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What is the Biliary System, Lab Reports of Anatomy

Ateneo de Davao University (ADDU)Anatomy

Anaphy of the Biliary System and materials needed

Typology: Lab Reports

2019/2020

Uploaded on 02/02/2023

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BILIARY SYSTEM

RADIOGRAPHIC PROCEDURES IN THE BILIARY SYSTEM

1. Oral cholecystography

2. Cholangiography: Intravenous, IOC and Post Operative

3. Percutaneous Extraction of Retained Biliary Calculi (Burhenne Technique)

4. Percutaneous Transhepatic Cholangiography

5. Endoscopic Retrograde Cholangiopancreatography

I. ORAL CHOLECYSTOGRAPHY

What is the procedure all about?

The oral cholecystogram study is used to diagnose(problems related to your gallbladder,

such as gallbladder cancer or(decreased or blocked bile flow(in the biliary duct system of

your liver.

The x-ray can show inflammation of the organ, a condition known as cholecystitis. It can

also reveal other abnormalities such as(polyps(and(gallstones.

Indications

This is an investigation which has largely become redundant over the last decade with

the widespread use of US and, to a lesser extent, of other more sophisticated imaging

tools such as endoscopic retrograde cholangiography (ERCP) and magnetic resonance

cholangiography (MRCP). The indication for its use now is to demonstrate suspected

pathology in the gallbladder when ultrasound is not available or has failed to

demonstrate the gallbladder.

The cystic duct and common bile duct may also be seen. The examination is unlikely to

be successful when the serum bilirubin is greater than 34 μmol/l.

Contraindications

1. Severe hepatic or renal disease

2. Acute cholecystitis

3. Dehydration

4. Intravenous cholangiography within the previous week (although this is now a

rarely undertaken investigation)

5. Previous cholecystectomy.

ANATOMY & PHYSIOLOGY

1. Gallbladder

small, pear-shaped organ on the right side of your abdomen, it sits just under the

liver.

holds the digestive fluid called bile that’s released into your small intestine.

connected to other parts of digestive system through a series of bile ducts called

the biliary tract.

2. Biliary duct

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BILIARY SYSTEM

RADIOGRAPHIC PROCEDURES IN THE BILIARY SYSTEM

Oral cholecystography
Cholangiography: Intravenous, IOC and Post Operative
Percutaneous Extraction of Retained Biliary Calculi (Burhenne Technique)
Percutaneous Transhepatic Cholangiography 5. Endoscopic Retrograde Cholangiopancreatography I. ORAL CHOLECYSTOGRAPHY  What is the procedure all about? The oral cholecystogram study is used to diagnose problems related to your gallbladder, such as gallbladder cancer or decreased or blocked bile flow in the biliary duct system of your liver. The x-ray can show inflammation of the organ, a condition known as cholecystitis. It can also reveal other abnormalities such as polyps and gallstones.  Indications  This is an investigation which has largely become redundant over the last decade with the widespread use of US and, to a lesser extent, of other more sophisticated imaging tools such as endoscopic retrograde cholangiography (ERCP) and magnetic resonance cholangiography (MRCP). The indication for its use now is to demonstrate suspected pathology in the gallbladder when ultrasound is not available or has failed to demonstrate the gallbladder.  The cystic duct and common bile duct may also be seen. The examination is unlikely to be successful when the serum bilirubin is greater than 34 μmol/l.  Contraindications
Severe hepatic or renal disease
Acute cholecystitis
Dehydration
Intravenous cholangiography within the previous week (although this is now a rarely undertaken investigation)
Previous cholecystectomy. **ANATOMY & PHYSIOLOGY
Gallbladder**  small, pear-shaped organ on the right side of your abdomen, it sits just under the liver.  holds the digestive fluid called bile that’s released into your small intestine.  connected to other parts of digestive system through a series of bile ducts called the biliary tract. 2. Biliary duct

