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Atrial is reported using ioglycamate (Biligram) drip infusion on 150 patients. Satisfactory demonstration of the biliary tree was obtained in 115 (76 per cent) patients. Side effects were minimal and no serious complications occurred. The use of this contrast medium in a 12 hour drip in cases of jaundice is discussed.

Two patients in whom computed tomography (CT) and sonography suggested the diagnosis of Caroli's disease are reported. The biliary/nonbiliary nature of the hepatic cysts was evident on a CT scan of the liver obtained immediately after intravenous cholangiography. This allowed an accurate analysis of the relationship of the biliary ducts to the cysts and easy identification of contrast medium, where present, within them. The use of this technique may avoid more invasive procedures that, although accurate in defining anatomic changes of the biliary ducts, may cause infection in patients with biliary stasis and cholangitis.

A radioimmunoassay for glycocholate was used as an estimate of serum bile salts in patients with serum bilirubin levels less than 5 mg/dl undergoing oral cholecystography. Most subjects also had a percutaneous liver biopsy. Intravenous cholangiography was performed in most subjects who had a nonvisualized gallbladder after receiving single doses of iopanoic acid on two consecutive days. The pathologic status of nonvisualized gallbladders was ascertained by surgery, prospective follow-up, necropsy and/or ultrasound. In 20 subjects with well-visualized gallbladders, the serum cholate conjugates (CC) were lower than 3.5 μM in all but two subjects, both of whom had inflammatory liver disease (chronic active hepatitis, alcoholic hepatitis). Those with faintly or poorly visualized gallbladders, but with no evidence of gallbladder or gallstone disease by other criteria, also had levels less than 3.5 μM, except for one subject with inflammatory liver disease. By contrast, 11 subjects with nonvisualized, although normal gallbladders by the above clinical criteria, exhibited serum CC greater than 3.5 μM. Six subjects had diminished gallbladder visualization, but normal gallbladders on clinicopathological grounds; all but one with chronic active hepatitis had serum CC greater than 3.5 μM. In conclusion, when the serum cholate conjugates are less than 3.5 μM, nonvisualization of the gallbladder with oral cholecystography supports a diagnosis of a diseased gallbladder. In addition, a serum CC level greater than 3.5 μM may predict insufficient hepatic capacity to secrete iopanoic acid adequate for gallbladder visualization in noninflammatory liver disease. The serum cholate conjugates appear to provide greater information on this hepatic function than the serum bilirubin or bromsulfophthalein retention.

The maximum biliary excretion rate of iotroxamide was found to be significantly greater than that of iodipamide in bile-fistula dogs. High bile salt excretion rates had no effect on the rate of biliary excretion of either compound, but the choleresis associated with greater bile salt excretion reduced the biliary concentration of both agents. Both are potent choleretics, stimulating about 23.5 ml of bile per mmole of contrast agent excreted in bile. This obligatory coupling of the contrast agents with water as they are excreted in bile imposes a limit on the maximum concentration that can be achieved in bile. Since iotroxamide is excreted more rapidly in bile than iodipamide for any equimolar plasma concentration, it may be a superior contrast agent for intravenous cholangiography.

The biliary and urinary excretion and the choleretic effect of ioglycamide were studied in unanesthetized bile fistula dogs using stepwise increasing infusion rates to obtain multiple steady states. The results are compared with data from previously reported experiments in the same animals using iodoxamate and iodipamide. The rate of biliary excretion and the choleretic effect of ioglycamide are similar to those of iodipamide and iodoxamate. Like iodipamide and iodoxamate, the relation between infusion rate or plasma concentration and biliary excretion or concentration of ioglycamide are hyperbolic and can be fitted to saturation kinetics. Quantitatively, the excretion of ioglycamide and iodipamide are virtually identical. However, for any equimolar infusion rate or plasma concentration, more iodoxamate than ioglycamide is excreted in the bile. Despite the greater biliary excretion of iodoxamate, the maximum biliary concentration of ioglycamide, iodipamide, and iodoxamate is the same at low basal bile flow because the choleretic effects of the three compounds are equal. The data suggest that, theoretically, with any equimolar dose ioglycamide will be identical to iodipamide as a contrast material for intravenous cholangiography, but that iodoxamate may be superior to ioglycamide because more iodoxamate is excreted in the bile. This advantage of iodoxamate might become apparent clinically in patients with high basal bile flow or if smaller doses of the contrast material are used. However, at the presently recommended doses of the two compounds, it is unlikely that the use of ioglycamide for intravenous cholangiography will be any different than iodoxamate.

