Biliary System

Question 1

3 ways to inject contrast for a biliary exam

Answer 1

Intravenous - injection of a bolus of contrast into a vein or by drip infusion (intravenous cholangiogram)
Direct injection - inserting a needle via a percutaneous transhepatic puncture (PTC)
Indewelling drainage tube - post operative injection into a t-tube (t-tube cholangiogram)

Question 2

Adavantages of laparoscopic gall bladder surgery over cholecystectomy

Answer 2

Less pain
Faster recovery
Shortened hospitalization 
Smaller aesthetic incisions 
Cost savings 
*not everyone is a candidate for laparoscopic surgery though*

Question 3

Cholegraphy

Answer 3

The general term used to describe radiographic visualization of the biliary tract using a radiopaque contrast media

Question 4

Cholecystography

Answer 4

Study of the gull bladder (not common anymore, replaced by ultrasound)

Question 5

Cholangiography

Answer 5

Study of the bile ducts

Question 6

Cholecystangiography/cholecystocholangiography

Answer 6

Study of both the gull bladder and biliary ducts

Question 7

What is a diagnostic Endoscopic retrograde cholangiopancreatography (ERCP) and where is it performed

Answer 7

Demonstrates strictures, dilations, or small lesions, within the biliary or pancreatic ducts
Check the patency of the biliary and pancreatic ducts
Visualize stones (choleliths) not detected by other modalities
Is performed in the DI or GI department

Question 8

What is a therapeutic ERCP and where is it performed

Answer 8

Removal of small lesions
Removal of choleliths
Dilate a blocked or narrowed duct such as the hepatopancreatic duct
Performed in the DI/GI department

Question 9

Contraindications of performing a ERCP

Answer 9

If there is a pseudocyst in the pancreas contrast must not be injected as it may rupture or cause pancreatitis
Pseudocyst is a dilated space resembling a cyst which a collection of fluid and necrotic debris
Hypersensitivity to contrast agents

Question 10

ERCP procedure

Answer 10

Pt’s vitals will be monitored during procedure. O2 is administered via nasal prongs throughout the procedure
Pt is in a Left lateral position to begin with and a mouth guard is inserted to prevent biting on the endoscope. Pt’s throat is sprayed with anesthetic to decrease pain/gage reflex to ease passing of endoscope into the stomach and duodenum. Pt is then moved into a sims position for the remainder of the exam
At the hepatopancreatic ampulla (ampulla of Vader) a small cannula is directed into the ampulla and contrast is injected into the CBD
Fluoro is used to visualize the ducts during injection of contrast to ensure the ducts aren’t overfilled. Obliques may be taken to prevent superimposition of the CBD and pancreatic duct (must be done quickly b/c the contrast drains within 5 min)

Question 11

ERCP patient prep

Answer 11

Pt must be NPO one hour before the exam
Pt arrives in the Fluoro department on a stretcher
Ensure there are lead aprons for all ppl involved in the ppl involved
Dr explains the procedure to the pt and the consent form is signed prior to sedation being given

Question 12

ERCP post procedure

Answer 12

Pt should be NPO for a least one hour after to prevent aspiration of food or water, could last up to 10 hours

Question 13

Contrast Media used for a ERCP

Answer 13

Water soluble iodinated contrast
Dense contrast can opacify small ducts well but may obscure small stones
If stones are suspected a more dilute contrast should be used

Question 14

Structures shown by an ERCP

Answer 14

CBD, common hepatic duct, pancreatic duct
Absence of pathology will demonstrate the hepatopancreatic ampulla (ampulla of vater) spilling contrast into the duodenum papilla
If the pt has a tumour on the head of their pancreas it is demonstrated by a displaced duodenum around the pancreas

Question 15

Who performs Percutaneous Transhepatic cholangiography, where it is done and what is it

Answer 15

Performed in the x-Ray department using fluoro equipment by a the rad, nurse, and x-Ray tech
Is an invasive procedure that requires the puncture site to be surgically prepared. A direct puncture of the biliary ducts with a Chiba needle. Once the needle is in the correct location the contrast is administered directly into the biliary ducts and images are taken

Question 16

Indications for PCT

Answer 16

Obstructive jaundice - diagnostic exam to determine if the obstruction may be due to Calculi or biliary stenosis, can be therapeutic once the cause of jaundice is diagnosed

