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Oral cholecystography in the diagnosis of chronic gall-bladder-disease
ORAL CHOLECYSTOGRAPHY IN THE DIAGNOSIS OF CHRONIC
GALL,RLADDER,DISEASE*
ROBERT C. PENDERGRASS,M.D. AMERICUS, GA.
T
Indigestion; 28 cases. Sour stomach: 14 cases. Gas: 27 cases. Belching: 27 cases. Nausea or vomiting or both: Ig cases. Heart burn: 5 cases. Palpitation : 4 cases. Constipation: 25 cases. CIay stooIs: 6 cases. Tarry stools: I case. Jaundice: 13 cases. Headache: I I cases. Joint pains: 7 cases
HE diseased gal bIadder may underIie so many variabIe symptoms referabIe to the abdomen, the chest, the head, and even the extremities that it is often a diffrcuIt task to untangIe the maze of conflicting symptoms and pIace guiIt where guilt beIongs. Our most reIiabIe aids in this task are: (I) a carefuIIy taken and thoughtfuIIy considered history, (2) a compIete physica exanination, (3) clinica laboratory studies and (4) roentgenoIogic examinations of the gaI1 bIadder and intestina1 tract. This paper wiI1 dea1 chiefly with the Iast named aid, roentgenIogic examination.
Type of foods causing distress: a11 foods, 6 cases; greasy foods, 4 cases; sweets, I case; fruit juices, I case; and in 18 cases no particuIar type of food was mentioned. It is easiIy seen that the compIaints of indigestion, gas, beIching and constipation predominated in this smaI1 series. Next in order of frequency were nausea, sour stomach, jaundice and headache. It is notable that 7 of the 30 patients compIained of joint pains.
SYMPTOMATOLOGY WhiIe the ancient dictum of the probabiIity of gal1 bIadder disease in the patient who is “fair, fat, forty, fuI1 of Aatus” and compIaining of upper abdomina1 pain, is stiI1 a quite reIiabIe guide, other symptoms shouId direct our suspicion to this organ. Among the more prominent of these are headache, constipation and chronic arthritis. PrecordiaI pain simuIating angina pectoris, even in radiation down the Ieft arm, may occur. L. W. Grove” has operated upon severa patients whose symptoms were aImost cIassic of angina, but remova of a caIcuIous gaI1 bIadder resuIted in compIete reIief. A study of the symptomatoIogy in 30 operated cases in our series gave the foIlowing resuIts : FemaIes 21 cases; maIes g. Average age: femaIes 42; males 45. Duration of symptoms: average six and one-haIf years; varied from six months to thirty years. Pain: upper abdomina1 17 cases; right lower quadrant 4 cases; right ffank 2 cases; generaIized abdominal pain 5 cases; and no pain compIained of in I case. * Read before The Chattahoochee
DIFFERENTIAL DIAGNOSIS In their recent book1 Graham, CoIe, Copher and Moore Iist the folIowing conditions which may be cIinicaIIy confused with chronic ChoIecystitis: Iesions of the stomach and duodenum; spastic constipation; intestinal aIIergy; carcinoma of the hepatic fIexure; chronic appendicitis; cirrhosis of the Iiver; syphiIis of the liver; Iesions of the kidney; hemoIytic icterus; spina Iesions, such as Pott’s disease; chronic Iesions of the right Lung, such as pIeurisy; sIipping of the eIeventh rib over the twelfth with resuItant pain; and among the rarer causes, parasitic diseases of the gaII bIadder, such as echinococcus cysts and round worm infection.
Valley Medical and Surgical Association, Albany, Georgia, JuIy 9, 1930. 6
NEW SERIES VOL. XI, No.
Pendergrass-OraI
I
LABORATORY
DIAGNOSIS
The chief vaIue of Iaboratory studies lies in differentiation of the obstructive and
ChoIecystography
American
Journal
of Surgery
7
their presence is detected before empIoying choIecystography. ChoIecystography has been subjected
a
hemoIytic types of jaundice, by means of the Van Den Bergh reaction, red ceI1 fragility tests, icterus index, examination of bIood smears, determination of bilirubin content of the urine, etc. Leucocytosis is not a constant factor except in empyema of the gal1 bladder. Analysis of the materia1 obtained by magnesium suIphate drainage of the gal1 bIadder is considered vaIuabIe by some, but my persona1 experience with this method as a diagnostic agent is so Iimited as to make any opinion expressed worthIess. ROENTGENOLOGIC GALL
EXAMINATION
OF
THE
BLADDER
RoentgenoIogic examination of the gal1 bIadder shouId consist of (I) preliminary and (3) ffat fiIms, (2) choIecystography barium mea1 examination of the stomach and duodenum where indicated. On the flat fiIms we may demonstrate opaque caIcuIi; occasionaIIy, the outIine of an enIarged gal1 bIadder, such as a hydropic gal1 bIadder; and in some instances renaI stones, spina Iesions, enIarged Iiver, or pancreatic caIcification. Any confusing shadows may be better identified later if
c
FIG. I. Sthenic habitus. Norma1 gall bladder. (a) TweIve hours after taking dye orally. (b) Fourteen hours after dye. (c) Two hours after fatty meal. Note decrease in size of shadow and upward migration.