 a tube that carries bile from the liver and gallbladder, through the pancreas and into the small intestine.  the common bile duct starts where the ducts from the liver and gallbladder join and ends at the small intestine.  when food is being digested, bile is released from the gallbladder and passes through the pancreas into the small intestine, where it helps digest fats PATHOLOGY PREPARATION INSTRUCTIONS TO PATIENT a. To secure full cooperation from the patient, explain the purpose of the preliminary preparation and the procedure to be followed. b. Tell the patient the approximate lime required for the examination, allowing for the possibility of delay if the colon requires further cleansing or the emptying time of the gallbladder is delayed. c. Give the patient clearly printed instructions covering (l) the preliminary preparation of the intestinal tract, (2) the preliminary diet, (3) the exact lime to ingest the oral medium, (4) the avoidance of laxatives for 24 hours before the ingestion or injection of the medium, (5) the avoidance of all food, both solid and liquid, after receiving an oral

A spot-film device - is an electromechanical component of a fluoroscopic x-ray system that is intended to be used for medical purposes to position a radiographic film cassette to obtain radiographs during fluoroscopy.
Xray cassette -acts as a light-proof container in which films or imaging plates are placed for exposure to radiation. For the technologists, the cassette ensures that the highest-quality image will not be compromised by outside light.
Fluoroscopy - can be used for diagnosing (finding out the cause of) a health problem such as heart or intestinal disease. It also can be used to guide treatments such as implants or injections, or in orthopedic surgery. It helps the healthcare provider look inside organs, joints, muscles, and bones
Fatty meal –  In the earlier years of radiology, patients were often given a fatty meal after satisfactory visualization of the gallbladder. The fatty meal consisted of a commercially available bar, eggs and milk, or eggnog. The meal caused the gallbladder to contract, and additional diagnostic information was seldom obtained  An injection of the hormone cholecystokinin will also cause the gallbladder to contract. The fatty meal is seldom used today because of the diagnostic capability of ultrasonography. Contrast medium
Sodium ipodate (Biloptin); 6 capsules each containing 500 mg. This is the most widely used agent.
Iopanoic acid (Telepaque); 6 capsules each containing 500 mg. Patient preparation for Biloptin
A laxative 2 days prior to the examination.
Light, fat-free diet on the day before the examination.
No food from 18:00 h on the day before the examination until after the examination has been completed. Liquids (without milk) are allowed. The cholecystographic agent is taken with water after the last meal prior to the patient's appointment. Position/Projection PA PROJECTION Position of patient: Prone - If the patient is thin, place the pillow lengthwise and adjust it so that it extends inferiorly as far as the transmamillary line or a little below it. Position of part Prone. - Adjust the patient’s body so that the right side of the abdomen is centered to the midline of the grid.

- Rest the patient’s left cheek on the pillow to rotate the vertebrae slightly toward the left side -. Flex the patient’s right elbow, and adjust the arm in a comfortable position. If necessary, place the left arm alongside the body. - Elevate the patient’s ankles to relieve pressure on the toes. - Center the IR according to the body habitus of the patient. - If the patient has pendulous breasts, have her spread the breasts superiorly and laterally to ensure that the gallbladder region is cleared - Immobilize the abdomen with a compression band if necessary. - Respiration: Suspend respiration at the end of expiration. Watch for an indication of tenseness, and allow about 2 seconds to elapse after the cessation of respiration before making the exposure. This interval permits peristaltic action to subside and gives the patient time to relax. PA UPRIGHT POSITION - Adjust the body so that the previously localized gallbladder is centered to the midline of the grid - Elevate the gallbladder to (or almost to) the location it assumed in the prone position by instructing the patient to fully extend the arms. Otherwise, depending on the habitus of the patient, center the IR 2 to 4 inches (5 to 10 cm) below the prone level to allow for the change in gallbladder position. The remainder of the procedure is the same as for the prone position. CENTRAL RAY - Perpendicular and centered to the gallbladder at a level appropriate to the patient’s body habitus STRUCTURES SHOWN - The upright PA projection presents a somewhat axial representation of the opacified gallbladder. The foreshortening in the PA projection is caused by the angle between the long axis of the obliquely placed gallbladder and the plane of the IR. The degree of angulation and consequently the amount of foreshortening vary according to body habitus and are influenced by body position, being less in the upright position PA OBLIQUE PROJECTION (LAO position) Position of part - The degree of rotation necessary for satisfactory demonstration of the gallbladder depends on the location of the organ in reference to the vertebrae (thin subjects require more rotation than do heavier patients), the angulation of the long axis of the organ, and whether the right colic flexure is clear - With the patient in the prone position, elevate the right side to the desired degree of obliquity (15 to 40 degrees) - Instruct the patient to support the body on flexed knee and elbow.

