Although emphysematous cholecystitis may be diagnosed with the aid of plain radiography of the liver and upper abdomen,

computed tomography is helpful in confirming the diagnosis and describing the extent of the disease preoperatively (Poleynard and Harris). Also, as in the case of ultrasound, computed tomography with enhancement by the injection of meglumine diatri oate may show the gallbladder wall to be thic!ened and enlarged, and often there are associated stones responsible for the acute cholecystitis. "ertainly it is believed by #olomon and associates that computed tomography has a distinct place in the assessment of acute inflammation of the gallbladder. #imilar positive results were reported by Havrilla and co$wor!ers. "omputed tomography has also been found valuable in the diagnosis of gallbladder carcinoma (%ig. &'()) (*tai et al+ ,eh). -f ./ patients with gallbladder carcinoma studied by *tai and associates, the lesion was suggested in .0 computed tomographs. 1he gallbladder cancer was described as massive, thic!ened wall, or intraluminal+ .2 of their ./ cases were diagnosed correctly as cancer. 1here were misleading signs in 3. 1hey reported that some cases of chronic cholecystitis and liver tumor were difficult to differentiate from gallbladder cancer. 4i!ewise lymph node metastases and bile duct extension were difficult to distinguish. ,eh utili ed both ultrasonography and computed tomography for the diagnosis of carcinoma of the gallbladder, with ultrasonography being performed on 5& patients and computed tomography on /. %re6uently there were associated gallstones, dilated bile ducts, or metastatic lesions in the liver or retroperitoneal lymph nodes. 1he diagnosis was made or suggested by ultrasonography in 7&.0 per cent of the 5& patients, and the computed tomography corrfelated well with ultrasonographic features.

Pneumobilia 8as in the biliary tree may of course be well demonstrated by plain radiography, of the upper abdomen if the patient is !ept erect for approximately ( minutes. -n the other hand, computed tomography, ultrasound, and radionuclide scans have also been helpful and were studied in .( patients with biliary$enteric anastomoses by 8rant and associates. 1hese patients are also particularly fre6uently studied for metastatic disease. 1he demonstration of the metastatic disease is an important reason for utili ation of computed tomography and radionuclide scanning. 1here were no discrepancies in this study among radionuclide studies, computed tomography, and ultrasound diagnoses of liver metastases.

A good overview of this entire subject has been presented by 9reel.

Hepatic Contrast Agents for Computed Tomography #elt er and associates have made a special study to identify, design, synthesi e, and test new particulate contrast agents of high atomic numbers that might be useful for computed tomography. 1heir search was directed to substances that would be highly selective for the liver. 1hey utili ed suspensions of cerium, gadolinium, and dysprosium oxide, as well as silver iodide colloid. All four experimental agents were selectively concentrated in the reticuloendothelial system of rats and rabbits and produced greater and longer opacification of normal livers and large liver$to$tumor differences in rabbits with hepatic tumors. 4esions as small as ( mm were visible with computed tomography. *t is possible, however, that the toxicity of these agents as well as their long$term retention may limit their clinical utili ation.

Summary Although most investigators have a favorable early experience with computed tomography in the evaluation of the liver and biliary tract and suggest that it has a very promising future in replacing more invasive types of diagnostic procedures, the limitation of the various scanners and the display is still a great one. :odels of computed tomographs that are capable of reconstructing coronal or sagittal planes from contiguous cross$sectional data will probably improve the applications of computed tomography significantly. 1he exact role that computed tomography will ultimately play in diagnosis is yet to be demonstrated. *t is interesting that despite the disadvantage of ioni ing radiation a comparative study of diagnoses from computed tomographic and ultrasonic examinations of the abdomen in .) pediatric patients showed computed tomography to have a significant advantage over ultrasound in the differential diagnosis of abnormal cases. -f the .) cases, a correct diagnosis was possible by both modalities in all but 3 instances. %indings from each techni6ue considered separately would have resulted in erroneous diagnoses in & instances using computed tomography and ) using ultrasound alone. 1he . examinations, therefore, were considered complementary (;rasch et al).

Biliary Angiography (Deutsch; Farrell; Ruzicka and Rossi; Rosch; Redman and Reuter !"ig# 4-63) <isuali ation of the gallbladder by selective celiac and mesenteric angiography during selective aortography shows the normal gallbladder to have a wall thic!ness of . to 3 mm six to eight seconds after visuali ation of the cystic artery. "ontrast medium has to be directed into the hepatic artery for this to be shown.

