For medical students

1. HEPATOBILIARY STUDIES
PERCUTANEOUS AND ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY AND T-TUBE
CHOLANGIOGRAM
BY; AMETO COXSON RAY
U/21030019/MMI

2. (PTC )PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY
OUTLINES
• Introduction
• Anatomy of biliary system (glance)
• Indication and contraindication of PTC
• Contrast media
• Patent preparation
• Technique of procedure
• Filming’s
• Aftercare
• Complication of procedure

3. (PTC )PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY
• Percutaneous transhepatic cholangiography (PTC);
• It is the radiological examination that involves the investigation of the
biliary system by the percutaneous administration of the contrast
media directly in one of the intrahepatic duct using the chiba needle

4. Transportation of bile
• The liver cells secrete bile, bile flow from liver to right and left hepatic
ducts.
• These ducts drains into common hepatic duct.
• The common hepatic duct then joins with cystic duct ( which drains
the gallbladder) to form the common bile duct .
• About 50% of the bile produced by liver is first stored in gall bladder .
• When food is eaten , the gall bladder contract and releases stored
bile into the duodenum to help break down the fat.

9. INDICATIONS
Biliary obstruction that might be due to:
1. Choledocholithiasis
2. Chronic pancreatitis, cancer
3. Ampullary stenosis
4. Haemobilia
5. Benign strictures: post-traumatic, post-operative, post- inflammatory or
post-infective.
6. perforated gastro duodenal ulcer

10. • Intra-hepatic abscess
• To evaluate biliary-enteric anastomosis
• To define the level of bile leakage, biliary-enteric or biliary cutaneous
fistulas
• Congenital anomalies
• To depict the anatomy of the biliary and pancreatic system
• Cholestatic jaundice
• Prior to therapeutic intervention, e.g. biliary drainage procedure

11. CONTRAINDICATIONS
Coagulation Problem ( Platelet count< 100,000 mm3 and INR greater than
1.5) .
• Biliary Infection.
• Hypersensitivity to contrast medium
• Severe heart disease and respiratory disease
• Poor General condition of patient
• Extreme Jaundice.
• Ascites.
• Anemic
• Immediately after an hydatid cyst removal .
• Hydatid disease.

12. CONTRAST MEDIA
• LOCM or HOCM, 20 ml
• Sedative: Midazolam and Analgesic: Lidocaine 3%

13. EQUIPMENT’S
• Ultrasound Machine, Fluroscopic Unit with spot film device and tilting table.
• Chiba needle (flexible 18 -22 G, 15-20 cm long, with stainless steel needle.
• 21F , 15cm long with outer and inner diameter 0.7 and 0.5 mm respectively).
Skin antiseptic solutions: Povidone iodine, Spirit, Savlon .
Sterile towels, Gauzes, Cotton swabs, Scissors, Gloves, , forceps.
Disposable syringes, Collection bags.
Local anesthetic injection: Lignocaine 2%.
• Guide wires, Dilators, Metallic stents.
• Catheters:
Exterior drainage catheters
Internal drainage catheters

15. Equipment Required
• Vascular Ascess
Sheath and dilators

16. J tipped Stiff Guide wire

17. PRELIMINARY IMAGING
US to confirm position of liver and dilated ducts.

18. Patient Position/Location
• Nil per oral for at least 6 hours.
• Sedation/ Analgesics if required.
• I/V line is opened in arm to administer medications during the examination.
• Blood report that should include the platelets count, prothrombin time,
hemoglobin, HBsAg test, HIV test, and blood grouping.
• CT, MRI, ultrasound reports should be assessed to localize the lesion before
the
examination.
• Informed consent should be signed and examination should be explained to
the

19. Patient Position/Location
Right/left/bilateral drainage may be performed
Right-sided access generally preferred
– Straighter course for wire/catheter manipulation
– May have higher radiation exposure to operators’ hands with left- sided
access
 For PTBD, appropriate lobe to drain depends on
– Site of obstruction
 Right or left drainage usually sufficient for distal common duct obstruction
 If confluence obstruction, may perform bilateral drainage or unilateral
drainage of larger lobe

