The radiological procedure of percutaneous transhepatic cholangiography (PTC)

1. (PTC )PERCUTANEOUS
TRANSHEPATIC CHOLANGIOGRAPHY
Yashawant ku.Yadav
Bsc.MIT 2nd year
(NAMS) Bir Hospital

2. 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. INTRODUCTION
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. ANATOMY

5.  This organ is not only special due to its function, but also due to its organization.
Specifically, you can study and think of the liver in two separate ways - an anatomical one
divided into lobes and a functional one divided into sectors and segments. In a way it
follows a similar logic to the lungs.
 However, the distribution of the portal blood supply and biliary drainage of the liver allows
the organ to be functionally divided into four sectors, which are subsequently divided to
give a total of eight segments

6. BILIARYTREE ANATOMY

7. CONTD..

8. CONTD..

9. CONTD..

10. 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 gastroduodenal ulcer

11. CONTD..

12. CONTD..
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

13. CONTRAINDICATIONS
 Bleeding tendency: -
1. platelets less than 100 000 –
2. prothrombin time 2 s greater than control
 Biliary tract sepsis
 a patient who is unfit for surgery
 Hydatid disease.
 Positive serological test for Australian antigen/HIV
 Ascites
 Contrast hypersensitivity

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

15. EQUIPMENT’S
 Fluoroscopy unit with spot film device and tilting table
 Chiba needle (a fine, flexible 22-G needle, 18-cm long).
Skin antiseptic solutions: Povidone iodine, Spirit, Savlon .
Sterile towels, Gauzes, Cotton swabs, Scissors, Gloves.
 Disposable syringes, Collection bags.
Local anesthetic injection: Lignocaine 2%.
 Catheters –
External drainage catheters –
Internal drainage catheters –
Balloon dilatation catheters

16. PATIENT PREPARATION
 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
patient clearly.
 Prophylactic antibiotic is given to the patient from 24 hours before the
examination and upto 3 hours after the examination.

17. TECHNIQUE
1. Preliminary film:
 Patient lies supine on the table and the preliminary film of the right
upper quadrant of the abdomen up to the upper iliac crest centering 2
inches above the right lower costal margin in the mid-clavicular line is
taken.
 It use to conform the location of dilation of biliary duct and location of
liver

18. CONTD..
 PTC performed as a sterile technique with a patient on the fluoroscopic table
which preferably tilting table
 Two approaches:-
1. Right flank approach ( Lateral)
2. Epigastric approach
 Procedure is done under the local anesthesia with i.v sedation and analgesic with
appropriate patient monitoring .

19. RIGHT FLANK APPROACH
Pt 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 .

20. CONTD..
 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

21. CONTD…
 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 on CC angulation with
out withdrawing tip from liver .

22. CONTD..
 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

23. AFTER CARE
Ask patient to 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.

24. COMPLICATIONS
Leakage of bile into the peritoneal cavity .
Intraperitoneal hemorrhage .
Septicemia
Hypotension
Formation of biliary fistula
Rarely mortality.

25. FINDINGS

32. REFERENCE'S
1. A Guide to Radiological Procedures (Stephen chapman)
2. Radiological procedure guide . ( Avinash sir )
3. Google scholar ( articles ) PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY WITH THE CHIBA NEEDLE
4. Radiological Procedures - A Guideline – ( Dr. Bhushan N. Lakhkar)