Disorders of gallbladder function related to duodenogastric reflux in technetium-99m DISIDA hepatobiliary scintigraphy.

Controversy exists over the relation between gallbladder dysfunction and the propensity for duodenogastric reflux. To evaluate this, Tc-99m DISIDA hepatobiliary imaging studies in 120 patients were reviewed, excluding patients who had had cholecystectomy or subtotal gastrectomy before scintigraphy. Serial images were obtained at 5, 10, 15, 30, 45, and 60 minutes and up to 24 hours, if indicated, after intravenous injection of 5-10 mCi of Tc-99m DISIDA. Normally, the liver, bile ducts, gallbladder, common bile duct, and bowel are visualized sequentially. Reversal of the normal sequence of gallbladder (GB) and bowel visualization indicates GB dysfunction; nonvisualization of the GB reflects cystic duct obstruction or absent GB function. Duodenogastric reflux is identified by radiotracer localized in the area just below or immediately adjacent to the tip of the left hepatic lobe. The intragastric location of the tracer may be verified by oral administration of 300 uCi of Tc-99m sulfur colloid. Twenty-nine patients had duodenogastric reflux between 10 and 60 minutes after injection. Of the 29 patients, 22 had a nonvisualized gallbladder, four had reversal of appearance of GB and bowel activity, and three had a normal study. GB dysfunction or nonfunction is more frequently demonstrated when duodenogastric reflux is present than with normal gallbladder function (P less than 0.001). In conclusion, gallbladder malfunction is closely associated with duodenogastric reflux, an abnormality that may be diagnosed noninvasively by Tc-99m DISIDA hepatobiliary scintigraphy.

Technetium-99m BIDA biliary scintigraphy in the evaluation of the jaundiced patient.

Biliary scintigraphy using 99mTc p-butyl acetanilidiminodiacetic acid (BIDA) was performed as part of the diagnostic evaluation on 96 patients with jaundice (serum bilirubin greater than 2 mg/dl) to assess its value in this group of patients. The results of scintigraphy revealed no obstruction to the flow of the scintigraphic agent into the duodenum in 54 patients, delayed appearance of the agent (normal upper limit 60 min) in the duodenum indicating partial obstruction in 22 patients, and complete obstruction of the duct demonstrated by absence of agent in the duodenum in 20 patients. The findings were correlated with the final diagnosis and the overall results show accuracy of 92.7%, sensitivity of 97.3%, and specificity of 89.8%. Biliary scintigraphy was thus found to be useful in differentiating nonobstructive, partially obstructive, and completely obstructive causes of jaundice.

COTA (colon-ovarian tumor antigen). An immunohistochemical study.

A goat anti-serum was prepared against mucinous ovarian cyst fluid and absorbed with normal colon and a variety of normal tissues until the only residual immunoreactivity was directed against colon cancer and ovarian tumor mucin. The set of antigenic determinants defined by this anti-serum has been called COTA, standing for colon-ovarian-tumor-antigen. This highly absorbed anti-serum (anti-COTA) was used for immunohistochemical staining of 42 different tissues in parallel with staining with a goat anti-CEA, which was also highly absorbed. The results suggest that COTA is a highly sensitive and specific antigen for colon carcinoma and may have potential for the early detection of malignant changes predictive of cancer of the colon.

Preliminary findings in the evaluation of hepatic malignancies by radioimmunodetection, X-ray computed tomography, and magnetic resonance imaging.

In 12 consecutive patients with suspected metastatic carcinoma of the liver, we evaluated the sensitivity of radiolabeled antibodies to tumor antigens, magnetic resonance imaging, and X-ray computed tomography imaging in the detection of hepatic malignancies. Studies were performed with 131I labeled antibodies to CEA and/or CSAp; polyclonal, monoclonal and F(ab')2 antibodies were used. Nontarget radioactivity was diminished by administration of 99mTc reagents simulating nontumor distribution and use of a computer subtraction method. In nine patients with confirmed liver neoplasms, radioimmunodetection disclosed the foci of hepatic malignancies. In three patients with suspected liver neoplasms, the antibody studies were positive, but at this time have not been confirmed. X-ray computed tomography each disclosed mass lesions in five patients and magnetic resonance in three. These findings suggest that radioimmunodetection provides greater accuracy in the detection and localization of cancer than other diagnostic modalities currently used.

The surgical implications of herniation of the urinary bladder.

The urinary bladder is often involved in an inguinal hernia, but herniation of the entire bladder into the scrotum is rare. As many as 4% of inguinal hernias may involve the bladder, usually in the form of a sliding hernia. Most urinary bladder herniations are diagnosed at the time of inguinal herniorrhaphy, and are therefore most commonly repaired through an inguinal incision. If the diagnosis requires amendment, alternative surgical approaches are available. We studied two patients with massive inguinoscrotal herniation of the urinary bladder, commonly referred to as "scrotal cystocele." We reviewed the literature, incidence, causes, diagnosis, and surgical consideration of herniation of the urinary bladder, and gave particular attention to the interrelationship of bladder herniations with inguinal hernias.

Scintiscanning in the evaluation of biliary enteric anastomoses.

