The evaluation of gallbladder function by quantitative radionuclide cholescintigraphy before and after ESWL for gallstones: Preliminary report

We assessed changes of gallbladder function including concentration and contraction in patients with gallstones after extracorporeal shock-wave lithotripsy (ESWL). The abilities of concentration and contraction were expressed as filling fraction (FF) at 90 min and ejection fraction (EF) at 30 min after a fatty diet by Tc-99m DISIDA Cholescintigraphy. A total of 12 patients who had symptomatic gallstones without cholecystitis were included in our study. ESWL failed in three cases: FF decreased in two of three cases and increased in one of three cases, whereas EF decreased in two of three cases and increased in one of three cases. In another nine cases, ESWL was successful and the gallstones were fragmented. One month after ESWL, in three of these nine cases, the gallstones had completely disappeared. In the three cases at 1 month after ESWL, FF decreased in two of three cases and increased in one of three cases, whereas EF decreased in one of three cases and increased in two of three cases. In the remaining six cases after ESWL, there were still some residual stone fragments in the gallbladder. In these six cases after 6 months, no fragments were found in the gallbladders, the third Tc-99m DISIDA Cholescintigraphy was performed. In these six cases, the changes of FF and EF, before ESWL, 1 month after ESWL, and 6 months after ESWL, were irregular and fluctuant. However, no significant improvement of gallbladder function was demonstrated even when ESWL was successful. In our preliminary results, we found that not only the residual stone fragments but also the procedure of ESWL may impair gallbladder function by evidence of a noninvasive and quantitative Tc-99m DISIDA Cholescintigraphy.     

Three-dimensional sonographic evaluation of gallbladder contractility: comparison with cholescintigraphy

PURPOSE: To compare three-dimensional sonography (3D US) with quantitative cholescintigraphy for assessing gallbladder contractility. METHODS: Gallbladder radioactivity was assessed in 35 patients with suspected gallbladder disease using a gamma camera 5, 30, 60, and 90 minutes after technetium 99m (Tc-99m) DISIDA injection and 30 and 60 minutes after ingestion of a high-fat meal. Immediate gallbladder images were obtained via 3D US. Gallbladder radioactivity at 120 minutes after injection of Tc-99m DISIDA was defined as 100%, and gallbladder contractility was calculated. Gallbladder volume on 3D US was calculated using a dedicated software. Pearson correlation analysis and simple linear regression analysis were used. RESULTS: The mean gallbladder volume on 3D US was 25.3 ml after fasting and 6.6 ml after a high-fat meal. The mean gallbladder contractility index was 77.7% on cholescintigraphy (range, 18-99) and 73.4 on 3D US (range, 16.7-97.3). A linear correlation between cholescintigraphy and 3D US contractility indices was observed. The r value on Pearson analysis was 0.92 and R(2) of the coefficient of determination was 0.85. The difference in measured contractility between the 2 methods ranged from +21.5% to -15.0% (mean +/- SD, 4.4 +/- 8.7%). CONCLUSIONS: 3D US is a reliable and easy method for clinical measurement of the volume of the gallbladder and its contractility.     

Gallbladder opacification 12–24 h after angiography by CT examination: a multivariate analysis

Background: To examine the incidence and predisposing factors of gallbladder opacification in delayed computed tomography (CT) after angiography. Methods: CT examination 12–24 h after angiography was performed in 389 patients. Univariate and multivariate analyses were made. Results: Two hundred thirty-three of 389 patients (60%) revealed gallbladder opacification. Type of contrast medium (P < 0.01), total bilirubin (P < 0.01), and serum creatinine (P < 0.01) were significant and independent factors relating to gallbladder opacification. Ioxaglate (70%, relative odds = 2.86) and iohexol (63%, relative odds = 2.03) showed higher gallbladder opacification rates than that of iopamidol (45%, relative odds = 1.43) and diatrizoate (30%). Patients with a lower serum bilirubin level (relative odds = 1.67) and a raised serum creatinine level (relative odds = 2.01) showed higher incidence of gallbladder opacification. Conclusion: Gallbladder opacification after angiography is not an abnormal finding on delayed CT in patients with not only abnormal renal function but also normal hepatobiliary and normal renal function, especially for modern contrast media. Received: 13 June 1995/Accepted: 22 July 1995     

Gallstone ileus: increased diagnostic sensitivity by combining plain film and ultrasound