20. Right PTC/PTBD access
– Patient supine on fluoroscopy table
– Right mid-axillary line approach
– 9th to 11th intercostal space
□ Ask patient to take deep breath; prefer access below lung margin
– Advance needle, initially parallel to table, toward T12 vertebral body

21. Left PTC/PTBD access
 Patient supine on fluoroscopy table
– Subxiphoid or subcostal approach
– Visualize dilated duct with ultrasound
 If accessible, segment II duct preferred: Forms less acute angle with
left main duct
Segment III duct courses vertically; may be more accessible than
segment II duct

22. TECHNIQUE
Obtain IV access: give antibiotics, sedation and analgesia.
• Patient is placed in a supine position, and sterile preparation and draping are performed.
•Puncture the duct: aim for a point where the duct is large enough to accommodate
the catheters and drains that you plan to use, but fewer complications the more
peripherally you puncture
• Through USG guidance chiba needle is inserted into dilated duct.
• Confirm intraduct position: free backflow of bile indicates that you are in the
duct; make sure you put a decent length of the 0.018-inch wire into the duct.
• Stellate from the Chiba needle is removed and once bile observed, a J tipped stiff guide wire
(150cm long. 0.035”) is inserted up to the area it could reach

23. Technique
• Exchange the 0.018-inch wire for the 0.035-inch J wire: using the coaxial set.
• Dilate a tract into the duct: Use 5F or 6F dilators, depending on the size of
catheter you intend to use.
• Introduce the catheter you hope to use to cross the stricture; most
operators use either a Cobra or a biliary manipulation catheter.
• Take a sample of bile: for microbiology ± cytology.
• Cross the stricture: this is often harder than it sounds.
We usually start with the curved hydrophilic wire.
The process is similar to crossing a stricture or occlusion in a blood vessel

24. Technique
• Confirm intraluminal position: always ensure that you are either in the distal
bile duct or through to the duodenum.
• Exchange for the Amplatz super-stiff wire: aim to have the wire into the 3rd
part of the duodenum.
• Confirm free drainage: make sure you do this before you attach the
catheter!
• Fix the drain catheter to the skin: there are many options for this; so either
use a suture or a proprietary skin fixation device.

26. Contrast is injected to opacify the biliary
system

27. Technique
Two approaches are used
1 Right lateral(mid-axillary approach
2. Anterior .Subcostal or Left sided subxiphoid
• Procedure is done under the local anesthesia with i.v sedation and
analgesic with appropriate patient monitoring .

28. FEATURES RIGHT SIDED PUNCTURE LIFT SIDED PUNCTURE
1.Patient comfort Painful, restricted patient movement. Less painful, Increased patient comfort.
2. Technical ease of puncture Difficulty
3. Associated risk Pleural transgression, injury to intercostal
neurovascular - bundle
4. Radiation exposure Less radiation to operator
Higher radiation exposure to
operator’s hands
Segment three duct- antero-inferior to
segment two duct.
5. Preferred duct Anterior sectorial duct below 10th rib at
mid-axillary line line.
Subxiphoid or substernal

29. RIGHT FLANK APPROACH
• Patient is placed in supine position , Right hand is turned over the head
The puncture site is slightly anterior to midway between the tabletop and
the xiphisternum: inferior to the right costophrenic angle on full
inspiration and superior to the hepatic flexure of the colon on full
expiration.
• A flexible chiba needle is inserted medially under the fluoroscopic
guidance
• Angulation slightly anteriorly to the coronal plane and directed cranially
towards the point midway between the right cardio phrenic angle and
first part of duodenum which can be usually identified by luminal gas .

