Percutaneous Transhepatic Cholangiogram PTC

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

Indications for imaging

Jaundice may be caused by obstruction, infection, scarring, stones, or a carcinoma in the bile ducts, liver, pancreas. a leak in a bile duct may allow bile to flow into the abdominal cavity. PTC allows visualisation of the ducts 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,

Contraindications Patients at increased risk of bleeding Biliary tract sepsis Hydatid disease

Equipment
General fluoroscopic with spot film device 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 checked before the procedure takes place. antibiotic cover typically ampicillin 500 mg. 24 hours before procedure and for 3 days after nil by mouth for 4 hours before procedure

Technique
The patient lies supine and the area of needle insertion, deep tissue and liver capsule are anesthetized - 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.

 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containing contrast media attached, contrast media is injected under fluoroscopic control as the needle is slowly withdrawn until a duct is demonstrated, this may require several manipulations of the needle up to 10 times. A biliary sample is withdrawn for analysis and then contrast media is injected to fill the ductal system and identify the level of obstruction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, 45degree RPO, Rt Lateral, Trendelenberg Erect, 45degree RPO, Rt Lateral

 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 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, and septicaemia.

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