Background: Gallstone ileus is an uncommon cause of mechanical obstruction. Its high mortality rate can be reduced with earlier diagnosis and treatment. We wanted to determine whether ultrasound (US) performed after plain film increases the sensitivity for the preoperative diagnosis. Methods: We performed a 5-year retrospective analysis of radiologic and sonographic results of 23 patients who had surgery because of gallstone ileus. Results: Rigler's triad was identified by plain abdominal film in two patients (9%) and by US in 16 patients (69%). Plain abdominal film contributed to a definitive diagnosis in four cases and to a probable diagnosis in six cases (sensitivities of 17% for definitive diagnoses and 43% for definitive and probable diagnoses). US confirmed the diagnosis in six cases of probable gallstone ileus and provided the diagnosis in seven of 13 patients without suspected gallstone ileus based on plain abdominal film. The best results were obtained by combining plain film and US findings, with sensitivities of 74% for definitive diagnoses and 96% for definitive plus probable diagnoses. Conclusion: The preoperative diagnosis of gallstone ileus significantly increases by combining plain film and US findings. Received: 7 July 2000/Revision accepted: 4 October 2000     

Xanthogranulomatous cholecystitis: a radiological study of 12 cases and a review of the literature

Background: Twelve cases of xanthogranulomatous cholecystitis (XGC) are presented, and their radiologic appearance is described. Methods: Four men and eight women, aged 31–82 years old, with XGC were reviewed. Abdominal ultrasound (US) was performed in all patients. Computed tomography (CT) was performed in five patients, barium enema examination in two, and percutaneously CT-guided fine-needle aspirative biopsy of the gallbladder in one. Results: Barium enema examination showed an indentation of the hepatic flexure. Cholelithiasis was present in all patients, and sludge was present in six. The gallbladder wall was thickened in all patients, irregular in nine, and could not be properly differentiated from surrounding liver parenchyma or from other adjacent structures in most patients. A curvilinear halo, hypoechoic on US and with low attenuation on CT, within the gallbladder wall was found in three patients and pericholecystic fluid in two others. On CT, the pericholecystic fat had streaky soft tissue densities in three cases. Percutaneously CT-guided fine-needle aspirative biopsy of the gallbladder was nondiagnostic. The diagnosis of gallbladder carcinoma was considered preoperatively in three patients. Conclusion: Despite the characteristic histologic appearance of XCG, radiologic findings are nonspecific, varying from signs observed in other forms of cholecystitis to the appearance of a gallbladder neoplasm. Received: 5 April 1995/Accepted: 15 May 1995     

CT imaging of biliary enteric fistula

Background: To define the signs useful for differentiating between gallbladder–enteric fistula (GB-EF) and common bile duct–enteric fistula (CBD-EF) on computed tomography (CT) because the prognosis and management of the two are different. Methods: CT scans in 13 patients with pneumobilia, who had not had surgical biliary–enteric anastomosis and endoscopic sphincterotomy, were reviewed. The presence of fistula itself, the location of air in the biliary system, and the appearance of the gallbladder were assessed. Results: The causes of pneumobilia were GB-EF in seven patients, CBD-EF in three patients, emphysematous cholecystitis (EC) in one patient, gallbladder cancer (GBC) in one patient, and incompetent sphincter of Oddi in one patient. In three of seven GB-EF patients (43%) and in none of the three CBD-EF patients (0%), the fistula itself was detected. Air was detected in the common bile duct in four of seven GB-EF (57%) and in all three CBD-EF (100%) patients, and GBC. In six of seven GB-EF (86%) and in one of three CBD-EF (33%) patients, the gallbladder was contracted. Thus, the location of air and the contraction of gallbladder were useful signs to differentiate GB-EF from CBD-EF. Conclusion: CT can distinguish between GB-EF and CBD-EF. Received: 17 December 1996/Accepted: 5 February 1997     

