PERCUTANEOUS TRANSHEPATIC CHOLECTSTOGRAPHY FOR DIFFERENTIATING INTRA-AND EXTRAHEPATIC NEONATAL CHOLESTASIS

Abstract

Methods of imaging the biliary tract in adults include ERCP and transhepatic cholangiography. In infants with cholestatic jaundice, in whom biliary atresia is a diagnostic possibility and early intervention critical, the patient's small size and lack of dilated intrahepatic ducts often precludes the use of these tests. We report two patients, four and five weeks old, in whom sonographically guided percutaneous transhepatic gallbladder puncture was used to facilitate a contrast study of the complete extrahepatic biliary tree. These infants presented with direct hyperbilirubinemia, acholic stools, normal ultrasound studies, and nonexcreting Disida scans on Phenobarbital. Percutaneous liver biopsies showed features of both intra and extra-hepatic syndromes. To visualize the biliary tree without an operative cholangiogram, we punctured the gallbladder under ultrasound guidance with a 22 gauge spinal needle easily visible on the sonar-grams using an anterior transhepatic approach. The AP diameters of the gallbladders measured .5 and .7 cm. Bile was aspirated allowing immediate visual inspection of color. Renograffin was injected showing complete absence of a common hepatic duct in one case, confirmed surgically as biliary atresia, and small, but patent extrahepatic ducts in the second case, showing progressive nonsyndromic bile duct paucity. IV sedation was used and there was no bleeding or bile leak. Ultrasound guided percutaneous transhepatic cholecystography offers a safe, sensitive technique for the early differentiation between intra and extrahepatic neonatal cholestasis.

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