A 65-year-old man presents with obstructive jaundice. The patient’s workup begins with a CT scan. Which of the following statement(s) is/are true concerning his diagnosis?

a. A CT scan demonstrating intrahepatic biliary obstruction with a decompressed gallbladder and a nondilated extrahepatic biliary tree will be consistent with a Klatskin tumor

b. The presence of biliary obstruction seen on the CT scan requires further evaluation with invasive cholangiography either percutaneously or endoscopically

c. Percutaneous transhepatic cholangiography would be the preferred technique for a suspected proximal cholangiocarcinoma in that it will better visualize the proximal extent of the tumor in the biliary tree

d. The placement of a transhepatic biliary catheter can prove useful in surgical management of proximal bile duct cancers

Jaundice is the most frequent presenting symptom in patients with cholangiocarcinoma, occurring in 90% of patients. The diagnosis begins with abdominal imaging to detect ductal dilatation. A CT appearance of a proximal cholangiocarcinoma or a Klatskin tumor will show a dilated intrahepatic biliary tree with a decompressed gallbladder and normal caliber distal bile duct. When biliary obstruction is present, further visualization of the biliary tree is required either through percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiopancreatography (ERCP). PTC is preferred for more proximal lesions because ERCP may fail to adequately visualize the proximal portion of the biliary tree. For lower bile duct lesions, ERCP may be the preferred route. The management of hilar tumors can often be facilitated by the placement of transhepatic percutaneous catheters which can facilitate both resection, reconstruction, and may serve as a route for administration of local radiation therapy. These tumors are often found to be unresectable because of direct vascular invasion into the portal vein or hepatic arteries. Therefore, selective celiac angiography can be helpful preoperatively to determine if these major adjacent vascular structures are involved with the tumor.