is a special x-ray procedure that is done with contrast media (x-ray dye) to visualize the bile ducts after the removal of the gallbladder. The bile ducts drain bile from the liver into the duodenum (first part of the small bowel). This procedure will visualize any stones remaining in the bile ducts.
Contraindications :
- non-consent by patient to procedure
- contrast or iodine allergy
- pregnancy (? pregnancy test required)
- barium study within last 3 days
Preparation :
- patient identification (3 Cs- correct patient, correct side, correct procedure)
- Patient should be wearing a hospital gown
- consent form
- no diet restrictions (some centres suggest fast from solids for 4 hours prior to procedure)
- collect relevant previous imaging for ease of access prior to procedure
- ? prophylactic dose of broad spectrum antibiotic prior to procedure (immunosupressed patients)
- Some operators prefer the T-tube to be clamped prior to the procedure to allow the bile duct to fill with bile. Air in the bile duct can give a false impression of a gallstone.
Procedure :
- the patient is positioned supine on the X-ray table
- A slightly RPO position can help to ensure the CBD is not superimposed over the patient's spine.
- a preliminary/scout image of the RUQ should be acquired.
- The tip of the T-tube is cleaned with antiseptic
- the T-tube should be raised and tapped to ensure there are no air bubbles lurking in the tube.
- A butterfly needle should be inserted into the T-tube
- The syringe plunger is withdrawn to remove bile from within the duct. (optional)
- An early filling image should be obtained.
- The entire biliary tree should be imaged during injection of contrast medium.
- Injection should continue until the entire biliary tree is opacified and there is passage of contrast into the deuodenum.
- If the intrahepatic ducts do not fill, the patient can be tilted trendelenburg and further contrast injected into the T-tube.
- The patient may need to lie on their left hand side to fill the left hepatic duct.
- At least 2 views of the entire biliary tree should be recorded by spot film (DSI)
oblique views are often taken
Technique Notes :
- Contrast media should be diluted with saline so that small biliary stones are not obscured by an overly dense contrast media
- Preliminary/scout images are important. Failure to take a preliminary/scout image is one of the most frequently made errors by Radiology Registrars performing fluoroscopy procedures
- air-bubbles can often be distinguished from stones by their behaviour- air bubbles tend to float 'up hill' and can change shape and may separate into two smaller bubbles.
- If the examination is marred by air bubbles, the biliary system can be flushed with saline and the study repeated.
- If there is any question of distal obstruction, a delayed drainage image should be obtained
Post Procedure Care :
- patient can eat and drink normally
- warn patient to advise of any itching or rash post procedure
- patient should remain in hospital for observation for at least 24 hours post procedure
- If the T-tube is removed at the end of the procedure, the wound should be checked for bile leakage for 24 hours
Complications :-
- persistent biliary fistula (rare)
- biliary peritonitis
- cholangitis
