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A case of trabecular type of gallbladder duplication, a very rare congenital anomaly of the gallbladder, is reported. Diagnosis was made by endoscopic retrograde cholangiography and was confirmed by oral cholecystography. Sonography could not visualize the accessory gallbladder.
The available surgical and non-surgical therapy options for treatment of gallstone disease are presented. Conventional cholecystectomy is regarded as standard therapy of symptomatic cholecystolithiasis. Other modes of therapy may be indicated under certain circumstances, depending on the results of imaging procedures. In this context conventional X-ray examination, oral and intravenous cholecystography, sonography, computed tomography, endoscopic retrograde cholangiography/cholecystography, and magnetic resonance imaging are discussed and their influence on therapeutic decisions is explained.
409 roentgenological studies were performed, using the method of serial cholecystography prior to and after giving a bile-expelling breakfast, in 102 patients with duodenal ulcer, in 174 patients after trunk and in 89 patients after selective vagotomy with pyloroplasty. It was found that the volume of the gallbladder beyond the digestion act following trunk vagotomy is increased by 20%, on the average, by 30%--after selective vagotomy. It is concluded that there are no principal differences in the influence of trunk and selcetive vagotomy on the tonus and motility of the gallbladder.
Forty-three cholangio-cholecystographies were carried out with iotroxamide. A the same time, the behavior of various serum enzymes was controlled. Iotroxamide satisfactorily demonstrated the biliary tract for the diagnosis in 37 of our patients (86.5%). Only an inadequate or incomplete evaluation was possible for 6 of our patients (13.5%). Due to the pharmacokinetic characteristics of iotroximide, the time-density ratio is very favorable. As a result, the contrast radiograph of the biliary tract including the gallbladder was available for evaluation as early as 30 minutes after the infusion and almost always within 60 minutes. Minor subjective side effects were observed in only 4 cases. With the exception of 2 cases with obstructed bile flow, the serum-enzyme level was not significantly altered after administration of the contrast medium.
The ultrasonic criteria for the diagnosis of gallbladder calculi are: (1) echo-dense structures which disturb the smooth contour of the posterior border of the gallbladder; (2) sonic shadowing, and (3) echoes from within the gallbladder. Diagnostic confidence increases greatly in cases in which internal echoes, contour irregularities, and sonic shadows have occurred simultaneously. A case is presented in which all three criteria are fulfilled, but which represents an artifact, i.e., "pseudostone." This was confirmed by varying the patient's respiration and showing that the "pseudostone" represented echoes from a loop of bowel which produced a significant impression on the posterior wall of the gallbladder during deep inspiration. The absence of cholelithiasis was confirmed by oral cholecystography.
The paper presents the results obtained upon examination of inpatients with various types of biliary dyskinesia. The examination included: fraction chromatic duodenal intubation, stepwise manometry, cholecystography, ultrasound investigation of the liver, gall bladder, biochemical tests of the bile. Fraction duodenal intubation discovered gall bladder dysfunction. The manometry was necessary for diagnosis of duodenal hypertension. X-ray revealed primary defects in gall bladder motility. It is concluded that the diagnosis of functional disorders implies combined clinical and instrumental modalities.
The preoperative cholecystography and postoperative radiography of gallstones were compared in 68 patients. Calcified structures were detected in 32% of the stones which were free of calcium in the native roentgenograms. The possibility is stressed that the calciumocontent of cholecystographic transparent stones may be responsible for the failure of CDCA-therapy. 52 of the 68 patients additionally received a fat meal. A contraction of the gallbladder was not observed in 25% of these cases. From the missing contraction of the gallbladder should not be concluded that a CDCA-therapy is contraindicated. A functional analysis with a synthetic derivate of cholecystokinin is recommended.
Compared with the intravenous cholangiography the infusion cholangiography is the more effective and unambiguous investigation method of the gallbladder and the bile ducts. It considerably enlarges the diagnostic possibilities in the area of the bile ducts. A serum bilirubin level of more than 2 mg/100 ml allows positive cholangiograms by means of the infusion method, but is nearly always the cause for negative findings in intravenous application. In a hypalbuminaemia lower than 3 g/100 ml, in an increase of the alkaline serum phosphatase, of the serum transaminase and a pathological retention of bromsulphalein the bile ducts cannot be demonstrated also in the infusion cholangiography. A 20% glucose solution is sufficient as solvent in the infusion cholangiography. In the negative case the cholecystography and the intravenous cholangiography may be supplemented and enlarged by application of the infusion cholangiography as a more evident method of X-ray examination.