Question 17

Procedure for a PCT

Answer 17

Recent blood work done to determine INR or PT to see how quickly blood clots, should be within normal range
Fluoro room is set up and lead aprons are available for staff
Sterile tray, contrast and additional equipment prepared (Chiba needle)
Pt is supine on the table with right arm above their head to allow easy access to the liver. Depending on body habitus they may need to be slightly rotated into a LPO
Vital signs are monitored throughout the procedure b/c sedation may be given in order to ease pt discomfort
Important that the pt remains still throughout the procedure which can take up to 1hr, provide sponges and pillows where needed

Question 18

Risks/complications of a PTC

Answer 18

Pnuemothorax - possbility of puncturing a lung. Often a chest x-Ray is ordered post-procedure to determine no pneumothorax occurred
Liver hemorrhage - liver may hemorrhage internally or bile may space into the peritoneal cavity
Peritonitis - bile may escape into he peritoneal cavity leading to the inflammation of surrounding tissue

Question 19

What is Biliary drainage procedure and stone extraction, who performs it and where

Answer 19

Therapeutic procedure to remove a stone or dilate the restricted portion of the biliary tract allowing the stones to pass on its own. Drainage of the bile may also be done to decompress the biliary ducts.
Done in the DI department by the rad using specialized equipment

Question 20

Procedure for biliary drainage and stone extraction

Answer 20

PTC performed and a drainage/extraction will follow
A needle is inserted through the lateral abdominal wall into the biliary duct. The needle is larger than a Chiba needle and will vary in diameter thickness and length depending on its purpose
A guide wire is passed through the lumen of the needle into the correct location. Needle is then removed leaving the guide wire in place
A catheter is passed over the guide wire and placed in the correct location, the guide wire is then removed leaving the catheter in place
Catheter can then be left for prolonged drainage or it can be used to attempt removing the remaining stones. Done with Fluoro and a wire basked/small balloon catheter. Stone extraction is usually attempted after the catheter has been in place for some time

Question 21

Operative Cholangiogram is performed to investigate

Answer 21

Patency of the biliary ducts
Functional status of the hepatopancreatic ampulla sphincter
Possible presence of stones or lesions not previously detected
Strictures/dilations of the ducts

Question 22

Operative Cholangiogram procedure

Answer 22

Performed in OR during surgery. Usually done during a cholecystectomy
Once the gallbladder is removed a smaller catheter is inserted into the remaining cystic duct and contrast is directly injected in the CBD through the catheter and an exposure is taken demonstrating ducts filled with contrast
Spillage of the contrast into the duodenum indicates there are no biliary calculi or other obstructions
Performed under fluoro

Question 23

Radiographs taken for a operative Cholangiogram

Answer 23

AP projection - URQ
RPO - 15-20 degree rotation prevents the biliary tree from superimposing with the spine
Trendelenburg position may be required to fill the intrahepatic ducts of the liver with contrast media

Question 24

Post Operative Cholangiogram (T-tube delayed Cholangiogram)

What, where, who

Answer 24

Performed in the x-ray department following a cholecystectomy by a surgeon who is concerned about residual stones in the biliary ducts post surgery
The catheter left in place after the surgery is shaped like a T and extends to the outside of the body to allow access to the ducts if a stone or stricture still exists

Question 25

Post operative Cholangiogram (T-Tube) procedure

Answer 25

Contrast is injected directly into the tube to visualize the biliary ducts
Pt’s preceding meal should be withheld before performing a T-tube exam. The T-tube should be clamped off the morning of the procedure to allow the catheter to fill completely with bile preventing any air bubbles from occurring (could be mistaken for stones when CM is injected)
Pt is RPO on fluoro table. Premeds not required
CM is hand injected with a syringe directly into the T-tube by rad
Images performed demonstrate the caliber/patency of the ducts, status of sphincter, any residual stones
If stones are present they may be removed with a guide wire passed into the T-tube and advanced superior to the stones. Then a basket catheter is inserted over the guide wire and the guide wire is removed. Basket catheter removes stones by pulling the stones with the basket catheter through the T-tube catheter

Question 26

Contrast Media used to Post operative Cholangiogram

Answer 26

Water soluble - density recommended to be no more than 15-30% b/c small stones may be obscured with a higher concentration

Question 27

Clinical Indications for Post Operative Cholangiogram

Answer 27

Residual calculi or strictures/dilations in the biliary system