Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography, and MR cholangiography

OBJECTIVE. In this investigation we compared the diagnostic performance of unenhanced helical CT, oral contrast-enhanced CT cholangiography, and MR cholangiography for the diagnosis of choledocholithiasis. SUBJECTS AND METHODS. Fifty-one patients referred for endoscopic retrograde cholangiography of suspected biliary stones were studied with unenhanced helical CT, MR cholangiography, and helical CT performed after oral administration of a cholangiographic contrast agent (iopodic acid). The studies were randomized for interpretation. Two radiologists evaluated the images by consensus and determined the presence and location of stones. We used retrograde cholangiography findings as the standard of reference. Sensitivity and specificity (with 95% confidence intervals [CIs]) of the three examinations were calculated and compared using the exact form of the McNemar test. RESULTS. Bile duct stones were revealed with retrograde cholangiography in 26 patients (51%). Sensitivity was 65% (95% CI, 44.4-82%) for unenhanced helical CT, 92% (95% CI, 73-99%) for CT cholangiography, and 96% (95% CI, 78-99%) for MR cholangiography. Specificity was 84% (95% CI, 63-95%) for unenhanced helical CT, 92% (95% CI, 73-99%) for CT cholangiography, and 100% (95% CI, 83-100%) for MR cholangiography. The sensitivity of CT cholangiography and MR cholangiography was significantly higher than that of unenhanced helical CT (p<0.01). Differences in specificity were not significant. CONCLUSION. Our results indicate that oral contrast-enhanced CT cholangiography and MR cholangiography are significantly more sensitive than unenhanced helical CT for the detection of bile duct calculi.     

Ultrasonic cholangiography. Gray-scale B-scan evaluation of the common bile duct.

Gray-scale B-scanning permits evaluation of major portions of the bile ducts, especially those with significant dilatation. Injection of contrast material containing microscopic air bubbles through a T-tube with simultaneous ultrasonography detected multiple echoes filling in the previously echo-free area which represented the common bile duct, outlining both the duct and portions of the major tributaries. Reflections could be obtained from stones within the duct. Follow-up examinations after surgery could be used to demonstrate shrinkage of the duct. Jaundice due to extra- or intrahepatic obstruction was successfully differentiated noninvasively.     

Percutaneous transhepatic cholangiography with selective catheterization of the common bile duct.

Percutaneous transhepatic cholangiography was performed in 86 patients with juandice in whom the diagnosis could not be established by conventional means. Selective catheterization of the common bile duct was employed and cholangiograms of high quality were obtained. In cases of obstruction of the biliary passages, the catheter was left indwelling centrally in the biliary passages for external bile drainage. Thus immediate postcholangiogram surgery was not required in these patients. The procedure was successful in all 60 patients with obstructive jaundice. In 26 patients the possibility of obstruction was ruled out. Complications occurred in four patients but were not exclusively due to the procedure. The incidence of complications may be maintained at an acceptably low level if the technique is meticulously followed.     

Helical CT cholangiography with oral cholecystographic contrast material

Twenty asymptomatic volunteers underwent helical computed tomographic (CT) cholangiography 10-12 hours after ingesting iopanoic acid. Three observers assessed the images for the extent of bile duct visualization and image quality. The common bile duct and common hepatic duct were adequately visualized in 19 (95%) subjects. Helical CT cholangiography with oral cholecystographic contrast material is feasible and deserves further clinical studies.     

Rotational cine cholangiography: evaluation for use in diagnosing bile duct carcinoma.