30. • Needle movement should be during suspended respiration , end
expiration or end inspiration.
• Needle entry into a bile duct is identified by aspiration of bile or
injection of contrast media.
• It is important to inject adequate amount of contrast media higher
amount injection in high grade obstruction will increase risk of septic
shock .
• Injection of contrast media out side the duct should be minimum it
tends to obscure the ROI , may be painful and can produce pseudo
obstruction in intra hepatic biliary duct

31. • Injection of contrast media into portal vein or hepatic vein is recognize
by rapid flow of C/M from needle .
• Injection of contrast media lymphatic system beaded appearance on
image.
• Injection of contrast media in liver parenchyma recognize by persistent
amorphous stain
• Injection of contrast media periportally – static branches stain
• Injection of contrast media in to bile duct slow oil like flow of contrast
media away from the needle tip.
• Multiple needle passes may produce haemobilia
• If biliary radical id punctured to first pass repeated attempts are made

32. • Filming's is done after successfully administration of C/M
1. Frontal
2. LPO,
3. Lateral
4. Trendelenberg position
• After filming aspiration of contrast and bile out of gall bladder to
decompress system

33. PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY

34. PTC

35. FINDINGS

41. AFTER CARE
• Advice for rest on right lateral position as this gives compression to
the puncture site.
• Pulse and Blood pressure measurement half hourly for 6 hrs.
• Antibiotic Prophylaxis
• Observe signs and symptoms of peritonitis and intraperitoneal
hemorrhage for 24 hours.
• Vital signs recorded half hourly for 12- 24 hours.
• An External draining catheter should be flushed through with normal
saline and exchanged at every three months.
• Checking of punctured site for bleeding, leakage of bile, intra-
peritoneal haemorrhage & any sign of peritonitis at the same time.
• The bile in the collection bag also checked for colour, amount,&
presence of blood,

42. COMPLICATIONS
• Sepsis
• Haemorrhage /Bleeding
• Localized Inflammatory/Infectious
• Abscess, peritonitis, cholecystitis, Pancreatitis
• Perforation of bile duct above the stricture on passage of guide wire
.Bile leakage
• Biliary peritonitis
• Pleural effusion, Pneumothorax in right approach
• Cholangitis

43. PROCEDURE OF ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY( ERCP) AND T-TUBE
CHOLANGIOGRAPHY
• Introduction
• Anatomy of associated organs
• Indication And Contraindications
• Equipment’s
• Patients preparation
• Technique
• Filming

44. Procedure of ERCP and

45. Introduction
Endoscopic retrograde cholangiopancreatography (ERCP) is combined
endoscopic and fluoroscopic procedure in which an upper endoscope is led into
a second part of the duodenum, making it possible for passage of other tools via
the major duodenal papilla into the biliary and pancreatic ducts.
Contrast material may be injected in these ducts, allowing for radiologic
visualization and therapeutic interventions when indicated.

46. Anatomy
• The main pancreatic duct connects to the common bile duct and
drains at the ampulla of Vater (hepato-pancreatic ampulla), controlled
by the sphincter of Oddi.
• The major duodenal papilla is the opening of the ampulla of Vater
into the second part of the duodenum.
• The common bile duct and the pancreatic duct may remain separate
or merge at the end of the papilla, or they may form a common duct.

48. Indications
• Obstructive jaundice
• Chronic pancreatitis ( controversial indication due to viability of safer
diagnostic modalities).
• Gallstones with dilated bile ducts on ultrasonography
• Bile duct tumors and obstructions
• Suspected injury to bile ducts either as a result of trauma or
iatrogenic
• Sphincter of Oddi dysfunction
• Choledocholithiasis ( calculus of CBD)
• Bile duct leak post cholecystectomy
• Patient with pancreatic or biliary cancer

49. Therapeutic purposes
• Tissue sampling in patient with pancreatic or biliary cancer
• Endoscopic sphincterotomy (both of the biliary and the
pancreatic sphincters)
• Removal of stones
• Insertion of stent
• Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic
strictures after liver transplantation)

50. Contraindicaion
• HIV positive patient
• Previous gastric surgery
• Oesophageal obstruction
• Acute pancreatitis
• Pancreatic pseudocyst
• When glucagon or buscopan contraindicated
• Severe cardio/respiratory disease
• Coagulation disorder

51. Contrast media
• Non ionic low osmolar contrast agent e.g. Omnipaque ,ultravist,
optiray:200mgI/ml
• Dose :- 20 ml
• ANTIBIOTIC IN CM :-the addition of antibiotics to CM has been
advocated by some center to decrease septic complication of ERCP.

