Version May 2024
INTRODUCTION — Biliary obstruction may involve the extra- or intrahepatic bile ducts and may be related to nonmalignant (eg, bile duct stones) or malignant (pancreaticobiliary cancer) causes (figure 1). Patients usually present with jaundice, abdominal pain, pruritus, and/or cholangitis. There are several options for treating biliary obstruction including endoscopic intervention, percutaneous transhepatic intervention, and surgery. Percutaneous transhepatic cholangiography (PTC) is an interventional radiologic procedure that is usually performed when endoscopic biliary access via endoscopic retrograde cholangiography (ERC) is technically limited. PTC involves transhepatic insertion of a needle into a bile duct, followed by injection of contrast material to opacify the bile ducts. PTC localizes the site of obstruction and facilitates therapeutic interventions, such as biliary drainage, removal of bile duct stones, dilation of biliary strictures, and stent placement.
This topic will discuss patient preparation, technique, postprocedure care, and adverse events related to PTC. The clinical applications for PTC are discussed in more detail 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 "Primary sclerosing cholangitis in adults: Clinical manifestations and diagnosis" and "Primary sclerosing cholangitis in adults: Management".)
PATIENT SELECTION
Clinical applications — The role of PTC in managing biliary disorders is primarily a therapeutic one because other methods of diagnostic testing (eg, magnetic resonance imaging with magnetic resonance cholangiopancreatography, endoscopic ultrasound) provide high diagnostic accuracy without the risks associated with percutaneous intervention. However, the initial cholangiogram helps to define biliary anatomy and guide therapeutic interventions.
PTC is indicated for patients with suspected or established biliary obstruction when endoscopic access is technically challenging or visualization of the biliary tree is limited [1]. Conditions associated with difficult biliary access (ie, unsuccessful guidewire cannulation of the common bile duct during endoscopic retrograde cholangiography [ERC]) include (see "Management of difficult biliary access during ERCP in adults"):
●Surgically altered anatomy (eg, Roux-en-Y gastric bypass) (see "ERCP in patients with Roux-en-Y anatomy")
●Gastroduodenal obstruction
●Duodenal diverticulum or other anatomic variation
As an example, the intrahepatic bile ducts in patients with primary sclerosing cholangitis may not easily be opacified during ERC. For these patients, we perform PTC to define extent of disease, obtain tissue samples, dilate stricture(s), and/or perform stent placement to relieve biliary obstruction. (See "Primary sclerosing cholangitis in adults: Clinical manifestations and diagnosis" and "Clinical manifestations and diagnosis of cholangiocarcinoma".)
PTC facilitates multiple interventions including removal of bile duct stones, sludge, or blood clots, placement of a biliary catheter for drainage, obtaining biopsies or brushings for pathology, and placement of a biliary guidewire to allow for subsequent endoscopic access (image 1A-C).
Contraindications — There are no absolute contraindications to PTC; however, the following factors may increase the risk of procedure-related adverse events:
●Hemostatic disorders – Patients with an untreated hemostatic disorder may be at higher risk for bleeding, and we assess and optimize the coagulation status in such patients. In general, the targets for laboratory values prior to the procedure are international normalized ratio (INR) <1.8 (and ideally <1.5) and platelet count ≥50,000/microL. The decision to proceed with PTC and related interventions in patients with hemostatic disorders is individualized and informed by severity of coagulopathy, severity of underlying disease, procedure-related bleeding risk, and alternatives to PTC [2-4].
●Ascites – Patients with ascites are at increased risk for leakage of ascitic fluid around the percutaneous catheter site, procedural technical difficulty due to ascites displacing the liver, and higher radiation doses [1,5]. Thus, we typically perform paracentesis prior to PTC to reduce the volume of ascites and minimize these risks [2].
●Nondilated biliary ducts – PTC may be technically limited and associated with a higher risk of adverse events in patients with nondilated intrahepatic ducts [2,6,7]. However, PTC may be accomplished in some patients with nondilated ducts, such as patients with postoperative biliary leaks. (See "Complications of laparoscopic cholecystectomy", section on 'Biliary injury'.)
