Ultrasound-guided transhepatic computed tomography cholecystography in beagle dogs.

This study was performed to evaluate the feasibility of ultrasound-guided computed tomography (CT) cholecystography and to establish an optimal protocol. In 8 healthy beagles, CT cholecystography was conducted using four contrast formulas; two dilution ratios (1:1 vs. 1:3) and two total volumes (8 mL vs. 16 mL) of 300 mgI/kg iohexol after ultrasound-guided percutaneous contrast injection into the gallbladder. CT images were obtained at 3, 10, and 30 min after injection and assessed qualitatively and quantitatively. For all contrast formulas, CT cholecystography showed the gallbladder and the intra- and extrahepatic bile ducts. The volume of the gallbladder and size of bile duct were significantly larger when using a volume of 16 mL iohexol than an 8 mL volume regardless of the dilution ratio. The distinction between the common bile duct and duodenum, the filling of the gallbladder, and the patency of bile duct were effectively assessed using a 16 mL volume of contrast agent with either dilution ratio. Beam-hardening artifacts deteriorated CT image quality for visualizing the biliary system when using the dilution ratio of 1:1. Patency of the bile tract could be easily evaluated using a curvilinear planar reconstruction. There was no significant difference in CT scan time among the different conditions. Minor leakage of contrast agent temporarily occurred after contrast injection in 30% of 32 sets of CT cholecystography. Ultrasound-guided percutaneous cholecystography can visualize both gallbladder and biliary tract with minimal artifacts using a contrast agent volume of 16 mL with a 1:3 dilution ratio.

Percutaneous US-guided Cholecystocholangiography with Microbubbles for Assessment of Infants with US Findings Equivocal for Biliary Atresia and Gallbladder Longer than 1.5 cm: A Pilot Study.

Purpose To evaluate the feasibility of ultrasonographically (US) guided percutaneous cholecystocholangiography (PCC) for early exclusion of biliary atresia (BA) in infants suspected of having BA with equivocal US findings or indeterminate type of BA and a gallbladder longer than 1.5 cm at US. Materials and Methods This study was approved by the ethics committee; written informed parental consent was obtained. From February 2016 to December 2016, nine infants (four boys, five girls; mean age, 60.2 days; median age, 57 days; age range, 23-117 days) with conjugated hyperbilirubinemia and gallbladder longer than 1.5 cm at US were referred for US-guided PCC after US findings were equivocal for BA (n = 7) or the type of BA was unclear (n = 2). PCC was performed with a US machine with incorporated contrast pulse sequencing, contrast-specific software, and a linear transducer by injecting diluted contrast material via an 18-gauge needle. Images from US and US-guided PCC were evaluated in consensus by two radiologists. US criteria for BA were fibrotic cord sign (>2 mm) and gallbladder length-to-width ratio greater than 5.2. BA was excluded at PCC when contrast material was visualized in the gallbladder, common hepatic ducts, and common bile duct and during passage to the duodenum. Patients in whom BA was diagnosed after PCC underwent surgery or liver biopsy as the reference standard. Nonparametric and Fisher exact tests were used. Results US-guided PCC was successful in all patients. There were no procedural-related complications. BA was excluded in five of the nine patients. The median serum direct bilirubin level in these patients slightly decreased 1 week after PCC, from 91.1 µmol/L (interquartile range [IQR], 81.6-113.8 µmol/L) to 65.3 µmol/L (IQR, 57.8-74.7 µmol/L); however, this difference was not statistically significant (P = .062). BA was diagnosed in four patients, with the diagnosis confirmed at surgery (n = 2) or liver biopsy (n = 2). BA in two patients with unclear type of BA was defined as type III without patency of the common bile duct in one patient and as type III with patency of the common bile duct in the other. Conclusion In this highly selected group of infants with indeterminate type of BA or inconclusive US findings, US-guided PCC enabled the diagnosis of BA in four infants and the exclusion of BA in five. US-guided PCC may be a safe and effective tool to exclude BA early in infants with equivocal US findings. © RSNA, 2017.

Near-infrared cholecystocholangiography with direct intragallbladder indocyanine green injection: preliminary clinical results.