OBJECTIVE: We evaluated the usefulness of rotational cine cholangiography in the preoperative diagnosis of bile duct carcinoma. SUBJECTS AND METHODS: Rotational cine cholangiography was performed in both the transverse and cephalad anterior oblique planes in 60 patients with obstructive jaundice. Using strict diagnostic criteria, the capability of this technique to detect the confluence of the right hepatic duct and the left hepatic duct, the right anterior segmental duct and the right posterior segmental duct, and the left medial segmental duct was investigated. The angle at which the confluence was revealed was also investigated. In 26 patients with resected bile duct carcinomas, the preoperative diagnosis of cancer spread obtained using this procedure was compared with the histopathologic findings. RESULTS: Overall detectabilities of the confluences of the right hepatic ducts and left hepatic ducts, the right anterior segmental ducts and right posterior segmental ducts, and the left medial segmental ducts were 97.6%, 87.0%, and 93.1%, respectively. The angles of the confluences of the right hepatic ducts and left hepatic ducts and of the right anterior segmental ducts and right posterior segmental ducts were widely distributed: on the other hand, those of the left medial segmental ducts were distributed mainly from 0 degrees to 20 degrees . The accuracies of diagnosis of cancer invasion were 91.7% in the common hepatic ducts, 100% in the right hepatic ducts, 91.7% in the left hepatic ducts, 100% in the right anterior segmental ducts, 83.3% in the right posterior segmental ducts, and 100% in the left medial segmental ducts. CONCLUSION: Rotational cine cholangiography is reliable not only in detecting the confluence of the bile ducts but also in diagnosing the longitudinal extent of cancer spread along the bile duct wall.     

Common bile duct obstruction: assessment by transcholecystic cholangiography

Percutaneous transcholecystic cholangiography was performed in 20 patients. Fifteen patients had normal-sized bile ducts on sonograms and computed tomographic scans, and five had partial common bile duct obstruction. Gallbladder pressures were measured in 14 patients. In all cases the intrahepatic and extrahepatic bile ducts were well visualized. Only one clinically significant complication, bile peritonitis, occurred, and it was relieved by inserting a cholecystostomy catheter. Techniques as well as the potential indications for transcholecystic cholangiography are discussed. The authors believe the transcholecystic approach is a useful alternative to transhepatic cholangiography.     

Double common bile duct: curved-planar reformatted computed tomography (CT) and gadobenate dimeglumine-enhanced MR cholangiography

We present the case of a 61-year-old female with double common bile duct (CBD) with an opening into the lesser curvature of the stomach. We discuss the role of curved-planar reformatted computed tomography (CT) and gadobenate dimeglumine (Gd-BOPTA)-enhanced T1-weighted MRI in confirming the diagnosis of this uncommon disease.     

Mangafodipir trisodium-enhanced magnetic resonance cholangiography for detection of bile leaks

PURPOSE: To assess the value of contrast-enhanced magnetic resonance cholangiography with Teslascan perfusion for the detection and localization of trauma-induced and postoperative bile leaks. MATERIALS AND METHODS: Between October 2002 and December 2004, 7 patients with suspected bile duct leaks after trauma (n = 2) or surgery (n = 5) requiring morphological evaluation were included. MRI examination included single shot fast spin- echo T2 weighted and gradient echo T1 weighted images prior to and 112 minutes in average after IV administration of mangafodipir trisodium. The results of contrast enhanced MR cholangiography were correlated to surgery (n = 3), clinical course (n = 3) and percutaneous drainage (n = 1). RESULTS: Mangafodipir trisodium-enhanced imaging showed extravasated Teslascan in collections in 6 patients (86%) whereas the combination of T2 weighted images and mangafodipir trisodium enhanced images revealed biliary collections in 7 patients (100%). The fistula between bile duct and collection was visualized in 4 patients (57%) before mangafodipir trisodium perfusion and in 3 patients (43%) after injection. In one patient the fistula was visible only after injection. Combination of both pre- and post injection MR correctly depicted the origin of bile leak in 5 cases (71%). CONCLUSION: Mangafodipir trisodium-enhanced magnetic resonance cholangiography is a non invasive technique that can successfully detect the presence of bile duct leaks. The combination of T2 weighted MR cholangiography and mangafodipir trisodium-enhanced T1 weighted MR cholangiography increases the sensitivity in detection and localization of the site of bile leak.     

术中胆道造影胆总管阻塞征象的研究

目的探索术中胆道造影中出现的假性胆总管阻塞征(简称假性阻塞)X线征象，减少误诊。材料与方法搜集整理200例术中胆道造影，其中男性72例女性128例，年龄为23～84岁，手术时胆囊切除经胆囊管注入造影剂，造影剂为60％胆影葡胺或12．5％碘化钠溶液10～20ml。结果本组出现假性阻塞55例占27．5％。X线表现常能鉴别假性阻塞与真性阻塞，假性阻塞表现为阻塞远端钝圆、有柔软感，而不象真性阻塞的远端有僵直感。如胆总管括约肌痉挛时，可向胆总管内注入1％普鲁卡因5ml，使痉挛缓解。结论熟悉术中胆道造影胆总管假性阻塞与真性阻塞X线征象十分重要否则会误诊。     