The evaluation of symptomatic patients who have undergone biliary enteric anastomoses, particularly when the diversion was into the jejunum, is difficult. Conventional techniques for evaluation, such as oral cholecystography (OCG), intravenous cholangiography (IVC), ultrasonography (US), computer-assisted tomography scanning (CT scanning), or endoscopy are not adequate to provide definitive information on the patency of the anastomoses. Hepatobiliary scintiscanning using 99mTc-HIDA and BIDA (iminodiacetic acid derivatives) was performed on 12 patients. The patients were from 11 to 72 years of age and included ten men and two women. The scan results were correlated with US, CT scan, percutaneous transhepatic cholangiography (PTC), operative findings, and final diagnosis. Scanning was highly accurate in this group and could be performed successfully even in jaundiced patients (total serum bilirubin level up to 20.0 mg/dl). In patients in whom dilated bile ducts were demonstrated (by US, CT scan, or scintiscan), only the scintiscan revealed the true patency of the anastomoses. The advantages of the technique are that it is simple and noninvasive. Delayed transit of bile (scanning agent) to bowel is a very reliable indication of partial or complete obstruction. Scintiscanning is the only technique that demonstrated the functional state of biliary secretion and excretion into bowel in patients with previous biliary enteric anastomoses.

Amylase isoenzymes in the evaluation of trauma patients.

In traumatized patients, elevation of the levels of serum amylase is often noted and may lead to a diagnosis of pancreatitis or pancreatic injury. In the presence of multiple injuries, it is often difficult to evaluate clinically for pancreatitis or pancreatic injury. Since the serum amylase is derived from both the pancreatic and the salivary glands, it is useful to determine the origin of the elevated levels of serum amylase in these patients. A total of 31 patients including 21 trauma patients were studied, and the total serum amylase and also the pancreatic (P) and salivary (S) fractions were determined by isoelectric focusing. Compared with the normal control group, most trauma victims had elevated total amylase levels (normal, 30-128 U). In six patients with head and facial trauma, the P-fraction was 7.6 per cent, and the S-fraction was 92.4 per cent (normal, P 35-50%; S 50-65%), while in six patients with penetrating abdominal trauma, the P-fraction was 81 per cent, and the S-fraction was 19 per cent. These differences were statistically significant. The data demonstrate the value of measuring fractions of amylase in addition to total amylase levels. In patients with head and facial trauma alone, elevated levels of serum amylase are due to an increase in the salivary fraction. Elevation of total serum amylase in traumatized patients does not necessarily indicate pancreatic injury. Measurements of amylase fractions were thus useful in evaluation of trauma patients.

Characterization of a common antigen of colorectal and mucinous ovarian tumors, COTA.

A new colon cancer antigen is reported. It is designated as COTA, Colon-Ovarian Tumor Antigen, because it is found in mucins produced by both tissues during malignancy. The new antigen was identified by making antibodies against human colon cancer tissue in goats. The antisera were exhaustively absorbed with lyophilized extracts of normal colon, lung, liver, spleen, kidney, plasma, and the well-known colon tumor antigen, carcinoembryonic antigen (CEA). The new antigen was identified by immunodiffusion. Studies of 28 malignant tissue extracts, 10 ovarian adenocarcinoma cyst fluids, 43 normal tissues, and 5 plasma samples revealed that this antigen is found only in colon tumors and mucinous ovarian adenocarcinomas. The antigen was not detected in serous adenocarcinoma of the ovaries, extracts of adenocarcinoma of lung, breast, kidney or stomach nor in the extracts of normal tissues. Other tests show that this antigen is not CEA, Ca 19-9, or CSAp. It is stable to heating at 65 degrees for 5 minutes; it elutes from an ion exchange matrix (DEAE) with 0.3-0.5M NaCl; it migrates to the alpha-2 region on immunoelectrophoresis; and its size, by exclusion chromatography on Sepharose 4B, is 3-15 million daltons. Anti-COTA stains colon cancer tissue sections indicating that COTA is present in goblet-cell mucin.

Biliary levels of ceforanide.

Ceforanide levels in plasma, gallbladder bile, gallbladder tissue, and common bile duct were studied in 10 patients with normal biliary tracts and in 35 patients with biliary disease at various intervals after intravenous injection of 1 g of the drug. Peak blood levels were obtained within 1 h of administration (mean, 67 +/- 15 micrograms/ml). Patients with a normal bilary tract, as well as patients with chronic cholecystitis and a patent cystic duct, achieved high gallbladder bile levels of ceforanide within 2 h (mean, 76 +/- 25 micrograms/ml) and attained even higher levels by 4 h (mean, 182 +/- 51 micrograms/ml). However, all patients with chronic cholecystitis and an occluded cystic duct had very low drug concentrations in the gallbladder bile (14 +/- 7 micrograms/ml at 2 h). Despite this difference in gallbladder bile levels, ceforanide levels of 21 +/- 3 micrograms/g were achieved at 1 to 3 h in gallbladder tissue in both groups with chronic cholecystitis. The concentration of ceforanide in common bile duct was 149 +/- 59 micrograms/ml at 2 h after administration, with levels over 60 micrograms/ml present from 1 to 4 h after administration. These results indicate that ceforanide reaches high levels in the biliary tract. Its potential value in the prevention and treatment of biliary infections should be assessed.

The value of scintigraphy in the diagnosis of biliary disease.

Scintigraphy was performed on 180 patients with suspected biliary tract disease using technetium-99m-labelled derivatives of iminodiacetic acid. Most of the patients were also evaluated by conventional techniques and the results were correlated with the findings at operation and with histological examination of tissue removed whenever indicated. The technique was very accurate in the diagnosis of acute cholecystitis. In chronic cholecystitis it was useful in the diagnosis only when the cystic duct was obstructed. Scintigraphy has no value in the diagnosis of gallstones. However, it permits visualisation of the biliary tract even in the presence of jaundice and is useful in distinguishing obstructive from non-obstructive types of jaundice.