 Prone 20° LAO, centred 7.5 cm to the right of the spinous processes, 2.5 cm cephalad to the lower costal margin.  This film is taken when the patient makes an appointment. There has been controversy regarding the usefulness of this film. Some believe that 5% of calculi will be missed if it is omitted, while others believe that virtually all radio-opaque gallstones are seen within the opacified gallbladder.Other pathology, outside the gallbladder, may be found in 5% of patients. Films

Prone 20° LAO - contrast medium fills the fundus of the gallbladder.
Supine 20° RPO - contrast medium fills the neck and Hartmann's pouch.
Erect 20° LAO - may demonstrate floating gallstones.
Overlying bowel shadows may be removed by rotating the patient under fluoroscopic control or by tomography.
Prone 20° LAO, 30 min after a fatty meal (chocolate or a proprietary fat emulsion). The value of this film was assessed by Harvey who found it was: a) essential for the cholecystographic diagnosis of adenomyomatosis and cholesterolosis b) occasionally helpful in diagnosing small stones c) of little value in assessing the biliary ducts or separating the gallbladder from overlying bowel gas d) of no value in the diagnosis of functional biliary tract disorders. If the gallbladder is not seen on the first film, the patient is asked the following questions:
What time were the tablets taken? (Sufficient time is needed for absorption and concentration in the gallbladder.)
How many tablets were taken?
Did diarrhea or vomiting develop after the tablets were taken? If the tablets have been taken, a 35 x 43-cm supine abdominal film is taken. This may demonstrate: a) a gallbladder in an abnormal position, or b) unabsorbed contrast medium. This has a flakey appearance and can be distinguished from esterified contrast medium that has passed through the liver and biliary tract, which causes a more uniform, fainter opacification. If the gallbladder is only poorly seen, the patient is given a further standard dose to be taken that evening and repeat films are taken the following day. Additional techniques For better visualization of the ducts, manufacturers make the following recommendations:

Biloptin - (i) 12 capsules at the usual time or (ii) 6 capsules 10-12 h before the examination plus another 6 capsules 3 h before.
Telepaque - 3-6 tablets are taken 4 h after a fatty lunch on the day preceding the examination, and then a full dose of 6 tablets after a fat-free meal in the evening. Aftercare None. Complications  Side-effects, even of a trivial nature, are rare with sodium ipodate.  Mild gastrointestinal disturbances - nausea, with or without vomiting and diarrhoea - may occur.  The incidence of diarrhoea is greatest with iopanoic acid.  Skin reactions - urticaria, vasodilatation and pruritus - have been recorded.  Cholecystographic agents have a uricosuric action and alteration of serum urate may precipitate an attack of gout. II. CHOLANGIOGRAPHY What is the procedure all about? A choloangiogram is a special x-ray procedure that is done with contrast media to visualize the bile ducts after the cholecystectomy (removal of the gallbladder). The bile ducts drain bile from the liver into the duodenum (first part of the small bowel).
Common Bile Ducts  A tube that carries bile from the liver and gallbladder, through the pancreas, and into the small intestine. The common bile duct starts where the ducts from the liver and gallbladder join and ends at the small intestine. It is part of the biliary system. 2. Gallbladder  The gallbladder is a sac located under the liver. It stores and concentrates bile produced in the liver. Bile aids in the digestion of fat and is released from the gallbladder into the upper small intestine in response to food (especially fats). 3. Cystic duct  A tube that carries bile from the gall bladder. It joins the common hepatic duct to form the common bile duct. It is part of the biliary duct system. 4. The left hepatic duct and the right hepatic duct  Transfer bile from the liver. These ducts are formed by the intrahepatic ducts and are a part of a ductal system that leads to the gallbladder 5. Right Intrahepatic bile ducts and left intrahepatic bile ducts