52. Equipment‘s
SIDE -VIEWING ENDOSCOPE

53. • FLUOROSCOPY WITH IITV SYTEM AND SPOT
FILM DEVICE

55. Catheter guide wires and cannula
Guide wire ERCP CATHETER ERCP cannula

56. Biliary cytology brush
Biliary expandable stent
CBD extraction balloon

57. CBD stone retrieval basket Endoscopic lithotripter Pancreatic stent

58. sphincterotome

59. Patient preparation
• NPO at least 6 hrs before the procedure
• Information about
-any medication (warfarin or other anticoagulant), cardiac disease
- barium x-ray or ct scan in the past 2-3 days
-Any chance of pregnancy , major illness and recent surgery
• Stop taking aspirin or anti-inflammatory drugs 5 days prior to ERCP
• Recent blood test report – PT, billirubin, albumin, LFT ,Haemogram
profile etc.
• Counseling , informed consent
• Remove radiopaque materials
• In case of obstructed duct may required to administer antibiotic I/V
prior to ERCP and continue for 24 hrs if contrast has been instilled

60. Premedication
• Known case of allergy to iodinated contrast medium is pre treated
with either prednisone 40 mg 24 hrs and 2 hrs before or 40 mg daily
for 3 days before the exam
• Smooth muscle relaxant - Buscopan 20 mg I/M before 10 min or 0.6
mg I/M atropine 1 hrs is given to reduce duodenal spasm and relax
the sphincter of oddi

61. Pre-procedure investigations
• Liver tests
• Recent blood test– PT, bilirubin, albumin, LFT ,Haemogram profile
• Platelet count and coagulation profile
• Imaging
• Ultrasound
• CT
• CT cholangiogram
• MRCP
• Endoscopic Ultrasound

62. Procedure
• To ease passage of endoscope, patients throat is sprayed with a local
anesthetic(4%, 50-100 mg xylocaine) ,this causes temporary pharyngeal
paresis
• Pt lies on the left side on fluoroscopy table a flexible camera
(endoscope) is inserted through the mouth, down the esophagus,
into the stomach, through the pylorus into the duodenum to the
ampulla of Vater
• A polythene catheter or cannula with prefilled CM is inserted into the
ampulla

63. • A test dose of CM is injected under the fluoroscope to determine the
position of cannula
• Then radio contrast is injected into the bile ducts and/or pancreatic
duct
• If it is desirable to opacify both the biliary tree and pancreatic duct
then the latter should be cannulated .
• A sample of bile should be sent for culture and sensitivity if there is
evidence of biliary obstruction.
Fluoroscopy is used to look for blockages, or other lesions such as
stones ,also spot images are taken as required when duct filling
completes

65. TECHNIQUE
• The point of entry of the needle is usually planned by using
ultrasound guidance (increasingly used worldwide).
• A direct fluoroscopic approach was described initially and is still used
commonly.
• A long two-part needle (approximately 15 cm) 22 G is inserted under
ultrasound guidance into one of the peripheral ducts; after removing
the needle stylet one can observe bile reflux at the needle hub or
inject a small amount of contrast to confirm duct puncture on
fluoroscopy.

66. • Once a satisfactory position of the needle is confirmed, an adequate
amount of contrast material is injected and various projections of the
biliary tree are obtained to evaluate the obstructive pathology.
Images are taken in PA, RAO and LAO views.
POST PROCEDURAL CARE
Provided all has gone well, no specific post-procedural care is required,
other than routine cardiovascular observations.

