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.

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.

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.

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%.

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.

[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.

Diagnostic accuracy of computed tomography imaging of surgically treated acute acalculous cholecystitis in critically ill patients.

BACKGROUND: Acute acalculous cholecystitis (AAC) is a potentially fatal condition mainly affecting critically ill patients. Current experience from computed tomography (CT) findings in AAC is contradictory. METHODS: CT images of 127 mixed medical-surgical intensive care unit patients were retrospectively reviewed for the following findings: bile density, thickness and enhancement of the gallbladder (GB) wall, subserosal edema, greatest perpendicular diameters of the GB, width of extrahepatic bile ducts, gas within the GB, ascites, peritoneal fat edema, and diffuse tissue edema. Forty-three of these patients underwent open cholecystectomy, and 8 patients revealed a normal GB, 26 an edematous GB, and 9 a necrotic AAC. RESULTS: Abnormal CT findings were present in 96% of all the intensive care unit patients. Higher bile density in the GB body and subserosal edema was associated with an edematous GB (specificity, 93.6%; sensitivity, 23.1%). The most specific findings predicting necrotic AAC were gas in the GB wall or lumen, lack of GB wall enhancement, and edema around the GB (specificity, 99.2%, 94.9%, and 92.4%, respectively; and sensitivity, 11.1%, 37.5%, and 22.2%, respectively). CONCLUSIONS: The frequency of nonspecific abnormal findings in the GB of critically ill patients limits the diagnostic value of CT scanning in detecting AAC. However, in the case of totally normal GB findings in CT, the probability of necrotic AAC is low.

Differentiation of nonneoplastic and neoplastic gallbladder polyps 1 cm or bigger with multi-detector row computed tomography.

OBJECTIVE: To evaluate useful computed tomographic features to differentiate nonneoplastic and neoplastic gallbladder polyps 1 cm or bigger. METHODS: Thirty-one patients with 32 nonneoplastic polyps and 67 patients with 73 neoplastic polyps 1 cm or bigger underwent unenhanced and dual-phase (arterial and portal venous phases) multi-detector row computed tomography. Gallbladder polyps were diagnosed by cholecystectomy. Computed tomographic features including size (1.5 cm), surface (smooth or irregular), shape (pedunculated or sessile), accompanying wall thickening, basal indentation, perception on unenhanced images, and enhancement pattern between 2 groups were compared using univariate and multivariate analyses. RESULTS: On univariate analysis, age 55 years or older (P = 0.0019), size bigger than 1.5 cm (P < 0.0001), irregular surface (P = 0.0033), sessile shape (P = 0.0016), accompanying wall thickening (P = 0.0056), basal indentation (P = 0.0236), and perception on unenhanced images (P < 0.0001) were significantly more frequent in neoplastic polyps as compared with nonneoplastic polyps. On multivariate analysis, size bigger than 1.5 cm (P = 0.0260), sessile shape (P = 0.0397), and perception on unenhanced images (P < 0.0001) were statistically significant. CONCLUSIONS: Size bigger than 1.5 cm, sessile shape, and perception on unenhanced images are the main factors that differentiate neoplastic from nonneoplastic gallbladder polyps 1 cm or bigger.

Effect of intravenous morphine comedication on bile duct visualization, diameter and volume applying intravenous CT cholangiography in a porcine liver model.

BACKGROUND/AIMS: To determine whether intravenous morphine comedication improves bile duct visualization, diameter and/or volume applying intravenous CT cholangiography in a porcine liver model. METHODS: 12 Landrace pigs underwent intravenous CT cholangiography. Eight minutes after initiation of the contrast material infusion, either morphine sulfate (n = 6 animals) or normal saline (n = 6 animals) was administered. Eighteen consecutive CT scans of the liver were acquired with 2-min intervals starting with initiation of the contrast material infusion. Maximum bile duct visualization scores, diameters and volumes and time to maximum bile duct visualization scores, diameters and volumes were determined. RESULTS: Maximum bile duct visualization scores, diameters and volumes and time to maximum bile duct visualization scores, diameters and volumes were not significantly different when the morphine group was compared to the normal saline group. Maximum bile duct visualization scores ranged between 4.00 ± 0.00 and 2.83 ± 1.47. Maximum bile duct diameters ranged between 6.77 ± 0.40 and 2.10 ± 1.35 mm. Maximum bile duct volume was 16.41 ± 7.33 ml in the morphine group and 16.79 ± 5.65 ml in the normal saline group. CONCLUSION: Intravenous morphine comedication failed to improve bile duct visualization and to increase bile duct diameter and volume applying CT cholangiography.

Laparoscopic cholecystocholangiography for diagnosis of prolonged jaundice in infants, experience of 144 cases.