$ormal %allbladder &easurements 1he normal measurements of the gallbladder were derived angiographically by =edman and =euter from .( normal gallbladders and are presented in 1able &$7. 1hey concluded that gallbladders measuring more than 3( s6 cm or those having a diameter of more than ( cm may be considered distended. -thers have been able to study the angiographic pattern of carcinoma of the gallbladder (>eutsch, ( cases), hydrops, empyema, and chronic cholecystitis. *t is thought that the angiographic demonstration of a dilated gallbladder should lead the physician to search for other abnormalities to explain its presence, particularly if there is obstructive jaundice present+ however, oral cholecystography, being a different examination, cannot be evaluated in this manner.

Figure 4-63. Cystic

artery variations. In A the solid vessel line indicates the most frequent site of origin of the cystic artery. The interrupted vessel lines show the more common variations. In B, the cystic artery arises from the right hepatic, which is a branch of the superior mesenteric artery. In C, three of the more common variations of double cystic arteries are shown. (From Ru ic!a FF "r, Rossi #$ Radiol Clin %orth &m '$()*+, ,+-../

Hepatic angiography was performed

following the percutaneous

transhepatic

catheteri ation of the hepatic vessels by Hoevels and ?ilsson. <ascular lesions of the liver were demonstrated in ./ of 73 patients. 1hese included aneurysm, hematoma, ar$ terioportal venous fistula, arteriohepatic venous fistula. ?o clinical complications were observed in .. of these ./ cases. -ne patient needed a blood transfusion. *n & patients with severe hemorrhage from an intrahepatic aneurysm, transcatheter emboli ation was performed. 1wo of their patients died within /. hours because of liver insufficiency.

Specific 'iseases of the Hepato( )0iliary)1allbladder 2ystem "H-4@4*1H*A#*# "holelithiasis is indeed a major medical problem. *t is estimated that in the Anited #tates alone, .2 million people have gallstones and each year (22,222 undergo cholecystectomy (#choenfield). *n patients with sic!le cell disease the incidence ranges from 52 to 3/ per cent and increases with age (Phillips and 8erald). *t is possible that this incidence is even greater in those with sic!le cell disease than has been previously reported (Phillips and 8erald). 1he clinical history and laboratory findings may be very nonspecific (probably 5( per cent). Another 32 per cent will probably have specific biliary symptoms, and some (2 per cent of patients will have gallstones at autopsy which escaped detection during their lifetime (9ey and Bechsler). Bhen clinical manifestations are present, the three basic symptoms are biliary colic, cholecystitis, and cholangitis. :any nonspecific symptoms are blamed on gallstones, which prove not related directly to gallstone disease, such as fatty food intolerance, dyspepsia, pyrosis, belching, and bloating. ;iliary colic is perhaps a misnomer, since actually it is a steady severe pain of sudden onset usually re6uiring a narcotic for relief, rising rapidly to a plateau, which remainsCsteady for .2 minutes to even three hours. Perhaps in about &2 per cent of cases these episodes last less than one hour. *t rarely waxes and wanes as the DcolicE would indicate. 1he patient moves about greatly with this pain unli!e other acute abdominal surgical episodes. 8enerally, this pain will subside in about three$ 6uarters of patients within three days or actually progress in one$6uarter

to perforation or gangrene of the gallbladder. Pathogenesis and Risk Factors (Coyne et al, a, b, c) 1here are three stages in the formation of gallstonesF (5) saturation of bile with cholesterol, (.) crystal formation and (3) aggregation of these crystals to form gallstones. 1he cholesterol in stage 5 is secreted by the liver and maintained in solution by the bile itself, bile acids, and lecithin, which are also secreted by the liver. 8enerally, patients with gallstones have a decreased amount of bile acid in comparison with normal controls (Hol bach). :oreover, patients with gallstones have decreased hepatic bile acid synthesis compared with normal subjects+ and patients with gallstones have a greater cholesterol secretion for a given amount of bile acid secretion than patients without gallstones (8runde et al). :oreover, there is an increased hepatic cholesterol synthesis in these patients. *n summary, then, the defect in gallstone patients seems to be (5) small bile acid pool with an inappropriately decreased rate of bile acid synthesis in the liver and (.) increased hepatic cholesterol synthesis and increased cholesterol secretion into the body. 1hese represent 72 per cent of the gallstones in the Anited #tates, the remainder being calcium bilirubinate. 1he incidence of gallstones is higher in women than in men (Holland and Heaton). -ral contraceptives increase the cholesterol saturation of bile in young women without gallstones (;ennion et al). Also certain racial groups, such as the American *ndians, have a higher incidence of cholesterol gallstones than the general population (#ampliner et al). -besity is another ris! factor. Also it has been shown that increasing dietary cholesterol increases the per cent of cholesterol in bile (>en;esten et al). How May Gallstones Be Diagnosed Radiographically

