS, Dasyam AK, Dasyam N, Hosseinzadeh K. Adult bile duct strictures: role of MR imaging and MR cholangiopancreatography in characterization. Radiographics 2014; 34 (03) 565-586
- 6 Skoczylas K, Pawełas A. Ultrasound imaging of the liver and bile ducts - expectations of a clinician. J Ultrason 2015; 15 (62) 292-306
- 7 Irie H, Honda H, Kuroiwa T. et al. Pitfalls in MR cholangiopancreatographic interpretation. Radiographics 2001; 21 (01) 23-37
- 8 Yarmenitis SD. Ultrasound of the gallbladder and the biliary tree. Eur Radiol 2002; 12 (02) 270-282
- 9 Shea JA, Berlin JA, Escarce JJ. et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med 1994; 154 (22) 2573-2581
- 10 Yeh BM, Liu PS, Soto JA, Corvera CA, Hussain HK. MR imaging and CT of the biliary tract. Radiographics 2009; 29 (06) 1669-1688
- 11 McMahon CJ. The relative roles of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound in diagnosis of malignant common bile duct strictures: a critically appraised topic. Abdom Imaging 2008; 33 (01) 10-13
- 12 Singh A, Gelrud A, Agarwal B. Biliary strictures: diagnostic considerations and approach. Gastroenterol Rep (Oxf) 2015; 3 (01) 22-31
- 13 Cui XY, Chen HW. Role of diffusion-weighted magnetic resonance imaging in the diagnosis of extrahepatic cholangiocarcinoma. World J Gastroenterol 2010; 16 (25) 3196-3201
- 14 Iacono C, Ruzzenente A, Campagnaro T, Bortolasi L, Valdegamberi A, Guglielmi A. Role of preoperative biliary drainage in jaundiced patients who are candidates for pancreatoduodenectomy or hepatic resection: highlights and drawbacks. Ann Surg 2013; 257 (02) 191-204
- 15 Kim JY, Lee JM, Han JK. et al. Contrast-enhanced MRI combined with MR cholangiopancreatography for the evaluation of patients with biliary strictures: differentiation of malignant from benign bile duct strictures. J Magn Reson Imaging 2007; 26 (02) 304-312
- 16 Park MS, Kim TK, Kim KW. et al. Differentiation of extrahepatic bile duct cholangiocarcinoma from benign stricture: findings at MRCP versus ERCP. Radiology 2004; 233 (01) 234-240
- 17 Kühn JP, Busemann A, Lerch MM, Heidecke CD, Hosten N, Puls R. Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts compared with patients with dilated intrahepatic bile ducts. AJR Am J Roentgenol 2010; 195 (04) 851-857
- 18 Gupta P, Maralakunte M, Rathee S. et al. Percutaneous transhepatic biliary drainage in patients at high risk for adverse events: experience from a tertiary care referral centre. Abdom Radiol 2019; [epub ahead of print] DOI: 10.1007/s000261-091-02344-1.
- 19 Saad WE, Wallace MJ, Wojak JC, Kundu S, Cardella JF. Quality improvement guidelines for percutaneous transhepatic cholangiography, biliary drainage, and percutaneous cholecystostomy. J Vasc Interv Radiol 2010; 21 (06) 789-795
- 20 Bonshock R, McLaughlin S, Duncan C. et al. Complication rates of percutaneous biliary drainage in the presence of ascites. J Vasc Interv Radiol 2017; 28: S54
- 21 Patel V, McLaughlin SW, Shlansky-Goldberg R. et al. Complication rates of percutaneous biliary drainage in the presence of ascites. Abdom Radiol (NY) 2019; 44 (05) 1901-1906
- 22 Gupta P, Kalra N, Kumar A, Kochhar R, Gupta V, Khandelwal N. Balloon dilatation of a benign biliary stricture through a T-tube tract. Indian J Radiol Imaging 2015; 25 (01) 21-24
- 23 Funaki B. Percutaneous biliary drainage. Semin Intervent Radiol 2007; 24 (02) 268-271
- 24 Boraschi P, Donati F. Biliary-enteric anastomoses: spectrum of findings on Gd-EOB-DTPA-enhanced MR cholangiography. Abdom Imaging 2013; 38 (06) 1351-1359
- 25 Romagnuolo J, Bardou M, Rahme E, Joseph L, Reinhold C, Barkun AN. Magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disease. Ann Intern Med 2003; 139 (07) 547-557
- 26 Morimoto K, Shimoi M, Shirakawa T. et al. Biliary obstruction: evaluation with three-dimensional MR cholangiography. Radiology 1992; 183 (02) 578-580
- 27 Dewbury KC, Joseph AE, Hayes S, Murray C. Ultrasound in the evaluation and diagnosis of jaundice. Br J Radiol 1979; 52 (616) 276-280
- 28 Chan YL, Chan AC, Lam WW. et al. Choledocholithiasis: comparison of MR cholangiography and endoscopic retrograde cholangiography. Radiology 1996; 200 (01) 85-89
- 29 Mendler MH, Bouillet P, Sautereau D. et al. Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases. Am J Gastroenterol 1998; 93 (12) 2482-2490
- 30 Ferrari FS, Fantozzi F, Tasciotti L, Vigni F, Scotto F, Frasci P. US, MRCP, CCT and ERCP: a comparative study in 131 patients with suspected biliary obstruction. Med Sci Monit 2005; 11 (03) MT8-MT18
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