The dye is then removed from blood by the liver which excretes it into the bile
The iodine is concentrated enough just as it is secreted into bile that it does not need to be further concentrated by the gallbladder in order to outline the bile ducts and any gallstones that may be within them. **Materials:
Flouroscopy with x-ray machine**  Fluoroscopy is a type of medical imaging that shows a continuous X-ray image on a monitor, much like an X-ray movie. During a fluoroscopy procedure, an X-ray beam is passed through the body. 2. Cholangiography catheter  Used for access and diagnostic evaluation of the bile ducts during percutaneous cholecystectomy procedures. 3. Syringe  fine needle Contrast Medium: cholografin POSITION & PROJECTION POSITION AP OBLIQUE PROJECTION (RPO)
Place the patient in the supine position for a preliminary or scout radiograph of the abdomen.
Place the patient in the RPO position 15 degrees to 40 degrees for an AP oblique projection of the biliary ducts.
Obtain a scout or localization radiograph and /or tomogram to check for centering and exposure factors.
Advice the patient that a hot flush may occur when the contrast medium is injected.
Timed from the completion of the injection, duct studies are ordinarily obtained at 10 minutes interval until satisfactory visualization is obtained.
Maximum opacification usually requires 30 to 40 minutes. B. Preoperative Cholangiography  Intraoperative cholangiography (IOC) is the use of radiography with contrast media injected directly into the biliary tree to determine biliary anatomy, assess the biliary tree for obstructive processes, and to evaluate for potential injury to the biliary tract Indications  During cholecystectomy or bile duct surgery, to avoid surgical exploration of the common bile duct. Contraindications  None. **PATHOLOGY
JAUNDICE**  Is the yellow color seen in the skin of many newborns. Jaundice happens when a chemical called bilirubin builds up in the baby’s blood. During pregnancy, the mother’s liver removes bilirubin for the baby, but after birth the baby’s liver must remove the bilirubin. 2. PANCREATITIS  Is inflammation of the pancreas. The pancreas is a long, flat gland that sits tucked behind the stomach in the upper abdomen. The pancreas produces enzymes that help digestion and hormones that help regulate the way your body processes sugar (glucose). 3. ELEVATED BILIRUBIN LEVEL

 Bilirubin passes through the liver and is eventually excreted out of the body. Higher than usual levels of bilirubin may indicate different types of liver or bile duct problems. Sometimes, higher bilirubin levels may be caused by an increased rate of destruction of red blood cells.

4. ABNORMAL LIVER FUNCTION TEST RESULTS  Liver function tests can be abnormal because: Your liver is inflamed (for example, by infection, toxic substances like alcohol and some medicines, or by an immune condition). Your liver cells have been damaged (for example, by toxic substances, such as alcohol, paracetamol, poisons). 5. A HIGH LIPASE LEVEL  A very high level of lipase is usually a sign of acute pancreatitis. Higher than normal levels of lipase may be caused by: Diseases of the pancreas, including a blocked duct (tube), or pancreatic cancer. Chronic kidney diseases PREPARATION

