Patent Cystic Duct Research Articles

Abstract No. 223 Early human experience with percutaneous cholecysto-enteric anastomosis: a novel percutaneous approach for internal gallbladder drainage using lumen-apposing metal stents

High surgical risk patients with acute cholecystitis are frequently treated with a percutaneous cholecystectomy tube. These are associated with frequent tube complications and patient discomfort. Endoscopic Ultrasound (EUS) -guided gallbladder (GB) drainage is well described but can be difficult in the non-acute setting of a decompressed GB with a patent cystic duct and a cholecystostomy tube. Following our prior animal feasibility studies, we describe our early human experience with a novel percutaneous approach for the creation of an internal cholecysto-enteric anastomosis using a lumen apposing metal stent (PCEA-LAMS).

Management of Dual Chambered Gallbladder with Apple Core Narrowing with Segmental Cholecystitis and Cholangitis from Choledocholithiasis

Septated gallbladder is rare, when seen almost never have we seen an apple-core lesion with all the stones in one half of the gallbladder and none in the infundibulum but two in the bile duct. We present a case of a 58-year-old lady who presented with abdominal pain. She had normal vital signs except temperature of 100.2°F and right-upper-quadrant abdominal tenderness. Laboratory tests revealed, Total bilirubin of 1.4 mg/dl, Direct Bilirubin of 0.7 mg/dl, AST of 281 U/L, ALT of 367 U/L, ALP of 164 IU/L. Ultrasonography showed a Gallbladder wall of 3.6 mm, CBD diameter of 5 mm, and cholelithiasis. HIDA showed a visualization of the gallbladder in 60 min demonstrating patent cystic duct and later the duodenum. MR showed an apple-core like focal stricture in the midportion of the gallbladder with the distal half showing signs of inflammation, stones, and cholecystitis and a normal proximal gallbladder with normal extrahepatic bile ducts with no choledocholithiasis. She underwent Laparoscopic cholecystectomy with cholangiogram which demonstrated two CBD stones. One of them was removed with Lap trans-cystic-CBDE, later she needed ERCP to remove the other stone. She had a total of 6 days of hospital stay and had no future issues. Pathology did not reveal any malignancy. We demonstrate an unusual septated gallbladder with US, HIDA, MRI, and pathological correlation. An entity of partial chronic cholecystitis and choledocholithiasis should be considered in such a setting. Knowing the existence of apple-core lesion gallbladder should be helpful to manage rare presentation.

Percutaneous cholecystostomy for acute cholecystitis after stent insertion in patients with malignant biliary obstruction: clinical outcomes of 107 patients.

The outcome of percutaneous cholecystostomy (PC) in malignant patients with acute cholecystitis (AC) after biliary stent insertion has not been investigated in a large group. To evaluate the clinical outcomes of PC for AC after stent insertion in patients with malignant biliary obstruction. From April 2007 to February 2019, 107 patients (57 men, 52 women; mean age = 67.5 years; age range = 27-93 years) who had undergone PC for AC after biliary stent insertion were retrospectively evaluated. Of the 107 patients, 86 underwent biliary stent insertion by the endoscopic approach and the remaining 21 patients by the percutaneous approach. All patients were classified into three groups: those with stent-induced AC; those with cancer-induced AC; and those with AC without mechanical cause (biliary stent, GB stone, or cancer invasion). The mean survival time, recurrence rate, symptom improvement, and cystic duct patency in each patient group were analyzed. Stent-induced AC (n = 40, 37.4%) developed with a mean onset time of six days (range = 0-14 days), AC without mechanical cause (n = 27, 25.2%), 87 days (range = 15-273 days), and cancer-induced AC (n = 40, 37.4%), 137 days (range = 15-447 days) after stent insertion. Symptom resolution and significant improvement in laboratory test values were achieved in 95 patients (88.8%) within four days after PC. PC is a technically safe and effective method for the treatment of AC after biliary stent insertion in patients with malignant biliary obstruction.

Diagnosing cystic duct patency during myocardial perfusion imaging (MPI), using Tc99m Sestamibi (MIBI), as an adjunct benefit in the acute setting.

