Ultrasound guided percutaneous cholecystocholangiography for early differentiation of cholestatic liver disease in infants.

Direct visualization of the extrahepatic biliary tree is difficult in infants and young children without resorting to an intraoperative cholangiogram. Small size and lack of dilated intrahepatic ducts especially in infants with cholestatic jaundice often preclude using the techniques of percutaneous transhepatic cholangiography or endoscopic retrograde cholangiopancreatography. We studied the feasibility of ultrasound-guided percutaneous cholecystocholangiography (US-guided PCC) in differentiating extrahepatic from intrahepatic causes of cholestatic jaundice in four infants. Clinical, laboratory, radiographic, and histologic criteria had not conclusively excluded extrahepatic obstruction prior to the use of this technique. Four infants, between 4 and 10 weeks of age, were studied without complications. In one patient, biliary atresia was diagnosed at 4 weeks of age; in another, aspirated bile was cultured leading to a specific diagnosis of bacterial cholangitis; and, in two others, intrahepatic cholestasis was confirmed by the demonstrated patency of the extrahepatic biliary tree. In infants and young children in whom a gallbladder lumen can be seen, US-guided PCC offers a potential rapid, nonoperative means of differentiating intrahepatic and extrahepatic causes of cholestatic jaundice, defining the anatomy of the extrahepatic biliary tree, and directly sampling gallbladder bile.