Bile Aspiration Research Articles

Treatment of acute cholecistitis by direct-puncture bile aspiration with ultrasound-image control

Treatment of acute cholecistitis by direct-puncture bile aspiration with ultrasound-image control

Bedside Method for Placing Small Bowel Feeding Tubes in Critically III Patients: A Prospective Study

Enteral delivery of nutrients is important for optimal treatment of critically ill patients. It maintains gut digestive and barrier functions, decreases gut bacterial translocation, decreases the incidence of sepsis, and improves outcome. Gastric emptying is impaired in many critically ill patients and feeding into a gastroparetic stomach leads to large gastric residuals and aspiration. We describe a simple bedside technique for placement of small bowel feeding tubes. Using this technique, we successfully placed 213/231 (92 percent) of feeding tubes in critically ill patients. Three percent were in the first portion of the duodenum, 25 percent in the second portion, 47 percent in the third portion, and 17 percent in the proximal jejunum. The average time for placement of small bowel feeding tubes was 40 +/- 14 min (mean +/- SD). Abdominal roentgenograms failed to properly locate 13 (6 percent) tubes. The most accurate and cheapest methods for confirming small bowel location of feeding tubes were bile aspiration, pH change from acidic to basic, and blue dye injection.

Percutaneous interventional gallbladder procedures: Personal experience and literature review

Our experience with 58 percutaneous gallbladder procedures in 48 patients are discussed. Diagnostic procedures consisted of needle aspiration of bile (n = 5) to evaluate the gallbladder as a source of infections and transcholecystic cholangiography (TCC) (n = 32) for bile duct visualization. Percutaneous cholecystostomy (PC) (n = 21) was performed for gallbladder or bile duct decompression or stone dissolution. Ultrasound and/or fluoroscopic guidance were used, and the procedures were successful in all but one patient. The overall complication rate was 13.8% (8/58 procedures) but only 5.2% were considered serious (three instances of bile peritonitis). No vasovagal reactions or hemorrhage occurred. We also reviewed the complications in 231 cases of PC that have been reported in the English literature. The overall complication rate was 7.8%, and the most significant problems were death (n = 1), peritonitis (n = 3), and severe vasovagal reactions (n = 4).

Comparison of gall bladder bile and endoscopically obtained duodenal bile.

In 10 patients with gall stone disease (eight women, two men; mean (SD) age 47.4 (13) years), bile was obtained by endoscopic aspiration after stimulation of the gall bladder with ceruletid and also by fine needle puncture of the gall bladder under local anaesthetic. The total lipid concentration of the puncture bile samples was mean (SD) 11.9 (4.7) g/dl, significantly higher than the endoscopic bile samples (3.9 (3.3) g/dl, p less than 0.001). Total bile acids, phospholipids, and biliary cholesterol (expressed in mol%) and cholesterol saturation index showed no significant differences between the two types of samples. The glycocholic acid concentration in the endoscopically obtained bile (27.7 (6.6) mol% v 23.3 (5.4) mol%; p less than 0.01) was significantly higher than the puncture bile samples. Puncture bile exhibited a significantly shorter nucleation time (3.5 (3.3) days v 19.6 (11.9) days; p less than 0.001). For determination of the nucleation time, endoscopic bile aspiration after gall bladder stimulation with ceruletid led to adequately concentrated samples in 50% of the study subjects. Cholesterol monohydrate crystal formation in native bile was observed in six samples of puncture bile and in three samples of the endoscopically obtained bile. The presence of cholesterol crystals and the determination of nucleation time in the puncture bile were the best discriminants between cholesterol and pigment gall stones and correlated well with computed tomogram analysis.

The Double Contrast Method by Endoscopic Transpapillary Catheterization in the Gallbladder

Abstract: Endoscopic transpapillary catheterization in the gallbladder was attempted in 18 cases and double contrast images of the gallbladder was successfully obtained in 10 cases. In a case with a polypoid lesion, its edge and surface were nicely delineated by this method, but it was still hard to distinguish it from malignant lesions. Precise identification of tiny stones which will be easily missed by conventional ERC was made using this method. As for technology obtaining good cholecystgrams, sufficient aspiration of bile was considered to be important. Our experience with this quite new technique suggested that this method is effective in making an accurate diagnosis of gallbladder diseases. We named it double contrast images of the gallbladder by endoscopic transpapillary catheterization in the gallbladder (ETCG).