Getting a physical exam to check your overall health
Letting your doctor know about any allergies you have, especially to contrast dye
Not eating for at least 12 hours before the surgery
Avoiding blood thinners, aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen
All operating room personnel should do appropriate protective garments prior to scrubbing and gowning.
Before having surgery, you’re likely to be given general anesthesia. Depending on the type of surgery, your doctor then makes either one large incision for traditional open surgery or several smaller cuts for laparoscopic surgery.
Next, they insert a catheter through one of these cuts and place it in your cystic duct, which connects your gallbladder to your common bile duct. Using this catheter, they’ll inject a special type of dye into the duct. This dye will allow your surgeon to view your bile ducts on a monitor while they remove your gallbladder and check for gallstones. MATERIALS :
The Stainless-Steel Basin offers multiple surgical benefits. Its principal use is to work as a receptacle for solutions, fluids or blood throughout the surgery.
A kidney basin is a shallow kidney shaped basin, widely used in surgical procedures for carrying dressing, bandages, small instruments, soiled dressing and other medical waste. It can be held close to a patient’s body conveniently because of its shape.
Beak scissors are required for cutting skin, undermining the subcutis and deeper fascial layers, cutting sutures, and removing wound dressings. Scissors may have long or short handles, and the blades are straight or curved and serrated or smooth.
Open-End Ureteral Catheter. Used for access and catheterization of the urinary tract, including the following applications: Delivery of contrast media. Drainage of fluids from the urinary tract. Delivery of irrigation fluids to the urinary tract.
The guidewire is the device used to guide the catheter into place during CVC insertions. The purpose of a guidewire is to gain access to the blood vessels using a minimally invasive technique.
Three-way stopcock with an integrated extension tubing for minimizing manipulation during intravenous administration of fluids/drugs through an i.V. Catheter. Minimizes chances of mechanical irritation and infection by taking. The administration site away from insertion site.
Contrast Media – a substance introduced into a part of the body in order to improve the visibility of internal structure during radiography

Pathology: PREPARATION

Patient identification (3 Cs- correct patient, correct side, correct procedure)
Ask for patient’s History prior to procedure to determine if the patient has allergies or has had prior reactions to the contrast media, collect relevant previous imaging for ease of access prior to procedure.
Patient should be wearing a hospital gown
No diet restrictions (some centres suggest fast from solids for 4 hours prior to procedure)
Prophylactic dose of broad-spectrum antibiotic prior to procedure (immunosuppressed patients)
Explain the procedure to the patient, what could possibly happen during and after the procedure.
Make sure Consent is signed 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.

MATERIALS

Surgical gloves - worn to prevent contamination of the patient during invasive procedures and to protect the hand from exposure to potentially infectious.
Gauze Pads - a transparent fabric of open weave and differing degrees of fine-ness, most often cotton muslin, used in surgical procedures and for bandages and dressings. It may be sterilized and permeated by an antiseptic or lotion.
Moisturize Towel - also often referred to as surgical towels, are 100% cotton, very absorbent, and extremely low lint cloths.
Syringe - a device for withdrawing, injecting, or instilling fluids. A syringe for the injection of medication usually consists of a calibrated glass or plastic cylindric barrel having a close-fitting plunger at one end and a small opening at the other to which the head of a hollow-bore needle is fitted.
Lead Apron - a protective shield of lead and rubber that may be worn by a patient, radiologic technologist or radiologist, or both during exposure to x-rays or other diagnostic radiation. It is intended to guard against excessive exposure of the reproductive and other vital body organs to ionizing radiation.
T-tube catheter - a T-shaped tube placed in the common bile duct following procedures involving the duct, such as after choledochotomy. Equipment  Fluoroscopy unit with spot film device. Contrast medium  HOCM or LOCM 150; 20-30 ml. Preliminary film:  Coned supine PA of the right side of the abdomen. Technique
The examination is performed on or about the tenth postoperative day, prior to pulling out the T-tube.
The patient lies supine on the X-ray table. The drainage tube is clamped off near to the patient and cleaned thoroughly with antiseptic.
A 23-G needle, extension tubing and 20 ml syringe are assembled and filled with contrast medium. After all air bubbles have been expelled the needle is inserted into the tubing between the patient and the clamp. The injection is made under fluoroscopic control, the total volume depending on duct filling. Films  PA and oblique views positioned under fluoroscopic control. PROCEDURE
You will be taken into the screening/fluoroscopy room and asked to lie down on the fluoroscopy table.
The fluoroscopy equipment uses x-rays to obtain real-time moving images of the body.
A small beam of continuous x-rays passes through the body to an image intensifier, which is suspended over the X-ray table.
The sequence of images produced can be viewed on a computer monitor.
X-ray pictures are taken of the abdominal area. The tube draining the bile duct is cleaned and a small needle is inserted into it.
A small amount of contrast (X-ray dye) is injected into the bile ducts through the tube while x- ray pictures are taken. POSITION/PROJECTION AP PROJECTION

