Percutaneous Transhepatic Cholangiography

Purpose: 1. To determine the cause of upper abdominal pain following cholecystectomy. 2.To distinguish between obstructive and non-obstructive jaundice. 3.To determine the location, the extent and, commonly, the cause of mechanical obstruction. Discussion: Percutaneous transhepatic cholangiography is a fluoroscopic examination in which by passing a needle through the liver and into an intrahepatic bile duct, iodinated dye can be injected directly into the biliary system. The intrahepatic and extrahepatic biliary ducts, and occasionally the gallbladder, can be visualized and studied for partial or total obstruction from gallstones, benign strictures, malignant tumors, congenital cysts, and anatomic variations. This is especially helpful in patients with jaundice. Equipment: - General fluoroscopic with spot film device or high quality image grab - General sterile procedures pack - Skin prep - Sterile towels - Local anaesthetic equipment - Chiba needle - flexible 22 gauge 18 cm long.

PROCEDURE
Before 1. Explain the procedure to the patient. Rationale: To inform patient and be aware to the procedure. 2. Obtain informed consent. Rationale: For legal purposes. 3. Assess the patient for allergy to iodinated dye or shellfish. Rationale: To avoid allergic reaction to the contrast medium. 4. Keep the patient NPO after midnight on the day of the test. Rationale: For proper visualization of the hepatic system. During 1. The patient is placed supine on an x-ray table in the radiology department. Rationale: For proper visualization of the hepatic system. 2. The abdominal wall (over the liver) is anesthetized with lidocaine (Xylocaine). Rationale: To promote comfort from the

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REMARKS

procedure. 3. With the use of televised fluoroscopic monitoring, the needle is advanced through the skin and into the liver. Rationale: For proper visualization of the hepatic system. 4. When bile flows freely out from the liver through the needle, radiographic dye is injected. Rationale: To asses for obstructions or stones. 5. X-ray films are obtained immediately. Rationale: To asses for obstructions or stones. 6. If an obstruction is found, a catheter or stent is placed over a guide wire and left temporarily in the biliary tract. Rationale: To establish drainage and decompression of the biliary tract. After 1. Keep the patient on bed rest for several hours. Rationale: To prevent potential bleeding. 2. If indicated, place a sand bag over the needle insertion site. Rationale: To prevent potential bleeding and bile leakage. 3. Repeatedly asses the patient's vital signs. Rationale: To note if there is deviation from normal. 4. Assess the patient for signs of bacteremia or sepsis. Rationale: To asses for presence of septicemia. 5. If a catheter is left in the biliary tract, establish a sterile, closed drainage system. Rationale: To avoid infection. 6. Withhold high doses of pain medications. Rationale: This may blunt the abdominal signs associated with hemorrhage or bile extravasation. Performed by: __________________________ Evaluated by: ___________________________

Before 1.Assess the client's understanding of the procedure, providing explanattion, clarification, and emotional support. 2. Type and cross-match the patient's blood. The patient may bleed and require a transfusion. 3. Verify the results of coagulation studies are within the normal range. 4. Premidicate the patient as indicated, usually with atropine and meperidine. 5. Clean the site for puncture with antiseptic solution. After 1. Keep the patient NPO for a few hours after the test in the event intraabdominal bleeding or extravasation develops that require surgery. 2. Observe the needle insertion site for bleeding and bile leakage. 3. Note that fever and chills may indicate bacteremia and sepsis. 4. Instruct the patient to report signs of bleeding (increased pulse and decreased blood pressure).