Chronic acalculous gallbladder disease: multiimaging evaluation with clinical-pathologic correlation

Despite the recent advances in hepatobiliary imaging, the diagnosis of chronic acalculous gallbladder disease remains difficult. A retrospective study was undertaken to assess the value of a multiimaging approach in detecting chronic acalculous gallbladder disease and in predicting which patients would obtain symptomatic relief after cholecystectomy. Of 199 patients with chronic cholecystitis, 26 (13%) had no gallstones. Of these 26, only 17 (65%) had symptoms related to chronic cholecystitis; in the remainder, the histologic diagnosis was made incidentally. After cholecystectomy, 13 (76%) of the 17 symptomatic patients obtained long-term symptomatic relief, while in four, the symptoms recurred. Among patients with histologic changes of chronic cholecystitis, biliary scintigraphy was the most sensitive technique (sensitivity, 89%). The sensitivity of sonography and oral cholecystography was 61.5% and 66%, respectively. However, for identifying symptomatic patients who may obtain long-term symptomatic relief after cholecystectomy, the accuracy of sonography, oral cholecystography, and biliary scintigraphy was 82%, 86%, and 38%, respectively. When two tests were in agreement the accuracy was 88%. For chronic acalculous cholecystitis, more than one study must be performed in order to make the correct diagnosis and to predict good results from cholecystectomy.     

Cholelithiasis in the morbidly obese: diagnosis by US and oral cholecystography

Forty-two morbidly obese patients underwent cholecystectomy at the time of gastroplasty, primarily for prophylactic reasons. Preoperatively, 37 patients underwent ultrasonography (US) of the gallbladder and oral cholecystography, four US only, and one oral cholecystography only. There was one indeterminate US study (2.4%) and one indeterminate oral cholecystogram (2.7%). At US study, gallstones were detected in six of the eight patients with gallstones (sensitivity = 75%), and the gallbladders of all 32 patients without gallstones were categorized as normal (specificity = 100%). The gallstones not identified measured 1-2 mm in diameter. Oral cholecystographic study enabled detection of gallstones in three of the seven patients with gallstones (sensitivity = 43%) and categorized as normal all 30 gallbladders without gallstones (specificity = 100%). The gallstones not seen were small and included those not detected by US. The results suggest that US is equal or superior to oral cholecystography for detection of cholelithiasis in obese patients.     

Nonvisualized gallbladder by cholecystosonography.

To further define the significance of gallbladder nonvisualization by cholecystosonography, we studied follow-up data on 25 consecutive patients in whom the gallbladder could not be identified despite adequate fasting. In one patient, intravenous cholangiography demonstrated a large gallbladder but no gallstones. In the 24 cases for which a pathoanatomic diagnosis was established, all but two had diseased gallbladders with obliteration of the lumen. This 88% accuracy for positive prediction confirms results of previous sonographic studies and matches the diagnostic significance of nonvisualization at oral cholecystography. We recommend oral cholecystography for all ultrasonic nonvisualized gallbladders for greater diagnostic accuracy when surgery is contemplated.     

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.     

Sonography of adenomyomatosis of the gallbladder: radiologic-pathologic correlation

Sonograms of six patients with adenomyomatosis of the gallbladder were reviewed and correlated with oral cholecystographic and pathologic findings. The gallbladder was visualized in four of the six patients by oral cholecystography, which also revealed intramural diverticula. Five of the six patients showed sonographic evidence of diffuse or segmental thickening of the gallbladder wall and intramural diverticula, seen as anechoic or echogenic foci within the wall. Intramural diverticula containing bile appeared as anechoic spaces; those containing biliary sludge or gallstones appeared as echogenic foci with or without acoustic shadows or reverberation artifacts. There was good correlation between sonographic and pathologic findings in three patients. The authors conclude that adenomyomatosis of the gallbladder should be suspected when (a) there is diffuse or segmental thickening of the gallbladder wall and (b) intramural diverticula are seen as anechoic or echogenic foci with or without associated acoustic shadows or reverberation artifacts.     

Cholecystokinetic cholecystography: efficacy and tolerance studies of ceruletide.

