The document discusses various imaging techniques for the biliary tract, including oral cholecystograms, intravenous cholangiograms, and cholangiography. An oral cholecystogram involves taking contrast agent pills before an X-ray exam to visualize the gallbladder. Intravenous cholangiograms inject iodine dye intravenously, which is then excreted in bile ducts and gallbladder to image them. Both techniques are now rarely used due to availability of more accurate ultrasound, CT, and MRI exams. Cholangiography refers more broadly to X-ray imaging of the bile ducts.

1. MAAJID MOHI UD DIN MALIK
LECTURER COPMS AU
BATHINDA PUNJAB
IMAGING OF BILIARY TRACT

2. BILIARY TRACT
• The biliary tract, (biliary tree or biliary system) refers to
the liver, gall bladder and bile ducts, and how they work together
to make, store and secrete bile. Bile consists of
water, electrolytes, bile acids, cholesterol,
phospholipids and conjugated bilirubin. Some components are
synthesized by hepatocytes (liver cells), the rest are extracted
from the blood by the liver.
• Bile is secreted by the liver into small ducts that join to form
the common hepatic duct. Between meals, secreted bile is stored
in the gall bladder. During a meal, the bile is secreted into
the duodenum to rid the body of waste stored in the bile as well as
aid in the absorption of dietary fat and oils.

4. WHAT IS AN ORAL CHOLECYSTOGRAM?
• An oral cholecystogram is an X-ray
examination of your gallbladder. Your
gallbladder is an organ located in the
upper right-hand side of your
abdominal cavity, just underneath your
liver. It stores bile, a fluid produced by
your liver that aids in digestion and
absorption of fats from your diet.

5. • Oral refers to the oral medication you take
before the test. The medication is an iodine-based
contrast agent that makes your gallbladder more
clearly visible on the X-ray.
• This procedure is now rarely performed since the
first-line method for imaging of your gallbladder
is an abdominal ultrasound or CT scan typically
followed by a hepatobiliary scan or endoscopic
retrograde cholangiopancreatography. These
tend to be more accurate when it comes to
diagnosis of gallbladder conditions.

6. PURPOSE OF THE ORAL CHOLECYSTOGRAM
• The oral cholecystogram study is used to
diagnose problems related to your
gallbladder, such as gallbladder cancer
or decreased or blocked bile flow in the
biliary duct system of your liver.
• The X-ray can show inflammation of the
organ, a condition known as cholecystitis. It
can also reveal other abnormalities such
as polyps and gallstones.

7. INDICATIONS
• This study used to be indicated for
the evaluation of gallstones within
the gallbladder, and to assess the
cystic duct for obstruction.

8. CONTRAINDICATIONS
• Relative contraindications to this study include impaired
hepatic excretion due to liver disease or abdominal
illnesses that impair absorption, such as ileus, vomiting or
diarrhea as well as contrast allergy.

9. EQUIPMENT
• Basic fluoroscopic and plain film equipment.

10. PREPARING FOR ORAL CHOLECYSTOGRAM
 Preparing for oral cholecystogram is a multistep process.
What to eat two up to two days before:
 Two days before the test, you generally can eat normal
meals. If instructed otherwise, follow your doctor’s
directions closely to ensure accurate test results.
What to eat the day before:
 Follow a low-fat or fat-free diet the day before the
procedure. Ideal choices include:

11. TAKING THE CONTRAST MEDICATION BEFORE
THE TEST
• The evening of the day before the test, you’ll take the
contrast agent medication. The medication is available in
pill form. You’ll take a total of six pills, one each hour. Your
doctor will tell you what time to start taking the first pill.
• Take each dose of medication with a full glass of water. On
the evening before the test, don’t eat any solid foods after
you’ve started taking the contrast agent. Drinking water is
fine until midnight. By then, you should be fully fasting. You
should also refrain from smoking cigarettes or chewing
gum.

12. WHAT TO EXPECT THE MORNING OF THE ORAL
CHOLECYSTOGRAM
• Don’t eat or drink anything the morning of your procedure. Ask
your doctor ahead of time if you’re allowed to take routine
medications, or if you should skip it. You may be able to take a
few sips of water, but be sure to ask your doctor first.
• If you’ve completed certain types of gastrointestinal imaging in
the few days before your oral cholecystogram, your doctor may
recommend a rectal laxative, or enema, to clear your bowels.
• The contrast agents used in certain imaging tests, such as
an upper gastrointestinal series or barium enema, can obscure
your gallbladder. Clearing your bowels makes your gallbladder
more visible.

