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Date issued: October 2023

Review date: October 2025

Ref: B-475/Oncology/CG/PTC and Biliary drainage v2 

PDF:  PTC and biliary drainage final October 2023 v2.pdf [pdf] 410KB

Introduction

This booklet has been designed to explain a Percutaneous Transhepatic Cholangiogram (PTC) and biliary drainage. It explains what is involved and what the possible risks are. It will hopefully supplement the information given to you by your doctors, surgeons, specialist nurses and ward nurses. It may not cover all your concerns so if you have any other questions or worries after reading this booklet, please don’t hesitate to contact one of the staff or wards listed towards the end of the booklet.

What is a PTC?

A PTC is a procedure performed by an interventional radiologist (specialised X-ray doctor) who uses X-rays to look at the bile ducts (the tubes in your liver which carry bile from your liver to the bowel). Contrast medium (X-ray dye) is injected directly into a bile duct in the liver through a thin needle inserted through the skin on your right side. The contrast allows detailed pictures of the bile ducts to be seen using X-rays.                                                                           

Why do I need a PTC?

Bile is a fluid that helps digest fat in food. It is produced in the liver and flows through bile ducts which are tubes in the liver. These tubes normally carry the bile from the liver to the bowel. If bile cannot flow through the bile ducts and out from the liver into the bowel due to a narrowing or blockage of the bile ducts, it collects in the blood and is seen as a yellow discolouration of the skin and eyes (jaundice). This can result in itching of the skin, dark urine, light coloured stools, fatigue, and a bile duct infection.

If your doctor believes you have a blocked bile duct and you have developed some of these symptoms, you may need a PTC to X-ray your bile ducts to find the cause of the blockage.

There are several conditions that can cause a blockage or narrowing of the bile ducts, these include:

• Inflammation pancreatitis (inflammation of the pancreas), sclerosing cholangitis (inflammation of the bile ducts).

• Tumours, cancer of the pancreas, gallbladder, bile duct, liver or enlarged lymph nodes.

• Gallstones, either in the gallbladder or bile duct.

• Injury to the bile duct during surgery.

• Infection. 

You will have more than likely have had pictures of your liver and bile ducts taken by ultrasound, CT (Computed Tomography) or MRI (Magnetic Resonance Imaging) to identify a narrowing or blockage of the bile ducts. A PTC is usually recommended either to get more detailed pictures of the bile ducts or as the start of a treatment to treat a narrowing or blockage of the bile ducts such as:

• Placement of a drainage catheter (tube) across the narrowing to deal with infection or to prepare you for an operation by reducing jaundice.

• Sampling of tissue (biopsy) to make a diagnosis.

• Removal of gallstones (stone like objects that form in your gallbladder or bile ducts).

• Balloon dilation (stretching) of the narrow area.

• Placement of a stent (a hollow metal or plastic tube) across the narrowing to keep the bile duct open. This is often a permanent treatment for jaundice due to cancer. 

Are there any alternatives?

Endoscopic retrograde cholangiopancreatography (ERCP) is an alternative way of gaining access to the common bile duct. This involves passing a tube with a camera (the endoscope) through the mouth into the stomach and duodenum and up into the bile duct. A PTC is often required when the ERCP is not possible or has already been tried and failed. A PTC may be the only possible option after some surgical operations.

What preparation do I need?

Your blood clotting can be abnormal if your bile ducts are blocked. You will need to have a blood test before the  procedure to check this. Your doctor or clinical nurse specialist will arrange this. You may need to have an injection of vitamin K or a special infusion to correct blood clotting before the procedure.

If you are taking Warfarin, Clopidogrel, aspirin or other blood thinning medication or Metformin please inform the radiology department as these may need to be stopped for a number of days before the procedure. Please continue to take all other medications as usual.

Please also let us know if you have asthma, or are allergic to any medications, skin cleansing preparations, iodine or the contrast medium (special dye used to highlight blood vessels on X-ray) used for the PTC.

You may already be an inpatient in hospital or, if not, you will be admitted into hospital on the previous day or the day of your procedure. You will not be allowed to eat for 6 hours prior to the procedure. You may drink small amounts of clear fluids like water up to 2 hours before the procedure.

A cannula (needle) will be inserted into a vein in your hand, this allows us to administer antibiotics to minimise the risk of infection. You may have an intravenous drip in your arm to keep you hydrated.

If you are pregnant or think you might be pregnant, you must tell the imaging staff, so that appropriate protection or advice can be given.

What happens before the procedure?

When it is time for the procedure you will be taken down on your bed to the radiology department. A nurse will check your details. If you are allergic to anything (such as medicines, latex, plasters) please tell the nurse.

The interventional radiologist will explain the procedure answering any questions you have. When all the questions have been answered you will be asked to sign a consent form for the procedure. If you are having general anaesthesia, the anaesthetic doctor will see you before the procedure.

What happens during the procedure?

You will be taken into the interventional radiology room and helped onto the X-ray table. The radiologist will perform an ultrasound scan of the liver before starting the procedure.

You will have a device attached to your finger to monitor your heart rate and breathing. A cuff will be placed on your arm to monitor your blood pressure. You will be given oxygen either via a mask or tubing under your nose.

You may be given a general anaesthetic or a sedative with painkillers through the cannula in your hand. You may be  fully unconscious during the procedure or should be very drowsy and relaxed.

The upper part of your abdomen (tummy) will be cleaned with antiseptic fluid and covered with a sterile towel.

The interventional radiologist will give you an injection of local anaesthetic into your abdomen to numb the area. This may sting but should not last very long.

An X-ray camera suspended over the table will be used to take images during the procedure. It may come close to you but should not touch you.