The effect of intravenous and intramuscular administration of ceruletide on gallbladder contraction was investigated in 67 normal volunteers and patients. Of the 45 normal volunteers, 33 received the drug intravenously and 12 intramuscularly in graded ascending doses. By either means of injection, ceruletide produced a substantial contraction of the gallbladder with a measurable reduction in gallbladder area. Based on findings in these groups, the 22 patients requiring oral cholecystography for clinical evaluation received 0.3 microgram/kg intramuscularly. The intramuscular administration of synthetic ceruletide after oral cholecystography, in a dose of 0.o microgram/kg, afforded a safe and effective means of gallbladder contraction, with resultant cystic and common bile duct visualization. Side effects occurred less frequently when the drug was administered intramuscularly and were minimal and self-limiting. Peak contraction (40% or greater reduction in size) occurred as early as 5-15 min after after intramuscular injection and in most instances within 30 min.     

Ultrasonics in the diagnosis of hyperplastic cholecystoses of focal and segmental extension type

The authors describe the sonographic (US) patterns of hyperplastic cholecystoses observed from January 1983 to April 1987 - 39 cases of focal extension and 12 of segmental extension--and confirm the higher sensibility of US versus oral cholecystography. Sonography (SG) allows a straight visualization of the gallbladder wall and its lesions, both in case of limited thickening of the wall (focal cholecystosis) and in case of more extensive thickening (segmental cholecystosis). To cholecystographic findings of focal lesions, SG gives additional information, adding a fundamental diagnostic element: the lack of acoustic shadowing distal to the nodular masses. Nonetheless, SG does not allow a discrimination between focal cholesterolosis and adenomyomatosis, except for particular cases, such as multiple nodular masses, and coexistence with the "comet tail" pattern--the latter due to parietal deposits of cholesterol. Furthermore, the differential diagnosis of focal cholecystoses includes some neoplasms of the gallbladder, and gallstones stuck to the wall, with no acoustic shadowing. In segmental cholecystoses, the direct evaluation of the entity and extension of the wall thickening remains a fundamental diagnostic element, even though such a morphologic detail is often integrated by the functional relieve of hypercontractility of the gallbladder wall after a fatty meal (both oral cholecystography and SG demonstrate it).     

Ultrasonic evaluation of gallbladder function prior to non-surgical treatment of gallstones

A comparative analysis of ultrasonic and oral cholecystographic assessment of gallbladder function in symptomatic patients with cholelithiasis is presented. Ultrasonic evaluation demonstrated non-contractile gallbladders in all but one patient with non-opacification during oral cholecystography, whereas all those opacifying on oral cholecystography contracted on ultrasonography. Both techniques showed similar abilities to quantify the size and number of biliary calculi within the limits necessary to determine suitability for treatment. Although computed tomography remains necessary to quantify gallstone density prior to non-surgical treatment, ultrasonography is a safe, acceptable, cheap and preferable alternative to oral cholecystography in assessing gallbladder function.     

The significance of functioning gallbladder visualization on hepatobiliary scintigraphy in infants with persistent jaundice.

The purpose of this study was to determine whether gallbladder visualization can help exclude biliary atresia in hepatobiliary scintigraphic studies of infants with persistent jaundice. METHODS: One hundred fifty-two infants with persistent jaundice (49 patients with a final diagnosis of biliary atresia and 103 with biliary patency) were studied using both hepatobiliary scintigraphy and abdominal sonography. Food was withheld for 4 h before the examination, and the infants were fed nothing but glucose until 6 h after the initial injection of (99m)Tc-disofenin or until the gallbladder was seen. If the gallbladder was seen, the infants were fed milk, and imaging was continued to observe gallbladder contractility. RESULTS: In none of the 49 patients with biliary atresia could the gallbladder be seen with hepatobiliary scintigraphy, but abdominal sonography revealed 9 normal-sized gallbladders. Of the 103 patients with biliary patency, hepatobiliary scintigraphy detected the gallbladder more frequently (74%, 76/103) than did abdominal sonography (63%, 65/103). All visualized gallbladders contracted after the infants were fed milk. If we include visualization of both the gallbladder and bowel radioactivity as criteria, the specificity of biliary atresia on hepatobiliary scintigraphy increases to 86% (89/103). CONCLUSION: Gallbladders were usually visible on hepatobiliary scintigraphy of fasting patients with biliary patency. A functioning gallbladder, with or without visualization of bowel radioactivity, indicated biliary patency.     