Objective:Tc99m methoxy isobutyl isonitrile (MIBI) has been used for myocardial perfusion imaging (MPI) for the detection of ischemia. This study aimed to investigate the feasibility of effectively evaluating cystic duct patency, during routine visual analysis of the raw MPI and/or with the three-dimensional reconstructed data.Methods:A retrospective investigation of 91 patients undergoing cardiac MIBI scan for acute chest pain and hepatobiliary scintigraphy (HBS) was performed, within no more than 3 months for suspected gallbladder obstructive disease. Gallbladder visualization during either the stress or rest portion of the MIBI was indicative of cystic duct patency. These results were compared to those by the HBS studies.Results:Ten patients had the MIBI and HBS 4 days apart, both analyses concurred 100% with the diagnosis of cystic duct patency. 16 patients had both examinations between 4 days and 3 weeks and had an agreement of 87.5% with cystic duct patency. 65 patients had both tests 3 weeks to 3 months apart and had an agreement of 84.6% with cystic duct patency.Conclusion:The initial results of this study indicate that MPI with Tc99m MIBI is useful in detecting a patent cystic duct, above all in the setting of acute gallbladder pathology.Advances in knowledge:In this article, we introduce a novel method to diagnose cystic duct patency in the acute setting thus effectively ruling out acute cholecystitis, during MPI. Our method can potentially improve patient outcomes by reducing the volume of imaging needed to exclude a diagnosis of acute gallbladder pathology. This in turn, keeps in line with decreasing the cost for the patient, leading to a more sound value-based care.

Agenesis of Gall Bladder with Patent Cystic Duct

We herein report an unusual case of choledocholithiasis with agenesis of gall bladder. Although the presentation was not unusual, the findings on investigations were unique. The radiological findings and management of the case are discussed here, and the interesting radiological images are included along with the unique features.

Safety and Efficacy of Early Tube Removal Following Percutaneous Transhepatic Gallbladder Drainage: an Observational Study.

Background:There are currently no guidelines concerning the advisability and timing of tube removal following percutaneous transhepatic gallbladder drainage (PTGBD). The present study aimed to assess the feasibility and risks of early removal of the PTGBD tube under the scenario of subsiding inflammation, patent cystic and common bile ducts, and absence of intraperitoneal leakage.Methods:Patient background and outcomes were assessed retrospectively in 701 cases of acute cholecystitis treated with PTGBD. The median times until tube removal and tube dislodgement and the cumulative rates of tube dislodgement were calculated.Results:Tube removal was performed in 275 patients after a median time of 16 days (range: 6 to 213 d); biliary peritonitis was observed in 2 patients following tube removal. Tubes were removed in 8 and 35 patients within 7 and 10 days, respectively. Tube dislodgement was observed in 82 patients after a median time of 12 days (range: 1 to 125 d).Conclusion:The present study suggests that drainage tube removal is safe and effective when performed after a short drainage period of 7 to 10 days if the criteria for the removal of the drainage tube were met.

Outcomes of Patients Treated With Upfront Cholecystostomy for Severe Acute Cholecystitis.

Percutaneous cholecystostomy tube (PCT) placement is a treatment method for acute cholecystitis, both in adult patients unsuitable for surgery and those failing to improve with conservative management. The purpose of this study was to assess the outcomes of patients undergoing cholecystostomy. A review of consecutive patients who underwent PCT insertion over a 10-year period was performed. Outcomes assessed included cholecystostomy dwell time, tubogram requirement, cholecystostomy reinsertion, cholecystectomy, bile leaks, and mortality. One hundred eight patients (77 male individuals, 31 female individuals) were included. The mean age was 70 years (range: 29 to 93 y). A total of 89 transhepatic and 19 transperitoneal PCTs were inserted. Fifty-nine patients (55%) had a subsequent tubogram to assess cystic duct patency or catheter position. Mean catheter dwell time was 17 days (range: 1 to 154 d). Eleven (10%) required PCT reinsertion. Time to reinsertion ranged from 2 to 163 days (mean=38 d). Fifty-three patients (50%) had no further biliary intervention after removal of the cholecystostomy catheter. One patient required subsequent drainage of a hepatic abscess, and another developed a biloma. Thirty-two patients (30%) underwent cholecystectomy (66% laparoscopic, 34% open). Thirty-day mortality after PCT insertion was 8.3%. Twenty patients (19%) died of non-cholecystostomy-related illness during the 10-year follow-up period. Cholecystostomy is an important treatment method of acute cholecystitis as a bridge to cholecystectomy or as an alternative definitive treatment option in those unsuitable for surgery. A tubogram is not always necessary before tube removal. Cholecystostomy tubes can be removed safely with little risk of bile leak if patients are clinically well, and clean-appearing bile is draining.