13. ORAL CHOLECYSTOGRAM PROCEDURE
• Oral cholecystogram can be performed as an
outpatient procedure while you’re awake. You might
be given a special high-fat drink to stimulate your
gallbladder to contract and release bile, which can
help your doctor identify problems.
• The doctor will likely have you lie down on an exam
table, but you may be asked to stand. This depends
on the what views of your gallbladder are required.

14. • Then, they’ll use an X-ray camera called a
fluoroscope to see your gallbladder. You may be able
to see what the doctor is seeing on a monitor,
depending on the room setup. Your doctor will take X-
rays throughout the examination.
• Oral cholecystogram is painless. However, you might
experience diarrhea, nausea, or stomach
cramping due to the contrast agent. If done as an
outpatient imaging study, typically you can go home
after the procedure, as long as no complications
arise.

15. RISKS OF ORAL CHOLECYSTOGRAM
• Severe risks caused by oral cholecystogram are rare. Some
people may experience mild temporary symptoms, such as:
• diarrhea
• nausea
• vomiting
• Some people may also experience problems caused by an
adverse reaction or mild allergic reaction to the contrast
agent. Allergy or intolerance symptoms can include:
• rash
• itching
• nausea

18. CALCIFIED STONES

20. INTRAVENOUS CHOLANGIOGRAM (IVC)
• The intravenous cholangiogram or IVC is a
radiologic (x-ray) procedure that is used primarily
to look at the larger bile ducts within the liver and
the bile ducts outside the liver. The procedure can
be used to locate gallstones within these bile ducts.
IVC also can be used to identify other causes of
obstruction to the flow of bile, for example,
narrowing's (strictures) of the bile ducts and
cancers that may impair the normal flow of bile.

21. HOW IS AN INTRAVENOUS
CHOLANGIOGRAM DONE?
• To do an IVC, an iodine-containing dye is injected
intravenously into the blood. The dye is then
removed from blood by the liver which excretes it
into the bile. The iodine is concentrated enough
just as it is secreted into bile that it does not need
to be further concentrated by the gallbladder in
order to outline the bile ducts and any gallstones
that may be within them. The gallbladder is not
always seen on an IVC since the iodine-containing
bile may bypass the gallbladder entirely and empty
directly into the small intestine.

22. INTRAVENOUS CHOLANGIOGRAM PROCEDURE
• Intravenous Cholangiography (IVC) is rarely performed
since, the relatively higher occurrence of reactions to
the contrast medium and the availability of other
diagnostic imaging procedures. When Intravenous
Cholangiography (IVC) is done to study the biliary
ducts of cholecystectomized patients. It is also used to
study the biliary ducts and gallbladder of
noncholecystectomized patients when these structures
are not seen by OCG and when, because a patients has
a symptoms of vomiting or diarrhea, a patient cannot
retain the orally administered medium long enough for
its absorption.

23.  In cases of nonvisualization, immediately instituting the intravenous procedure may save time
for the radiology department and the patient as well as spare the patient the rigors of having
the intestinal tract prepared again.

24. POSITION OF PATIENT
• Place the patient in the supine position for a preliminary or scout
radiograph of the abdomen.
Place the patient in the RPO position 15° to 40° for an AP oblique
projection of the biliary ducts.
Obtain a scout or localization radiograph and / or tomogram to check
for centering and exposure factors.
Advice the patient that a hot flush may occur when the contrast
medium is injected.
Timed from the completion of the injection, duct studies are ordinarily
obtained at 10 minutes intervals until satisfactory visualization is
obtained. Maximum opacification usually requires 30 to 40 minutes.

25. INDICATIONS
• The IVC is not used as much today as it was. Its use always
was limited, because it did not work when there was more
than a minimal amount of jaundice, and many of the
conditions it was used to detect also caused substantial
jaundice. The IVC has been largely replaced by other
diagnostic procedures—by ERCP (endoscopic retrograde
cholangiopancreatography), endoscopic ultrasound and,
increasingly, by MRI cholangiography, none of which are
affected by jaundice. It is sometimes used when ERCP is
unsuccessful.

26. CONTRAINDICATIONS:
• Intravenous cholangiography is not generally
indicated for patients who have liver disease or for
those whose biliary ducts are not intact. The
probability of obtaining radiographs of diagnostic
value greatly decreases when the patient’s bilirubin
is increasing or when it exceeds 2mg /dl. In cases
of obstructive jaundice and postcholecystectomy,
ultrasound has become the preffered technique for
demonstrating the biliary system.

27. RADIOGRAPHY OF THE BILIARY SYSTEM

28. POSTOPERATIVE CHOLANGIOGRAPHY

29. CHOLANGIOGRAPHY