67. Contd…
• To ease passage of endoscope, patients throat is sprayed with a
local anesthetic(4%, 50-100 mg xylocaine) ,this causes temporary
pharyngeal paresis
• Pt lies on the left side on fluoroscopy table
• A flexible camera (endoscope) is inserted through the mouth, down
the esophagus, into the stomach, through the pylorus into the
duodenum to the ampulla of Vater
• A polythene catheter or cannula with prefilled CM is inserted
into the ampulla

68. Contd…
• A test dose of CM is injected under the fluoroscope to determine the
position of cannula
• Then radio contrast is injected into the bile ducts and/or pancreatic
duct
• If it is desirable to opacify both the biliary tree and pancreatic duct
then the latter should be cannulated .
• A sample of bile should be sent for culture and sensitivity if there is
evidence of biliary obstruction.

69. Contd…
• Fluoroscopy is used to look for blockages, or other lesions such as
stones ,also spot images are taken as required when duct filling
completes
• Oblique spot radiographs may be taken to prevent overlap of
common bile duct and pancreatic duct

70. Filming‘s
• CM drains from normal ducts within approx 5min radiographs must be
exposed immediately
• PANCREAS
• prone , both oblique
• BILE DUCT
1. Early filling to show calculi
A. prone - straight and post. Obliques
B. supine - straight , both obliques trendlengberg to fill intrahepatic duct ,
semi erect to fill lower end of common bile duct and GB.

72. Contd….
2. films after removal of endoscopewhich may obscure the duct
3. delayed films to assess the GB andemptying the common bile duct

73. ERCP IN THERAPEUTIC USES
When ERCPs are done to allow some sort of treatment ,they are
referred to as therapeutic ERCP
It includes;
A . Sphincterotomy
B . Stone removal
C . Stent placement
D . Balloon dilatation
E . Tissue sampling

74. Indication for therapeutic ERCP
• Bile duct stone
• Bile duct injury
• Bile duct stricture due to tumor or scarring
• Post cholecystectomy syndrome
• Some cases of pancreatitis
• Replacement of an obstructed ampullary stent

75. Sphincterotomy
• It is cutting the muscle that surrounds the opening of the ducts or
Papilla
• The cut is made while looking through the ERCP scope at the papilla
• A small wire on a sphincterotome uses electric current to cut the
tissue
• The sphincterotome has a special cautery unit that seals the tissue
after the cut and prevent bleeding

76. Before papillotomy
During papillotomy

77. After papillotomy

78. Stone remove
• Most common treatment through ERCP
• Stones may have formed in the GB and travelled into the bile duct or
may form in the duct itself
• After sphincterotomy the opening of the bile duct is enlarged and
stones can be pulled from the duct into the bowel
• A variety of balloon and baskets attached to specialized catheter can
be passed through ERCP scope into the ducts allowing stone removal

79. Stone remove

80. EXTRACTION WITH DORMIA BASKET
• Dormia basket is useful device for stone extraction.
• It is made up of 4 parallel wires
• Stone can be trapped in- between and extracted with it’s content via
papilla

82. Mechanical lithotripsy
• The basket for lithotripsy in the bile duct shows a very similar design
to retrieval basket although tensile strength of the wire is much
higher.
• A metal lithotripsy is pushed over the basket to stabilize device to
the higher occurring force.
• The forces are mechanically applied to the baskets wire to cut
stone to pieces.
• The fragments are then extracted one by one from the bile duct

84. Stent placement
•Indications
-To treat obstruction in the bile duct
-To treat biliary leak
 Stents are placed into the bile or pancreatic duct to bypass stricture
or narrow part of the duct
Two types of stents plastic or metal are commonly used
Plastic stent looks like a small straw

85. • The plastic stent is pushed through ERCP scope into the blocked
duct to allow normal drainage
• Plastic stent is placed temporarily and should be removed in follow up
ERCP
• The metal stent is flexible and springs open to a larger diameter than
plastic stent
• Metal stent are placed permanently

89. Balloon dilation
ERCP catheter fitted with dilating balloon is placed across a narrow
area or stricture
Often performed when the case of narrowing is benign
After balloon dilation a temporary stentis placed for few month to
help drainage

