Current Concepts of Cholangiography

Current Concepts of Cholangiography

Current Concepts of Cholangiography ROBERT E. WISE, M.D. The roentgenologic examination of the bile ducts includes two basic techniques, that is, the...

2MB Sizes 33 Downloads 186 Views

Current Concepts of Cholangiography ROBERT E. WISE, M.D.

The roentgenologic examination of the bile ducts includes two basic techniques, that is, the indirect and the direct methods of opacification. With the indirect technique the oral and intravenous administration of the contrast agent, both before and after cholecystectomy, are utilized. Direct technique includes T tube cholangiography with its several variations, operative and postoperative, and the percutaneous transhepatic methods. Changes in surgical techniques and philosophies frequently reflect progress in diagnosis. Conversely, improved surgical technique frequently is the impetus to the development of improved roentgenologic diagnostic techniques. Progress and change in both areas produce evolution in our practice and it behooves us, from time to time, to pause and review our philosophies. INDIRECT CHOLANGIOGRAPHY

Oral Despite the widespread use of oral cholecystography since the introduction of the procedure by Graham and Cole 2 in 1924, oral opacification of the bile ducts in conjunction with oral cholecystography has never achieved significant popularity. Although the common bile duct is frequently opacified after the administration of a fat meal in association with a well-opacified normal gallbladder, the duct rarely can be opacified when the gallbladder is diseased and poorly functioning. Thus, the net result is frequent opacification of normal bile ducts and rare opacification of the abnormal common bile duct usually associated with a diseased gallbladder, where the need is greatest. Twiss 6 devised an ingenious method of opacification of the bile ducts by the ingestion of oral cholecystographic agents after the gallbladder had been removed. The intravenous method, however, has proved superior and we have come to rely on it rather than on the oral method. 731

732

ROBERT

E.

WISE

Intravenous Although we use the intravenous method of cholangiography to the exclusion of the oral method after cholecystectomy, we do not do so for routine examination of the gallbladder. A decade has passed since the introduction of intravenous cholangiography in this country. Sodium iodipamide, the product originally used, has largely been replaced by iodipamide methylglucamine (Cholografin, Squibb). Innumerable reports have appeared in the world's literature testifying to the widespread use of the technique. Manufacturers' data" indicate that approximately one million intravenous cholangiographic studies have been performed in this country to date. We have performed more than 4000 studies. At this tenth anniversary of our first attempts at the procedure, it is appropriate that we review our philosophies with respect to indications for the procedure, technique, safety, diagnosis, and especially our estimation of its value. Pharmacology. Iodipamide methylglucamine (Cholografin) continues to be supplied in 20 ml. ampules of the 52 per cent solution. Only one attempt has been made to introduce another intravenous cholangiographic agent in this country, but this was unsuccessful. Presently, another compound BL-419 (Schering, A. G., Berlin) is under investigation in West Germany but as yet no well-documented reports are available. 4 It is our practice to use a dose of 20 ml. of the 52 per cent solution of iodipamide methylglucamine. Attempts to enhance opacification and to produce opacification of ducts which had previously not been opacified by the use of a double dose have been uniformly unsuccessful. We believe, therefore, that increasing the dosage beyond the standard 20 ml. is of no value. Reactions. With the exception of the 1 ml. intravenous test dose, preliminary testing has been of no value. The test dose is followed by a three minute waiting period. If no reaction ensues, the remaining dose, 19 mI., is injected at a uniform rate over a ten minute period. This has reduced our reaction rate to a minimum, with little or no drop in blood pressure and only rare episodes of nausea and vomiting. This experience indicates that, unlike urographic contrast agents, this compound must be injected slowly if reactions are to be avoided. The number of contraindications has decreased since our original experience. Patients with allergic backgrounds are given premedication for two or three days with an antihistaminic compound before the study is performed. This policy has proved safe and we have no reason to regret it. An antihistaminic compound also is routinely administered intramuscularly 20 minutes before the contrast agent is injected. Although the value of this has been questioned, at the present time we believe it the best policy.

CURRENT CONCEPTS OF CHOLANGIOGRAPHY

733

Figure 1. A, Routine intravenous cholangiogram film with only fair opacification of the common bile duct. No calculi are visible. B, Laminagram of A. Note increase in contrast and demonstration of radiolucent defects representing calculi.