Since the successful dissolution of cholesterol gallstones is depending to a vast degree on the selection of patients put to test, selection of apt patients was to be the center point of the work session. Furthermore therapy and side effects was being discussed. The best method of choosing patients for chenodeoxycholic-acid-(CDC)-therapy is presented by oral, less by intravenous, cholecystography. Normally this examination provides us with a fair judgement on structure of stones, size of stones and total stone volume, factors which are of considerable importance for any therapeutic success. Determination of the lithogenic index and the finding of cholesterol cristals in the bile could be competent criteria of selection, but these methods are far to complicated. These measurements could only be applied for the determination of the minimal maintenance dosage before onset of long lasting therapy after stone dissolution. The toxic side effects of CDC-therapy seem to be of minor degree in human beings. Changes of liver tissue that could be unequivocally traced back to CDC could not be detected, in contrast to animal experiments, where as there seems to be a correlationbetween an often observed elevation of transaminases and the CDC-dosage applied. There is no negative influence upon fat metabolism of the patient. There were found no morphologic or functional disorders of the gastro-intestinal tract due to CDC-treatment with the exception of chologenic diarrhea. We have still to wait for the results of long-term studies.
Oral cholecystography and intravenous cholangiography are the two studies most frequently used to confirm the diagnosis of biliary tract disease. Since it is not always practical to obtain these in acutely ill patients, gray scale sonography was evaluated to determine its accuracy. One hundred eight patients had sonography performed prior to operation. The sonogram was correct in 96 of the 108 patients (89%). There were four false-negatives (3.7%), one false-positive (0.9%), and seven patients (6.4%) in whom the study was nondiagnostic. Stones were seen in 88 patients and confirmed in 87 patients for an accuracy of 98.9% Sonography is a simple, noninvasive procedure by which cholelithiasis can be accurately detected. Because of the high correlation between sonography and operative findings, we suggest that cholecystosonography be used as the initial screening study in patients suspected of having biliary tract disease.
The accuracy and possible clinical value of grey scale ultrasonography in the detection of gallstones has been prospectively studied in 100 unselected patients presenting with recurrent biliary colic, acute cholecystitis or acute pancreatitis. Adequate visualization of the gallbladder was obtained in 79 cases, with 3 false positive and no false negative reports. Oral cholecystography remains the initial investigation of choice in patients presenting with recurrent biliary colic, but grey scale ultrasound has been shown in this study to be a reliable means of detecting gallstones in the 'acute' situation, when conventional contrast radiology is of limited value.
Following extracorporeal shock wave lithotripsy it is not known whether gallstone fragments are cleared from the gallbladder without the use of oral dissolution therapy. To assess the efficacy of lithotripsy and dissolution therapy, alone or in combination, 35 patients were randomized to one of three treatment groups: lithotripsy alone, dissolution therapy alone or combined lithotripsy and dissolution therapy. All patients had symptomatic gallstones, functioning gallbladders and comparable stone profiles. Lithotripsy was administered using a piezoelectric lithotripter. Dissolution therapy consisted of combined bile acid and terpene. Clearance was assessed at 6 months using ultrasound and oral cholecystography. Patients with less than 50 per cent stone clearance at the end of 6 months were considered failures. The number of patients with total or partial clearance in the combined group (7/10) was significantly greater than those in the lithotripsy alone group (0/10, P less than 0.002). Gallstone clearance following lithotripsy appears to be dependent upon dissolution therapy.
One hundred and eighty-two patients with an ultrasonographic and/or pathological diagnosis of polypoid lesions of the gallbladder (PLG) were reviewed to determine the reliability of ultrasonography in the diagnosis of PLG and the indications for operation in this disease. Of the 182 patients operated on, PLG were demonstrated by the gross appearance of the resected gallbladder in 172. Histologically benign lesions were present in 159 gallbladders and malignant lesions in 13. Cholesterol polyps accounted for most benign PLG. The sensitivity of ultrasonography in detecting PLG was 90.1 per cent, significantly higher than that of oral cholecystography, computed tomography or endoscopic retrograde cholangiopancreatography (P less than 0.01). The specificity of ultrasonography in the diagnosis of PLG was 93.9 per cent. Therefore, ultrasonography is a highly sensitive method for investigating PLG, and the preoperative diagnosis of PLG in this unit has now become entirely dependent on this technique. The size and number of PLG, the presence of gallstones and the patient's age all correlate with the nature of PLG, and these features are helpful in differentiating malignant from benign lesions before operation. Surgical treatment is indicated when PLG exceed 1.0 cm in diameter, when PLG are single in number, when PLG are associated with gallstones, when patients with PLG are over the age of 50 years, or when clinical symptoms of PLG are apparent.
