The intravenous cholangiographic diagnosis of partial obstruction of the common bile duct.

Abstract

IN AN ATTEMPT to evaluate the role of intravenous cholangiography in the diagnosis of partial obstruction of the common bile duct, to determine the relationship of common duct size to partial obstructions of the duct, and to establish criteria for roentgenographic diagnosis, we have reviewed our experiences of the past two and one-half years. Since a significant number of postcholecystectomy patients either exhibit the same symptoms as before operation or develop new symptoms, the problem is worthy of attention. The implications are: (a) that the gallbladder disease was not responsible for the precholecystectomy complaints, (b) that the surgical procedure was incomplete and should have gone beyond simple removal of the gallbladder and at times beyond removal of common duct calculi, or (c) that mechanical or inflammatory injury to the common bile duct may have taken place at the time of or shortly after cholecystectomy. Walters (1) in 1956, was of the opinion that the most frequent causes of pain after cholecystectomy are overlooked common duct calculi, stricture of the bile ducts, gallbladder remnants with or without stones, inflamed or calcareous elongated cystic duct remnants, malfunction of the sphincter of Oddi, pancreatitis, intra-abdominal ulcer or neoplasm and retroperitoneal lesions. It is well recognized that residual common duct calculi account for a high percentage of postcholecystectomy pain. Intravenous cholangiography has been most widely used in the search for these calculi. Meagher and Campbell (2), in a review of cholecystitis at Boston City Hospital from 1951 to 1953, found the incidence of comcommon duct calculi, mud, or sludge, to be 43.2 per cent in chronic cholecystitis and 30 per cent in acute cholecystitis. Colcock and McManus (3) and Adams and Stranahan (4) reported a total of 2,460 patients operated upon at the Lahey Clinic for gallbladder disease with an incidence of common duct calculi of 16.8 per cent between 1941 and 1945 and 10.4 per cent between 1950 and 1953, or an overall incidence of 13.3 per cent. In a review of 1,356 patients, Colcock and McManus found 5 with common duct calculi but no associated stones in the gallbladder. In a recent review of 153 cases of choledocholithiasis, followed for periods of two to twelve years, Johnston, Waugh, and Good (5) reported the occurrence of residual calculi in approximately 8 per cent. Snodgrass, quoted by Preston (6), remarked that the chief purpose of exploration of the common bile duct in most reported series has been to detect and remove stones. Such procedures, he believed, may be followed by the persistence of disabling postoperative symptoms when coexisting stenosis or fibrotic stricture at the sphincter of Oddi is overlooked or remains uncorrected. Thus, a good result could not be expected from cholecystectomy alone.