When a 30-minute infusion is chosen for intravenous cholangiography, the optimal dose in subjects with normal and decreased hepatic function seems to be 0.6 ml/kg iodipamide. Delayed visualization of the ducts and gallbladder occurs in hepatic dysfunction, therefore, radiographs should be taken up to eight hours after the start of the examination if the cholangiogram is not diagnostic sooner. Prolonged infusion time, increased dosage, or both did not improve the radiographic results significantly when this method was not diagnostic. Contary to what is seen in obstructive jaundice, a markedly reduced gallbladder size, compared to its own baseline, was found in hepatic dysfunction.

Experiments were done to test the hypothesis that emptying the gallbladder prior to intravenous cholangiography (IVC) would result in earler and better opacification of the gallbladder. Five dogs were studied on two separate days in a crossover experiment. Each dog had a standard IVC (15-minute infusion of meglumine iodipamide) 2.5 cc/kg of following a 14-16-hour fasting period. On one of the days, 0.3 mcg/kg of Ceruletide was intramuscularly administered to each dog 30 to 45 minutes prior to the iodipamide infusion. Films obtained at the end of infusion and at 20, 40, 60, and 90 minutes were evaluated independently by three radiologists. The results indicate that pretreatment with Ceruletide produces a significant (p less than 0.05) improvement in the quality of gallbladder opacification during the first 90 minutes following iodipamide infusion. We conclude that earlier and better opacification of the gallbladder during IVC can be obtained by prior emptying of the gallbladder with a cholecystokinetic agent.

The investigation was performed in 6 cholecystectomized chronic bile fistula dogs in which, except in complete common bile duct obstruction, the bile was diverted and replaced with a constant taurocholate infusion of 0.3 mumoles per min. per kg. Iodipamide and iodoxamate were i.v. infused at a rate of 6.7 mumoles per minute per kg for 30 minutes. Different degrees of extrahepatic obstruction were simulated by producing different intrabiliary pressure conditions. Progressive hepatic parenchymal disease was induced by oral administration of dimethylnitrosamine. In both conditions basal (precontrast) bile flow, maximum biliary excretion rate and bile concentration of the contrast agents decreased with increasing hepatic dysfunction. This investigation suggests that, regardless of the underlying mechanism, the bile iodine concentration required for radiographic visualization of the biliary system is no longer attained in intravenous cholangiography when the basal bile flow decreases below 2 microliter per min per kg in the presence of a physiologic bile salt plasma pool. In hepatic dysfunction alkaline phosphatase correlated better with the maximum biliary excretion rate and concentration of the contrast agents than SGPT, SGOT, and serum bilirubin and therefore seems to be the best parameter to predict the chance of a successful intravenous cholangiography.

Because of relatively low acute toxicity, iosulamide meglumine has been recommended as an improved contrast material for intravenous cholangiography. It has been postulated that high doses of the compound could be given safely with the expectation of achieving greater biliary excretion and improved opacification of the biliary tree. Experiments performed in dogs show that higher rates of infusion of iosulamide result in greater urinary elimination without additional biliary excretion. Consequently, iosulamide is unlikely to have any special advantage as a contrast agent.

• Oral cholecystography and intravenous cholangiography are the two studies most frequently used to confirm the diagnosis of biliary tract disease. Since it is not always practical to obtain these in acutely ill patients, gray scale sonography was evaluated to determine its accuracy. One hundred eight patients had sonography performed prior to operation. The sonogram was correct in 96 of the 108 patients (89%). There were four false-negatives (3.7%), one false-positive (0.9%), and seven patients (6.4%) in whom the study was nondiagnostic. Stones were seen in 88 patients and confirmed in 87 patients for an accuracy of 98.9%. Sonography is a simple, noninvasive procedure by which cholelithiasis can be accurately detected. Because of the high correlation between sonography and operative findings, we suggest that cholecystosonography be used as the initial screening study in patients suspected of having biliary tract disease. (Arch Surg113:500-503, 1978)

99mTc-IDA (99mTc-dimethyl-acetanilide-iminodiacetic acid) hepato-biliary imaging was evaluated for its efficacy in distinguishing acute cholecystitis from acute pancreatitis. In a retrospective review, gallbladders were demonstrated by 99mTc-IDA in 13 of 15 patients (87%) with acute pancreatitis. This is significantly higher than reports on the frequency of gallbladder filling with oral and intravenous cholangiography in the presence of acute cholecystitis.