Nasobiliary Drainage

Placement of nasobiliary tubes has now become a widely accepted method for therapeutic drainage and instillation of solvents into the biliary tree. The author routinely uses a 300 cm long, 7 or 10 French, specially performed Teflon catheter, which adapts to the anatomy of the duodenum and bile ducts, for the following indications: decompression of obstructed bile duct in acute suppurative cholangitis; prevention of stone impaction after endoscopic sphincterotomy; sequential cholangiography; biliary fistula; instillation of solvents for common bile duct scones; local radiotherapy of biliary malignancies; aspiration of bile for chemical and bacteriological studies; and drainage of pancreatic pseudocysts. Pancreatic or biliary drains should supplement traditional diagnostic and therapeutic modalities in patients with surgical or medical lesions of the pancreas and biliary tree.

Acute cholecystitis: diagnostic accuracy of percutaneous aspiration of the gallbladder.

Results of gallbladder bile aspiration and culture were correlated with presence or absence of acute cholecystitis in 36 patients to test the role of these procedures in hospitalized patients with sepsis. Diagnostic aspiration of the gallbladder was performed in 11 patients, and in the remaining patients a combination of percutaneous aspiration, percutaneous cholecystostomy, or cholecystectomy was used. Bile culture was not helpful in the prediction of acute cholecystitis, since results were not available for a minimum of 24-48 hours after aspiration. In addition, gram-stained smears and bile cultures suffered from low sensitivity (48% and 38%, respectively); consequently, a negative test does not allow the diagnosis of acute cholecystitis to be excluded. Bile aspiration of the gallbladder thus has a limited role in the diagnosis of this condition.

Methyl tert-Butyl Ether Fails to Dissolve Retained Radiolucent Common Bile Duct Stones

Methyl tert-butyl ether (MTBE) has been recently proposed as a new therapeutic modality for the dissolution of cholesterol gallstones. To further evaluate efficacy and tolerability of this new litholytic agent, we have administered MTBE to 3 patients with nonobstructive radiolucent common bile duct stones after recent surgery. Methyl tert-butyl ether (8-11 ml/day) was infused after aspiration of bile via a Teflon catheter inserted through the postoperative T tube. Gentle aspiration and reinfusion were performed continuously to generate stirring. The total amount of MTBE retrieved during the entire procedure was equivalent to approximately 30% of the volume infused. In all cases, MTBE failed to dissolve the radiolucent stones, which were then dissolved with continuous infusion of monooctanoin via the biliary catheter. The characteristic odor of MTBE was detected on the breath of the patients, and nausea and somnolence developed during the treatment. Serum hepatic and pancreatic enzymes did not change after MTBE. In the third subject, who received 11 ml/day of MTBE for 2 consecutive days (total of 22 ml), histologic evidence of duodenitis was found around the papilla. In our opinion, the lack of efficacy of MTBE in dissolving retained radiolucent common bile duct stones was mainly related to its leakage from the common bile duct into the duodenum and the ensuing local chemical toxicity and systemic absorption. As MTBE needs a persistent stone-solvent contact to exert its litholytic action and, at the same time, its toxicity prevents the infusion of larger doses, MTBE use should be restricted to stones placed in closed chambers, such as the gallbladder.

Diagnostic and therapeutic percutaneous gallbladder procedures.

The authors report their experience with 24 patients who underwent a variety of percutaneous procedures involving the gallbladder. Twenty diagnostic and 13 therapeutic procedures were performed under sonographic, computed tomographic (CT), or fluoroscopic guidance; these procedures included biopsy of the gallbladder, diagnostic cholecystography, diagnostic aspiration of bile, gallstone dissolution and removal, cholecystostomy for drainage, and gallbladder abscess drainage. The indications for percutaneous cholecystostomy (performed in 11 patients) included relief of hydrops and empyema, gallstone dissolution, mechanical gallstone removal, and drainage for malignant obstruction. Each procedure was successful. There was one complicating episode of cholecystitis and four previously described episodes of vagal hypotension. Bile peritonitis did not occur in any of the patients. The authors discuss the various percutaneous gallbladder procedures and specific technical considerations in performing them.

