Gastrointestinal

Gastrointest Radiol I, 9 1 - 9 2 (1976)

Radiology by Springer-Verlag 1976

Five-Hour Reinforcement Cholecystography Andrew B. Crummy Department of Radiology of the University of Wisconsin Center for Health Sciences, Madison, Wisconsin, U.S.A.

Abstract. Pathologic diagnoses were reviewed in 115 patients in whom gallbladder disease was diagnosed radiologically based on nonopacification with the calcium ipodate rapid reinforcement technique. In all instances, the gallbladder was diseased. Therefore, the rapid reinforcement technique is valid and considerably reduces the time necessary to complete reinforcement cholecystography. Because the time required is only 5 h, increased convenience and decreased cost may be realized without compromising diagnostic accurracy. Key words: Cholecystography Cholelithiasis - Contrast agent.

Cholecystitis -

Unsatisfactory opacification occurs after an initial dose of 3 g of contrast agent in approximately 25% of oral cholecystograms [I]. In such circumstances it is customary to administer another dose of contrast agent and to refilm after an appropriate interval, usually the following day. An additional 10% to 15% of gallbladders will then be sufficiently opacified for diagnosis. Those that do not show pathology are considered to be normal. Conversely, failure of the gallbladder to opacify is indicative of gallbladder disease if extraneous causes can be excluded [2]. A major drawback of this technique is the amount of time required to complete the study if reinforcement is necessary. When one considers that 500,000 reinforcement cholecystograms are done annually, it is apparent that the loss of time and the expense are enormous [1]. Burhenne and Obata [1] as well as Mandelstam and Rosenbaum [3] have recently reported the use of 6g of iopanoic acid, in fractional doses, over a Addressfor reprint requests: Andrew B. Crummy, M.D., 1300 University Avenue, Madison, WI 53706, U.S,A.

40- to 48-hour-period. If the gallbladder is unsatisfactorily opacified under these conditions, one may diagnose gallbladder disease without needing to give additional contrast agent. This regimen is useful primarily in outpatients where a lead time of 48 h can conveniently be scheduled. The calcium salt of ipodate is absorbed and excreted in approximately 5 h in contrast to the sodium salt, which requires about 12 h to opacify the gallbladder. Therefore, if unsatisfactory opacification is encountered after the first 3 g dose of contrast agent, reinforcement cholecystography can be completed within 5 h with the use of calcium ipodate. This technique obviates the need for a 48-hour lead or 24-hour follow-up time.

Materials and Methods Three grams of contrast agent are given over a 1-hourperiod approximately 12 h before the examination. If opacification is nondiagnostic, 3 g of calcium ipodate granules, dissolved in warm water, are administered and the films repeated in 5 h. The examination is complete with the second set of films. If the gallbladder is not opacified and extraneous causes can be excluded, gallbladder disease is diagnosed. During the 5 h before refilming, patients are allowed small quantities of water, black tea or coffee, and also dry toast if they are not scheduled for a gastrointestinal series that day.

Results To test our hypothesis that the rapid reinforcement technique is valid, we reviewed the pathology reports on 620 consecutive cholecystectomies. Surgery without x-ray studies was performed on 295 patients, or

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A.B. Crummy: Reinforcement Cholecystography

Table 1. Nonopacification with reinforcement

Pathologic diagnosis

No. of patients

Chronic cholecystitis with stones Chronic cholecystitis without stones Carcinoma of the gallbladder

106 8 1

their examinations were performed at other institu.lions. Cholelithiasis was diagnosed in 210 patients off the basis of our cholecystograms. Gallbladder disease was diagnosed in 115 patients, based on nonopacification of the gallbladder with the rapid reinforcement technique. The pathologic diagnoses in these 115 patients were' chronic cholecystitis with calculi in 8 patients, chronic cholecystitis without stones in 8, and carcinoma of the gallbladder in 1 (Table 1). Thus, the diagnosis of gallbladder disease based on nonopacification following rapid reinforcement cholecystography was confined in all patients. We used the calcium idopate rapid reinforcement technique successfully with all currently employed oral cholecystographic agents: Tyropanoate sodium (Bilopaque), iocetamic acid (Cholebrine), ipodate

sodium (Orografin NA), and iopanoic acid (Telepaque). We are unaware of any complications occurring with the use of this technique. Discussion

The 6 g, 48-hour fractionated regimen is useful when there are no time constraints. However, when time is an important factor, as with inpatients, the calcium ipodate rapid reinforcement technique will speed diagnosis and thereby expedite patient care. Because of the large number of patients involved, substantial economic and social benefts will result without compromising diagnostic accuracy. References 1. Burhenne H J, Obata WG: Single-visit oral cholecystography. N Engl J Meal 292:627, 1975 2. Crummy AB: Same day reinforcement oral cholecystography. Wis Med J 65:84-86, 1966 3. Mandelstam P, Rosenbaum HD: Cholecystography with iopanoic acid "reinforcement" before initial study. JAMA 232:642, 1975 4. Mujahed Z, Evans JA, Whalen JP: The nonopacified gallbladder on oral cholecystography. Radiology 112 : 1 - 3, 1974

Five-hour reinforcement cholecystography.

Pathologic diagnoses were reviewed in 115 patients in whom gallbladder disease was diagnosed radiogically based on nonopacification with the calcium i...
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