Thirty patients from 15 to 69 years of age with congenital cystic dilatation of the common bile duct were studied. The diagnosis was made by intravenous cholangiography in 70% of the patients and by percutaneous transhepatic cholangiography and/or endoscopic retrograde cholangiopancreatiography in the entire group. Cystic dilatation was also noted in the intraphepatic bile ducts in 12 patients. A union between the common bile and main pancreatic ducts occurred at a high position in 17 of 18 patients in whom both ducts were adequately opacified, forming an abnormally long common channel. One patient with choledochodele had a normal union. The anomalous unions were of two types: the pancreatic duct entering the common duct and the common duct entering the pancreatic duct. The mode of union was correlated with the degree of extrahepatic bile duct dilatation, age of onset, and frequency and severity of symptoms. It is postulated that the congenital anomaly in the union of the two duct systems is the cause of the disease and the congenital choledochocele has a different etiology.

The meglumine salts of iodoxamic and iotroxamic acids are recently developed intravenous cholangiographic media. In several studies these two media have been shown to be significantly better than meglumine iodipamide and meglumine ioglycamate for opacification of the biliary tree and incidence of adverse effects. As part of a multi-centre double-blind trial 100 patients were given iodoxamate or iotroxamate. Comparisons of opacification, side effects and renal excretion of contrast were made. The results showed no statistically significant difference in biliary tree opacification; more frequent renal excretion of contrast with iodoxamate; and contrary to previous reports a slightly higher incidence of side effects with iotroxamate.

Of the many non-invasive conventional radiological methods used for indirect evaluation of the pancreas, the main modalities still used today include: plain film of abdomen and thorax, intravenous cholangiography and gastro-intestinal barium studies including hypotonic duodenography.

Errors in interpretation of intravenous cholangiograms are often made if 24-hour radiographs are not obtained. Three cases are presented in which radiographs, obtained 1/2--4 hours after administration of contrast material, failed to demonstrate gallstones in the visualized gallbladder. However, 24-hour radiographs revealed calculi in all three patients. Stratification of bile is thought to be the mechanism responsible. Delayed radiographs assure proper mixing of contrast material and bile, and provide optimal visualization of the gallbladder in patients undergoing intravenous cholangiography.

A variety of iodinated organic compounds are used clinically for oral cholecystography and for intravenous cholangiography. The specific physiologic and biochemical factors responsible for establishing the preference of these contrast media (CM) for hepatic elimination are not well established. Much of the early information concerning these organic compounds used as CM has been published [1]. In addition several more recent review articles have appeared [2–6]. However, during the past few years, a significant amount of new information has been reported about the mechanism of hepatic transport of many of these biliary CM. In addition, strides have been made in our understanding of hepatic and biliary physiology. The purpose of this chapter is to provide a general discussion of hepatic and biliary physiology and to summarize the more recent information concerning the pharmacology and hepatic disposition of biliary CM.

Choledochal cyst was diagnosed before operation in 14 out of 16 infants and children by means of a combination of diagnostic tests. Ultrasonic echogram showed a cystic mass in all 11 patients examined. The characteristic displacement of the duodenum was noted in 9 of 14 patients by contrast studies of the upper gastrointestinal tract, and hepatobiliary scintiscanning confirmed choledochal cyst in 7 of 8 patients (88%). A cyst was shown by oral or intravenous cholangiography in 3 of 4 patients. Onset of symptoms occurred from 7 days of age to 9-5 years; in 10 patients onset occurred under 12 months of age, in 3 from 13 to 24 months, and in the remaining 3 from 2 to 9-5 years. The first symptoms were jaundice, vomiting, acholic stools, and poor sucking. Obstructive jaundice and acholic stools were found in more than 80% of the patients, and abdominal mass in 60%. Vomiting occurred in 50% of the patients, one-third of whom showed failure to thrive, and 70% of patients over the age of 1-5 years had abdominal pain. About half of the patients had a mild to moderate degree of fever. In all patients primary excision of the cyst was followed by hepaticojejunostomy in Roux-en-Y fashion. The postoperative course was uneventful in 14 patients; 2 patients died, one from ascending cholangitis and one from hepatic failure.

