Sign in or
A T-tube cholangiogram is a fluoroscopic procedure in which contrast medium is injected through a T-tube into the patient's biliary tree. The T-tube is most commonly inserted during a cholecystectomy operation when there is a possibility of residual gall stones within the biliary tree.
- Patient must have T-tube insitu
- patient's with possibility of residual small gallstones post cholecystectomy
- obstructive jaundice
- bile duct stricture
- surgeon unable to explore bile duct during cholecystectomy surgery
- non-consent by patient to procedure
- contrast or iodine allergy
- pregnancy (? pregnancy test required)
- barium study within last 3 days
- patient identification (3 Cs- correct patient, correct side, correct procedure)
- Patient should be wearing a hospital gown
- consent form
- no diet restrictions (some centres suggest fast from solids for 4 hours prior to procedure)
- collect relevant previous imaging for ease of access prior to procedure
- ? prophylactic dose of broad spectrum antibiotic prior to procedure (immunosupressed patients)
- Some operators prefer the T-tube to be clamped prior to the procedure to allow the bile duct to fill with bile. Air in the bile duct can give a false impression of a gallstone.
Forrest et al, 1995 in Margaret F. Alexander, Josephine N. Fawcett, Phyllis J. Runciman Nursing practice: hospital and home : the adult. 2006, p146
- the patient is positioned supine on the X-ray table
- A slightly RPO position can help to ensure the CBD is not superimposed over the patient's spine.
- a preliminary/scout image of the RUQ should be acquired.
- The tip of the T-tube is cleaned with antiseptic
- the T-tube should be raised and tapped to ensure there are no air bubbles lurking in the tube.
- A butterfly needle should be inserted into the T-tube
- The syringe plunger is withdrawn to remove bile from within the duct. (optional)
- An early filling image should be obtained.
- The entire biliary tree should be imaged during injection of contrast medium.
- Injection should continue until the entire biliary tree is opacified and there is passage of contrast into the deuodenum.
- If the intrahepatic ducts do not fill, the patient can be tilted trendelenburg and further contrast injected into the T-tube.
- The patient may need to lie on their left hand side to fill the left hepatic duct.
- At least 2 views of the entire biliary tree should be recorded by spot film (DSI)
- oblique views are often taken
The T-tube is made of very flexible plastic. The flexibility of the plastic facilitates the percutaneous remove of the T-tube without surgical intervention. T-tubes are usually sized between 10 French (10F) and 16 French (16F). This is an AP/PA supine T-tube cholangiogram image. The biliary tree is outlined with contrast medium. There appears to be extravasation of contrast medium outside the biliary tree and minimal contrast in the deuodenum.
- Contrast media should be diluted with saline so that small biliary stones are not obscured by an overly dense contrast media
- Preliminary/scout images are important. Failure to take a preliminary/scout image is one of the most frequently made errors by Radiology Registrars performing fluoroscopy procedures
- air-bubbles can often be distinguished from stones by their behaviour- air bubbles tend to float 'up hill' and can change shape and may separate into two smaller bubbles.
- If the examination is marred by air bubbles, the biliary system can be flushed with saline and the study repeated.
- If there is any question of distal obstruction, a delayed drainage image should be obtained
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
- persistent biliary fistula (rare)
- biliary peritonitis
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