Endoscopic Retrograde Cholangiography (ERC) in Surgical Emergencies L. SAFRANY, N. VAN HUSEN, G. KAUTZ,* G. WITTRIN, M. CLEMENS,t R. WEITEMEYERt
Twelve patients, presenting with an acute abdomen of suspected biliary tract origin, had endoscopic retrograde cholangiography performed. Eight patients had either traumatic, spontaneous, or postoperative biliary tract fistulas with five leading to the peritoneal cavity, one to the colon, one to the bronchial tree, and one to the liver parenchyma from a ruptured gall-bladder. Each was confirmed by endoscopic retrograde cholangiography. Four patients with jaundice, following traumatic rupture of the liver, had a pathological communication between the intrahepatic biliary tracts and the hepatic vascular system. It is concluded that ERC is a reliable method for obtaining precise localization of biliary tract problems in surgical emergencies both pre- and post-
From the Departments of Medicine and Surgery, WestfAlische Wilhelms University, Munster West Germany and the Department of Surgery, St. Joseph's Hospital, Hamilton, Canada
the surgical criteria of an acute abdomen with jaundice. Acute pancreatitis was excluded in each patient. ERCP was performed prior to operation in each patient. Methods
operatively.
Endoscopic retrograde cholangiography was per-. formed in a manner previously described.6"11 The ERC was accomplished within 15 minutes and was tolerated well even in patients with severe multiple trauma.
T HE INDICATIONS FOR ELECTIVE endoscopic ret-
rograde cholangiography (ERC) have become more clearly defined in the last few years.6 However, in acute surgical emergencies involving the biliary tract, there are little data. 1,3-5 The patients in the present report illustrate a variety of problems in emergency biliary tract surgery during the course of 1870 ERCP examinations. Twelve patients are described who fulfill
Results
The biliary tract was demonstrated in all patients, and the pancreatic duct was filled in five patients, and no untoward results were noted. The appropriate diagnoses are listed in Table 1.
Medical Dept., Westfalische Wilhelms Universitait, Muinster, West Germany. t Surgical Dept., Westfalische Wilhelms Universitat, Munster, West Germany. t Surgical Dept., St. Joseph's Hospital, MacMaster University Medical Centre, Hamilton, Canada. Reprint requests: L. Safrany, Gastroenterologische Klinik, Reinhard-Nieter-Krankenhaus, 2940 Wilhelmshaven, West Germany. Submitted for publication: March 12, 1977. *
Reports Case 1. A 27-year-old female had increasing jaundice one week prior to admission (PTA). A cholecystectomy had been performed one year previously. She was septic and showed peritoneal signs of an acute abdomen. ERC showed the common bile duct and free flow of contrast media into the peritoneal cavity (Fig. 1). Case 2. A 65-year-old male was admitted with right sided upper abdominal pain, absent bowel sounds, and jaundice. An incipient
0003-4932-78-0100-0020-0060 X J.B. Lippincott Company
20
Vol. 187. No.
ERC IN SURGICAL EMERGENCIES
1
21
TABLE 1. Patient Diagnosis
Diagnosis
Number
Bilio-Peritoneal Fistula Perforated Gallbladder Bilio-Colonic Fistula Bilio-Bronchial Fistula Hepatic Cavitation (Rupture) with Bilio-Vascular Communication
5 1 1 1 4
12
ileus was evident on a flat film of the abdomen. ERC (Figs. 2a, and b) demonstrated choledocholithiasis with a biliary fistula communicating freely between the gallbladder and the transverse colon. Case 3. A 40-year-old female was admitted with septicemia six weeks after cholecystectomy. She had a chronic cough with bilecolored sputum. The assumed broncho-biliary fistula was localized with combined bronchography and retrograde cholangiography (Figs. 3a and b). The right lobe of liver communicated with the right lower lobe via a subphrenic abscess. Case 4. A 17-year-old male was admitted following blunt abdominal trauma. During the next several days he became anemic and deeply jaundiced. Endoscopy confirmed bleeding from the ampulla of Vater. ERC showed a central cavitation of the right lobe of liver, the cause of the hemobilia and jaundice (Fig. 4). Case 5. A 24-year-old male was admitted with increasing jaundice (bilirubin 23 mg) following blunt abdominal trauma. Previously the ruptured left lobe of liver had been surgically drained. ERC showed cavitation in the left lobe of liver with free flow of contrast into the inferior vena cava. The intraoperative cholangiogram is shown in Figure 5.
FIGS. 2a and b. (a, left) Two stones are shown in a dilated
common
duct.
(b,
right) In a later phase, flow of contrast media from the gallbladder
verse
strated.
to
the
trans-
colon is demon-
FIG. 1. The common bile duct is shown with free flow of contrast media into the peritoneal cavity.
22
*}~ ~ ~ :. . ;.
