Cholangiography. Percutaneous transhepatic cholangiography (PCCHG) Collection of tests on surgical diseases for final examinations at the Faculty of Dentistry

Despite the emergence and development of non-invasive methods for visualizing the bile ducts (MRI), the method of direct puncture and contrasting of the biliary system has not lost its relevance.

Indications

• Slight dilatation of the bile ducts
• Suspicion of benign ductal stricture
• Suspicion of choledocholithiasis with technically impossible ERCP
• Before reconstructive surgery in patients with previously performed biliodigestive anastomosis

• extremely serious condition of the patient
• intolerance to contrast agents

The method of percutaneous transhepatic cholangiography under ultrasound guidance was developed by Japanese authors in the late 70s and is currently the most common.

Ultrasound-guided PTCG has undeniable advantages, since the intrahepatic ducts and the tip of the needle are visible on the screen, which ensures the safety and effectiveness of the technique.

For puncture, the most expanded part of the intrahepatic bile ducts located close to the skin surface is selected.
With a total expansion of the biliary tree, the puncture of the left hepatic duct from a point in the epigastric region is considered optimal. In this case, the trajectory of the direction of the needle is the shortest, the costal arch does not interfere with the visualization of the bile ducts [Briskin B.S. et al., 1989]. PTCG is performed using a sector probe with thin needles 23–20 g (0.6–0.9 mm) in diameter, which are performed by puncturing the anterior abdominal wall through a larger diameter guiding needle (Fig. 2.6, A).

The puncture is performed while holding the breath on exhalation. The tip of the needle is visualized throughout the manipulation. If the image of the needle tip or duct disappears from the screen or moves off the guide marker line during puncture, the transducer angle must be carefully adjusted until a clear image is obtained. Any deviation of the needle from the target is immediately taken into account by the operator and the direction of the needle is changed. After the tip of the needle enters the lumen of the dilated bile duct, the maximum possible amount of bile is evacuated. Then a contrast agent is injected into the bile ducts and an X-ray examination is performed.

For percutaneous transhepatic cholangiography, disposable and reusable needles Chiba 23 - 21 G, 15 - 20 cm long, manufactured by MIT LLC, are most widely used.

Fig.1. Cholangiography under ultrasound guidance. A - with a guide needle, B - without a guide needle.

Possible Complications

• bleeding
• bile leakage
• allergic reactions

Percutaneous cholangiography in a patient with a large cyst of the common bile duct.

Percutaneous transhepatic cholangiography is a fluoroscopic examination of the bile ducts after direct injection of an iodine-containing contrast agent. The use of the method is most informative in patients complaining of persistent pain in the epigastric region after cholecystectomy, as well as in severe jaundice. If obstructive jaundice is suspected, CT or ultrasound is usually performed, but the use of percutaneous transhepatic cholangiography provides more detailed information about the nature of the obstruction. However, it should be borne in mind that this invasive intervention is associated with an increased risk of complications, in particular bleeding, septicemia, biliary peritonitis, penetration of a contrast agent into the abdominal cavity or under the hepatic capsule.

Target

• Determine the cause of pain in the epigastric region after cholecystectomy.
• Differentiate obstructive jaundice from other forms of jaundice.
• Determine the level, severity and cause of mechanical obstruction of the biliary tract.

Training

• It should be explained to the patient that the study allows fluoroscopic assessment of the condition of the bile ducts after direct injection of a contrast agent into them.
• The patient should refrain from eating for 8 hours before the study.
• The essence of the study should be explained to the patient and he should be informed by whom and where it will be performed.
• The patient is warned that he will be given a laxative on the evening before the study, and an enema will be given in the morning before the study.
• The patient is explained that during the examination, he will be placed on an inclined X-ray table in the supine position and then turned on his side.
• The patient should be warned that when the skin is anesthetized at the puncture site, he will feel a prick, and at the time of the puncture of the liver capsule, a quickly passing pain.
• It should also be warned that with the introduction of a contrast agent, he will have a feeling of pressure and heaviness in the epigastric region, as well as transient back pain on the right.
• Within 6 hours after the study, it is necessary to observe bed rest.
• It is necessary to ensure that the patient or his relatives give written consent to the study.
• It is necessary to find out if the patient is allergic to iodine, radiopaque agents, products with a high content of iodine and local anesthetics. He should also be warned about the possibility of adverse reactions associated with the introduction of a contrast agent, such as nausea, vomiting, hypersalivation, facial flushing, urticaria, sweating, anaphylaxis (in rare cases). With the introduction of a contrast agent into the biliary tract, tachycardia and fever may occur.
• Before conducting a study, it is necessary to determine the bleeding and clotting time, prothrombin time, and platelet levels. If necessary, before the study, ampicillin is administered prophylactically intravenously at a dose of 1 g every 4-6 hours for 24 hours.
• Anxious patients are prescribed sedatives before the study.

