1984, The British Journal of Radiology, 57, 685-687

AUGUST

1984

The early diagnosis of acute gall-bladder disease: the

accuracy of overnight eight-hour infusion cholangiography
By G. J. L. Thomson, C. J. Simpson, D. T. Hansell, M. A. Millar, J. S. H. Davidson, G. R. Gray,
D. C. Smith and G. Gillespie
Departments of Surgery and Radiology, Victoria Infirmary, Glasgow
(Received November 1983)

ABSTRACT

The reliability of overnight 8-hour infusion cholangiography

in confirming the diagnosis of acute cholecystitis or biliary
colic was assessed by a prospective study in 100 patients. 55
positive infusion cholangiograms were subsequently confirmed
at operation in 45 patients and by cholecystogram in 10
patients who did not have surgical treatment.The absence of
false positive examinations is of fundamental importance if
early cholecystectomy is to be performed without the risk of an
unnecessary laparotomy. Infusion cholangiography proved to
be a safe, simple and reliable investigation in the confirmation
of acute gall-bladder disease.

The traditional management of acute gall-bladder

disease in the United Kingdom has been conservative
because of the uncertainty regarding the accuracy of the
diagnosis and the practical difficulties and dangers
associated with surgery adjacent to an inflamed and
oedematous porta hepatis. Yet common experience
shows that in many patients the inflammatory process
fails to resolve completely, and even "delayed" surgery
may in a proportion of cases be fraught with the
difficulties of operating on a "sub-acute" or "chronic"
inflammatory mass. In this study we have explored the
diagnostic accuracy of overnight 8-hour cholangiography by using it as the principal diagnostic criterion,
enabling an early decision to be made regarding
cholecystectomy.
PATIENTS AND METHODS

One hundred consecutive patients admitted to the

general surgical wards of the Victoria Infirmary,
Glasgow, in whom the duty surgical registrar considered acute gall-bladder disease a likely diagnosis,
entered the study. Patients known to have gall stones,
patients with a serum amylase in the range suggestive of
acute pancreatitis, and patients whose history of pain
was greater than seven days were excluded. Chest X ray
and plain abdominal radiographs were obtained on
admission, and at midnight on the day of admission an
intravenous infusion of 1000 ml of normal saline, to
which 100 ml of Biligram (meglumine ioglycamide) had
been added under strict aseptic conditions in the
laminar flow cupboard of the hospital pharmacy, was
commenced, and was allowed to run for eight hours
(Lindblad et al, 1978). One hour following completion
of the infusion (i.e., 9 a.m.) a single X ray of the right
upper quadrant of the abdomen was performed. An
685

ultrasound examination was performed at this time

using EMI Sonic 4200 and Fischer Real Twin section
scanner. All ultrasound examinations were performed
by radiologists experienced in the use of grey-scale
ultrasonography. A cholangiogram was considered
positive (a) if a gall bladder containing stones was
demonstrated, (b) if contrast medium was visible in the
common bile duct without the gall bladder outlining,
or, (c) if excreted contrast medium was visible in the
gut, but not in the biliary tree. A positive ultrasound
examination demonstrated a gall bladder containing
calculi (the configuration of the gall bladder was not a
criterion). Confirmation of the diagnosis was obtained
at operation, by histological examination or by oral
cholecystogram in patients who did not have surgery.
RESULTS

Plain X ray
Eight patients had evidence of gall stones on plain
abdominal X ray.
Abnormal, i.e., "positive" infusion cholangiogram
(Table I)
In 55 patients, 8-hour infusion cholangiogram
provided evidence to substantiate the clinical diagnosis
of acute gall-bladder disease (Table I). The cholangiogram results correlated well with those obtained by
ultrasound.

TABLE I
POSITIVE INFUSION CHOLANGIOGRAMS

8 h Infusion cholangiogram
Stones in opacified gall
bladder
Non-opacifying gall
bladder-contrast in bile
duct.
Conjugated contrast in
bowel only

Ultrasound

16

15

Stones in gall bladder

26

23

Stones in gall bladder

13

13
2

Stones in gall bladder

Gall bladder not
demonstrated
Ultrasound not
performed

2
Total

55

55

VOL.