A previously undescribed sign of common bile duct obstruction during intravenous cholangiography - initial visualization of proximal intrahepatic ducts - was observed in 26 patients with surgically proven obstructive disease of the distal common duct. In all cases, opacification of intrahepatic biliary radicles occurred on standard interval films prior to visualization of the extrahepatic common bile duct, the reverse of the normal sequence. The abnormal opacification pattern reflects stasis of bile flow in the presence of distal obstruction and seems analogous to the urographic finding of opacified intra-renal calyces as the initial manifestation of distal ureteral obstruction. Recognition of the alteration in the initial cholangiographic opacification sequence signals the need for delayed films to confirm the diagnosis of a distal choledochal obstruction.

Caroli's disease (congenital dilatation of the intrahepatic bile ducts) was diagnosed in an 11-year-old girl with the aid of intravenous cholangiography. Recurrent abdominal pain, fever, and intermittent obstructive jaundice are the most common symptoms and usually develop during childhood or young adulthood. Operative cholangiography has been the most valuable method of diagnosing the condition and determining the location and extent of the disease process.

The purpose of this investigation was to compare the diagnostic value of intravenous cholangiography with 99mTc-pyridoxylideneglutamate, a new radioisotopic biliary imaging agent, in 15 patients with suspected hepatobiliary disease. Each subject had both examinations, and the studies were interpreted independently. The results suggest that intravenous cholangiography may provide more specific information about the ductal system but is of limited value in patients with elevated bilirubin. In these patients 99mTc-pyridoxylideneglutamate may show patency of the bile ducts and distinguish between partial and complete biliary tract obstruction. Depending upon the serum bilirubin level, both studies may provide useful and complementary information about the biliary tract.

Fine-needle cholangiography (FNC) in the jaundiced patient is well established, but its role in the diagnostic work-up of nonjaundiced patients has not been emphasized. We present 44 consecutive nonjaundiced patients with a serum bilirubin level of 2.4 mg% of less who underwent FNC. The indications were recurrent RUQ pain (77%), painless cholestasis (16%), and relapsing pancreatitis (7%). In all but two patients, one or more inconclusive techniques [oral cholecystography, ultrasonography, intravenous cholangiography, or endoscopic retrograde cholangiography (ERC)] had been employed prior to FNC. Biliary tract opacification was successful in 35 of 44 (80%). In nine of 35 (26%) choledocholithiasis and/or cholelithiasis was present. In four (11%) a significant extrahepatic biliary stricture was noted. More than five needle insertions were often required for successful entry. No complications occurred. Indications for FNC should be extended to include nonjaundiced patients with RUQ pain or painless cholestasis in whom oral cholecystography, ultrasonography, and intravenous cholangiography have been of no diagnostic help. The relative ease and low cost of FNC make it preferable to ERC in these patients.

We studied the value of tests commonly used in diagnosing obstructive jaundice in 188 patients operated on for biliary obstruction. Ultrasonography had a diagnostic accuracy of 87 percent for gallbladder stones, 82 percent for dilated ducts, and 80 percent for pancreatic masses. Computed tomography was 93 percent accurate in diagnosing dilated ducts, and 93 percent accurate in diagnosing a pancreatic mass. Intravenous cholangiography gave useful information in only 4 of 21 patients. Among 45 patients, endoscopic retrograde cholangiopancreatography was technically successful in 91 percent and gave accurate diagnostic information in 86 percent and partially diagnostic information in 7 percent; it detected all cases of common duct stones and had a 91 percent sensitivity for detecting pancreatic cancer. Among 75 patients, transhepatic cholangiography was technically successful in 95 percent and provided accurate diagnostic information in 90 percent and partially diagnostic information in 3 percent; it detected all cases of common duct stones and 95 percent of cases of benign strictures. With persistent jaundice, ultrasonography should be the first test because it is less costly than computed tomography and provides similar information. If more information is needed, transhepatic cholangiography and endoscopic retrograde cholangiopancreatography are equally accurate; transhepatic cholangiography more often opacifies the proximal biliary tree and endoscopic retrograde cholangiopancreatography provides direct access to the ampulla of Vater and the pancreatic duct.

