Cholangiography, Percutaneous Transhepatic
Percutaneous cholecystogram, PTC, PTHC.
To visualize and assess biliary ducts for causes of obstruction and jaundice, such as cancer or stones.
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.
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. Protocols may vary among facilities.
Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period.
- 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
(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is punctured with a thin needle under fluoroscopic guidance, and contrast medium is injected as the needle is slowly withdrawn.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.
- 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.
Pregnancy is a general contraindication to procedures involving radiation.
Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). 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 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
- Common bile duct cysts
- Gallbladder cancer
- Nonobstructive jaundice
- Tumors, strictures, inflammation, or gallstones of the common bile duct
Nursing Implications, Nursing Process, Clinical Judgement
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing the bile ducts of the gallbladder and pancreas.
- Explain that the procedure takes 45 to 60 min and is usually performed in the radiology department.
- Review the procedure with the patient.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing). A blood type and screen may be ordered for possible transfusion in the event of bleeding.
- Explain that pregnancy testing may be required.
- Discuss why an antibiotic will be administered at least 1 hr before the procedure (due to the possibility that percutaneous bile drainage may contain infected bile fluid, so antibiotics are given to avoid spreading an infection to other parts of the body).
- Discuss how there may be moments of discomfort or pain when the IV line is inserted, allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Baseline vital signs are recorded and monitored throughout the procedure.
- Adherance to organizational policies and the Centers for Medicare and Medicaid Services (CMS) quality measures is required regarding administration of prophylactic antibiotics.
- Ordered prophylactic antibiotics are administered 1 hr before incision, and the antibiotics used 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.
- The patient is instructed to inhale deeply and hold their breath as the needle is inserted.
- An ordered antiemetic drug may be administered if nausea occurs.
- An emesis basin is available for use.
- 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 bile specimen 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 is established if a catheter is left in place.
- 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.
- 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: Implementation & Evaluation Potential Nursing Actions
- Monitor the patient for complications related to the procedure.
- Note that a rare complication related to the PTC procedure is septicemia.
- Establishing an IV site and injection of contrast medium are invasive procedures that can cause rare complications. For additional information see Appendix A: Patient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated with Diagnostic Procedures.
- Immediately report symptoms such as difficulty breathing, chest pain, fever, hyperpnea, hypertension, nausea, palpitations, pruritus, rash, tachycardia, urticaria, or vomiting to the appropriate HCP.
- Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction.
- Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.
- Monitor for symptoms of bleeding to include hypotension, tachycardia, confusion with altered level of consciousness, pallor, anxiety and restlessness, shortness of breath.
- Follow post-procedure vital sign and assessment protocol.
- Generally, no specific post-procedural care is required as the complication rate is relatively low and mostly consists of discomfort at the puncture site.
- 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 post-procedural bleeding occurs, pressure should be applied and maintained over the needle insertion site (for several hours if bleeding is persistent).
- The patient is positioned in the right decubitus position for the first hour, followed by placement in the supine position for an additional 2 to 3 hr to avoid significant post-procedural bleeding.
- Instruct the patient to resume usual diet, fluids, medications, and activity as directed by the HCP, if no complications are present.
- Consider how to provide effective pain management related to the presence of stones or disease.
Followup Evaluation and Desired Outcomes
- Demonstrates proficiency in the care of the site and dressing changes.
- Agrees to follow therapeutic management guidelines related to medical diagnosis.