What is percutaneous transhepatic cholangiography?
Percutaneous transhepatic cholangiography is a minimally invasive diagnostic and/or therapeutic procedure to evaluate and treat obstruction in the biliary tract. The biliary tract is the drainage system for the liver and gallbladder.
The procedure involves injection of a contrast dye into the bile duct to produce an image of the biliary tract using continuous X-ray (fluoroscopy) to guide the surgeon. An ultra-sonar scan may also be used for the procedure. A catheter may be introduced through the same path if bile drainage is required.
Why is percutaneous transhepatic cholangiography performed?
Percutaneous transhepatic cholangiography is usually performed when noninvasive diagnostic procedures such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are not feasible.
Percutaneous transhepatic cholangiography is performed to find out the cause and location of biliary obstruction. The procedure is usually a preliminary step in treatment of biliary diseases.
The biliary tract, also known as the biliary system or biliary tree, consists of the liver, gallbladder and a network of drainage ducts. The biliary tract produces, stores and releases bile into the beginning portion of the intestine (duodenum). Bile fluid aids in digestion of fats and fat-soluble vitamins. Bile also carries the waste processed by the liver, to the duodenum to be excreted.
The liver produces bile, 50% of which is stored in the gallbladder. The hepatic ducts from the liver and the cystic duct from the gallbladder join to form the common bile duct that carries the bile to the duodenum. If the bile flow is obstructed in any part of the biliary system, it leads to jaundice and associated complications.
Causes of bile duct obstruction include
- Bile duct stones (choledocholithiasis)
- Gallstones (cholelithiasis)
- Bile duct strictures
- Inflammation and scarring of bile ducts (primary sclerosing cholangitis)
- Inflammation of the biliary system
- Inflammation of pancreas (pancreatitis)
- Systemic infections
- Benign tumors
- Abnormal tissue growth
- Cancer of
- pancreas
- bile duct
- liver
- gallbladder
- secondary cancer due to other cancers (metastasis)
Purely diagnostic percutaneous transhepatic cholangiography is uncommon, the procedure usually also includes placement of a catheter for draining the bile fluid.
How is percutaneous transhepatic cholangiography done?
Percutaneous transhepatic cholangiography is usually performed by an interventional radiologist in the radiology lab. The procedure may take up to an hour, and is performed using local anesthesia and mild sedation. Some people may require a nerve block with an epidural injection, or rarely, general anesthesia.
Preparation
Prior to procedure, the patient
- Undergoes imaging tests, and blood tests to check coagulation parameters and liver function.
- Will be administered a course of antibiotics to prevent infection.
- Must avoid eating anything for four to six hours prior to the procedure.
- Must check with the doctor before taking any regular medications.
- Must inform the doctor of any allergies.
- Must inform the doctor if pregnant.
Procedure
The interventional radiologist
- Administers painkillers and mild sedation through an IV line.
- Administers local anesthesia at the site chosen for needle insertion.
- Monitors the patient’s heart rate and blood pressure during the procedure.
- Inserts the needle through the liver (transhepatic) into the bile duct, from the right or middle of the upper abdomen, with ultra-scan and fluoroscopy guidance.
- Removes bile fluid and tissue for biopsy.
- Injects the contrast dye into the bile duct.
- Records X-ray films in the fluoroscope as the contrast dye spreads and reveals the biliary system by turning it opaque.
- Withdraws the needle if no intervention is required.
- Places a catheter for bile drainage, if required.
Post-procedure
- The patient will be able to leave shortly after the procedure or the next day, depending on the type of anesthesia used.
- The patient may experience some amount of post-procedure pain that can be resolved with painkillers.
- Further treatment will depend on examining the fluoroscopic films.
What are the risks and complications of percutaneous transhepatic cholangiography?
Percutaneous transhepatic cholangiography is generally a low-risk procedure. Potential complications include:
- Allergic reaction to the dye material
- Hemorrhage
- Infection
- Inflammation of the abdominal lining (peritonitis)
- Bile leakage
- Bile duct inflammation
- Injury to the liver
- Injury to the gallbladder
- Bowel perforation
- Puncture of the lung (pneumothorax), very rarely
- Sepsis
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iohexol
Iohexol is a nonionic water-soluble contrast agent used for X-ray (radiographic) imaging. Iohexol may be administered orally or as an injection depending on the type of radiologic procedure required. Common side effects of iohexol include headache, nerve pain (neuralgia), nausea, vomiting, backache, neck ache, stiffness, skin reactions, allergic reactions, and others.propofol
Propofol is an intravenous anesthetic drug used for general anesthesia and sedation during surgical procedures. Common side effects of propofol include injection site burning, stinging or pain; low blood pressure (hypotension), reduced cardiac output, elevated blood pressure (hypertension), pause in breathing (apnea), lung impairment (respiratory acidosis), impaired movement, high level of emulsified fats in the blood (hyperlipidemia), and high triglyceride level in blood (hypertriglyceridemia). Abuse of propofol can cause death and other injuries.succinylcholine
Succinylcholine is a skeletal muscle relaxant used for medical procedures done under general anesthesia, including tracheal intubation, mechanical ventilation, and surgeries. Common side effects of succinylcholine include postoperative muscle pain, jaw rigidity, muscle twitch (fasciculation), respiratory depression, cessation of breathing (apnea), low or high blood pressure (hypotension or hypertension), irregular heart rhythms (cardiac arrhythmias), slow or rapid heartbeat (bradycardia or tachycardia), cardiac arrest, increase in intraocular pressure (IOP), high blood potassium levels (hyperkalemia), severe life-threatening drug reaction with excessively high temperature (malignant hyperthermia), salivary gland enlargement, excessive salivation, rash, hypersensitivity reactions, and others.