Diagnosis Of Common Duct Stones Research Articles

Magnetic resonance cholangiopancreatography

Magnetic resonance cholangiopancreatography (MRCP) refers to selective or partially selective MR imaging of the pancreatic and biliary ducts. Complete or partial selectivity for ductal imaging is an important component of this definition, because this selectivity distinguishes MRCP from other cross-sectional modalities such as CT and ultrasound, which can also be used to assess pancreatic and biliary ductal disease. MRCP was first described in the 1980s. Since then MRCP has undergone considerable technical evolution and maturation and has reached the stage at which MRCP is a viable alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in most settings (Fig. 1). This article discusses some of the relative advantages and disadvantages of MRCP, important aspects of technique, and major clinical applications. Emphasis is placed on the scientific data supporting the contention that MRCP is competitive with ERCP. It should be noted that many clinical studies of MRCP use ERCP as the standard of reference. This carries the implicit and unstated assumption that ERCP results are absolute and objective. It is true that in practice ERCP is often considered the definitive test for structural disease of the pancreatic and biliary ducts. However, as with any other imaging test, ERCP is subject to error and variability, as illustrated by studies in which clinical or surgical results are used as the standard of reference. For example, in a study of 124 patients with suspected pancreatic cancer in which the standard of reference was biopsy or one year of clinical follow-up, the sensitivity and specificity of MRCP for the diagnosis of pancreatic cancer were 84% and 97%, respectively, compared with a sensitivity and specificity of 70% and 94% for ERCP. 1 Adamek HE Albert J Breer H Weitz M Schilling D Riemann JF. Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study. Lancet. 2000; 356: 190-193 Abstract Full Text Full Text PDF PubMed Scopus (225) Google Scholar Similarly, in a study of 72 patients undergoing cholecystectomy, preoperative ERCP had a sensitivity and specificity of 91% and 100%, respectively, for the diagnosis of common duct stones, using intraoperative cholangiography and bile duct exploration as a standard of reference. 2 Frey CF Burbige EJ Meinke WB Pullos TG Wong HN Hickman DM et al. Endoscopic retrograde cholangiopancreatography. Am J Surg. 1982; 144: 109-113 Abstract Full Text PDF PubMed Scopus (60) Google Scholar

Advances in the Imaging of Common Duct Stones Using Magnetic Resonance Cholangiography, Endoscopic Ultrasonography, and Laparoscopic Ultrasonography

Advances in magnetic resonance cholangiography (MRC) have resulted in consistently high sensitivity and specificity for the detection of common duct stones by MRC. There are multiple advantages to using MRC over endoscopic retrograde cholangiography (ERC) in the diagnosis of common duct stones, thereby reserving the use of ERC mainly as a therapeutic tool. Endoscopic ultrasonography has emerged as a modality capable of common duct stone detection and, when available, will compete with MRC and ERC for the diagnosis of common duct stones. However, its ability to image intrahepatic or proximal common duct stones would seem to be limited. Laparoscopic ultrasonography helps shorten operative time and costs less compared with intraoperative cholangiography. As more surgeons gather experience with laparoscopic ultrasonography and it becomes widely available, it has the promise to substitute for intraoperative cholangiography.

Some radiological aspects of common duct calculi

<h2>Summary</h2> Common duct stones may be unsuspected clinically and in such cases the diagnosis may be suggested by plain films and oral cholecystography. Confirmation by intravenous cholangiography is always necessary. The high incidence of acute cholecystitis associated with common duct stones is noted. A firm pre-operative diagnosis of common duct stones can be made in just over half the cases in which intravenous cholangiography is possible and in the remainder the calibre of the duct in nearly all cases will suggest an obstruction. In the latter group pre-exploratory operative cholangiography is of great value: in the former it is unnecessary. Tomography is helpful but is not always conclusive. Many cases without common duct stones are indistinguishable clinically from cases with stones. Intravenous cholangiography is of limited value in excluding common duct stones. Two cases are presented showing rim opacification with Biligrafin.

Cholecystectomy and Operative Cholangiography

This motion picture illustrates the technical points that have been adopted by us in developing practical operative cholangiography in conjunction with cholecystectomy. Close cooperation of the radiologist and the surgeon in an endeavor to eliminate all possible sources of error attains a greater degree of accuracy in diagnosis of common duct stones than surgical exploration or palpation alone. When this procedure is performed carefully and interpreted with the accumulated experience of past performance, it is dependable, frequently obviating common duct exploration in otherwise doubtful cases. The dependability will vary with the interest and ability of the professional team, the availability of equipment, and the frequency with which operative cholangiography is practiced. The surgical technique of cholecystectomy is well demonstrated in the film. The indications and judgment in three different circumstances are emphasized.

Intravenous Choledochography with a New Contrast Medium, “Cholografin”

