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PubMed2005

Biliary tree and cholecyst: post surgery imaging.

Recently, with improvements in surgical techniques there has been a substantial reduction in the incidence of biliary complications of hepatobiliary surgery. Nevertheless, bile duct injuries and other post-cholecystectomy complications are a serious problem and a major cause of morbidity and mortality. Early complications may include bile duct injury caused by mistakenly placed clips, erroneous cutting of bile ducts based on misinterpretation of biliary anatomy, periductal bile leakage that causes edema, fibrosis and secondary stricturing, and ischemia due to injury to the right hepatic artery. Bile duct strictures are the most common of the late complications and can develop a few months or many years after surgery. Early detection and accurate diagnosis have a fundamental importance for the successful treatment of these complications. Therefore, early and meaningful application of the imaging methods immediately after detection of the first symptoms is essential. Peroperative ultrasound and direct iodine contrast application into the biliary tree (operative cholangiography) are highly important for immediate visualization of the complications during surgery. Ultrasound can be used to aid in identification of ductal structures and the cholangiogram should be obtained to document the anatomy. Plain abdominal film could be made in the patients in poor clinical conditions after biliary surgery. Oral cholecystography has largely been replaced by ultrasonography (US) for evaluation of cholelithiasis and complications like post-cholecystectomy fluid collections. The same methodology replaced the conventional intravenous cholangiography. Nowadays computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiography (MRCP) and ultrasound (US) have essential roles as primary imaging modalities after biliary tree and gallbladder surgery in the evaluation of associated complications and residual biliary stones. We review the role of the imaging in complications after biliary tree and gallbladder surgery.

Biliary Tract Diseases↗
PubMed1982

Radiopharmaceuticals for hepatobiliary imaging.

Tests for liver function have by and large centered around clinical laboratory diagnostic procedures for a number of years. Besides these, radiographic imaging procedures, including oral cholecystography and intravenous cholangiography, serve a very useful purpose, but several of them are invasive and involve a certain degree of risk from the administered contrast media as well as discomfort to the patient. The cholescintigraphic procedures, though noninvasive, have not played a significant role in the evaluation of hepatobiliary disorders prior to the introduction of the currently available. 99mTc-labeled IDAs. These new hepatobiliary agents offer many advantages over the previously utilized radiopharmaceuticals (131I-rose bengal in particular) in terms of the high degree of specificity for localization in the gallbladder with rapid extraction rates by the polygonal cells of the liver and very low excretion via the GU tract. A detailed understanding of the structure distribution relationship of the various groups in the complex enable the design of agents with an improvement in hepatobiliary specificity and other desirable characteristics. In many clinical situations, even in patients with high bilirubin levels, the 99m-Fc-labeled IDAs offer far superior clinical information over the alternative diagnostic imaging modalities. Further, the absorbed radiation dose imparted to the critical organs is far lower than with the older agents. Thus, the introduction of the cholescintigraphic procedures with the 99mTc-labeled IDAs have ushered in a new phase in the diagnostic workup of patients with impaired hepatocellular function and other biliary disorders.

Biliary Tract↗
PubMed2002

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis.

BACKGROUND: The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients. METHODS: The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999. RESULTS: The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 plus minus 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury. CONCLUSIONS: The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.

Acute Disease↗
PubMed1993

Gallstone lithotripsy.

Extracorporeal shock-wave lithotripsy (ESWL) has been applied to patients with gallstones since the mid-1980s. Lithotriptors differ by their means of shock-wave generation, the mechanisms by which they are coupled to the patient, and their imaging systems. Entry in most treatment protocols is limited to symptomatic patients with one to three radiolucent stones having a diameter of 30 mm or less and a functioning gallbladder according to oral cholecystography. Treatments are given on an out-patient basis using intravenous analgesia and include adjuvant bile acid therapy. Deaths have not been reported, and the incidence of serious complications, related to the presence of fragments in the biliary system, is low. The studies show that ESWL is a safe and effective treatment for patients with a single gallstone less than or equal to 20 mm in diameter, but the efficacy for larger single stones and multiple stones is poor. To date, the Food and Drug Administration has not approved lithotriptors for the treatment of gallstones in the United States.