Gallstone composition in relation to buoyancy at oral cholecystography

Although it is recognized that some gallstones float at oral cholecystography, the reasons for this are not known. To determine how stone type and composition are related to stone buoyancy, the authors analyzed gallstones from 90 patients in the National Cooperative Gallstone Study. Seventeen patients had floating and 73 had nonfloating radiolucent stones at oral cholecystography. Stone analysis showed that all 17 floating stones were cholesterol stones; 64 of the nonfloating stones were cholesterol stones, while nine were pigment stones. The cholesterol contents of floating and nonfloating cholesterol stones were similar, 90.4% +/- 1.7 and 87.0% +/- 1.2 of stone weight, respectively. The calcium salt content of the nonfloating cholesterol stones was 3.2% +/- 0.6, while that of the floating cholesterol stones was only 1.1% +/- 0.4 (P = .02). The results indicate that floating gallstones are cholesterol stones with a significantly lower calcium salt content than that of nonfloating cholesterol stones.     

Preliminary abdominal films in oral cholecystography: are they necessary?

A survey of 45 radiologists with a special interest in gastrointestinal radiology showed that only 8% used a preliminary abdominal film for oral cholecystography. Review of 467 cases of oral cholecystography with preliminary films over a 1 year period disclosed 88 confirmed cases of cholelithiasis. Of these 88 cases, 27% had opaque gallstones visible on the preliminary film. In one-third of the cases, the opaque gallstones had a classic diagnostic appearance, while the remainder required oral cholecystography for confirmation. Opaque calculi were obscured by oral contrast material in 2% of cases. Other significant pathology on the preliminary films was found in 5.5% of the 467 cases.     

Hepatobiliary imaging in choledocholithiasis. A comparison with ultrasound

A retrospective analysis of preoperative biliary imaging and ultrasound in 22 patients with surgically proven choledocholithiasis was performed. Ultrasound detected dilated ducts greater than 7 mm in 11 of 14 jaundiced patients (79%). Hepatobiliary imaging was able to detect either absent or delayed bowel visualization or prominent bile ducts in 13 of 14 jaundiced patients (93%). Of eight nonjaundiced patients, ultrasound showed dilated ducts in three (38%). Hepatobiliary imaging showed either absent bowel activity or prominent ducts in six of eight nonjaundiced patients (75%). Twenty of 22 patients had stones in the gallbladder that were detected by ultrasound, although only one patient had actual visualization of the common duct stone. Hepatobiliary imaging may show abnormalities in choledocholithiasis with normal ultrasound studies.     

Imaging the gallbladder: a historical perspective

After Wilhelm Conrad Roentgen's discovery of the X-ray in 1895, it was initially thought that gallstones could not be visualized. Surgeons relied solely on the clinical examination to detect biliary disease. Today, no evaluation of the gallbladder would be complete without the performance of an imaging study. Radiology has gone through several eras in the imaging of gallstones. The plain film era, 1895-1924, was characterized by techniques that improved soft-tissue detail, allowing better detection of radiopaque stones. The contrast media era, 1924-1960, was initiated by the invention of IV cholecystography. In 1925, oral cholecystography was developed. During the era of expanding technology, 1960-1979, percutaneous transhepatic cholangiography, scintigraphy, and sonography came into use. The therapeutic era began in the 1980s.     

Persistent gallbladder opacification after iopanoic acid cholecystography: diagnostic implications for acalculous cholecystitis.

Recent reports in the surgical literature state that persistent dense visualization of an otherwise normal-appearing gallbladder 36 hr after the administration of iopanoic acid is highly suggestive of acalculous cholecystitis. To determine the incidence and significance of persistent gallbladder visualization, 324 patients and 66 asymptomatic controls were evaluated. An equal percentage (about 10%) of both groups showed persistent dense gallbladder opacification 36 hr after iopanoic acid ingestion. The results do not support the contention that patients with acalculous cholecystitis can be identified by simply obtaining an additional abdominal radiograph the day after oral cholecystography.     

The value of the fatty meal in oral cholecystography.

In order to assess the value of the after fatty meal films, 232 oral cholecystograms were reviewed. Gallbladder opacification, duct visualisation, separation of gallbladder from overlying bowel gas shadows, and the demonstration of abnormalities were assessed from the pre-fatty meal films, and then again in conjunction with those taken after fat, when contraction was also assessed. Of the 200 examinations given the fatty meal, 132 were adjudged normal, 63 had gallstones, four had adenomyomatosis (one with stones), and two cholesterolosis. The post-fatty meal films, were found to be essential for the diagnosis of adenomyomatosis and cholesterolosis, and considered to be occasionally helpful in diagnosing small stones. They were of little value in assessing the biliary ducts, or separating the gallbladder from overlying bowel gas, and of no value in the diagnosis of functional biliary tract disorders.     

