Visualization Of Gallbladder Research Articles

Practical hepatobiliary imaging using pretreatment with sincalide in 139 hepatobiliary studies.

Hepatobiliary studies were performed over a three-year period on 139 patients suspected of having cystic duct obstruction. Each patient was infused intravenously with sincalide, a C-terminal octapeptide of CCK, 15 minutes prior to the administration of the hepatobiliary imaging agent Tc-99m paraisopropyl iminodiacetic acid (PIPIDA). Analysis of the results demonstrated significant advantages in pretreating patients with sincalide in hepatobiliary studies in a small facility with a relatively large patient load. Most of our studies were completed within 2 hours without jeopardizing the sensitivity (97%) or accuracy (96%) of the test. The specificity (88%) was comparable to percentages reported by others. Most investigators have reported that chronic cholecystitis contributed to the majority of false-positive cases. In addition, inconsistency in the documentation of criteria for the determination of acute cholecystitis (surgical, radiologic, or histologic also could be a cause for such a discrepancy. Knowledge of some important variables may help improve the specificity of the test: an awareness of the following factors during scan interpretation: 1) the effectiveness of the sincalide pretreatment dose, 2) the patient's pretest status (fasting or nonfasting, postanalgesic medication or no analgesics), and 3) time limit for gallbladder visualization. With these variables in mind, the hepatobiliary imaging using pretreatment with sincalide is proven to be a practical procedure protocol with good sensitivity and accuracy as well as specificity.

Acute effects of nicotinic acid on hepatic transport of 99mTc-PIPIDA.

Hepatic injury has been associated with nicotinic acid treatment of schizophrenia and hypercholesterolemia. This association was implicated when the liver and biliary tract were not visualized after 99mTc-HIDA in a patient taking 3 g daily of nicotinic acid. We studied hepatic transport of 99mTc-PIPIDA both in vitro in isolated hepatocytes and in vivo in rabbits pretreated with nicotinic acid to further examine this association. Nicotinic acid increased uptake of PIPIDA by isolated hepatocytes and 7 days of nicotinic acid treatment in rabbits produced no abnormalities in hepatic uptake, gallbladder visualization, or biliary excretion of PIPIDA. We conclude that nicotinic acid does not have an inhibitory effect on uptake of biliary imaging agents and actually may be useful in enhancing hepatic imaging in patients with reduced liver function.

99m Tc-PIPIDA Cholescintigraphy in the Diagnosis of Gallbladder Disease

The efficacy of 99mTc cholescintigraphy in the diagnosis of gallbladder disease was studied in 116 patients. Sixty-one demonstrated gallbladder visualization (normal) and 55 had nonvisualization. In patients with acute abdominal pain, test sensitivity is 100%, specificity is 77%, and accuracy is 83% for the diagnosis of acute cholecystitis; no patient with gallbladder visualization had acute cholecystitis. Test sensitivity for any form of gallbladder disease is 66%, specificity is 82%, and accuracy is 71%; excluding patients with laboratory evidence of hepatobiliary disease, the predictability of acute or chronic cholecystitis increases to 100%. Cholescintigraphy demonstrated common bile duct patency in all eight post-cholecystectomy patients referred for evaluation of possible choledocholithiasis. Thus, gallbladder visualization with 99mTc-PIPIDA virtually excludes the diagnosis of acute cholecystitis, an abnormal test is a good predictor of gallbladder disease because of high specificity, and cholescintigraphy is extremely safe and simple to perform and may be used to demonstrate common bile duct patency.

Current role of intravenous cholangiography

One hundred consecutive intravenous cholangiograms were reviewed. In terms of bile duct and gallbladder visualization, 20 were of excellent quality, 40 were of adequate quality, and 40 were of poor quality or did not visualize. In retrospect, 12 of the studies were originally misinterpreted. Among the 29 patients who were eventually proven to have biliary tract disease, intravenous cholangiography was helpful in making the diagnosis in only 17 (59 percent). In 20 patients the study was performed to establish or rule out a diagnosis of acute cholecystitis; the test was helpful in only 9 (45 percent). It is concluded that intravenous cholangiography frequently results in marginal visualization that is subject to interpretive error. With the current variety of available tests that are able to visualize the biliary tree with a high degree of resolution, intravenous cholangiography has become a diagnostic anachronism.

Hepatobiliary scanning with 99mTc-PIPIDA in acute cholecystitis.