Chemotherapy, Adjuvant↗
PubMed1990

Cholecystectomy provides long-term symptom relief in patients with acalculous gallbladders.

Elective cholecystectomy was performed in 60 patients with biliary colic and acalculous gallbladders during a 5-year period. Gallbladder wall disease was significantly more common (p less than 0.01) in patients with acalculous gallbladders than in a similar symptomatic group with calculous gallbladders. Thirty-four of 43 patients (77%) available for long-term follow-up reported complete symptom relief after cholecystectomy. Preoperative ultrasonography, biliary scintigraphy, oral cholecystography, upper gastrointestinal series, and pathologic features of the gallbladder were equivocal in predicting long-term symptom relief. In patients with acalculous biliary colic, the best predictor of complete symptom relief is an adequate history of true biliary colic.

Adult↗
PubMed1985

Gallbladder disease in the morbidly obese.

During a 7 year period, 200 consecutive morbidly obese patients underwent a standardized gastric exclusion procedure. Group A was composed of the first 120 patients and Group B of the last 80 patients. In Group A, 22 patients had undergone a previous cholecystectomy and 12 patients had a cholecystectomy at the time of gastric exclusion because of positive diagnostic studies or palpation of stones. Of the remaining 87 patients in this initial group who were at risk for the development of gallbladder disease, 24 (27.6 percent) required a cholecystectomy in the first 3 postoperative years (mean 15.6 months). Twelve patients had acute cholecystitis, 3 patients had choledocholithiasis, and 1 patient had acute gallstone pancreatitis. In Group B, 18 patients had a previous cholecystectomy, 15 had positive diagnostic studies (ultrasonography and oral cholecystography) preoperatively, and 47 had negative studies. Cholecystectomy was routinely performed at the time of gastric exclusion surgery in the 62 patients with gallbladders in Group B. Of the 47 patients who had normal preoperative diagnostic studies, 40 (85.1 percent) had abnormal histologic findings in the gallbladder. Only seven patients in Group B had a normal gallbladder (14.7 percent). We conclude that gallbladder disease is considerably more frequent in the morbidly obese population (91.3 percent) than has previously been recognized, that diagnostic studies are frequently inaccurate, and that postoperative gallbladder disease is common (28.7 percent). On the basis of these results, routine cholecystectomy at the time of gastric exclusion surgery is recommended.

Adolescent↗
PubMed1991

The clinical importance of a thick-walled, tender gall-bladder without stones on ultrasonography.

Ultrasound examinations of 563 patients with right upper quadrant pain and a clinical suspicion of acute cholecystitis were reviewed. In 31 patients, a tender, dilated gall-bladder with a thick (more than 4 mm) partly hypoechoic wall without any detectable calculi was found on the emergency examination. This was interpreted as due to acute acalculous cholecystitis. None of the patients was critically ill. Twenty-one of the patients had follow-up studies with either oral cholecystography, cholangiography, or ultrasound. Fourteen of the 21 had gall-bladder calculi while seven did not. These seven patients presumably represent the true frequency (1.2%) of acute acalculous cholecystitis in this clinical setting. In five other patients with an initial diagnosis of acute acalculous cholecystitis the gall-bladder wall thickening probably was secondary to concomitant pancreatitis, appendicitis, hepatitis or peptic ulcer disease. A meticulous and careful search for gall-bladder calculi should be performed in the presence of a dilated, tender thick-walled gall-bladder.

Adult↗
PubMed1993

Radiological aspects of solvent dissolution of gall-stones.

Twenty-five patients were referred for solvent dissolution of gall-stones using methyl tertiary butyl ether (MTBE). All patients were assessed beforehand by ultrasound and oral cholecystography. Computed tomography was performed in 23 patients to assess stone calcification and gall-bladder anatomy. Successful stone dissolution was achieved in 15 patients and partial dissolution in six patients. Failure to catheterize the gall-bladder occurred in four patients. There were four biliary leaks, two requiring cholecystectomy. The CT appearances of the gall-bladder may have predicted problems with catheterization in three of the four cases, and the results suggest that cover of the gall-bladder by the liver of greater than 50% is a favourable predictor of successful catheterization. A thick-walled gall-bladder and excess fat between the liver and the lateral abdominal wall are adverse predictors of successful gall-bladder catheterization. Both tubography and ultrasound should be used to assess progress of dissolution. Newer, more effective solvents together with increased expertise in interventional techniques may encourage the more widespread use of solvent dissolution of gall-stones as an alternative to surgery in a selected population.

