Module 4:

Biliary System
Abby Louisse Pearl A. Ventura, RRT
Table Of Contents

05
Percutaneous
Transhepatic
01 Oral
Cholecystography
Cholangiography

02 Intravenous Endoscopic
Cholangiography
06 Retrograde
Cholangio-
Pancreatography

03 Post-Operative
Cholangiography
Anatomy
 Bile is manufactured by the liver, transported by
various ducts, and stored in the gallbladder
 Liver – largest solid organ in the human body &
weighs 3-4 lbs
 Superior border – the widest portion of the
liver, approximately 8”-9”
 Right border of the liver – its greatest
vertical dimension, approximately 6”-7”
 Gallbladder – typically nestled centrally in the
posterior, inferior region of the liver
Lobes of the Liver
 Partially divided into two major lobes and two minor lobes
 Falciform ligament – separates the right and left lobes
 Quadrate lobe – located on the inferior surface of the right lobe between the gallbladder
and the falciform ligament
 Caudate lobe – posterior to the quadrated lobe & extends superiorly to the diaphragmatic
surface
Function of the Liver
● Produce large amounts of bile
○ Secretes 1-3 pints (800 to 1000 mL), or
about 1 quart of bile per day
● Major Functions of Bile: To aid in the digestion of
fats by emulsifying (breaking down) fat globules
and the absorption of fat following its digestion
Gallbladder & Biliary Ducts
 Gallbladder – pear shaped sac composed of 3 parts: fundus, body, & neck
 Fundus – the distal end & the broadest part of the gallbladder
 Body – main section of the gb
 Neck –narrow proximal end which continues as the cystic duct (3-4 cm)
 7-10 cm long & approximately 3 cm wide
 Holds 30-40 mL of bile
 Functions of the Gallbladder
 To store bile
 To concentrate bile
 To contract when stimulated
Common Bile Duct

 Averages approximately 7.5 cm in

length
 Pancreatic duct (Duct of Wirsung)
 Hepatopancreatic ampulla or
ampulla of Vater
 Sphincter of Oddi
 Duodenal papilla (papilla of Vater)
Procedures of the
Biliary System
Routes of Administration
● By mouth
● By injection into a vein in a single bolus
or by drip infusion
● By direct injection into the ducts
Clinical Indications

1. Biliary Calculi (Gallstones)

○ Choledocholithiasis – presence of stones in the biliary ducts
○ Cholelithiasis – condition of having abnormal calcifications or stones in
the gallbladder
○ Milk calcium bile – the emulsion of biliary stones in the gallbladder.
2. Acute or chronic cholecystitis – Inflammation of the gallbladder.
3. Neoplasms – new growths, which may be benign or malignant.
4. Biliary stenosis – narrowing of one of the biliary ducts
Biliary tract examinations are performed to
determine the following:

 Function of the liver

 Patency and condition of the biliary ducts
 Concentrating and emptying power of the gallbladder
Technical Requirements:

 Small focal spot

 Clean and in contact intensifying screen
 Grid
 Closed collimation
 Make the Px comfortable
 Stabilize elevated parts
 Employ immobilization
 Use a short exposure time
 Adjust exposure factors
 Make exposures at the end of expiration
The gallbladder moves laterally and superiorly 1-3
inches on full expiration and medially and
inferiorly 1-3 inches on full inspiration.
 01
Oral Cholecystography
Radiographic examination of the gallbladder by
oral administration of contrast medium
Contraindicated to:
 Patients with vomiting or diarrhea, pyloric obstruction, malabsorption
syndrome, severe jaundice, liver dysfunction, hepatocellular disease, or
hypersensitivity to iodinated contrast media.
Instructions to Patient:
1. Explain the purpose of the preliminary preparation and the procedure.
2. Give the patient printed instruction covering:
a) Preliminary preparation of the intestinal tract
b) Preliminary diet
c) Exact time to ingest the oral medium
d) Avoidance of laxatives fro 24 hours before the ingestion of CM
e) Avoidance of all food, both solid and liquid
f) Time to report for the examination
3. Ask the patient how each step of the preparation procedure was followed.
4. For the oral technique, ask the patient whether any reaction such as vomiting
or diarrhea occurred.
5. Give the patient an early morning appointment if possible.
Scout radiograph may be taken on the day
before OCG to:
 Assess bowel fecal content to determine the extent of cleansing enemas
required
 Identify small radiopaque stones that might be otherwise be camouflaged by
the contrast medium
Preliminary Diet
 Some physicians:
o Noon meal rich in simple fats on the day before the examination
 All medical personnel:
o Fat-free evening meal to prevent the gallbladder from contracting and expelling the
opacified bile
 Breakfast is usually withheld
 OCG with Upper GI series – patient is kept NPO (non per os; nothing taken in through the
mouth)
Contrast Administration
 Single dose approximately 2-3 hours after the evening meal on the night before the
examination
 Single dose of 3 g is administered on the form of four to six tablets.
 Absorption time varies from 10-12 hours for most present-day oral agents
 Contrast administration is scheduled to allow enough time fro maximum concentration
of contrast agent in the gallbladder
 Exception: Ipodate calcium
o Rapidly absorbed & allows visualization of the biliary ducts in an average of 1.5
hours and visualization of the gallbladder in 3-4 hours.
Scout radiograph
 On the day of the examination, one or more preliminary radiographs are often obtained
 May be taken with the patient in supine or prone.
 If contrast is present, it is important to determine:
o Whether the concentration of the contrast medium is sufficient for adequate
visualization
o The exact location of the organ
o Whether a change in the exposure factors is needed
Projections
Biliary Tract & Gallbladder
PA Projection
 Prone with a pillow under the head
 Px’s left cheek on the pillow
 Center the IR according to the body habitus of the Px
 Suspend respiration at the end of expiration
 Upright: Center the IR 2-4 inches below the prone level to allow for the change of the
gallbladder position
 CR: Perpendicular & centered to the gb at a level appropriate to the Px’s body habitus
PA Projection
PA Oblique Projection (LAO Position)
✦ Thin subjects require more rotation
✦ From position, elevate the right side to the desired degree of obliquity ( 15-40
degrees)
✦ CR: Perpendicular to the midpoint of the IR at a level appropriate for the body
habitus of the Px
Lateral Projection
✦ Px lies on the right side
✦ Right lateral position – used to differentiate gallstones from renal stones or calcified
mesenteric lymph nodes if needed.
✦ Also required to separate the superimposition of the gallbladder and the vertebrae in
exceptionally thin patients & to place the long axis of a transversely placed gallbladder
parallel with the plane of the IR
✦ CR: Perpendicular to the midpoint of the IR at a level appropriate for the body habitus of
the Px
AP Projection (R Lateral Decubitus Position)
 Developed by Whelan
 Px on the right side with the body elevated 2-3 inches on a suitable support to center the
gallbladder region to the vertically placed IR
 CR: Directed horizontally to enter the localized area of the gallbladder
AP Projection (R Lateral Decubitus Position)
 The right lateral decubitus and upright positions are used to demonstrate stones that are
heavier than bile and that are too small to be visible other than when accumulated in the
dependent portion of the gallbladder.
AP Projection (R Lateral Decubitus Position)
 Note:
○ The right lateral decubitus position has the further advantage of permitting the
gallbladder to gravitate toward the dependent right side, where it will lie below
any adjacent gas containing loops of the intestine and away from bony