Ninety-five patients with clinically suspected acute cholecystitis underwent hepatobiliary scanning with 99mTc-PIPIDA. A positive scan (nonvisualization of the gallbladder with visualization of the common bile duct and gut) was found in 29 patients; 25 of them (86%) had surgically proven acute cholecystitis and 4 (14%) had chronic cholecystitis. Five of the 25 with acute cholecystitis had acalculous disease. A negative examination (gallbladder visualization) occurred in 63 patients; 18 (29%) had chronic cholecystitis and 45 (71%) were subsequently found to have nonbiliary disease. Three indeterminate studies (nonvisualization of both the gallbladder and gut) were obtained in patients with choledocholithiasis and chronic cholecystitis. In the evaluation of acute cholecystitis, the 99mTc-PIPIDA hepatobiliary scan was 100% sensitive and 94% specific.

Diagnosis of Acute Cholecystitis-Reply

In Reply.— We are in complete agreement with Drs Llaurado and Akhtar that delayed imaging will enhance the overall accuracy of hepatobiliary imaging (HBI) in the rapid evaluation of acute abdominal pain. This benefit of delayed imaging has been best shown by Weissman et al. 1 In their series, delayed imaging at two to four hours improved the specificity from 87.7% to 99%, but the sensitivity of HBI for the detection of acute cholecystitis fell (percentage fall not available from their data). We disagree with Drs Llaurado and Akhtar that delayed visualization of the gallbladder most probably excludes the diagnosis of acute cholecystitis (our italics). From the data of Weissman and co-workers, such delayed imaging is found with acute cholecystitis 18% of the time and chronic cholecystitis 82% of the time. In our preliminary work with delayed HBI, 26% of our patients with delayed gallbladder visualization actually had acute cholecystitis.

Biliary tract opacification: effect of iodine concentration and luminal size.

This study tested the hypothesis that the density of gallbladder and common duct visualization is dependent on the total amount of contrast material present (i.e., concentration and volume, rather than simply concentration). Finger cots (simulating gallbladders) and straws (simulating bile ducts) containing measured amounts of contrast material, were radiographed in a water phantom using standard radiographic factors. The films were classified by several radiologists as to their clinical usefulness. The concept that the gallbladder can be seen with lesser concentrations of iodine than the common duct, because the gallbladder is the thicker organ, was verified and is discussed.

The use of [99mTc](2,6-diethylacetanilide)-iminodiacetic acid ([99mTc]HIDA) in evaluating normal hepatobiliary dynamics.

Scintigraphic examination with [99mTc]HIDA was used to investigate fasting hepatobiliary dynamics in thirty normal subjects, fifteen males and fifteen females. Ten were studied in duplicate. All subjects visualized the bile ducts and showed gallbladder filling within 60 min. All but three demonstrated excretion of bile to the duodenum. Only five subjects showed activity in the gut before gallbladder visualization. Twenty-one had one or more contractions of the gallbladder. A significant positive correlation was found between age and excretory liver function in males, signifying a lower excretory capability with advancing age. The median percentage deviation for gallbladder and gut visualization in repeat tests was 40% and 88%, respectively. It is concluded that the hepatic bile in the fasting state is delivered to the gallbladder as well as to the duodenum. Furthermore, the results suggest a cyclic function of the biliary tract based upon coordination between the gallbladder and the sphincter of Oddi.

Spectrum of 99m-Tc-IDA cholescintigraphic patterns in acute cholecystitis.

Cholescintigraphy with 99m-Tc labeled iminodiacetic acid (IDA) derivatives has proved to be extremely reliable in the evaluation of suspected acute cholecystitis. The major diagnostic feature of the study is the presence (cystic duct patency) or absence (cystic duct obstruction) of gallbladder visualization. Secondary findings include degree and rate of liver uptake, visualization and caliber of the intrahepatic and common bile ducts, and the presence of intestinal activity as well as rapidity of biliary tract-to-bowel transit of the radiotracer. Various combinations of these secondary parameters result in a spectrum of cholescintigraphic patterns which can assist in determining the cause of the patient's acute clinical problem.

