1. Percutaneous Transhepatic
Cholangiography
Presenter: Dr. Dheeraj Kumar
MRIT, Ph.D. (Radiology and Imaging)
Assistant Professor
Medical Radiology and Imaging Technology
School of Health Sciences, CSJM University, Kanpur

2. Contents
• Introduction to Percutaneous
Transhepatic Cholangiography
(PTC)
• Indications and Contraindications
• Procedure Overview
• Imaging Technique
• Interpretation of Results
• Advantages and Disadvantages
• Complications and Safety Measures
• Case Studies
• Conclusion
• Questions and Discussion
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3. Introduction to Percutaneous Transhepatic
Cholangiography (PTC)
• Definition: Percutaneous
Transhepatic Cholangiography
(PTC) is a radiographic procedure
used to visualize and assess the
biliary system, including the bile
ducts within the liver and those
leading to the small intestine.
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4. Anatomy
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5. Purpose
• PTC serves several essential purposes in radiography and healthcare:
• Diagnosis and assessment of biliary system disorders.
• Evaluation of bile duct blockages, strictures, or leaks.
• Preoperative planning for biliary surgery.
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6. History
• History of PTC reflects the ongoing commitment of radiologists and medical researchers
to refine and expand the capabilities of diagnostic radiology.
• From early experiments with contrast agents to the development of sophisticated
percutaneous techniques, PTC has made a lasting impact on the field of medical imaging
and the diagnosis and treatment of biliary system disorders.
• In recent years, the field of interventional radiology has continued to evolve with the
development of less invasive alternatives like magnetic resonance
cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography
(ERCP).
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7. Pioneer Radiologists and Key Milestones
• Dr. Felix Berci: A pioneer in interventional radiology, Dr. Felix Berci
played a pivotal role in advancing PTC techniques in the 1960s and 1970s.
He introduced safer contrast agents and refined percutaneous puncture
methods.
• Dr. Jean-François Gigot: Dr. Gigot further advanced the field by
contributing to the understanding of PTC's diagnostic capabilities and its
role in guiding biliary surgery.
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8. Indications
• Suspected Biliary Obstruction: PTC is frequently performed when a patient
presents with symptoms such as jaundice, abdominal pain, or abnormal liver
function tests that may suggest biliary obstruction.
• Evaluation of Biliary Anatomy: It is utilized to obtain detailed information
about the biliary system's anatomy and any associated abnormalities.
• Preoperative Planning: Surgeons may request PTC images to plan surgical
interventions involving the biliary tract.
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9. Contraindications
• Allergy to Contrast Media: Individuals with known allergies to iodinated
contrast agents used in PTC should not undergo the procedure.
• Uncontrolled Bleeding Disorders: Patients with severe bleeding disorders
may not be suitable candidates for PTC due to the risk of hemorrhage.
• Severe Coagulopathy: Patients with coagulation disorders or anticoagulant
therapy may require careful consideration and potential adjustment of their
medications.
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10. Procedure Overview
• Patient Preparation:
• Consent and Explanation: Informed
consent is obtained from the patient,
and a detailed explanation of the
procedure is provided.
• Fasting Requirements: Patients are
typically instructed to fast for several
hours before the procedure to reduce
the risk of aspiration and ensure
optimal imaging conditions.
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11. Localization and Skin Marking
• Identifying the Puncture Site:
Imaging guidance, such as
ultrasound or fluoroscopy, is used
to identify the optimal puncture site
on the patient's abdomen.
• Skin Marking: The chosen puncture
site is marked on the patient's skin
for precise needle placement.
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12. Needle Puncture
• Accessing the Biliary System: A
thin, hollow needle is inserted
through the marked site, through
the liver tissue, and into the
biliary system under sterile
conditions and imaging guidance.
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13. Contrast Media Injection
• Visualization of the Biliary System:
A radiopaque contrast material is
injected through the needle into the
biliary system.
• Opacification of Ducts: The
contrast material opacifies the bile
ducts, allowing them to be
visualized on X-ray images.
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14. Imaging and Documentation
• X-ray or Fluoroscopy: Real-time X-ray images or fluoroscopic images
are captured to visualize the contrast's flow within the bile ducts.
• Static Images: Static images may be taken to document specific
findings or abnormalities.
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15. Catheter Placement
• Extended Contrast Injection
or Drainage: In some
cases, a catheter may be left
in place to facilitate
extended contrast injection,
drainage of bile, or
therapeutic interventions.
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16. Imaging Technique
• Radiographic Equipment:
• Fluoroscopy or X-ray Machine: PTC is
typically performed using fluoroscopy or
X-ray equipment to capture real-time and
static images.
• Image Intensifier: Fluoroscopy often
employs an image intensifier to enhance
image quality and reduce radiation
exposure.