%ifteen per cent of gallstones contain sufficient calcium to be seen on plain films of the -ccasional gallstones are fractured and loosened, with a D:ercedes$;en sign.E -ral cholecystography

abdomen.

?onvisuali ation of the gallbladder occurs in about .( to 32 per cent at first examination. At least two$thirds of those who had non$opacified gallbladders with a first dose will have opacification with a second dose on the second day. *f the bilirubin is over 3 mg per 522

ml, it is unli!ely that the gallbladder will opacify under any circumstances.

Altrasonography may demonstrate the gallbladder in )2 to )( per cent of normal fasting

patients (>oust and :a!lad). 1he gallstone itself is echogenic, the gallbladder appears cystli!e around it, and there is a sonic shadowing effect beyond the gallstone because of the poor penetration of the sound waves through the gallstones.

*ntravenous cholangiographyF if the bilirubin level is over & mg per 522 ml it is very

unli!ely that the ductal system will opacify (#chol et al). 1omography is used routinely with intravenous cholangiography for optimum results. -ne may opacify the gallbladder with this technology, obtaining a film of the gallbladder in approximately & hours, but sometimes as late as .& hours.

"omputer assisted tomography. @ndoscopic retrograde cholangiopancreatography (@="P). #!inny needle transhepatic cholangiography (P1").

1hese methods have all been previously described in considerable detail. Anfortunately, biochemical evidence of pancreatitis often occurs following @="P, but this ordinarily lasts only for several days without incident. Ascending cholangitis with septic shoc! is a possible complication of both @="P and transhepatic cholangiography. ;leeding and bile peritonitis may be minimal with the latter procedure. 8enerally, transhepatic cholangiography is successful in a jaundiced patient about /( per cent of the time and in the nondilated duct only .( per cent of the time. 1he combined diagnostic accuracy of both procedures is about )3 per cent.

4aparoscopy may help differentiate a normal from an inflamed gallbladder. 1his may be helpful in the .2 per cent of jaundiced patients in whom differentiation between medical and surgical jaundice is otherwise difficult.

&edical 'issolution of %allstones 1reatment with

chenodeoxycholic acid

(">") induces desaturation of cholesterol saturated bile

in gallstone patients. Borldwide experience with about .222 patients suggests that 02 per cent of patients treated with ">" for between 0 months and . years will undergo complete dissolution of their gallstones ("oyne, 5)/0b). "alcified cholesterol gallstones or pigment gallstones do not respond. 1he side effects to ">" treatment are (a) diarrhea, which is dose

related, mild, and often transient+ (b) hyperlipide$ mia+ and as a result, (c) possible atherogenesis. Hepatotoxicity may be a major potential problem. 1ransaminase elevations have been noted in approximately .2 per cent of patients with ">".

!onoperati"e #reat$ent o% Co$$on D&ct 'tones T-tube extraction by iritroducing a special catheter under fluoroscopic control and a >ormier bas!et or %ogarty biliary catheter may be performed (;urhenne, 5)72). Endoscopic papillotomy is similar to @="P, but there is a thin wire connected to an electrosurgical unit which applies a coagulation current and pulling action. *t thereby transects the sphincter (precisely between 52 and 5. oGcloc! on the 302$degree scale to avoid injury to the pancreatic duct or retroperitoneal perforation). :ortality in &/. such cases reported by "lassen was 5.2 per cent or ( patients. -ther complications included hemorrhage (5( patients)+ perforation (55 patients)+ cholangitis () patients)+ and pancreatitis (/ patients). (perati"e Manage$ent o% Co$$on D&ct 'tones
5.

1he operative cholangiogram is by far the most accurate indicator of the presence of

ductal stones. A negative cholangiogram unfortunately will miss stones in approximately 5& per cent of cases (#hore et al, a, b, c).
..

@xploration of the common bile duct is mandatory for acute suppurative cholangitis or a "holedochotomy, if necessary, should be performed with a minimum of instrumentation

palpable stone in the duct.

