The document discusses various radiographic procedures used to examine the gallbladder and biliary tract, including oral cholecystography, cholangiography, T-tube cholangiography, and ERCP (endoscopic retrograde cholangiopancreatography). It provides details on the indications, contraindications, procedures, and imaging for each type of examination. The various procedures are used to visualize the gallbladder and bile ducts, detect gallstones or other abnormalities, and manage biliary diseases.

1. Aroosa Manazir
Lecturer
Radiology Deprtment
Afro-Asian Institute affiliated with GCUF
Lahore, Pakistan

3.  Oral Cholecystography
 Cholangiography
 T-Tube Cholnagiography
 Endoscopic Retrograde
Cholngiopancreatography

4.  Radiographic study of
gall bladder and
sometimes biliary
channels too by the
oral administration of
contrast media.

5.  The gallbladder is a pear-shaped, hollow
structure located under the liver and on the
right side of the abdomen. Its primary
function is to store and concentrate bile, a
yellow-brown digestive enzyme produced by
the liver

7.  Suspected gallbladder disease
 To determine or rule out the presence of
intermittent obstruction of the bile ducts
 Recurrent biliary disease after biliary surgery
 Inflammation of organ
 Tumors
 Gallstones
 Other abnormalities like polyps
 Cystic duct and common bile duct may also
be seen

8.  Severe hepatorenal disease
 Acute cholecystitis
 Iodine sensitivity
 Pregnancy
 Dehydration
 IV choledogram within previous week

9.  Telepaque
 Biloptin
 Cholibrin

10.  Laxative 2 days prior to examination
 Fat containing evening meal on the evening
prior to contrast study
 Prone 20o LAO peliminary film is taken when
appointment is made
 CM is taken with water 14 hours pior to
appointment
 Food is forbidden untill the examination is
completed

11.  6 tablets of telepaque orally night before the
examination
 A prone oblique view with righr side raised to 200 is
tken after 12-16 hours for GB visulaization
 Then the patient usually lie in the supine position
and appropriate spot films for GB are taken
 Ask the patient to eat fatty meal
 After 30-40 minutes , films are taken to assess the
contractibility of GB and small filling defect (polyp
or stone)
 Cystic and common bile duct is usually seen after
post fatty meal film

13.  Preliminary film
 Patient Preparation
 Telepaque administration
 X-ay film after 12-16 hours
 Intake of fatty meal
 Another x-ray film after 30-
40 minutes

15.  Cholangiography is the x-
ray examination of the bile
ducts (biliary tract) after
administration of a contrast
dye to delineate these
channels on the images.
The procedure may be
performed either during
gallbladder removal surgery
(operative
cholangiography) or
postoperatively (T-tube
cholangiography).

16.  Operative
cholangiography involves
injecting the contrast dye
directly into the common
bile duct during open
surgery. X-ray films are
then used to guide the
surgeon and to identify
any stones or other
obstructions for
immediate removal.

17.  T-tube cholangiography is
typically performed 5 to 10
days after gallbladder
removal. Contrast dye is
injected through aT-
shaped rubber tube placed
in the common bile duct
during surgery, and x-rays
are then taken to detect
any residual stones or
other abnormalities

18. https://youtu.be/sFtRwDUTavo

19.  To exclude biliary tract calculi where
a) operative cholangiography was not
performed
b) the results of operative cholangiography
are not satisfactory or are suspected
 Assesment of biliary leaks following biliary
surgery

20.  None

21.  LOCM is preferred
 150mg I ml-1
 20-30 ml

22.  Antibiotics may be considered if previous
cholangitis or if immunosuppressed

23.  Coned Supine PA of the right side of the
abdomen

24.  Performed on or about 10th post-op day prior
to removingT-Tube
 Patient lies supine
 Drainage tube is clamped off near to the
patient and cleanedthoroughly with anti-
septic
 A 23G needle , extension tubing and 20 ml
syringe are assembledand filled with contrast.

25.  After all air bubbles have been removed , the
needle is inserted into the tubing between
patient and clamp.
 The injection is made under fluoroscopic
control.
 Volume of contrast medium depends on duct
filling.
 In case of liver transplant , only a small
volume is injected (10ml).