Ann. Surg. * January 1978
SAFRANY AND OTHERS
*,i5''..
_
..
right) Close-up view of communication and subphrenic abscess.
Case 6. A 57-year-old male was admitted twice in two months with severe pain in the epigastrium and left upper quadrant, which was associated with bilious vomiting. The temperature was 38.80, with an elevated leukocyte count. Twice he was treated successfully with antibiotics. The upper gastrointestinal series and oral and intravenous cholangiogram were negative with a normal gallbladder. ERCP also showed a normal gallbladder, but as filling ~of the gallbladder continued, a sealed perforation into the liver parenchyma became apparent, and this was confirmed at opera-
w~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ..
.~~: ....
...
FIGS. 3a and b. (a, left) Simultaneous bronchogram and cholangiogram showing bronchobiliary fistula communicating via a
......tion
..:
(Fig. 6).
Discussion
..C..a...... ^a_ ...W
,,,
Several methods to delineate available thet vascuded by, many.7'1'reormmena bhoeena halso are zall~~~~colangioraphy> ...i..lar and biliary anatomy of the liver. Initially, splenoportography was used to demonstrate a narrowed, obstructed or dilated venous segment. Also, lesions within the liver were demonstrated by liver scan Liver biopsy, oral or intravenous cholangiography were of aid in only a few instances.'1 Operative
_
131f The most successful and certain diagnostic method thus far as been selective hepatic angiography. The above patients demonstrate that ERCP in emergency situations can be especially helpful. It allows the surgeon to anticipate a difficult situation.13 FIG. 4. Traumatic cavitation of the central portion of liver causing hemobilia.
ERC IN SURGICAL EMERGENCIES
Vol. 187 . No. 1
23
FIG. 5. Traumatic cavitation in the left lobe of liver is seen with free flow of contrast into inferior vena cava.
FIG. 6. Sealed gallbladder perforation penetrating into the liver parenchyma.
Hemobilia, broncho-biliary fistula,16 bile peritonitis, bilemia, ruptured gallbladder all are cases where surgical intervention is indicated. ERC provides precise localization and a preoperative diagnosis.
7. Graff, R. J.: Considerations in the treatment of traumatic hemobilia. Am. J. Surg., 105:662, 1963. 8. Gunderson, A. E. and Green, R. M.: Traumatic Hemobilia: Accurate Pre-operative Diagnosis by Hepatic Artery Angiogram. Surgery 62:862, 1962. 9. Hendren, W. H., Warshaw, A. L., Fleischil, D. J. and Bartlett, M. K.: Traumatic Hemobilia: Non-operative Management with Healing Documented by Serial Angiography. Ann. Surg. 174:991, 1971. 10. Richter, J.: Zur Traumatischen Hemobilie. Zentralbl. Chir. 94:464, 1%9. 11. Safrany, L., Tari, J., Barna, L. and Torok, I.: Endoscopic Retrograde Cholangiography; Experience with 168 Examinations. Gastrointest. Endosc. 19:163, 1973. 12. Safrany, L., et al.: Die Hamobilie. Leber Magen Darm, 5: 229, 1975. 13. Sandblom, P.: Hemobilia. Surg. Clin. North Am. 53:1191, 1973. 14. Spencer, F. C., Menguy, R. and Eiseman, B.: Operative Cholangiography in the Management of Traumatic Hemobilia. Surgery 54:376, 1963. 15. Steichen, F. M. and Sheiner, N. M.: Traumatic Intrahepatic Hemobilia. Arch Surg. 92:838, 1966. 16. Watkins, L., et al.: Biliary-bronchial Fistula Demonstrated by ERCP. Can. Med. Assoc. J., 113:868, 1975. 17. Whelan, T. J. and Gillespie, J. T.: Treatment of Traumatic Hemobilia. Ann. Surg. 162:920, 1962.
References 1. Akovbiantz, A., et al.: Beitrag der Endoscopischen Retrograden Cholangiopancreatographie fur die Chirurgie von Gallenweg- und Pancreaserkrankungen: Schweiz. Med. Wochenschr. 107:741, 1975. 2. Becker, H. D., Schaefer, H. E. and Peiper, H. J.: Posttraumatische Hamobile Infolge Arterio-biliare Fisteln. Dtsch. Med. Wochenschr. 95:2316, 1970. 3. Blumgart, L. H., et al.: Endoscopy and retrograde choledochopancreatography in the diagnosis of the jaundiced patient. Lancet, 11: 1264, 1972. 4. Classen, M., Fruhmorgen, P., Kozu, T. and Demling, L.:
Endoscopic Radiologic Demonstration of Bilio-digestive Fistulas. Endoscopy 3:138, 1971. 5. Clemens, M., Wittrin, G., Safrany, L. and Schonleben, K.: Die Bronchobiliare Fistel. Chirug. 48:39, 1972. 6. Cotton, P.: Cannulation of the Papilla of Vater by ERCP. Gut, 13:1014, 1972.