BACKGROUND: Near-infrared (NIR) fluorescence cholangiography by systemic administration of indocyanine green (ICG) enhances the visualization of the biliary tree anatomy. However, the simultaneous enhancement of liver parenchyma can disturb the visualization of critical details. We herein proposed a new technique of NIR cholecystocholangiography by intragallbladder ICG injection to increase the safety during laparoscopic cholecystectomy. METHODS: A total of 46 patients scheduled for laparoscopic cholecystectomy for symptomatic lithiasis (n = 21) or cholecystitis (n = 25) were enrolled. A fluorescence cholangiography by direct gallbladder injection of ICG was performed in all cases. Of them, the ICG was injected through a previously placed percutaneous transhepatic gallbladder drainage catheter (n = 18) or by intraoperative, percutaneous needle puncture of the gallbladder (n = 28). Visualization of biliary structures, including the cystic duct (CD), the common bile and hepatic ducts (CBD and CHD), the gallbladder neck, and the Hartmann's pouch (HP), was performed using White Light (served as control modality) and by NIR enhancement. RESULTS: Cholecystocholangiography provided a significantly higher rate of visualization of the CD in case of cholecystitis with mild adhesions, and an improved visualization of the HP, CBD, and CHD in case of severe inflammation, when compared to White Light observation. There were no benefits of NIR in case of non-inflamed lithiasis. CONCLUSIONS: Clinical translation of NIR cholecystocholangiography has been successful with a noise-free visualization of biliary anatomy. It can be considered in difficult cases to increase the safety of laparoscopic cholecystectomy.

[Laparoscopic resection of giant hepatocellular carcinoma and the Barcelona staging]. / Nagyméretû hepatocelluláris karcinóma laparoszkópos reszekciója és a barcelonai kritériumok.

Liver resection is the most effective treatment for hepatocellular carcinoma, however, decision for surgery remained confusing. In Europe the most accepted Barcelona staging system sets minimal value on surgical interventions. Long lasting diagnostic steps and uncertainty for indication of resection are possible consequences of this approach. The reported case is an example for the fact that exceptionally large tumor having been grown during time-consuming diagnostic attempts might be removed by laparoscopic surgery. The case hopefully could lead to widespread acceptance of up-to-date surgical treatment of hepatocellular carcinoma.

A literature review of radiological findings to guide the diagnosis of gallbladder adenomyomatosis.

BACKGROUND: Gallbladder adenomyomatosis (GA) is a benign gallbladder entity discovered as an asymptomatic gallbladder mass. Since gallbladder cancer is in the differential diagnosis for gallbladder masses, the ability to differentiate benign disease avoids a more extensive oncologic resection. This study sought to review imaging modalities used to diagnose GA. METHODS: PubMed and SciVerse Scopus were systematically searched using the terms: "gallbladder adenomyomatosis" and "gallbladder imaging" for articles published between January 2000 and January 2015. RESULTS: A total of 14 articles were reviewed in this analysis. Contemporary series report the use of ultrasound (US), computed tomography (CT) or magnetic resonance imaging (MRI) in GA imaging. Ultrasound detection of Rokitansky-Aschoff sinuses, visualized as small cystic spaces with associated "comet-tail" or "twinkling" artifact, is pathognomonic for GA. A "Pearl-Necklace" sign of small connected sinuses on MRI or "Rosary" sign on CT are additional characteristics that may assist in establishing a diagnosis. CONCLUSION: Ultrasound is the most commonly used tool to investigate GA. If not diagnostic, CT or MRI are effective in attempting to differentiate a benign or malignant cholecystic mass. Characteristic signs should lead the surgeon to perform a laparoscopic cholecystectomy in symptomatic patients or manage non-operatively in asymptomatic patients.

Near-infrared cholecysto-cholangiography with indocyanine green may secure cholecystectomy in difficult clinical situations: proof of the concept in a porcine model.

BACKGROUND: Biliary injuries remain a major concern in laparoscopic cholecystectomy. New intraoperative guidance modalities, including near-infrared fluorescence cholangiography, are under evaluation. Initial results showed limitations in visualizing the biliary tree in specific clinical situations. The aim of this study was to examine the feasibility and potentiality of fluorescence cholecysto-cholangiography performed with a direct injection of indocyanine green (ICG) in the gallbladder and to compare it to systemic injection in such situations. MATERIALS AND METHODS: Seven pigs were included in this non-survival study. In two pigs, the gallbladder was punctured by a percutaneous needle, and 1 mL of ICG in different concentrations (0.001, 0.01, 0.1, and 1 mg/mL) was sequentially injected. Visibility and pattern of the fluorescent signal around Calot's triangle were examined and compared with those of two control pigs receiving 2.5 mg of intravenous ICG, 30 min prior to the operation. Different scenarios of cholecystitis were modeled using an injection of a mixture of blood and agarose gel around Calot's triangle area in the remaining three pigs, and the applicability of direct intragallbladder injection methods was evaluated. RESULTS: The fluorescent signal was identified immediately after intragallbladder injection, and the cystic duct became visible by 0.1 and 1 mg/mL of ICG. The whole cystic duct and the infundibulum of the gallbladder were clearly enhanced by intragallbladder ICG injection, but not by systemic injection. In the cholecystitis models, the cystic duct could be identified only after partial dissection, and fluorescence visualization of the gallbladder infundibulum provided crucial information to find the correct starting point of dissection. CONCLUSIONS: Fluorescence cholecysto-cholangiography through direct intragallbladder ICG injection could rapidly provide an adequate visualization of gallbladder neck and cystic duct and might be a valid option to increase the safety of cholecystectomy in case of cholecystitis.

