Gastrointest Radiol 16:49-52 (1991)
Gastrointestinal
Oral Cholecystography: Comparison of Conventional Screen-Film
with Photostimulable Imaging Plate Radiographs
Deep N. Srivastava, Akhilesh Kulshrestha, Ratni B. Gujral, and Rajendra V. Phadke
Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of MedicalSciences,Lucknow,India
Abstract. Oral cholecystography was performed on
ultrasonically proven cases of choMithiasis. The
conventional screen/film system and computed ra-
diography (CR) using the imaging plate were used
under practically identical conditions. The diag-
nostic accuracy of the two techniques was assessed
objectively, and the image quality was assessed
subjectively. The CR image proved to be better
than the conventional screen/film image, even with
the low-dose exposure. This paper describes our
experience in the area of the biliary tract system
with CR - a digital radiographic system using pho-
tostimulable phosphor.
Key words: Gallbladder, radiography - Computed
radiography, technique - Abdomen, imaging sys-
tems.
Diagnosis of biliary tract diseases has made a re-
markable progress following the recent develop-
ment of medical imaging techniques, such as ultra-
sound and computed tomography (CT). Sonogra-
phy, a noninvasive and simple procedure without
the risk of radiation, has become the method of
choice in biliary tract imaging. Despite the increas-
ing availability and popularity of ultrasound, oral
cholecystography still remains the most common
investigation for suspected diseases of the gall
bladder because of its reliability in detection of
gall stones and assessment of gallbladder function,
particularly when oral dissolution therapy is to be
started [1, 2]. Technological innovations have led
to development of new digital imaging systems in
medicine, but still conventional radiography main-
Address offprint requests to: Deep N. Srivastava, M.D., Depart-
ment of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute
of Medical Sciences,Lucknow-226001,India
Radiology
9 Springer-VerlagNewYorkInc.1991
tains a dominant position because a high-quality
radiographic image contains at least 4-6 mega-
bytes, whereas CT images contain 0.5 megabytes,
magnetic resonance imaging 0.3 megabytes, and
ultrasound only 0.07 megabytes [3]. A technologi-
cal difficulty to overcome is to eliminate such big
differences in the amount of recorded information
through the development of a practical digital ra-
diography to replace the analog x-ray film/screen
system [i.e., a computed radiography (CR)].
A number of studies have reported the applica-
tion of digital techniques to plain radiography
[4-7]. Because of the wide-exposure latitude (sys-
tem dynamic range) of the photostimulable imag-
ing plate technique, radiation dose to the patient
can be reduced by decreasing mAs levels compared
with those required for a conventional screen/film
combination. Due to the automatic sensitivity con-
trol, quality images of the same standard are pro-
duced which are comparable every time and re-
takes are avoided. In addition, digital radiographs
can be manipulated and postprocessing can be per-
formed to alter the enhancement of edges, contrast,
and brightness of the image.
A prospective evaluation of diagnostic accura-
cy and image quality of screen/film and the CR
system in oral cholecystography was undertaken
to compare the results.
Materials and Methods
Oral cholecystographywas performed on ultrasonicallyproven
cases of cholelithiasis.The conventionalscreen/filmsystemand
the CR systemwereused under practicallyidenticalconditions.
The study was conducted on a remote-controlledtable of Shi-
madzu unit (ZS-40)having provision of an imagingplate maga-
zine. This machine is specially designed for gastroenterology
work with conventional screen/film, as well as imaging plate
magazine for CR. The CR system used (model 901; Fuji) has
been describedin detail elsewhere[8]. Conventionalscreen/film
50
Fig. 1. Normal gallbladder opacified by oral cholecystography.
A Enhanced CR image obtained with a one-half exposure dose
is shown on the top, and the normally processed conventional
radiograph on the bottom. B Enhanced image with one-quarter
dose (top) as compared with conventional view.
Fig. 2. Gallbladder containing numerous radiolucent stones. A
Enhanced CR images at full exposure (top) as compared to
standard film (bottom). B Enhanced image at a one-half dose
exposure and its comparative radiograph (bottom row). C En-
hanced image at one-quarter exposure and its comparative ra-
diograph (bottom row).
radiography was performed by using a high-speed K Y O K K O
screen and double-coated polyester-based x-ray film, the expo-
sure conditions were a focal film distance (FFD) of 115 cm,
70-85 kV, and 140-160 mA. For CR the imaging plates were
used (instead of conventional screen/film) with the same, one
half, and one fourth the exposure dose. The radiation exposure
was reduced by decreasing the exposure time. Other parameters,
such as F F D and kV, were kept the same. Two images were
obtained which were set as appropriate in advance (left image
close to the conventional screen/film image and right image
with intensive image processing). Four parameters were taken
for evaluation of the gall bladder (e.g., wall, fundus, body,
neck, and gall stone). The image of each region was compared
with the conventional screen/film image and was graded on
a three-point scale. A CR image superior to the conventional
Table 1. Comparative evaluation of CR vs. conventional radiographs
Image quality grades Area of interest
Margins Fundus Body
Superior ( + ) 80% 77% 77%
Equivalent ( _ ) 6.6% 6.6% 6.6%
Inferior ( - ) 13.3% 16.6% 16.6%
D.N. Srivastava et al. : Computed Radiographic Imaging
screen/film image was graded (+), an equivalent image (+),
and an inferior image ( - ) . A few examples derived from our
clinical experience with the CR system are herein illustrated
(Figs. 1 and 2).