PREPROCEDURE EVALUATION — The diagnosis of a biliary disorder is often suspected based on presenting symptoms (abdominal pain, jaundice), laboratory studies, and imaging. Prior to PTC, we review the following:
●Laboratory testing – Complete blood count, liver enzymes (aspartate aminotransferase, alanine aminotransferase), alkaline phosphatase, total bilirubin, and INR.
●Imaging – Patients referred for PTC often have dilated bile ducts, which are visible on transabdominal ultrasound or with cross-sectional imaging (eg, magnetic resonance cholangiopancreatography, computed tomography). Thus, most patients will have had imaging prior to PTC. We review imaging studies to assess options for the needle insertion site, especially if the ductal dilation involves only one or a few liver segments. However, cross-sectional imaging is not required prior to the procedure.
PATIENT PREPARATION
Adjusting medications — The management of anticoagulants and antiplatelet agents for patients undergoing PTC is informed by the patient's risk of thromboembolic complications in the absence of therapy and the procedure-related bleeding risk. Our approach to medication adjustments for PTC is similar to the approach for other invasive procedures (table 1) [4]:
●Anticoagulants – We discontinue warfarin five days before the procedure and restart warfarin on the day after the procedure (algorithm 1). We typically discontinue direct oral anticoagulants (DOACs; eg, rivaroxaban, apixaban, dabigatran) two days before the procedure and restart DOACs on the day after the procedure.
Peri-procedure management of anticoagulants, including bridging for patients with high thromboembolic risk, is discussed in detail separately. (See "Perioperative management of patients receiving anticoagulants".)
●Antiplatelet agents – We discontinue aspirin and other antiplatelet agents (eg, clopidogrel) five days prior to the procedure. We restart antiplatelet agents on the day after the procedure. (See "Perioperative medication management", section on 'Medications affecting hemostasis'.)
We also consult with the clinician who is managing the patient's long-term anticoagulation (eg, cardiologist, neurologist) when adjusting these medications.
Sedation/anesthesia — Options for anesthesia for PTC include moderate procedural sedation or general anesthesia. Factors informing the specific approach include risk for airway difficulty, procedure indications and expected duration (eg, catheter exchange only, need for stent or drain placement), and the patient's hemodynamic status and comorbidities.
Both moderate sedation and general anesthesia (in addition to subcutaneous injection of a local anesthetic) are reasonable options for the initial PTC in which percutaneous access is established. Insertion of the percutaneous catheter through the skin, intercostal muscles, and the liver capsule may be painful; thus, sedatives and/or analgesic medications are indicated.
We generally perform subsequent procedures (eg, exchange of a percutaneous drainage catheter) with moderate sedation plus injection of local anesthetic. Issues related to use of anesthesia outside the operating room, including the administration of local anesthetics, are discussed separately:
●(See "Considerations for non-operating room anesthesia (NORA)".)
●(See "Monitored anesthesia care in adults".)
●(See "Subcutaneous infiltration of local anesthetics".)
Dietary restrictions — Patients take nothing by mouth for three to six hours prior to the procedure [3]. (See "Preoperative fasting in adults".)
Antimicrobial prophylaxis — We administer antimicrobial prophylaxis to all patients undergoing PTC, and this is consistent with society guidelines [8]. To prevent intra-abdominal infection, we use an antibiotic regimen with broad coverage against Enterococcus species and gram-negative organisms.
Our first choice for antimicrobial prophylaxis is to administer ceftriaxone 1 g, intravenously, once within 60 minutes prior to the procedure. However, there is no consensus among clinicians with regard to first-line antibiotic regimen. Alternatives to ceftriaxone are [8]:
●Ampicillin/sulbactam 1.5 to 3 g, once intravenously
●Cefotetan 1 g plus mezlocillin 4 g, once intravenously
●Ampicillin 2 g plus gentamicin 1.5 mg/kg, once intravenously (see "Dosing and administration of parenteral aminoglycosides")
PROCEDURE TECHNIQUE
Selecting an access site — Selecting a percutaneous access site is guided by the location of the biliary obstruction or injury. We typically establish percutaneous access to the biliary tree through the right and/or left hepatic ducts or, less frequently, by puncturing the gallbladder.
