Comparison of the dynamics of bile emptying by quantitative hepatobiliary scintigraphy before and after cholecystectomy in patients with uncomplicated gallstone disease.

PURPOSE: Quantitative hepatobiliary scintigraphy, a noninvasive method frequently used to diagnose several biliary tract disorders, shows abnormalities in bile secretion and outflow. It is well known that there are wide variations in the normal pattern of bile emptying, but the effect of cholecystectomy on the bile flow has not yet been investigated. The goal of the current study was to examine the dynamics and normal variations of bile flow by quantitative hepatobiliary scintigraphy before and after cholecystectomy in a group of patients with uncomplicated gallstone disease. METHODS: Twenty patients were evaluated before and after cholecystectomy through cholecystokinin octapeptide-augmented quantitative hepatobiliary scintigraphy, and quantitative parameters of bile emptying (Tmax: time to peak activity, T1/2: half-emptying time before and after cholecystokinin octapeptide and duodenum appearance time) were determined and then compared. RESULTS: Before operation, the bile outflow displayed wide variations, with a moderately delayed common bile duct emptying time in some patients. After cholecystectomy, the T1/2 of the common bile duct decreased significantly when compared with the preoperative status, with only minor patient-to-patient variation, indicating uniformly faster bile emptying (common bile duct T1/2 before and after operation: 30.5 +/- 14.8 and 18.8 +/- 2.6 min, respectively). Cholecystokinin octapeptide administration caused rapid bile outflow from the common bile duct, with a significant decrease in the T1/2 parameters before and after cholecystectomy. CONCLUSIONS: In patients with their gallbladders in situ, the bile emptying rate showed wide variations and may be moderately slow without distal common bile duct obstruction. After cholecystectomy, the rate of bile emptying accelerated and showed only minor variations, thereby increasing the sensitivity of quantitative hepatobiliary scintigraphy for showing partial biliary obstruction.     

The gallbladder emptying response to sequential exogenous and endogenous cholecystokinin

The gallbladder emptying response to sequential exogenous and endogenous cholecystokinin was measured by a noninvasive, nongeometric scintigraphic technique using a single dose of technetium 99m-labelled hepatobiliary agent. The mean latent period, ejection period, ejection fraction and ejection rate following 3 min infusion of 40 ng kg-1 of octapeptide of cholecystokinin were 2.8 +/- 0.7 min, 9.8 +/- 1.3 min, 34.0 +/- 9.9% and 3.5 +/- 2.0% per minute respectively. The corresponding values following 8 oz/70 kg of oral fatty meal were 15 +/- 6 min, 24.0 +/- 5 min (P less than 0.05), 55 +/- 9.1% and 2.8 +/- 0.6% per minute respectively. The total emptying for the combined stimuli was 71.4 +/- 14.0%. The wider range in latent and ejection period following fatty meal probably reflected the variations in time of the release into circulation and the duration of bioavailability of endogenous cholecystokinin. The lower rate of ejection was over compensated by longer duration of ejection resulting in higher degree of emptying following fatty meal. It is concluded that the gallbladder emptying pattern to exogenous and endogenous cholecystokinin can be studied sequentially using a single dose of technetium 99m-labelled hepatobiliary agent.     

The usefulness of hepatobiliary scintigraphy in the diagnosis of complications after adult-to-adult living donor liver transplantation

