Cholangiography, Percutaneous Transhepatic

Synonym/Acronym:
Percutaneous cholecystogram, PTC, PTHC.

Rationale
To visualize and assess biliary ducts for causes of obstruction and jaundice, such as cancer or stones.

Patient Preparation
There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 4 to 8 hr, or as ordered, prior to the procedure. Fasting is ordered because an empty stomach provides better visualization and as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. The patient may be instructed to prepare the bowel with a laxative the night before and a cleansing enema the morning of the procedure, by medical direction.

Note: If iodinated contrast medium is scheduled to be used in patients receiving metformin or drugs containing metformin for type 2 diabetes, the drug may be discontinued on the day of the test and continue to be withheld for 48 hr after the test.

Patients with heart valve disease may be premedicated with antibiotics.

Regarding the patient's risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken.

Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.

Ensure that this procedure is performed before an upper gastrointestinal (GI) study or barium swallow.

Normal Findings

  • Biliary ducts are normal in diameter, with no evidence of dilation, filling defects, duct narrowing, or extravasation
  • Contrast medium fills the ducts and flows freely
  • Gallbladder appears normal in size and shape.

Critical Findings and Potential Interventions
N/A

Overview

(Study type: X-ray, special/contrast; related body system: Digestive system.) Percutaneous transhepatic cholangiography (PTC) is a test used to visualize the biliary system in order to evaluate persistent upper abdominal pain after cholecystectomy and to determine the presence and cause of obstructive jaundice. The liver capsule is punctured with a thin needle under fluoroscopic guidance, and contrast medium is injected as the needle is slowly withdrawn. This study visualizes the biliary ducts without depending on the gallbladder's concentrating ability. The intrahepatic and extrahepatic biliary ducts, and occasionally the gallbladder, can be visualized to determine possible obstruction. In obstruction of the extrahepatic ducts, a catheter can be placed in the duct to allow external drainage of bile. Endoscopic retrograde cholangiopancreatography (ERCP) and PTC are the only methods available to view the biliary tree in the presence of jaundice. PTC is more invasive and painful to undergo than ERCP.

Indications

  • Aid in the diagnosis of obstruction caused by gallstones, benign strictures, malignant tumors, congenital cysts, and anatomic variations.
  • Determine the cause, extent, and location of mechanical obstruction.
  • Determine the cause of upper abdominal pain after cholecystectomy.
  • Distinguish between obstructive and nonobstructive jaundice.

Interfering Factors

Contraindications

Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.

Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are asked specifically if they have a known allergy to iodine or shellfish (shellfish contain high levels of iodine), it has been well established that the reaction is not to iodine; an actual iodine allergy would be problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.

Patients with conditions associated with preexisting renal insufficiency (e.g., chronic kidney disease, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs), because iodinated contrast is nephrotoxic.

Patients who are chronically dehydrated before the test, especially older adults and patients whose health is already compromised, because of their risk of contrast-induced acute kidney injury.

Patients with bleeding disorders or receiving anticoagulant therapy, because the puncture site may not stop bleeding.

Patients with cholangitis; the injection of the contrast medium can increase biliary pressure, leading to bacteremia, septicemia, and shock.

Factors that may alter the results of the study

  • Gas or feces in the GI tract resulting from inadequate cleansing or failure to restrict food intake before the study.
  • Retained barium from a previous radiological procedure.
  • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
  • Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.

Potential Medical Diagnosis: Clinical Significance of Results

Abnormal Findings In:

  • Anatomic biliary or pancreatic duct variations
  • Biliary cholangitis
  • Cholangiocarcinoma
  • Cirrhosis
  • Common bile duct cysts
  • Gallbladder cancer
  • Gallstones
  • Hepatitis
  • Nonobstructive jaundice
  • Pancreatitis
  • Tumors, strictures, inflammation, or gallstones of the common bile duct