Radionuclide cholescintigraphy in genetically confirmed Rotor syndrome.

A 7-year-old girl had been followed up for persistent conjugated hyperbilirubinemia since birth. Alanine aminotransferase, aspartate aminotransferase and γ-glutamyl transpeptidase activity was within the normal range, and liver protein synthesis had always been normal. Infectious etiology of jaundice, autoimmune diseases, drug-induced liver injury, hemolytic anemia, α-1 anti-trypsin deficiency, Wilson disease and Gilbert syndrome were ruled out. At the age of 8 years the patient underwent radionuclide dynamic cholescintigraphy, indicating poor accumulation of the radiotracer in the liver on one hand, and severe retention of the radiopharmaceutical in the blood pool (including the heart) on the other hand. Rotor syndrome was suspected and finally confirmed on molecular analysis. This case represents the first cholescintigraphy report in a pediatric patient with genetically proven Rotor syndrome.

Feasibility of percutaneous contrast ultrasound-guided cholecystography in dogs.

Differentiating hepatocellular disease versus biliary obstruction can be challenging in dogs presented for icterus. The purpose of this prospective study was to determine the feasibility of percutaneous contrast ultrasound-guided cholecystography in dogs. Ten normal dogs weighing 7.6-13.0 kg (median 9.8 kg) were recruited. All dogs were considered normal based on complete blood count, serum chemistry profile, ultrasound examination, and percutaneous radiographic cholecystography. Percutaneous contrast ultrasound-guided cholecystography was performed using 0.5 ml of commercially available contrast agent and two conventional ultrasound machines for simultaneous scanning at two different locations. Two observers independently evaluated the time to initial detection of contrast in the proximal duodenum and duration of contrast enhancement via visual monitoring. Dynamic contrast enhancement was calculated using time-intensity curves. Mean (± SD) and median (range) of time to initial detection were 8.60 s (± 3.35) and 8.0 s (2.0-11.0), respectively, and mean and median duration were 50.45 s (± 23.24) and 53.0 s (20.0 - 70.0), respectively. Mean, median, and range of peak intensity were 114.1 mean pixel value (MPV) (SD ± 30.7), 109.2 MPV, and 79.7-166.7, respectively, and mean, median, and range of time to peak intensity were 26.1 s (SD ± 7.1 s), 24.0 s, and 19.0-41.0 s, respectively. Findings indicated that percutaneous contrast ultrasound-guided cholecystography is a feasible technique for detecting and quantifying patency of the bile duct in normal dogs. Future studies are needed to assess the diagnostic utility of this technique for dogs with biliary obstruction.

Radiation-induced cholecystitis after hepatic radioembolization: do we need to take precautionary measures?

Controversy exists over the need to take precautionary measures during hepatic radioembolization to minimize the risk of radiation-induced cholecystitis. Strategies for a variety of clinical scenarios are discussed on the basis of a literature review. Precautionary measures are unnecessary in the majority of patients and should be taken only when single photon-emission computed tomography (CT; SPECT)/CT shows a significant concentration of technetium-99m macroaggregated albumin in the gallbladder wall. In this case report with quantitative SPECT analysis, it is illustrated how an adjustment of the catheter position can effectively reduce the absorbed dose of radiation delivered to the gallbladder wall by more than 90%.

Correlative imaging in gallbladder carcinoma.

Gallbladder carcinoma is a relatively rare malignant epithelial neoplasm, arising from gallbladder mucosa. It is the fifth most common gastrointestinal malignancy and the most common biliary tract cancer. Early diagnosis remains difficult, because clinical symptoms are sparse and non-specific, often resulting in advanced stage disease at the time of diagnosis. The most common feature of gallbladder carcinoma on different imaging modalities is focal wall thickening, associated with a large eccentric tumor mass. In this case we report the imaging characteristics of gallbladder carcinoma on ultrasound, MDCT and 18F-FDG PET/CT.