Role of99mTc-IDA cholescintigraphy in evaluating biliary tract disorders

Technetium-99m IDA cholescintigraphy has provided a new, noninvasive means of visualizing biliary tract function. It has become the procedure of choice in patients with suspected acute cholecystitis because of its ability to most accurately detect functional obstruction or patency of the cystic duct as opposed to ultrasound's ability to detect only anatomic changes such as the presence of calculi or a thickened gallbladder wall. These latter findings are more important in establishing the diagnosis of chronic cholecystitis where ultrasound shares a position of prime importance with the oral cholecystogram. Tc-99m IDA cholescintigraphy has also been particularly useful in evaluating bile leaks, biliary-enteric anastomosis patency and the post-cholecystectomy patient with recurrent pain. In the patient with cholestasis, ultrasound is usually the procedure of choice since it establishes whether or not ductal dilatation is present and frequently can determine the cause of obstruction. Cholescintigraphy has played an ancillary role in many cases by demonstrating the level of partial obstruction, but it does not have the anatomic resolution to visualize the cause of obstruction. Occasionally, in the evaluation of cholestasis, cholescintigraphy has proven to be the only modality which has identified the presence of acute common duct obstruction or localized intrahepatic ductal obstruction. All in all, Tc-99m IDA cholescintigraphy has had a dramatic impact upon hepatobiliary diagnosis.     

Cervical esophageal webs: association with gastroesophageal reflux

Background: We investigated whether there is a significant association between cervical esophageal webs and gastroesophageal reflux on pharyngoesophagography. Methods: We studied 50 patients with cervical esophageal webs on pharyngoesophagrams and 50 control subjects. The control group was matched to the webs group for age, sex, and symptomatology. Patients with cervical esophageal webs and controls were compared to determine the prevalence of gastroesophageal reflux, hiatal hernias, reflux esophagitis, and abnormal esophageal motility. Pearson's chi-square test was used to determine any statistically significant differences in the frequencies of these findings between groups. Results: Thirty-nine (78%) of 50 patients with cervical esophageal webs versus 27 (54%) of 50 patients in the control group had gastroesophageal reflux (p = 0.01). When patients were classified based on degree of gastroesophageal reflux, 22 (44%) of 50 patients with cervical esophageal webs versus 21 (42%) of 50 controls had mild reflux (p = 0.84), whereas 17 (34%) of 50 patients with webs versus six (12%) of 50 controls (p < 0.009) had moderate/marked reflux. Thus, the prevalence of moderate/marked gastroesophageal reflux was significantly greater in patients with webs than in the controls. However, no significant differences were found in the prevalence of mild gastroesophageal reflux, hiatal hernias, reflux esophagitis, or abnormal esophageal motility. Conclusion: We found a significant association between cervical esophageal webs and gastroesophageal reflux independent of age, sex, or symptomatology. Radiologists should be aware of this association, so that patients with cervical esophageal webs on pharyngoesophagography are evaluated for gastroesophageal reflux at the time of the barium study or advised to undergo further testing for gastroesophageal reflux disease. Received: 15 December 2000/Accepted: 24 January 2001     

Complications of “dropped” gallstones after laparoscopic cholecystectomy: technical considerations and imaging findings

New laparoscopic techniques have revolutionized the practice of surgery. Laparoscopic cholecystectomy has become one of the most commonly performed surgeries worldwide. Although shorter hospital stays and patient comfort have offered clear advantages over open cholecystectomy, the technique has resulted in several specific complications, including bile duct injury and gallbladder perforation. Although rarely clinically significant, intraperitoneal gallstone spillage can cause abscess formation and adhesions. Although these patients can present with a confusing clinical picture, their characteristic radiologic features should be recognized. We present two cases of complicated intraperitoneal gallstone spillage radiologically diagnosed and treated with laparoscopic and interventional radiologic techniques. Received: 13 April 1999/Accepted: 19 May 1999     

Impaired gallbladder and gastric motility and pathological gastro-oesophageal reflux in gallstone patients

