Synonym/Acronym
T-tube cholangiography.
Rationale
A postoperative evaluation to provide ongoing assessment of the effectiveness of bile duct or gallbladder surgery.
Patient Preparation
There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 4 to 8 hr, or as ordered, prior to the procedure. Fasting is ordered because an empty stomach provides better visualization and as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. The patient may be instructed to prepare the bowel with a cleansing enema the morning of the procedure, by medical direction.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
Normal Findings
- Biliary ducts are normal in size.
- Contrast medium fills the ductal system and flows freely.
Study type: X-ray, special/contrast; related body system: Digestive system.
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 such as sodium diatrizoate (Hypaque) 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.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). 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 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.
Factors That May Alter the Results of the Study
- 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.
- Air bubbles resembling calculi may be seen if there is inadvertent injection of air.
- Metallic objects (e.g., jewelry, body rings) 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 movement can produce blurred or otherwise unclear images.
Abnormal Findings Related to
- Appearance of channels of contrast medium outside of the biliary ducts, indicating a fistula.
- Filling defects, dilation, or radiolucent shadows within the biliary ducts, indicating calculi or tumor.
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing the bile ducts of the gallbladder and pancreas.
- Explain that the procedure takes about 60 to 90 min and is usually performed in the radiology department.
- Review the procedure with the patient.
- Explain that pregnancy testing may be required.
- Discuss how there may be moments of discomfort or pain when the IV line is inserted allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
Procedural Information
- The T-tube is clamped 24 hr before and during the procedure, if ordered, to help prevent air bubbles from entering the ducts.
- Baseline vital signs are recorded and monitored throughout the procedure.
- Positioning for this procedure is in the supine position on an examination table.
- A kidney, ureter, and bladder (KUB) or plain film is taken to ensure that no stool or barium from a previous study will obscure visualization of the biliary system.
- 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 is advised that there may be 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.
- At the completion of the procedure, the area around the T-tube is draped and the end of the T-tube is cleansed with 70% alcohol.
- The T-tube is removed if findings are normal and a dry, sterile pressure 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, and then a percutaneous removal is performed.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Note that a rare complication related to the cholangiography procedure is septicemia.
- Establishing an IV site and injection of contrast medium are invasive procedures that can cause rare complications. For additional information see Appendix A: Patient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated with Diagnostic Procedures.
Treatment Considerations
- Follow post-procedure vital sign and assessment protocol.
- Carefully monitor the patient for fatigue and fluid and electrolyte imbalance.
Clinical Judgement
- Consider how to allay growing concerns over ongoing gallbladder or bile duct disease and lack of progress toward resolution.
Follow-Up and Desired Outcomes
- Understands there are no food or fluid restrictions for a postsurgical study and that the usual diet, fluids, medications, and activity may be resumed as directed by the HCP.
- Acknowledges the importance of monitoring the T-tube site and changing sterile dressing, as ordered.
- Demonstrates proficiency in the care of the site and dressing changes.