Gall-bladder Shadow Research Articles

Segmental ultrasonic test for the study of cholecystodyskinesia

Ten patients of ages 35 to 61 years with ‘cholecystopathy’ received an injection of 20 ml, 40% biligrafin. X-rays of the gall-bladder area were taken before and at certain intervals after the injection. This was followed by ultrasonic stimulation (applied using the impulse technique) for ten to twenty minutes at frequencies of 3 MHz, effective intensity of 1.4−2.8 W cm −2 and with paraffin oil as a contact agent. The dorsal segments were subjected to ultrasonic stimulation of weaker intensity but longer duration than the ventral segment. The gall-bladder shadow was analysed planimetrically, and an approximate volumetric calculation was attempted. The results show that the gall-bladder responds to segmental ultrasonic stimulation by both contraction and dilatation, presumably through a cutaneous visceral reflex arch, a qualitatively and quantitatively different response to that of egg yolk. Segmental ultrasonic stimulation of the gall-bladder seems to be a suitable complement to fatty meal treatment, particularly where this ‘contra-indicated’. In addition it offers the possibility of differentiating between hyper and hypokinetic forms of gall-bladder dyskinesia. Finally, it was observed that a more marked effect on the gall-bladder can be produced by dorsal-segmental stimulation than by stimulation over the ventral points.

Effect of Glucagon on Size of Visualized Human Gallbladder Before and After a Fat Meal

Four methods of measuring the size of the gallbladder shadow were employed in a study to determine the effect of the administration of glucagon and a fat meal on a standard cholecystogram. These methods included an estimate by an experienced roentgenologist, measurement of the width of the gallbladder shadow, determination of the weight of a photographic reproduction of the shadow, and estimation of the volume represented by the shadow. Some measure of the sensitivity of the methods of measure was obtained by determining the sample size needed to give statistical significance. At a ± 20% change of the over-all mean, approximately, 7, 7, 14, and 22 subjects for visual estimate, picture width, weight, and volume, respectively, would be needed to show a significant difference in response. Evaluation of the gallbladder shadow by the roentgenologist was most easily accomplished and was at least as good as any of the other methods. When a fat meal was given first or after glucagon there was a decrease in the size of the gallbladder shadow by all four methods. When glucagon was given first there was an increase in the width of the gallbladder shadow. No significant change was demonstrated with the other methods of evaluation. When glucagon was given after fat the gallbladder shadow increased in size significantly (P

Human tolerance of iopanoic acid (Telepaque).

Overdose of gallbladder contrast material has not previously been reported in the radiological literature. The following case report suggests that the margin of safety of this drug is quite wide. Case Report A 50-year-old, 130-lb. Caucasian woman was given a prescription for 6 iopanoic acid tablets (Telepaque) for a gallbladder examination. The prescription was filled at a drugstore. Instead of 6 tablets, the patient was given 60 tablets (a total of 30 g), possibly due to a misunderstanding on the part of the druggist who filled the prescription. The patient noted that the directions called for her to take one tablet every five minutes and proceeded to ingest the entire contents of the bottle over a five-hour period. On the following morning, the patient presented at the Radiology Department with extreme nausea as well as some diarrhea and vomiting. Films of the gallbladder showed an excellent gallbladder shadow. The patient was kept under observation for several hours and sent home with no other apparent ill effects.

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Size of the gallbladder in patients with diabetes mellitus.

The surface of the X-ray shadow of the gallbladder was determined by a planimeter in 100 random patients examined for complaints suggesting gallbladder disease, in whom the viscus was well visualized and no gallstones were discernible. No correlation was found between the gallbladder size and body surface or sex. The mean surface of the gallbladder shadow in thirty-two diabetic patients was significantly larger than the mean surface in forty-three nondiabetic individuals. The frequency of large gallbladders (over 24 sq. cm.) was higher among the diabetic than the nondiabetic individuals. Elimination of twenty-seven diabetic and nondiabetic patients with clinical signs of cholecystitis, duodenal ulcer or gastroduodenitis did not alter the relationship between the gallbladder size and presence of diabetes, found for the whole group. In some diabetic patients the large gallbladder may be a manifestation of biliary dyskinesia due to autonomic neuropathy (“diabetic neurogenie gallbladder”). A search for diabetes is justified in patients with a large gallbladder.

