Fluoroscopic Procedures ( hepatobiliary system )

1. Aroosa Manazir
Lecturer
Radiology Deprtment
Afro-Asian Institute affiliated with GCUF
Lahore, Pakistan

3.  Oral Cholecystography
 Cholangiography
 T-Tube Cholnagiography
 Endoscopic Retrograde
Cholngiopancreatography

4.  Radiographic study of
gall bladder and
sometimes biliary
channels too by the
oral administration of
contrast media.

5.  The gallbladder is a pear-shaped, hollow
structure located under the liver and on the
right side of the abdomen. Its primary
function is to store and concentrate bile, a
yellow-brown digestive enzyme produced by
the liver

7.  Suspected gallbladder disease
 To determine or rule out the presence of
intermittent obstruction of the bile ducts
 Recurrent biliary disease after biliary surgery
 Inflammation of organ
 Tumors
 Gallstones
 Other abnormalities like polyps
 Cystic duct and common bile duct may also
be seen

8.  Severe hepatorenal disease
 Acute cholecystitis
 Iodine sensitivity
 Pregnancy
 Dehydration
 IV choledogram within previous week

9.  Telepaque
 Biloptin
 Cholibrin

10.  Laxative 2 days prior to examination
 Fat containing evening meal on the evening
prior to contrast study
 Prone 20o LAO peliminary film is taken when
appointment is made
 CM is taken with water 14 hours pior to
appointment
 Food is forbidden untill the examination is
completed

11.  6 tablets of telepaque orally night before the
examination
 A prone oblique view with righr side raised to 200 is
tken after 12-16 hours for GB visulaization
 Then the patient usually lie in the supine position
and appropriate spot films for GB are taken
 Ask the patient to eat fatty meal
 After 30-40 minutes , films are taken to assess the
contractibility of GB and small filling defect (polyp
or stone)
 Cystic and common bile duct is usually seen after
post fatty meal film

13.  Preliminary film
 Patient Preparation
 Telepaque administration
 X-ay film after 12-16 hours
 Intake of fatty meal
 Another x-ray film after 30-
40 minutes

15.  Cholangiography is the x-
ray examination of the bile
ducts (biliary tract) after
administration of a contrast
dye to delineate these
channels on the images.
The procedure may be
performed either during
gallbladder removal surgery
(operative
cholangiography) or
postoperatively (T-tube
cholangiography).

16.  Operative
cholangiography involves
injecting the contrast dye
directly into the common
bile duct during open
surgery. X-ray films are
then used to guide the
surgeon and to identify
any stones or other
obstructions for
immediate removal.

17.  T-tube cholangiography is
typically performed 5 to 10
days after gallbladder
removal. Contrast dye is
injected through aT-
shaped rubber tube placed
in the common bile duct
during surgery, and x-rays
are then taken to detect
any residual stones or
other abnormalities

18. https://youtu.be/sFtRwDUTavo

19.  To exclude biliary tract calculi where
a) operative cholangiography was not
performed
b) the results of operative cholangiography
are not satisfactory or are suspected
 Assesment of biliary leaks following biliary
surgery

20.  None

21.  LOCM is preferred
 150mg I ml-1
 20-30 ml

22.  Antibiotics may be considered if previous
cholangitis or if immunosuppressed

23.  Coned Supine PA of the right side of the
abdomen

24.  Performed on or about 10th post-op day prior
to removingT-Tube
 Patient lies supine
 Drainage tube is clamped off near to the
patient and cleanedthoroughly with anti-
septic
 A 23G needle , extension tubing and 20 ml
syringe are assembledand filled with contrast.

25.  After all air bubbles have been removed , the
needle is inserted into the tubing between
patient and clamp.
 The injection is made under fluoroscopic
control.
 Volume of contrast medium depends on duct
filling.
 In case of liver transplant , only a small
volume is injected (10ml).