1340 Variable Effect on the Sphincter of Oddi From Narcotics

INTRODUCTION: Several studies have shown an increase in biliary pressure after administration of narcotics. Direct sphincter of Oddi (SO) manometry has demonstrated that the sphincter of Oddi is particularly sensitive to all narcotics including morphine, meperidine, pentazocine, fentanyl, and codeine. Opiates are known to increase the phasic wave (via mu receptors) as well as basal pressure (via non-mu receptors) of the SO. This case report illustrates a possible difference in affinity among narcotics to these receptors leading to SO dysfunction. CASE DESCRIPTION/METHODS: 54 years old male with a history of knee meniscal repair presented to the emergency department with epigastric pain associated with nausea and vomiting for one day. The patient described the pain as severe, sharp, and worsening with food intake. He denied alcohol use, illicit drug abuse, or taking any medication. He had a lipase of 200 U/L, with normal transaminases and bilirubin. Physical exam revealed severe tenderness on the epigastric area. CT showed acute edematous interstitial pancreatitis. Ultrasound of the liver and HIDA scan demonstrated a patent cystic and common bile duct. The patient was started on IV fluids and IV morphine. The patient reported slight relief of abdominal pain with low doses of IV morphine. Therefore, the frequency and dose of morphine were increased. Interestingly, the patient reported acute worsening of the epigastric pain a few minutes after administration of higher morphine doses lasting for approximately 2 hours. Laboratory studies drawn during pain exacerbation showed no elevation of transaminases or lipase. IV morphine was discontinued resulting in immediate abdominal pain relief. Upon further questioning, the patient reported recent use of oxycodone and tramadol for knee pain without any side effects from these medications. DISCUSSION: Opiates have been reported to incite biliary colic pain and their effect on the SO represents the most likely etiology. Our patient showed a particular susceptibility to morphine, but not to other narcotics previously prescribed suggesting a possible variable effect on the OD from different narcotics. It is worth noting that our patient denied cholecystectomy, a known risk factor that predisposes to SO dysfunction. In conclusion, SO dysfunction should be considered in patients with pancreatitis reporting worsening of abdominal pain while on opioids. SO manometry is contraindicated during acute pancreatitis, therefore discontinuation of the narcotic helps guide diagnosis.

Abstract No. 542 Can cystic duct patency be a reliable indicator in the management of the a cholecystostomy tube?

Routinely, cholecystostomy tubes are placed in the septic patent who would otherwise be unfit for surgical management. Classical thought is that the patient should progress to cholecystectomy after recovery from the acute illness. However, with greater attention on outcomes, it seems that cholecystostomy tubes may be remaining in-situ for a longer duration. The goal of this study is to identify if patency of the cystic duct is a viable indicator for the removal of a cholecystostomy tube. We retrospectively reviewed all cholecystostomy tube placements between 2015 to 2016 at our institution. Cases where excluded tube placement was for an obstructing mass, palliative, prior cholecystostomy tube, or lost to follow-up. Data collected include indication for placement, age, duration until cystic duct opening and total tube time in situ, underwent a capping trial and outcome, surgery status, if the tube dislodged, and if died with tube in situ. Data was compared with a Cox Regression survival analysis and descriptive measures. 31 people (45.6% of eligible cholecystostomy tube placements) were identified to have a patent cystic duct during placement or with routine management. Half of the population had patency by 37 days after placement. There was no significance difference in time for the cystic duct to open between acute calculous versus acalculous cholecystitis as the indication for placement. As for outcomes, 45.3% proceeded with cholecystectomy, 12.9% passed with tube in-situ, and 42% where able to have the tube removed. Of those removed, 2 people (15.4%) had a recurrent cholecystitis at a mean of 246 days, who went on to tube replacement and subsequent tube removal at patency of cystic duct. Our analysis suggests that cystic duct patency may be a valid indicator for the management of a cholecystostomy tube without a large proportion of the population having to have re-intervention.

Sa1042 SINGLE INSTITUTIONAL DIAGNOSTIC ACCURACY OF INTRAOPERATIVE CHOLANGIOGRAMS AND EVALUATION OF PREDICTORS OF POSITIVE FINDINGS.