CT and MR features of xanthogranulomatous cholecystitis: an analysis of consecutive 49 cases.

OBJECTIVE: To study the CT and MR features of xanthogranulomatous cholecystitis (XGC). MATERIALS AND METHODS: 49 patients had pathologically confirmed XGC. All patients underwent contrast enhanced CT, and 10 patients had additional plain MRI. The CT and MRI results were retrospectively analyzed. RESULTS: On CT, all patients had thickening of gallbladder wall, with 87.8% cases showed diffuse thickening. 85.7% cases had intramural hypo-attenuated nodules in the thickened wall. Continuous mucosal line and luminal surface enhancement were noted in 79.6% and 85.7% cases, respectively. Gallbladder stones were seen in 69.4% patients. The coexistence of the above 5 CT features was seen in 40% cases, and 80% cases had the coexistence of ≥ 4 features. Diffused gallbladder wall thickening in XGC is more likely to have disrupted mucosal line, and XGC with disrupted mucosal line is more likely to be associated with liver infiltration. In 60% patients the inflammatory process extended beyond gallbladder, with the interface between gallbladder and liver and/or the surrounding fat blurred. 40% cases had an early enhancement of liver parenchyma. Infiltration to other surrounding tissues included bowel (n=3), stomach (n=2), and abdominal wall (n=1). On MR images, 7 of 9 intramural nodules in 7 subjects with T1-weighted dual echo MR images showed higher signal intensity on in-phase images than out-of-phase images. CONCLUSION: Coexisting of diffuse gallbladder wall thickening, hypo-attenuated intramural nodules, continuous mucosal line, luminal surface enhancement, and gallbladder stone highly suggest XGC. XGC frequently infiltrate liver and surrounding fat. Chemical-shift MRI helps classifying intramural nodules in the gallbladder wall.

Does Courvoisier's sign stand the test of time?

AIM: To investigate the validity of Courvoisier's sign, in the age of cross-sectional imaging and image analysis software by objectively measuring gallbladder volumes at magnetic resonance cholangiopancreatography (MRCP) in patients with and without biliary obstruction and to assess whether gallbladder volume is more significantly increased in patients with gallstone-related rather than non-gallstone-related biliary obstruction. MATERIALS AND METHODS: All MCRP investigations that were performed at a tertiary hepatobiliary centre over a 2-year period were analysed. The information recorded included the presence or absence of gallbladder stones as well as the presence and type of common bile duct (CBD) disease. Gallbladder volume was calculated from MRCP studies using image analysis software. RESULTS: Three hundred and ninety-four of 645 examined MRCPs (61.1%) were eligible for analysis. A statistically significant difference in mean gallbladder volume existed between the summated obstructive and non-obstructive groups (p < 0.001). In addition, a significant difference existed in mean gallbladder volume between those with CBD stones and non-gallstone CBD obstruction (p = 0.03). CONCLUSION: A significant difference was observed in gallbladder volumes in the group with biliary obstruction from choledocholithiasis compared with the group with biliary obstruction from other causes. Thus, objective measurement of gallbladder volume from modern cross-sectional imaging studies appears to validate Courvoisier's sign as a valuable clinical sign, which could be applied to modern imaging studies in distinguishing different causes of biliary obstruction in the jaundiced patient.

Xanthogranulomatous cholecystitis: sonographic and CT features and differentiation from gallbladder carcinoma: a pictorial essay.

The imaging features of xanthogranulomatous cholecystitis closely resemble those of gallbladder carcinoma, especially those of the wall-thickening variety. There is an overlap between these two conditions with respect to the clinical features and certain imaging findings. However, certain finer details like the presence of intramural hypoattenuating nodules and the type of mucosal enhancement may help to differentiate these two conditions. In this article, we have highlighted some of these imaging features. The importance of making an accurate diagnosis lies in the significant difference between the prognosis and the surgical management of the two disease entities.

[Quality of life of patients with gallstone disease and gallbladder cholesterosis in the conservative and surgical treatment].