Exploration of the Biliary System in Recurrent Acute Pancreatitis of Undetermined Etiology Despite Normal Cholecystography

The incidence of pancreatitis associated with biliary tract disease is high in certain parts of the world, including Israel. Sometimes, pancreatitis is the first or only manifestation of gallstone disease. However, this may be accompanied by a normal oral or intravenous cholangiogram. Between 1968 and 1980, 173 patients with acute pancreatitis were treated at the Hadassah University Medical Center in Jerusalem. One hundred and two patients (59%) suffered from proven biliary tract disease. In 36 of these 102 patients, repeat preoperative oral and intravenous cholecystograms failed to demonstrate disease in the biliary system. All were referred to surgery on the basis of a high index of suspicion only. At surgery, acute or chronic cholecystitis were found in all cases; gallstones were found in 32 and some degree of pancreatitis in 32. Operative cholangiography demonstrated a common entrance of the ductus choledochus and the pancreatic duct with reflux of contrast material into the pancreatic duct in at least 52.8% of the cases. In 14 patients (38.9%), palpation and cholangiography did not reveal stones and only bile aspiration and filtration through gauze demonstrated many tiny stones. All patients underwent cholecystectomy, and 11 additionally had a common duct exploration. The follow-up period ranged from 2 to 12 years (mean 7 years) with no signs or symptoms of recurrent pancreatitis or biliary tract disease. It has become our practice to attempt proving gallbladder disease radiographically in all cases of recurrent pancreatitis with no other known etiologic background. Failing this, surgical exploration of the biliary system is undertaken.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous ultrasound-guided puncture of the gallbladder (PUPG).

Percutaneous ultrasound-guided puncture of the gallbladder (PUPG) is a new method for antegrade study of the gallbladder and the common bile duct. All procedures were scheduled immediately prior to planned surgery. Under ultrasound guidance, a 22-gauge sheathed needle was placed into the gallbladder lumen, and dilute (25% to 30%) diatrizoate meglumine (Hypaque) was injected. Indications in five patients included: evaluation of the common bile duct for calculi and/or obstruction, specifically in one patient who had hypersensitivity to intravenous contrast material; aspiration of bile for gram stain, crystal analysis, and cytology; evaluation of the gallbladder lumen for intraluminal masses; and to establish the anatomic site of an occult abscess. A small bile leak occurred in one patient who had no obstruction, and a more significant leak occurred in a patient who had obstructive jaundice and ampullary carcinoma. PUPG obviated the need for surgical intervention in three patients. Although the method has limited indications, we feel that it has great diagnostic potential in conditions related to the gallbladder and biliary ducts.

Concentration and excretion of contrast agents during oral cholecystography as measured by computed tomography in dogs.

Nine healthy mongrel dogs were given 2 consecutive doses of 1 of 3 cholecystographic contrast agents (iopanoic acid, sodium ipodate, and sodium tyropanoate), followed by daily computed tomograms (CT) and abdominal radiographs in a randomized crossover study in order to determine: (a) the maximum time for excretion of the contrast material from the gallbladder, (b) the maximum time for elimination of contrast material from the blood, and (c) the correlation between the density of the gallbladder on CT and the actual concentration of iodine in the gallbladder bile. In all 9 animals gallbladder opacification disappeared on CT within 4 days after administration of the contrast material. Plain abdominal radiographs did not show gallbladder opacification after 2 1/2 days. Daily blood iodine measurements showed that all of the contrast material was cleared from the blood within 7 days after administration. In 7 dogs CT imaging of the gallbladder was followed by percutaneous aspiration of bile from the gallbladder using CT guidance. There was a direct linear correlation between the actual concentration of iodine in the bile and the density of the gallbladder on CT (r = 0.925). This suggests that CT measurements can be used to determine the concentration of contrast agents in the gallbladder during oral cholecystography.

The enzymatic determination of total phospholipids in bile and bile-rich duodenal aspirates

The enzymatic determination of total phospholipids in bile and bile-rich duodenal aspirates

Endoscopic biliary drainage for detection of gallbladder disease

Aspiration of gallbladder bile stimulated by the injection of sincalide during duodenoscopy can provide a presumptive diagnosis of biliary tract disease in patients whose symptoms are suggestive but whose cholecystograms or echograms are unrevealing. The finding of cholesterol crystals or calcium bilirubinate pigment or both was associated with histologic evidence of cholecystitis, often with cholesterolosis or small stones, in 31 of 33 patients.