Impaired gallbladder motility is common in gallstone patients and might be associated with other gastrointestinal defects. Twenty patients with small stones in an opacified gallbladder at oral cholecystography and 20 healthy subjects homogeneous for sex, age and body size were studied by ultrasonography to assess gallbladder and gastric emptying simultaneously in response to a standard liquid meal (120 kcal, 11 g fat, 200 mL). The same subjects underwent ambulatory 24-h gastro-oesophageal pH monitoring. Dyspeptic symptoms were specifically investigated using a questionnaire. Gallstone patients had a significantly larger fasting (P < 0.05) and residual (P < 0.005) gallbladder volume with slower (P < 0.05) and less complete (anova , 0.001 < P < 0.05) gastric emptying than healthy control subjects. The speed of antral emptying was significantly correlated with the speed of gallbladder emptying (n = 40, r = + 0.31, P < 0.05). Pathological gastro-oesophageal reflux was present in 75% and 15% of patients and control subjects respectively (P < 0.05). Overall, 95% of gallstone patients had abnormal pH profiles resulting from pathological gastro-oesophageal reflux and/or prolonged gastric alkalinization. The speed of post-prandial antral emptying was significantly correlated with the duration of the longest gastro-oesophageal reflux episode (r = + 0.30, P < 0.03) and duodeno-gastric reflux episode (r = + 0.80, P < 0.02). Best predictors for gastric alkalinization were the following indices of gallbladder function: large fasting volume (P = 0.03), large ejection volume (P = 0.009) and slower emptying (P = 0.032). Gallbladder and gastric motility were similar in patients with (n = 12) and without (n = 8) dyspeptic symptoms. Pathological gastro-oesophageal reflux was found in 83% of dyspeptic patients and in 25% of patients without dyspepsia (P < 0.01). When reflux was present, it was significantly less in asymptomatic than in dyspeptic patients [time at pH < 4, median (range): 6.4% (3.2–22.6%) vs. 47.8% (2.1–87%), P < 0.05]. This study shows that a subgroup of gallstone patients with small—mainly asymptomatic—stones have impaired gallbladder and gastric motility as well as abnormal gastro-oesophageal pH-profiles. These findings point to the existence of multiple functional defects of the upper gastrointestinal tract in gallstone disease.     

Abstracts of the European Association of Poisons Centres and Clinical Toxicologists XXII International Congress*

Abstract

Background: Taking Sauropus androgynus, a Malaysian food, to reduce weight began as a fad in Taiwan in 1994. Some advocates of this fad developed pulmonary dysfunction. The aim of this study is to report the lung injury in patients taking Sauropus androgynus. Methods: From July 1995 to November 1995, we investigated 104 nonsmoking patients (one male and 103 females) with chest roentgenography, pulmonary function test, and Technetium 99m-labeled diethylene triamine penta-acetate (Tc-99m DTPA) radioaerosol inhalation lung scintigraphy. Results: Among the 90 patients receiving Tc-99m DTPA inhalation lung scan, 46 (51.1%) patients had increased clearance of Tc-99m DTPA from lung and 20 (22.2%) patients had inhomogeneous deposition of the submicronic radioaerosol. Eighteen (18/100) patients had obstructive ventilatory impairment in pulmonary function test. Analyzing the results, we found that the patients with respiratory symptoms (n=42) took more vegetables (p=0.016, had increased clearance of Tc-99m DTPA (p=0.010) and had lower FEV, (p=0.001), FEV₁/FVC (p>0.001), FEF_25–75 (p=0.001), VC (p=0.002) and DL_co (p=0.009) than the patients without respiratory symptoms (n=62). FEV, and FEV₁/FVC were significantly reduced in patients with severe impairment of alveolar permeability. The cumulative dosage and duration of exposure were significantly associated with the reduction of FEV₁ and FEV₁/FVC     

Fascioliasis: US, CT, and MRI findings with new observations

Background: The purpose of this study is to describe the ultrasonographic (US), computed tomographic (CT), and magnetic resonance imaging (MRI) findings in fascioliasis and to emphasize the impact of radiology in diagnosis. Methods: Radiologic findings in 23 consecutive patients with fascioliasis were prospectively recorded. All patients had at least one US and CT examination, and 10 of them were studied by MRI. All diagnoses were confirmed by serologic methods. In the first three cases, initial diagnosis was reached by microscopic demonstration of the parasites' eggs in bile obtained by US-guided gallbladder aspiration. Results: In the hepatic phase of fascioliasis, multiple, confluent, linear, tractlike, hypodense, nonenhancing hepatic lesions were detected by CT. On US, the parasites could be clearly identified in the gallbladder or common bile duct as floating and nonshadowing echogenic particles. MRI showed the lesions as hypo- or isointense on T1-weighted images and as hyperintense on T2-weighted images. Conclusions: CT findings in the hepatic phase and US findings in the biliary phase are characteristic of fascioliasis. Because clinical and laboratory findings of fascioliasis may easily be confused with several diseases, radiologists should be familiar with the specific radiologic findings of the disease to shorten the usual long-lasting diagnostic process. Received: 15 December 1999/Accepted: 26 January 2000     