superimposition when it occupies a low and/or medial position.
 02
Intravenous
Cholangiography
Radiographic examination of the gallbladder by
venous route of contrast medium
The following steps are observed:
 Place the patient in the supine position for a preliminary radiograph of the abdomen.
 Place the patient in RPO position (15-40 degrees) for an AP oblique projection of the
biliary ducts
 Obtain scout radiograph to check for centering and exposure factors.
 Advise 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-
minute intervals until satisfactory visualization is obtained.
Contraindications
 Contraindicated to patients who have liver disease or for those whose biliary
ducts are not intact.
 The probability of obtaining radiographs of diagnostic value greatly decreases
when the patient's bilirubin is ncreasing or when it exceeds 2 mg/dl .
 03
Post-Operative
Cholangiography
Biliary tract examination that is performed by way of
the T-shaped tube left in the common bile duct for
post-operative drainage
Contraindications:
✦ Include hypersensitivity to iodinated contrast media, acute infection of the biliary system,
and elevated creatinine or blood urea nitrogen (BUN) levels
Patient Preparation
 The drainage tube is clamped the day preceding the examination to let the
tube fill with bile as preventive measure against air bubbles entering the
ducts.
 The preceding meal is withheld.
 When indicated, a cleansing enema is administered about 1 hour before the
examination.
 NPO at least 8 hours.
Contrast Medium
 Water-soluble organic contrast medium
 No more than 25% to 30% because small stones may be obscured with a higher
concentration
Injection Process
 Drainage of excess bile is performed at the beginning of the procedure.
 Wear gloves throughout the procedure.
 After duct drainage and under fluoroscopic control, the iodinated contrast agent is
injected fractionally, and fluoroscopic spot images are obtained
 If residual stones are detected, the radiologist may elect to remove them. A basket
catheter may be passed over a guidewire, and the stones may be removed.
Procedure
 Drainage of excess bile is performed at the beginning
of the procedure.
 Wear gloves throughout the procedure.
 Obtain preliminary radiograph of the abdomen.
 Place the patient in RPO position with the right upper
quadrant of the abdomen centered to the midline of
the grid.
 Contrast medium is injected under fluoroscopic
control.
 24 x 30 cm IRs are exposed serially after each several
fractional injections of medium & then at specified
intervals until most of the contrast solution has
entered the duodenum.
 Stern, Schein, & Jacobson – stressed the importance
of obtaining a lateral projection to demonstrate the
anatomic branching of the hepatic ducts in this plane
& to detect any abnormality.
 05
Percutaneous Transhepatic
Cholangiography
Technique employed for pre-operative radiologic
examination of the biliary tract
Uses:
 Used for patients with jaundice when the ductal system has been shown to be dilated by
CT or ultrasonography but the cause of the obstruction is unclear
 Often used to place a drainage catheter for the treatment of obstructive jaundice
Procedure
 Place the Px on the radiographic table in the supine position.
 Px’s right side is surgically prepared & appropriately draped.
 Administer local anesthesia.
 Chiba needle is held parallel to the floor and inserted through the right intercostal space
and advance to the liver hilum.
 Stylet of the needle is withdrawn & a syringe filled with contrast medium is attached to
the needle.
 Under fluoroscopic control, the needle is slowly withdrawn until the contrast medium is
seen to fill the biliary ducts.
 After the biliary ducts are filled, the needle is completely withdrawn and serial or spot AP
projections of the biliary area are taken.
 06
Endoscopic Retrograde
Cholangio-Pancreatography
Procedure used to demonstrate diagnose biliary and
pancreatic pathologic conditions
Contraindications
✦ Primary contraindications for ERCP include hypersensitivity to iodinated contrast
medium, acute infection of the biliary system, possible pseudocyst of the pancreas, and
elevated creatinine or BUN levels
Patient Preparation
 The procedure should be clearly explained to the patient, and a careful clinical history
should be taken
 The patient should be placed in a hospital gown and should be NPO at least 8 hours
before the procedure.
Contrast Medium
● Iodinated, water-soluble contrast media
Procedure
 Obtain AP scout film of the abdomen (this depends, some doctors preferred an image
collimated and focused to the gallbladder & biliary ducts)
 The endoscopist locates the hepatopancreatic ampulla.
 A small cannula is passed though the endoscope & directed into the ampulla.
 Once the ampulla is properly placed, the contrast medium is injected into the common
bile duct.
 The patient may then be moved, fluoroscopy performed, and spot radiographs are taken.