The right-sided approach is performed through the intercostal route, whereas left-sided access is obtained through the xiphoid (subcostal) route. Although the left-sided route has been associated with less pain, it is also associated with a higher risk of arterial injury [3].
Cannulating the biliary tree — After the site is selected, the abdominal wall is cleansed with antibacterial solution. We inject lidocaine at the site, first superficially and then deeply into the abdominal wall. Using ultrasound or fluoroscopic guidance, we puncture a peripheral bile duct with a 21-gauge needle and then confirm the needle position by injecting a small amount of contrast material. Prior to contrast injection, we decompress the bile ducts by allowing contrast or bile to flow through the side arm of the sheath because excessive contrast injection into a dilated system increases the risk of biliary sepsis [9]. (See 'Infection' below.)
Next, we insert a guidewire through the needle into a central bile duct and then introduce a plastic drainage cannula over the guidewire. For cannula insertion, we may use sheaths and dilators to distend the tract if such maneuvers are indicated, based on the size and anatomy of the peripheral bile ducts.
Establishing biliary drainage — For patients with biliary obstruction, we may insert a catheter over the guidewire and advance it across the obstructed biliary segment and into the duodenum. This technique allows for external drainage via the percutaneous catheter and for internal drainage into the duodenum. When internal drainage has been well established, we cap the external catheter to promote internal drainage, thereby maintaining enterohepatic bile salt circulation. Internal drainage may be achieved through the internal drainage catheter or by a patent bilioenteric tract.
We typically measure serum bilirubin within 12 to 24 hours after the procedure to confirm that drainage is adequate by demonstrating a decline in bilirubin level. In our experience, patients with cholangitis will have slower drainage than those without biliary tract infection because of the higher viscosity of infected bile. (See 'Post-procedure care' below.)
POST-PROCEDURE CARE — After the procedure, patients are recovered from sedation or anesthesia. Post-anesthetic care is discussed in detail separately. (See "Overview of post-anesthetic care for adult patients".)
Post-procedure care also includes:
●Monitoring – Most patients who undergo an initial PTC remain hospitalized overnight for observation. We typically check total bilirubin and alkaline phosphatase levels on the day following PTC. A gradual improvement in laboratory values is expected for patients who underwent biliary stenting and/or drainage [3].
Length of hospital stay is informed by complexity of procedure (eg, initial or subsequent PTC), the underlying condition, patient's clinical status and comorbidities, and risk of adverse events. As an example, we discharge patients who are hemodynamically stable and without signs of adverse events on the day after the procedure. (See 'Adverse events' below.)
We instruct patients to monitor the drain site for catheter dislodgement, peri-catheter leakage, and catheter occlusion. Patients with an occluded catheter often present with acute cholangitis (eg, fever, abdominal pain, jaundice). (See "Acute cholangitis: Clinical manifestations, diagnosis, and management", section on 'Clinical manifestations'.)
Patients who had a follow-up PTC for catheter exchange or removal are usually discharged on the same day after recovering from anesthesia.
●Diet – Patients may resume their normal diet after the procedure.
ADVERSE EVENTS
Incidence — PTC is generally regarded as a safe procedure, but adverse events can occur even when standard infection control measures and good technique are used. Estimated rates of major complications range from 4 to 9 percent, and estimated rates of minor complications range from 2 to 38 percent [2]. Major complications related to PTC with biliary drainage include cholangitis and bleeding, whereas minor complications include catheter occlusion (8 percent), catheter dislodgement (6 percent), and leakage around the catheter (3 percent) [3,10]. (See 'Infection' below and 'Bleeding' below.)
Infection — Cholangitis is a major infectious complication of PTC, with reported rates ranging from 5 to 9 percent of procedures, while the rates of post-procedure sepsis are lower and range from 1 to 2 percent [2,3]. The management of cholangitis includes decompression of the obstructed bile ducts and antimicrobial therapy, and these issues are discussed separately. (See "Acute cholangitis: Clinical manifestations, diagnosis, and management", section on 'Management'.)
