Indication
Most biliary imaging is non invasive with US, MRCP or CT.
Most percutaneous cholangiography is performed in the angio suite prior to intervention.
There are a few situations where you will need to perform cholangiograms.
To check patency of biliary drains. (PTC)
To check patency of and leak from cholecystostomy tubes with imaging of the CBD.
To check patency of the CBD following operative T tube insertion.
For all examinations you must answer the following questions before performing the procedure:
What is the clinical question to be answered?
What study will you perform?
How do you perform this study and what equipment is required?
Who will supervise or review your images when you need assistance?
Anatomy
A percutaneous cholangiogram taken through a cholecystostomy tube
The pancreatic duct is rarely visualised during percutaneous cholangiography.
Equipment
Sterile pack, chlorhexadine, sterile towel, 20ml syringe x 2, saline, contrast (niopam).
Technique
This is a sterile procedure
As the drainage tube has often been inserted due to infection, most patients should be given antibiotics prior to imaging, or ensure sepsis has settled prior to imaging.
Clean and drape the appropriate tube.
Take a control film of the tube if visible. Often the distal end of the tube may not initially be visible. The nature of the tube, pathology and indication for cholangiogram will guide your control film.
Control film - T Tube not visible
Gently aspirate some bile and flush a small volume of saline 3-5 ml to ensure the tube is patent. Ensure that you do not introduce air. Air bubbles will mimic calculi.
Gently inject Niopam using a small 10ml or 20 ml syringe. Start by opacifying just the tube using fluoroscopic guidance. You can make adjustments to your radiography i.e. centring, magnification and conning to optimise imaging. Take an exposure of the tube.
Early view showing filling of the T Tube. Now is the time to make adjustments.