to the unfair demands of the unduIy critica and the exaggerated claims of the enthusiastic. If we consider the rationaIe of the procedufe, we may Iearn how much and how IittIe we should expect from it. To understand ChoIecystography, it is
8
Pendergrass-OraI
American Journal of Surgery
necessary to review briefly the physioIogy of the gaII bIadder. From the mass of cIinica1, anatomica1, and Iaboratory inves-
ChoIecystography
It consists in introducing into the circulation, either intravenousIy or via the intestina1 tract, a haIogenated pthaIein
b
a
tigations, which have been abIy reviewed by Graham,2 AIvarez,j and others, the foIlowing facts seem definiteIy estabIished : (I) BiIe is excreted by the liver and fiIIs the gaI1 bIadder IargeIy by way of the cystic duct. (2) The gaI1 bIadder concentrates biIe. (3) At periodic intervaIs, and apparentIy in response to digestive activity, the gaI1 bIadder empties its contents into the common duct and thence into the duodenum. The chief components of the emptying act seem to be (I) contraction of the gaI1 bIadder waII and (2) washing out of the gaI1 bIadder by the recurring flow of Iiver biIe.3 The theory of a contrary innervation of the sphincter of Odi and the gaI1 bIadder is as yet in the throes of dispute among the physioIogists. Alvarez6 states that there seems to be a connection but doubts the theory of contrary innervation, and thinks that the causes are chiefly chemica1, as shown by the work of Boyden concerning ‘the effect of egg yoIk and fat on emptying of the gal1 bIadder. ChoIecystography, or th! Graham test, is primariIy a test of gall bIadder function, and is based on the physioIogic factors.
JANUARY, 1931
c
Hypersthenic habitus. Norma1 dye concentration but delayed emptying. (a) Fourteen hours after dye. Film made in expiration. (6) Fourteen hours after dye. Film made in inspiration. Note gaII bIadder shadow projected beIow rib. (c) Four hours after fatty meal. Slight decrease in density but no decrease in size of shadow.
FIG.
2.
containing iodine. Carried by the circuIation to the liver, the dye is excreted in the bile and then obeys to some extent the physioIogica1 Iaws governing the con-
NEU.
SERIES VOL. Xl, No.
Pendergrass-
I
@-aI
centration and expukion of bile by the gaIl bIadder. It is thus obvious that the folIowing for requisites are necessary
ChoIecystography
American Journul of
surgery 9
(2) The Iiver must be able to excrete the dye into the bile. (3) The cystic duct must be open.
b
a
FIG. 3. Asthenic habitus. Norma1 gal1 bIadder. (a) Thirteen hours after dye. Note gaIl bIadder shadow overlying transverse processes of spine. (6) Same. LateraI view used to project gaI1 bladder clear of transverse processes.
obtaining a shadow cholecystography :
of the gaIl bIadder
by
(4) The concentrate
gall bIadd er must be able the dye to some degree.
to
a b Frc. 4. Asthenic habitus. Use of vertical obIique position to project gaI1 bladder shadow away from spine. (a) Posteroanterior view, prone position. Note gall bIadder shadow (retouched) overIying spine. (b) VerticaI oblique view (Bucky technic) showing gal1 bladder clear of spine.
(I) Suffkient circuIation.
dye
must
enter
the
In interpreting therefore note (I)
cholecystograms the time required
we for
IO
American
Journal of Surgery
Pendergrass-OraI
appearance of dye in the gaII bIadder; (2) the degree of dye concentration as noted by the density of the gaI1 bIadder
ChoIecystography
JANUARY. ,931
by reason of their contrast with the more dense dye shadow. In the ora method of ChoIecystography,
b
a
FIG. 5. Two cases of extrinsic deformity of gaII bIadder. (a) Angulation at neck of gaII bIadder (6) SimiIar anguIation, and aIso an incisura in mid-portion of the organ.
shadow; (3) the time required for the gaI1 bIadder to empty the dye-stained biIe in
(retouched).
as used in the cases herein summarized, a gaI1 bIadder shadow of good intensity
b
a
FIG. 6. MuItipIe choIestero1 stones, 26 stones found at operation.
(a) Fourteen hours after dye. Note muItiple negative shadows. (6) Two hours after fatty mea1. Note contracted gaI1 bIadder with negative shadows remaining within its outIine. This excludes gas as cause of shadows.
response to a fatty mea1 and (4) whether or not choIestero1 stones are demonstrated
shouId be obtained in from tweIve to sixteen hours after administration of the dye,
NEW SERIES VOL. XI, No.
Pendergrass-OraI
I
and the organ shouId be at Ieast one-haIf empty two hours after a meal of egg yoIk, butter and cream has been eaten.
a
ChoIecystography TECHNIC
OF
The technic as foIIows :
American
ORAL
Journal
of SCIW~Y
I I
CHOLECYSTOGRAPHY
used
in our
Iaboratory
is
b
FIG. 7. SingIe
negative density defect. One choIestero1 stone and “strawberry” mucosa found at operation. (a) Fourteen hours after dye. (6) Two hours after fatty mea1. Note ring of dye surrounding stone shadow. Excellent function despite presence of stone and diseased mucosa.
As we are reminded by Alvarez, a diseased gaII bladder may show a fairIy good concentration of the dye, and it is aIso known that a diseased gall bIadder wiI1 empty its contents fairIy readiIy in many cases. In other words, the degree of concentration of the dye is not in direct proportion to the amount of pathoIogy existing in the gaI1 bIadder. We know that a gaI1 bIadder which contains stones is diseased, eIse stones wouId not be present; yet such gaI1 bIadders wiI1 often empty we11 in response to a fatty meaI. Iilingworth’0 in a recent articIe discussing cholesterosis of the gaI1 bladder, states: “ChoIecystography indicates that in uncompIicated cases the concentration of biIe and the emptying in response to fats are not affected.” In many cases the major pathoIogy is found in the outer coats of the gall bIadder and not in the mucosa, and this may expIain to some extent the discrepancy in concentration of the dye by a diseased, viscus.