Isolation, Hepatic Distribution, and Intestinal Absorption of the Glucuronide Metabolite of Iopanoic Acid

Iopanoic acid (Telepaque) is an oral contrast agent that is absorbed from the intestinal tract, removed from the blood by the liver, conjugated with glucuronide acid in the liver, transported across the canalicular membrane into the biliary tree, and, ultimately, collected and concentrated in the gallbladder. The authors performed a variety of experiments to assess the role of the conjugation step on the excretion of iopanoic acid (IOP). A procedure was developed to isolate and purify the glucuronide metabolite of iopanoic acid (IOP-G) from dog bile. IOP-G from bile was bound to a column of neutral resin (Amberlite XAD-2) and washed with several solutions to remove some of the biliary contaminants selectively. IOP-G was eluted from the column, isolated and purified by ether extraction, and recrystallized with heptane. Final yield of IOP-G varied from 60–75% with a purity of approximately 95%. The maximum rate of biliary excretion of iopanoate (Emax) in rats was achieved with a dose of 300 μmol/kg of either IOP or IOP-G. The Emax after giving IOP-G was 60% higher than the Emax after administering IOP. Neither IOP nor IOP-G were choleretic. Therefore, the biliary concentration of iopanoate was higher after administering IOP-G than when IOP was given. Additional studies were performed to determine the effect of bile salt excretion on the Emax of iopanoate in rats following the intravenous infusion of either IOP or IOP-G. Taurocholate was given intravenously at 2 and 4 μmol/min/kg. Bile salt excretion enhanced the Emax of iopanoate in rats in a similar manner as that previously found in dogs. The effect of taurocholate on the Emax when IOP-G compared to IOP was given was determined. The hepatic concentration of iopanoate was significantly higher after IOP-G than after IOP administration. In addition, the liver concentration was four times greater than the plasma concentration. The distribution of iopanoate among the various subcellular fractions after IOP and IOP-G injection was determined. It is possible that the difference between the plasma and hepatic concentration of IOP-G is sufficient to opacify the liver on CT scan. Following elimination from the gallbladder, conjugates of contrast agents are believed to be poorly absorbed from the intestine. However, we found significant absorption of IOP-G from isolated jejunal loops in dogs. This is in agreement with recent reports indicating that there is considerable enterohepatic circulation of IOP-G. The rate of absorption (intestinal flux, Jd) was determined from the maximum aqueous solubility (Cm) and the permeability coefficient (P) in the intestine (Jd = Cm ± P). Although the permeability of IOP-G is approximately one-third that of IOP, the intestinal flux is 10 times greater because IOP-G is 40 times more soluble in aqueous solution than IOP. These data suggest that an enterohepatic circulation of IOP-G occurs and may account for persistent or recurring gallbladder visualization.

Gallbladder visualization after intravenous pyelography

Gallbladder visualization using the newer IVP contrast materials is rare, and occurs in cases of depressed renal function or acute ureteral obstruction. Mechanisms are discussed.

Emptying the gallbladder prior to intravenous cholangiography: effect on gallbladder visualization.

Experiments were done to test the hypothesis that emptying the gallbladder prior to intravenous cholangiography (IVC) would result in earler and better opacification of the gallbladder. Five dogs were studied on two separate days in a crossover experiment. Each dog had a standard IVC (15-minute infusion of meglumine iodipamide) 2.5 cc/kg of following a 14-16-hour fasting period. On one of the days, 0.3 mcg/kg of Ceruletide was intramuscularly administered to each dog 30 to 45 minutes prior to the iodipamide infusion. Films obtained at the end of infusion and at 20, 40, 60, and 90 minutes were evaluated independently by three radiologists. The results indicate that pretreatment with Ceruletide produces a significant (p less than 0.05) improvement in the quality of gallbladder opacification during the first 90 minutes following iodipamide infusion. We conclude that earlier and better opacification of the gallbladder during IVC can be obtained by prior emptying of the gallbladder with a cholecystokinetic agent.

Serum bile salts as an aid to oral cholecystogram interpretation.

A radioimmunoassay for glycocholate was used as an estimate of serum bile salts in patients with serum bilirubin levels less than 5 mg/dl undergoing oral cholecystography. Most subjects also had a percutaneous liver biopsy. Intravenous cholangiography was performed in most subjects who had a nonvisualized gallbladder after receiving single doses of iopanoic acid on two consecutive days. The pathologic status of nonvisualized gallbladders was ascertained by surgery, prospective follow-up, necropsy and/or ultrasound. In 20 subjects with well-visualized gallbladders, the serum cholate conjugates (CC) were lower than 3.5 μM in all but two subjects, both of whom had inflammatory liver disease (chronic active hepatitis, alcoholic hepatitis). Those with faintly or poorly visualized gallbladders, but with no evidence of gallbladder or gallstone disease by other criteria, also had levels less than 3.5 μM, except for one subject with inflammatory liver disease. By contrast, 11 subjects with nonvisualized, although normal gallbladders by the above clinical criteria, exhibited serum CC greater than 3.5 μM. Six subjects had diminished gallbladder visualization, but normal gallbladders on clinicopathological grounds; all but one with chronic active hepatitis had serum CC greater than 3.5 μM. In conclusion, when the serum cholate conjugates are less than 3.5 μM, nonvisualization of the gallbladder with oral cholecystography supports a diagnosis of a diseased gallbladder. In addition, a serum CC level greater than 3.5 μM may predict insufficient hepatic capacity to secrete iopanoic acid adequate for gallbladder visualization in noninflammatory liver disease. The serum cholate conjugates appear to provide greater information on this hepatic function than the serum bilirubin or bromsulfophthalein retention.

