Percutaneous Transhepatic Cholangiography

Percutaneous Transhepatic Cholangiography

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Over the past few decades, biliary interventions have evolved a great deal. Opacification of the biliary system was first reported in 1921 with direct puncture of the gallbladder. Subsequent reports described direct percutaneous biliary puncture. The technique was revolutionized in 1960s with the introduction of fine-gauge (22- to 23-gauge) needles.

During the 1970s, percutaneous biliary drainage (PBD) for obstructive jaundice and percutaneous treatment of stone disease was introduced. Percutaneous cholecystostomy was first described in the 1980s. With the advent of metallic and plastic internal stents, further applications in the treatment of biliary diseases were developed.

Current percutaneous biliary interventions include percutaneous transhepatic cholangiography (PTC) [1] and biliary drainage to manage benign [2, 3]  and malignant obstruction and percutaneous cholecystostomy. [4]  Percutaneous treatment of biliary stone disease with or without choledochoscopy is still performed in selected cases. Other applications include cholangioplasty for biliary strictures, biopsy of the biliary duct, and management of complications from laparoscopic cholecystectomy and liver transplantation. [5]

Common causes of benign biliary obstruction include bile duct stones, strictures, sclerosing cholangitis, iatrogenic conditions, inflammatory processes (eg, pancreatitis), and infections (eg, HIV infection, oriental and parasitic cholangitises). Common malignant causes of biliary obstruction include carcinoma of pancreas, cholangiocarcinoma, and metastatic disease. Other causes of biliary obstruction include Caroli disease, Mirizzi syndrome, retroperitoneal fibrosis, ampullary carcinoma, and gallbladder carcinoma.

This article outlines the procedure for percutaneous cholangiography. For descriptions of other biliary interventions, see Percutaneous CholecystostomyPercutaneous Biliary Drainage, and Biliary Stenting.

PTC is indicated for the evaluation of biliary anatomy in the presence of biliary obstruction when endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful.

In patients with a history of anatomy-altering surgical procedures, however, PTC might be the preferred procedure because ERCP in these settings may require specialized equipment and expertize that may not be universally available. Such procedures include the Billroth II procedure, Roux-en-Y gastric bypass surgery, and the Whipple procedure, to name a few.

PTC is indicated if there is an inaccessible papilla (eg, in ampullary carcinoma or duodenal obstruction from malignancy). Other indications for PTC include the management of postoperative or posttraumatic bile leakage.

Of the two procedures used to evaluate the biliary anatomy, ERCP and PTC, ERCP is the first test of choice. PTC is more invasive and painful than ERCP, mainly because the PTC procedure involves puncturing the liver capsule. It also poses the risks of hemoperitoneum and bile peritonitis.

PTC is now usually reserved for patients in whom ERCP is unsuccessful when the biliary system cannot be cannulated or when the obstructing lesion prevents contrast material from opacifying the cephalic portions of the biliary system.

Initial clinical evaluation of a patient with jaundice and biliary tract disease should include history taking, physical examination, and pertinent laboratory tests. After the initial workup, radiologic examinations are required to determine the cause of biliary obstruction. Ultrasonography (US), magnetic resonance imaging (MRI), and computed tomography (CT) are commonly used for this purpose. Cross-sectional imaging provides information about the pattern of biliary dilatation and the level of obstruction, and it can potentially reveal the cause. [6]

Young M, Bhimji SS. Percutaneous Transhepatic Cholangiogram. Treasure Island, FL: StatPearls; 2018. [Full Text].

Köcher M, Cerná M, Havlík R, Král V, Gryga A, Duda M. Percutaneous treatment of benign bile duct strictures. Eur J Radiol. 2007 May. 62 (2):170-4. [Medline].

Morita S, Kitanosono T, Lee D, Syed L, Butani D, Holland G, et al. Comparison of technical success and complications of percutaneous transhepatic cholangiography and biliary drainage between patients with and without transplanted liver. AJR Am J Roentgenol. 2012 Nov. 199 (5):1149-52. [Medline].

Link BC, Yekebas EF, Bogoevski D, Kutup A, Adam G, Izbicki JR, et al. Percutaneous transhepatic cholangiodrainage as rescue therapy for symptomatic biliary leakage without biliary tract dilation after major surgery. J Gastrointest Surg. 2007 Feb. 11 (2):166-70. [Medline].

Putzer G, Paal P, Chemelli AP, Mark W, Lederer W, Wiedermann FJ. Resolution of biliary stricture after living donor liver transplantation in a child by percutaneous trans-hepatic cholangiography and drainage: a case report. J Med Case Rep. 2013 Jun 20. 7:160. [Medline]. [Full Text].

Yoon JH. Biliary papillomatosis: correlation of radiologic findings with percutaneous transhepatic cholangioscopy. J Gastrointestin Liver Dis. 2013 Dec. 22 (4):427-33. [Medline].

Ignee A, Cui X, Schuessler G, Dietrich CF. Percutaneous transhepatic cholangiography and drainage using extravascular contrast enhanced ultrasound. Z Gastroenterol. 2015 May. 53 (5):385-90. [Medline].

Nolsøe CP, Nolsøe AB, Klubien J, Pommergaard HC, Rosenberg J, Meloni MF, et al. Use of Ultrasound Contrast Agents in Relation to Percutaneous Interventional Procedures: A Systematic Review and Pictorial Essay. J Ultrasound Med. 2018 Jun. 37 (6):1305-1324. [Medline].

Khan MA, Atiq O, Kubiliun N, Ali B, Kamal F, Nollan R, et al. Efficacy and safety of endoscopic gallbladder drainage in acute cholecystitis: Is it better than percutaneous gallbladder drainage?. Gastrointest Endosc. 2017 Jan. 85 (1):76-87.e3. [Medline].

Altaf Dawood, MBBS, MD Chief Medical Resident and Clinical Instructor, Department of Internal Medicine, University of Nevada School of Medicine

Altaf Dawood, MBBS, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Vijay Jayaraman, MD Assistant Professor of Medicine, Division of Gastroenterology, University of Nevada School of Medicine

Vijay Jayaraman, MD is a member of the following medical societies: American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Medical Society of the State of New York, New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Douglas M Coldwell, MD, PhD Professor of Radiology, Director, Division of Vascular and Interventional Radiology, University of Louisville School of Medicine

Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Heart Association, SWOG, Special Operations Medical Association, Society of Interventional Radiology, American Physical Society, American College of Radiology, American Roentgen Ray Society

Disclosure: Received consulting fee from Sirtex, Inc. for speaking and teaching; Received honoraria from DFINE, Inc. for consulting.

Kyung J Cho, MD, FACR, FSIR William Martel Emeritus Professor of Radiology (Interventional Radiology), Frankel Cardiovascular Center, University of Michigan Health System

Kyung J Cho, MD, FACR, FSIR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Gary P Siskin, MD Professor and Chairman, Department of Radiology, Albany Medical College

Gary P Siskin, MD is a member of the following medical societies: American College of Radiology, Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North America

Disclosure: Nothing to disclose.

Author: Altaf Dawood, MBBS, MD, Chief Medical Resident and Clinical Instructor, Department of Internal Medicine, University of Nevada School of Medicine.

Altaf Dawood is a member of the following medical societies: American College of Physicians.

Coauthor(s): Vijay Jayaraman, MD, Assistant Professor of Medicine, Division of Gastroenterology, University of Nevada School of Medicine

Disclosure: Nothing to disclose.

Percutaneous Transhepatic Cholangiography

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