Other reported infectious or inflammatory complications include abscess, peritonitis, cholecystitis, and pancreatitis [2].
Bleeding — Hemobilia (ie, bleeding into the biliary system) is a potential complication of PTC with biliary intervention that results from communication between the biliary tract and a vascular structure. Reported rates of hemobilia range from 2 to 20 percent [3]. Severe hemobilia is defined as continuous bloody output into the drainage bag, drop in hemoglobin level, and/or hemodynamic instability; however, severe bleeding is uncommon following PTC. Causes of severe hemobilia include communication of the biliary tract with a major blood vessel such as the portal vein or a branch of the hepatic artery [11-13].
Most episodes of bleeding after PTC are typically self-limiting or are treated with transcatheter endovascular embolization. In a study including 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]. (See "Angiographic control of nonvariceal gastrointestinal bleeding in adults".)
SUMMARY AND RECOMMENDATIONS
●Background – Percutaneous transhepatic cholangiography (PTC) is an interventional radiologic procedure that involves transhepatic insertion of a needle into a bile duct, followed by injection of contrast material to opacify the bile ducts. PTC and subsequent interventions are often performed when endoscopic retrograde cholangiography (ERC)-guided biliary access is challenging or limited in patients with biliary obstruction. (See 'Introduction' above.)
Conditions associated with difficult endoscopic biliary access include surgically altered anatomy (eg, Roux-en-Y gastric bypass), gastroduodenal obstruction, and duodenal diverticulum. (See "Management of difficult biliary access during ERCP in adults".)
PTC facilitates multiple interventions including removal of bile duct stones, dilation of biliary strictures, placement of a biliary stent, and sampling tissue with biopsies or brushings. (See 'Clinical applications' above.)
●Preprocedure evaluation – The diagnosis of a biliary disorder is often suspected based on presenting symptoms (abdominal pain, jaundice), laboratory studies, and imaging. Prior to PTC, we review the following:
•Laboratory testing – Complete blood count, liver enzymes (aspartate aminotransferase, alanine aminotransferase), alkaline phosphatase, total bilirubin, and international normalized ratio (INR).
•Imaging – Prior to referral for PTC, most patients will have had imaging (eg, transabdominal ultrasound, magnetic resonance cholangiopancreatography, computed tomography). We review prior imaging to assess biliary tree anatomy and options for the needle insertion site. However, cross-sectional imaging is not required prior to the procedure.
●Patient preparation
•Adjusting medications – Our general approach to preprocedure medication adjustments includes (table 1) (see 'Adjusting medications' above):
-Anticoagulants – We discontinue warfarin five days before the procedure and restart warfarin on the day after the procedure. We typically discontinue direct oral anticoagulants (DOACs) two days before the procedure and restart DOACs on the day after the procedure (algorithm 1). (See "Perioperative management of patients receiving anticoagulants".)
-Antiplatelet agents – We discontinue aspirin and other antiplatelet agents (eg, clopidogrel) five days prior to the procedure. We restart antiplatelet agents on the day after the procedure. (See "Perioperative medication management".)
We also consult with the clinician who is managing the patient's long-term anticoagulation (eg, cardiologist, neurologist) when adjusting these medications.
•Antimicrobial prophylaxis – We use antibiotic prophylaxis for all patients undergoing PTC. We suggest ceftriaxone as first-line prophylaxis (Grade 2C) because of its spectrum of activity and clinical experience. We typically administer ceftriaxone 1 g, intravenously, once within 60 minutes prior to the procedure. (See 'Antimicrobial prophylaxis' above.)
●Post-procedure care – After PTC, patients are recovered from sedation or anesthesia. (See "Overview of post-anesthetic care for adult patients".)
Most patients who undergo an initial PTC remain hospitalized overnight for observation. We typically check serum total bilirubin and alkaline phosphatase on the following day.
●Adverse events – PTC is generally regarded as a safe procedure, but adverse events can occur even when standard infection control measures and good technique are used. Major complications related to PTC with biliary drainage include cholangitis and bleeding, whereas minor complications include drain occlusion, drain dislodgement, and leakage around the drain. (See 'Adverse events' above.)
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