To determine our institutional false-positive (FP) rate of Intraoperative Cholangiograms (IOC) and compare predictors to those listed in current guidelines. IOC is often performed during a cholecystectomy to determine patency of cystic duct and presence of residual stones. Unfortunately, IOCs have reported false-positive rates of up to 60%. It is unclear whether these rates are due to misinterpretation of the cholangiogram (artifacts/air bubbles), passage of the stones prior to endoscopic evaluation, or non-visualization of stones at the time of removal. This high FP rate results in potentially unnecessary endoscopic retrograde cholangiopancreatography (ERCP) and exposing patients to associated risks of pancreatitis, hemorrhage, and perforation. Retrospective review from 2002-2017 identified all IOC (1507 patients) performed at our institution. A total of 245 patients were included in our study, defined as having a positive IOC. In all the included patients, we collected demographics, indication for cholecystectomy, IOC findings, blood tests before and after cholecystectomy, ERCP/Endoscopic ultrasound (EUS) results (Table 1), and number of days between cholecystectomy and endoscopic evaluation. Analysis using SPSS was performed to assess for statistically significant associations between potential risk factors and a positive IOC. The data from 245 patients was analyzed using SPSS (version 24). 184 patients (75.2%) were female and 61 (24.8%) were male. The mean age was 47.9 years (SD 20.49 years). 241 patients (98.4%) had either non-passage of contrast into the duodenum, filling defects on IOC, or both. Stones were present in 145 patients (59.2%) at the time of ERCP, giving a FP rate of 40.8%. The mean length of time between IOC and ERCP was 1.75 days (range 1-9 days). Univariate analysis revealed that patients who had an elevated direct bilirubin level prior to cholecystectomy and an elevated total and direct bilirubin level after cholecystectomy, were more likely to have a stone on ERCP (p < 0.021). However, these factors were not significant predictors on multivariate analysis. No additional factors, including transaminases, pancreatic enzymes, or WBC were found to be predictors of stone on ERCP (Table 2). 5 patients (0.56%) who had a stone on EUS, did not have a stone on ERCP. High FP rates of IOC render its use controversial. Bilirubin was the only predictor of stone on ERCP. This reinforces the need to evaluate the role of additional tests such as EUS, with prospective studies to help determine which patients can avoid ERCP. Further validation of currently published guidelines should also be performed to improve results.Tabled 1Endoscopic Findings.PROCEDURE:Imaging only, n (%)20 (8.1)EUS only, n (%)3 (1.2)ERCP only, n (%)213 (87)EUS followed by ERCP, n (%)9 (3.7)EUS FINDINGS (n=12):No stones, n (%)3 (25)Stone(s), n (%)9 (75)CBD dilated on EUS , n (%)7 (58)ERCP FINDINGS (n=222):No stones, n (%)100 (45)Stone(s), n (%)145 (65)CBD dilated on ERCP , n (%)94 (42) Open table in a new tab Tabled 1Potential Predictors of stone on ERCP.N (Patients with stone on ERCP)MeanStd. DeviationP ValuePre-CCY T.Bili1452.2662.91780.484Pre-CCY D.Bili1451.1921.95780.022Pre-CCY AST145236.45263.4510.46Pre-CCY ALT145295.4303.6540.161Pre-CCY Alk Phosph145174.88118.3650.63Pre-CCY WBC1459.59493.96810.626Post-CCY T.Bili1452.313.15590.018Post-CCY D.Bili1451.2482.07830.02Post-CCY AST145137.58116.3920.183Post-CCY ALT145230.8195.0140.089Post-CCY Alk Phosph145164.0691.0070.63Post-CCY WBC1459.46343.230380.764 Open table in a new tab

4:03 PM Abstract No. 168 Results of percutaneous cholecystostomy tube placement in 324 patients