I. The patient is given a cathartic, preferabIy castor oil, on the night before the dye is taken, and an enema the foIIowing morning. 2. The afternoon after the cathartic, preliminary flat fiIms are taken. 3. Supper that same evening at 7 P. M. consists of dry toast, baked Irish potato or cream of wheat, or oatmea1, and either tea, coffee or water. No miIk is aIIowed. a 4. One hour Iater (8 P. M.), Keraphen, powdered preparation of tetraiodophenoIphthaiein, is given in a haIf gIass of cold water, foIIowed by a haIf gIass of coId water. After that, no food or drink is aIIowed unti1 after the first fIIm of the series is made at g A. M. the foIIowing day. In our Iater cases, we have aIIowed fruit juices, weak tea, and coffee without cream after taking the dye, as they seem to have no effect on emptying of the gal1 bIadder, and the fruit juices apparentIy aIIay nausea in some patients. 3. Films are obtained at thirteen and fifteen hours after taking the dye. Then
12
American
Journal
of Surgery
Pendergrass-OraI
the patient is given a mea1 of two soft boiIed eggs with butter, buttered toast, one gIass of sweet miIk and one gIass of
a
ChoIecystography
JANU~Y.
ROENTGENOGRAPHIC
,931
TECHNIC
The prehminary ffat fiIms are usualIy made on a IO X 12 fiIm using fast exposure,
b
FIG. 8. Hypersthenic habitus. Single negative density Ming defect simulating stone (retouched). Compare with Fig. 7. (a) Showing singte, rounded negative density shadow. 14 hrs. (b) Oblique view, showing rounded shadow partIy projected from gal1 bladder shadow. Defect due to gas.
pure cream. Two hours later a fiIm is made, and if the gall bIadder is not at Ieast one-haIf empty a second fiIm is made at four hours after the fatty mea1. The foIIowing additiona points have been heIpfu1 in empIoying this technic: I. In nervous patients who are subject to nausea at the Ieast provocation, barbita1 grain v or IuminaI grain jss is given two hours before taking the dye. 2. Where a tendency to diarrhea is known to exist, paregoric dr. I to 2 is given one hour before the evening mea1, on the same day the dye is taken. This sIows intestina1 peristaIsis and apparentIy aIIows a better absorption of the dye. Fitzgibbon8 has recentIy advocated this practice. We have empIoyed paregoric with good resuIts in patients who have been subjected to operations such as gastroenterostomy or pyIoropIasty, in whom smaI1 intestinal peristaIsis is usuaIIy increased. 3. When such a meal is not readiIy avaiIabIe, an egg maIted miIk made with pure cream produces quite a satisfactory emptying of the gaI1 bIadder.
as for a stomach, on one film; and on another we empIoy Bucky technic, with a medium sized cone centered over the gaII bIadder region. The choIecystograms are made with Potter-Bucky technic, a comparativeIy low voItage, 25 ma. doubIe screens, cone. Two exposures are usuaIIy made, to produce varying densities. If the gaI1 bIadder is unusuaIIy high, one fiIm is made in inspiration; otherwise expiration is the method of choice. If the transverse processes of the spine overIap the gaI1 bIadder shadow, an obIique or Iateral view is taken. Where spine pressure affects the dye shadow, sand bags are used to support the patient from the tabIe, or fiIms are made in the erect position. The Mms shouId show: good density of the spine and ribs; the outIine of the Iiver edge; the outIine of the right kidney and a cIear outIine of the gaI1 bIadder. Over-exposure is the most common fauIt. Any respiratory movements make the fiIms worthIess, especiaIIy in detecting smaI1 stone shadows.
hrw
SERIFS VOL. >(I. No.
Pendergrass-Oral
I
When stone shadows are seen, or even suspected, a film shouId be made after the emptying mea1, since the stones may often
ChoIecystography
Journal Ame~,can
of Surgery
I3
after ingestion, and emptying of at Ieast one-haIf the dye in two hours after taking the fatty mea1 described in the technic.
a
be better detected when they are more cIoseIy packed together in the contracted viscus. The persistence of identica1 negative density shadows in the HIed and partly emptied gaII bIadder definitely confirms the nature of such shadows. Where gas shadows simuIate stones, several examinations in various positions may prove the true nature of the shadows in question. AN~\LYSIS OF 2 16 ROENTGENOLOGIC EXAMINATIONS A study of 2 I 6 consecutive examinations of the gaIl bIadder made in our cIinic is here presented. Of this number, 14 patients had only ffat fiIm examinations without choIecystography. The remaining 202 had either choIecystography aIone or a preIiminary flat film examination foIlowed by choIecystography. The 202 choIecystograms represent 202 cases; in many of these the examination was repeated at Ieast once, so that the actual numberof roentgenoIogic examinations was somewhat Iarger. The choIecystographic findings were classified as foIIows : I. Normal. In this group are those patients showing a norma concentration of the dye in from tweIve to sixteen hours
c
FIG. 9. Use of ChoIecystography
to confirm diagnosis of opaque gallstone, shadow of which noted on upper edge of UterosaIpingograph. (a) Rounded opaque shadow noted on Aat film. (b) Fourteen hours. Posteroanterior view. (c) Fourteen hours. LateraI view. Note ring shadow remaining within limits of dye shadow.
2. Pathological. These were divided as foIIows : a. Absent shadow. b. Faint shadow. c. MottIed shadows suggestive of calculi. d. DeIayed emptying.