Living donor liver transplantation has become an accepted procedure to overcome the shortage of adult donor organs. The aim of this study was to evaluate the usefulness of hepatobiliary scintigraphy in the diagnosis of complications after adult-to-adult living donor liver transplantation. We analysed 82 hepatobiliary scintigraphy studies performed using technetium-99m DISIDA in 60 adult patients (44 males, 16 females) who had been transplanted with a living donor's hepatic lobe (right lobe, 32; left lobe, 28). Indications for hepatobiliary scintigraphy were abnormal symptoms and/or liver function tests ( n=54) or suspected bile leak or biloma ( n=28). Median interval between transplantation and scintigraphy was 69 days (9 days to 23 months). Scintigraphic findings were classified into hepatic parenchymal dysfunction, total biliary obstruction, segmental biliary obstruction, bile leak and normal graft. Scintigraphic findings were confirmed by liver biopsy in 17 cases, and by radiological and clinical follow-up in 65 cases. There were 29 events relating to biliary complications (six total biliary obstructions, eight segmental biliary obstructions and 15 bile leaks) and 19 relating to non-biliary complications (15 cases of rejection, two of infection and two of vascular compromise) in 38 patients. Hepatobiliary scintigraphy provided the correct diagnosis in all eight segmental and five of six total biliary obstructions, and in all 15 cases of bile leak. Of the 19 non-biliary complications, 16 showed parenchymal dysfunction regardless of the aetiology and three showed total biliary obstruction on scintigraphy. All but three of 34 normally functioning grafts were normal on scintigraphy. The diagnostic sensitivity and specificity of scintigraphy for biliary obstruction in the 54 patients with abnormal symptoms or liver function tests were 93% (100% for segmental, 83% for total) and 88% (35/40), respectively. The sensitivity and specificity were each 100% (15/15, 13/13) for bile leak in the 28 patients with suspected bile leak or biloma. Hepatobiliary scintigraphy is an accurate diagnostic modality in the evaluation of biliary complications after adult-to-adult living donor liver transplantation, although it has limitations as a means of differential diagnosis of non-biliary complications.     

Pharmacokinetics and clinical application of technetium 99m-labeled hepatobiliary agents

Hepatobiliary imaging, introduced first in late 1950s with iodine 131 rose bengal, has undergone major changes since the introduction of technetium 99m-labeled agents in the late 1970s. 99mTc-labeled iminodiacetic acid (IDA) agents, with their high hepatic uptake and fast biliary excretion, provide superior image resolution in addition to supplying simultaneous physiologic parameters quantitatively. The measurement of hepatic extraction fraction by deconvolutional analysis aids in separating hepatocyte from biliary disease. Excretion half-time calculation by nonlinear least square fit provides a quantitative method of analyzing hepatobiliary function and correlates directly with the severity of disease. The measurement of gallbladder ejection fraction, ejection rate, and common bile duct bile reflux index following cholecystokinin, enables quantification of the degree of obstruction to bile flow through the common bile duct. The combined application of morphologic and physiologic parameters enables diagnosis of various hepatobiliary disease, especially in early stages. Quantitative functional parameters not only provide criteria for diagnosis, but also assist in monitoring the therapeutic benefit from drugs and interventional techniques such as endoscopic sphincterotomy or balloon dilation of the obstruction. Biliary dynamic studies with cholecystokinin assist in distinguishing common bile duct dilation without obstruction from dilation with obstruction. Methods of application of 99mTc-IDA agents in quantitative physiologic studies are reviewed and future direction of their use is proposed.     

Laparoscopic versus conventional cholecystectomy. Use of biliary scintigraphy.

Laparoscopic cholecystectomy has become a popular alternative to traditional open cholecystectomy for uncomplicated, acute cholecystitis. At some centers, laparoscopic cholecystectomy is already the more frequently performed procedure. The presence or suspicion of common bile duct (CBD) stones or obstruction may necessitate conventional surgery or additional procedures. This report describes a patient with acute cholecystitis for whom the surgical management changed based on biliary scintigraphy. The demonstration of an unsuspected CBD obstruction by biliary imaging allowed the surgeon to change the initial plan for laparoscopic cholecystectomy to conventional open surgery. Stones in the common bile duct were removed.     