Technique. Our radiographic technique remains the same as that originally published/on that is, a high contrast, low kilovoltage technique. In the postcholecystectomy patient, films are made at 20 minute intervals usually for a two hour interval to estimate the degree of drainage in order to assess properly the question of obstruction, applying the time-densityretention concept. Laminagraphy is used in approximately half of the cases. It has proved invaluable in the search for calculi (Fig. 1). We remain opposed to the routine use of morphine, since it produces an artificial or pharmacologic obstruction and prevents proper evaluation of the drainage of the duct. Indications. We recommend intravenous cholangiography for all patients who complain of the same or new symptoms referable to the biliary tract after removal of the gallbladder. The intravenous procedure should not, at the present time, replace routine oral cholecystography. Unquestionably, however, it provides more positive evidence of gallbladder disease when opacification of the gallbladder is not obtained with the oral method. Therefore, we utilize the intravenous method in the event of nonopacification of the gallbladder with a single dose of an oral cholecystographic agent. If opacification is poor, while we still occasionally administer a "double dose" of oral cholecystographic agent, we tend to substitute the intravenous method with increasing frequency. The benefits of this policy are twofold: intravenous study (1) confirms or excludes gallbladder disease with accuracy, and (2)

734

ROBERT

E.

WISE

Figure 2. A, Intravenous cholangiogram prior to cholecystectomy. Note dilated common bile duct. B, Laminagram of A demonstrates a calculus in the distal common bile duct at arrow. (Small stones were found in the gallbladder at surgery. A large calculus was removed from the distal common duct.)

provides valuable preoperative information concerning the common bile duct (Fig. 2). In the event of nonopacification of the gallbladder in the presence of opacification of the bile ducts, the information has proved to be extremely reliable in predicting gallbladder or common bile duct disease, or both, and pancreatic disease, as may be seen in Table 1. Visualization. The rate of opacification of the bile ducts remains approximately 89 per cent. Selection of cases for the procedure is frequently made on a clinical rather than a laboratory estimation of liver function. Figure 3, however, provides a reasonably reliable scheme for prediction of

Table 1.

Visualized Biliary Ducts with Nonvisualization oj the Gallbladder (723 Cases) *

Group 1 Primary gallbladder disease, normal common duct Group 2 Primary common duct or pancreatic disease, gallbladder normal Group 3 Combined gallbladder and common duct disease Group 4 Normal gallbladder and common duct (portal cirrhosis)

CASES

PER CENT

86

69.9

12

9.7

24

19.5

1

0.8

* From Wise, R. E.: Intravenous Cholangiography. Springfield, Illinois, Charles C Thomas, 1962, p. 63.

735

CURRENT CONCEPTS OF CHOLANGIOGRAPHY

B.S.P. RETENTION (%)

o

30

40---0VER 40 ....

1001.-~r---J----L---L----------~

80

o

20

O·L---.---.----,---.----~--~~

2 3 4 OVER 4-. SERUM BILIRUBIN (MG.'~) Figure 3. Relation of serum bilirubin values and bromsulphalein retention to visualization. (From Wise, R. E.: Intravenous Cholangiography. Springfield, Illinois, Charles C Thomas, 1962, p. 21.)

probability of opacification of the bile ducts for any given level of serum bilirubin or degree of bromsulphalein retention. Obstruction of the Common Bile Duct. The time-density-retention concept as a means of predicting obstruction of the common duct, first introduced by us in 1955, 9 remains a reliable means of determining the presence or absence of obstruction. Utilizing this concept, if the retention of contrast medium or density in the common duct is greater at 120 minutes than at 60 minutes, the evidence is considered sufficient to justify a diagnosis of partial obstruction of the common duct. Failure to utilize this method of evaluation of the cholangiogram will result in failure of diagnosis of large numbers of impacted, partially obstructing calculi located in the distal common duct, for we have found that approximately 40 per cent of common duct calculi are not visible on the intravenous cholangiogram. 7 Common Duct Dilatation. We remain unconvinced that the common bile duct undergoes a significant degree of dilatation following removal of the gallbladder. Our evidence continues to refute the original thesis of Judd and Mann3 that removal of the gallbladder results in dilatation of the common duct. In every instance in our experience, when the size of the common bile duct has increased after cholecystectomy, organic disease, in the form of calculus, tumor or stenosis was discovered at exploratory operation. Dilatation of the common duct following cholecystectomy appears, therefore, to be a valid indication for common duct exploration.