Procedure and aftercare

• After laying and fixing the patient on the X-ray table in the supine position, the right upper quadrant of the abdomen is treated and isolated with sterile linen, the skin, subcutaneous tissues and liver capsule are infiltrated with a local anesthetic solution.
• At the end of expiration, the patient holds his breath, under fluoroscopic control, a needle is inserted into the tenth intercostal space along the right midclavicular line.
• The needle is advanced towards the xiphoid process and penetrates into the liver parenchyma. Then the needle is carefully withdrawn, injecting a contrast agent in order to identify the bile duct. When the needle is in the bile duct, it is fixed and the remaining amount of contrast agent is injected.
• On the x-ray screen, the degree of filling of the bile ducts is assessed, pictures are taken in the position of the patient on the back and side, after which the needle is removed.
• The puncture site is covered with a sterile drape.
• The main physiological indicators are determined until they stabilize.
• To prevent bleeding, the patient is not allowed to stand up for at least 6 hours, preferably lying on his right side.
• Periodically check for bleeding from the puncture channel, as well as swelling and pain at the puncture site. You should make sure that there are no symptoms of peritonitis (chills, fever up to 38.8-39.4 ° C, abdominal pain, abdominal wall tenderness, bloating). If these symptoms appear, you should immediately notify your doctor.
• After the study, the patient can return to his usual diet and diet.

Precautionary measures

Percutaneous transhepatic cholangiography is contraindicated in cholangitis, severe ascites, refractory coagulopathy, iodine allergy, and pregnancy due to a high risk of teratogenicity.

Normal picture

Normally, the bile ducts are not dilated, regular in shape, evenly filled with a contrast agent.

Deviation from the norm

The main difference between the radiological picture in mechanical and other types of jaundice is the diameter of the bile ducts. With obstructive jaundice, they are enlarged; for other types of jaundice, their normal diameter is characteristic. Bile duct obstruction can be due to both cholelithiasis and cancer of the biliary tract, pancreas, or hepatopancreatic ampulla; in the latter case, due to the direct attachment of the tumor to the common bile duct, its displacement or stricture is determined.

With a normal diameter of the bile ducts and signs of intrahepatic cholestasis, a liver biopsy is necessary, which allows differentiating between hepatitis, cirrhosis, and liver granulomatosis. In patients with mechanical obstruction of the bile ducts, a drainage tube can be placed for percutaneous drainage of bile.

Factors affecting the result of the study

Severe obesity or gas in the abdomen overlapping the image of the bile ducts (poor image quality).

B.H. Titova

"Percutaneous transhepatic cholangiography" and others

Percutaneous transhepatic cholangiography is an antegrade contrast study of the bile ducts by percutaneous blind puncture of the liver in order to confirm the subhepatic mechanical genesis of prolonged intense jaundice.

Percutaneous transhepatic cholangiography allows you to establish the level and suggest the cause of impaired patency of the hepatic or common bile duct, the ampulla of the major papilla. The cause of obturation may be a stone, tumor, helminthic invasion; there is a compression of the ducts in cancer of the pancreas, gallbladder, liver and duodenum, retroperitoneal sarcoma. Violation of the flow of bile is observed with pancreatic cysts, capitate pseudotumorous pancreatitis, cicatricial stricture of the duct and BSDK, iatrogenic damage to the hepatic or common bile duct (crossing, ligation) during cholecystectomy and resection of the stomach due to penetrating duodenal ulcer. Known anamnestic, clinical and laboratory differential diagnostic signs are not absolutely reliable. allows you to detect stones in the gallbladder and in the extrahepatic bile ducts, dilatation of the ducts, enlargement of the liver and pancreatic head, focal and diffuse changes in these foci. Similar diagnostic information is obtained from CT of the upper abdomen. For an examination for jaundice, you can contact the Khimki Medical Center.

