Percutaneous transhepatic cholangiogram (PTC)

A percutaneous transhepatic cholangiogram (per-kew-tay-nee-us trans-hep-attic col-an-jee-o-gram) is a way of looking at your bile ducts using x-rays. This test is also called a PTC. 

You may have a sample of tissue (biopsy) taken during a PTC. If your bile duct is blocked your doctor may put a drain or stent in so the bile can drain.

What is a PTC?

Your doctor puts a needle through the skin of your tummy (abdomen) into your liver and bile ducts. They inject a special dye (contrast medium) and take x-rays. The contrast medium makes it easier for your doctor to see the bile ducts.

Your doctor normally gives you sedation to relax you before a PTC. Some people may have a PTC under a general anaesthetic . This means they are asleep during the procedure. 

When do you have a PTC?

A PTC helps your doctor find out what might be causing your symptoms. You might have this test if your doctor thinks there is a blockage in your bile ducts and to find out what’s causing it.

If the bile ducts are blocked, bile cannot flow out of the liver and it builds up in your body. This can cause:

• yellowing of your skin and the whites of your eyes (jaundice)

• itchy skin

• abdominal pain

• dark coloured pee

• light coloured poo

• a high temperature - also called a fever

• feeling or being sick

You usually have a PTC if you can't have an endoscopic retrograde pancreatography (ERCP).  Or if you have had an ERCP but it didn’t work. For example, if your doctor wasn’t able to take biopsies or drain the bile ducts.

Preparing for a PTC

Before the PTC you usually have a blood test to check how well your blood clots.

Let the x-ray department know if you're taking medicines that thin your blood. These medicines include:

• aspirin

• clopidogrel

• apixaban, dabigatran and similar medicines – these are called direct oral anticoagulants (DOACs)

• arthritis medicines

• warfarin

The hospital will tell you if you should stop these medicines before the PTC. They will also tell you when to stop eating and drinking before the procedure.

You may be able to go home the same day as the PTC. Or you might need to stay in hospital for a night or more. If you can go home the same day, you will need to arrange someone to take you home and stay with you overnight. This is because you have sedation or a general anaesthetic for the procedure.

What happens during a PTC

You usually have the test in the x-ray department. A specialist doctor called an interventional radiologist carries out the test. A radiographer and a nurse will also be in the room to help.

Just before the test

You change into a hospital gown and lie down on the x-ray couch. You normally lay on your back. Your doctor puts a small tube (cannula) into your arm or the back of your hand. They can use this to give you sedation and painkillers. If you are having a general anaesthetic, the anaesthetist will give you medicines to make you sleep instead.

You may also have an injection of antibiotics into the cannula to help prevent infection.

During the test

Your doctor cleans your upper abdomen. They inject a local anaesthetic into your skin over your liver. This numbs the area.

They put a long thin needle through the skin and into your liver and bile ducts. They use ultrasound or x-rays to make sure the needle is in the right place. If you are awake, you may feel some discomfort when the needle goes in. Tell your doctor or nurse if you have any pain.

The needle has a syringe on the end containing contrast medium. Your doctor injects the contrast medium into your bile ducts. You may have a warm sensation through your body after it has gone in. This is normal. The x-ray camera is above you but it doesn’t touch you. The contrast medium shows up on the x-rays, so your doctor can see if there is a blockage and where it is.

Your doctor can also take a sample of cells from the bile duct using a very small brush (brush cytology). Or they may take a tissue biopsy using a needle. A specialist doctor called a pathologist looks at the cells or tissue under a microscope. This is to see if it contains cancer.

Depending on what your doctor sees during the PTC, they might put a drain or stent in the bile duct. This can relieve the symptoms of a build up of bile.

Drain

A drain is a thin tube that helps drain the bile.  The drain has little holes down the length of it. This means the bile can get into the drain from anywhere along the tube.  

