Percutaneous transhepatic cholangiography (PTC) is a radiographic technique used to visualize the biliary tree. It can be used diagnostically when other imaging methods like MRCP or ERCP have been unsuccessful. PTC involves inserting a needle into the liver under imaging guidance and injecting contrast dye to outline the biliary ducts. It is indicated when ERCP has failed or is not possible, to evaluate biliary obstructions or leaks, or as the first step in percutaneous biliary interventions like stent placement. Potential complications include bile leakage, peritonitis, bleeding, and cholangitis.

1. MAAJID MOHI UD DIN MALIK
LECTURER COPMS AU,
BATHINDA PUNJAB
PERCUTANEOUS TRANSHEPATIC
CHOLEDOCHOGRAPHY

2. PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY (PTC)
Percutaneous transhepatic
cholangiography (PTC) is a radiographic
technique employed in the visualization of
the biliary tree and can be used as the first
step in a number of percutaneous biliary
interventions (e.g. percutaneous
transhepatic biliary stent placement)

3. INDICATIONS
Purely diagnostic percutaneous transhepatic cholangiography
is performed when other less invasive methods of imaging the
biliary tree (e.g. MRCP, ERCP, CT IVC) have proven
unsatisfactory.
Indications include:
 Failed ERCP / ERCP not feasible (e.g. patients with
gastrojejunostomy)
 Biliary system delineation in presence of intra- and
extra-hepatic biliary calculi
 To identify an obstructive cause of jaundice, and
differentiate from medically treatable cause.

4. Anatomic evaluation of
complications of ERCP
Delineating bile leaks
Percutaneous biliary stent placement
Postoperative stricture dilatation
Stone removal

5. CONTRAINDICATIONS
Bleeding
Gross ascites
Biliary tract sepsis

6. PROCEDURE
Preprocedural evaluation
Before beginning the procedure it is imperative
that one should evaluate all the available imaging
data of the patient and understand the correct
indication for this invasive procedure. Routine
investigations that need to be looked at are liver
function tests, baseline blood investigations like
full blood count, coagulation profile if any of
these tests are abnormal corrective measures
should be taken before the procedure.

7. POSITIONING/ROOM SET UP
Usually, the procedure is done under local
anesthesia with or without sedation
(depending upon the patient cooperation).
If the PTC is the first step in a likely
painful or time consuming percutaneous
biliary intervention, then many centers
would prefer to have the patient
anaesthetized.

8. • An IV cannula should be placed to maintain
vascular access throughout the
procedure. Preprocedural broad-spectrum
antibiotics are usually administered via an
intravenous route.
• Routine skin preparation and draping
should be performed, exposing a large area
overlying the liver, such that a number of
trajectories can be employed if need be.

9. EQUIPMENT
• Routine trolley pack
• Chiba needle (22G, 15 cm long)
• Connecting tube
• Water-soluble iodinated contrast

10. 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.

11. 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.

12. POST PROCEDURAL CARE
Provided all has gone well, no specific
post-procedural care is required, other
than routine cardiovascular
observations.

13. COMPLICATIONS
• Bile leakage
• Biliary peritonitis
• Bleeding
• Cholangitis

14. PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY

15. PTC

16. IMAGING AND INTERVENTIONAL
TECHNIQUES IN SURGERY

17. ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY

18. ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
ERCP is a procedure that enables us to examine
the pancreatic and bile ducts. A bendable, lighted
tube (endoscope) about the thickness of your
index finger is placed through your mouth and
into your stomach and first part of the small
intestine (duodenum). In the duodenum a small
opening is identified (ampulla) and a small plastic
tube (cannula) is passed through the endoscope
and into this opening. Dye (contrast material) is
injected and X-rays are taken to study the ducts
of the pancreas and liver.

20. WHY IS AN ERCP
PERFORMED?
ERCP is most commonly performed to diagnose
conditions of the pancreas or bile ducts, and is also used
to treat those conditions. It is used to evaluate symptoms
suggestive of disease in these organs, or to further clarify
abnormal results from blood tests or imaging tests such
as ultrasound or CT scan. The most common reasons to
do ERCP include abdominal pain, weight loss, jaundice
(yellowing of the skin), or an ultrasound or CT scan that
shows stones or a mass in these organs.

