World Congress of Gastroenterology

WCOG 2019

Intrahepatic Cholangiocarcinoma : Percutaneous Hepatocholangioscopic Biopsy
Mehmet Giray Sönmez 1 Süleyman Bakdık 2 Tevfik Küçükkartallar 3 Ahmet Atıcı 1 Gökhan Ecer 1 Ahmet Öztürk 1

1- Department Of Urology, Meram Medical Faculty , Necmettin Erbakan University, Meram Konya
2- Department Of Radiology, Meram Medical Faculty , Necmettin Erbakan University, Meram Konya
3- Department Of General Surgery, Meram Medical Faculty ,Necmettin Erbakan University, Meram Konya


Introduction:Cholangiocarcinoma(CCA) is the second most common primary liver tumor type and accounts for around 3% of all gastrointestinal cancers.  CCAs are over 90% adenocarcinoma. They may develop in intrahepatic and extrahepatic bile ducts. Percutaneous fine needle aspiration biopsy, brushcytology, curettage and cytological examination methods can be used to determine tissue diagnosis. ERCP can be used to provide tissue samples with different methods, including brush cytology, fine-needle aspiration, and transpapillary biopsy. These methodshave a low sensitivity of 46%-73%. Combination of brush citology and Ultrasound guided needle biopsy provide: 70% sensitivity. Despitethefact that 30% of all cytological examinations havenegative results!


Endoscopic access to intrahepatic bile ductsand taking samples (an image-guided biopsy)in patients with CCA may result in and increase the accuracy and diagnosis.

In this casereport, we present a patient who was diagnosed as intrahepatic CCA pathologically by Percutaneous Hepatocholangioscopic biopsy.


Case Presentation:  49 y, male patient. He has applied severe diarrhea, nausea, loss of appetite and jaundice.No chronicalillness and no medication. Physical examination: icterus only- no significant sign. Abdominal USG scan revealed : ‘’dilatation of intrahepatic bile ducts”


       His liver biochemistry at presentation was:

       Total Bilirubin 17,23 Mg/Dl                               

       Direk Bilirubin 10,39mg/Dl  

       I. Bilirubin 6,84 Mg/Dl

       ALP: 378 U/L  

       GGT: 1491 U/L

       AST 176 U/L                                                                      

       ALT 81 U/L

       Amilase 56 U/L

       Lipase 32 U/L 

       Cancer antigen 19-9 (CA 19-9), 0,6U/ mL. 

       His hepatitis B and C screening and autoimmune profile were negative.




Percutaneous Transhepatic Cholangiography: Preoperative PTC images give 

information about Biliar Drainage. No opaque material access to choledoc 

and left hepatic lobe.

MRCP: Dilatation of the right and left main bile ducts,common bile ducts and wirsung are normal. There is no mass at main bile ducts.It was like the scirrhous type of stenosis.Findings onthisstudy suggestive of Klatskin tumor include a dilated intrahepatic biliary tree.Therefore, percutaneous biopsy could not be performed and biopsy was performed with cholangiography.


Surgical Technique:Intrahepatic bile duct was entered percutaneously with 18 Gauge needle with the aid of ultrasonography (USG) by interventional radiologist with the patient in the supine position and under general anesthesia. Bile secretion was observed inside the injector cylinder, and bile ducts were monitorized with fluoroscopy after injection of opaque material .Then a 0.035 inch soft-edged hydrophilic guidewire was inserted and a 10 F vascular introducer sheath was advanced over the guidewire. 

The end of this sheath which is outside the skin was used as access sheath by cutting the end to allow entrance of instrumentsThen intrahepatic bile duct was entered with 9.5F pediatric rigid cystoscope (Karl-Storz, Tuttlingen, Germany) by the urologist through the vascular sheath. Intrahepatic CCA was seen and biopsy was taken under direct examination with forceps.



Percutaneous Hepatocholangioscopic Biopsy Pathology: Adenocarcinoma (Intrahepatıc Cholangiocarcinoma)



Conclusion: Percutaneous ultramini hepatocholangioscopic biopsy technique, percutaneous enterance and minaturized ınstrument use the tumoral tissue from bile ducts and biopsies under direct vision can improve the accuracy of pathological diagnosis.

We believe that is a useful  and minimally invasive procedure  for determinating of stricture or tumor.Also we can use this technique for patients who do not want surgery without any pathological diagnosis.



Adenocarcinoma, Intrahepatıc Cholangiocarcinoma, Minimally invasive procedure,  Percutaneous Hepatocholangioscopic Biopsy,