The upside-down view in gallbladder diagnosis.

No radiographic examination of the gallbladder for stones can be called adequate unless it utilizes the effects of gravity which causes the stones to stratify or to settle on the dependent-most wall of the organ. Without such utilization an astounding number of gallstones will go undetected. The easiest way to enlist the aid of gravity is upright spot-filming under fluoroscopic control. This furnishes the additional benefits of exposures in varying degrees of rotation and of compression. The right lateral decubitus study, done without fluoroscopic control, is a poor second-best. Difficulty in “freeing” the opacified gallbladder from superimposed colonic contents or the bony pelvis is encountered occasionally. Any of the following maneuvers may help in such a case: 1. 1. Make the exposure after the patient has exhaled as deeply as possible. The gallbladder will have ascended. 2. 2. The contraction that often follows the fatty meal may be just enough to “free” the gallbladder. (Sometimes a peristaltic rush of colonic contents may have occurred after the fatty meal.) 3. 3. Administer a cleansing enema. 4. 4. Fill the colon with air or water, which makes a homogeneous milieu over the gallbladder. We have never used this method, but often purposely film the gallbladder through a pocket of naturally occurring colonic gas free of solid contents, if necessary. 5. 5. The right lateral decubitus study may prove the presence of stones. In this view rib, duodenal, or colonic contents may obscure the gallbladder shadow, but even the unobscured shadow without filling defects does not exclude stones because films made with varying degrees of rotation and of pressure are not readily available. 6. 6. Repeat the gallbladder examination the next day: the state of the colon might then be more favorable to the unimpeded visualization of the gallbladder. Rarely none of these maneuvers suffices. Gravity then might be enlisted by spot-filming with the patient upside-down. No special equipment is required. The patient is positioned so that his knees with a pillow beneath them are flexed over the head of the table at right angles; a reliable assistant maintains the right angle flexure by holding the lower legs firmly; the foot-stand is positioned so that the patient may comfortably grasp it with up-stretched arms; one or more table-fixed compression bands may be positioned over the thighs and pelvis for additional support. After full explanation of the procedure to the patient, the table is slowly elevated with several stops to allow accommodation of an aging circulation and with frequent words of encouragement, until the full upright position of the table has been reached. Spot-filming is then done, and the patient lowered slowly.

ALTERED CONCEPTS OF THE MECHANISM OF NONVISUALIZATION OF THE GALLBLADDER.

Several observations made in the course of routine clinical cholecystography in recent months have rekindled an interest in our department in the basic mechanisms that determine whether or not visualization of the gallbladder will occur. The first such observation concerns the instance in which good opacification is apparent, but surgical extirpation reveals marked sclerosis of the gallbladder wall to an extent that suggests possible interference with the organ's ability to concentrate contrast material. The second observation is the instance in which initial examination with contrast material fails to reveal a gallbladder shadow, and yet repeat examination with a similar dose on the following day demonstrates good opacification (Fig. 1). In Rosenbaum's series of 450 consecutive patients examined by cholecystography (1), in 66 visualization was initially absent or inadequate without evidence of gallstones. Findings were normal in 10 per cent of those with initial nonvisualization and in 64 per cent of those with initially inadequate visualization on repeat examination with an additional dose of contrast material. In our experience in these circumstances, the density of the gallbladder after the second dose usually appears to be more than can be explained by a simple doubling of the quantity of contrast material in the gallbladder. Therefore, one must postulate a mechanism whereby a higher percentage of the second dose in comparison to the first can be retained within the organ. In an attempt to explain these and other related phenomena encountered in clinical cholecystography, we speculated on the possibility of reabsorption of cholecystographic material from the inflamed gallbladder. If such a phenomenon occurs and were of importance in terms of visualization or nonvisualization, one might have an explanation for the clinical circumstances just cited. The gallbladder with a very thick wall, for example, would opacify readily since the wall could absorb neither water nor the cholecystographic material. In this circumstance the gallbladder lumen might be considered as a dilated extension of the common bile duct. Opacification of the bile ducts in individuals with a previous cholecystectomy is not uncommon. Furthermore, if reabsorption of the contrast material proved to be significant, one might explain second-dose visualization by hypothesizing that with the first dose, a marginally inflamed gallbladder reabsorbs the contrast material at a rate that prevents sufficient concentration for visualization. With the second dose, however, many of the serum and tissue protein binding sites are occupied, leading to a more sustained elevation of available opaque material in the blood and to an inhibition of reabsorption of contrast material through the marginally in-flamed gallbladder wall.

