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GI Studies

42 Surgical Cholangiography

Anatomy

  • Liver (produces bile)
  • Gallbladder (stores and releases bile)
  • Cystic duct (connects gallbladder to common bile duct)
  • Hepatic ducts (right and left) → join to form the common hepatic duct
  • Common bile duct (CBD) → joins pancreatic duct, empties into duodenum
  • Ampulla of Vater (hepatopancreatic ampulla) and Sphincter of Oddi (regulates bile flow)
  • Duodenum (site of bile entry)

Indications, Contraindications, and Patient Preparation

Indications

  • To evaluate biliary anatomy and function during or after gallbladder surgery
  • To check for residual stones in the common bile duct after cholecystectomy
  • To assess patency of bile ducts and sphincter of Oddi
  • To investigate unexplained jaundice or biliary obstruction

Contraindications

  • Allergy to iodinated contrast media
  • Severe infection (e.g., cholangitis) may be a relative contraindication — radiologist will weigh risks
  • Unstable surgical patients where prolonged imaging is unsafe

Patient Preparation

  • No special prep if intraoperative (performed during surgery)
  • If T-tube cholangiography (post-op), patient should be NPO for several hours before the exam

Procedure Types

Intraoperative Cholangiography

  • Performed during gallbladder surgery (cholecystectomy)
  • Contrast medium: Water-soluble iodinated contrast injected into cystic duct catheter
  • Imaging: Fluoroscopy and spot images taken while surgeon manipulates ducts
  • Purpose: Confirm ductal anatomy, rule out stones before completing surgery

Evaluation Criteria

  • Entire biliary tree visualized (hepatic ducts → CBD → duodenum)
  • No evidence of stones, strictures, or leakage
  • Contrast flows freely into duodenum

Postoperative (T-tube) Cholangiography

  • Performed several days after gallbladder removal
  • A T-tube catheter remains in common bile duct for drainage
  • Contrast medium: Water-soluble iodinated contrast injected through T-tube
  • Imaging: Spot images obtained as contrast outlines biliary system
  • Purpose: Detect retained stones, strictures, or leaks after surgery

Evaluation Criteria

  • Complete filling of biliary ducts with contrast
  • Visualization of contrast entering duodenum
  • Absence of leaks or filling defects (stones)

Procedure Adaptation

  • Patient position: Supine for imaging; surgical positioning if intraoperative
  • Contrast injection: Must be done slowly to avoid duct rupture or reflux into pancreatic duct (risk of pancreatitis)
  • Pediatrics: Lower volume of contrast; indications often congenital (e.g., biliary atresia)
  • Post-op patients: May be tender; move slowly and explain procedure carefully

Exposure Factors & Technical Considerations

  • SID: 40 inches
  • kVp: 65–75 (lower kVp enhances contrast in biliary system, because we are using iodinated contrast)
  • mAs: Short exposure times
  • Contrast: Water-soluble iodinated contrast (NEVER barium)
  • Imaging equipment: Fluoroscopy with spot or digital capture
  • Collimation: Center over right upper quadrant; include liver, ducts, and proximal duodenum
  • Shielding: Standard shielding where possible, though limited intraoperatively

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Hows & Whys of Surgical Cholangiography

Anatomy & Physiology

  • Why is the sphincter of Oddi important in cholangiography?
    It regulates bile flow into the duodenum and can be a site of obstruction.
  • Why might a patient still have stones after gallbladder removal?
    Stones may remain in the common bile duct or hepatic ducts — surgical cholangiography detects these.

Contrast & Technique

  • Why is iodinated contrast used instead of barium?
    Because it is water-soluble, safe if leakage occurs, and provides rapid duct visualization.
  • Why must contrast be injected slowly?
    Rapid injection may overdistend ducts or reflux into the pancreatic duct, increasing risk of pancreatitis.

Clinical Considerations

  • Why is intraoperative cholangiography performed during gallbladder surgery?
    To confirm ductal anatomy and ensure no stones remain before the surgery is completed.
  • Why is a T-tube used after gallbladder surgery?
    It allows bile drainage, prevents obstruction during healing, and provides access for postoperative cholangiography.
  • What does a filling defect on cholangiogram indicate?
    A possible stone, stricture, or mass within the biliary duct.
  • Why should the radiologist be careful to observe contrast reaching the duodenum?
    It confirms patency of the bile ducts and sphincter of Oddi.

 

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Radiographic Procedures Review Guide Copyright © 2025 by Carla M. Allen and Taylor M. Otto. All Rights Reserved.