The portal vein (PV) was frequently visualized during infusion intravenous cholangiography with tomography. Although visualization was usually faint, the PV was occasionally seen as well as or better than the common duct (CD). Occasionally, there is sufficient periportal fat to enable PV visualization without contrast material, but PV visualization is probably usually due to a combination of faint venous opacification and surrounding periportal and omental fat. If unrecognized, the opacified portal vein may occasionally be mistaken for a dilated common duct.

With the availability of computed tomography (CT), ultrasonography (US), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP), the use of intravenous cholangiography (IVC) has waned. A retrospective study of 69 intravenous cholangiograms performed from 1979 through 1982 assessed the utility of intravenous cholangiography, as well as its effect on patient management, at an institution where CT was highly developed. In no case after normal findings on CT and/or ultrasound examination did IVC make a positive pathologic diagnosis. After abnormal results on CT and/or US examinations, in no case did IVC add to the diagnosis. Finally, after technically suboptimal results of CT and/or US examinations, IVC made only 1 positive pathologic diagnosis. Overall, IVC correctly demonstrated only 5 of 9 cases of common duct stones or strictures. Of the 26 cases with anatomical correlation there were a total of 7 false-positive and -negative IVC examinations. In this series, IVC was rarely useful in the diagnosis of biliary tract disease. Given the high inaccuracy rate of IVC in this study, its use for the exclusion of biliary tract disease is discouraged.

Biliary tract opacification was assessed in a double-blind clinical study that compared iodoxamate with iodipamide. Both drip infusion and direct (bolus) intravenous cholangiography were used to administer the contrast agents. The infusion method with either agent produced better opacification than bolus administration. Regardless of method used, iodoxamate produced greater biliary tract opacification, fewer unexplained failures, and fewer contrast reactions. Neither agent was successful in patients with elevated bilirubin levels, nor did either agent alter hepatic, renal, or hematologic function.

Reflux of Cholografin into the pancreatic duct was shown during intravenous cholangiography of a patient in whom acute pancreatitis was surgically proved on the following day. A common duct stone was not found at surgery. The relationship of pancreatitis and bile reflux into the pancreatic duct is briefly discussed.

The stratification (layering) phenomenon in the gallbladder is a source of errors in interpretation of intravenous cholangiography. It may mimic stones that do not exist or conceal stones that do. To avoid false-positive or false-negative interpretations, it is suggested that delayed films be taken at 4 hours in cases which demonstrate a layering phenomenon. By this time, a normal gallbladder will be homogeneously opacified and a diseased one will reveal its stones. Horizontal beam roentgenograms are mandatory for complete evaluation.

IN AN ATTEMPT to evaluate the role of intravenous cholangiography in the diagnosis of partial obstruction of the common bile duct, to determine the relationship of common duct size to partial obstructions of the duct, and to establish criteria for roentgenographic diagnosis, we have reviewed our experiences of the past two and one-half years. Since a significant number of postcholecystectomy patients either exhibit the same symptoms as before operation or develop new symptoms, the problem is worthy of attention. The implications are: (a) that the gallbladder disease was not responsible for the precholecystectomy complaints, (b) that the surgical procedure was incomplete and should have gone beyond simple removal of the gallbladder and at times beyond removal of common duct calculi, or (c) that mechanical or inflammatory injury to the common bile duct may have taken place at the time of or shortly after cholecystectomy. Walters (1) in 1956, was of the opinion that the most frequent causes of pain after cho...

INTRAVENOUS cholangiography with iodipamide sodium was introduced in clinical medicine in 1953 as a method for rapid high contrast visualization of the biliary ducts and gall bladder.1 An abundant literature is now available concerning the merits of this procedure in the study of a variety of chronic biliary-tract disorders. Only a few reports, however, have emphasized the possible value of utilizing intravenous cholangiography in the evaluation of the patient with an acute abdominal illness.2 3 4 During the past three years at Grady Memorial Hospital intravenous cholangiography has been performed as an emergency procedure in an unselected group of patients who were . . .