3.

and manipulation. 1his may be done by an appropriate fiberoptic scope inserted at the time of operation. 1his type of fiberoptic scope may also be utili ed for visuali ation of the major hepatic duct as well. @xtraction of the stones is thereafter feasible. Chronic Cholecystitis and Cholelithiasis "hronic cholecystitis is usually associated with cholelithiasis and is characteri ed by fatty food intolerance, constant or intermittent postprandial epigastric or right upper 6uadrant

distress, belching, nausea, vomiting, and flatulence, with or without biliary colic. 1he gallbladder may show minimal to severe chronic inflammatory changes even to the point of calcification of the wall. 1he gallbladder wall is almost always thic!ened, and adhesions to adjacent structures may be present. 8allstones are present in )2 to )( per cent of the patients (Palayew+ #meets and -p den -rth). Perforation of the gallstone into adjacent bowel may lead to chronic cholecystoenteric fistula.

*n addition to the previous roentgen findings of radiopa6ue calculi and the D:ercedes$;en signE on plain films of the abdomen, there may be a soft tissue mass due to a distended gallbladder+ mil! of calcium bile in the gallbladder+ a calcified or DporcelainE gallbladder, which is always associated with cystic duct obstruction, and in these instances the calcium lies in the submucosa+ or gas in the gallbladder which is due to either infection or communication with the gastrointestinal tract.

;arium studies may be helpful in outlining a fistula between the gastrointestinal tract and the gallbladder+ and occasionally there is a pressure defect of the enlarged gallbladder on the duodenum or on the anterior portion of the hepatic flexure of the colon which has been called the DpadE sign (8hahremani and :eyers).

%A**B*A''+R A$' B,*,AR- ',S+AS+ ,$ R+*AT,.$ T. B./+* ',S+AS+ .ral Cholecystography in Patients 0ith Small Bo0el 'isease *n a study of 7& patients with proven small bowel disease who later underwent oral cholecystography (4ow$;eer et al) the gallbladder was visuali ed in )( per cent. #eventy$five per cent of the remaining nonvisuali ed gallbladders contained stones. 1he patients with small bowel disease were ( with "rohnGs disease who had good opacification of the gallbladder and &( with "rohnGs disease with ileal bypass or resection, . of whom had poor visuali ation of the gallbladder. 1he remaining patient with poor visuali ation of the gallbladder was an adult patient with celiac disease. *n another related study in patients with ileostomy (Hones et al, 5)/0), the prevalence of gallstones was studied in patients with ileostomies, who had undergone surgery for ulcerative colitis. 1here were (( patients in all, and 55 of these were found to have gallbladder disease. 1his is considerably higher than the number found in a control population in the same area. *n patients with cystic fibrosis of the pancreas or mucoviscidosis, pathologic findings in the liver and biliary tract are well !nown (=ovsing and #loth+ lGHeureux et al). *t is well !nown, for example, that the gallbladder may be hypoplastic and often has an obstructed cystic duct. 1here are numerous mucus$ containing cysts within the gallbladder in the submucosa, but inflammatory changes are notoriously absent. =ovsing and #loth carried out a study of the biliary tract in &5 patients with cystic fibrosis. 1here were changes in 5), consisting of a microgallbladder in 0 patients and no filling or only partial filling of the biliary ducts in 55 patients. 8allstones were present in one and were probably present in another. *n the study conducted by lGHeureux and associates, 7& consecutive patients with cystic fibrosis underwent oral cholecystography. 1his test was abnormal in &0.& per cent (3) of the patients). *n general, abnormality increased with age. 1here were .0 patients with a nonvisuali ed gallbladder following a se6uential two$dose oral cholecystographic techni6ue. 1en of their patients were found to have calculi, with an incidence of 55.) per cent.

*t may thus be concluded that mucoviscidosis and biliary tract andIor gallbladder disease of various types often coexist.