Biliary complications of gallstone lithotripsy detected by Tc-99m DISIDA scintigraphy

Extracorporeal shock wave lithotripsy (ESWL) has been reported to be a safe and relatively effective non-invasive treatment for radiolucent gallbladder calculi in selected patients. Ideally, the goal of successful treatment is the passage of all fragments from the gallbladder into the intestinal tract. Biliary colic has been reported in up to 35% of treated patients, although complications such as cholecystitis, cholangitis, common bile duct obstruction, and pancreatitis are surprisingly infrequent. Cholescintigraphy is the procedure of choice in patients with biliary colic and suspected acute cholecystitis. It has proven to be more sensitive than ultrasound in detecting acute common bile duct (CBD) obstruction, since functional obstruction precedes morphologic dilatation of the CBD. This report reviews two cases of post-lithotripsy cystic and common duct obstruction and discusses the role of Tc-DISIDA scintigraphy following gallstone ESWL.     

Iodinated cholylglycyltyrosine: a new agent for hepatobiliary imaging

The characteristics of radiolabelled cholylglycyltyrosine (CGT), a recently synthesised bile acid, were studied. 125I-CGT-Na was found to have a short plasma half-life of 1.6 +/- 0.4 min in rats and 3.1 +/- 0.7 min in dogs. Biliary clearance studies showed the cumulative biliary output of the tracer over 20 min in rats to be 95.7% of the total dose administered, with a mean biliary transit time (50% retention time) of 4.0 +/- 0.1 min, i.e. similar to the biliary kinetics of taurocholate. 131I-CGT-Na proved to be satisfactory for hepatobiliary imaging in rats and dogs at doses of 35 microCi (1.3 MBq) in rats and 90 microCi (3.3 MBq) in dogs. Satisfactory hepatic images were also obtained in rats that had high bilirubin levels produced by obstruction or the recycling of bile. These results show that CGT has better pharmacokinetics than currently used hepatobiliary imaging agents, and that this new compound may be useful in scintigraphy even in the presence of jaundice.     

Detection of common bile duct stones by hepatobiliary scintigraphy

Hepatobiliary scintigraphy and direct X-ray cholangiography were compared in 29 patients with common bile duct (CBD) stones confirmed at surgery. The scintigraphic findings included no visualization of the biliary system (NV), pooling of bile in the biliary system (PB), prolonged transit time over 60 min (PTT), filling defect in the CBD image (FD), and reflux of bile toward the intrahepatic ducts after gallbladder stimulation (RB). The positive rates of NV, PB, PTT, FD, and RB in patients with CBD stones were 7%, 31%, 17%, 48%, and 14%, respectively. One or more of these five findings was found in 83%. Although the NV was a useful finding suggesting complete obstruction of the CBD, it shared little in the diagnosis of CBD stone. The positive rate of the PB was relatively high and it would be a useful finding as an indication of the presence of passage disturbance of the CBD. The PB was usually accompanied by the FD. The PTT had some usefulness in the detection of incomplete obstruction of the CBD in patients with a visualized gallbladder. In patients with no visualization of the gallbladder, however, the transit time tended to be shorter than that of gallbladder visualized patients. Therefore, the judgment of PTT in patients with no visualized gallbladder needed another criteria. The FD was the most frequent among the five findings and the sites of FD correlated well with CBD stones on direct X-ray cholangiography. The FD would be a reliable finding indicating CBD stone or CBD stenosis. Although the RB was a finding limited in patients with a visualized gallbladder, it seemed to be a helpful findings for the detection of CBD stone in patients with a mildly dilated CBD.     

超声对华支睾吸虫感染所致胆道梗阻的诊断价值

目的 探讨华支睾吸虫感染所致胆道梗阻的超声影像特点及其诊断价值.资料与方法 回顾性分析43例华支睾吸虫感染患者的胆道梗阻声像图表现,并与胆总管病变引起的胆道梗阻作比较.结果 43例华支睾吸虫感染所致胆道梗阻患者均表现为肝内胆管轻至中度扩张,以次级胆管明显,胆管壁增厚,回声增强,胆囊肿大,胆总管轻度扩张,扩张程度与肝内胆管不成正比.胆总管病变引起的胆道梗阻其肝内胆管扩张程度与胆总管成正比.结论 华支睾吸虫感染所致胆道梗阻超声表现具有特征性,超声可作为该病的有效诊断方法.     