PURPOSE: Cholangiography is often crucial for establishing the definitive diagnosis in infants with prolonged jaundice. Here, we describe our protocol of using the two-hole laparoscopic technique and discuss its benefits. METHODS: 144 consecutive patients with suspected biliary atresia were included in this retrospective study. A 5-mm umbilical port is introduced for a 30 degrees laparoscope. An additional 5-mm trocar was inserted at right subcostal incision. A liver biopsy was performed first if needed. The fundus of gallbladder was then exteriorized through the incision of the working port after pneumoperitoneum was released and a catheter is inserted into the gallbladder for cholangiography. RESULTS: The average duration of operation was 34 min (range 20-55 min). Laparoscopic cholangiography failed in 21 cases (14.6%) where atrophic gallbladder was found and BA was confirmed by subsequent laparotomy. For the remaining 123 cases, biliary atresia were diagnosed in 88 (71.5%), biliary hypoplasia in 14 (11.4%), and cholestasis in 21 (17.1%), respectively. There was no bleeding or any other complications intraoperatively. CONCLUSION: The technique of laparoscopic cholecystocholangiography is simple, safe and efficient. It can provide an accurate diagnosis. Furthermore, for patients without biliary atresia, unnecessary laparotomy can be avoided.

[Factors contributing to gallstone formation and their interaction].

AIM: to study factors contributing to gallstone formation and to elucidate their relationship. SUBJECTS AND METHODS: The examination of 230 patients with various hepatobiliary abnormalities used dynamic ultrasonic cholecystography, multifractional duodenal intubation, followed by a microscopic study and determination of the physicochemical properties of bile. Enzyme immunoassay was employed to measure the peripheral blood levels of gastrin, insulin, T3, T4, thyroid-stimulating hormone, cortisol, and growth hormone. RESULTS: All the patients were found to have signs of an early (gallstone pre-formation) stage of cholelithiasis. Decreased emptying of the gallbladder and its hypotonia and altered bile physicochemical properties were ascertained to be poor predictors of possible gallstone formation. CONCLUSION: Correlation analysis has shown the important role of hormonal factors in the formation of lithogenic bile.

The imaging evaluation of cholelithiasis in the obese patient-ultrasound vs CT cholecystography: our experience with the bariatric surgery population.

BACKGROUND: The purpose of this study was to compare computed tomography (CT) cholecystography and ultrasound for gallstone detection in preoperative bariatric surgery patients. METHODS: The study included 16 asymptomatic prebariatric surgery patients. On the same day, each patient underwent abdominal CT 4 h after IV cholecystograffin injection, and gallbladder ultrasound. CT and ultrasounds were reviewed by two independent, blinded radiologists, and scored as follows: no gallstones, possible gallstones, definite gallstones, indeterminate. CT and ultrasound results were compared. RESULTS: Ultrasound detected definite gallstones in three patients, possible gallstones in one patient, and no gallstones in ten patients. Two scans were considered indeterminate. CT cholecystography detected definite gallstones in six patients, possible gallstones in zero patients, and no gallstones in nine patients, and was indeterminate in one patient. All three patients with gallstones seen sonographically had definite gallstones on CT. The patient with possible gallstones detected sonographically had definite stones detected at CT. One of the two patients with indeterminate ultrasounds had gallstones detected at CT. The other patient had both studies indeterminate. One patient with no gallstones sonographically had definite gallstones at CT. No patients with a negative CT had gallstones seen on ultrasound. Nine patients had no gallstones on either modality. CONCLUSIONS: CT cholecystography is more sensitive and specific for the detection of gallstones in the obese population. CT cholecystography should be considered in place of ultrasound in the preoperative workup of these patients.

Cross-sectional imaging of acute and chronic gallbladder inflammatory disease.

OBJECTIVE: The purpose of this article is to provide a comprehensive review of the clinical and cross-sectional imaging features of a variety of acute and chronic gallbladder inflammatory diseases. CONCLUSION: Inflammatory gallbladder diseases are a common source of abdominal pain and cause considerable morbidity and mortality. Although acute uncomplicated cholecystitis and chronic cholecystitis are frequently encountered, numerous other gallbladder inflammatory conditions may also occur that can be readily diagnosed by cross-sectional imaging.

Combination of magnetic resonance cholangiopancreatography and computed tomography for preoperative diagnosis of the Mirizzi syndrome.

OBJECTIVE: To determine the diagnostic accuracy of combined magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) for preoperative diagnosis of Mirizzi syndrome. MATERIALS AND METHODS: Fifty-two patients with surgically proven Mirizzi syndrome (n = 13) and cholecystitis without evidence for Mirizzi syndrome (n = 39) underwent both MRCP using single-shot turbo spin echo and 3-dimensional turbo spin echo sequences and CT. Two blinded observers independently and retrospectively reviewed the combination of MRCP and CT images and CT images alone. Diagnostic accuracy for a combined protocol and CT was evaluated. RESULTS: The overall sensitivity, specificity, positive and negative predictive values, and accuracy of the combination of MRCP and CT were 96.0%, 93.5%, 83.5%, 98.5%, and 94.0%, respectively. Corresponding values of CT were 42.0%, 98.5%, 93.0%, 83.5%, and 85.0%, respectively. The sensitivity, negative predictive value, and accuracy of combined protocol were significantly higher than those of CT alone (P = 0.000, 0.001, and 0.042, respectively). Interobserver agreement was better for combined images (kappa = 0.906) than for CT images alone (kappa = 0.812). CONCLUSIONS: A combination of MRCP and CT is useful for preoperative diagnosis of Mirizzi syndrome.