Babeh Edi

Percutaneous Transhepatic Cholangiogram PTC

Percutaneous transhepatic cholangiography (per-kyoo-TAN-ee-us trans-heh-PAT-ik ko-LAN-jee-AH-gra-fee). A procedure to x-ray the hepatic and common bile ducts. This procedure is done under local anaesthesia by a radiologist. During the exam, a thin needle is inserted through the skin (percutaneous) and through the liver (transhepatic) into a bile duct. Then contrast media is injected, and the bile duct system is outlined - imaging is performed fluoroscopy with selected images hard copied.   Indications for imaging Jaundice may be caused by obstruction,  infection, scarring, stones, or a carcinoma in the bile ducts, liver, pancreas. Or, a leak in a bile duct may allow bile to flow into the abdominal cavity. PTC allows visualisation of the ducts are to see if they are partially or completely blocked. If necessary, a thin, flexible tube (catheter) may be inserted to allow the bile to drain into a collection bag outside the body, or into the small intestine. This procedure is called biliary drainage. Drainage catheters may be placed to divert bile. Stones can be removed, or balloon sphincter dilatation can be performed. Contraindications Patients at increased risk of bleeding Biliary tract sepsis Non availability of prompt surgical facilities Hydatid disease Portal Hypertension Seen most frequently in patients with liver disease such as cirrhosis or hepatitis, portal hypertension is a condition in which scarring in the liver creates a blockage to the flow of blood through the liver. The main vein to the liver is the portal vein. Because of this blockage, the pressure in the portal vein becomes very high, causing adjacent veins in the abdomen to become over dilated. In turn, these dilated veins (varices) rupture and cause life-threatening internal bleeding. By lowering the pressure in the portal vein, the risk of haemorrhage is greatly reduced.   Anatomy  Demonstrated Equipment General fluoroscopic with spot film device or high quality image grab General sterile procedures pack Skin prep Sterile towels Local anaesthetic equipment Chiba needle - flexible 22 gauge 18 cm long. Contrast agents Low osmolar 200 mg/ml 20 - 60 ml. Patient Preparation Haemoglobin, prothrombin time and platelets are need to be corrected before the procedure takes place. Prophylactic antibiotic cover typically ampicillin 500 mg q.d.s. 24 hours before procedure and for 3 days after Mil by mouth for 4 hours before procedure Premedication Omnopon 10mg and hyoscine 0.2mg i.m. Technique The patient lies supine and the area of needle insertion, deep tissue and liver capsule are infiltrated with local anaesthetic - and time given for it to act. Under fluoroscopic control the Cheba needle is introduced into the liver in suspended respiration, when correctly positioned the patient is permitted to breath gently. The stillette is withdrawn from the needle and a syringe containing contrast media attached, contrast media is injected under fluoroscopic control as the needle is slowly withdrawn until a duct is demonstrated, this may require several manipulations of the needle up to 10 times. A biliary sample is withdrawn for analysis and then contrast media is injected to fill the ductal system and identify the level of obstruction Films Control film right upper quadrant before procedure Supine - PA, 45degree RPO, Rt Lateral, Trendelenberg Erect - PA, 45degree RPO, Rt Lateral other images as required. Sometimes hypertonic duodenography may be used to better demonstrate the lesion but this is less common with CT availability. Biliary Drainage Catheter Placement if required Following the initial injection of contrast (x-ray dye) into the bile duct during a PTC, the interventional radiologist next guides a small guide wire through the needle, into the ducts and across the site of blockage while watching the wire and ducts on x-ray. Over this wire, a small tube (catheter) is then inserted to allow the bile to be drained from the liver, relieving the jaundice caused by blockage of the duct. Aftercare Pulse respiration and blood pressure half hourly for 6 hours Check puncture site for bleeding at the same time. Complications Mortality less than 1% Allergic reactions are rare Cholangitis, haemorrhage, Subphrenic abscess, shock, bacteraemia, septicaemia. Radiation protection 28 day rule if applicable Direct lead rubber gonad protection Minimised screening time and mA - pulsed fluoroscopy with grabbed images. Evaluation of the Image ID and anatomical markers must be present and correct in the appropriate area of the film. Optimal exposure should penetrate all the structures including the contrast media and contrast should be low enough to visualise fully the bone and soft tissue structures. Radiographs   PTC demonstrating dilated ducts Image of the bile ducts, following the injection of x-ray dye, showing a large gallstone trapped in the duct The same duct, following removal of the stone through the drainage catheter     Related Projections / Examinations /Additional modalities Ultrasound - ERCP - CT - MRRef: A guide to radiological procedures Chapman & Nakielny Useful links Cancer of the bile ducts :http://www.cancersupportivecare.com/bileduct.html