Adult↗
PubMed1988

Assessment of gallbladder function by ultrasound: implications for dissolution therapy.

Successful treatment of gallstones by oral dissolving agents depends upon a functioning gallbladder. Thirty-one patients were assessed by oral cholecystography and ultrasound before and after a fatty meal. A correlation was demonstrated between radiological opacification and contraction on ultrasound. It is suggested that assessment of gallbladder function may be made by ultrasound methods alone, and an oral cholecystogram is not necessary prior to dissolution therapy.

Adult↗
PubMed1996

Congenital bronchobiliary fistula: diagnosis and postoperative surveillance with HIDA scan.

Congenital bronchobiliary fistula (CBBF) is an extremely rare anomaly with myriad presentations that often include common bile duct abnormalities. Traditionally, bronchoscopy and bronchography have been used to establish the diagnosis. A full-term neonate with pneumonia and bilious secretions was diagnosed as having CBBF by means of a HIDA scan. Successful repair consisted of a right thoracotomy, high ligation of the fistula via an extrapleural approach, and cholecystography to confirm biliary drainage into the duodenum. The HIDA scan is a safe and efficient means to diagnose CBBF. When used in combination with surgical contrast studies, it provides clear delineation of all variations of this abnormality, enabling one-stage correction.

Biliary Fistula↗
PubMed1996

Acalculous cholecystitis in children.

Acalculous cholecystitis (AC) is a rare disease in children, and its spectrum has not been well established. Twenty-five children with AC were identified (treated between 1970 and 1994) by retrospective clinical and pathological review. The authors recognized two distinct forms of this disease: acute (duration of symptoms < 1 month) and chronic (duration > 3 months). Thirteen children had acute AC. Seventy-five percent were males; the age range was from 2 months to 20 years. Of these cases, six occurred in the immediate postoperative period, five were in association with a systemic medical illness, and two had an infectious cause (Salmonella). The mean time of onset of symptoms ranged from 4 to 30 days after surgery or hospitalization (mean, 16 days). All children presented with fever, right-upper-quadrant pain, and vomiting. Other manifestations included jaundice (38%) and right-upper-quadrant mass (23%). Most had leukocytosis (76%) and abnormal liver function test results (62%). Ultrasonography was the most commonly used radiological test, and all 10 cases tested met the ultrasonographic criteria for acute AC. Cholecystectomy was performed in nine children, and pathological examination confirmed cholecystitis. No postoperative complications occurred. The other four children were managed nonoperatively with intravenous antibiotics. One died, but the other three recovered fully. Twelve children had chronic AC. Sixty-seven percent were females; the age range was 7 to 18 years. All presented with chronic symptoms of right-upper-quadrant pain and nausea or vomiting. The leukocyte count and results of liver function tests were normal. Seventy-five percent had evidence of abnormal gallbladder function (noted by a radionuclide hepatobiliary scan or cholecystography). All children in this group underwent cholecystectomy, with pathological confirmation of chronic inflammation. No complications occurred, and all patients had complete resolution of symptoms. The authors conclude that AC in children occurs in two distinct patterns. The acute and chronic forms differ in their clinical setting and presentation. Cholecystectomy is effective treatment of AC, although there may be a role for nonoperative management in selected cases.

Acute Disease↗
PubMed1987

Sclerosing cholangitis with neonatal onset.

Sclerosing cholangitis is characterized by irregular narrowing of extrahepatic or intrahepatic bile ducts, and in adults is defined mainly by radiologic findings. We describe eight children with cholestasis from the first week of life, followed by early cirrhosis and portal hypertension. Histologic examination of the liver showed absence of interlobular bile ducts in the early cholestatic phase in two patients and biliary cirrhosis later in all patients. Radiologic examination by percutaneous cholecystography under ultrasound guidance, carried out at age 8 months to 9 years, disclosed abnormal intrahepatic bile ducts with rarefaction of segmental branches, stenosis, and focal dilation. The extrahepatic ducts were involved in six patients. No intestinal disease has been found in these patients.