14
American
Journal
of Surgery
Pendergrass-OraI
e. Definite caIculi shadows. 3. Repetition of Examination Requested but Not Obtained. Cause of such request.
a
ChoIecystography
JANUARY,,931
subjected to a repetition of the study where the first examination was unsatisfactory. We regard repetition of the test
b
FIG. IO. Two cases of hydropic gaII bIadder containing caIcuIi, confirmed at operation. (a) Fourteen hours. Note Iarge shadow with faint dye concentration. Negative shadows can be made out in Iower portion of gal1 bIadder. 36 stones found at operation. (b) Hydropic gaI1 bIadder. 16 hrs. 6 choIestero1 stones found at operation; puruIent materia1 in gaI1 bladder. Dye concentration faint on origina Mm; retouched.
a. Absent shadow. b. Faint shadow. c. Confusing gas shadows. The resuIts of the examinations, grouped here, were as foIIows: I. Normal, 78 cases or 38 per cent. 113 cases or 51 per 2. Pathological, cent, divided as foIIows: a. Absent shadow, 23 cases or 20 per cent. b. Faint shadow, 43 cases or 38 per cent. c. MottIed shadows suggestive of caIcuIi, 12 cases or I0 per cent. d. DeIayed emptying, 18 cases or 16 per cent. e. Definite caIcuIi shadows, 17 cases or 15 per cent. 3. Repetition of Examination Requested but Not Obtained. EIeven cases divided as foIIows : a. Absent shadow, 7 cases. b. Faint shadow, 3 cases. c. Gas defects, I case. AI1 cases cIassified as pathoIogica1 were
as one of the most important features of a carefuIIy made ora examination. It is noted that cases showing no shadow and those showing definite caIcuIi shadows constitute about one-third of the tota pathoIogica1 cases. The other two-thirds, in which a diagnosis of pathoIogica1 gaII bIadder was based on the Iess definite findings of faint shadow, mottIed shadow and deIayed emptying, offer the chief diagnostic probIem, and to my mind the richest fieId for future developments in choIecystography. Oakmang recentIy caIIed attention to the diagnostic vaIue of the faint shadow in ora choIecystography. It is in these cases that the persona1 equation of the evaIuation of a norma shadow enters. They offer more diagnostic pitfaIIs than any other group of cases, and deserve the carefu1 consideration of everyone interpreting choIecystograms. TechnicaIIy good fiIms are a necessity here, since under or over exposure may render it diflicuIt to judge the actua1 concentration
NEW
SERIES VOL. XI, No. I
PendergrassaraI
of the dye. Moore, Graham, et aI. state that retention of the dye beyond a two or three hour period after a fatty mea1 is of no pathologica significance if concentration is norma prior to the meal, and offer as expIanation either reabsorption of dye from the intestina1 tract or prolongation of the starvation period. In case of a faint shadow coupIed with deIayed emptying, the diagnosis of a pathoIogica1 gaI1 biadder may be safeIy made. This certainly is true of the hydropic gaI1 bladder, and 2 such cases are incIuded in this series and were confirmed at operation. Of the 200 patients examined 30, or 14 per cent, have to our knowIedge come to operation. These cases have been reviewed as foIIows, comparing the roentgenologic diagnosis and the operative diagnosis : Of the 26 cholecystographies in which a diagnosis of “pathoIogica1 gaI1 bIadder” aIone was made thirteen times a11 13 showed a chronic ChoIecystitis and 4 also showed stones, an agreement of IOO per cent in the preoperative and postoperative diagnosis. Of 6 cases in which stones were diagnosed, 6 showed stones at operation, an agreement of I00 per cent. Of 4 cases diagnosed as normal, 2 were norma and 2 showed caIcuIi, an agreement of 50 per cent. A review of these fiIms indicates that the degree of dye concentration was beIow norma and the diagnosis of a normaI gaII bIadder was not warranted in the face of the faint shadow. In 3 cases in which a repetition of the test was asked but not obtained, 2 were norma and I showed a chronic choIecystitis at operation. Of 3 Aat fiIm studies which showed no pathoIogy but in which use of the dye method was requested, I case was norma and z were pathoIogica1, of which I had a gumma of the Iiver in addition to a diseased gaI1 bIadder. in I flat fiIm study showing stones, diagnosis was confirmed at operation.
ChoIecystography
American Jot~d
of SUCWY
I 5
COMMENT
The writer wishes to emphasize that ChoIecystography represents onIy one witness for the prosecution in the case against the diseased gaI1 bIadder. It is not infaIIibIe. The roentgenoIogic findings shouId be carefuIIv correIated with the history, physica1 fin&ngs and Iaboratory reports, and in borderIine cases, if the cIinica1 indications of a diseased gaI1 bIadder are stronger than the roentgenoIogic evidence, then the cIinica1 findings shouId form the basis of the diagnostic decision. It is aIso to be remembered that a recent miId attack of ChoIecystitis may Ieave the gaI1 bIadder so IittIe impaired that dye concentration is normaI. FaiIure to recognize this fact may Iead to error in the retrospective diagnosis of recent attacks of upper abdomina1 pain. If choIecystography is employed with a fuI1 recognition of its possibiIities and its Iimitations; with proper regard for detaiIs of technic; with judgment in interpretation; and with broad cIinica1 approach to the case in question, then and onIy then, is it a reIiabIe aid in the diagnosis of chronic gaI1 bIadder disease. SUMMARY I. The diagnosis of chronic gaI1 bIadder disease is discussed with reference to the differentia1 diagnosis, symptomatoIogy, Iaboratory diagnosis, and roentgenoIogic diagnosis. 2. Thirty operated cases are anaIyzed according to symptomatoIogy. 3. The rationaIe, technic, and interpretation of choIecystograms are discussed. 4. The findings in 2 16 consecutive examinations of the gaI1 bladder are tabuIated. 5. Comparison of the roentgenoIogic and operative diagnosis in 30 operated cases is presented. 6. Comment is made upon the reIative position of ChoIecystography in the diagnostic scheme in chronic gaI1 bIadder disease. [For BibIiography see p. 35..]