DISIDA kinetics measure liver function in dogs

We have investigated the ability of 99Tcm-disofenin (DISIDA) kinetics to measure liver function. Two approaches have been used: first, quantitative analysis of serial liver images, and second, clearance estimation from whole blood concentration-time data. Graded liver dysfunction was produced in 11 dogs over three months by common bile duct ligation and surgical relief of biliary obstruction one month later. The kinetic analysis of serial liver images showed clear abnormalities during biliary obstruction, with calculated rates of liver uptake falling in stages from 11.09 to 5.15 cts s-1 (p less than 0.001), and rates of elimination from the liver from 8.8 to 1.6 x 10(-4) cts s-1 (p less than 0.0001). These parameters paralleled the deterioration and recovery of liver function through the experimental period, and had not fully recovered 7 weeks after relief of biliary obstruction (10.5 and 6.2 x 10(-4) cts s-1 respectively). Serial blood sampling after injection of DISIDA permitted calculation of whole blood disposition rates (for hepatic clearance). Mean values fell from 256 to 67 ml min-1 with chronic biliary obstruction (p less than 0.001), and returned to almost normal (206 ml min-1) 10 days after surgical relief of biliary obstruction. It is clear that the gradual nature of recovering liver function was more sensitively identified by image analysis than serial blood data. Serial liver biopsies showed marked changes following biliary obstruction. These improved over a period of 7 weeks following its relief, when there was still considerable residual abnormality. This work supports the view that hepatic abnormalities caused by biliary obstruction do not recover quickly following its relief. DISIDA kinetics can quantitate both major and minor degrees of hepatic dysfunction, and may prove to be a valuable method to quantitative liver function.     

Characterization of basal hepatic bile flow and the effects of intravenous cholecystokinin on the liver,sphincter, and gallbladder in patients with sphincter of Oddi spasm

The major objectives of this project were to establish the pattern of basal hepatic bile flow and the effects of intravenous administration of cholecystokinin on the liver, sphincter of Oddi, and gallbladder, and to identify reliable parameters for the diagnosis of sphincter of Oddi spasm (SOS). Eight women with clinically suspected sphincter of Oddi spasm (SOS group), ten control subjects (control group), and ten patients who had recently received an opioid (opioid group) were selected for quantitative cholescintigraphy with cholecystokinin. Each patient was studied with 111–185 MBq (3–5 mCi) technetium-99m mebrofenin after 6–8 h of fasting. Hepatic phase images were obtained for 60 min, followed by gallbladder phase images for 30 min. During the gallbladder phase, 10 ng/kg octapeptide of cholecystokinin (CCK-8) was infused over 3 min through an infusion pump. Hepatic extraction fraction, excretion half-time, basal hepatic bile flow into the gallbladder, gallbladder ejection fraction, and post-CCK-8 paradoxical filling (>30% of basal counts) were identified. Seven of the patients with SOS were treated with antispasmodics (calcium channel blockers), and one underwent endoscopic sphincterotomy. Mean (±SD) hepatic bile entry into the gallbladder (versus GI tract) was widely variable: it was lower in SOS patients (32%±31%) than in controls (61%±36%) and the opioid group (61%±25%), but the difference was not statistically significant. Hepatic extraction fraction, excretion half-time, and pattern of bile flow through both intrahepatic and extrahepatic ducts were normal in all three groups. Gallbladder mean ejection fraction was 9%±4% in the opioid group; this was significantly lower (P<0.0001) than the values in the control group (54%±18%) and the SOS group (48%±29%). Almost all of the bile emptied from the gallbladder refluxed into intrahepatic ducts; it reentered the gallbladder after cessation of CCK-8 infusion (paradoxical gallbladder filling) in all eight patients with SOS, but in none of the patients in the other two groups. Mean paradoxical filling was 204% (±193%) in the SOS group and less than 5% (P<0.05) in both the control and the opioid group. After treatment, six of the SOS patients had complete pain relief and one, partial pain relief. The basal tonus of the sphincter is variable in patients with SOS, and allows relatively more of the hepatic bile to enter the GI tract than the gallbladder. Due to simultaneous contraction of the sphincter and gallbladder in response to CCK-8, most of the bile emptied from the gallbladder refluxes into intrahepatic ducts, and reenters the gallbladder immediately after cessation of hormone infusion. The characteristic features of gallbladder filling, emptying, and paradoxical refilling with cholecystokinin provide objective parameters for noninvasive diagnosis of SOS by quantitative cholescintigraphy.     