Determine the technical success and clinical outcome of cholecystostomy tube placement along with removal rate after placement. A database search was performed from January 2010 to September 2017 for the term “cholecystostomy tube” yielding 1,160 patients. Patients with no indication for cholecystostomy (n = 625; 53.9%) or an outside hospital placed cholecystostomy (n = 211; 18%) were excluded. 324 (27.9%) patients with cholecystostomy tubes were included in the analysis. 312 (96.2%) tubes were placed by interventional radiology and 12 (3.8%) intraoperatively by surgery. Indication for cholecystostomy tube placement, ultrasound findings, initial lab studies, candidacy for surgery, comorbidities, access route, tube size, dwell time, bile culture results, reason for tube removal, follow-up, and complications were recorded. The indications for cholecystostomy tube placement included: acute cholecystitis (n = 270; 83.3%), perforated cholecystitis (n = 22; 6.8%), and emphysematous cholecystitis (n = 18; 5.6%). Ultrasound findings included: wall thickening (n = 208; 64.2%), calculi (n = 187; 57.7%), and pericholecystic fluid (n = 143; 44.1%). 297 (91.7%) patients were not surgical candidates. The most frequent reason for removal was cholecystectomy (n = 96; 29.6%). 36 (11.1%) had a patent cystic duct on follow-up, 19 (5.9%) had cholecystoscopy and stone removal, 15 (4.6%) underwent double J stent placement, and 3 (0.01%) had liver transplants. 94 patients died (29%), 33 (10.2%) had tubes migrate or fall out. 256 (79%) had transhepatic and 56 (17.2%) had transperitoneal tubes. Mean tube size was 7-French. Mean dwell time was 89 days (range, 0-586 days). 45 (13.9%) patients had tubes at the end of study period, and 19 (4.2%) were lost to follow-up, 13 (28.9%) had ongoing tube changes, 8 (17.8%) scheduled cholecystectomy, and 4 (8.9%) getting downsized with plans for removal. 321 (99%) of patients had no major adverse events, 2 (0.006%) had bile leak, and 1 (0.001%) developed septic shock. Cholecystostomy tube placement was possible in all patients and clinical symptoms resolved after placement in all cases. A majority of patients were able to have their tubes removed.

Percutaneous Cholecystostomy: Long-Term Outcomes in 324 Patients.

To report technical success and clinical outcome of cholecystostomy tube placement along with timing-and method-of tube removal. A retrospective review of cholecystostomy tubes placed from January 2010 to September 2017 was performed at a single academic center. This search yielded 1160 patients. Of these patients, 324 (27.9%) met inclusion criteria for cholecystostomy placement, 199 (61.4%) males and 125 (38.6%) females, with mean age of 67years (range 6-101years). The indication for cholecystostomy tube placement, technical success, surgical candidacy, medical comorbidities, clinical outcome, tube indwelling time, complications, and follow-up were recorded. Indications for cholecystostomy tube placement included: acute cholecystitis (n=270; 83.3%), perforated cholecystitis (n=22; 6.8%), emphysematous cholecystitis (n=18; 5.6%), and other (n=14; 4.3%). Technical success was 100%. Many patients had multiple medical comorbidities including (most commonly): debilitation (n=211; 65.1%), cardiovascular disease (n=194; 59.9%), multisystem disease (n=181; 55.9%), and malignancy (n=131; 40.4%). After tube placement, 96 (29.6%) patients underwent definitive cholecystectomy, 94 expired (29.0%), 36 (11.1%) had a patent cystic duct on follow-up cholangiogram and subsequent cholecystostomy removal, 14 (4.3%) underwent cholecystoscopy with stone removal, and 3 (0.9%) had liver transplantation. Forty-five (13.9%) patients had indwelling tubes at the end of the study period. Mean tube indwelling time was 89days (range 0-586days). Technical success for cholecystostomy tube placement was 100% with all patients having clinical resolution of acute cholecystitis. Many patients were able to have tubes subsequently removed.

Gallbladder opacification on gadoxetate disodium-enhanced CT scan.

This study aimed to evaluate the radiologist's ability to identify excreted gadoxetate disodium within the gallbladder on CT scan. Thirty three healthy adults underwent imaging of the liver during work-up for potential liver donation. Three patients had undergone prior cholecystectomy and therefore were excluded. Imaging consisted of gadoxetate disodium-enhanced magnetic resonance cholangiography (MRC) and multiphase contrast-enhanced CT scan of the abdomen and pelvis. Two fellowship-trained abdominal imaging radiologists, who were blinded to the MRC images and the contrast agent used during MRC, independently reviewed the CT scans of the 30 patients that were included. The scans were evaluated for the presence or absence of abnormal hyperdensity within the gallbladder. Three patients did not receive intravenous gadoxetate disodium, 4 patients had their MRC after the CT scan, and 1 patient had the CT scans 5days following the MRC. Twenty two patients had the CT scan within 24h following the gadoxetate disodium-enhanced MRC. Of the 22 patients expected to have gadolinium in the gallbladder, both reviewers identified hyperdensity in the same 20 patients (90%). Both reviewers reported no abnormal hyperdensity within the gallbladder in the remaining 10 patients. CT scan can reveal excreted gadoxetate disodium within the gallbladder lumen and therefore gadoxetate disodium-enhanced CT scan can potentially play a role in the evaluation of cystic duct patency and work-up of acute cholecystitis.