91. • In ERCP tissue sampling is a technique to take samples of tissue from
the papilla or from bile or pancreatic duct
• There are several diff. sampling technique although the most
common is to brush the area with subsequent examination of the
cells obtained
• Tissue samples can help to decide if a stricture or narrowing is due to
cancer

92. Contd..
Cytology forceps

93. Contd..
Brush cytology

95. EUS (ENDOSCOPY ULTRASOUND)
• EUS employs a duodenoscope with distal ultrasound probe that can
be used to image organs , blood vessels , lymph nodes and bile ducts
• The EUS scope is advanced within the gastrointestinal tract that
allows visualization of the pancreas and adjacent structure
• Preferable in high risk pt in ERCP or potential complication to ERCP

97. • CBD stone

98. DIVERTICULA

99. Biliary stone Gallstone

100. Biliary stenosis Biliary dilation

101. STENOSIS

102. Aftercare
• Nil orally (0.5-3hrs) until sensation has returned to the pharynx
• Vitals should be checked half-hourly for 6 hrs
• Maintain antibiotic in case of biliary or pancreatic obstruction
• Serum/urinary amylase if pancreatitis is suspected

103. COMPLICATIONS
• GENERAL
- common to all endoscopic procedure
- Medication reaction
- Oxygen desaturation
- Cardio pulmonary accident
- Hemorrhage and perforation induce by instrument passage.

104. Advancement in ERCP
• INTRADUCTAL ENDOSCOPY
• Describe the use of an endoscope to evaluate the biliary and
pancreatic duct.
• It allows direct visualization of the biliary and pancreatic duct.
• This technique is developing that promises greater opportunity
to provide improved diagnosis and therapy regarding lesion in the
biliary and pancreatic duct.

105. Radiation protection
• Decrease fluoroscopy time
• Use time alarm/reminder
- Alarm rings after a predetermined duration of fluoroscopy time
(5min)
• Use pulse fluoro mode (not continuous)
• Maintain appropriate distance
• Avoid magnification mode
• Use collimator.

106. T-TUBE CHOLANGIOGRAPHY
• A T-Tube cholangiogram is a procedure done after a patient’s
gallbladder has been removed and a surgeon has placed a tube in the
patient’s right side to drain the bile ducts.
• The bile ducts and first section of the small bowel (duodenum) will
be imaged
• This exam takes about 30 minutes.

108. Contd
• Indications
• Patient's with possibility of residual small gallstones post cholecystectomy
obstructive jaundice
• Bile duct stricture
• Surgeon unable to explore bile duct during cholecystectomy surgery
• Contraindications
• Contrast or iodine allergy
• Pregnancy (? pregnancy test required)
• Barium study within last 3 days
•

109. Prepare for a T-Tube Cholangiogram
• Do not eat or drink anything after 10:00 pm (22:00) the night before test.
• Can still take your medications with a small amount of water.
• Notify the technologist if you have any allergies (especially to iodine or
• seafood).

110. What will happen during the Tube Cholangiogram
• Contrast medium will be injected through the T-Tube while taking x- ray
images.
• Pt. may be asked to hold your breath. While injecting the contrast media.
• This test takes about 15-30 minutes
After the T-Tube Cholangiogram pt. will be able to resume normal activity.

111. Contd..
• TECHNIQUE
• Contrast media should be diluted with saline so that small biliary stones are not
obscured by an overly dense contrast media
• Preliminary/scout images are important.
Failure to take a preliminary/scout image is one of the most frequently made errors
by Radiology Registrars performing fluoroscopy procedures
• Air-bubbles can often be distinguished from stones by their behaviour- air bubbles
tend to float 'up hill' and can change shape and may separate into two smaller
bubbles.
• If the examination is marred by air bubbles, the biliary system can be flushed with
saline and the study repeated.
• If there is any question of distal obstruction, a delayed drainage image should be
obtained.

112. • This is an AP/PA supine T-tube cholangiogram image.
• The biliary tree is outlined with contrast medium.
There appears to be extravasation of contrast medium outside the
biliary tree and minimal contrast in the duodenum.