The Close Relationship of the Gallbladder to the Hepati Fle!ure in Relation to "nterpretation of #isease $Ghahre%ani and &e'ers(. #ince the gallbladder is so closely applied to superior medial aspect of the right flexure of the colon, there is provision for a direct extension of gallbladder inflammation or its involvement by neoplasm to the adjacent colon. *t has been emphasi ed that the resultant secondary colonic abnormalities may be noted and must be carefully analy ed to relate the disease to either primary biliary tract disease or colonic disease. Actually, in acute cholecystitis, barium enema examination may show evidence of mar!ed indentation by the enlarged gallbladder with spasm and mucosal edema in the colon. "hronic cholecystitis may result in involvement of the adjacent colon by fibrous adhesions and inflammatory reactions. 1his may further lead to a DpseudotumorE appearance in the colon resembling even a papillary lesion or primary carcinoma. "holecystocolic fistu$ lae may occur. 1his close relationship must be borne in mind in every instance in which the possibility of gallbladder disease andIor hepatic flexure disease may exist. Cholecystographic 'iagnoses 0ith *i1er 'isease 1hese findings have been to a great extent summari ed by Anton (5)/.)+ however, the cholan$ giographic findings in diseases of the liver at postmortem study were extensively reviewed by 4egge and associates. 1here is a considerable spectrum of changes found in the biliary ducts in association with cirrhosis of the liver, fatty infiltration, or lymphoma and also with extrinsic displacement and narrowness of the biliary ductal system with metastatic deposits. 1he intrahepatic bile ducts are normal in si e in many diseases of the liver, including infiltrative diseases and cirrhosis and when there are small tumor nodules. "hanges in the liver very often result not only from fibrosis and collapse but also from regeneration or increase in hepatic mass, as occurs with a diffuse infiltration in metastatic tumors. #uch changes should indeed be readily differentiated if these patients might be subjected to transhepatic or 1$tube

cholangiography. 1hey are !nown to exist with primary carcinoma of the bile ducts, sclerosing cholangitis, cholangitic hepatitis, and large metas$ tases. =adiographically the clue should be displacement of thf biliary radicles, if one is familiar with the exact anatomy of the liver as it should be portrayed, as well as increased narrowness of the biliary tree following injection. 1he bile duct has also been carefully studied in association with chronic pancreatitis and with sclerosing cholangitis (Bells et al). Cholecystographic 'iagnoses /ith Pancreatic 'isorders Bith chronic inflammatory disease of the pancreas, @="P examinations will demonstrate not only abnormalities of the pancreatic duct but associated changes in the common bile duct in perhaps as many as && per cent of the patients, suggesting an abnormality perhaps even of the sclerosing cholangitic variety (Bells et al). Sclerosing Cholangitis #clerosing cholangitis is a rare disorder characteri ed by nonspecific inflammatory fibrosis in the submucosa of the biliary tree. 1his may lead to progressive obstructive jaundice. *t is often associated with another disease, such as ulcerative colitis, "rohnGs disease, retroperitoneal fibrosis, carcinoma of the pancreas, =iedelGs thyroiditis, or orbital pseudotumor. 1he @="P examination or operative cho$ langiogram will usually demonstrate a variation in caliber of the biliary tree due to areas of smooth narrowness and a tendency toward beading. Altimately, the changes include multiple strictures and a Dpruned$treeE appearance. 1hese changes may be generali ed or patchy. 1he findings may indeed be confused with a sclerosing cholangiocarcinoma, infective cholangitis, primary biliary cirrhosis, post$ surgical or traumatic strictures, and impressions on the intrahepatic duct by multiple hepatic space$ occupying lesions, particularly metastases. -ne must recall the associated diseases, particularly when the diagnosis of sclerosing cholangitis is suggested. Congenital Biliary Atresia -ne must recall that congenital biliary atresia is one of the diseases of infancy with a high incidence of cervical herniation of the lung and bone changes suggestive of ric!ets. At times there is a definite generali ed deminerali ation of the bones and metaphysial abnormalities with

fractures at the me$ taphyses. 1here is no good correlation, however, between the bony changes and the liver dysfunction+ and it certainly does not universally occur (7 out of 37 cases in a series reported by 9atayama et al). Aberrant ,nsertion of the Common Bile 'uct Among abnormalities of the common bile duct that may be visuali ed by cholangiography, aberrant insertion of the common bile duct, particularly into a duodenal diverticulum, must be !ept in mind. 1his is often associated with biliary and pancreatic disease and can be surgically relieved (=ose). Choledochal Cysts 1his is a rare malformation of the biliary ductal system and is usually considered an anomaly. *t is sometimes associated with a clinical complex that includes jaundice or a history suggestive of intermittent jaundice. At times a mass is palpable, particularly in the infant. <arieties of choledochal cysts have been illustrated (%ig. &$(/). AC2T+ CH.*+C-ST,T,S Acute cholecystitis varies considerably in its clinical manifestations from mild transient episodes of upper abdominal pain to intense prolonged epigastric intermittent colic!y pain. @arly effective treatment is essential. 1here is some variation, however, as to the imaging techni6ue that gives one the best corroboration of diagnosis. #ome would obtain an intravenous cholangiogram or oral cholecysto$ gram if the patient has not had previous biliary studies or substantiated evidence of biliary disease (Hermann). *nfusion tomography of the gallbladder has strongly been suggested (9at berg et al). *n many instances a gallbladder wall visuali ation with a somewhat Dfu y appearanceE is demonstrable by either tomography of the right upper 6uadrant or even excretory urography. @ven gallstone formation around metallic foreign bodies has been described as an unusual cause of acute cholecystitis (#anows!i and Arbaje$=amire ). -thers report that radionuclide studies of the gallbladder and liver are strongly indicated in these suspected patients (#haffer et al). "holescintigraphy may assess the dynamic events associated with gallbladder filling and