磁共振胆道造影在胆道梗阻定位和定性诊断中的价值

目的：通过ＭＲＩ胆道造影（ＭＲｃｈｏｌａｎｇｉｏｇｒａｐｈｙ，ＭＲＣ）与ＣＴ、ＵＳ、经皮穿刺胆道造影术（ＰＴＣ）或内窥镜逆行胰胆管造影术（ＥＲＣＰ）及手术、病理的对照研究，评价ＭＲＣ显示胆道梗阻部位，确定梗阻原因的能力。材料与方法：３０例梗阻性黄疸的患者在ＧＥＳｉｇｎａ１．５Ｔ超导系统上进行了ＭＲＣ检查，并与ＰＴＣ或ＥＲＣＰ、ＣＴ、ＵＳ、手术及病理对照。结果：本组资料中，ＭＲＣ显示胆道梗阻的部位准确性达１００％，优于有损伤性的ＰＴＣ或ＥＲＣＰ。ＭＲＣ确定梗阻原因的准确性达７０％，类似于ＰＴＣ或ＥＲＣＰ、ＣＴ、ＵＳ。结论：初步研究结果表明，无损伤性的ＭＲ胆道造影在梗阻性黄疸的定位和定性上具有很高的敏感性、准确性，对于梗阻性黄疸，特别是行ＥＲＣＰ失败和不宜行ＰＴＣ或ＥＲＣＰ的病人是最有效的替代方法。     

动态CT、内镜逆行胆管造影和MR胆管成像鉴别硬化性胆管炎合并自身免疫性胰腺炎与胆管周围浸润癌

目的比较硬化性胆管炎合并自身免疫性胰腺炎(SC-AIP)与胆总管周围浸润癌在动态CT、内镜逆行胆管造影(ERC)和MR胆管成像(MRC)中的表现,并评估ERC和MRC对这两种疾病的鉴别诊断效能。方法比较58例SC-AIP与93例胆总管周围浸润癌病人的动态CT、ERC、MRC所示的胆总管改变。两位放射医生分别对两种疾病鉴别的信心进行评分,比较ERC和MRC的诊断效能。结果在CT上,与胆总管周围浸润癌相比,SC-AIP更易累及胰腺内胆总管、胆总管壁较薄、向心性管壁增厚、外周边缘光滑、上游胆道扩张程度和强化程度均较低(P≤0.05)。在ERC和MRC中,与胆总管周围浸润癌相比,SC-AIP多表现为边缘光滑、渐进性和对称性狭窄、多部位受累和沙漏样表现(P≤0.027)。与ERC相比,MRC具有更好的诊断效能。结论动态CT、ERC和MRC有助于鉴别SC-AIP与胆总管周围浸润癌。MRC是替代ERC鉴别这两种疾病的有价值的方法。     

Detection of common bile duct stones before laparoscopic cholecystectomy. Evaluation with MR cholangiography

Purpose:
To assess the diagnostic value of MR cholangiography (MRC) for detecting common bile duct (CBD) stones in candidates for laparoscopic cholecystectomy (LC). Material and Methods:
A series of 95 selected patients with gallstones and suspected CBD lithiasis (abnormal serum liver tests and/or CBD size ≥6.5 mm at US) were referred to our institution for MRC, before LC. MRC was performed on a 0.5 T magnet through a non-breath-hold, respiratory-triggered, fat-suppressed, thin-slab, heavily T2-weighted fast spin-echo sequence and through a breath-hold, thick-slab, single-shot T2-weighted sequence in the coronal plane. Axial T1- and T2-weighted sequences were first obtained. Two observers in conference reviewed source images and maximum intensity projections to determine the presence or absence of choledocholithiasis. MR findings were compared with endoscopic retrograde cholangiography and intraoperative cholangiography (IOC); IOC was always performed during LC. Results:
CBD calculi (single or multiple) were identified in 41 out of 95 patients (43%). Two false-positive and 4 false-negative cases were found on MRC. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of MRC for choledocholithiasis were 90%, 96%, 94%, 95%, and 93%, respectively. Conclusion:
MRC is a highly effective diagnostic modality for evaluation of patients with risk factors for CBD stones prior to LC.     