Evaluation of cystic duct patency: comparison of functional MR cholangiography with gadoxetate disodium and hepatobiliary scintigraphy in suspected acute cholecystitis

PurposeThis study aims to compare assessment of cystic duct patency between gadoxetate disodium MRI and hepatobiliary scintigraphy. Materials and methodsWe performed a prospective study of patients who underwent gadoxetate disodium MRI within 16 h of scintigraphy. ResultsThe gallbladder filled on MRI and scintigraphy in 8 patients, none with acute cholecystitis. The mean time to gallbladder filling was 14.6 and 18.9 min for MRI and scintigraphy, respectively. The gallbladder did not fill on both MRI and scintigraphy in 3 patients, all of whom had acute cholecystitis. ConclusionEvaluation of cystic duct patency using gadoxetate disodium MRI is comparable to hepatobiliary scintigraphy.

Hepatobiliary phase of gadoxetic acid-enhanced MR in patients suspected of having gallbladder dyskinesia: comparison with hepatobiliary scintigraphy

ObjectiveTo compare hepatobiliary phase of gadoxetic acid-enhanced magnetic resonance (HMR) and hepatobiliary scintigraphy (HBS) for evaluation of cystic duct patency and gallbladder contractility in patients suspected of having gallbladder dyskinesia. Materials and methodsEighteen patients underwent HMR and HBS. Cystic duct patency and gallbladder ejection fraction (GBEF) were compared to determine a significant difference between HMR and HBS. ResultsHMR and HBS had 15 concordant and 3 discordant results for cystic duct patency. GBEF in eight patients showed no significant difference between both modalities. ConclusionHMR may be an alternative to HBS for the functional evaluation of cystic duct patency and GBEF.

Endoscopic treatment for Bouveret syndrome

Gallstone ileus is an uncommon cause for small bowel obstruction. Less than 3 % of cases are due to a gallstone impacted in the duodenum or pylorus resulting in a gastric outlet obstruction, described by Bouveret in 1896. Most of the successful therapeutic maneuvers described involve open surgical removal of the stone through either a gastrotomy or duodenotomy, and reported morbidity is not insignificant. Endoscopic techniques continue to evolve, allowing for more complex procedures and avoidance of open surgery and its accompanying high morbidity. This video displays a rarely used endoscopic method of relieving gastric outlet obstruction caused by a stone in a patient with Bouveret syndrome. Video of successful endoscopic retrieval of a gallstone lodged in the pylorus is presented. An endoscopic retrieval basket is used, and key maneuvers highlighted include passage of the closed device distal to the stone, opening of the basket, and withdrawal of the stone under direct vision. After successful retrieval, endoscopic inspection revealed a normal duodenum and relief of the obstruction. Cholecystectomy was not performed, given that most cholecystoduodenal fistulae are large and will spontaneously close, especially if a patent cystic duct is present. Liver function tests were normal postoperatively, so no further evaluation of the bile duct was necessary. With new advances in technology, the endoscopic approach should be considered as the first line of treatment for cases of Bouveret syndrome because most patients are elderly with multiple comorbidities.

Determination of cystic duct patency using hepatobiliary MRI with gadoxetate disodium: Is T1 precontrast imaging necessary?

To determine the need for precontrast T1-weighted imaging in determining cystic duct patency using hepatobiliary phase imaging with gadoxetate disodium-enhanced magnetic resonance imaging (MRI). MRI exams using gadoxetate disodium from October 4, 2008 to April 14, 2010 were reviewed in a retrospective fashion. Two reviewers independently reviewed only the 20-minute T1-weighted delayed postcontrast images to determine the presence of excreted contrast in the gallbladder lumen. Contrast was deemed present if hyperintense signal material was seen in the antidependent portion of the gallbladder lumen. The actual presence of contrast in the gallbladder was determined by directly comparing the pre- and postcontrast T1-weighted images using consensus review. In all, 187 cases were included. Three (1.6%) were deemed indeterminate due to complete homogeneous opacification of the gallbladder. All three cases were identified as indeterminate by both reviewers. Of the remaining 184 cases, 136 filled (74%) and 48 did not fill (26%). Both reviewers correctly identified 136/136 cases of gallbladder filling. Reviewer A identified 47/48 cases of nonfilling and reviewer B identified 46/48 cases of nonfilling. Sensitivity and specificity were 100% and 98% for reviewer A and 100% and 96% for reviewer B, respectively. The presence of excreted contrast in the gallbladder lumen can be determined using gadoxetate disodium-enhanced MRI without precontrast T1-weighted imaging.