A fine needle will be passed through the skin and adjusted under X-ray guidance until it is in the right place inside the liver. X-ray dye will be injected through the needle and  pictures taken. You may experience a warm sensation   throughout your body. This is normal and wears off quickly. You may be asked to lie still while the X-ray pictures are being taken.

In most cases, after these pictures have been taken the radiologist continues to perform a further procedure to treat the narrowing of the bile duct. The exact procedure intended in your case will be discussed with you individually prior to the procedure.

These may include:

Biliary drainage: This is where an external drain (a tube) is inserted in order to drain and remove excess bile from the bile ducts into a collection bag. The drainage tube is secured to the skin and covered with a dressing. It may be left in for a few days, weeks, until the condition has improved, or further surgery has been completed. In some conditions the external biliary drain will be permanent, and you will be shown how to care for this.

Biliary biopsy: Occasionally a sample of tissue is needed to diagnose the cause of the bile duct narrowing and plan your treatment. This may be obtained by passing a small biopsy needle through a tube (sheath) placed where the needle had passed through the skin to the narrowing or blockage of the bile duct.

Biliary balloon dilatation: Biliary dilation is when the stricture (narrowing) within the bile ducts is opened up with a balloon attached to a catheter. This balloon is inflated at the point of the narrowing, to stretch the duct open.

You might find this uncomfortable and experience some pain. This should only last a short time and go once the balloon is deflated. Please let the nurse or doctor know if you require any pain killers. A drainage catheter may be inserted afterwards if needed.

Biliary stenting: Biliary stenting is when a plastic or metal stent is placed across the stricture (narrowing) in order to relieve the blockage permanently. An external drainage catheter may be left in place for a few days or until your doctors are satisfied that the bile duct stent is working properly.

It is not always possible to complete the whole planned procedure in one session. If this should happen, you will have to have an external drainage tube left in place and go back to the radiology department to complete the procedure after a few days. In these cases, the success rate is usually higher on the second attempt.

Are there any risks?

PTC and biliary drainage are safe procedures, but as with any medical procedure there are some risks and possible complications that can arise:

The liver is a large organ containing a lot of blood. There is a risk of bleeding, though this is generally very slight. If bleeding were to continue, then it is possible you might need a blood transfusion. Very rarely, an operation or another radiological procedure is required to stop the bleeding. 

You may feel pain during or after the procedure. You will be given regular pain killers after the procedure to help with the pain.  

Infection: If the bile is infected, there is a small risk that  infection might be released into your bloodstream, making you unwell for a period. We might give you antibiotics before the procedure to help minimise this risk.

Reaction to the ‘contrast medium’ (the special dye containing iodine used in the examination). This is very rare but can happen.

The use of imaging guidance such as X-rays or ultrasound during the procedure helps to minimise the risk of  complications. The radiologist performing the procedure will discuss the risk factors relevant to your condition with you before starting and will be happy to answer any questions you may have.

What happens after the procedure?

You will be taken back to the ward where you will need to be on bed rest for 6 hrs. You will have your pulse, blood pressure and your temperature monitored to ensure there are no complications.

You can eat and drink normally unless instructed otherwise by the doctor. Please tell the nursing staff if you feel unwell or feverish.

You may need to continue antibiotic treatment. If you have any pain, please inform the ward staff and they can give you pain relief. It is normal to feel discomfort after this procedure and simple pain killers (Paracetamol and or Codeine) work very well for a few days to relieve this discomfort.

If you have an external drainage catheter, you will need to take care of the drainage bag and make sure the tube does not kink (bend), or the bile will not be able to pass through. Please be careful that the tube does not get pulled, as this could cause it to fall out. The nursing staff will measure and record the amount of bile collected in the bag and change the wound dressing when needed.

In most patients the drainage tube and bag are only kept on for a few days but sometimes they need to stay for longer e.g., a few weeks or even months. In very rare cases, the drainage tube is permanent. If the tube is kept draining for a long time, then you will need to drink extra fluid and take extra salts to compensate.

The doctor will review your condition to decide when the catheter can be removed and when you can go home. If you are discharged home with the catheter and bag in place, the nursing staff will teach you how to care for the catheter at home, such as how to empty the bag and change the dressing. You may need further support from your GP Practice or District Nurse at home with this.

How to care for a permanent Biliary drain

If you are sent home with the drain and a bag attached,  empty the bag daily or more regularly if required. Always measure the amount of fluid coming out of the bag and keep a record of this.

Whether it is on free drainage or whether your catheter (drain) is closed off with a cap (bung) it should be flushed with 10mls of saline (salt water) every week.

After flushing the catheter, a new bung or new bag should be re-attached. When you flush the drain, you must only push the saline in and never attempt to draw back on the syringe.  This should be performed by a nurse or relative that has been shown how to do this.

The wound site should be assessed when the catheter is flushed and a new dressing applied. The dressing should   also be changed if there is any leakage of fluid from around the catheter. The equipment you need for flushing the tube (bags, bungs, saline, syringes and dressings) will be given on discharge from the ward. If you need any more supplies, your GP Practice Nurse/ District Nurse or nurse specialist will be able to help source this.  

The biliary drain will need to be changed every 3 months. The radiology department will contact you directly and give you a date and time for the procedure.     

At home post procedure

You may have a small amount of bruising where the catheter was inserted. This is normal and is nothing to worry about. If you notice any swelling or redness around the insertion site, have a temperature or continue to experience pain, please either ring your GP or 111 out of hours or go the nearest Emergency Department.

Contact numbers for further information:

Derriford Radiology Department:      01752 430838/432063

Cancer Nurse Specialist:                  01752 431527

Wolf Ward:                                        01752 439677

Stonehouse Ward:                            01752 431488