emptying very accurately, particularly when the radionuclide ))mtechnetium H*> A (iminodiacetic acid) is utili ed. *n these instances the radionuclide is excreted in the bile and not only visuali ed by an Anger camera but also programmed for data processing of changes in time with respect to activity in the liver, biliary ductal system, gallbladder, small intestine, and stomach. 1he first 02 minutes are used to detect filling of the gallbladder. "holecysto!inin may then be infused at 2.2.2 AI!gIminute for 32 minutes to initiate gallbladder contraction, while the passage of the radionuclide into the small intestine andIor stomach is monitored. 1he stomach region may be defined with scintigraphy utili ing the radionuclide ))mtechnetium$sulfur colloid. *n this manner, the rate at which the gallbladder is filled, the fraction of liver activity that partitions into the gallbladder instead of the duodenum, and the rate of gallbladder emptying as well as duodenogastric reflux may be recorded. 1here may be approximately a ($minute time lag between gallbladder emptying and the injection of the cholecysto!inin. 8allbladder evacuation is definitely slower in patients with cholelithiasis, although filling may appear rather normal. *n an update on radionuclide imaging in hepatobiliary disease (=osenthall, 5)/7) this technology was emphasi ed once again. *ndeed, it is claimed that the introduction of
))m

technetium$labeled .,0$ dimethylacetanilide iminodiacetic acid (H*>A) significantly assists

the clinical study of bile flow. ;asically this radionuclide complex is metaboli ed by the hepatocyte and excreted into the biliary tract. *n the presence of liver failure a greater amount of the radionuclide is excreted by the !idney. 1his entire methodology is reviewed by =osenthall, and it is outside the scope of this text, except to mention that this is a very important technology to utili e particularly in the presence of acute cholecystitis. Bhen the gallbladder fills, one may postulate that a patent cystic duct exists. 1his effectively excludes the possibility of an acute cholecystitis, since the precipitating cause of acute cholecystitis is obstruction of the cystic duct in about )7 per cent of the cases. %alse negatives rarely occur in the presence of acalculous cholecystitis, wherein the gallbladder is indeed visuali ed+ but if this is suspected, a slow infusion of cholecysto!inin will demonstrate a failure of normal contraction of the gallbladder. 1herefore, it should be stressed that with this radionuclide techni6ue, nonvisuali ation of the gallbladder implies cholecystitis but not necessarily acute cholecystitis. ?onvisuali ation may also occur with chronic cholecystitis. 1he exact reason for this is not !nown. =osenthall claimed that this radionuclide techni6ue is superior to oral cholecystography and intravenous cholangiography, particularly in patients with acute manifestations of hepatobiliary disease,

since the patency of the cystic duct can be demonstrated in the presence of jaundice and no pharmacologic ha ard exists. :oreover, the study is completed within 02 minutes, and gas and fecal material do not hinder accurate interpretation. :oreover, by other techni6ues it is very difficult to exclude the possibility of acute pancreatitis+ however, the radionuclide study shows all normal gallbladders even in the presence of acute pancreatitis, especially if there is no associated or coincident chronic cholecystitis. Anfortunately, the radionuclide techni6ues do not disclose cholelithiasis unless the stones are large, because the resolution with the gamma camera is insufficient for this purpose. Hence, oral cholecystography, ultrasound, or intravenous cholangiography may be used for these other purposes. -ther uses of this scintigraphic techni6ue are (5) the assessment of cholangiointestinal anastomoses in gastroenterostomies and (.) the differential diagnosis of jaundice. -ther investigators have substantiated these findings (Pare et al, 5)/7+ Beissman et al, 5)/), 5)75).