Nursing Implications

Before the Study: Planning and Implementation

Teaching the Patient What to Expect

  • Inform the patient this procedure can assist in assessing the bile ducts of the gallbladder and pancreas.
  • Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing) or to assess for impaired kidney function (creatinine level and estimated glomerular filtration rate) if use of iodinated contrast medium is anticipated. The liver is a vascular organ; therefore, a type and screen of the patient's blood may be ordered for possible transfusion in the event of bleeding. Percutaneous bile drainage may have infected bile, and as such an antibiotic will be administered at least 1 hr before the procedure in order to avoid spreading the infection to other parts of the body.
  • Pregnancy is a general contraindication to procedures involving radiation. Explain to the female patient that she will be asked the date of her last menstrual period. Pregnancy testing may be performed to determine the possibility of pregnancy before exposure to radiation.
  • Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort or pain experienced when the IV line or catheter is inserted to allow infusion of fluids such as saline, anesthetics, sedatives, contrast medium, medications used in the procedure, or emergency medications.
  • Explain that contrast medium will be injected, by catheter, at a separate site from the IV line.
  • Advise that a burning and flushing sensation may be felt throughout the body during injection of the contrast medium, and the patient may experience an urge to cough, flushing, nausea, or a salty or metallic taste.
  • Inform the patient that the procedure is usually performed in the radiology department by a health-care provider (HCP), with support staff, and takes approximately 60 min.
  • Instruct the patient to remove jewelry and other metallic objects from the area of examination.
  • Baseline vital signs will be recorded and monitored throughout the procedure. Protocols may vary among facilities.
  • Adhere to organizational policies and the Centers for Medicare and Medicaid Services (CMS) quality measures regarding administration of prophylactic antibiotics. Administer ordered prophylactic antibiotics 1 hr before incision, and use antibiotics that are consistent with current guidelines specific to the procedure.
  • Positioning for this procedure is in the supine position on a tilting examination table where a kidney, ureter, and bladder (KUB) or plain film is taken to ensure that no stool or barium from a previous study will obscure visualization of the biliary system.
  • Advise the patient they will be instructed to inhale deeply and hold their breath as the needle is inserted. An area over the upper right quadrant of the abdomen is prepped and draped and local anesthetic is given to the abdominal wall. The needle is inserted and advanced under fluoroscopic guidance. Contrast medium is injected when placement is confirmed by the free flow of bile. A specimen of bile may be sent to the laboratory for culture and cytological analysis. If an obstruction is found during the procedure, a catheter is inserted into the bile duct to allow drainage of bile. At the end of the procedure, the contrast medium is aspirated from the biliary ducts, relieving pressure on the dilated ducts. A closed and sterile drainage system will be established if a catheter is left in place.
  • Advise taking slow, deep breaths if nausea occurs during the procedure. An ordered antiemetic drug can be administered as needed. An emesis basin can be ready for use.
  • Explain to the patient they will be monitored for complications related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm).
  • Explain that once the study is completed, the needle or catheter is removed, and a pressure dressing is applied over the puncture site.

Potential Nursing Actions

Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

  • If iodinated contrast medium is scheduled to be used in patients receiving metformin or drugs containing metformin for type 2 diabetes, the drug may be discontinued on the day of the test and continue to be withheld for 48 hr after the test.

Safety Considerations

  • Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure where bleeding is a potential complication.

After the Study: Potential Nursing Actions

Avoiding Complications

  • PTC, establishing an IV site, and injection of contrast medium are invasive procedures. Complications are rare but include risk for allergic reaction (related to contrast reaction), bile peritonitis, bleeding from the puncture site (related to a bleeding disorder or the effects of natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties), extravasation of bile, hematoma (related to blood leakage into the tissue following needle insertion), hemoperitoneum, infection (which might occur if bacteria from the skin surface is introduced at the puncture site), tissue damage (related to extravasation or leaking of contrast into the tissues during injection), nerve injury or damage to a nearby organ (which might occur if the needle strikes a nerve or perforates an organ), nephrotoxicity (a deterioration of renal function associated with contrast administration), and septicemia. Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm, infection, injury). Immediately report symptoms such as difficulty breathing, chest pain, fever, hyperpnea, hypertension, nausea, palpitations, pruritus, rash, tachycardia, urticaria, or vomiting to the appropriate HCP. Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation. Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction.

Treatment Considerations

  • Do not allow the patient to eat or drink for several hours after the procedure as a precaution in the event a return to surgery is required related to postprocedural bleeding. If no complications present, the patient can resume usual diet, fluids, medications, and activity as directed by the HCP.
  • Symptoms of bleeding to monitor for are hypotension, tachycardia, confusion with altered level of consciousness, pallor, anxiety and restlessness, shortness of breath.
  • Pressure should be maintained over the needle insertion site for several hours if bleeding is persistent. The patient may be placed in the right decubitus position for the first hour, followed by placement in the supine position for an additional 2 to 3 hr in order to avoid significant post procedural bleeding. Observe/assess the puncture site for signs of bleeding, hematoma formation, inflammation, ecchymosis, or leakage of bile. Notify the HCP if any of these is present.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and as ordered. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.

Safety Considerations

  • Renal function should be assessed before metformin is resumed. Advise diabetic patients to avoid all medications containing metformin for 48 hr following a procedure with iodinated contrast. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal adverse effect of metformin (related to renal impairment that does not support sufficient excretion of metformin).

Followup Evaluation and Desired Outcomes

  • Generally no specific postprocedural care is required. The complication rate is relatively low and most complications, such as discomfort at the puncture site, are of limited duration.
  • Demonstrates proficiency in the care of the site and dressing changes.

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