Fatal endotoxic shock of biliary tract origin complicating transhepatic cholangiography.

A 70-year-old man was admitted to hospital with a five-month history of painless jaundice. Previous history included quiescent Pott's disease of the spine, endogenous depression, and Parkinsonism. Exammation showed obvious jaundice and a pronounced lumbar kyphosis. There was no ascites, hepatosplenomegly, or a palpable abdominal tumour. Haematological investigations were normal. The E.S.R. (Westergren) was 135 mm/in the first hour. Liver function tests were: total bilirubin 150 mg/100 ml (8-5 mg conjugated), alkaline phosphatase 27 K.A. units, SGPT 37 units, phrombin time 17 seconds (control 12 seconds), serum proteins were normal. There was no evidence of occult gastrointestinal bleeding. Liver biopsy showed changes of extrahepatic obstruction. Hypotonic duodenogphy and pancreatic arteriography were thought to be normal. Arrangements were made for percutaneous transhepatic cholangiography to be followed by laparatomy. The lateral approach was used and white bile was aspirated on the second attempted puncture. The extrahepatic biliary *tract was shown to be dilated proximal to a stone, which was partially occluding the distal end of the common bile duct (see fig.).