GALL,RLADDER,DISEASE*
ROBERT C. PENDERGRASS,M.D. AMERICUS, GA.
T
Indigestion; 28 cases. Sour stomach: 14 cases. Gas: 27 cases. Belching: 27 cases. Nausea or vomiting or both: Ig cases. Heart burn: 5 cases. Palpitation : 4 cases. Constipation: 25 cases. CIay stooIs: 6 cases. Tarry stools: I case. Jaundice: 13 cases. Headache: I I cases. Joint pains: 7 cases
HE diseased gal bIadder may underIie so many variabIe symptoms referabIe to the abdomen, the chest, the head, and even the extremities that it is often a diffrcuIt task to untangIe the maze of conflicting symptoms and pIace guiIt where guilt beIongs. Our most reIiabIe aids in this task are: (I) a carefuIIy taken and thoughtfuIIy considered history, (2) a compIete physica exanination, (3) clinica laboratory studies and (4) roentgenoIogic examinations of the gaI1 bIadder and intestina1 tract. This paper wiI1 dea1 chiefly with the Iast named aid, roentgenIogic examination.
Type of foods causing distress: a11 foods, 6 cases; greasy foods, 4 cases; sweets, I case; fruit juices, I case; and in 18 cases no particuIar type of food was mentioned. It is easiIy seen that the compIaints of indigestion, gas, beIching and constipation predominated in this smaI1 series. Next in order of frequency were nausea, sour stomach, jaundice and headache. It is notable that 7 of the 30 patients compIained of joint pains.
SYMPTOMATOLOGY WhiIe the ancient dictum of the probabiIity of gal1 bIadder disease in the patient who is “fair, fat, forty, fuI1 of Aatus” and compIaining of upper abdomina1 pain, is stiI1 a quite reIiabIe guide, other symptoms shouId direct our suspicion to this organ. Among the more prominent of these are headache, constipation and chronic arthritis. PrecordiaI pain simuIating angina pectoris, even in radiation down the Ieft arm, may occur. L. W. Grove” has operated upon severa patients whose symptoms were aImost cIassic of angina, but remova of a caIcuIous gaI1 bIadder resuIted in compIete reIief. A study of the symptomatoIogy in 30 operated cases in our series gave the foIlowing resuIts : FemaIes 21 cases; maIes g. Average age: femaIes 42; males 45. Duration of symptoms: average six and one-haIf years; varied from six months to thirty years. Pain: upper abdomina1 17 cases; right lower quadrant 4 cases; right ffank 2 cases; generaIized abdominal pain 5 cases; and no pain compIained of in I case. * Read before The Chattahoochee
DIFFERENTIAL DIAGNOSIS In their recent book1 Graham, CoIe, Copher and Moore Iist the folIowing conditions which may be cIinicaIIy confused with chronic ChoIecystitis: Iesions of the stomach and duodenum; spastic constipation; intestinal aIIergy; carcinoma of the hepatic fIexure; chronic appendicitis; cirrhosis of the Iiver; syphiIis of the liver; Iesions of the kidney; hemoIytic icterus; spina Iesions, such as Pott’s disease; chronic Iesions of the right Lung, such as pIeurisy; sIipping of the eIeventh rib over the twelfth with resuItant pain; and among the rarer causes, parasitic diseases of the gaII bIadder, such as echinococcus cysts and round worm infection.
Valley Medical and Surgical Association, Albany, Georgia, JuIy 9, 1930. 6
NEW SERIES VOL. XI, No.
Pendergrass-OraI
I
LABORATORY
DIAGNOSIS
The chief vaIue of Iaboratory studies lies in differentiation of the obstructive and
ChoIecystography
American
Journal
of Surgery
7
their presence is detected before empIoying choIecystography. ChoIecystography has been subjected
a
hemoIytic types of jaundice, by means of the Van Den Bergh reaction, red ceI1 fragility tests, icterus index, examination of bIood smears, determination of bilirubin content of the urine, etc. Leucocytosis is not a constant factor except in empyema of the gal1 bladder. Analysis of the materia1 obtained by magnesium suIphate drainage of the gal1 bIadder is considered vaIuabIe by some, but my persona1 experience with this method as a diagnostic agent is so Iimited as to make any opinion expressed worthIess. ROENTGENOLOGIC GALL
EXAMINATION
OF
THE
BLADDER
RoentgenoIogic examination of the gal1 bIadder shouId consist of (I) preliminary and (3) ffat fiIms, (2) choIecystography barium mea1 examination of the stomach and duodenum where indicated. On the flat fiIms we may demonstrate opaque caIcuIi; occasionaIIy, the outIine of an enIarged gal1 bIadder, such as a hydropic gal1 bIadder; and in some instances renaI stones, spina Iesions, enIarged Iiver, or pancreatic caIcification. Any confusing shadows may be better identified later if
c
FIG. I. Sthenic habitus. Norma1 gall bladder. (a) TweIve hours after taking dye orally. (b) Fourteen hours after dye. (c) Two hours after fatty meal. Note decrease in size of shadow and upward migration.