Thoracobilia: A Surgical Complication of Hepatic Echinococcosis and Amebiasis

Thoracobilia designates a clinical syndrome characterized typically by tender hepatomegaly, chill, fever, and expectoration of bile. Pathologically this syndrome is always due to a biliary fistula opening into a bronchus, often of the right lower lobe. The disorder may be congenital or acquired and may arise from a variety of etiological factors, including trauma and infection. Ten patients with thoracobilia among 25,985 inpatients (0.03% of hospital admissions) were studied. They represented 2.6% of patients with a primary liver disease and 22.7% of those who also showed a lesion in the right hemithorax. The hospital course was one of fulminant evolution of disease in 2 patients and chronic illness in the remaining 8. All patients had surgical treatment. Operations consisted of lobectomy (right lower lobe or right lower and middle lobes), wedge resection, simple closure of the fistula, and drainage of the liver abscess or cyst. All 10 patients had complications, and 8 of the 10 had major complications. Three deaths in the amebic group and 2 in the hydatid group gave a 50% mortality. Massive aspiration of bile caused 4 of the 5 deaths. Thoracobilia is a surgical condition with serious complications and high mortality. Its best treatment is emergency thoracotomy with resection of the diseased lobe, tight closure of the diaphragm, and separate subdiaphragmatic drainage of the liver abscess.

Gallstone Pancreatitis

In four cases of pancreatitis the etiology could not be determined by any of the accepted diagnostic measures. Only at exploration could associated biliary tract disease be demonstrated. Aspiration of bile during operation for detecting tiny stones was important. Common entrance of pancreatic and bile ducts was demonstrated in all four cases. Prompt treatment of biliary tract disease prevented the recurrence of attacks during follow-up of 18 to 30 months.

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY: ITS USE AND LIMITATIONS.

A review of accumulated experience with 423 attempts at percutaneous transhepatic cholangiography verifies the usefulness of this procedure in differentiating obstructive from non-obstructive jaundice. The procedure is not uniformly successful nor is it infallible. Failure to aspirate bile is not a completely reliable indication that posthepatic obstruction is not present. Conversely, aspiration of bile after introduction of the exploring needle or catheter, without obtaining a cholangiogram, should not be used as proof of extrahepatic obstruction. Although fatalities are rare, complications occur and percutaneous transhepatic cholangiography is not without risk, especially of bile peritonitis. Bile peritonitis may ensue even when the exploring catheter is left in situ. It would seem wiser and safer, therefore, to schedule operation within 4–8 hr. of transhepatic cholangiography when an obstructing lesion has been identified, or when the examination is unsuccessful and diagnosis is still obscure. The procedure would appear to be especially valuable in cases of jaundice in which the diagnosis is still in doubt after all other studies have been performed. However, the hazards attending its performance alone dictate that it not be used inall cases of obstructive jaundice.

Entero-Hepatic Circulation of Bromsulphalein

Summary 1.The intra-duodenal instillation of either a 2 mg./kg. or a 5 mg./kg. dose of BSP resulted in significant serum dye concentrations in 6 subjects. 2.The effect of duodenal aspiration of bile containing dye on serum BSP levels, during the 2 mg./kg. and 5 mg./kg. intravenous tests could not be adequately determined because, in most instances, an insufficient quantity of dye was recovered during the test period. In one patient, following a 5 mg./kg. dose of BSP, recovery of a high percentage of the intravenously administered dye resulted in a significant reduction in the serum dye concentrations at 30 and 45 minutes. 3.Changes in serum BSP concentrations produced by common duct aspiration of bile-containing dye during the 2 mg./kg. and 5 mg./kg. intravenous tests varied relative to the amounts of BSP recovered. Although percentagewise dye recoveries and reductions in serum concentrations were not too different for 2 mg./kg. and 5 mg./kg. tests, only after the 5 mg./kg. dose were the quantitative reductions in serum BSP levels sufficiently great to alter the interpretation of the test. 4.It is recommended that in the clinical application of the BSP test, dye retention be estimated at 30 minute after a 2 mg./kg. dose. As demonstrated in this study, this would minimize the influence on the time and dose factors of the entero-hepatic circulation of BSP.