Constancy and variability of gallbladder ejection fraction: impact on diagnosis and therapy.

The main objective of this study was to test the constancy and variability of gallbladder (GB) ejection fraction (EF) in long-term studies to (a) determine whether EF ever becomes normal once it is low, (b) determine how long it takes for the EF to become abnormal once it is found to be normal, (c) explore the cause of low EF, and (d) define objective parameters for biliary and nonbiliary abdominal pain. METHODS: Fifty-two patients (42 women, 10 men) who underwent quantitative cholescintigraphy twice (total studies, 104), over a mean period of 38.54 mo between studies, were chosen for retrospective analysis. They were divided into the following groups: control (n = 13; nonbiliary abdominal pain), chronic acalculous cholecystitis (CAC) (n = 27; biliary abdominal pain), chronic calculous cholecystitis (CCC) (n = 6; biliary abdominal pain), and opioid (n = 6; nonbiliary abdominal pain). The last group had received an opioid before cholecystokinin-8 (CCK-8) infusion in one study but not in the other study. A GBEF value of > or =35% was considered normal with a 3-min infusion and > or =50% as normal with a 10-min infusion of CCK-8. RESULTS: The mean GBEF value was reproducible between the 2 sequential studies in the control group (66.0% +/- 20.5% vs. 73.9% +/- 17.7%), CAC group (24.4% +/- 22.3% vs. 16.9% +/- 10.9%), and CCC group (20.8% +/- 20.9% vs. 27.5% +/- 34.5%) but not in the opioid group (14.8% +/- 14.6% vs. 56.5% +/- 31.7%). The severity of GBEF reduction in CAC increased with time: 7.2% +/- 8.1% within 12 mo, 16.1% +/- 14.9% in 13-47 mo, and 23.5% +/- 21.3% in 48-168 mo. None of the 27 patients with CAC developed a gallstone as detected by ultrasound during the study period. In 5 patients with CAC, a mean period of 52.6 +/- 28.9 mo was required for conversion from normal to a low EF. CCK-induced cystic duct spasm is the etiology for low EF in both CAC and CCC. CONCLUSION: Normal and low GBEF values are reproducible in long-term studies. Once the EF reaches a low value, it does not return to normal, and a normal value requires many years to become abnormal. CCK-induced cystic duct spasm is the cause of low GBEF in CAC and CCC, and the severity of EF reduction is similar for both. Exclusion of opioid intake immediately before the study is critical before attributing a low GBEF value to an irreversible GB motor dysfunction.     

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.     

Rare localization of a portal cavernoma in the wall of the common bile duct

The first communication on biliary complications secondary to a portal cavernoma was published in 1965 [Br. J. Surg. 52 (1965) 636.], and since then several cases have been reported in the medical literature. These biliary complications, studied initially by anterograde or retrograde cholangiography, and later MR cholangiography [Van Hoe L, Van Beckevoort D, Van Steenbergen W. Atlas of across-sectional and projective MR cholangiography. Berlin: Springer; 1999. p. 166-7.], appear to be secondary to a double mechanism which produces a compression of the common bile duct (CBD) and ischemic changes. The biliary abnormalities most frequently found are a dilatation of the intrahepatic biliary ducts associated with extrinsic strictures and segmental dilatation of the CBD [J. Radiol. 83 (2001) 341.]. We report a rare type of portal cavernoma characterized by a thickening of the walls of the CBD and by a dilatation of the intrahepatic biliary ducts. The thickened walls of the CBD were evaluated by ultrasound and by magnetic resonance imaging.     