经皮肝穿胆道造影术靶胆管定位穿刺方法的应用

目的 精确测定肝内扩张胆管位置.设计穿刺途径,提高经皮肝穿胆道造影术(PTC)成功率.方法 对73例恶性阻塞性黄疸患者进行PTC,其中30例采用经皮肝穿靶胆管定位方法穿刺为实验组,43例采用传统法为对照组.实验组:在CT或MRI片上,取肝内胆管扩张最明显的层面,选择外周直径合适,与预计针道走行方向呈锐角的肝内胆管分支为靶胆管,靶胆管中点作为穿刺进入点,测量穿刺进入点至背部体表的距离为h值,h值为确定穿刺层面的参考值;分别测量靶胆管两端至腹部(矢状面)正中线距离为a值和b值,(a-b)值为靶胆管体表投影区的参考值;穿刺点定在h值层面与右侧肋膈角下2个肋间隙肋骨上缘相交点,针尖对准靶胆管体表投影区进行水平穿刺.对照组:取右侧腋中线肋膈角下2个肋间隙(常为第8～10肋间隙肝脏中部)肋骨上缘为穿刺点,针尖指向胸10～胸12椎体之间进行水平穿刺,至接近椎体右缘2～6 cm处.结果 实验组穿刺次数为1～4次,共62次,每例平均2.07次,成功率为48.4%;对照组穿刺次数为1～9次,共186次,每例平均4.33次,成功率为23.1%;两组比较具有显著性差异(χ2=14.294,P<0.01).结论 经皮肝穿胆道造影术靶胆管定位穿刺准确测定可提高穿刺成功率,减少肝脏损伤等并发症,对PTC是一种有效方法.     

肝内胆管脓肿的CT诊断

目的 :探讨肝内胆管脓肿的CT诊断和鉴别诊断。方法 :回顾性分析经临床、病理证实的 2 7例肝内胆管脓肿患者的CT表现及临床资料。结果 :2 7例均可见肝脓肿及胆源性病变表现。肝脓肿CT平扫表现为低密度肿块 ,单发圆形(8例 )、多房或簇状 (9例 )或不规则多发 (10例 ) ,增强扫描示脓肿实质部分明显强化 ,呈“肿块缩小征”6例 ,“周围充血征”8例 ,“簇状征”9例 ,“环靶征”仅 4例。胆源性病变CT表现包括胆管扩张、胆管壁增厚并明显强化 ,胆道积气及胆道结石等。结论 :CT扫描可发现肝脓肿及胆道病变 ,是临床诊断肝内胆管脓肿最可靠的影像学方法。     

Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography

OBJECTIVE: The purpose of our study was to compare the accuracy of helical CT cholangiography and that of MR cholangiography in the diagnosis of aberrant bile ducts or cystic ducts before laparoscopic cholecystectomy. SUBJECTS AND METHODS: A total of 120 consecutive patients, including 114 patients with cholecystolithiasis and six with gallbladder polyps, were treated using laparoscopic cholecystectomy between November 1996 and August 1998. Eighteen (15%) of the 120 patients were suspected of having aberrant bile ducts or cystic ducts on helical CT cholangiography, and 16 of these 18 patients were subsequently examined on MR cholangiography. For the 16 patients who underwent both imaging examinations, findings from helical CT cholangiography and MR cholangiography were compared with intraoperative cholangiography. RESULTS: Aberrant bile ducts in 13 patients and aberrant cystic ducts in three patients were divided into six types on the basis of the results of intraoperative cholangiography. Although these types were clearly identified using helical CT cholangiography in all 16 patients, the anatomic variants were not correctly identified in seven (44%) of the 16 patients with MR cholangiography. False-negative findings were mainly a result of the insertion sites of the cystic ducts or aberrant bile ducts being obscured by aberrant bile ducts or duodenum. Two (2%) of the 120 patients developed mild adverse reactions to the contrast material, but neither required treatment. CONCLUSION: Helical CT cholangiography clearly showed aberrant bile ducts and cystic ducts, but visualization of these structures on MR cholangiography was unsatisfactory because of overlapping duodenum and hepatic ducts.