Synonym/acronym: T-tube cholangiography.
A postoperative evaluation to provide ongoing assessment of the effectiveness of bile duct or gall bladder surgery.
Area of applicationGallbladder, bile ducts.
ContrastIodinated contrast medium.
After cholecystectomy, a self-retaining, T-shaped tube may be inserted into the common bile duct. Postoperative (T-tube) cholangiography is a fluoroscopic and radiographic examination of the biliary tract that involves the injection of a contrast medium through the T-tube inserted during surgery. This test may be performed during surgery and again 5 to 10 days after cholecystectomy to assess the patency of the common bile duct and to detect any remaining calculi. The procedure will also help identify areas of stenosis or the presence of fistulae (as a result of the surgery). T-tube placement may also be done after a liver transplant because biliary duct obstruction or anastomotic leakage is possible. This test should be performed before any gastrointestinal (GI) studies using barium and after any studies involving the measurement of iodinated compounds.
This procedure is contraindicated for
- Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
- Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very problematic because iodine is required for the production of thyroid hormones. In the case of shellfish the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
- Patients with conditions associated with preexisting renal insufficiency (e.g., renal failure, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycocides and NSAIDs) because iodinated contrast is nephrotoxic
- Elderly and compromised patients who are chronically dehydrated before the test because of their risk of contrast-induced renal failure
- Patients with bleeding disorders or receiving anticoagulant therapy because the puncture site may not stop bleeding
- Patients with cholangitis; the injection of the contrast medium can increase biliary pressure, leading to bacteremia, septicemia, and shock
- Patients with acute cholecystitis or severe liver disease; the procedure may worsen the condition
- Determine biliary duct patency before T-tube removal
- Identify the cause, extent, and location of obstruction after surgery
- Biliary ducts are normal in size.
- Contrast medium fills the ductal system and flows freely.
Abnormal findings related to
- Appearance of channels of contrast medium outside of the biliary ducts, indicating a fistula
- Filling defects, dilation, or radioloucent shadows within the biliary ducts, indicating calculi or neoplasm
Factors that may impair clear imaging
- Gas or feces in the GI tract resulting from inadequate cleansing or failure to restrict food intake before the study.
- Retained barium from a previous radiological procedure.
- Metallic objects within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.
- The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.
- Air bubbles resembling calculi may be seen if there is inadvertent injection of air.
- Failure to follow dietary restrictions and other pretesting preparations may cause the procedure to be canceled or repeated.
- Consultation with a health-care provider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Considerations Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
- Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the examination room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their radiation level.
Nursing Implications and Procedure
- Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
- Patient Teaching: Inform the patient this procedure can assist in assessing the bile ducts of the gallbladder and pancreas.
- Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
- Obtain a history of results of the patient’s gastrointestinal and hepatobiliary systems, symptoms, and previously performed laboratory tests and diagnostic and surgical procedures.
- Ensure that this procedure is performed before an upper GI study or barium swallow.
- Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
- Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
- If iodinated contrast medium is scheduled to be used in patients receiving metformin (Glucophage) for non–insulin-dependent (type 2) diabetes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side effect of metformin related to renal impairment that does not support sufficient excretion of metformin.
- Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort and some pain experienced during the test. Inform the patient that the procedure is usually performed in the radiology department by an HCP and takes approximately 30 to 60 min.
- Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
- Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications. Explain that the contrast medium will be injected through the t-tube that was left in place.
- Instruct the patient to remove jewelry and other metallic objects in the area to be examined.
- Note that there are no food or fluid restrictions for a post-surgical study but the patient should follow the standard pre-operative restrictions on food and fluids for 8 hr prior to an operative cholangiogram. Protocols may vary among facilities.
- Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
- Potential complications:
Cholangiography and establishing an IV site are invasive procedures and have potential risks that include allergic reaction related to contrast reaction, bleeding, septicemia, bile peritonitis, and extravasation of the contrast medium.
- Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
- Ensure that the patient has complied with dietary, fluid, and medication restrictions for 8 hr prior to the procedure.
- Ensure that the patient has removed all external metallic objects from the area to be examined prior to the procedure.
- Administer ordered prophylactic steroids or antihistamines before the procedure if the patient has a history of allergic reactions to any relevant substance or drug.
- Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
- Have emergency equipment readily available.
- Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
- Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
- Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities.
- Establish an IV fluid line for the injection of saline, sedatives, or emergency medications.
- Clamp the T-tube 24 hr before and during the procedure, if ordered, to help prevent air bubbles from entering the ducts.
- An x-ray of the abdomen is obtained to determine if any residual contrast medium is present from previous studies.
- The patient is placed on an examination table in the supine position.
- The area around the T-tube is draped; the end of the T-tube is cleansed with 70% alcohol. If the T-tube site is inflamed and painful, a local anesthetic (e.g., lidocaine) may be injected around the site. A needle is inserted into the open end of the T-tube, and the clamp is removed.
- Contrast medium is injected, and fluoroscopy is performed to visualize contrast medium moving through the duct system.
- The patient may feel a bloating sensation in the upper right quadrant as the contrast medium is injected. The tube is clamped, and images are taken. A delayed image may be taken 15 min later to visualize passage of the contrast medium into the duodenum.
- For procedures done after surgery, the T-tube is removed if findings are normal; a dry, sterile dressing is applied to the site.
- If retained calculi are identified, the T-tube is left in place for 4 to 6 wk until the tract surrounding the T-tube is healed to perform a percutaneous removal.
- Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
- Instruct the patient to resume usual diet, fluids, medications, and activity, as directed by the HCP. Renal function should be assessed before metformin is resumed, if contrast was used.
- Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and as ordered. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
- Monitor T-tube site and change sterile dressing, as ordered.
- Instruct the patient on the care of the site and dressing changes.
- Monitor for reaction to iodinated contrast medium, including rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
- Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
- Carefully monitor the patient for fatigue and fluid and electrolyte imbalance.
- Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
- Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
- Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.
- Related tests include CT abdomen, hepatobiliary scan, KUB, MRI abdomen, and US liver and biliary system.
- Refer to the Gastrointestinal and Hepatobiliary systems tables at the end of the book for tests by related body systems.