The main method for diagnosing the cause of subhepatic jaundice is endoscopic retrograde cholangiopancreatography. Endoscopic examination of the duodenum allows to identify a stone strangulated in the papilla papilla, polyps and papillary cancer, peripapillary diverticula, and a number of other diseases. ERCP cannot be performed for a number of reasons: if it is impossible to pass a duodenoscope into the descending part of the duodenum due to cicatricial and ulcerative deformity of the pylorus and bulb, if the intestine is compressed by a sharply enlarged pancreas, if it is impossible to catheterize the papilla ampulla due to papillitis, severe stenosis of the papilla, parapapillary diverticulitis. ERCP in some cases is complicated by ascending purulent cholangitis, pancreatitis, septicemia.

The invention by employees of Hiba University in Japan of a special flexible needle, the use of which significantly reduced the risk of bleeding and bile leakage into the abdominal cavity during percutaneous transhepatic cholangiography. The Hiba needle with a mandrin has a length of 15-20 cm, a diameter of 0.7 mm and a cut angle of 30°. The study can also be performed using the stylet catheter RIS, manufactured in Sweden, which is a piercing stylet 24.5 or 27 cm long with a fitted external catheter with a diameter of 1.6 mm.

Method of percutaneous transhepatic cholangiography

The puncture is performed under local infiltration anesthesia using anterior, lateral and extraperitoneal access. With an anterior approach, the patient lies on his back. The puncture is carried out slightly below the right costal arch at a distance of 4-6 cm from the midline. The needle is directed from front to back at an angle of 45°. With lateral access in the supine position, the puncture is performed in the 9th intercostal space along the right midaxillary line. The needle is directed strictly perpendicular to the sagittal plane. With posterior access, the puncture is carried out in the position of the patient on the stomach along the lower edge of the XI right rib at a distance of 8 cm from the spinous process of Th11. The needle is directed slightly upward. The needle penetrates through the extraperitoneal field of the liver, as a result of which bleeding and bile leakage into the abdominal cavity are excluded.

From any access, the needle is inserted into the liver to a depth of 12 cm. After removing the mandrin, creating a vacuum with a syringe, the needle is slowly shifted in the opposite direction. The appearance of bile in the syringe indicates that the needle is in the intrahepatic bile duct. The extraction of the needle is stopped, bile is aspirated (up to 200 ml) in order to reduce intraductal hypertension. After making sure that the needle is in the correct position by test injection of several ml of water-soluble contrast, 30-40 ml of contrast is injected under x-ray control. The filling of the bile ducts is fixed on radiographs.

After the completion of the X-ray examination, the maximum aspiration of the contrast solution and bile is carried out, the ducts are lavaged with saline with heparin, and. The need for washing with an antibiotic solution is due to cholangitis, which often complicates duct obstruction. In case of severe hyperbilirubinemia, it is advisable to carry out external removal of bile through a radiopaque catheter with a diameter of 3 mm, inserted into the duct with the help of a conductor.

Along with positive reviews of percutaneous transhepatic cholangiography, there are reports of a significant number of failures, the cause of which is the difficulty of blind puncture of slightly dilated bile ducts. The level of obstruction of the ducts affects the information content of the study. With a block in the terminal part of the common bile duct, the study is more conclusive than with a block of ducts in the gates of the liver. Selective liver arteriography helps to clarify the cause of high biliary obstruction.

• Medical treatment

  In conditions of biliary hypertension in cholangitis, the independent value of drug therapy is relatively small. It is advisable to consider it only as an intensive short-term preparation of the patient for urgent decompression of the bile ducts. When the condition is threatened, intensive care should be combined with immediate decompression.

  • Pain therapy.

    Scopolamine IV or IM 20 mg 4 r / day or metamizole sodium (Analgin, Baralgin M) 2.5 g 4 r / day or pentazocine IV or IM 30 mg 4 r / day day or pethidine in / in - 25-150 mg / day.

  • Antibacterial therapy.

    It includes the appointment of cephalosporins, as well as ureidopenicillins, which, if necessary, are prescribed with aminoglycazides.

