Gastrointest Radiol 6, 177 183 (1981) Gastrointestinal Radiology Combined Approach to the Differential Diagnosis of Cholestatic Jaundice with Endoscopic Retrograde Cholangiopancreatography, Percutaneous Transhepatic Cholangiography, Ultrasonography, and Liver Biopsy Antonio Ginestal-Cruz 1, Jos6 Pinto-Correia 1, Ermelinda Camilo i, Nuno Grima 1, Anabela Cardaso 1, Am61ia Baptista 2, Antdnio Gargat+ 3, Jos6 C. Ribeiro 4, and Armando Lacerda 3 Departments of i Medicine 2, 2 Pathology, 3 Radiology, and ~ Medicine 1, University Hospital of Santa Maria, Lisbon, Portugal Abstract. A prospective study of 33 patients with cho- lestatic jaundice was performed with combined use of endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), ultrasonography, and liver biopsy. A higher rate of success with PTC in 25 cases of extrahepatic cholestasis was offset by the better score of ERCP in 8 cases of intrahepatic cholestasis and its wider diagnostic scope. The procedures were complementary in 10 cases. Ultrasonic imaging of in- trahepatic bile ducts proved useful for selecting the first cholangiographic technique. Liver biopsy estab- lished etiology in intrahepatic cholestasis. Our com- bined approach allowed us to develop through objec- tive criteria a diagnostic flow chart of cholestasis. Key words: Biliary tract, obstruction - Cholestasis, differential diagnosis - Cholangiography, techniques. Clinical and biochemical data which define the syn- drome of "cholestatic jaundice" [1] allow for a cor- rect distinction between intrahepatic and extrahepatic lesions in about 85% of cases [2]. Recently introduced computer-based diagnostic models may reach a some- what higher accuracy with a certain probability [3]. However, clinical diagnosis does not provide informa- tion about the anatomical location of these lesions, and in some patients it cannot be determined whether or not surgical intervention is indicated. Increasing evidence supports the need for a shorter delay in therapeutic decision making concerning cho- lestatic jaundice, mainly because the chances of suc- cessful and low-risk surgery are inversely correlated to the duration of biliary tract obstruction [4]. Such Address reprint requests to: Dr. A. Ginestal-Cruz, Department of Medicine 2, Gastroenterology Center, University Hospital of Santa Maria, 1600 Lisbon, Portugal quick decisions can be reached only after complete and early diagnosis of the type of cholestasis and the nature and level of the obstructive lesion. Over the last 10 years, new invasive and noninva- sive techniques have been developed, These include percutaneous transhepatic cholangiography with skinny needle (PTC) [5], endoscopic retrograde chol- angiopancreatography (ERCP) [6], ultrasonography [7], and computed tomography [8], which provide a wide range of diagnostic methods for use in choles- tatic patients. However, the high yield of diagnostic information obtained by these techniques was put forward mostly in competitive and alternative terms. The results were variable depending on local expert- ise. We aimed to find out not only the relative place and diagnostic value but also the probable comple- mentary roles of both recently developed and older techniques, i.e., which to use in the individual patient. There are still too few prospective controlled studies of a combined approach to cholestasis [9-12], and all published series have reported a direct comparison of only 2 different techniques. We started with a nonselective protocol in which 2 invasive imaging techniques (PTC and ERCP), 1 non- invasive technique (ultrasonography), and 1 morpho- logical technique (liver biopsy) were performed and evaluated on each patient. Analysis of the results and conclusions drawn from this study could then be the basis for a selective and sequential diagnostic work-up of cholestasis cases to be tested later. Patients and Methods Thirty-three consecutive patients with clinical and biochemical fea- tures of cholestatic jaundice were prospectively studied between February and July 1978. Seventeen were males and 16 females, with ages ranging from 30 to 84years (mean age: 61.Syears). The duration of jaundice before admission varied widely (Table 1). 0364-2356/81/0006-0177 $01.40 9 1981 Springer-Verlag New York Inc.