The iodinated contrast agents used in oral cholecystography impair peripheral iodothyronine-5'-deiodinase activity, resulting in a transient decrease in serum 3,5,3'-triiodothyronine (triiodothyronine, T3) and in increases in serum 3,3',5'-triiodothyronine (reverse T3, rT3) and thyroxine (T4) concentrations. A related iodinated contrast agent, diatrizoate, is employed in coronary angiography. The effect of diatrizoate (Renografin-76) on serum T4, T3, rT3, and thyroid stimulating hormone (thyrotropin, TSH) concentrations and the TSH and T3 responses to thyrotropin releasing hormone (TRH) were evaluated in seven euthyroid patients before and on the fifth day following coronary angiography. No significant changes were observed. Thus, diatrizoate, in contrast to the oral cholecystographic agents, appears to have little or no clinically important effect on thyroid hormone metabolism in man.
Gallbladder bile collected by duodenal intubation or during surgery was examined microscopically in patients who were free of stones and in patients with proven stones. None of the 16 patients free of stones had cholesterol monohydrate crystals or calcium bilirubinate granules in bile. Among the 17 patients with proven cholelithiasis, 13 with cholesterol stones had cholesterol monohydrate crystals in their bile, but only 2 of the 4 patients with pigment stones had calcium bilirubinate granules. These data confirm that cholesterol monohydrate crystals are sensitive and specific for cholesterol stones, whereas calcium bilirubinate granules lack sensitivity for the diagnosis of pigment stones. From these results, the diagnostic usefulness of microscopic examination of bile collected from the duodenum was studied prospectively in 46 patients with symptoms suggestive of cholelithiasis but in whom stones had not been visualized at cholecystography and ultrasonography. In 15 of them, bile was found to be abnormal: cholesterol monohydrate crystals were seen in 11, cholesterol crystals + calcium bilirubinate granules in 2 and calcium bilirubinate granules in 2. To date, nine of these patients have been operated on: 6 (all with cholesterol monohydrate crystals) had small cholesterol gallstones and 3 (2 with cholesterol monohydrate crystals and 1 with calcium bilirubinate granules) had signs strongly suggestive of the recent migration of gallstones. One patient refused operation, but minute pigment stones were found to be associated with calcium bilirubinate granules at duodenal intubation. In the other 31 patients, bile contained neither cholesterol monohydrate crystals nor calcium bilirubinate granules. They were not operated on and were followed up with repeated investigations for 12 to 24 months.(ABSTRACT TRUNCATED AT 250 WORDS)
Sixteen patients with a "phrygian cap" deformity of the gall bladder seen with oral cholecystography were further evaluated with both bistable and gray scale ultrasound. The bistable technique produced internal echoes that were suspicious of gall stones. When this same area was reevaluated with the more accurate gray scale technique, the folded-fundus deformity was clearly visualized.
Cholecystocolonic fistula is an unusual complication of biliary tract disease. Many of the signs and symptoms of these fistulas are nonspecific, so the diagnosis is often not suspected preoperatively. It is important to make the diagnosis then to prevent fecal contamination when the fistula is divided. We recently encountered a patient who, while undergoing laparoscopic cholecystectomy, was found to have a fistula between the gallbladder and the proximal transverse colon. Important features in the management of this case are (1) maintaining a high index of suspicion for the presence of this complication, (2) use of cholecystography to establish the diagnosis, and (3) use of laparoscopic stapling techniques to divide the fistula while preventing fecal soilage.
SZ-Alpha 1-antitrypsin deficiency, leading to severe transient neonatal cholestasis with mild hepatitis is rare. In our patient, intrahepatic bile duct hypoplasia was suspected. Since cholecystography and hepatic scintigraphy failed to reveal intrahepatic bile ducts, a diagnostic surgical liver biopsy was performed. Typical intrahepatocytic PAS-positive granules and a low serum alpha 1-antitrypsin concentration allowed a correct diagnosis of the SZ phenotype. The administration of an elementary diet quickly improved the clinical condition of our patient. Follow-up studies of this case and others will allow a better establishment of prognostic criteria and help in genetic counselling.