OBJECTIVE: to investigate the quality of life of patients with gallstone disease and gall bladder cholesterosis on a background of conservative therapy and after surgery. MATERIALS AND METHODS: the study involved 60 patients with GSD and GBC treated conservatively, 75 patients with GSD and GBC treated surgically, the control group - 35 men aged of 20,6 +/- 1,2. A survey using questionnaires GIC, SF-36, ultrasound, radiography, CT of the abdomen, cholecystography, examined the range of blood lipids. RESULTS: reduction in QOL in the CL was detected in 92.8% of patients on all scales, progressing during the exacerbation of the disease (58.3%). The overall QOL score was reduced (up to 92,5 +/- 7,0) when compared with CG (346,7 +/- 8,2, p <0,001) and the maximum score (410.0). Conservative therapy improves the QOL of patients with gallstone disease in 50.7% of cases at all scales. The overall score increased to 155,9 +/- 5,6, p < 0,001, but remained lower than in the CG. When GBC reduced QOL was found in 75.8% of patients on all scales, progressing during the exacerbation of the disease (40.8%). Contact of worsening QOL with the duration of relapse stable disease (p < 0,001). Conservative therapy improves the QOL of patients with GBC in 54.1% of cases at all scales. The overall score has increased from 51,9 +/- 5,5 to 135,1 +/- 2,6 (p< 0.001), but remained lower than in the CG. QOL of patients with GSD and GBC reduced by all indicators, the GSD to a greater extent. In patients with GSD main factors reducing the QOL are pain (34.5% and 100% in the period of exacerbation of the disease) and non-use of previously familiar food (62.0%) because of fear of pain attack at GBC - emotional quotient (66.9% - thought about the inevitability of surgery and the possibility of malignancy). When GSD QOL of patients before CE decreased (93.6%) to a greater extent than in patients prior to conservative treatment due to the pain factor (65.4%), total score amounted to 86,4 +/- 5,1 and 92,5 +/- 7,0, respectively, p <0.05. The main factors of nuclear explosion-QOL differences were pain attacks (65.4% and 35.7%) and emotional quotient. The factors of higher-QOL after the CE (59.1%) are the elimination of pain attack (100%), normalization of stool. The total score improved from 86,4 +/- 5,1 to 128,4 +/- 6,3, p <0,001, but remained lower than in the CG (p <0,001) and a comparison with the highest scores (p < 0,001). When GBC quality of life of patients before CE decreased (95.1%) to a greater extent than in patients prior to conservative treatment (75.8%) due to emotional factors: the thought of the possibility of malignancy. The total score was 40,2 +/- 5,3 and 51,9 +/- 5,5, respectively, p<0.05. Surgical treatment improves QOL of patients with GBC (61.8%) in all major scales. The total score improved from 40,2 +/- 5,3 to 122,6 +/- 6,0, p < 0,001, but remained lower than in the CG (p < 0,001) and a comparison with the highest scores (p < 0,001). CONCLUSION: the results allow us to recommend a conservative therapy for cholelithiasis patients as a method of choice in the presence of indications for its place-of. The determining factor is the density of lithotherapy concrement, as measured by CT. In case of impossibility of conservative therapy should prompt surgical treatment of cholelithiasis before the development of irreversible changes in the organs of hepato-pancreatoduodenal system.

Efficacy of US-guided percutaneous cholecystocholangiography for the early exclusion and type determination of biliary atresia.

PURPOSE: To evaluate the efficacy of ultrasonographically (US)-guided percutaneous cholecystocholangiography (PCC) for early diagnosis and characterization of biliary atresia in infants with cholestatic liver disease. MATERIALS AND METHODS: Institutional review board approval was obtained for this study. Parental informed written consent was obtained. From October 2003 to August 2010, 22 infants (12 male, 10 female; age range, 1-138 days) were referred to the radiology department for PCC. Indications for PCC were suspected biliary atresia at 24-hour delayed technetium 99m-diisopropyl-phenylcarbamoylmethyl-iminodiacetic acid (DISIDA) scintigraphy because no excretion was observed in the small bowel (n = 17) or when the results of the scan or liver biopsy could not be obtained within 3 days because of a delay in schedule (n = 5). A diagnosis of biliary atresia was excluded when there was contrast material visualized in the gallbladder, biliary system, and passage to the duodenum. Patients with biliary atresia underwent surgery as the reference standard. RESULTS: Among the 18 patients who underwent successful PCC, biliary atresia was excluded in 13, with diagnoses as follows: total parenteral nutrition-associated cholestasis (TPNAC) (n = 6), neonatal hepatitis (n = 4), congenital syphilis (n = 1), neonatal lupus (n = 1), and congenital cytomegalovirus hepatitis (n = 1). Biliary atresia was diagnosed in five patients (four with type IIIb and one with type IIIa) and was confirmed at surgery. In four infants in whom US-guided gallbladder puncture had failed, biliary atresia (n = 2) and TPNAC (n = 2) were diagnosed. CONCLUSION: PCC is a safe and useful technique for early exclusion when biliary atresia cannot be ruled out after traditional screening tests; in addition, it may be useful for preoperative type determination of biliary atresia. © RSNA, 2011.