to the unfair demands of the unduIy critica and the exaggerated claims of the enthusiastic. If we consider the rationaIe of the procedufe, we may Iearn how much and how IittIe we should expect from it. To understand ChoIecystography, it is
8
Pendergrass-OraI
American Journal of Surgery
necessary to review briefly the physioIogy of the gaII bIadder. From the mass of cIinica1, anatomica1, and Iaboratory inves-
ChoIecystography
It consists in introducing into the circulation, either intravenousIy or via the intestina1 tract, a haIogenated pthaIein
b
a
tigations, which have been abIy reviewed by Graham,2 AIvarez,j and others, the foIlowing facts seem definiteIy estabIished : (I) BiIe is excreted by the liver and fiIIs the gaI1 bIadder IargeIy by way of the cystic duct. (2) The gaI1 bIadder concentrates biIe. (3) At periodic intervaIs, and apparentIy in response to digestive activity, the gaI1 bIadder empties its contents into the common duct and thence into the duodenum. The chief components of the emptying act seem to be (I) contraction of the gaI1 bIadder waII and (2) washing out of the gaI1 bIadder by the recurring flow of Iiver biIe.3 The theory of a contrary innervation of the sphincter of Odi and the gaI1 bIadder is as yet in the throes of dispute among the physioIogists. Alvarez6 states that there seems to be a connection but doubts the theory of contrary innervation, and thinks that the causes are chiefly chemica1, as shown by the work of Boyden concerning ‘the effect of egg yoIk and fat on emptying of the gal1 bIadder. ChoIecystography, or th! Graham test, is primariIy a test of gall bIadder function, and is based on the physioIogic factors.
JANUARY, 1931
c
Hypersthenic habitus. Norma1 dye concentration but delayed emptying. (a) Fourteen hours after dye. Film made in expiration. (6) Fourteen hours after dye. Film made in inspiration. Note gaII bIadder shadow projected beIow rib. (c) Four hours after fatty meal. Slight decrease in density but no decrease in size of shadow.
FIG.
2.
containing iodine. Carried by the circuIation to the liver, the dye is excreted in the bile and then obeys to some extent the physioIogica1 Iaws governing the con-
NEU.
SERIES VOL. Xl, No.
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I
@-aI
centration and expukion of bile by the gaIl bIadder. It is thus obvious that the folIowing for requisites are necessary
ChoIecystography
American Journul of
surgery 9
(2) The Iiver must be able to excrete the dye into the bile. (3) The cystic duct must be open.
b
a
FIG. 3. Asthenic habitus. Norma1 gal1 bIadder. (a) Thirteen hours after dye. Note gaIl bIadder shadow overlying transverse processes of spine. (6) Same. LateraI view used to project gaI1 bladder clear of transverse processes.
obtaining a shadow cholecystography :
of the gaIl bIadder
by
(4) The concentrate
gall bIadd er must be able the dye to some degree.
to
a b Frc. 4. Asthenic habitus. Use of vertical obIique position to project gaI1 bladder shadow away from spine. (a) Posteroanterior view, prone position. Note gall bIadder shadow (retouched) overIying spine. (b) VerticaI oblique view (Bucky technic) showing gal1 bladder clear of spine.
(I) Suffkient circuIation.
dye
must
enter
the
In interpreting therefore note (I)
cholecystograms the time required
we for
IO
American
Journal of Surgery
Pendergrass-OraI
appearance of dye in the gaII bIadder; (2) the degree of dye concentration as noted by the density of the gaI1 bIadder
ChoIecystography
JANUARY. ,931
by reason of their contrast with the more dense dye shadow. In the ora method of ChoIecystography,
b
a
FIG. 5. Two cases of extrinsic deformity of gaII bIadder. (a) Angulation at neck of gaII bIadder (6) SimiIar anguIation, and aIso an incisura in mid-portion of the organ.
shadow; (3) the time required for the gaI1 bIadder to empty the dye-stained biIe in
(retouched).
as used in the cases herein summarized, a gaI1 bIadder shadow of good intensity
b
a
FIG. 6. MuItipIe choIestero1 stones, 26 stones found at operation.
(a) Fourteen hours after dye. Note muItiple negative shadows. (6) Two hours after fatty mea1. Note contracted gaI1 bIadder with negative shadows remaining within its outIine. This excludes gas as cause of shadows.
response to a fatty mea1 and (4) whether or not choIestero1 stones are demonstrated
shouId be obtained in from tweIve to sixteen hours after administration of the dye,
NEW SERIES VOL. XI, No.
Pendergrass-OraI
I
and the organ shouId be at Ieast one-haIf empty two hours after a meal of egg yoIk, butter and cream has been eaten.
a
ChoIecystography TECHNIC
OF
The technic as foIIows :
American
ORAL
Journal
of SCIW~Y
I I
CHOLECYSTOGRAPHY
used
in our
Iaboratory
is
b
FIG. 7. SingIe
negative density defect. One choIestero1 stone and “strawberry” mucosa found at operation. (a) Fourteen hours after dye. (6) Two hours after fatty mea1. Note ring of dye surrounding stone shadow. Excellent function despite presence of stone and diseased mucosa.
As we are reminded by Alvarez, a diseased gaII bladder may show a fairIy good concentration of the dye, and it is aIso known that a diseased gall bIadder wiI1 empty its contents fairIy readiIy in many cases. In other words, the degree of concentration of the dye is not in direct proportion to the amount of pathoIogy existing in the gaI1 bIadder. We know that a gaI1 bIadder which contains stones is diseased, eIse stones wouId not be present; yet such gaI1 bIadders wiI1 often empty we11 in response to a fatty meaI. Iilingworth’0 in a recent articIe discussing cholesterosis of the gaI1 bladder, states: “ChoIecystography indicates that in uncompIicated cases the concentration of biIe and the emptying in response to fats are not affected.” In many cases the major pathoIogy is found in the outer coats of the gall bIadder and not in the mucosa, and this may expIain to some extent the discrepancy in concentration of the dye by a diseased, viscus.