It is now possible to visualize the hepatic and common ducts in cholecystectomized patients by the intravenous use of a new preparation called “Cholografin”2 (1) . This compound is the disodium salt of N:N1 adipic-di (3-amino-2:4 :6-triiodophenylcarboxylic acid). It is prepared as a 20 per cent isotonic solution. The iodine content, 64.32 per cent, is firmly bound in the molecule and not split off after the substance is injected intravenously. The substance is actively excreted by the liver cells and appears in the bowel a few minutes after intravenous injection. The common duct fills within twenty minutes and can be demonstrated roentgenographically. In the presence of jaundice, however, the common duct is not visualized. Instead, the compound is excreted by the kidneys in sufficient concentration to produce good urograms. Following cholecystectomy, symptoms may recur which resemble or are identical with those which existed prior to operation. These symptoms may appear shortly after surgery or may develop several months or years later. The most common causes for persistence of symptoms following cholecystectomy are erroneous preoperative diagnosis, calculi in the biliary ducts, common duct stricture, stone or inflammation of the cystic duct remnant, adhesions involving the stomach or the duodenum, residual cholangitis, hepatitis and pancreatitis, removal of functioning gallbladder, biliary dyssynergia, and an unrecognized malignant lesion U). The diagnosis of common duct stone in the post-cholecystectomy patient is not difficult when there are typical attacks of biliary colic followed by jaundice, and sometimes chills and fever . The problem is less easily solved in many patients who have attacks simulating biliary colic in the absence of jaundice. Technic of Examination The examination is best carried out in the morning, and the patient must be fasting. A laxative, such as castor oil or compound licorice powder, may be given the night before the examination. During a period of six to ten minutes, 40 c.c, of a 20 per cent solution of the medium is injected intravenously. If the injection is given too rapidly, some reaction may occur. Films made at twenty minutes after injection are viewed while wet, in order that exposure intervals and positioning of the patient may be changed if necessary. Correct positioning is important. multiple film studies with different degrees of rotation in both the erect and recumbent positions and in the lateral decubitus are helpful in separating overlying ribs and gas shadows from portions of the main hepatic and common ducts. For good contrast, 45 to 50 kv. and 400–800 mas. are used. Reactions If the tissues around the veins are injected inadvertently, local irritation will result. Slight nausea, dizziness, sneezing or restlessness occurred after injection in a few of our cases, but this was believed to have been due to rapid injection.

AbstractThe Roentgen Appearance of Common Duct Stone, ShlerD. O., HamptonA. O.,Amer. Journ. Roentg., September 1944, lii, 298.

The aim of this paper is to emphasise that the diagnosis of common duct stone can be made by careful study of the plain radiograph of the abdomen or the “spot” radiograph of the bile duct area. The authors base their experience on twelve proved cases of common duct stone.

DIFFERENTIATION OF SURGICAL JAUNDICE FROM SEVERE DAMAGE OF LIVER (SUBACUTE YELLOW ATROPHY) CLINICALLY SIMULATING IT

With the discovery of vitamin K and the development of methods for measuring plasma prothrombin levels, operation on the jaundiced patient lost much of its terror. By simple preoperative and postoperative procedures, abnormal bleeding in most cases of obstruction of the common duct, whether by stone, tumor or stricture, can now be anticipated and prevented. The liver in these cases is usually normal or so little impaired that the prothrombin level is rapidly brought to normal when the body is given an adequate amount of vitamin K and of bile or bile salts. It has been well established that if the prothrombin level remains normal, unusual bleeding in uncomplicated obstruction of the common duct does not occur. The diagnosis of common duct stone may often be fairly clear, particularly when gallbladder colic, chills, fever and jaundice are present. The preoperative diagnosis of carcinoma of the head of the pancreas or

The value of blood diastase in the diagnosis of common duct stone

The value of blood diastase in the diagnosis of common duct stone

Visualization of Biliary and Pancreatic Ducts by the Use of Sodium Iodide

A male, aged 30, came to the Clinic for an examination on January 1, 1930, with a chief complaint of chills, fever, and jaundice of two years' duration. In 1919, the patient had had a cholecystostomy performed for chills, fever, and jaundice. Following this he felt well until March, 1928, when he developed severe chills followed by fever and became jaundiced for several days. He continued to have these attacks more frequently until September, 1928, when cholecystectomy was performed. Following this, the patient obtained relief for three months, when the same trouble reappeared. This time he had severe chills, lasting for from thirty to sixty minutes, with an associated fever. He also became nauseated and vomited, and marked jaundice was present, with some pruritus. During the past two years he has had attacks once a month, lasting for several days, but for the five weeks previous to examination the attacks have occurred once or twice a week, being much more severe than the previous ones. Following an attack, he becomes very weak and prostrated. His stools were usually acholic, and the urine very dark. Physical Examinations.—The patient was apparently very sick. The skin and sclera were jaundiced II, the liver palpable in the midline and tender II on pressure. The spleen was palpable on inspiration. He had hemorrhoids II. The feces were acholic. His blood pressure was 110 systolic and 80 diastolic. His pulse rate was 70 and his temperature normal. Laboratory Examination.—Blood count: hemoglobin 65 per cent, erythrocytes 3,920,000, leukocytes 4,900. Fractional test meal: total acidity 20, free hydrochloric acid, 16. Blood Wassermann, negative. The roentgenologic examination of the stomach was negative. The diagnosis of common duct stone was made and exploration was advised, but this was not done until March 2, 1931. When he opened the abdominal cavity, the surgeon found very dense adhesions with many small pockets containing vaseline, which had been poured into the wound at the last operation. He was finally able to dissect the liver free from adhesions and to discover the stump of the gall bladder. Because of the patient's poor condition, a mushroom catheter was sutured into the stump of the gall bladder. The patient made an uneventful convalescence and much bile drained through the catheter. Two weeks following operation, sodium iodide was injected through the catheter until the patient complained of distress. One ounce of 12 per cent solution was used and a roentgenogram was made. The roentgenogram (Fig. 1) showed: I, Drainage tube; II, pancreatic duct; III, dilated common bile duct; IV, cystic duct; V, stump of gall bladder; VI, junction of common bile duct and pancreatic duct; VII, dye seen in duodenum; VIII, hepatic duct; IX, right and left hepatic ducts and some of the biliary tree in liver.