Ptc )percutaneous transhepatic cholangiography

The radiological procedure of percutaneous transhepatic cholangiography (PTC)

1. ( Ptc ) percutaneous transhepatic cholangiography Yashawant ku . Yadav Bsc.MIT 2 nd 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. Biliary tree anatomy

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10. Indications Biliary obstruction that might be due to: Choledocholithiasis Chronic pancreatitis, cancer ampullary stenosis Haemobilia Benign strictures: post-traumatic, post-operative, post- inflammatory or post-infective. 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: - platelets less than 100 000 – 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 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:- Right flank approach ( Lateral) 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 Frontal LPO, Lateral 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

26. Reference's A Guide to Radiological Procedures (Stephen chapman) Radiological procedure guide . ( Avinash sir ) Google scholar ( articles ) PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY WITH THE CHIBA NEEDLE 4. Radiological Procedures - A Guideline   – (  Dr. Bhushan N. Lakhkar )