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17. Contrast Media Characteristics
• Radiopaque Properties: The
contrast media used in PTC has
radiopaque properties, making
it visible on X-ray images.
• Opacification of Bile Ducts: It
selectively opacifies the bile
ducts, enhancing their visibility.
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18. Timing and Image Sequence
• Real-time Imaging: Real-time
fluoroscopy allows continuous
monitoring of the contrast flow during
injection.
• Static Images: Static X-ray images
are taken at specific points to
document findings and provide
detailed anatomical information.
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19. Interpretation of Results
Normal vs. Abnormal Findings:
• Normal Bile Duct Anatomy: In a normal PTC, the radiologist observes well-defined
bile ducts with a characteristic branching pattern.
• Identification of Abnormalities: PTC is invaluable for identifying various
abnormalities, including:
• Bile Duct Blockages: The procedure can pinpoint the location and extent of blockages caused
by factors like gallstones or tumors.
• Biliary Strictures: Narrowing or strictures in the bile ducts can be precisely identified.
• Biliary Leaks: PTC can detect leaks in the biliary system, often as a result of injury or surgery.
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20. Radiologist's Role
• Image Analysis: Radiologists play a central role in interpreting PTC
results. They analyze the images, identify abnormalities, and provide
detailed reports.
• Collaboration with Healthcare Team: Radiologists collaborate closely
with surgeons, gastroenterologists, and other healthcare professionals
to determine the best course of treatment based on the PTC findings.
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21. Advantages
• Direct Visualization: PTC provides direct visualization of the biliary
system, offering precise anatomical information.
• Diagnostic Precision: It is highly effective in diagnosing a wide range
of biliary conditions, guiding treatment decisions.
• Minimally Invasive: PTC is less invasive than surgical exploration and
can often replace more invasive procedures.
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22. Disadvantages
• Invasive Nature: PTC is an invasive procedure, involving percutaneous
access to the liver, which carries inherent risks.
• Risk of Complications: There is a risk of complications such as bleeding,
infection, or bile leakage, although these are relatively uncommon.
• Limited Therapeutic Role: While PTC is primarily diagnostic, it may also
guide some therapeutic interventions. However, it may not be suitable for
all cases or therapeutic purposes.
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23. Potential Complications
• Bleeding: PTC may lead to bleeding at the puncture site or within the
liver.
• Infection: Infection is a possible complication, although strict sterile
techniques are employed to minimize this risk.
• Perforation: Rarely, there may be unintended perforation of structures
within the liver or bile ducts.
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24. Safety Measures
• Sterile Technique: PTC is performed under strict sterile conditions to reduce
the risk of infection.
• Monitoring: Patients are closely monitored during and after the procedure to
detect and manage complications promptly.
• Preventive Measures: Care is taken to minimize bleeding risks, including
assessment of coagulation status, and correction of coagulopathies when
necessary.
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25. Case Studies
• Case 1: Biliary
Obstruction: Detail a
case where PTC
identified a biliary
obstruction, leading to a
diagnosis and treatment
plan.
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26. Case 2: Biliary Stricture
• Present a scenario
involving a biliary
stricture,
demonstrating how
PTC can precisely
locate and
characterize the
stricture.
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27. Case 3: Complications and Management
• Discuss a case
where complications
arose during PTC
and describe the
appropriate
management and
intervention.
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28. Conclusion
• The diagnostic significance of PTC in evaluating biliary system disorders.
• Indications and contraindications for the procedure.
• The procedure overview, including patient preparation, needle puncture, contrast media injection,
and imaging techniques.
• The role of radiologists in interpreting PTC results.
• Advantages, disadvantages, and safety considerations.
• Potential complications and safety measures.
• Real-world case studies showcasing the diagnostic and therapeutic utility of PTC.
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29. Questions and Discussion
Open the Floor for Questions? and Discussion @@
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30. Thank You
Express gratitude to the Students for their active participation, attention, and
contributions during the presentation.
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31. References
• "Radiologic Science for Technologists: Physics, Biology, and Protection"Authors: Stewart C.
Bushong, Publication Year: 2019, Publisher: Elsevier
• "Interventional Radiology Procedures in Biopsy and Drainage“, Authors: Ronald S. Arellano, Aldo
A. Maksoud,Publication Year: 2020, Publisher: Springer
• "Percutaneous Transhepatic Cholangiography: Techniques and Applications“,Authors: C. Christian,
H. Weismann, S. Dengler, et al.,Publication Year: 2021
• "Complications of Percutaneous Transhepatic Cholangiography in the Management of Postsurgical
Biliary Leaks and Strictures“, Authors: Arno NK Joseph, Peter Thuluvath, Publication Year: 2020
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