Hepatobiliary scintigraphy in the assessment of biliary obstruction after hepatic resection with biliary-enteric anastomosis

We investigated the usefulness of hepatobiliary scintigraphy (HBS) for diagnosing biliary obstruction after curative hepatic resection with biliary-enteric anastomosis. The study population consisted of 54 patients who underwent surgery for benign (n=18) or malignant (n=36) biliary disease. We analysed 68 technetium-99m DISIDA scintigrams which were performed at least 1 month after the surgery (median: 9 months). Final diagnosis was made by operative exploration, other invasive radiological studies or clinical and radiological follow-up for at least 6 months after the surgery. Diagnostic accuracy was analysed according to the pretest likelihood of biliary obstruction. There were two total and 15 segmental biliary obstructions. In patients with symptoms of biliary obstruction and abnormal liver function, HBS always allowed correct diagnosis (two instances of total obstruction, seven of segmental obstruction and seven of non-obstruction). Among the patients with non-specific symptoms or isolated elevation of serum alkaline phosphatase, HBS diagnosed segmental biliary obstruction in seven of the eight instances, and non-obstruction in 22 of 23 instances. There were no cases of biliary obstruction and no false-positive results of HBS in 21 instances with no clinical signs or symptoms of biliary obstruction. The diagnostic sensitivity and specificity of HBS for biliary obstruction were 94% (16/17) and 97% (50/51), respectively. In conclusion, HBS is a highly accurate modality for the diagnosis of segmental biliary obstruction during long-term follow-up after hepatic resection with biliary-enteric anastomosis. Received 1 August and in revised form 14 October 1999     

Reflux sign in cholescintigraphy after administration of a gallbladder contracting agent

This study reviewed 12 patients with the reflux sign in cholescintigraphy to assess its diagnostic usefulness in evaluating biliary passage. The reflux sign was determined by appearance or increase of the radioactivity in peripheral intrahepatic bile ducts after intramuscular injection of 10 micrograms of ceruletide diethylamine (caerulein). Of the 12 patients, there were common bile duct (CBD) stone in four, chronic pancreatitis in two, biliary dyskinesia in two, papillary adenoma of the CBD, dilated CBD, papillitis, and juxtapapillary duodenal diverticulum in one each. Cholangiographically, dilated caliber of the CBD more than or equal to 12 mm was found in five and equivocal caliber of 8 to 11 mm was in the remaining seven. Apparent stenosis of the CBD was found in four with dilated CBD. There were two patients who had CBD stone with equivocal caliber of the CBD. The reflux sign seems to be a sensitive finding indicating the presence of biliary dysfunction, and would be helpful for the detection of incomplete obstruction of the CBD or CBD stone, especially in a patient with equivocal caliber of the CBD.     

Hepatobiliary scintigraphy in the assessment of biliary obstruction after hepatic resection with biliary-enteric anastomosis