Technetium-99m-pyridoxylideneglutamate: a new hepatobiliary radiopharmaceutical. II. Clinical aspects.

Technetium-99m-pyridoxylideneglutamate (99mTc-PG) is a nontoxic radiopharmaceutical that was found to undergo rapid biliary excretion in normal humans. The biliary tree and gallbladder were seen within 10-15 min of injection and by 20 min marked accumulation of radioactivity was noted in the gallbladder and gastrointestinal tract. Of ten "control" volunteers, seven had normal 99mTc-PG-cholescintigrams. In the remaining three, the gallbladder was not visualized. Gallbladder disease was not excluded in these three subjects. Of 24 patients referred for investigation of right upper quadrant abdominal pain, 13 proved to have gallbladder disease. All seven patients with acute cholecystitis and one of four patients with chronic cholecystitis had nonvisualization of the gallbladder on the cholescintigram whereas five patients with chronic cholecystitis or cholesterolosis had normal cholescintigrams. Six of the eight patients with nonvisualization of the gallbladder on cholescintigram had contrast radiologic studies (oral cholecystogram or intravenous cholangiogram or both), and in all six, nonvisualization of the gallbladder was also reported on the contrast study. cholescintigraphy was found to be greatly inferior to contrast radiologic studies in the detection of gallbladder stones.Eleven patients had complete extrahepatic biliary obstruction and this diagnosis was correctly made in all 11 by the cholescintigram. Fourteen patients had incomplete extrahepatic biliary obstruction. The correct diagnosis was made on the cholescintigram in seven but in the remaining seven it was not possible to distinguish between incomplete extrahepatic biliary obstruction and hepatocellular disease. Malignant lesions (carcinomas of head of pancreas, gallbladder, common bile duct or ampulla of Vater) were the cause of obstruction in 10 of the 25 patients with complete or incomplete obstruction and the diagnosis of obstruction due to malignancy was correctly made in 8 of these 10 by means of a scintigraphic equivalent to Courvoisier's sing. Finally, 11 patients had hepatocellular disease and a nonspecific pattern consistent with either imcomplete biliary obstruction or hepatocellular disease was observed on the cholescintigram in all 11. The 99mTc-PG cholescintigram is suggested for a role complementary to that of contrast radiologic studies in the preoperative investigation of patients with possible surgical disease of the biliary tract. Contrast radiologic techniques are advocated as being more appropriate in the nonjaundiced patient with suspected gallbladder disease whereas the 99mTc-PG cholescintigram is advocated as being more appropriate in the patient with jaundice. The value of the 99mTc-PG cholescintigram lies in the confidence with which complete extrahepatic biliary obstruction can be diagnosed. The "scintigraphic Courvoisier's sign" seems a useful indicator of malignant obstruction.     

Biliary carcinoma: CT evaluation of extrahepatic spread

The authors studied the computed tomographic (CT) images obtained in 56 patients with pathologically proved biliary cancer and 75 patients with no evidence of biliary disease, attempting to define the normal anatomy of the lymphatic system draining the bile ducts and the prevalence of extrahepatic spread of primary biliary cancer into these retroperitoneal planes. Of 20 patients with gallbladder cancer, 14 (70%) had proved adenopathy and nine (45%) had peritoneal spread at presentation, and another three later developed carcinomatosis. Of 22 patients with proximal cholangiocarcinoma, 16 (73%) had nodal involvement at presentation, four later developed adenopathy, and five had peritoneal dissemination. Distal or diffuse cholangiocarcinomas were less associated with metastatic nodes or peritoneal spread. For all biliary cancers, the nodes most commonly involved were the node of the foramen of Winslow, the superior pancreatoduodenal node, and the posterior pancreatoduodenal chain. Extrahepatic tumor spread produced proximal intestinal obstruction in 13 patients (23%). CT reliably demonstrates lymphatic or other extrahepatic spread of biliary cancers, which may have an important bearing on management decisions.     