T-tube should be brought out obliquely towards the right flank (to avoid irradiation of the radiologist’s fingers).
Following discovery of the retained stone on the tenth day post-T-tube cholangiogram, the patient:  should be discharged with the T-tube clamped for at least 4 weeks to allow the formation of a solid fistulous tract.
Admission to hospital on the day prior to the procedure.
Prophylactic antibiotics and pre-medication 1 h prior to the procedure.
Analgesia during the procedure.  Technique
The patient lies supine on the X-ray table. A T-tube cholangiogram is performed to accurately localize the retained calculus.
The T-tube is slowly withdrawn from the patient.
The steerable catheter is advanced down the T-tube track and its tip is positioned just beyond the calculus. A basket is then inserted through the catheter and opened beyond the stone. The opened basket and catheter are then slowly withdrawn and the stone engaged. The basket should not be closed as the stone may be disengaged or fragmented. The catheter system with the engaged stone in the basket should be slowly withdrawn to the skin surface in one movement.
The duct system is opacified by intermittent injections of contrast through the steerable catheter.
At the end of the procedure a suction catheter or similar is manipulated into the duct system and sutured to the skin.
Stones up to 10 mm in diameter may be extracted through a 14-F tract. Stones greater than 10 mm will require fragmentation ( i f soft) or endoscopic sphincterotomy/surgery. Multiple stones m ay require repeated procedures.
A completion cholangiogram should be performed via the suction catheter on the day following the procedure, when the gas bubbles have cleared.  Aftercare
Pulse and blood pressure half-hourly for 6 h.
Bed rest for 12 h.  Complications  Morbidity 4%.  Due to the contrast medium
‘Allergic’ reactions - rare
Pancreatitis.  Due to the technique
Fever
Perforation of the T-tube tract. IV. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY  A percutaneous transhepatic cholangiogram (PTC) is an x-ray of the bile ducts. These are the tubes that carry bile from the liver to the gallbladder and small intestine.  The liver capsule is punctured with a thin needle under fluoroscopic guidance, and contrast medium is injected as the needle is slowly withdrawn.  Study visualizes the biliary ducts without depending on the gallbladder’s concentrating ability. The intrahepatic and extrahepatic biliary ducts, and occasionally the gallbladder, can be visualized to determine possible obstruction.  INDICATIONS
Cholestatic jaundice, to confirm or exclude extrahepatic bile ductobstruction.
Prior to therapeutic intervention, e.g. biliary drainage procedure.

 CONTRAINDICATIONS

Bleeding tendency: a. platelets less than 100 000 b. prothrombin time 2 s greater than control
Biliary tract sepsis
Non-availability of prompt surgical facilities should they be necessary, or a patient who is unfit for surgery
Hydatid disease. ANATOMY & PHYSIOLOGY: The liver  the largest gland in the body, is an irregularly wedge-shaped gland. It is situated with its base on the right and its apex directed anteriorly and to the left.  The liver has numerous physiologic functions.The primary consideration from the radiographic standpoint is the formation of bile BILE: ( PRODUCT OF THE LIVER)  Is the greenish-yellow fluid (consisting of waste products such as BILIRUBIN , cholesterol, and bile salts) that is secreted by the liver cells to perform 2 primary functions: a. To carry away waste b. To break down fats during digestion  Bile passes out of the liver through the bile ducts and is stored in the gallbladder. After a meal, it is released into the small intestine.  When the bile ducts become blocked, bile builds up in the liver, and jaundice (yellow color of the skin) develops due to the increasing level of bilirubin in the blood. BILE DUCTS:Intrahepatic and extra extrahepatic duct 1.INTRAHEPATIC ic bile ducts are a network of small tubes that carry bile inside the liver.  Left Right Hepatic Ducts –Formed by smallest ducts called ductules that comes together.Transfer bile from the liver. 2.EXTRAHEPATIC BILE DUCTS  Extrahepatic bile ducts are small tubes that carry bile from the liver and gallbladder to the small intestine. They are made up of : a. Common Hepatic Duct-A tube that carries bile out of the liver. It is formed from the intersection of the right and left hepatic ducts. b. Cystic Duct- tube that carries bile from the gall bladder. It joins the common hepatic duct to form the common bile duct

