Forty-two patients with acute
cholangitis, as evidenced by
fever (95%),
jaundice (86%), and right upper quadrant
pain (67%), were treated with fluid and
electrolyte resuscitation, broad spectrum
antibiotic coverage, and initial percutaneous transhepatic biliary drainage (PTD). Despite
a 17% incidence of nondilated ductal systems, drainage was established in all patients using a 22-gauge "skinny" needle and "accordion"
catheter. No attempt was made at definitive cholangiogram; only 1-2 mL of contrast were injected to confirm placement of the
catheter.
Sepsis began to resolve in all patients within 24 hours of PTD, after which definitive cholangiogram was performed. PTD was accompanied by
a 7% (3/42) complication rate, none of which contributed to subsequent morbidity and mortality. Two patients in severe
septic shock had PTD but died within 8 hours of admission, constituting a 5% mortality rate. Definitive
therapy after resolution of
sepsis included: surgical (16 patients), internal/external drainage (14 patients), balloon dilatation (10 patients),
mono-octanoin infusion (1 patient), and ampullary dilatation (1 patient). The surgical morbidity rate was 18%. There was no mortality. PTD is effective in providing
decompression as initial
therapy for acute
cholangitis with minimal morbidity. Accurate diagnosis provided by the definitive cholangiogram obviates the need for multiple
surgical procedures. PTD provides a portal to the biliary tract for alternative procedures (i.e., internal/external drainage, balloon dilatation), especially in patients with
medical contraindications to surgery.