26.  Images during filling.
 PA andOblique after
satisfactory
opacifiction of biliary
system.

27.  None

28.  Due to contrast medium
 Due to technique

30.  Percutaneous transhepatic
cholangiography (PTC) is a
procedure performed for
diagnostic and/or therapeutic
purposes by first accessing the
biliary tree with a needle and then
usually shortly after that with a
catheter (percutaneous biliary
drainage or PBD). At some point
during the procedure, contrast is
injected into one or more bile
ducts (cholangiography) and also
possibly into the duodenum

31.  Prior to therapeutic intervention
 Place a percutaneous biliary stent
 Dilate a post-op biliary stricture
 Stone removal
 To facilitate ERCP
 Rarely for diagnostic purposes

32.  Bleeding tendency
 Biliary tract sepsis

33.  LOCM
 150mg ml-1
 20-60 ml

34.  Fluoroscopy unit
 Chiba needle (a fine,
flexible 22G needle ,
15-20cm long)
 Appropriate catheters
and wire for drainage

35.  Haemoglobin, platelets and prothrombin
time is checked, corrected if necessary.
 Prophylactic antibiotics e.g: ciprofloxacin
500-750mg oral before and after procedure
 NPO or clear fluids only for 4h prior to
procedure.
 Ensure, patient is well hydrated.
 Sedation and analgesia with oxygen and
monitoring

36.  Ultrasound to confirm
position of liver and
dilated ducts

37.  Patient lies supine
 Using US , a spot is marked over right or left
lobe of liver (Right lobe = intercostal b/w mid
& ant axillary lines. Left lobe = subcostal ,
left of xiphisternum in epigastrium)
 Marked spot site is anesthetized including
skin, deeper tissue and liver capsule.
 With the help of US or fluoro , Chiba needle is
inserted into the liver during arrested
respiration.

38.  Stillete is withdrawn and needle is connected
to syring and tubing prefilled with contrast.
 Contrast is injected
 If duct is not entered, withdraw needle to
app2-3cm and then further attemptsare
made by directing the needle cranially,
caudally, anteriorly or posteriorly.
 Excessive parenchymal inj should be avoided.
 If intrahepatic ducts are dilated , bile should
be sent for culture.

39.  Contrast isinjected to outline the duct
system.
 Don’t overfill obstructed biliary system.
 For diagnostic PTC , only the needle is
removed after suitable images are taken.

40.  PA
 LAO
 RAO
 Delayed Images

41.  Bed rest
 Pulse and BP
measurement half
hourly for 6 hrs.

42.  Due to contrast
 Due to technique

45.  Endoscopic — Refers to a tool called an
endoscope, a long, thin (about the width of your
little finger), flexible tube with a camera on the
end.
 Retrograde — Refers to the direction (backward)
in which the endoscope injects a liquid for X-rays
of parts of the GI tract called the bile duct system
and pancreas.
 Cholangio — Refers to the bile duct system.
 Pancreatography — Refers to the pancreas.
 The process of taking these X-rays is known as
cholangiopancreatography.

46.  Mangement of bile duct stones
 Management of biliary strictures
 Evaluation of ampullary lesions
 Patient unsuitable for MRCP or unavailibility
of endoscopic ultrasound.
 Chronic panreatitis
 Diffuse biliary disease
 Post-cholecystectomy syndrome

47.  Oesophageal obstruction
 Pyloric stenosis
 Gastric/duodenal obstruction
 Previous gastric surgery
 Severe cardiac/respiratory disease

48.  Pancreas
 LOCM 240/300 mg I
ml-1
 Bile ducts
 LOCM 150mg I ml-1

49.  Side-viewing endoscope
 Polythene catheters
 Fluoroscopic unit

50.  NPO 4-6 hrs prior to procedure
 Premedication
 Prophylactic antibiotics

51.  Prone AP and LAO of upper abdomen

52.  Patient is sedated until concious sedation is
achieved.
 Pharynx is anasthetized with 50-100mg
Xylocaine spray.
 Patient lies prone or on let side, then
endoscope is introduced.
 Catheter prefilled with contrast is inserted
into ampulla of vater

53.  A small test contrast injection is made to
check the site of cannulation.
 Both biliary tree and pancreatic duct has to
be opacified , the later should be cannulated
first.
 If bilary obstruction is evidenced, bile is sent
for culture and sensitivity.

54.  Pancreas
 Prone
 Both posterior obliques
 Bile ducts
 Early filling images (Prone & Supine )
 Images after removal of endoscope
 Delayed images

55.  NPO until sedation and conciousness is
reversed.
 Pulse , temp and BP half hourly for 6 hrs
 Maintain antibiotics

56.  Due to contrast medium
 Due to technique

57.  https://youtu.be/5VgoDJ31V_0
 https://youtu.be/h7gCWo1b7ZA