736

ROBERT

E. W rSE

Pancreatic Disease. The intravenous cholangiogram has added little to the diagnosis of pancreatic disease. The common bile duct is infrequently affected in chronic pancreatitis, especially when the disease has not advanced to the calcific stage, but, in far-advanced chronic pancreatitis, the duct may be partially obstructed. In these instances, the intravenous cholangiogram has provided valuable preoperative information concerning the status of the duct. The use of the cholangiogram in the early diagnosis of carcinoma of the head of the pancreas has been disappointing. Almost never have we been able to detect early lesions by means of the cholangiogram and therefore do not rely upon it in the search for malignant disease. Stricture. The majority of strictures usually have produced such a degree of obstruction that visualization by means of intravenous cholangiography is precluded. In many situations in which laboratory and clinical studies are inadequate, however, the intravenous cholangiogram has proved to be of value. One invaluable use for the procedure has been in follow-up studies of stricture repair procedures. Although clinical and laboratory evidence are usually adequate, mnny equivocal situations remain where additional information is necessary for complete evaluation. The cholangiogram usually provides valuable information graphically in this regard. A decade of experience with the intravenous cholangiogram has justified our initial enthusiasm for its potentialities. It is considered a relatively safe procedure to which patients with significant symptoms may be submitted without fear. No procedure has succeeded in replacing it for investigation of the postcholecystectomy patient who has persistent or new symptoms referable to the right upper abdominal quadrant. The net result of our experience has been the gratification derived from the rare errors of diagnosis when the patients are submitted to choledochostomy. Equally gratifying has been the knowledge that the presence of organic disease has been safely excluded in many instances, with subsequent treatment for functional disease without fear that serious organic disease has been overlooked. DffiECT CHOLANGIOGRAPHY

Operative The technique of operative cholangiography has been known for many years. Its great popularity has been the result of the accuracy with which calculi in the common bile duct could be detected at surgery. Although we use it in this manner at times, its greatest value in our practice has been in delineating the anatomy of the bile ducts, particularly in stricture cases (Fig. 4). It has been invaluable for the proper positioning of drainage and

CURRENT CONCEPTS OF CHOLANGIOGRAPHY

737

Figure 4 (Polaroid Rapid Process Film). A, Initial operative cholangiogram showing opacification of the right hepatic duct and branches. B, After repositioning of the drainage tube repeat cholangiogram shows satisfactory opacification of both major divisions of the bile ducts, indicating satisfactory position of the drainage tube.

Figure 5. Direct puncture cholangiogram performed on the operating table reveals a complete stricture at the level of the junction of the common hepatic and common bile duets.

738

ROBERT

E.

WISE

Figure 6 (Polaroid Rapid Process Film). Operative T tube cholangiogram demonstrating good opacification of all ducts without abnormality.

prosthetic tubes and in the estimation of patency or obstruction of the individual ducts. Several methods of introduction of the contrast medium are available to the surgeon. At times, prior to complete exposure and exploration of the common duct, direct needle puncture (Fig. 5) may yield valuable information concerning the pathologic condition. Frequently, in repair procedures, it has been advantageous to inject the medium into the drainage tubes to insure that all portions of the ductal system are being drained properly. After T tube placement, cholangiography may be performed very simply, and is frequently done to confirm the absence of calculi or other abnormality after exploration has been completed (Fig. 6). We have come to rely heavily upon the Polaroid rapid radiographic process for the major portion of our operative cholangiographic work. Originally, we used the conventional 3000X paper to good advantage but more recently have been fortunate to have available, on a research basis, a semitransparent film. This possesses distinct advantages of detail and convenience in viewing compared with the 3000X paper product. It is not commercially available. * We are not prepared at the present time to evaluate either of these

* Research materials furnished by the Polaroid Corporation, Cambridge, Massachusetts.