57, No. 680

G. J. L. Thomson et al
TABLE II
NORMAL INFUSION CHOLANGIOGRAMS

8 h Infusion cholangiogram
Negative examination

Ultrasound
37 31 Normal gall bladder
4 *Gall stones?
2 fGall bladder not visualised

*8 h infusion cholangiogram and subsequent oral cholecystogram negative

fin one patient subsequent traditional intravenous cholangiogram demonstrated stones; in one patient, the subsequent oral
cholecystogram was negative.

cause for jaundice in the other patient was identified. In

a single anicteric patient a technical failure occurred for
which no certain explanation can be given. He
subsequently had a cholecystectomy after the gall
bladder had failed to opacify on oral cholecystectography; a thickened gall bladder not containing stones
was subsequently removed. There were no side-effects
from the infusion cholangiogram in any of the 100
examinations.
DISCUSSION

Early surgery for biliary colic or cholecystitis will not

only prevent the discomfort and hazards of recurrent
attacks (Glenn & Dillon, 1980) but should reduce the
length and the costs of hospitalisation without an
Forty-five of these patients underwent chole- increase in morbidity or mortality (McArthur et al,
cystectomy, 39 having early surgery after the diagnosis 1975; Van der Linden & Edlund, 1981; Jarvinen &
had been made, and in six, operations were carried out Hastbacka, 1975). However, it is essential to be able to
at later dates. The remaining ten patients have had reach a diagnosis quickly and accurately to avoid
unnecessary surgery as a result of mistaken diagnosis
positive oral cholecystograms in the follow-up period,
period.
(Essenhigh, 1966). This study reinforces the impression
that clinical diagnosis is often inaccurate; to improve
Normal infusion cholangiograms (Table II)
the accuracy of diagnosis, standard contrast-medium
Thirty-seven patients had normal infusion cholangio- radiology has, in the last decade, been supplemented by
grams, conflicting with the clinical impression of acute grey-scale ultrasound and radionuclide scanning. Ultragall-bladder disease; 31 of this group had a negative sound gives no information on hepatobiliary function,
ultrasound examination. The results of four ultrasound and radionuclide scanning is not available in every
examinations were positive, and in two patients the gall hospital. Conventional intravenous cholangiography
bladder was not visualised. One of the latter was found has been criticised on grounds of safety, and a
on formal intravenous cholangiography to have gall diagnostic error rate of up to 40% has been reported
stones, the other had a normal oral cholecystogram at (Essenhigh, 1966; Goodman et al, 1980). Administrafollow-up three months later. Follow-up oral tion of contrast medium by infusion rather than bolus
cholecystography on 26 patients revealed a further four injection greatly reduces the risk of hypersensitivity
patients with gall stones, and one patient had gall reactions (Shehadi, 1975). Most diagnostic errors relate
stones at laparotomy. Thus five patients had false to common duct stones, and the infusion technique
negative infusion cholangiograms. Four false negative used in this study aims to give information about the
ultrasound examinations and four false positive ultra- gall bladder only. The infusion cholangiogram was not,
sound examinations (in whom oral cholecystogram and should not be, relied on to assess the patency of the
and infusion cholangiogram proved negative) occurred common bile duct.
in this group.
Although Lindblad recorded good results from
infusion cholangiography in the diagnosis of acute
Non-opacifying or "failed" cholangiograms (Table III) cholecystitis, two films, one at 8 h and one at 24 h after
Seven patients with significantly abnormal liver infusion, were required to make the diagnosis
function tests had non-opacifying cholangiograms and (Lindblad et al, 1978). The single film examination
clinical jaundice (which is now considered a contra- employed in this study allows the diagnosis to be made
indication). Six of this group proved to have calculi on within 12 hours of admission.
ultrasound and at subsequent surgery. A hepatocellular
Grey scale ultrasonography has the advantage of
being non-invasive and is useful in the jaundiced patient
where infusion cholangiography is unreliable and,
TABLE III
therefore, contra-indicated. Although ultrasound has
NON-OPACIFYING CHOLANGIOGRAMS
been shown to detect very small calculi (Hessler et al,
1981), most series contain false positive examinations,
8 h Infusion cholangiogram
Ultrasound
limiting its application in the identification of patients
for early surgery (Cintora et al, 1979; McKay et al,
Disturbed liver function
7 6 Stones in gall bladder
1978). Radionuclide scanning using "Tcm-pyrm? Technical failuref
1 1 Gall bladder not visualised
idoxylidene
.glutamate or "Tc m HIDA has been used
1 Normal gall bladder*
increasingly in the diagnosis of gall-bladder disease
(Down et al, 1979). In one study, however, it has
*Subsequently confirmed as hepato-cellular jaundice
proved insufficiently reliable in isolation in diagnosing
fStones demonstrated in gall bladder.
686