26.  Images during filling.
 PA andOblique after
satisfactory
opacifiction of biliary
system.

27.  None

28.  Due to contrast medium
 Due to technique

30.  Percutaneous transhepatic
cholangiography (PTC) is a
procedure performed for
diagnostic and/or therapeutic
purposes by first accessing the
biliary tree with a needle and then
usually shortly after that with a
catheter (percutaneous biliary
drainage or PBD). At some point
during the procedure, contrast is
injected into one or more bile
ducts (cholangiography) and also
possibly into the duodenum

31.  Prior to therapeutic intervention
 Place a percutaneous biliary stent
 Dilate a post-op biliary stricture
 Stone removal
 To facilitate ERCP
 Rarely for diagnostic purposes

32.  Bleeding tendency
 Biliary tract sepsis

33.  LOCM
 150mg ml-1
 20-60 ml

34.  Fluoroscopy unit
 Chiba needle (a fine,
flexible 22G needle ,
15-20cm long)
 Appropriate catheters
and wire for drainage

35.  Haemoglobin, platelets and prothrombin
time is checked, corrected if necessary.
 Prophylactic antibiotics e.g: ciprofloxacin
500-750mg oral before and after procedure
 NPO or clear fluids only for 4h prior to
procedure.
 Ensure, patient is well hydrated.
 Sedation and analgesia with oxygen and
monitoring

36.  Ultrasound to confirm
position of liver and
dilated ducts

37.  Patient lies supine
 Using US , a spot is marked over right or left
lobe of liver (Right lobe = intercostal b/w mid
& ant axillary lines. Left lobe = subcostal ,
left of xiphisternum in epigastrium)
 Marked spot site is anesthetized including
skin, deeper tissue and liver capsule.
 With the help of US or fluoro , Chiba needle is
inserted into the liver during arrested
respiration.

38.  Stillete is withdrawn and needle is connected
to syring and tubing prefilled with contrast.
 Contrast is injected
 If duct is not entered, withdraw needle to
app2-3cm and then further attemptsare
made by directing the needle cranially,
caudally, anteriorly or posteriorly.
 Excessive parenchymal inj should be avoided.
 If intrahepatic ducts are dilated , bile should
be sent for culture.

39.  Contrast isinjected to outline the duct
system.
 Don’t overfill obstructed biliary system.
 For diagnostic PTC , only the needle is
removed after suitable images are taken.

40.  PA
 LAO
 RAO
 Delayed Images

41.  Bed rest
 Pulse and BP
measurement half
hourly for 6 hrs.

42.  Due to contrast
 Due to technique

45.  Endoscopic — Refers to a tool called an
endoscope, a long, thin (about the width of your
little finger), flexible tube with a camera on the
end.
 Retrograde — Refers to the direction (backward)
in which the endoscope injects a liquid for X-rays
of parts of the GI tract called the bile duct system
and pancreas.
 Cholangio — Refers to the bile duct system.
 Pancreatography — Refers to the pancreas.
 The process of taking these X-rays is known as
cholangiopancreatography.

46.  Mangement of bile duct stones
 Management of biliary strictures
 Evaluation of ampullary lesions
 Patient unsuitable for MRCP or unavailibility
of endoscopic ultrasound.
 Chronic panreatitis
 Diffuse biliary disease
 Post-cholecystectomy syndrome

47.  Oesophageal obstruction
 Pyloric stenosis
 Gastric/duodenal obstruction
 Previous gastric surgery
 Severe cardiac/respiratory disease

48.  Pancreas
 LOCM 240/300 mg I
ml-1
 Bile ducts
 LOCM 150mg I ml-1

49.  Side-viewing endoscope
 Polythene catheters
 Fluoroscopic unit

50.  NPO 4-6 hrs prior to procedure
 Premedication
 Prophylactic antibiotics

51.  Prone AP and LAO of upper abdomen

52.  Patient is sedated until concious sedation is
achieved.
 Pharynx is anasthetized with 50-100mg
Xylocaine spray.
 Patient lies prone or on let side, then
endoscope is introduced.
 Catheter prefilled with contrast is inserted
into ampulla of vater

53.  A small test contrast injection is made to
check the site of cannulation.
 Both biliary tree and pancreatic duct has to
be opacified , the later should be cannulated
first.
 If bilary obstruction is evidenced, bile is sent
for culture and sensitivity.

54.  Pancreas
 Prone
 Both posterior obliques
 Bile ducts
 Early filling images (Prone & Supine )
 Images after removal of endoscope
 Delayed images

55.  NPO until sedation and conciousness is
reversed.
 Pulse , temp and BP half hourly for 6 hrs
 Maintain antibiotics

56.  Due to contrast medium
 Due to technique

57.  https://youtu.be/5VgoDJ31V_0
 https://youtu.be/h7gCWo1b7ZA