21. ERCP may be used before or after gallbladder
surgery to assist in the performance of that
operation. Bile duct stones can be diagnosed and
removed with an ERCP. Tumors, both cancerous and
noncancerous, can be diagnosed and then treated
with indwelling plastic tubes that are used to bypass
a blockage of the bile duct. Complications from
gallbladder surgery can also sometimes be diagnosed
and treated with ERCP.
In patients with suspected or known pancreatic
disease, ERCP will help determine the need for
surgery or the best type of surgical procedure to be
performed. Occasionally, pancreatic stones can be
removed by ERCP.

23. WHAT PREPARATION IS REQUIRED?
The stomach must be empty, so you should not eat or
drink anything for approximately 8 hours before the
examination. Your physician will be more specific
about the time to begin fasting depending on the time
of day that your test is scheduled.
Your current medications may need to be adjusted or
avoided. Most medications can be continued as usual.
Medication use such as aspirin, Vitamin E, non-
steroidal anti-inflammatories, blood thinners and
insulin should be discussed with your physician prior
to the examination as well as any other medication you
might be taking. It is therefore best to inform your
physician of any allergies to medications, iodine, or
shellfish.

24. It is essential that you alert your physician if you
require antibiotics prior to undergoing dental
procedures, since you may also require antibiotics
prior to ERCP.
Also, if you have any major diseases, such as heart or
lung disease that may require special attention
during the procedure, discuss this with your
physician.
To make the examination comfortable, you will be
sedated during the procedure, and, therefore, you
will need someone to drive you home afterward.
Sedatives will affect your judgment and reflexes for
the rest of the day, so you should not drive or operate
machinery until the next day.

25. WHAT CAN BE EXPECTED DURING THE
ERCP?
Your throat will be sprayed with a local anesthetic before
the test begins to numb your throat and prevent gagging.
You will be given medication intravenously to help you
relax during the examination. While you are lying in a
comfortable position on an X-ray table, an endoscope will
be gently passed through your mouth, down your
esophagus, and into your stomach and duodenum. The
procedure usually lasts about an hour, but this may vary
depending on the planned intervention. The endoscope
does not interfere with your breathing.

26. Most patients fall asleep during the procedure or
find it only slightly uncomfortable. You may feel
temporarily bloated during and after the
procedure due to the air used to inflate the
duodenum. As X-ray contrast material is injected
into the pancreatic or bile ducts, you may feel
some minor discomfort.

28. WHAT HAPPENS AFTER ERCP?
You will be monitored in the endoscopy area for 1-2 hours
until the effects of the sedatives have worn off. Your
throat may be sore for a day or two. You will be able to
resume your diet and take your routine medication after
you leave the endoscopy area, unless otherwise
instructed.
Your physician will usually inform you of your test results
on the day of the procedure. Biopsy results take several
days to return, and you should make arrangements with
your physician to get these results. The effects of sedation
may make you forget what you were instructed to do
after the procedure. Call your surgeon’s office for the
results or any further questions.

29. WHAT COMPLICATIONS CAN
OCCUR?
ERCP is safe when performed by physicians who have
had specific training and are experienced in this
specialized endoscopic procedure. Complications are
rare, however, they can occur. Pancreatitis due to
irritation of the pancreatic duct by the X-ray contrast
material or cannula is the most common complication. A
reaction to the sedatives can occur. Irritation to the vein
in which medications were given is uncommon, but may
cause a tender lump lasting days to a few weeks. Warm
moist towels will help relieve this discomfort.

30. If your ERCP included a therapeutic procedure such
as removal of stones or placement of a stent (drain),
there are additional small risks of bleeding or
perforation (making a hole in the intestine or bile
duct). Blood transfusions are rarely required. It is
important for you to recognize the early signs of
possible complications and to contact your physician
if you notice symptoms of severe abdominal pain,
fever, chills, vomiting, or rectal bleeding.

31. ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY

32. ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY

33. ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY