Therapeutic options for biliary tract disease in advanced cirrhosis

Between 1979 and 1984, 21 male cirrhotic patients with advanced liver disease, cholecystitis, and jaundice were seen. Eight patients had persistent symptoms of acute cholecystitis despite intense symptoms of acute cholecystitis despite intense medical management. Of these patients, five underwent cholecystostomy and survived. The other three patients had cholecystectomy and one died. Thirteen patients presented with jaundice. Twelve patients underwent endoscopic retrograde cholangiography which revealed gallbladder stones in four but no stones in the common bile duct. They did not undergo further surgical procedures. One patient presented with jaundice, cholangitis, and pancreatitis was found to have stones in the common bile duct and underwent endoscopic sphincterotomy with removal of multiple small, pigmented stones. This patient died from sepsis and renal failure 37 days after sphincterotomy. Endoscopic retrograde cholangiography was unsuccessful in four patients who later underwent percutaneous transhepatic cholangiography which revealed stones in one and cirrhotic ductal changes in three. The remaining jaundiced patient underwent cholecystectomy and common bile duct exploration which revealed no ductal stones. This patient died 21 days after operation from sepsis and multiple organ system failure. Three of five patients with gallstones on endoscopic retrograde cholangiography or percutaneous transhepatic cholangiography died, but none of the deaths were due to biliary tract disease. At last follow-up the two surviving patients were asymptomatic. The overall mortality rate was 14 percent (3 of 21 patients). Cholecystostomy in cirrhotic patients with advanced liver disease and acute cholecystitis is associated with minimal mortality and morbidity. Cirrhotic patients with jaundice are probably best evaluated initially by endoscopic retrograde cholangiopancreatography which is safe, diagnostic, and sometimes therapeutic.