I. The patient is given a cathartic, preferabIy castor oil, on the night before the dye is taken, and an enema the foIIowing morning. 2. The afternoon after the cathartic, preliminary flat fiIms are taken. 3. Supper that same evening at 7 P. M. consists of dry toast, baked Irish potato or cream of wheat, or oatmea1, and either tea, coffee or water. No miIk is aIIowed. a 4. One hour Iater (8 P. M.), Keraphen, powdered preparation of tetraiodophenoIphthaiein, is given in a haIf gIass of cold water, foIIowed by a haIf gIass of coId water. After that, no food or drink is aIIowed unti1 after the first fIIm of the series is made at g A. M. the foIIowing day. In our Iater cases, we have aIIowed fruit juices, weak tea, and coffee without cream after taking the dye, as they seem to have no effect on emptying of the gal1 bIadder, and the fruit juices apparentIy aIIay nausea in some patients. 3. Films are obtained at thirteen and fifteen hours after taking the dye. Then
12
American
Journal
of Surgery
Pendergrass-OraI
the patient is given a mea1 of two soft boiIed eggs with butter, buttered toast, one gIass of sweet miIk and one gIass of
a
ChoIecystography
JANU~Y.
ROENTGENOGRAPHIC
,931
TECHNIC
The prehminary ffat fiIms are usualIy made on a IO X 12 fiIm using fast exposure,
b
FIG. 8. Hypersthenic habitus. Single negative density Ming defect simulating stone (retouched). Compare with Fig. 7. (a) Showing singte, rounded negative density shadow. 14 hrs. (b) Oblique view, showing rounded shadow partIy projected from gal1 bladder shadow. Defect due to gas.
pure cream. Two hours later a fiIm is made, and if the gall bIadder is not at Ieast one-haIf empty a second fiIm is made at four hours after the fatty mea1. The foIIowing additiona points have been heIpfu1 in empIoying this technic: I. In nervous patients who are subject to nausea at the Ieast provocation, barbita1 grain v or IuminaI grain jss is given two hours before taking the dye. 2. Where a tendency to diarrhea is known to exist, paregoric dr. I to 2 is given one hour before the evening mea1, on the same day the dye is taken. This sIows intestina1 peristaIsis and apparentIy aIIows a better absorption of the dye. Fitzgibbon8 has recentIy advocated this practice. We have empIoyed paregoric with good resuIts in patients who have been subjected to operations such as gastroenterostomy or pyIoropIasty, in whom smaI1 intestinal peristaIsis is usuaIIy increased. 3. When such a meal is not readiIy avaiIabIe, an egg maIted miIk made with pure cream produces quite a satisfactory emptying of the gaI1 bIadder.
as for a stomach, on one film; and on another we empIoy Bucky technic, with a medium sized cone centered over the gaII bIadder region. The choIecystograms are made with Potter-Bucky technic, a comparativeIy low voItage, 25 ma. doubIe screens, cone. Two exposures are usuaIIy made, to produce varying densities. If the gaI1 bIadder is unusuaIIy high, one fiIm is made in inspiration; otherwise expiration is the method of choice. If the transverse processes of the spine overIap the gaI1 bIadder shadow, an obIique or Iateral view is taken. Where spine pressure affects the dye shadow, sand bags are used to support the patient from the tabIe, or fiIms are made in the erect position. The Mms shouId show: good density of the spine and ribs; the outIine of the Iiver edge; the outIine of the right kidney and a cIear outIine of the gaI1 bIadder. Over-exposure is the most common fauIt. Any respiratory movements make the fiIms worthIess, especiaIIy in detecting smaI1 stone shadows.
hrw
SERIFS VOL. >(I. No.
Pendergrass-Oral
I
When stone shadows are seen, or even suspected, a film shouId be made after the emptying mea1, since the stones may often
ChoIecystography
Journal Ame~,can
of Surgery
I3
after ingestion, and emptying of at Ieast one-haIf the dye in two hours after taking the fatty mea1 described in the technic.
a
be better detected when they are more cIoseIy packed together in the contracted viscus. The persistence of identica1 negative density shadows in the HIed and partly emptied gaII bIadder definitely confirms the nature of such shadows. Where gas shadows simuIate stones, several examinations in various positions may prove the true nature of the shadows in question. AN~\LYSIS OF 2 16 ROENTGENOLOGIC EXAMINATIONS A study of 2 I 6 consecutive examinations of the gaIl bIadder made in our cIinic is here presented. Of this number, 14 patients had only ffat fiIm examinations without choIecystography. The remaining 202 had either choIecystography aIone or a preIiminary flat film examination foIlowed by choIecystography. The 202 choIecystograms represent 202 cases; in many of these the examination was repeated at Ieast once, so that the actual numberof roentgenoIogic examinations was somewhat Iarger. The choIecystographic findings were classified as foIIows : I. Normal. In this group are those patients showing a norma concentration of the dye in from tweIve to sixteen hours
c
FIG. 9. Use of ChoIecystography
to confirm diagnosis of opaque gallstone, shadow of which noted on upper edge of UterosaIpingograph. (a) Rounded opaque shadow noted on Aat film. (b) Fourteen hours. Posteroanterior view. (c) Fourteen hours. LateraI view. Note ring shadow remaining within limits of dye shadow.
2. Pathological. These were divided as foIIows : a. Absent shadow. b. Faint shadow. c. MottIed shadows suggestive of calculi. d. DeIayed emptying.