Gall bladder histology and the oral cholecystogram

Summary Sixty-seven cases of chronic cholecystitis have been reviewed and a comparison made between variations in the gall bladder shadow after oral cholecystography and different histological parameters of disease. A strong correlation was found between the density of the cholecystogram and the normality of the epithelium, and inversely with the degree of thickness of the wall and fibrosis of the lamina propria. Oedema, inflammatory cellular infiltrate and the presence of Rokitansky-Aschoff sinuses were not obviously related to function. Provided that minor histological changes are disregarded both a normal cholecystogram and absence of a shadow are adequate reflections of the condition of the gall bladder wall in the respects stated. The subjective radiological estimation of a faint gall bladder shadow remains valid as an indication of disease, but fails to indicate its degree of severity.

Oral cholegraphy by biloptin.

Oral cholegraphy by Biloptin was carried out in 177 cases. In each case the dose was 3 g in the evening prior to the examination and 3 g in the morning of the examination. Reactions were comparatively few and mild. Little or no relationship was found between the density of the gall-bladder shadow and the presence and degree of cholecystitis as discovered at operation. The property which makes Biloptin superior to older oral opaque media is its ability in a high proportion of cases to opacify the common bile duct, irrespective of the state or indeed the presence of the gall-bladder. This is of considerable diagnostic value in detecting lesions of the common bile duct; in providing a pre-operative record of the width of the duct; and when only the common bile duct is shown, in providing a reliable index of disease of the gall-bladder.

Adenomyomatosis of the gall-bladder (intramural diverticulosis).

Adenomyomatosis is a hyperplastic condition of the epithelial and muscular elements of the gall-bladder wall. It is also known under many other names but that used here is preferred as it is descriptive and is noncommital as far as aetiology is concerned. The condition is not uncommon but for various reasons has been rather neglected in the past. It is thought to predispose to stone formation and cholecystitis but may be found without either. It is probably a degenerative condition, the incidence increasing with advancing age. There may be associated cholesterosis. The lesions are of three main types: generalised, segmental and fundal. The radiological features of these are described. The main diagnostic points are collections of contrast medium in the dilated Rokitansky-Aschoff sinuses around the main gall-bladder shadow, strictures, septa, kinks and filling defects. The condition may be diagnosed even when Rokitansky-Aschoff sinuses are not visualised. Concentration of opaque medium and contraction afte...

Clinical trials with bunamiodyl (Orabilix) and comparison of it with iopanoic acid (Telepaque).

Orabilix, a new cholecystographic medium, was administered to 37 patients, 25 of whom were also investigated with iopanoic acid (Telepaque). Comparison of the two contrast media indicated slightly better tolerance with Orabilix, there being a reduction in the incidence of diarrhoea. The density of the gall-bladder shadow was as good with Orabilix as with Telepaque using a weight by weight equivalent of the two media.

Gallbladder visualization following the use of 70 per cent sodium acetrizoate (urokon sodium) for intravenous pyelography.

In the course of a kidney examination of a 6-year-old girl, a retrograde pyelography study was done two hours after the intravenous injection of 12.5 c.c. of Urokon Sodium (70 per cent). The two-hour time interval was purely incidental. The scout film was negative, but the first pyelogram of the series showed a well defined gallbladder shadow, partially superimposed upon the shadow of the opacified right kidney. Since we had not previously encountered this phenomenon, and were not familiar with the work of Porporis (1) or Orloff (2), we set up a preliminary survey to determine, if possible, the frequency with which such findings might occur. The next 24 consecutive patients receiving intravenous Urokon Sodium (70 per cent) for kidney studies were returned for gallbladder films two hours after receiving the contrast medium. Their ages varied from three to seventy-four years. No attempt at selection of cases was made. Gallbladder shadows were classified on the basis of density as follows: * barely visible, ...

