How do you triage PSC patients with multifocal, predominantly intrahepatic dominant strictures and recurrent cholangitis (without advanced cirrhosis) between ERCP (targeted minimal-contrast drainage), percutaneous drainage, and early transplant evaluation?

A lot to untangle from this one question:

1. Recurrent cholangitis is an indication for liver transplantation even in the absence of cirrhosis. Once a patient has had two episodes of cholangitis within a year, that triggers a transplant evaluation in my practice. The challenge will be in the patient's ability to access the cadaveric donor pool, as most of the time, the MELD score is still low.
2. Dominant strictures need to be sampled to evaluate for possible aneuploidy or malignancy risk. If these are intrahepatic, it may be difficult to reach them endoscopically, so PTC may be the better route.
3. In the same vein, drainage for intrahepatic strictures may be difficult via ERCP, and PTC may provide a better chance (might require a right and left d...