Results
The details of the observations are given in Ta-
bles 1 and 2. The quality of image was improved
in more than three quarter of the cases in CR as
compared to the conventional screen/film combi-
nation (Table 1). There was no loss in diagnostic
information by reducing the exposure time up to
one fourth; however, the noise (granularity) was
increased by reducing the exposure dose by more
than one half (Table 2). This increase in granular-
ity can be explained by the fact that in such low-
dose images, the granularity is mainly determined
by the quantum noise of the x-ray exposure.
In many of the cases the size and number of
stones were better appreciated on CR when com-
pared to the conventional screen/film system,
which may prove to be a helpful feature in evalua-
tion of patients who are on oral dissolution thera-
PY.
Neck Gall stone (number, size, outline)
83.3 % 80%
6.6% 16.6%
10% 3.3%
D.N. Srivastava et al. : Computed Radiographic Imaging
Table 2. Evaluation of CR images at different exposure doses
Exposure Same dose 1/2 dose 1/4 dose
Diagnostic Optimum Optimum Optimum
information
Image quality Optimum Optimum Reduced
Granularity Optimum Optimum Increased
Discussion
The basic concept of the CR system is to reduce
the exposure dose to a minimum; to provide rich
diagnostic information by producing consistently
sharp images that offer a wide latitude and allow
image processing; and to convert x-ray image in-
formation into digital signals to be stored for fu-
ture retrieval and distant transmission.
In Fig. 3 a generalized block diagram of the
CR system is shown. The basic x-ray image detec-
tor is the imaging plate, made by densely applying
crystals of phosphors on a support layer of a po-
lymer material. When exposed to x-rays, the energy
is temporarily stored within the crystals and emit-
ted as fluorescent blue light when an He-Ne laser
beam scanning light is irradiated on it. The optical
signals are then converted to time-serial electric
signals, and after A/D (analog to digital) conver-
sion, image processing, D/A (digital to analog)
conversion, and conversion to optical signals, an
x-ray image is recorded by a laser beam on a film.
The residual image can be erased from the imaging
plate allowing it to be used again and again.
The major image-processing techniques of CR
consist of gray-scale conversion and spatial-fre-
quency enhancement for the specified spatial-fre-
quency range. A CR processed by the image pro-
cessor is printed as a hard copy on a single-coated
transparent film by a high-resolution laser printer.
Two differently processed images obtained from
one x-ray exposure are printed on a single film.
We find it appropriate to process one image to
resemble the characteristic curve of a conventional
screen/film radiograph (normally processed im-
age), mainly by gradation conversion, and to pro-
cess the complementary image by gray-scale con-
version to expand the image contrast and its spa-
tial-frequency enhancement (enhanced image).
Normally processed images reflect the degree of
x-ray attenuation of the various tissues, but the
enhanced image allows better visualization of the
contour of the object. The image processor au-
tomatically selects the type of processing required
for a given examination. The type of image pro-
51
I X-RAY TUBE I
9
I PATIENT I
t
IMAGING PLATE
(re~ords an X-ray Image)
t
IMAGE READER
(Converts X-ray Image to electric signals)
t
IMAGE PROCESSOR
(does gradation and frequency processing)
t
IMAGE RECORDER ~ AUTOMATIC
(Converts electric signals to
light for film recording) 11 FILM PROCESSOR
Fig. 3. Generalized block diagram of CR system.
cessing may also be normally controlled by using
an image-processing console.
The major clinical merit of the CR system is
that it presents constantly clear images of high
quality; this was confirmed with respect to the gall
bladder in this study (Tables 1 and 2). Calcifica-
tions were shown clearly due to the wide dynamic
range and the image processing of the CR system.
However, the gall stones particularly at the base
of the gall bladder and in cases where the density
of the image of the contrast medium was low could
be more easily demonstrated. The images at one
half and one fourth of the normal exposure dose
were practically equivalent to conventional screen/
film images as a result of the high sensitivity.
Costs involved in digital imaging have not been
fully analyzed [9, 10]. The costs in CR system are
dependent upon the number of images that one
wishes to save as hard copy. The cost will be fur-
ther reduced because the number of repeated ex-
aminations can be dramatically reduced with the
use of the imaging plate technique. In a cost analy-
sis by Nudelman et al. of a photoelectronic digital
radiology department, it was predicated that, al-
though start-up costs are high, over time the
photoelectronic-digital systems promise to be sig-
nificantly less expensive than a film-based system
for long-term hospital use [11].
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Received: April 2, 1990; accepted: May 4, 1990