Twelve patients, presenting with an acute abdomen of suspected biliary tract origin, had endoscopic retrograde cholangiography performed. Eight patients had either traumatic, spontaneous, or postoperative biliary tract fistulas with five leading to the peritoneal cavity, one to the colon, one to the bronchial tree, and one to the liver parenchyma from a ruptured gall-bladder. Each was confirmed by endoscopic retrograde cholangiography. Four patients with jaundice, following traumatic rupture of the liver, had a pathological communication between the intrahepatic biliary tracts and the hepatic vascular system. It is concluded that ERC is a reliable method for obtaining precise localization of biliary tract problems in surgical emergencies both pre- and post-
From the Departments of Medicine and Surgery, WestfAlische Wilhelms University, Munster West Germany and the Department of Surgery, St. Joseph's Hospital, Hamilton, Canada
the surgical criteria of an acute abdomen with jaundice. Acute pancreatitis was excluded in each patient. ERCP was performed prior to operation in each patient. Methods
operatively.
Endoscopic retrograde cholangiography was per-. formed in a manner previously described.6"11 The ERC was accomplished within 15 minutes and was tolerated well even in patients with severe multiple trauma.
T HE INDICATIONS FOR ELECTIVE endoscopic ret-
rograde cholangiography (ERC) have become more clearly defined in the last few years.6 However, in acute surgical emergencies involving the biliary tract, there are little data. 1,3-5 The patients in the present report illustrate a variety of problems in emergency biliary tract surgery during the course of 1870 ERCP examinations. Twelve patients are described who fulfill
Results
The biliary tract was demonstrated in all patients, and the pancreatic duct was filled in five patients, and no untoward results were noted. The appropriate diagnoses are listed in Table 1.
Medical Dept., Westfalische Wilhelms Universitait, Muinster, West Germany. t Surgical Dept., Westfalische Wilhelms Universitat, Munster, West Germany. t Surgical Dept., St. Joseph's Hospital, MacMaster University Medical Centre, Hamilton, Canada. Reprint requests: L. Safrany, Gastroenterologische Klinik, Reinhard-Nieter-Krankenhaus, 2940 Wilhelmshaven, West Germany. Submitted for publication: March 12, 1977. *
Reports Case 1. A 27-year-old female had increasing jaundice one week prior to admission (PTA). A cholecystectomy had been performed one year previously. She was septic and showed peritoneal signs of an acute abdomen. ERC showed the common bile duct and free flow of contrast media into the peritoneal cavity (Fig. 1). Case 2. A 65-year-old male was admitted with right sided upper abdominal pain, absent bowel sounds, and jaundice. An incipient
0003-4932-78-0100-0020-0060 X J.B. Lippincott Company
20
Vol. 187. No.
ERC IN SURGICAL EMERGENCIES
1
21
TABLE 1. Patient Diagnosis
Diagnosis
Number
Bilio-Peritoneal Fistula Perforated Gallbladder Bilio-Colonic Fistula Bilio-Bronchial Fistula Hepatic Cavitation (Rupture) with Bilio-Vascular Communication
5 1 1 1 4
12
ileus was evident on a flat film of the abdomen. ERC (Figs. 2a, and b) demonstrated choledocholithiasis with a biliary fistula communicating freely between the gallbladder and the transverse colon. Case 3. A 40-year-old female was admitted with septicemia six weeks after cholecystectomy. She had a chronic cough with bilecolored sputum. The assumed broncho-biliary fistula was localized with combined bronchography and retrograde cholangiography (Figs. 3a and b). The right lobe of liver communicated with the right lower lobe via a subphrenic abscess. Case 4. A 17-year-old male was admitted following blunt abdominal trauma. During the next several days he became anemic and deeply jaundiced. Endoscopy confirmed bleeding from the ampulla of Vater. ERC showed a central cavitation of the right lobe of liver, the cause of the hemobilia and jaundice (Fig. 4). Case 5. A 24-year-old male was admitted with increasing jaundice (bilirubin 23 mg) following blunt abdominal trauma. Previously the ruptured left lobe of liver had been surgically drained. ERC showed cavitation in the left lobe of liver with free flow of contrast into the inferior vena cava. The intraoperative cholangiogram is shown in Figure 5.
FIGS. 2a and b. (a, left) Two stones are shown in a dilated
common
duct.
(b,
right) In a later phase, flow of contrast media from the gallbladder
verse
strated.
to
the
trans-
colon is demon-
FIG. 1. The common bile duct is shown with free flow of contrast media into the peritoneal cavity.
22
*}~ ~ ~ :. . ;.
Ann. Surg. * January 1978
SAFRANY AND OTHERS
*,i5''..
_
..
right) Close-up view of communication and subphrenic abscess.
