INTRODUCTION — 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 [1].
This topic 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 "Treatment options for locally advanced, unresectable, but nonmetastatic cholangiocarcinoma".)
●(See "Acute cholangitis: Clinical manifestations, diagnosis, and management".)
●(See "Repair of common bile duct injuries".)
●(See "Treatment of advanced, unresectable gallbladder cancer".)
●(See "Liver transplantation in adults: Endoscopic management of biliary complications".)
TECHNIQUE — 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 moderate 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 of the operating room: General considerations, preparation, monitoring, and mitigating complications".)
Antibiotic prophylaxis — Intravenous antibiotic prophylaxis should be given prior to PTC in patients with obstructive jaundice. It is important to select antibiotics that include coverage of Enterococcal species and gram-negative bacilli, both of which are found in infected bile ducts. In addition to antibiotic prophylaxis, the bile ducts should be decompressed prior to contrast injection, because injection into a dilated system can result in biliary sepsis [5]. (See "Acute cholangitis: Clinical manifestations, diagnosis, and management".)
Access sites — Percutaneous access to the biliary tree is usually via the left or right hepatic ducts, but can also be achieved through puncture of the gallbladder. The left hepatic duct is preferred because the subcostal route used to access the left hepatic duct is less painful than the intercostal route used to approach the right hepatic duct, and because accessing the left duct is less likely to transgress the pleural space [6]. However, in cases of segmental biliary obstruction, which may be due to a variety of causes, the location of the dilated ducts typically dictates the route of access.
Cannulation — Using ultrasound or fluoroscopic guidance, a peripheral bile duct is punctured with a 21-gauge needle, and position confirmed with injection of a small volume of contrast material. A guidewire is then inserted through the needle into a central bile duct, and a plastic drainage cannula is passed over the guidewire. Insertion of the cannula may require the use of sheaths and dilators to distend the tract.
A catheter can then be inserted through the cannula and can be advanced across an obstruction into the duodenum, thereby draining bile both internally and externally. Adequate drainage is usually confirmed by a steady decline in serum bilirubin concentrations. Drainage from an infected system is slower than from a noninfected tract due to the greater viscosity of infected bile. The external limb of the catheter can be closed to enhance internal drainage and preserve the enterohepatic bile salt circulation.
INTERVENTIONS — Access to the biliary tree permits a number of diagnostic and therapeutic interventions. As an example, sclerosing cholangitis and cholangiocarcinoma are two diseases in which the intrahepatic bile ducts may not easily be opacified via endoscopic retrograde cholangiopancreatography (ERCP). In this setting, percutaneous transhepatic cholangiography (PTC) is useful for documenting the extent of disease, obtaining tissue for histological diagnosis, dilating a stricture, or inserting a stent to relieve obstruction (image 1A-C). (See "Primary sclerosing cholangitis in adults: Clinical manifestations and diagnosis" and "Clinical manifestations and diagnosis of cholangiocarcinoma".)
Stones, sludge, or blood clots can also be removed during PTC and access to the biliary tree accomplished during PTC can facilitate subsequent interventions via ERCP by placement of a guidewire. Biopsies and brushings can be obtained when malignancy is suspected. (See "Endoscopic methods for the diagnosis of pancreatobiliary neoplasms".)
COMPLICATIONS
Bacteremia — Bacteremia is a potential complication of percutaneous transhepatic cholangiography that warrants antibiotic prophylaxis [7]. However, the risk of cholangitis and sepsis is low. In one study of 154 patients, the rate of cholangitis following cholangiography with subsequent biliary drain exchange was 2 percent, and the rate of sepsis was 0.4 percent [8].
Severe hemobilia — Another complication of percutaneous biliary cholangiography and drainage is severe hemobilia resulting from communication of the tract with a major vascular structure; and the rate of severe hemobilia ranges from 0.2 to 4 percent [9-13]. In one series of 13 patients who underwent percutaneous transhepatic drainage complicated by severe hemobilia, hepatic arteriography was used to identify the source of bleeding, and transcatheter embolization effectively stopped the bleeding in all cases [9]. The embolization agents that were used included embolization microcoils, occluding spring emboli, cyanoacrylate, detachable balloons, and gelatin sponge pledgets. (See "Angiographic control of nonvariceal gastrointestinal bleeding in adults".)
In a second series with 3110 patients who underwent 3780 percutaneous transhepatic biliary drainage procedures, hepatic arterial injury occurred after 72 procedures (2 percent) [11]. All patients were treated with transcatheter embolization, with technical and clinical success rates of 100 and 96 percent, respectively.
While hepatic artery injury is a rare complication of percutaneous transhepatic biliary drainage, intrahepatic ductal dilation and left-sided puncture have been identified risk factors [11,12].
SUMMARY AND RECOMMENDATIONS
●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. It 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. (See 'Introduction' above.)
●Intravenous antibiotic prophylaxis should be given prior to PTC in patients with obstructive jaundice. It is important to select antibiotics that include coverage of Enterococcal species and gram-negative bacilli, both of which are found in infected bile ducts. (See 'Antibiotic prophylaxis' above.)
●Access to the biliary tree permits a number of diagnostic and therapeutic interventions including dilation, brushings, and biopsies of biliary strictures, removal of intrahepatic stones, and placement of a stent or a guidewire to facilitate subsequent endoscopic retrograde cholangiopancreatography. (See 'Interventions' above.)
●Although percutaneous transhepatic cholangiography is generally safe and well tolerated, complications such as bacteremia or severe hemobilia can occur. (See 'Complications' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jonathan B. Kruskal, MD, PhD, who contributed to an earlier version of this topic review.