Excretion cholecystocholangiography; a study based on 1,400 cases examined with telepaque and/or cholegrafin.

The frequent demonstration of the biliary ducts following the advent of Telepaque (1) and the magnificent visualization obtained with Cholegrafin (2) gave rise to a large series of scientific communications (3) indicating the importance of these examinations and leading consequently to their routine employment by radiologists everywhere. The present work proposes to set forth the results obtained in a group of 1,400 private patients from the civil population, in whom oral procedure was combined with the intravenous method to determine the normals which in our opinion should be sought routinely in such studies; to learn to recognize the shadows which in certain cases of congenital anomalies serve the surgeon as a guide to successful operative intervention; and to discuss the value of the normal radiologic examination of the biliary passages from the clinical point of view. Although many writers speak of oral or intravenous cholangiography (1–16), the term cholecystocholangiography (17, 18) is more appropriate. To differentiate the procedure from the cholangiography done at operation or with the aid of laparoscopy, it has seemed to us that we should call it “excretion cholecystocholangiography.” This single term includes examination both of the gallbladder and the ducts. In our opinion, in spite of the fact that the substances employed and the methods of introduction into the organs are different, we are dealing with a single radiologic study, which can be accomplished by either means alone or with both at the same time. We begin our examination with the oral method, using Telepaque, (a) because ingestion of the contrast material the preceding afternoon is more easily accomplished than intravenous injection in the office; (b) because failure of visualization of the gallbladder when this organ is permeable shows that its functions of concentration have been lost; (c) because the degree of density is an index of the manner in which these functions have been carried out (20). When the oral procedure fails to produce a gallbladder shadow during elimination of the medium, recourse is had immediately to Cholegrafin, since a large number of gallbladders not shown by Telepaque fill very well with the intravenous preparation (12), and because visibility of the ducts is good in the presence of a vesicular block or when the patient has been cholecystectomized. In such cases we advise that the examination be completed in this one session. In cholecystectomized patients we have often used Telepaque, because, with the technic advised by Twiss and his collaborators (22), and very often with routine examinations, shadows of the common duct and the hepatic trunk duct may be obtained.

A comparative trial of telepaque and biliodyl in 50 cases.

Oral cholecystography was performed on 50 patients, using Telepaque and Biliodyl in each patient. The radiographic appearances were similar with each medium but two patients showed a gall-bladder shadow with Biliodyl only. The side effects were more numerous and more severe with Biliodyl.

On the relative merits of the oral and intravenous methods of cholegraphy.

In order to assess the relative merits of the oral and intravenous methods of cholegraphy, 100 unselected cases referred for X-ray examination of the gall bladder have been examined by both methods, using the compounds Telepaque and Biligrafin respectively. In the detection of stones in the gall bladder, Telepaque is more accurate than Biligrafin. Absence of the gall bladder shadow after Biligrafin, provided the ducts are visualised, is reliable evidence of gall bladder disease; after Telepaque it may be due to other factors, such as failure of absorption. Biligrafin demonstrates the bile ducts more often and more clearly than Telepaque. It is concluded that the two methods are complementary. A practical scheme is to reserve the intravenous method for those cases in which the oral method has failed to demonstrate the gall bladder or bile ducts.

Experiences with the upright fluoroscopic spot-film examination of the gallbladder.

