Chapter III: GB And Biliary Tract PDF

Edgardo S. Lapastora Jr.RRT  CHOLEGRAPHY- general term used for radiologic exam of the biliary tract w/ the use of radiopaque C.A.   CHOLYCYSTANGIOGRAPHY or CHOLECYSTOCHOLANGIOGRAPHY- G.B. and bile ducts   CHOLECYSTOGRAPHY- g.b.   CHOLANGIOGRAPHY- bile ducts  Admi...

Edgardo S. Lapastora Jr.RRT  CHOLEGRAPHY- general term used for radiologic exam of the biliary tract w/ the use of radiopaque C.A.   CHOLYCYSTANGIOGRAPHY or CHOLECYSTOCHOLANGIOGRAPHY- G.B. and bile ducts   CHOLECYSTOGRAPHY- g.b.   CHOLANGIOGRAPHY- bile ducts  Administration of C.A.  Mouth (oral)  Injected into vein in a single bolus or by drip infusion I.V  Direct injection into the ducts ◦ percutaneuos transhepatic puncture ◦ during biliary tract surgery-operative or immediate ◦ through in dwelling drainage tube- post op delayed or T-tube  Method of Exam: Named according to: ◦ Route of entry of the medium ◦ portion of the biliary tract examined  Route of C.A  Mouth ----intestine----carried to the liver through portal viens  IV------bld circulation ----CA is excreted w/ the bile & conveyed to the G.B. by the system  PURPOSE OF THE PROCEDURE  function of the liver its ability to remove C.A from the bloodstream & excrete it with the bile  patency & condition of the biliary ducts  concentrating & end the emptying power of the G.B.  Appearance of calculi or stones:  *pure cholesterol(fat)- black  - 50 to 60% are pure cholesterol  -25 to 30% -cholesterol and crystalline salts   *calcified- white  - 10 to 15 crystalline calcium salts  -ingestion of four to six tablets or capsules, during the evening preceeding the examination  -oral CM used for GB re also called “cholecystopaques”  Contraindications:  1. Advanced hepatorenal disease ◦ -severe jaundice ◦ -acute or chronic liver failure ◦ -renal failure ◦ -hepatocellular disease  2.Active GI disease-vomitting, severe diarrhea,or  malabsorption syndrome  3. Hypersensitivity to iodine containing compounds  4. Pregnancy  -ingestion of four to six tablets or capsules, during the evening preceeding the examination  -oral CM used for GB re also called “cholecystopaques”  Contraindications:  1. Advanced hepatorenal disease ◦ -severe jaundice ◦ -acute or chronic liver failure ◦ -renal failure ◦ -hepatocellular disease  2.Active GI disease-vomitting, severe diarrhea,or  malabsorption syndrome  3. Hypersensitivity to iodine containing compounds  4. Pregnancy  Indications:  Choledocholethiasis Neoplasms  Cholelithiasis Biliary Stenosis  Milk calciulm bile Congenital anomalies  Cholecystisis  Px Preparation:  Px w/ fat free diet should eat fat 1 to 2 days before GB exam  Laxatives are avoided 24 hours before exam Noon with fatty foods  Light evening meal without fat or fried food  NPO  Take 4 to 6 capsules of CM after the meal but before 9  No breakfast  Report to xray dept morning  Px Interview:  Ask the px how many pills were taken at what time  Question the px on any reaction from the pill  Determine if the px has not had breakfast  Make sure that the px still has GB  Px Interview:  Ask the px how many pills were taken at what time  Question the px on any reaction from the pill  Determine if the px has not had breakfast  Make sure that the px still has GB  Ask a female px of childbearing age regarding a possible pregnancy  Imaging Routine:  Scout : PA proj ( 10x12 or 14x17) taken to determine the presence and location of GB, presence of choleliths, adequate concentration of CM,correctness of exposure factors. ◦ Some departmental routine is a full abdomen w/ positioning of PA abdomen centered at IC or slightly above  Ppx- prone  Pp- align MSP to long axis of table, with the right halve or abdomen centered  CR- perpendicular to IR  For average sthenic px Cr to level of L2, ½ to 1” above the lowest margin of the rib cage  IR centered to CR  Inst: respiration suspended GB and area or the cystic duct  SS- region of opacified   LAO ( 10x 12 lenghtwise)- projects GB away from the vertebral column, ideal to delineate between gas trapped in bowel and radiolucent stones in the GB  Ppx semiprone, left side down  Pp-rotate px 15 to 40°(less rotation on hyperstenic, more rotation asthenic  ≈ right half of abdomen to CR and to the midline of the table  Center film  CR- perpendicular  Inst- suspended respiration upon expiration  SS- same as above  Right Lateral Decubitus (10x12 lengthwise)- opacified bladder projected away from the vertebral column, stratify or laye any possible choleliths within the GB, maybe performed when px cannot stand erect  Ppx-px on radiolucent pads lying on right side facing the IR  Pp- adjust the cart end to center the bladder on the IR  Ensure that there is no rotation of the body  CR- horizontal  RP- center the film  Inst - suspended respiration upon expiration  SS-provides dropping of GB away from the vertebra,stratified GB stones  PA ERECT (10x12 Lwise) – possible stratification of any choleliths w/in the GB  PPx-px erect facing the VGCH  Pp- align a point on abdomen about 2” more inferior than the scout film  For asthenic px, a slight rotation of 10 to 15° LAO  CR- horizontal  RP- midpoint of film  Inst- respiration suspended upon expiration  SS- entire opcified bladder and area of cystic duct  OPERATIVE (or IMMEDITATE) CHOLANGIOGRAM ◦ Performed to accomplish the ff: ◦ Reveal any choleliths not previously reported ◦ Investigates the patency of the biliary ducts ◦ Determine the status of papilla of Vater ◦ Demonstrate any lesions, strictures or dilatations w/in the ducts  Procedure: ◦ Performed during surgery ◦ If the surgeon suspects residuals stones in one of the biliary ducts after the GB has been removed ◦ A small catheter is inserted into the remaining portion of the cystic duct and contrast media is introduced ◦ Radiographic images are then obtained  POST OPERATIVE (T-TUBE OR DELAYED) CHOLANGIOGRAPHY- usually done after cholesectomy.  A special T-tube catheter is inserted into the common bile duct which extend outside the body and then clamped off  PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)- it involves a direct puncture of the biliary ducts with a needle passing through the liver tissue  Three major risk:  Liver hemorrhage  Pneumothorax  Escape of bile  After the site of puncture is surgically prepared and local anesthetics are given,the radiologist inserts the needle into the liver in the approximate loation of the biliary ducts  Under flouro the radiologist adjust the needle while slowly injecting CM  A larger needle or loop catheter is inserted into the duct containing w/ stone   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)- a special type of endoscope called deudoscope is commonly used. Therapeutic: ERCP can be performed to relive certain pathologic conditions, removal of choleliths, or small lesions, repair stenosis Diagnosis: Insertion of cathether or injection cannula common bile duct or main pancreatic duct under fluoroscopic control, followed by retro grade injection of CM into the biliary ducts Precautions: 1.NPO 1 hr or more 2.Review of the px history if the px has pancreatitis or pseudocyst of pancreas 3.Ensure that all persons in the flouro room wear protective apron