Your doctor puts one end of the drain into your bile duct. Or they may pass the drain through the bile duct and into the small bowel. The other end is outside your body. They may attach a drainage bag to the end of the tube and the bile flows into the bag. Sometimes they may put a cap on the end so the bile drains straight into your small bowel.

You might have the bile drained before you have surgery for bile duct cancer.

Stent

A stent is a tube that keeps the bile ducts open if they are blocked by a cancer. This means the bile can flow through the ducts again. If a stent works you should not need a drain long term.

What happens after a PTC

You go back to the ward after the test. You may feel sleepy due to the sedation or general anaesthetic. If you have had sedation, you might not remember much about having the procedure done.

You need to stay lying down afterwards. Your nurse will tell you when you can get up and when you can start eating and drinking. They regularly check your blood pressure, heart rate and where the needle went in. This is normally covered with a dressing.

If you have a drain, your nurse will check how much bile has drained into the bag. Your doctor will tell you how long the drain needs to stay in for.

Going home after a PTC

Your doctor or nurse will tell you when you can go home after the procedure. This depends on what you have had done and your general health. Before you go, your nurse will tell you:

• what problems to look out for and who to contact
• when to remove the dressing
• if you need to take any antibiotics or painkillers when you get home
• when you can return to your normal activities

Sometimes your doctor may be happy for you to go home with the drain. Your nurse will show you how to look after it. This includes emptying the bag and changing the dressing. If you need help with this they may ask a district or community nurse to visit you at home.

Possible risks

A PTC is a very safe test. But like all procedures there are risks. Your doctor will make sure the benefit of having a PTC outweighs any of these risks.

Some of the possible risks include:

Infection

There's a risk of infection after having a PTC. You may have a high temperature or feel generally unwell. Infections after a PTC can also cause jaundice and upper abdominal pain. You should contact your doctor if you have any of these symptoms.

Some people may have a serious reaction to an infection after a PTC. This is called sepsis. Symptoms include:

• Slurred speech or confusion
• Extreme shivering or muscle pain
• Passing no urine (in a day)
• Severe breathlessness
• It feels like you’re going to die  
• Skin mottled or discoloured

Call 999 or go to your local Accident and Emergency (A&E) immediately if you have any of these.

Bruising and bleeding

You may have some bruising on your abdomen after a PTC.

Or you may have some bleeding. This usually stops on its own. If it doesn’t, you may need a blood transfusion . Rarely you might need an operation to stop the bleeding.

Bile leak

Sometimes bile can leak into your abdomen after a PTC. This can cause an infection in your abdomen (peritonitis) or an abscess. If you don’t have a drain, your doctor might put one in until the bile stops leaking.

Lung problems

Rarely the needle can go into the space around the lung (plural cavity). This can cause fluid to collect in the space (pleural effusion). Or it can cause the lung to collapse. This is called a pneumothorax.

Tell your doctor or nurse straight away if you have shortness of breath or chest pain. Your doctor might need to drain the fluid or put a tube into the lung for a few days until it expands again.

Inflammation of the pancreas (pancreatitis)

You might have mild inflammation of the pancreas . This can cause pain in your abdomen. It's important to tell your nurse or doctor if you get any pain. They can give you painkillers to help control this.

Inflammation of the pancreas can also be severe. You might need to stay in hospital longer if this happens.

Allergic reaction

There is a risk of having an allergic reaction to the contrast medium. This can cause itching, problems with your breathing, heart rate and blood pressure. If this happens, the staff will give you medicines to control the reaction. 

Tell your doctor or nurse if you feel itchy or start to feel unwell.

Getting your results

You should get your results within 1 or 2 weeks. 

Waiting for results can make you anxious. Ask your doctor or nurse how long it will take to get them. Contact the doctor who arranged the test if you haven’t heard anything after a couple of weeks.

You might have contact details for a specialist nurse who you can contact for information if you need to. It may help to talk to a close friend or relative about how you feel. You may want them to go with you to get the results for support.