Overview of Percutaneous Cholangiography
Percutaneous cholangiography, often referred to as PC, is a medical procedure that doctors have been using for over 40 years. This technique helps doctors to examine both the inside (intrahepatic) and outside (extrahepatic) of the bile ducts – which are tubes that transport bile from your liver to your gallbladder and small intestine. Bile helps your body digest fats. This procedure can help find and manage a range of conditions that affect these bile ducts.
PC can be used in combination with two other techniques – endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) – to diagnose and treat various conditions that affect the bile ducts. ERCP is a procedure that uses a thin, flexible tube (endoscope) and ultrasound technology to view the inside of these ducts. This is a less invasive approach and is generally used more often. However, PC is a great alternative when ERCP doesn’t work, when the problem is in the upper part of the bile ducts, or when the patient isn’t a good fit for ERCP.
Anatomy and Physiology of Percutaneous Cholangiography
The successful operation of your liver and gallbladder depends on the good health of two components of your bile system, one inside your liver (intrahepatic) and one outside your liver (extrahepatic). The part inside your liver involves small tubes known as biliary ducts, blood vessels from the hepatic artery, and a big blood vessel called the portal vein. Usually, we can’t really see these small tubes in routine imaging such as scans, unless they become abnormally large due to disease.
The part outside your liver consists of various ducts, the gallbladder (where bile is stored), and the common bile duct (a tube that carries bile from the liver and gallbladder to the intestines). When a doctor is carrying out imaging studies of this system, they have to take into account any possible congenital (birth) anomalies. These can include unusual positioning or size of the tubes carrying bile, the cystic duct, cysts in your bile system (known as choledochal cysts), growths called diverticulum, and unusual places where bile and pancreatic ducts meet.
Choledochal cysts have their own classification system called the Todani system. Type I, which make up 80 to 90% of these cysts, are sausage-shaped and found outside the liver. Type II, which make up 3%, are shaped like pouches, and are found within the intrahepatic and extrahepatic ducts. With type III, making up 5%, we see a condition called choledochocele. Type IV includes multiple cysts in the ducts. If these are located both inside and outside the liver and are sausage-shaped, it’s type A, while those only outside the liver are type B. Finally, type V involves multiple cystic dilations inside the liver and is also known as Caroli disease.
Why do People Need Percutaneous Cholangiography
Percutaneous cholangiography (PC) is a procedure that gives doctors a view of your bile ducts, which are pathways leading from your liver to your small intestine. This technique can help doctors examine the upper, or “proximal,” parts of your bile ducts more easily than the lower, or “distal,” parts. The doctor might suggest PC for a variety of reasons.
For example, if you have a blockage in your bile ducts, a condition known as biliary obstruction, a doctor can use PC to identify the problem and figure out how to treat it. Similarly, PC can help if you have cholangitis, an inflammation of the bile ducts often caused by an infection. Another use of PC is to detect biliary leaks, where bile is escaping from your ducts into your abdomen.
PC is also helpful if a bile duct treatment called ERCP fails or if the doctor need to take a tissue sample. After you’ve had a liver transplant, you might have PC to check whether your bile ducts are functioning correctly.
Obstructions of your bile ducts can be due to various benign (non-cancerous) conditions such as gallstones or inflammation. Malignant (cancerous) causes of obstruction can occur due to the growth or invasion of a mass blocking your bile ducts, often due to pancreatic cancer.
PC doesn’t just diagnose problems, it can also treat them. For instance, if you have cholangitis, an infection in your bile, the doctor can drain the infected bile. PC is also useful in removing gallstones that are stuck within your bile ducts, widening the narrow parts of your bile ducts due to non-cancerous reasons, or inserting a tiny tube called a stent to keep your bile duct open if a cancerous growth is causing the obstruction.
When a Person Should Avoid Percutaneous Cholangiography
PC, a medical procedure, may not be suitable for certain circumstances. This usually happens when the risk of complications is high, or the possibility of success is low. Several factors relating to the patient’s overall health and the nature of their illness can influence the safety and success rate of PC.
Some of the absolute reasons why PC cannot be done include if the patient has an unfixable issue with their blood that prevents it from clotting properly (irreversible coagulopathy), or if they are taking a blood-thinning medication called clopidogrel that they can’t stop taking.
Relative reasons, not as strict but still important, include if the patient is taking aspirin, has a large amount of fluid build-up in their belly (large volume ascites), or has a problem with maintaining stable blood pressure and heart function (hemodynamic instability).
Most patients in these situations are severely ill, and medical professionals should try to resolve any of these issues if possible before considering this procedure.
Who is needed to perform Percutaneous Cholangiography?
A procedure called PC is typically performed in a special area of the hospital called the interventional radiology suite. This room is specifically equipped with imaging tools, supplies to administer medications, and specialized devices used for this procedure.
An Interventional Radiologist, a doctor trained in using imaging technology to guide treatment, leads the process. There are also technical assistants who help with imaging and intervention, contributing to make the procedure smooth.
A specialized type of nurse, called a registered nurse, is also present. Their role is to assist with nursing tasks, monitor the patient’s condition throughout the procedure, and provide necessary medications. Monitoring the patient immediately after the procedure is very important. This is done by the same registered nurse under the supervision of the radiologist to ensure the patient’s well-being and swift recovery.
Preparing for Percutaneous Cholangiography
Before any surgery or procedure that goes inside the body, doctors need to know a lot about the patient’s medical history. This includes any past surgeries or illnesses the patient had. The doctor will also need to look at any recent images (like MRI or CT scans) of the patient’s body to see if more detailed pictures are necessary.