The Effect of Nonfractionated and Fractionated Administration of Lopanoic Acid on Gallbladder Visualization

The Effect of Nonfractionated and Fractionated Administration of Lopanoic Acid on Gallbladder Visualization

Persistent gallbladder opacification after iopanoic acid cholecystography: diagnostic implications for acalculous cholecystitis.

Recent reports in the surgical literature state that persistent dense visualization of an otherwise normal-appearing gallbladder 36 hr after the administration of iopanoic acid is highly suggestive of acalculous cholecystitis. To determine the incidence and significance of persistent gallbladder visualization, 324 patients and 66 asymptomatic controls were evaluated. An equal percentage (about 10%) of both groups showed persistent dense gallbladder opacification 36 hr after iopanoic acid ingestion. The results do not support the contention that patients with acalculous cholecystitis can be identified by simply obtaining an additional abdominal radiograph the day after oral cholecystography.

Aspirin effect on canine iopanoate transport maximun.

Iopanoate saturation kinetics were measured in four dogs both drug free and following six days of low dose aspirin ingestion. Each animal acted as its own control. In post aspirin ingestion studies there was s significant (P less than .001) decrease in the apparent Vmax of iopanoate. The volume of distribution showed no significant change, and gallbladder visualization showed no significant change despite the decrease in Vmax. Although aspirin pretreatment decreases the control Vmax by 50%, its mechanism and significance in the clinical setting will require further study.

Renal Pseudotumor on Urography Secondary to Gallbladder Empyema

AbstractA case of gallbladder empyema is presented, which opacified initially on excretory urography and then on nephrotomography, mimicking a renal mass. Correct diagnosis was accomplished by angiography and ultrasound examination. With normal renal function gallbladder visualization on urography is indicative of a gallbladder abnormality.

111In-phenolphthalexon, a new chelate for extended cholescintigraphy: formulation and preclinical characterization.

The first 111In chelate exhibiting hepatobiliary excretion, a 111In-phenolphthalexon, has been formulated and tested in rats. The preparation of the chelate is simple, reflecting its inherently high stability. Its capability for extended cholescintigraphy allowed distinct visualization of the gallbladder and the bowel to the level of the rectosigmoid in dogs. No lethality or acute toxicity was induced by administration of the chelate.

Combined cholangiography and cholecystography using sodium iopanoate.

Cholangiography and cholecystography were performed in fasted dogs and human subjects using sodium iopanoate given intraduodenally in doses of 10 and 20 mg/kg. The same studies were performed after intraduodenal administration of fat or after intravenous administration of cholecystokinin (CCK) in dogs and after a fatty meal, to stimulate endogenous release of CCK, in human subjects. In both the animals and human subjects, peak blood iodine concentrations were reached by 30 minutes after iopanoate administration. At a dose of 10 mg/kg, radiographic visualization of both bile ducts and gallbladder was inconsistent. At 20 mg/kg (one-half the clinical dose for standard oral cholecystography,) the common bile duct was visualized within 60 minutes and the gallbladder within 90 minutes. Gallbladder density increased over the next 6 hours. Prior administration of fat or CCK led to earlier and denser gallbladder opacification. The common bile ducts opacified with the use of iopanoate were small in caliber, averaging only 3 mm. This probably reflects the fact that, unlike iodipamide, iopanoate has little or no choleretic effect. Therefore, because it would not increase the volume of bile in the duct, iopanoate would not increase duct size.

RADIOGRAPHIC CHANGES AFTER SMALL BOWEL BYPASS FOR MORBID OBESITY

The presence of multiple intestinal air-fluid levels and the distention of jejunum and colon are common and expected sequelae of small bowel bypass procedures for morbid obesity. The radiologist must be familiar with these findings in order to avoid the misdiagnosis of bowel obstruction.