We investigated the usefulness of hepatobiliary scintigraphy (HBS) for diagnosing biliary obstruction after curative hepatic resection with biliary-enteric anastomosis. The study population consisted of 54 patients who underwent surgery for benign (n=18) or malignant (n=36) biliary disease. We analysed 68 technetium-99m DISIDA scintigrams which were performed at least 1 month after the surgery (median: 9 months). Final diagnosis was made by operative exploration, other invasive radiological studies or clinical and radiological follow-up for at least 6 months after the surgery. Diagnostic accuracy was analysed according to the pretest likelihood of biliary obstruction. There were two total and 15 segmental biliary obstructions. In patients with symptoms of biliary obstruction and abnormal liver function, HBS always allowed correct diagnosis (two instances of total obstruction, seven of segmental obstruction and seven of non-obstruction). Among the patients with nonspecific symptoms or isolated elevation of serum alkaline phosphatase, HBS diagnosed segmental biliary obstruction in seven of the eight instances, and non-obstruction in 22 of 23 instances. There were no cases of biliary obstruction and no false-positive results of HBS in 21 instances with no clinical signs or symptoms of biliary obstruction. The diagnostic sensitivity and specificity of HBS for biliary obstruction were 94% (16/17) and 97% (50/51), respectively. In conclusion, HBS is a highly accurate modality for the diagnosis of segmental biliary obstruction during long-term follow-up after hepatic resection with biliary-enteric anastomosis.     

Gallbladder function: methods for measuring filling and emptying

Cholescintigraphy with [99mTc] disofenin was used to determine the optimal dose and method of administration of the octapeptide of cholecystokinin, and to determine the kinetics of gallbladder filling and emptying in 22 patients without disease of the liver or gallbladder. The peak filling rate of the gallbladder occurred at 30 min after injection; filling was complete at 1 hr. A 45-min constant intravenous infusion of the octapeptide 20 ng/kg X hr resulted in progressive emptying of the normal gallbladder; the mean ejection fraction at 45 min was 77.2 +/- 4.9%. A 1-min injection of 20 ng/kg resulted in a rapid, short-lived emptying; the mean ejection fraction was 52.2 +/- 9.3%. Doubling or halving the infusion dose produced no greater response or a smaller response. We conclude that a constant 45-min infusion technique is superior to short injection times, because of more complete emptying, no side effects, and more consistent response.     

Gallbladder filling and post-ceruletide emptying in prairie dogs and rabbits

The filling and emptying characteristics of the gallbladder in prairie dogs and rabbits were studied to assess the importance of the residual bile in the pathogenesis of gallstones. In prairie dogs under ketamine/xylazine anesthesia, a significantly larger fraction (p = 0.001) of hepatic bile entered the gallbladder (87 +/- 8%) than the intestine during fasting and very little bile emptied (0-3% ejection fraction) following ceruletide infusion. In rabbits under similar anesthesia, only a small fraction of hepatic bile entered the gallbladder (4 +/- 2%) during fasting, and the gallbladder emptied almost completely (85% ejection fraction) following ceruletide infusion. The resultant higher residual bile in the prairie dog gallbladder and lower residual bile in the rabbit gallbladder may explain why gallstones form so readily in prairie dogs but not in rabbits when fed a lithogenic diet. These similarities and differences in gallbladder function must be taken into account when considering any animal as a model for gallstone formation.     

Value of sonography, computer tomography, hepatobiliary scintigraphy and nuclear magnetic tomography in diseases of the gallbladder and bile ducts

The effectiveness of ultrasound, computed tomography, hepatobiliary scintigraphy and nuclear magnetic resonance in diseases of the biliary tract is described. Ultrasound should be the first examination in clinical suspicion of cholelithiasis and has a higher accuracy than oral cholecystography. Computed tomography is very expensive and should be carried out in suspected gallbladder carcinoma, cholecystitis with abscess formation, tumour in the porta hepatis and pancreatic head and in sonographically unclear cases. Nuclear magnetic resonance can determine the ability of the gallbladder to concentrate bile. Ultrasound can distinguish with high accuracy between obstructive and inflammatory jaundice. In clinical suspicion of bile duct lesions an infusion cholangiogram must be carried out, if bilirubin is lower than 5 mg%; if bilirubin is higher, an ERC or PTC should be performed. If in biliary obstruction a suspicion of tumour in porta hepatis or head of the pancreas is present, computed tomography should be effected.