Bile Ducts↗
PubMed1998

Wrist arthrography today.

In recent years, wrist arthrography has been criticized for having low sensitivity and low specificity. This largely has been due to widely varying and less than rigorous technique and the reliance on criteria for abnormality that are now known to be invalid. Other criticisms have included the length of time needed to perform a three-compartment arthrogram with or without comparison to the contralateral side and the radiation dose to the patient. It is our belief, however, that with the use of the patient's history, symptoms and physical examination to develop a focused examination strategy, and with the use of digital equipment, the examination can be performed quickly and with minimal radiation dose to the patient. In order to improve the accuracy of arthrography, the radiologist must abandon the concept that simply identifying a communicating defect between the carpal compartments is a criterion for abnormality. He or she must utilize a meticulous approach to determine the site of communication to evaluate the features of the defects in order to determine the significance of the defect. As more is learned about the nature of traumatic and attritional defects and with further technologic advancements in cross-sectional imaging and three-dimensional rendering, it is quite possible that arthrographic imaging of the wrist will experience a resurgence of interest in the evaluation of posttraumatic wrist pain, avoiding the fate of such examinations as pneumoencephalography and oral cholecystography as many have predicted.

Arthrography↗
PubMed1976

A symptomatic discriminant to identify recurrent ulcer in patients with dysperpsia after gastric surgery.

A questionnaire has been completed by 99 patients referred for investigation of symptoms after gastric operations. The replies were analysed in an attempt to distinguish patients with a recurrent peptic ulcer from those with no recurrent ulcer. All cases were investigated by barium meal, endoscopy, and oral cholecystography. All recurrent ulcers were confirmed by reoperation and patients with gastric carcinoma, gallstones, or symptomatic hiatus hernia were excluded. The study was retrospective in 40 patients in whom the diagnosis was already confirmed when the questionnaire was analysed and prospective in 59 in whom the diagnosis was originally unknown. The replies were analysed with (a) a small computer using Bayes' theorem, (b) weighted tables, and (c) a discriminant analysis. The computer prediction of the prospective data was 85% accurate. The results of simpler methods were almost as good as the computer prediction, and questions related only to the severity of pain and vomiting accurately distinguished recurrent ulcer from other causes of dyspepsia in 81% of patients.

Diagnosis, Computer-Assisted↗
PubMed1977

Dissolution of cholesterol gallstones by ursodeoxycholic acid.

44 patients with radiolucent gallstones in gallbladders visible on cholecystography were randomly alloted to three treatment groups: ursodeoxycholic acid (600 mg/day), ursodeoxycholic acid (150 mg/day), a placebo. At the end of six months' treatment, cholecystograms of all the patients were interpreted by radiologists who were not aware of the treatment. Dissolution of gallstones occurred in 8 (26%) of the 31 patients treated with ursodeoxycholic acid, but not in the placebo group. Ursodeoxycholic acid had no hepatotoxicity, as assessed by standard liver-function tests. These results indicate that ursodeoxycholic acid, the 7beta epimer of chenodeoxycholic acid, is effective in the dissolution of cholesterol gallstones.

Adult↗
PubMed1985

Radiographic and ultrasonographic diagnosis of liver diseases in dogs and cats.

Various techniques utilized for the clinical investigation of small animal patients with signs of liver disease are discussed. The author reviews the evaluation of survey radiographs and selected radiographic contrast techniques, such as cholecystography. The author also outlines the basic principles of hepatic ultrasonography and includes examples of normal and abnormal hepatic ultrasonograms to demonstrate the application of this new imaging modality to the diagnosis of liver diseases.

Animals↗
PubMed1979

Photoelectron emission microscopy of biological tissue; the influence of glutaraldehyde and heavy or biligrafin on the emission image of chicken liver in methacrylate.

The effect of various preparations on the emission image was studied taking into account the influence of UV wave length, section thickness and specimen support. By suitable selection of these parameters, images with sufficient contrast can be obtained of unstained specimens which are only fixed with glutaraldehyde. With glutaraldehyde fixation intravitally injected Biligrafin used as a stain in cholecystography is recognized in the emission image of liver tissue labeling the intravital transport path from the blood capillaries to the bile ducts. Hypotheses for the image forming process are discussed.

Aldehydes↗