What Is Percutaneous Transhepatic Cholangiogram?

Percutaneous transhepatic cholangiogram (PTC) is a minimally invasive procedure done to evaluate and treat obstructions of the biliary tract, the drainage system of your liver and gallbladder. A PTC procedure involves the injection of contrast dye into the bile duct to produce an image using fluoroscopy (a type of continuous X-ray) or ultrasound.

In this article, we will discuss the purpose of a PTC, its side effects, how the procedure is done, and what the results mean.

Purpose of Procedure

A percutaneous transhepatic cholangiogram serves as a diagnostic, minimally-invasive tool to image the bile ducts and nearby tissues. It is considered a first-line procedure for diagnosing biliary tract obstructions.

Other procedures that aid in the diagnosis of biliary tract conditions include ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) with cholangiopancreatography (MRCP) (magnetic resonance imaging that visualizes the biliary and pancreatic ducts non-invasively), and endoscopic retrograde cholangiopancreatography (ERCP).

PTC serves as both a diagnostic and treatment method. It is sometimes done for obtaining diagnostic samples, especially when ERCP is not an option or if it has been unsuccessful. It is also used to treat a person with a confirmed bile duct obstruction diagnosis or who is suspected to have an obstruction.

The types of diseases that obstruct the drainage of the bile and the bile ducts are either malignant or benign. One of the more common types of malignant diseases linked to the bile ducts is cholangiocarcinoma (also called bile duct cancer), cancer that starts in the thin tubes that carry bile to the liver.

An example of a benign condition of the bile and bile ducts is bile duct stenosis (stricture), a narrowing of the bile duct.

Other common causes of bile duct obstruction include:

• Choledocholithiasis (bile duct stones)
• Cholelithiasis (gallstones)
• Primary sclerosing cholangitis (inflammation and scarring of the bile ducts)
• Inflammation of the biliary system
• Pancreatitis (inflammation of the pancreas)
• Systemic infection (an infection of the bloodstream)
• Benign tumors
• Abdominal trauma

As a diagnostic tool, the PTC test creates a roadmap of the bile ducts, which can also help in determining a treatment plan. When that roadmap is complete, a blockage can be treated with a stent or a thin tube called a drain. That stent or drain can help the body rid itself of bile—a process called percutaneous biliary drainage.

Risks and Contraindications

PTC should be avoided or considered as a last option in certain situations. This is because some complications related to the procedure can range from mild to life-threatening for some people. Fortunately, for most people, serious complications with PTC are uncommon and complications that do occur are self-limiting. 

Complications linked to PTC are:

• Allergic reaction to the contrast dye
• Damage to nearby organs or the liver
• Excessive blood loss
• Sepsis (systemic reaction to infection)
• Bile duct inflammation
• Bile duct leakage
• Infection

When PTC is used to treat obstructions, it can correct obstructions in segments, as recommended by the Society of Interventional Radiology. PTC should only be used minimally to provide a tolerable therapeutic effect.

Before the Procedure 

Before the PTC, your doctor will want you to undergo other imaging studies and bloodwork to check your coagulation limits and liver function. Let your doctor know about any allergies you have. If you are pregnant, your doctor needs to know this as well.

You should also let your healthcare professional know if you have a bleeding disorder and/or are taking any blood thinners, such as Warfarin (coumadin) and Plavix (clopidrogrel).

Timing and Location

A PTC test is usually done by an interventional radiologist in a radiology lab. The procedure can take up to an hour to perform.

It is often done under local anesthesia, and you will be given a mild sedative. Some people are given a nerve block using an epidural injection rather than general anesthesia.

What to Wear

You will not need to wear anything specific for the procedure. This is because you will be given a hospital gown to wear for the procedure and will be asked to remove all jewelry.

Food and Drink

You will be asked to not eat or drink for at least six hours before the PTC procedure.

Check with your healthcare professional to see if it is safe for you to take any daily medications on the day of the procedure and how you should take those. Your doctor will likely advise you to discontinue the use of any blood-thinning medicines several days before the procedure.

Cost and Health Insurance 

Because PTC is largely considered a therapeutic method done in cases where ERCP is not an option, it is a good idea to check with your insurance what costs they will cover for a PTC procedure.

Your insurance might require a preauthorization approval before you have the procedure done. Your doctor’s office can help you get that, but it is always wise to reach out to your insurance company if you have any further questions or concerns. You might also be responsible for a co-pay or deductible depending on your insurance coverage.