%rading of Se1erity of Chronic Cholecystitis by 2tilization of .ral Cholecystography

(Owen et

al))

An effort has been made to grade the severity of chronic cholecystitis by the

image density at oral cholecystography by comparison of the densities obtained and the study of the resulting cholecystectomy specimens. -wen and associates have indicated in their study that there is a linear relationship between the gallbladder opacification and the grade of chronic cholecystitis+ that the occurrence of gallstones is independent of the degree of gallbladder opacification+ and that the presence of gallstones does not correlate with the severity of chronic cholecystitis. 1hey have suggested strongly that oral cholecystographic techni6ues be standardi ed, so that uniform grading of the severity of chronic cholecystitis by the gallbladder image density could be employed.

B+$,%$ T2&.RS A$' PS+2'.T2&.RS ." TH+ %A**B*A''+R (Table 4-9) "hristensen and *sha! have studied benign tumors and pseudotumors of the gallbladder at considerable length, reporting on 572 cases. 1hey subdivided these into .& cases of polyps

consisting of 3 inflammatory and .5 cholesterol polyps and )5 cases of hyperplasia, most of which were adenomyoma$ tosis. 1hese patients were very carefully studied in relation to their age, sex, and race, as well as symptomatology, and the literature was reviewed. -n the basis of these studies, these authors recommended a simplified classification of benign tumors and pseudotumors of the gallbladder, as shown in 1able &$). RA',.*.%- ." CH.*+C-ST+CT.&- C.&P*,CAT,.$S =adiographic studies may be valuable in suggesting or confirming a diagnosis postoperatively following cholecystectomy even when other clinical findings may not be evident. Plain films, contrast studies, ultrasound, and computed tomography are all useful modalities in this area (4ove et al). #ome of the entities to be considered are incisional hernias and infection, which probably constitute the most important problems+ damage to the common bile duct, producing either jaundice or fistula+ problems in relation to the retained cystic duct stump, where there is a higher incidence of biliary distress, gallstones, adhesions, inflammatory changes and even neuromas (an elongated cystic duct remnant is found in nearly /2 per cent of severe postcholecystectomy complaints)+ drainage tube problems+ retained stones within the ductal system+ hepatic artery injuries, particularly when it is not clearly identified at operation, leading to inadvertent ligation+ sub$ hepatic accumulations of fluid, probably the most fre6uent complication following biliary tract surgery after which it occurs in ( to 0 per cent of cases+ pancreatitis+ and various bowel complications, which are probably the rarest of the complications. 1here may be inadvertent damage to the hepatic flexure or the duodenum particularly. 1he reader is referred to a comprehensive study of these various complications by 4ove and associates. $e0 Trends ,n %allbladder Imaging !Simeone and "errucci Although a great deal of emphasis is still placed upon oral cholecystography, recent progress with respect to gray$scale ultrasound, including real$time scanning, has made remar!able inroads in the diagnosis of the entire spectrum of gallbladder disease. As noted previously, gallstones are readily detected by ultrasonography. "alculi are displayed as echogenic foci with a DshadowingE effect almost universally (Hublit et al). 1he

predictive accuracy of cholelithiasis when a shadowing effect is produced is somewhere between )( and )7 per cent even with millimeter$si ed calculi. Bith the nonvisuali ed gall$ bladder by oral cholecystography, the predictive accuracy of the presence of cholelithiasis with ultrasonography is on the order of )2 per cent. *n some instances, there is no shadowing effect by the gallstone, and under these circumstances the predictive accuracy is estimated at 72 per cent. #ludge or mil! of calcium bile (not the same entity) in the gallbladder is visuali ed with an accuracy of somewhere between 2 and ( per cent. 1he various patterns may be typified as followsF At times the gallstone may be visuali ed as an acoustic shadow that moves with gravity. A shadowing effect is present in most instances. -ccasionally a similar shadowing effect may be produced by sound refraction artifacts or poc!ets of bowel gas (#ommer et al+ 1aylor et al, 5)/)). *n another pattern the gallbladder itself may not be visuali ed, but a gallstone may be seen as well as its shadowing effect. *n a third pattern the gallstone and gallbladder are not visuali ed. *n these instances the gallbladder lumen may be obliterated by varying combinations of calculi and fibrotic scarring. Bhen there is nonvisuali ation by ultrasonography of either a gallstone or the gallbladder, the differential diagnosis must include chronic cholecystitis+ gallbladder carcinoma+ obstruction of the biliary tree proximal to the cystic duct+ and congenital absence of the gallbladder. Bhen nonshadowing focal opacities within the gallbladder are recogni ed, the differential diagnosis must include cholesterol crystals, polyps, mucin plugs, blood clots, or pus. A fluid level may at times be demonstrable with sludge or viscous bile, but the li!elihood of discrete calculi in conjunction with this is very small. 1hic!ening of the gallbladder wall may also be demonstrated by ultrasound, and this has a high correlation with surgically proven acute and chronic cholecystitis (#anders). However, caution must be exercised in the interpretation of gallbladder wall thic!ness when ascites is present or when the patient has not been fasting. A very thin sonolucent pericholecystic fluid accumulation may occur with acute cholecystitis (:archal et al). 1he sensitivity of this particular sign is yet to be proved. Pericholecystic abscess, carcinoma of the gallbladder, and papilloma of the gallbladder, which indeed were rarely diagnosed preoperatively (except for the latter), can now be identified by ultrasound, although their sonographic appearances are often very similar. At times there is a

