The Value of the Upright Position in Gall-Bladder Examinations

Abstract

SINCE 1928, various authors, particularly Sandström (8) and Åkerlund (1), in Sweden, and Bernstein (4) and Eliasz (6), in Germany, have recomended the x-ray examination of the gall bladder in the upright position. The credit for improvement of diagnosis and for the contribution of new physiologic data concerning the gall bladder is due mainly to these four men, but in only a few institutions has the examination of the gall bladder in the upright position become a routine procedure. It is my intention to demonstrate in this paper the value of this type of examination and to speak in behalf of its wider application. First, let me say a few words in regard to technic. It is not the best procedure to take x-rays of the gall bladder simply with the patient in the erect position, although this alone may yield interesting results in some cases. It is preferable to focus the gall bladder by fluoroscopic examination in order to obtain the most favorable angle and the most favorable degree of compression for the roentgenograph in the upright position. This type of examination can best be carried out by the use of the so-called “snapshot device,” which was originally designed for taking exposures of the gastro-intestinal tract. Before the improvement of diagnostic accuracy by this method of examination is demonstrated, some observations of normal cholecystograms will be discussed. If one looks at a cholecystogram of a normal gall bladder with the patient in the supine position, it usually appears to be of a fairly uniform density (Fig. 1-A). The same gall bladder in the upright position shows the fundus filled with a rather dense dye, while the upper half of the body of the gall bladder casts only a very faint shadow (Fig. 1-B). This observation indicates that the gall bladder must contain biles of different concentrations. Thus it is obvious that the rather hazy idea which we have concerning the contents of the gall bladder, namely, that liver bile flowing into the gall bladder most likely mixes with the concentrated bile already present in this organ, is erroneous. Figure 1-B shows that biles of various concentrations which do not mix can be present simultaneously within the gall bladder. This explains some observations of normal cholecystograms which were hitherto obscure. A young woman, who complained of indefinite discomfort in the right upper quadrant and who was suspected to have gall-bladder disease, did not show any definite gall-bladder shadow 14 hours after double oral dye. After the fatty meal, however, a dense gall-bladder shadow was easily visualized (Figs. 2-A and 2-B). It is only in the light of the previously discussed layer formation of bile that we can understand this peculiar phenomenon.