Functional evaluation of cystic duct patency with Gd-EOB-DTPA MR imaging: an alternative to hepatobiliary scintigraphy for diagnosis of acute cholecystitis?

To determine if MR cholangiography with Gd-EOB-DTPA can be used to assess cystic duct patency and to establish normal time range for reflux of contrast material into the cystic duct/gallbladder. This retrospective study is HIPAA-compliant and IRB-approved with waiver for informed consent granted. From September 2008 to June 2009, 300 patients who underwent Gd-EOB-DTPA-enhanced MR imaging for various clinical indications, not specifically limited to evaluation for acute cholecystitis, were identified. 112 patients were excluded: prior cholecystectomy (n = 93), severe technical limitations (n = 9), or absence of appropriate clinical follow-up (n = 10). 188 total patients (82 male, 106 female, mean age 51.0 years) were included in the final dataset. Time between contrast administration and contrast reflux into the cystic duct/gallbladder on delayed phase imaging was measured. Reflux of contrast into the gallbladder was identified in 130/188 patients (69.1%) on delayed phase imaging. Average time to gallbladder reflux was 15:24 ± 5:51 minutes (range: 6:01-41:05 min). 58/188 patients (30.9%) demonstrated no reflux of contrast into the gallbladder at time of final delayed phase images. Of 58 patients who demonstrated no reflux into cystic duct/gallbladder, 15 patients demonstrated no extrahepatic biliary excretion, limiting evaluation of cystic duct patency. A total of 173 patients demonstrated biliary excretion of contrast with 76% overall sensitivity of detection of cystic duct patency. MR cholangiography with hepatobiliary MR contrast agents such as Gd-EOB-DTPA can demonstrate cystic duct patency with high sensitivity. MR protocols can be designed within a clinically feasible timeframe to optimize diagnosis of acute cholecystitis.

Gd-EOB-DTPA as a Functional MR Cholangiography Contrast Agent: Imaging Gallbladder Filling in Patients With and Without Hepatobiliary Dysfunction

To evaluate cystic duct patency on hepatobiliary-phase magnetic resonance (MR) images after intravenous gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) administration. A radiology information system search identified patients with gallbladders that had MR imaging after intravenous Gd-EOB-DTPA injection. No patients had acute cholecystitis. Magnetic resonance image findings were correlated with clinical notes, other imaging studies, time of contrast injection, and serum laboratory tests. Contrast accumulated in the gallbladder in 80% of patients (n = 100) with hepatobiliary-phase MR imaging at a median of 22 minutes (range, 15-83 minutes). Absence of contrast accumulation in the gallbladder (n = 20) was associated with hepatobiliary imaging less than 30 minutes after contrast administration, gallbladder contraction, cholelithiasis, elevated liver function tests, elevated bilirubin, and cirrhosis. Functional assessment of cystic duct patency by Gd-EOB-DTPA-enhanced liver MR is best conducted when hepatobiliary-phase T1-weighted imaging is delayed by more than 30 minutes after contrast injection. Hepatobiliary dysfunction is associated with nonfilling of the gallbladder.

A Diagnostic Dilemma of Atypical Gallbladder Appearance on Tc-99m HIDA Cholescintigraphy Resolved With SPECT/CT

Tc-99m HIDA cholescintigraphy is the diagnostic procedure of choice for acute cholecystitis. Acute cholecystitis is associated in vast majority of the cases with cystic duct obstruction. The demonstration of presence (cystic duct patency) or absence (cystic duct obstruction) of visualization of the gallbladder on cholescintigraphy is critical to the diagnosis of acute cholecystitis. The visualization of the gallbladder rules out acute cholecystitis in most of the cases. Although, in most cases, determination of visualization or nonvisualization of gallbladder is straight forward, occasionally it can be challenging. We describe a patient with suspected acute cholecystitis, in whom an unusual appearance of the gallbladder on hepatobiliary scintigraphy was clarified with SPECT/CT, an approach that is rarely used in Tc-99m HIDA cholescintigraphy.