99mTc-EHIDA SPECT 30 min胆囊显像对内镜微创保胆手术治疗胆石症的指导价值

目的探讨~(99m)Tc-EHIDA SPECT 30 min胆囊显像对内镜微创保胆手术治疗胆石症的指导价值。方法回顾性分析因胆石症行胆囊~(99m)Tc-EHIDA SPECT显像的患者791例。其中,男388例,女403例,年龄(53.5±29.5)岁。对比分析~(99m)Tc-EHIDA SPECT 30 min胆囊显影结果与保胆治疗的情况。结果胆石症患者中,633例~(99m)Tc-EHIDA SPECT 30 min胆囊显影,提示胆囊管通畅,而158例患者~(99m)Tc-EHIDA SPECT 30 min胆囊未显影,提示胆囊功能异常。SPECT显示胆囊功能是否正常与保胆手术治疗胆石症之间的符合率为80.03%(633/791)。SPECT胆囊显影组与未显影组保胆率比较,差异有统计学意义(2=95.66,P=0.000),其优势比(OR)为7.91(95%CI:4.99～12.55)。结论~(99m)Tc-EHIDA SPECT 30 min胆囊显像是一种安全、快速、简便和非创伤性的检查方法,能够有效判断胆囊功能状态,对内镜微创保胆手术治疗胆石症有一定的指导作用。     

Dilatation of the cystic duct in patients with obstructive jaundice

Background: It is well known that obstructive jaundice causes biliary dilatation, but sonographic (US) findings of the cystic duct in patients with obstructive jaundice are rarely reported. Methods: We reviewed US findings in 25 such patients. Results: US findings of dilated cystic duct could be divided roughly into two patterns: tortuous and tubular. The former pattern was a tortuously dilated cystic duct arising from the gallbladder neck, running predominantly deeply, turning anteromedially, and then joining the posterior face of the common hepatic duct. The latter pattern was a straight dilated cystic duct running parallel with the common hepatic duct, giving the appearance of a septated bile duct. Conclusion: A better understanding of the US findings of dilated cystic duct translates into improved biliary US diagnosis.     

Gadopentetate dimeglumine as an oral negative gastrointestinal contrast agent for MRCP

Background: We investigated the feasibility of using intravenous magnetic resonance (MR) contrast agent as a gastrointestinal oral negative contrast agent to null the bowel signal during MR cholangiopancreatography (MRCP). Methods: In the first part of the study, a phantom study was performed to select the optimal concentration of MR contrast agent to be used as an oral negative contrast agent in MRCP. In the second part of the study, 23 consecutive patients suffering from different pancreaticobiliary diseases were imaged with a single-shot fast spin-echo pulse sequence. The data acquisition was started without oral contrast agent and then repeated with oral contrast agent. From the MR images taken with and without oral contrast agent, the gallbladder, cystic duct, common bile duct, and pancreatic duct were assessed and graded by two radiologists. Results: The oral contrast agent was tolerated well by all patients. In all patients the high signal intensity from the intestinal fluid was completely suppressed. The depictions of the gallbladder and cystic duct were slightly and moderately improved, respectively, whereas the depictions of the common bile duct and pancreatic duct were markedly improved by the oral contrast agent administration. Conclusion: Diluted intravenous MR contrast agent can be an effective and safe oral negative contrast agent in eliminating signal intensity of the gastrointestinal tract, thus improving the depiction of the biliary system in MRCP. Received: 14 September 1999/Revision accepted: 12 January 2000     

Ultrasound appearances of intra- and extrahepatic biliary ascariasis

Background: To determine the range of ultrasonographic (US) appearances of Ascaris lumbricoides roundworms in the biliary system, their distribution in the intra- and extrahepatic parts of the system, and associated features. Methods: All cases of biliary ascariasis during a 10-year period were reviewed. There were 42 cases in which diagnosis was based on established US criteria, and 2 cases diagnosed surgically in which US had been negative. These 44 cases occurred in 36 patients. Results: In the US-diagnosed cases, worms were present in intrahepatic ducts in 32 cases, in the main duct in 37, and in the gallbladder in eight. In six cases, the liver was lifted off the main portal vein by a bundle of worms obliterating the lumen of the main bile duct. Worms packing and dilating intrahepatic ducts produced pseudotumorous appearances in the liver in four cases and bundlelike appearances in three. Worms were also seen in the pancreatic duct in two cases. Stones in intrahepatic ducts were present in 12 patients. Conclusion: Biliary ascariasis should be searched for inside and outside the liver. The appearances of bundles and boluses are different from those of single worms. Intra- and extrahepatic biliary stones may be present. Received: 7/30/96/Accepted: 9/4/96     

