Percutaneous transhepatic cholangiography
- Stephan Anderson, MD
Stephan Anderson, MD
- Associate Professor of Radiology
- Boston University School of Medicine
- Section Editors
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology; Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
- Jonathan B Kruskal, MD, PhD
Jonathan B Kruskal, MD, PhD
- Section Editor — Kidney Disease
- Professor of Radiology
- Harvard Medical School
Percutaneous transhepatic cholangiography (PTC) involves transhepatic insertion of a needle into a bile duct, followed by injection of contrast material to opacify the bile ducts. PTC is usually performed for evaluation of patients who are found to have biliary duct dilation on ultrasonography or other imaging tests and who are not candidates for endoscopic retrograde cholangiopancreatography (ERCP). Included in this group are patients who have surgically altered anatomy preventing endoscopic access to the biliary tree and those in whom ERCP was unsuccessful. PTC has close to 100 percent sensitivity and specificity for identifying the cause and site of biliary tract obstruction, being more accurate in this regard than ultrasonography or CT scan.
PTC also permits a number of therapeutic interventions, including drainage of infected bile in the setting of cholangitis, extraction of biliary tract stones, dilation of benign biliary strictures, or placement of a stent across a malignant stricture .
This topic review will discuss the basic aspects of the technique of PTC and the complications that may be seen. The clinical utility of PTC in different disease states is discussed separately. (See "Diagnostic approach to the adult with jaundice or asymptomatic hyperbilirubinemia".)
PTC is usually performed in patients with dilated bile ducts, which are easily recognized on transabdominal ultrasound or with all cross-sectional imaging modalities, including magnetic resonance cholangiopancreatography and computed tomography. These imaging studies are useful for planning the site of needle insertion during PTC, especially if the ductal dilation involves only one or a few liver segments. PTC may be technically limited and associated with a higher incidence of complications in the absence of dilatation of the intrahepatic ducts, although it has been performed successfully in some settings, such as in patients with postoperative biliary leaks [2-4].
Anesthesia — Since the percutaneous catheter traverses skin, intercostal muscles, and the liver capsule, the procedure can be painful and should be performed using local anesthesia and conscious sedation. Sedation is particularly important if additional procedures such as biopsy or stent insertion are planned. Some institutions prefer to use an intercostal nerve block, which may not reduce pain arising from puncture of the liver capsule or from intrahepatic manipulations. (See "Procedural sedation in adults outside the operating room".)
- Kavanagh PV, vanSonnenberg E, Wittich GR, et al. Interventional radiology of the biliary tract. Endoscopy 1997; 29:570.
- Teplick SK, Flick P, Brandon JC. Transhepatic cholangiography in patients with suspected biliary disease and nondilated intrahepatic bile ducts. Gastrointest Radiol 1991; 16:193.
- Cozzi G, Severini A, Civelli E, et al. Percutaneous transhepatic biliary drainage in the management of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts. Cardiovasc Intervent Radiol 2006; 29:380.
- Kühn JP, Busemann A, Lerch MM, et al. Percutaneous biliary drainage in patients with nondilated intrahepatic bile ducts compared with patients with dilated intrahepatic bile ducts. AJR Am J Roentgenol 2010; 195:851.
- Wu SM, Marchant LK, Haskal ZJ. Percutaneous interventions in the biliary tree. Semin Roentgenol 1997; 32:228.
- Hayashi N, Sakai T, Kitagawa M, et al. US-guided left-sided biliary drainage: nine-year experience. Radiology 1997; 204:119.
- Ozden I, Tekant Y, Bilge O, et al. Endoscopic and radiologic interventions as the leading causes of severe cholangitis in a tertiary referral center. Am J Surg 2005; 189:702.
- Ginat D, Saad WE, Davies MG, et al. Incidence of cholangitis and sepsis associated with percutaneous transhepatic biliary drain cholangiography and exchange: a comparison between liver transplant and native liver patients. AJR Am J Roentgenol 2011; 196:W73.
- Savader SJ, Trerotola SO, Merine DS, et al. Hemobilia after percutaneous transhepatic biliary drainage: treatment with transcatheter embolotherapy. J Vasc Interv Radiol 1992; 3:345.
- Choi SH, Gwon DI, Ko GY, et al. Hepatic arterial injuries in 3110 patients following percutaneous transhepatic biliary drainage. Radiology 2011; 261:969.