CuRRENT CoNCEPTS OF CHOLANGIOGRAPHY

739

Figure 7. Percutaneous transhepatic- cholangiogram. A, Initial film after first injection of contrast medium, giving false impression of obstruction of right hepatic duct. B, Repeat film after aspiration and reinjection, demonstrating complete obstruction of the common hepatic duct. Complete stricture was found at operation. C, Polaroid film for comparison with A, demonstrating equivalent yield of detail and information.

products in the detection of calculi but, in the areas of use described above, they have proved ideal. Adequate detail has been present. The ten or 35 second processing time has saved an enormous amount of time, providing one or more cholangiograms without significant loss of time. Percutaneous Transhepatic

Since the introduction of transhepatic cholangiography in 1952 by Carter and SaypoP the procedure has slowly gained in popularity until it is in common use today. Its value lies in the significant information which may be gained concerning the status of the bile ducts in the jaundiced patient. Our limited experience does not permit an estimate of morbidity rate but, from a review of the literature, one is forced to conclude that the information to be gained outweighs the slight risk, provided adequate surgical help is immediately available. One significant case is shown in Figure 7.

SUMMARY

We remain enthusiastic with respect to the information provided by the intravenous cholangiogram. It is unquestionably the procedure of choice in the postcholecystectomy patient. We are using it with increasing

740

ROBERT

E.

WISE

Figure 8. A, Intravenous cholangiogram showing a common bile duct with minimal dilatation. A solitary calculus is visible at arrow. B, Operative cholangiogram. Conventional radiograph demonstrates a calculus in the distal common bile duct. C, Operative cholangiogram (Polaroid 10 second paper radiograph) demonstrates concave deformity at distal end of common bile duct produced by calculus. D, Postoperative T tube cholangiogram demonstrates a normal biliary tract.

frequency before surgery when the gallbladder fails to opacify after the use of an oral cholecystographic agent. Percutaneous transhepatic cholangiography has a distinct place in the evaluation of the bile ducts in the jaundiced patient in the differentiation of hepatocellular and extrahepatic obstructive types of jaundice and for evaluation of the status of the bile ducts in known stricture and choledocholithiasis problems.

CURRENT CONCEPTS OF CHOLANGIOGRAPHY

741

Our increasing work in reparative bile duct procedures has been aided significantly by the use of operative cholangiography, especially the ten or 35 second rapid radiographic process (Polaroid). As our familiarity with these techniques for opacification of the bile ducts has increased, we have come to rely upon them to an ever-increasing degree. With increasing frequency, patients with bile duct problems are studied with the intravenous cholangiogram. This is frequently followed by cholangiography on the operating table (Fig. 8). A T tube cholangiogram is performed before removal of the T tube. The intravenous cholangiogram then remains available for postoperative evaluation if the symptoms return. Thus, the various forms of cholangiography provide a graphic means of evaluation of the bile ducts at any stage of diagnosis or treatment.

REFERENCES 1. Carter, R. F. and Saypol, G. M.: Transabdominal cholangiography. J.A.M.A. 148: 253-255 (Jan. 26) 1952. 2. Graham, E. A. and Cole, W. H.: Roentgenologic examination of the gallbladder, new method utilizing intravenous injection of tetrabromphenolphthalein. J.A.M.A. 82: 613-614 (Feb. 23) 1924. 3. Judd, E. S. and Mann, F. C.: The effect of removal of the gall-bladder: an experimental study. Surg. Gynec. & Obst. 24: 437-442 (April) 1917. 4. Schering, A. G.: Personal communication. 5. E. R. Squibb & Sons: Personal communication. 6. Twiss, J. R., Gillette, L., Beranbaum, S. L., Poppel, M. H. and Hanssen, E. C.: Postcholecystectomy oral cholangiography. A.M.A. Arch. Int. Med. 95: 59-65 (Jan.) 1955. 7. Wise, R. E.: Intravenous Cholangiography. Springfield, Illinois, Charles C Thomas, 1962, 139 pp. 8. Wise, R. E. and O'Brien, R. G.: Intravenous cholangiography: a prpliminary report. Lahey Clin. Bull. 9: 52-56 (Oct.) 1954. 9. Wise, R. E. and O'Brien, R. G.: Interpretation of the intravenous cholangiogram. J.A.M.A. 160: 819-827 (March 10) 1956. 10. Wise, R. E. and Twaddle, J. A.: Choledocholithiasis: Postcholecystectomy diagnosis by intravenous cholangiography. S. CLIN. NORTH AMERICA 38: 673-678 (June) 1958. 11. Wise, R. E., Johnston, D. O. and Salzman, F. A.: The intravenous cholangiographic diagnosis of partial obstruction of the common bile duct. Radiology 68: 507-525 (April) 1957.