prominent rimli!e halo or mass surrounding the gallbladder with an abscess. At times a mass may be identified even surrounding the gallbladder. Ander these circumstances, when this represents a gallbladder carcinoma, it may be differentiated from an abscess by the presence of dilated bile ducts or hepatic metastatic lesions. Bith regard to the radionuclide imaging procedures (Harvey et al)
))m

technetium lidofenin

())mtechnetium$labeled$dirnethylacetanilide iminodiacetic acid) is now widely employed. *t is particularly advantageous in patients with acute right upper 6uadrant pain suspected of having acute cholecystitis. 1he imaging agent (abbreviated JKJtechnetium H*>A) is actively ta!en up by the liver cells and within one hour is excreted unchanged into the biliary system and bowel. ?ormally, liver activity pea!s within ( to 52 minutes+ the common bile duct, gallbladder, and duodenum are usually visuali ed in 5( to 32 minutes. Bhen the gallbladder is not visuali ed, cystic duct obstruction may be postulated. *n general, visuali ation of the gallbladder establishes patency of the cystic duct and excludes the diagnosis of acute cholecystitis with an accuracy exceeding )2 per cent and. probably on the order of )( per cent. ?onvisuali ation of the gallbladder with visuali ation of the common bile duct may then be seen. Bhen cholescintigraphy, ultrasonography, and contrast cholangiography are compared, it is probable that cholescintigraphy is the most sensitive to active cholecystitis. "holangiography and ultrasound visuali e gallstones. However, cholescintigraphy is not specific when the bilirubin level exceeds ( mg per dl (=osenthall et al). -ccasionally, nonvisuali ation by scintigraphic techni6ues results from chronic cholecystitis, but generally patients with chronic right upper 6uadrant symptoms are more effectively investigated by oral cholecystography and ultrasound. 1hus,
in summary,

the complementary nature of oral cholecystography, ultrasonography, and

cholescintigraphy may be emphasi ed. Although oral cholecystography is still preferred as the screening techni6ue for detection )f cholelithiasis, there has been a steady improvement in ultrasonography for this purpose, and very li!ely ultrasonography should be used immediately following oral cholecystography if the former fails to visuali e the gallbladder. Anfortunately, 5$mm to .$mm calculi are not seen by oral cholecystography and yet are routinely displayed by ultrasonography. :oreover, in the presence of pregnancy, or a history of allergy to oral cholecystographic media, suspected acute cholecystitis, hepatic dysfunction, and right upper 6uadrant pain

syndromes, ultrasonography or cholescintigraphy may well be the initial examinations. *oni ing radiation is, of course, to be avoided in the presence of pregnancy if possible. ?eedless to say, there are disadvantages to the ultrasonographic examination, such as interference by bowel gas and barium and failure of reflection of the physiological function of the liver. @mpyema of the gallbladder presents a complication in the natural history of acute cholecystitis (%ry et al). *t is believed by %ry and associates that probably approximately 55 per cent of patients, usually men, undergoing cholecystectomy may be found to have empyema of the gallbladder. 1he operative findings may include perforation of the gallbladder and extrabiliary abscesses. *t will be recalled that empyema of the gallbladder gives roentgen evidence of a halo around the gallbladder by conventional radiography in many instances.