The purpose of this brief paper is to describe further experiences (1) with the upright fluoroscopic spot-film examination of the gallbladder and to compare it with other procedures. Cholecystographic technics fall into four groups: 1. Examination with the patient horizontal and an overhead tube. Today such examination cannot be called acceptable. 2. Examination of the upright patient with an overhead tube, taking advantage of the effect of gravity with stratification. This represents a real advance, but with a number of shortcomings: Aiming is difficult; intestinal gas is frequently superimposed upon the gallbladder shadow; in certain body types the gallbladder is projected upon bony structures of the pelvis. 3. Examination of the patient in the right lateral decubitus with a horizontal ray, as described by Kirklin (2). This offers the gravitational advantages of the upright study, theoretically without the frequent superimposition of intestinal gas and bony structures. Without elaborate accessories, however, such as a table that can be rotated on its long axis, the gallbladder shadow actually is often obscured by gas and bone. 4. Spot-filming with a fine-focus (1.0 mm. square, or less) rotating anode tube beneath the table. This affords definite advantages over the previous technics. Radiography of the gallbladder with a spot-film device that does not have such a tube is, however, not to be advised. The stationary anode with larger focal spot will not allow the definition demanded for detecting lesions in the range of 1 mm. It is strongly urged that the gallbladder and gastrointestinal examinations be combined. We have several cases on file in which one of the two examinations was done repeatedly over the years; only when the other was finally done was a positive diagnosis obtained and the difficulty relieved. We are convinced that a clinical differential diagnosis between gallbladder disease and gastric ulcer is often impossible, especially in women. Our technic is as follows: A high-fat lunch the day before the examination aids in emptying the gallbladder of viscid contents which might interfere with the entrance of the fresh medium-containing bile. A preliminary scout film of the abdomen before taking the six tablets of Telepaque is certainly desirable, but the nature of our practice makes this difficult. After preliminary fluoroscopic examination of the thorax, the abdomen is scanned and the gallbladder shadow is then sought. Palpation with attendant movement of the viscera may help in demonstration of the less dense gallbladders. Spot-films are made with varying degrees of compression and rotation. Occasionally it may be necessary to cleanse the hepatic flexure with a 1.0 per cent tannic acid-water enema if a completely unobstructed view of the gallbladder cannot be obtained with any degree of rotation.

Combined intravenous cholecystography and pyelography.

A method of examining both renal and biliary systems within a period of 90 minutes is described. Intravenous media are used, namely diodone and Biligrafin, and the technique makes use of a preliminary fatty meal and intravenous pethidine to control the time of appearance of the gall bladder shadow. Early films demonstrate the renal pelvis and calyces, and a water diuresis is then induced to reduce the density of the pyelogram; succeeding films show the biliary tract. The method is sufficiently adaptable to accommodate variations from the normal discovered in the course of the examination (Table I).

Experience with five orally given cholecystographic mediums.

The history of cholecystography has been reviewed in the literature. 1 Iodophthalein sodium (Iodeikon), producing a high degree of cholecystographic accuracy, was the first orally given cholecystographic medium to be popularized. In fact, it is doubtful whether the administration of subsequent orally given mediums actually has increased the accuracy of diagnosis for cholecystic disease. The chief objections to iodophthalein sodium were its disagreeable taste and the high incidence of nausea, vomiting, and diarrhea following oral administration. Iodoalphionic acid (Priodax) was tolerated much better and almost universally replaced iodophthalein sodium. Monophen, 2-(4-hydroxy-3,5-diiodobenzyl)-cyclohexane carboxylic acid, although well tolerated and capable of producing equally good cholecystograms, never became popular and is no longer manufactured. Although iodoalphionic acid is employed occasionally, iopanoic acid (Telepaque) and iophenoxic acid (Teridax) are the cholecystographic mediums used most frequently today. It is generally agreed that an ideal orally given cholecystographic medium should produce a gallbladder shadow of sufficient

Clinical and Roentgenologic Evaluation of Routine 2-Gram Telepaque Dosage in Cholecystography