Case 6. A 57-year-old male was admitted twice in two months with severe pain in the epigastrium and left upper quadrant, which was associated with bilious vomiting. The temperature was 38.80, with an elevated leukocyte count. Twice he was treated successfully with antibiotics. The upper gastrointestinal series and oral and intravenous cholangiogram were negative with a normal gallbladder. ERCP also showed a normal gallbladder, but as filling ~of the gallbladder continued, a sealed perforation into the liver parenchyma became apparent, and this was confirmed at opera-
w~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ..
.~~: ....
...
FIGS. 3a and b. (a, left) Simultaneous bronchogram and cholangiogram showing bronchobiliary fistula communicating via a
......tion
..:
(Fig. 6).
Discussion
..C..a...... ^a_ ...W
,,,
Several methods to delineate available thet vascuded by, many.7'1'reormmena bhoeena halso are zall~~~~colangioraphy> ...i..lar and biliary anatomy of the liver. Initially, splenoportography was used to demonstrate a narrowed, obstructed or dilated venous segment. Also, lesions within the liver were demonstrated by liver scan Liver biopsy, oral or intravenous cholangiography were of aid in only a few instances.'1 Operative
_
131f The most successful and certain diagnostic method thus far as been selective hepatic angiography. The above patients demonstrate that ERCP in emergency situations can be especially helpful. It allows the surgeon to anticipate a difficult situation.13 FIG. 4. Traumatic cavitation of the central portion of liver causing hemobilia.
ERC IN SURGICAL EMERGENCIES
Vol. 187 . No. 1
23
FIG. 5. Traumatic cavitation in the left lobe of liver is seen with free flow of contrast into inferior vena cava.
FIG. 6. Sealed gallbladder perforation penetrating into the liver parenchyma.
Hemobilia, broncho-biliary fistula,16 bile peritonitis, bilemia, ruptured gallbladder all are cases where surgical intervention is indicated. ERC provides precise localization and a preoperative diagnosis.
7. Graff, R. J.: Considerations in the treatment of traumatic hemobilia. Am. J. Surg., 105:662, 1963. 8. Gunderson, A. E. and Green, R. M.: Traumatic Hemobilia: Accurate Pre-operative Diagnosis by Hepatic Artery Angiogram. Surgery 62:862, 1962. 9. Hendren, W. H., Warshaw, A. L., Fleischil, D. J. and Bartlett, M. K.: Traumatic Hemobilia: Non-operative Management with Healing Documented by Serial Angiography. Ann. Surg. 174:991, 1971. 10. Richter, J.: Zur Traumatischen Hemobilie. Zentralbl. Chir. 94:464, 1%9. 11. Safrany, L., Tari, J., Barna, L. and Torok, I.: Endoscopic Retrograde Cholangiography; Experience with 168 Examinations. Gastrointest. Endosc. 19:163, 1973. 12. Safrany, L., et al.: Die Hamobilie. Leber Magen Darm, 5: 229, 1975. 13. Sandblom, P.: Hemobilia. Surg. Clin. North Am. 53:1191, 1973. 14. Spencer, F. C., Menguy, R. and Eiseman, B.: Operative Cholangiography in the Management of Traumatic Hemobilia. Surgery 54:376, 1963. 15. Steichen, F. M. and Sheiner, N. M.: Traumatic Intrahepatic Hemobilia. Arch Surg. 92:838, 1966. 16. Watkins, L., et al.: Biliary-bronchial Fistula Demonstrated by ERCP. Can. Med. Assoc. J., 113:868, 1975. 17. Whelan, T. J. and Gillespie, J. T.: Treatment of Traumatic Hemobilia. Ann. Surg. 162:920, 1962.
References 1. Akovbiantz, A., et al.: Beitrag der Endoscopischen Retrograden Cholangiopancreatographie fur die Chirurgie von Gallenweg- und Pancreaserkrankungen: Schweiz. Med. Wochenschr. 107:741, 1975. 2. Becker, H. D., Schaefer, H. E. and Peiper, H. J.: Posttraumatische Hamobile Infolge Arterio-biliare Fisteln. Dtsch. Med. Wochenschr. 95:2316, 1970. 3. Blumgart, L. H., et al.: Endoscopy and retrograde choledochopancreatography in the diagnosis of the jaundiced patient. Lancet, 11: 1264, 1972. 4. Classen, M., Fruhmorgen, P., Kozu, T. and Demling, L.:
Endoscopic Radiologic Demonstration of Bilio-digestive Fistulas. Endoscopy 3:138, 1971. 5. Clemens, M., Wittrin, G., Safrany, L. and Schonleben, K.: Die Bronchobiliare Fistel. Chirug. 48:39, 1972. 6. Cotton, P.: Cannulation of the Papilla of Vater by ERCP. Gut, 13:1014, 1972.