14
American
Journal
of Surgery
Pendergrass-OraI
e. Definite caIculi shadows. 3. Repetition of Examination Requested but Not Obtained. Cause of such request.
a
ChoIecystography
JANUARY,,931
subjected to a repetition of the study where the first examination was unsatisfactory. We regard repetition of the test
b
FIG. IO. Two cases of hydropic gaII bIadder containing caIcuIi, confirmed at operation. (a) Fourteen hours. Note Iarge shadow with faint dye concentration. Negative shadows can be made out in Iower portion of gal1 bIadder. 36 stones found at operation. (b) Hydropic gaI1 bIadder. 16 hrs. 6 choIestero1 stones found at operation; puruIent materia1 in gaI1 bladder. Dye concentration faint on origina Mm; retouched.
a. Absent shadow. b. Faint shadow. c. Confusing gas shadows. The resuIts of the examinations, grouped here, were as foIIows: I. Normal, 78 cases or 38 per cent. 113 cases or 51 per 2. Pathological, cent, divided as foIIows: a. Absent shadow, 23 cases or 20 per cent. b. Faint shadow, 43 cases or 38 per cent. c. MottIed shadows suggestive of caIcuIi, 12 cases or I0 per cent. d. DeIayed emptying, 18 cases or 16 per cent. e. Definite caIcuIi shadows, 17 cases or 15 per cent. 3. Repetition of Examination Requested but Not Obtained. EIeven cases divided as foIIows : a. Absent shadow, 7 cases. b. Faint shadow, 3 cases. c. Gas defects, I case. AI1 cases cIassified as pathoIogica1 were
as one of the most important features of a carefuIIy made ora examination. It is noted that cases showing no shadow and those showing definite caIcuIi shadows constitute about one-third of the tota pathoIogica1 cases. The other two-thirds, in which a diagnosis of pathoIogica1 gaII bIadder was based on the Iess definite findings of faint shadow, mottIed shadow and deIayed emptying, offer the chief diagnostic probIem, and to my mind the richest fieId for future developments in choIecystography. Oakmang recentIy caIIed attention to the diagnostic vaIue of the faint shadow in ora choIecystography. It is in these cases that the persona1 equation of the evaIuation of a norma shadow enters. They offer more diagnostic pitfaIIs than any other group of cases, and deserve the carefu1 consideration of everyone interpreting choIecystograms. TechnicaIIy good fiIms are a necessity here, since under or over exposure may render it diflicuIt to judge the actua1 concentration
NEW
SERIES VOL. XI, No. I
PendergrassaraI
of the dye. Moore, Graham, et aI. state that retention of the dye beyond a two or three hour period after a fatty mea1 is of no pathologica significance if concentration is norma prior to the meal, and offer as expIanation either reabsorption of dye from the intestina1 tract or prolongation of the starvation period. In case of a faint shadow coupIed with deIayed emptying, the diagnosis of a pathoIogica1 gaI1 biadder may be safeIy made. This certainly is true of the hydropic gaI1 bladder, and 2 such cases are incIuded in this series and were confirmed at operation. Of the 200 patients examined 30, or 14 per cent, have to our knowIedge come to operation. These cases have been reviewed as foIIows, comparing the roentgenologic diagnosis and the operative diagnosis : Of the 26 cholecystographies in which a diagnosis of “pathoIogica1 gaI1 bIadder” aIone was made thirteen times a11 13 showed a chronic ChoIecystitis and 4 also showed stones, an agreement of IOO per cent in the preoperative and postoperative diagnosis. Of 6 cases in which stones were diagnosed, 6 showed stones at operation, an agreement of I00 per cent. Of 4 cases diagnosed as normal, 2 were norma and 2 showed caIcuIi, an agreement of 50 per cent. A review of these fiIms indicates that the degree of dye concentration was beIow norma and the diagnosis of a normaI gaII bIadder was not warranted in the face of the faint shadow. In 3 cases in which a repetition of the test was asked but not obtained, 2 were norma and I showed a chronic choIecystitis at operation. Of 3 Aat fiIm studies which showed no pathoIogy but in which use of the dye method was requested, I case was norma and z were pathoIogica1, of which I had a gumma of the Iiver in addition to a diseased gaI1 bIadder. in I flat fiIm study showing stones, diagnosis was confirmed at operation.
ChoIecystography
American Jot~d
of SUCWY
I 5
COMMENT
The writer wishes to emphasize that ChoIecystography represents onIy one witness for the prosecution in the case against the diseased gaI1 bIadder. It is not infaIIibIe. The roentgenoIogic findings shouId be carefuIIv correIated with the history, physica1 fin&ngs and Iaboratory reports, and in borderIine cases, if the cIinica1 indications of a diseased gaI1 bIadder are stronger than the roentgenoIogic evidence, then the cIinica1 findings shouId form the basis of the diagnostic decision. It is aIso to be remembered that a recent miId attack of ChoIecystitis may Ieave the gaI1 bIadder so IittIe impaired that dye concentration is normaI. FaiIure to recognize this fact may Iead to error in the retrospective diagnosis of recent attacks of upper abdomina1 pain. If choIecystography is employed with a fuI1 recognition of its possibiIities and its Iimitations; with proper regard for detaiIs of technic; with judgment in interpretation; and with broad cIinica1 approach to the case in question, then and onIy then, is it a reIiabIe aid in the diagnosis of chronic gaI1 bIadder disease. SUMMARY I. The diagnosis of chronic gaI1 bIadder disease is discussed with reference to the differentia1 diagnosis, symptomatoIogy, Iaboratory diagnosis, and roentgenoIogic diagnosis. 2. Thirty operated cases are anaIyzed according to symptomatoIogy. 3. The rationaIe, technic, and interpretation of choIecystograms are discussed. 4. The findings in 2 16 consecutive examinations of the gaI1 bladder are tabuIated. 5. Comparison of the roentgenoIogic and operative diagnosis in 30 operated cases is presented. 6. Comment is made upon the reIative position of ChoIecystography in the diagnostic scheme in chronic gaI1 bIadder disease. [For BibIiography see p. 35..]