AUGUST 1984

8-hour infusion cholangiography

acute gall-bladder disease (Stephens et al, 1982).
Scanning may fail to detect any abnormality in a
patient with a functioning gall bladder, 30% of the
patients in this study coming into this category.
Although the technique is becoming increasingly
available, it does require about 60 min of departmental
time to perform.
The absence of false positive results in this series
requires emphasis, as this is essential if a policy of early
surgery is adopted. In addition, the examination is
economical both in financial terms and in terms of
radiological time. Interpretation of the film does not
require skilled radiological ability. In conclusion,
infusion cholangiography is ideally suited for general
use in the rapid diagnosis of acute gall-bladder disease
in the anicteric patient.

cholecystitis and choledocholithiasis. Surgery, Gynecology &

Obstetrics, 151, 528-532.
GOODMAN, M. W., ANSEL, H. J., VENNES, J. A., LASSER, R. B.

& SILVIS, S. E., 1980. Is intravenous cholangiography still

useful? Gastroenterology, 79, 642-645.
HESSLER, P. C , HILL, D. S., DETORIE, F. M. & Rocco, H. F.,

1981. High accuracy of sonographic recognition of gall

stones. American Journal of Roentgenology, 136, 517-520.
JARVINEN, H. J. & HASTBACKA, J., 1980. Early cholecystectomy

for acute cholecystitis. Annals of Surgery, 191, 501-505.

LlNDBLAD,

L.,

ROSENGREN,

K.,

ZACHRISSON,

B-F.

&

SCHERSTEN, T., 1978. Infusion cholecystography. An aid in

the diagnosis of acute cholecystitis. Scandinavian Journal of
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MCARTHUR, P., CUSCHICRI, A., SELLS, R. A. & SHIELDS, R.,

1975. Controlled clinical trial comparing early with interval

cholecystectomy for acute cholecystitis. British Journal of
Surgery, 62, 850-852.
M C K A Y , A. J., DUNCAN, J. G., IMRIE, C. W., JOFFE, S. N. &

REFERENCES
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administered contrast media. American Journal of Roentgenology, 124, 145-152.
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T. P. J., 1982. Hida scanning without ultra-sound is

insufficient for early diagnosis of acute gallbladder disease
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in

Book review
Introduction to Radiology in Clinical Paediatrics. By Jack O.
Haller and Thomas L. Slovis, pp. xi + 206, 1984 (Blackwell
Scientific, Oxford), 26.00.
ISBN 0-8151-4108-4
It is encouraging that many clinicians participate in the
interpretation of their patients' radiological investigations,
whether through clinico-radiological meetings or individual
consultations. The authors of the book, both practising clinical
radiologists, have directed this work towards the clinician.
The introductory chapter explains the nature and production of radiographs, indicates the radiation dose to the child
and suggests proper utilisation of radiographs, although in this
country we, hopefully, will be slightly more stringent in our
indications.
Chapters then follow which are system-orientated and
follow basically similar patterns. Technical factors are
discussed and, in particular, methods of gauging adequacy of
exposure are considered. Pathological conditions are con-

687

sidered after normal appearances have been described. In the

gastrointestinal tract, contrast studies are discussed and in the
urinary tract cystography, urography, ultrasound and radionuclide imaging are all discussed and an attempt is made to
integrate their use. Perhaps in this country more emphasis
would have been placed on ultrasound than on urography in
the very young.
Next follows a chapter on abdominal and pelvic masses. The
skeleton and central nervous system are then dealt with
sensibly, but necessarily briefly. The final chapter is concerned
with more specialised techniques.
The text is instructive, the illustrations and radiographs clear
and as a primer in paediatric radiology this book should find a
useful place. Clinical students should also find it instructive,
not least because the text is easy to read and generally
stimulating.
DONALD G. SHAW