Role of cholecystokinetic agents in 99mTc-IDA cholescintigraphy

Cholecystokinin (CCK) and its C-terminal octapeptide analog, Sincalide, have been utilized in two separate roles for the evaluation of gallbladder disease. These are: (1) prior to cholescintigraphy to evacuate the gallbladder and optimized subsequent filling with radiotracers, and (2) to study contractile function of visualizing gallbladders on cholecystography and cholescintigraphy. As a preparation for 99mTc-IDA studies, it clearly facilitates earlier gallbladder filling in patients with chronic cholecystitis, thereby ruling out complete cystic duct obstruction. The problem lies in the fact that the use of CCK as a premedication markedly decreases the sensitivity of the study to detect chronic cholecystitis, since the findings become indistinguishable from patients with normal gallbladders. For this reason, the authors prefer to obtain delayed images, since chronic cholecystitis is frequently associated with gallbladder filling beyond the first hour. The role of CCK in detecting abnormal gallbladder function in the normally visualizing gallbladder also is controversial. Other studies as well as the author's experience suggests that as much as one-forth of positive cases may be associated with normal gallbladders at surgery and often even on microscopic examination. However, most importantly, the great majority of these patients are relieved of their symptoms following surgery. It appears reasonable that CCK or Sincalide cholecystography or cholescintigraphy may be detecting functional abnormalities before anatomic changes occur and can, therefore, serve as a useful examination in selecting symptomatic patients who may benefit from cholecystectomy.     

Disorders of gallbladder function related to duodenogastric reflux in technetium-99m DISIDA hepatobiliary scintigraphy

Controversy exists over the relation between gallbladder dysfunction and the propensity for duodenogastric reflux. To evaluate this, Tc-99m DISIDA hepatobiliary imaging studies in 120 patients were reviewed, excluding patients who had had cholecystectomy or subtotal gastrectomy before scintigraphy. Serial images were obtained at 5, 10, 15, 30, 45, and 60 minutes and up to 24 hours, if indicated, after intravenous injection of 5-10 mCi of Tc-99m DISIDA. Normally, the liver, bile ducts, gallbladder, common bile duct, and bowel are visualized sequentially. Reversal of the normal sequence of gallbladder (GB) and bowel visualization indicates GB dysfunction; nonvisualization of the GB reflects cystic duct obstruction or absent GB function. Duodenogastric reflux is identified by radiotracer localized in the area just below or immediately adjacent to the tip of the left hepatic lobe. The intragastric location of the tracer may be verified by oral administration of 300 uCi of Tc-99m sulfur colloid. Twenty-nine patients had duodenogastric reflux between 10 and 60 minutes after injection. Of the 29 patients, 22 had a nonvisualized gallbladder, four had reversal of appearance of GB and bowel activity, and three had a normal study. GB dysfunction or nonfunction is more frequently demonstrated when duodenogastric reflux is present than with normal gallbladder function (P less than 0.001). In conclusion, gallbladder malfunction is closely associated with duodenogastric reflux, an abnormality that may be diagnosed noninvasively by Tc-99m DISIDA hepatobiliary scintigraphy.     

Scintigraphic criteria for the diagnosis of obstructive hepatobiliary diseases with Tc-99m IDA

The purpose of this study is to define the scintigraphic parameters that reliably predict the presence of obstructive hepatobiliary diseases. Gallbladder and intestinal visualization times noted during cholescintigraphy with Tc-99m IDA were compared to functional and morphologic parameters for their ability to accurately diagnose biliary diseases. One hundred and twenty-five normal subjects and 127 patients with five different types of hepatobiliary diseases were studied. Bile pooling in segmental ducts with minimal prolongation of excretion t-1/2 was the feature most commonly seen in partial common bile duct obstruction, and biliary nonvisualization with marked prolongation of excretion t-1/2 was the primary feature of total obstruction. Sclerosing cholangitis showed band constrictions and beading along bile ducts with regional variation in excretion t-1/2, and primary biliary cirrhosis demonstrated normal bile ducts with uniform prolongation of excretion t-1/2. Patients with cholelithiasis showed normal image patterns of the major ducts. Intestinal visualization by 60 minutes was only 46% sensitive and 77% specific with an overall accuracy of 74% in the detection of biliary obstruction. Delayed gallbladder visualization and reduction in ejection fraction were sensitive but nonspecific indicators of biliary disease. We conclude that Tc-99m-IDA imaging is an accurate test for the diagnosis of obstructive hepatobiliary disease provided both quantitative functional and qualitative morphologic parameters are analyzed. Intestinal nonvisualization at 60 minutes alone is not reliable as a sole parameter for the detection of partial biliary obstruction.