Chiba needle (a fine, flexible 22-G needle, 18-cm long).-one of the most commonly used biopsy/percutaneous access needles. It is a two-part hollow needle with a beveled tip angled at 30 degrees. It is typically between 18-22 G and is primarily used for aspiration tissue biopsy, to aspirate fluid, and to gain percutaneous access to the biliary tree (e.g. PTC) and pelvicalyceal system of the kidney. It can also be used to puncture and thereby deflate an intravascular balloon if it fails to deflate through its own valve 1,2.
Drape - used during surgery to prevent contact with unprepared. surfaces and to maintain the sterility of environmental surfaces, equipment and the. patient's surroundings
Syringe
Gloves
Gauze & bandages
Antiseptic & local anesthesia Projection/Position Preliminary film  Supine PA of the right side of the abdomen. TECHNIQUE
The patient lies supine. Under fluoroscopic control a metal marker is placed on the skin in the right mid-axillary line such that its position overlies the liver during full inspiration and expiration. A second metal marker is placed on the xiphisternum.
Using aseptic technique the skin, deeper tissues and liver capsule are anaesthetized at the site of the first metal marker.
During suspended respiration the Chiba needle is inserted into the liver,but once it is within the liver parenchyma the patient is allowed shallow respirations. It is advanced parallel to the table top in the direction of the xiphisternum until just short of the right lateral margin of the spine.
The stilette is withdrawn and the needle connected to a syringe and extension tubing prefilled with contrast medium. Contrast medium is injected under fluoroscopic control while the needle is slowly withdrawn. If a duct is not entered at the first attempt, the needle tip is withdrawn to approximately 2-3 cm from the liver capsule and further passes are made,directingthe needle tip more cranially, caudally, anteriorly orposteriorly until a duct is entered. If a duct has not been entered after ten attempts, the procedure is terminated and the assumption is made that the ducts are not dilated. The incidence of complications is not related to the number of passes and the likelihood of success is directly related to the degree of duct dilatation and the number of passes made.
Excessive parenchymal injection should be avoided and when it does occur it results in opacification of intrahepatic lymphatics. Injection of contrast medium into a vein or artery is followed by rapid dispersion.
If the intrahepatic ducts are seen to be dilated, bile should be aspirated and sent for microbiological examination. (The incidence of infected bile is high in such cases.)

Contrast medium is injected to fill the duct system and define the lower end of an obstruction (if present). The needle is withdrawn. Care should be taken not to overfill an obstructed duct system because septic shock may be precipitated. FILMS Contrast medium is heavier than bile and the sequence of duct opacification is, therefore, gravity- dependent and determined by the site of injection and the position of the patient. Using the undercouch tube with the patient horizontal:
PA
45°RPO
Right lateral
Trendelenburg
Spot views of the gallbladder, if this has been opacified. Using the undercouch tube with the patient erect:
PA
45°RPO
Right lateral
Spot views of the gallbladder
When the above films have shown an obstruction at the level of the porta hepatis, a further film after the patient has been in the erect position for 30min may show the level of obstruction to be lower than originally thought. Additional films  Hypotonic duodenography-T his may be performed to give additional information regarding the site of an obstruction and its position relative to the duodenum. Delayed Films  Films taken after several hours, or the next day, may show contrast medium in the gallbladder if this was not achieved during the initial part of the investigation. AFTERCARE  Pulse and blood pressure half-hourly for 6 h. COMPLICATIONS  Morbidity approximately 3%; mortality less than 0.1%. Due to the contrast medium

What is the Biliary System, Lab Reports of Anatomy

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Download What is the Biliary System and more Lab Reports Anatomy in PDF only on Docsity!

BILIARY SYSTEM

RADIOGRAPHIC PROCEDURES IN THE BILIARY SYSTEM

MATERIALS

 CONTRAINDICATIONS