The doctor will also do certain blood tests to make sure it’s safe to do the surgery or procedure. This is to help understand how the patient’s blood clots, which is important during any surgery. The tests include a Complete Blood Count (CBC), which measures different parts of the blood, a platelet count, measuring how many blood clotting cells there are, INR (International Normalized Ratio), a test that looks at how long it takes the blood to clot, and aPTT (activated partial thromboplastin time), another blood clotting test. Ideally, the INR number should be less than 1.5 and there should be more than 50,000 platelets per microliter of blood.
The patient may also receive antibiotics before the procedure, depending on their current symptoms and the results of these blood tests. To prepare for the procedure, the patient should not eat or drink anything for a certain period of time, according to the hospital’s rules for surgeries or procedures that require sedation or anesthesia.
How is Percutaneous Cholangiography performed
Percutaneous cholangiography, or PC for short, is a procedure that is usually done in a radiology department that has the necessary tools to perform it. This procedure is done by doctors called interventional radiologists, who have special training in using imaging technology to guide procedures like PC.
Usually, patients that need PC have an enlargement of bile ducts, the tubes that carry bile from the liver to the small intestine. This enlargement could be due to various health conditions and makes the bile ducts easier to see on imaging tests. These imaging tests could include ultrasound, magnetic resonance cholangiopancreatography (a kind of MRI), or computed tomography (a kind of CT scan). Depending on the doctor’s preference, they may use a combination of these techniques to help them see and access the bile duct. These imaging tests are key in planning the procedure.
However, if the bile ducts inside the liver, or intrahepatic biliary ducts, are not enlarged, PC could be difficult to do and might have a higher chance of complications.
Before the procedure starts, the patient would need to lie down on their back in a position that allows easy access to the liver. The area on the upper belly where the liver is located will be cleaned and covered in a sterile cloth to prevent infections.
The procedure involves several steps that can be painful, like putting a catheter (a thin tube used for medical procedures) through the skin and liver. Therefore, the doctor usually gives the patient local anesthesia and moderate sedation to numb the area and help the patient feel relaxed. If other procedures like biopsy or stenting (inserting a tube) are needed, sedation can be especially important.
Antibiotics that can kill gram-negative bacteria and enterococcal bacteria are also given, since these bacteria are common in an obstructed biliary system.
The doctor will choose an approach to access the bile duct, the most common of which is from the right side of the patient, slightly towards the front, below the tenth rib. Other methods can include from the left-side near the belly button or through the gallbladder. The doctor will choose the method based on the patient’s specific health condition.
After the doctor accesses the bile duct, a catheter is inserted to drain the bile and inject contrast (a dye used to make the bile ducts more visible on imaging tests). Then, the catheter can be advanced across an obstruction (blockage) into the duodenum (the first part of the small intestine), which allows the bile to drain both inside (into the intestine) and outside (through the catheter).
The findings from this procedure will then guide the next steps, which may include placing a tube to drain bile, dilating (widening) the bile duct, or placing a stent. These techniques won’t be discussed further here.
Possible Complications of Percutaneous Cholangiography
The rate of complications from percutaneous cholangiography, a non-surgical procedure used to examine the bile ducts, is quite low, being under 2%. However, it’s important to be aware that there are four potential major complications.
1. The first is hemorrhage or bleeding, which is considered the top concern because the procedure can be quite complex. The bleeding can happen inside the liver or within the belly cavity. A type of bleeding known as hemobilia can occur if the tract involved in the procedure touches a large blood vessel. Hemobilia can be severe, but this is rare, happening in between 0.2 to 4 percent of cases. Usually, the bleeding stops on its own. If it doesn’t, and the patient becomes unstable, additional procedures may be necessary. The best way to handle this is by blocking the blood supply to the area (called embolization). A separate method, hepatic arteriography, is used to find the source of the bleeding. The goal of embolization is to preserve as much of the healthy liver tissue as possible.
2. The second major complication is infection, including skin infection (cellulitis), infection of the bile ducts (cholangitis), and a severe infection that spreads through the bloodstream (sepsis). To lower the chances of getting an infection, patients are given antibiotics before the procedure. Cholangitis is more common in another type of procedure called ERCP. This is because during ERCP, the area where the pancreas and bile duct connect gets opened, which lets gut bacteria into the bile ducts. Cholangitis commonly happens when there’s some form of blockage due to disease. Both cellulitis and cholangitis are typically treated with oral antibiotics. If sepsis happens, the patient may need to be hospitalized and given IV antibiotics.
3. Another possible complication is biliary leaks, where bile, a fluid produced in your liver, leaks into the belly or lung area.
4. Lastly, a lung collapse, or pneumothorax, can happen if the procedure is done on the right side. Patients with pneumothorax are closely monitored with regular chest X-rays. If the condition does not improve, a chest tube may be needed to help reinflate the lung.
It’s also important to note that other complications might arise during the procedure, but these are mostly related to managing any bile duct issues.
What Else Should I Know About Percutaneous Cholangiography?
Percutaneous cholangiography is a medical procedure that helps in diagnosing and treating patients with bile duct disease. This test is particularly helpful for patients who show symptoms like yellowing of the skin and eyes (jaundice) or other signs indicating a blockage in the bile ducts. In such cases, doctors might consider doing percutaneous cholangiography or another test called ERCP (Endoscopic Retrograde Cholangiopancreatography). The choice of test depends on the patient’s specific symptoms. Percutaneous cholangiography is essential as it helps the doctor in diagnosing the disease accurately and planning the further course of treatment.