Page 195 - Medicine and Surgery

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Chapter 5: Clinical 191

visualise the pancreatic and biliary ducts, particularly in pictures obtained. Complications include haemorrhage,
patients suspected of having biliary obstruction, stone bile leakage, bacteraemia and septicaemia. Emergency
or post-liver transplant. surgery may be required.

Liver biopsy
Endoscopic retrograde
cholangiopancreatography (ERCP) Liver biopsy is used to diagnose the cause of liver disease.
In jaundiced patients, imaging such as an ultrasound
ERCP is used in the diagnosis and treatment of condi-
(US) scan and endoscopic retrograde cholangiography
tions of the biliary tract and pancreas, such as in obstruc-
should initially be used to exclude an obstructing lesion.
tive jaundice or if obstruction of the pancreatic ducts is
It is also used for diagnosis of a space-occupying lesion
suspected. It provides more detailed information than
such as a tumour or abscess. Biopsy may be preceded by
an ultrasound scan. A side-viewing endoscope is passed
aCT scan to determine if metastatic disease is present
into the duodenum and a radio-opaque dye injected into
and may be guided by CT or ultrasound.
the biliary and pancreatic systems by means of a cannula
Prior to the biopsy coagulation studies should be
inserted into the papilla of Vater. This is followed by
checked and a sample sent to transfusion for group
real-time radiography.
and save serum. Hepatitis B and C surface antigen sta-
Further diagnostic and therapeutic manoeuvres:
tus should be known. Patients with abnormal clotting
Biopsy of periampullary tumours.

should have their liver biopsy postponed until this is
Sphincterotomy or balloon dilatation to allow gall-

corrected. If uncorrectable, biopsy may be undertaken
stone removal.
throughthehepaticveins,usingatransjugularapproach.
Dilatation of benign biliary strictures.

Abiopsy needle is passed percutaneously, and the
Insertion of stents to relieve obstructive jaundice.

biopsy taken whilst the patient holds their breath in
The rate of complications with a diagnostic ERCP is
expiration. Percutaneous aspiration of an abscess is
approximately 1%, but this rises with any therapeutic
occasionally performed. Complications include haem-
procedure. The most common complication is acute
orrhage, bile leakage and pneumothorax. After the pro-
pancreatitis. Haemorrhage and perforation occur less
cedure the patient should rest on their right side for 2
commonly. Ascending cholangitis may be prevented by
hours in bed and should gently mobilise after bed rest
antibiotics, which are given prophylactically to all pa-
for a further 4 hours.
tients with possible biliary obstruction.
Liver resection
Percutaneous transhepatic
cholangiography (PTC) Liver resection may be indicated in abdominal trauma,
and in tumours of the liver. However, in many cases of
Percutaneous transhepatic cholangiography is used to malignant tumours only complete removal of the liver
image the biliary tree, particularly the upper part, which and liver transplantation is curative. Localised metas-
is not well outlined by endoscopic retrograde cholan- tases may also be resected.
giopancreatography (ERCP). For example in obstruc- The liver is composed of several segments, as defined
tive jaundice with obstruction of the upper biliary tree by the blood supply and drainage, this is important in
and when malignancy of the biliary tract is suspected liver resection. The hepatic artery and portal vein each
or being evaluated. Prior to the procedure the clotting have a left and right branch and these supply the left and
profile is checked and the patient is given prophylactic righthemi-livers respectively. The left hemi-liver com-
broad-spectrum antibiotics. prises of the left lobe and the caudate and quadrate lobes;
A slim flexible needle is passed into the liver per- together these form four segments. The right hemi-liver
cutaneously and a radio-opaque dye injected. The im- comprises of the remainder of the right lobe and is also
age can be followed by real-time radiography and still further divided into four segments (see Fig. 5.3).