Early clinical evaluation and comparison with Priodax demonstrated the much denser gallbladder shadows found after ingestion of Telepaque in 3-gm. dosage and also showed a high incidence of unabsorbed contrast material in the colon. These findings pointed to the possibility that the 3-gm. dosage might be excessive, and it was suggested by others and concurred in by us that a thorough trial of a smaller dosage was indicated (1–6). Accordingly, a routine 2-gm. dosage was instituted at the University Hospital. Following the trial period for accumulation of data, this proved so satisfactory that it has been continued as standard cholecystographic procedure. A previous study at this institution (6) evaluated the side-effects of the 3-gm. dose of Telepaque in comparison with an equal dose of Priodax. Under identical conditions, cholecystographic subjects were interviewed by a physician as they passed through the gastrointestinal suite, and the side-effects of the 2-gm. dosage were tabulated. The contrast material was ingested exactly as in the previous study, i.e., following a fat-free meal the evening prior to examination. The incidence of side-effects as compared with the earlier Priodax and Telepaque (3-gm.) series is presented in Table I. The comparative figures show a small increase over the 3-gm. Telepaque group in absence of side-effects and a slight decrease in the two more frequent effects, mild diarrhea and mild dysuria, the reductions in these symptoms being in the neighborhood of 4 to 5 per cent. Thus it appears that the smaller 2-gm. dose enjoys an advantage in this respect when used as a routine procedure. The other chief concern in use of the reduced dosage is its effect on the density of the gallbladder shadow. A review of 500 examinations was carried out with the same standards employed in our previous studies (6), and gallbladder visualization was classified under the same headings: excellent, good, faint, or non-visualization, for each examination. The presence of stones was also recorded and it was noted whether they were radiolucent, radiopaque, or mixed. The incidence of residual contrast material in the colon was tabulated. Gallbladder visualization with 2-gm. dosage is compared with the previous study of 3-gm. dosage in Table II. While there appears to be a 13 per cent decrease in the “excellent” category, an increase of 9.2 per cent is noted in the “good” results. If the excellent and good classifications are combined and considered as “satisfactory” the 3-gm. dosage shows an advantage of 3.8 per cent over the 2-gm. dosage, S3 as compared to 79.2 per cent. This small decrease in diagnostic shadows with the lower dosage may be counterbalanced by the risk of obscuring stones by the dense shadows produced by 3 gm. Of the 500 patients receiving 2 gm., 487, or 97.4 per cent, showed residual contrast medium in the colon.

Stellate fissuring in gallstones.

Stellate cavities within the centers of gallstones have been known for many years, but only recently have we come to realize that these cavities may contain gas (1–3). The literature on this subject has recently been thoroughly reviewed (3, 4). Schwarz was able to collect 12 cases, to which he added one of his own. Since Hinkel's original report of 1 case (3) he has discovered another half dozen (5). It is the purpose of this paper to report 3 additional examples of fissuring in gallstones. It was possible to make the diagnosis of cholelithiasis in the first case only because of these fissures, since the stones themselves were not visible. Case Reports Case I: E. F., a 34-year-old housewife with a history of fatty food intolerance, experienced within a period of six months three acute attacks of right upper quadrant pain radiating to the right scapula, accompanied by nausea and vomiting. Cholecystography revealed several stellate radiolucent shadows overlying the faintly visualized gallbladder, Though no stones could be definitely seen, it was thought that these stellate shadows re presented gas-filled fissures within the centers of gallstones (Fig. 1). The x-ray diagnosis was partially functioning gallbladder with cholelithiasis, and cholecystectomy was performed. The pathological diagnosis was chronic calculous cholecystitis. A roentgenogram of the stones demonstrated the stellate fissures which were seen on the cholecystogram (Fig. 2). Comment: In this case the stones were of the same density as the faintly visualized gallbladder and were recognizable on the roentgenograms only because they contained radiolucent fissures. An earlier cholecystogram obtained elsewhere had been interpreted as showing nothing more than a moderate impairment of function. The patient was only thirty-four years old and the referring physician wanted to be absolutely certain that she had gall bladder disease before submitting her to surgery. Because of the visualization of the stellate fissures a definite diagnosis of cholelithiasis could be made. Case II: F. O., a 59-year-old obese female, with hypertension, gave a history of dyspepsia and intolerance for fried and fatty foods. Marked tenderness was elicited on palpation of the right upper quadrant. On cholecystograms the gallbladder shadow was barely visible. Within its lumen was a single large stellate radiolucent shadow and the presence of one or more non-opaque calculi was suggested (Fig. 3). The roentgen diagnosis was marked impairment of function with cholelithiasis, and cholecystectomy was performed. The. pathological diagnosis was chronic calculous cholecystitis. A film of the unopened gallbladder beautifully demonstrated the fissuring phenomenon (Fig. 4). Comment: That the gallbladder was diseased was obvious from the marked impairment of function. We would have been uncertain as to the presence of calculi, however, had it not been for the fissuring phenomenon.