What to Bring

If your doctor has given you a referral or test order form for the PTC procedure, make sure you have that with you when you arrive for the procedure. You should also bring your health insurance card, a form of personal identification, and payment for any required co-pay.

You will need to bring a family member or friend to drive you home after the procedure. The testing center will not discharge you without a driver as it will take several hours for the general anesthesia and sedation to wear off.

During the Procedure

You should arrive at the testing center at least an hour before the procedure’s start time so the nursing staff can complete any pre-procedure testing or preparations. After you arrive, you will be checked in by the radiologist's staff and asked if you have someone to drive home. The PTC procedure cannot occur if you don't have someone to drive you home.

Pre-Procedure

You will be taken to the preparation area where you will change into a hospital gown. If any bloodwork is needed, the radiologist's staff will take it before the procedure starts. The radiologist's staff will set up your intravenous (IV) line to administer medications needed for the procedure.

Shortly before the procedure start time, the radiologist will come by and introduce themselves. They will also explain the procedure in detail and answer any questions you may have.

Throughout the Procedure

The radiologist’s staff will take you to the procedure room when it is time for your procedure. You may be given an antibiotic in your IV if your doctor has requested one.

You will be given other medications into the IV, including a local anesthetic and/or medication to help you relax or relieve discomfort. You might feel a sting when the anesthetic is given.

Your skin will be cleaned and prepped. It is then covered with draping that only exposes a large area above the liver. Your heart rate and blood pressure will be monitored throughout the procedure.

Once you are fully sedated and the anesthesia has taken effect, the radiologist will insert a needle through the skin of the abdomen and to the bile ducts, using ultrasound and fluoroscopy guidance.

Depending on the level of sedation and/or anesthesia, you may feel some discomfort as the needle is advanced into the abdomen. The radiologist will then remove bile fluid and tissue for testing.

Next, contrast dye will be injected into the bile duct. The contrast dye will spread to reveal the biliary system. When the biliary system is visible, the radiologist can record X-ray images into the fluoroscope.

Once samples and images are taken, the needle is removed. If the PTC is being done for treatment purposes, a catheter or stent will be placed for bile drainage.

Post Procedure

After the procedure is complete, you will be taken to the recovery room, where you will stay for one to three hours. Because you have received anesthesia and sedation, you will need someone to drive you home. You will not be discharged without an escort, and you will not be able to drive yourself home.

Some people who have a PTC might need to be admitted overnight. If you were told you would need to spend the night at the hospital, bring an overnight bag.

After the Procedure

You will be provided discharge instructions before your discharge. Make sure you follow all discharge instructions and any additional ones your primary care professional gives you.

Side Effects

You may experience some amount of post-procedure pain. You can take an over-the-counter pain reliever to manage the pain. Reach out to your doctor if at-home treatment doesn’t help manage the pain.

PTC tends to be a low-risk medical procedure. If you experience symptoms of an allergic reaction or any severe pain in your abdomen near the procedure site, contact your doctor right away.

Interpreting Results

The results of a PTC procedure can either be normal or abnormal. If your doctor tells you your test was normal, this means the bile ducts are normally sized and appear in the same way they would for others your age.

Abnormal results might show that the ducts are enlarged. The ducts might also be blocked. Blockages could be caused by scarring or stones. An abnormal result could also mean cancer of the bile ducts, liver, pancreas, or a part of the gallbladder.

Follow-Up

Upon review of the fluoroscopic film, your treating physician will let you know if you need further treatment. Your doctor might recommend a second PTC to enable the removal of bile duct stones or to treat a bile duct stricture. A therapeutic PTC could be an alternative to surgery that could reduce surgical complications.

If your bile ducts were drained during the PTC, you will leave the hospital with a small bag attached to a catheter outside of the body. You will be given instructions on how to care for the bag and when to return to the hospital to have the catheter removed.

Summary

Percutaneous transhepatic cholangiogram (PTC) is done to evaluate and treat obstructions of the biliary tract. It is done under local anesthetic and sedation in a radiology lab. A needle is inserted through the skin of the abdomen to the bile ducts, using contrast dye and fluoroscopy or ultrasound for guidance.

A Word From Verywell

Different conditions can affect the bile ducts, including gallstones, infections, and inflammatory conditions. Most are treatable, but some like bile duct obstruction can be serious and life-threatening. The goal of treatment for obstruction is to alleviate the blockage. 

Some people have a higher risk for bile duct obstructions, including people with a history of gallstones. If you are concerned about your risk for a bile duct obstruction, talk to your doctor about your risk and how to reduce it.