    Cefotaxime (Claforan, Cefotaxime por.d / in.) IM 2 g 2p / day or ceftriaxone (Rocefin , Ceftriaxone por.d / in.) IM 2g 2r / day + piperacillin PO or IM 100-300 mg/kg/day or azlocillin po or IM 12–15 g/day +/- tobramycin IM 3–5 mg/kg/day or metronidazole (400 ml/day or Hemodez 200 ml/day or 10–20 % Albumin solution 100 ml/day.

• Surgical treatments

  Urgent decompression of the bile ducts is required. Decompression is understood as a surgical intervention aimed at creating conditions for a normal outflow of bile by external or internal drainage of the bile ducts. Surgical treatment is also used to remove gallstones, as one of the main causes of cholangitis.

  Methods of decompression of the biliary tract:

  • Endoscopic papillosphincterotomy.
  • Introduction of an endoprosthesis into the common bile duct.
  • Percutaneous transhepatic cholangiostomy.

  After surgery for chronic cholangitis, it is advisable to repeat courses of antibiotic therapy and carry out tubazh with a choleretic purpose.

• Treatment tactics

  The tactics of managing patients with cholangitis presents significant difficulties, which are due to the presence of a purulent process, obstructive jaundice and acute destructive cholecystitis. Each of these moments requires an early resolution, however, patients with obstructive jaundice do not tolerate long-term and traumatic surgical interventions.

  Therefore, first of all, it is advisable to ensure an adequate outflow of bile, which at the same time reduces the clinical manifestations of cholangitis, intoxication.

  The second stage is a radical intervention aimed at eliminating the cause of cholangitis.

  In order to decompress the biliary tract, endoscopic papillosphincterotomy is performed after preliminary retrograde cholangiography. With residual choledochal stones after papillosphincterotomy, the discharge of calculi from the biliary tract is sometimes noted, the cholangitis phenomena stop and the question of the need for a second operation disappears.

• Further management of patients

  All patients with cholangitis, including after surgery, are recommended diet therapy, which excludes spicy and fatty foods, smoked meats, spices. Food should contain many vitamins, vegetable fats.

  Sanatorium-resort treatment in sanatoriums of a gastroenterological profile is shown.

Medical research: reference book Mikhail Borisovich Ingerleib

Percutaneous transhepatic cholangiography

The essence of the method: percutaneous transhepatic cholangiography- invasive radiopaque examination of the bile ducts after their direct filling with an iodine-containing contrast agent, became widespread after the appearance of ultra-thin needles, which ensure the relative safety of puncturing the intrahepatic ducts, due to which artificial contrasting of the bile ducts is carried out. Percutaneous transhepatic cholangiography is indicated to identify the causes of pain after cholecystectomy, to determine the level, severity and nature of obstruction of the biliary tract in jaundice (calculus, tumor, stricture).

Indications for research:

Attention! Indications for percutaneous transhepatic cholangiography should be strictly argued, as this is an invasive procedure!

Secondary biliary cirrhosis of the liver;

Cholelithiasis;

Calculous cholecystitis;

Primary biliary cirrhosis of the liver;

Postcholecystectomy syndrome;

Cancer of the extrahepatic biliary tract;

gallbladder cancer;

Strictures of the bile ducts;

Cholangitis;

Chronic cholecystitis.

Conducting research: percutaneous puncture of the abdominal wall is performed under local anesthesia and X-ray control. The puncture needle is directed to the gate of the liver and placed in the lumen of the intrahepatic bile duct. After the introduction of contrast, radiographs are taken.

Contraindications:

Purulent cholangitis;

Hemorrhagic diathesis;

Severe disorders of the blood coagulation system.

Preparation for the study: In the evening before the study, you should follow a light diet. In the morning, the intake of any food is prohibited, since the procedure takes place strictly on an empty stomach. The day before, laxatives are given and cleansing enemas are prescribed. In connection with the feeling of anxiety that arises before the study, the patient is prescribed sedatives, sleeping pills, choosing individually the doses, timing and routes of their administration. Before and during the study, depending on its duration and severity, drugs are administered that relax smooth muscles and soothe.

Deciphering the results of the study should be carried out by a qualified radiologist, the final conclusion, based on all the data on the patient's condition, is made by the clinician who sent the patient for examination - a gastroenterologist, surgeon, oncologist, hepatologist.