NSAID injury to the small intestine

Purpose: To identify the clinical and radiologic findings in patients with diaphragm-like strictures in the small bowel. Patients and methods: We reviewed the histories, radiologic findings, and pathologic findings in two men and two women, all in their sixties, with a history of long-term nonsteroidal antiinflammatory drug (NSAID) or aspirin (ASA) usage and one or more radiologically demonstrated diaphragm-like strictures in the small bowel. Results: Two patients had long histories of NSAID usage, and two of ASA usage. One NSAID user had a long segment of jejunal involvement, and the other three had short segments of duodenal involvement. The ASA users presented with symptoms of esophageal disease, the small bowel lesions were unexpected, and ASA usage was not initially elicited. In one NSAID user and one ASA user, broader strictures with humps rather than diaphragms were also seen producing a lifesaver-like or bagel-like configuration. Conclusions: Multiple diaphragm-like strictures can occur in NSAID injury and are pathognomonic except in the rare patient with ulcerative enteritis complicating celiac disease. Single or few diaphragm-like strictures can occur in NSAID injury and peptic ulceration. ASA should be considered an NSAID with regard to small-bowel toxicity. A careful medication history is required when an unexplained small bowel abnormality is seen radiologically, and a dedicated small bowel examination is required when NSAID injury is suspected. Received: 9/16/96/Accepted: 10/30/96     

Changes in hepatic hemodynamics after orthotopic liver transplantation: color Doppler sonography

Background: Liver perfusion has an influence on therapy results in patients undergoing orthotopic liver transplantation (OLT). The objective of the present study was to investigate changes in hepatic hemodynamics in patients after OLT with color-coded Doppler sonography (CCDS). Methods: Forty-five consecutive patients were included. The examinations were done before, on postoperative day 1, and then weekly until the patients were discharged. Mean velocity of the portal (PV-V) and splenic (SV-V) veins and the maximum velocity and resistance index of the hepatic artery were determined. Results: After OLT a significant increase in PV-V and SV-V was observed. Twenty-five patients had normal perfusion of the hepatic artery, whereas 16 patients had abnormal flow patterns. In these patients prostaglandin I₂ was used until flow rates normalized. In four patients, CCDS could not detect perfusion of the hepatic artery. Conclusions: CCDS is a suitable method for evaluating hepatic hemodynamics before and after OLT. Changes in blood flow velocities in the liver-supplying vessels are detectable, but perfusion of the hepatic artery is seldom detectable. These observations are of special interest after OLT, where liver circulation has an influence on therapy results. Received: 12 January 2000/Accepted: 5 April 2000     

Retrograde cholangiography of malignant biliary strictures: spectrum of appearances and pitfalls

Abstract Purpose: To evaluate retrograde cholangiograms, ex~ plore the morphology of malignant biliary strictures, and determine if there are any features that may indicate a specific diagnosis. Materials and methods: The retrograde cholangiograms of 514 patients were reviewed. Cases with clinical fol~ low-up and subsequent studies indicating malignant in~ volvement of the biliary tree were identified. Fifty pa~ tients were found. Results: Carcinoma of the pancreatic head was the most common disease with 21 patients in this group. The morphology of the bile duct at the point of involvement was nonspecific comprising shouldered intrinsic ap~ pearing lesions as well as tapered in other cases. Pan~ creatic duct dilatation was a relatively specific finding occurring in 80% of this group. Other malignancies to involve the bile ducts included cholangiocarcinoma, metastases, ampullary carcinoma and gallbladder car~ cinoma. As with pancreatic carcinoma, the morphology of the lesion (e.g., shouldered versus tapered, length of stricture, severity of proximal dilatation) did not aid in the specific diagnosis of the pathology. Illustrative cases are presented where the morphology was unexpected for the eventual diagnosis (e.g., simulating intraluminal fill~ ing defects). Conclusion: The cholangiographic appearance of a bil~ iary stricture is usually not helpful in the specific diag~ nosis of the underlying etiology. Carcinoma of the pan~ creatic head may be suspected if pancreatic duct dilatation is also found. This article presents some un~ usual cholangiographic pitfalls that were identified, which initially distracted from the ultimate diagnosis. Received: 16 September 1996/Accepted: 30 October 1996