The treatment of acute cholangitis. Percutaneous transhepatic biliary drainage before definitive therapy

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.