A study of 10 patients following intravenous infusion of 40 ml. of iodipamide methylglucamine diluted with normal saline to 100 ml., administered in a one half-hour period, resulted in an increase in uric acid clearance and a decrease in free water clearance.There were no changes in clearance of inulin, paraminohippuric acid, osmoles, urine pH or calculated renal blood flow. Opacification of the biliary ducts was above average in 8 of the 10 patients studied.

Through the years the contribution of the radiologist to the definitive diagnosis of liver disease has been limited. A record of his efforts is a list of discouragements and disappointments. There still is no radiographic procedure that easily and quickly provides needed facts in many types of hepatic disorders. In conjunction with their clinical and research colleagues, radiologists will continue, however, to investigate all possibilities that promise better radiologic diagnosis of liver disease. The widespread use of oral or intravenous cholangiography has aided in diagnosis of conditions affecting the biliary duct. Cholangiography has limitations, however, and as an aid in the diagnosis of liver disease, it is of little value. Simple Techniques The ordinary scout film—or preliminary survey—of the abdomen, even though it has limited value, may reveal some useful information about the liver. Often this simple procedure can show the size and shape of the liver, the presence of

1. A brief history of the use of tomography in cholangiography is given. 2. A technique of carrying out the examination is described. 3. The results of 48 consecutive examinations are presented and discussed. 4. It is concluded that: (a) The facilities for tomography should be available whenever intravenous cholangiography is performed. (b) Tomographs must be taken unless the major bile ducts are clearly shown to be normal on the first plain film.

Because of its ability to demonstrate the bile ducts when the gallbladder has been resected or has ceased to function, sodium iodipamide (Cholografin) offered immediate promise in the examination of patients with digestive complaints persisting after cholecystectomy. In recent months we have examined 121 individuals with the varied symptoms of the postcholecystectomy syndrome, and we present in this paper our analysis of their intravenous cholangiograms. We offer, in addition, our observations in a control series of 46 patients who reported themselves free of symptoms after cholecystectomy. The postcholecystectomy syndrome is a familiar and discouraging disorder characterized by abdominal pain, nausea, and intolerance to certain foods, continuing unabated after cholecystectomy. Its very name is ambiguous in its implication that the operation has caused symptoms, when, in fact, it has simply failed to relieve them; for this reason we prefer Best's1more accurate term, "the recurrent biliary tract syndrome." Causes for

Cholografin 20 per cent (sodium N,N'-adipylbis (:3-amino-2,4,o,-triiodo) benzoate, Squibb) is of inestimable value in demonstrating the common du ct of the cholecystectomized patient. That it is useful also in the presence of jaundice is not so well known. Published accounts of visualizat ion of the ducts of jaundiced patients are few in number. Hastings-James and Glazebrook (1) report successful visualization in 1 of 2 cases. The degree of jaundice is not stated. Aldridge (2) was successful in 6 of 15 cases. His criteria for selection of patients were perhaps less rigid than those adopted by us, in that he included in his series patients who had been jaundiced within one week of the examination. Because the icterus index appears an unreliable criterion, we have used a serum bilirubin of 1.0 and above (normal in our laboratory 0.8) as indicative of jaundice. To date, we have attempted intravenous cholangiography with Cholografin in 26 jaundiced patients and have succeeded in visualizing the common duct in...

Five cases of choledochal cyst occurring in childhood are discussed with pertinent roentgenographic and clinical findings. The clinical manifestations were (1) in early infancy—obstructive jaundice, and (2) in children—the classical triad of jaundice, abdominal pain and mass. The most valuable roentgenographic findings were (1) on plain film of the abdomen—mass in the right upper quandrant., (2) on barium meal study—anterior, inferior and left sided displacement of gastric antrum and duodenal bulb, (3) lateral displacement of descending duodenum, and (4) inferior displacement of the third portion of the duodenum. Direct demonstration of the cyst may be accomplished by intravenous cholangiography, direct percutaneous cystography, and possibly oral cholecystography.

1. Dilated cystic-duct remnants or so-called re-formed gallbladders containing calculi may be demonstrated by means of intravenous cholangiography in patients who have undergone cholecystectomy. Six illustrative cases have been presented.

Chemical and histological studies are often unable to differen tiate chronic extrahepatic obstructive jaundice (due to calculi, neoplasia, or stricture) from chronic intrahepatic obstructive jaundice (caused by primary biliary cirrhosis or by drugs, . notably anabolic steroids and phenothiazine derivatives). Oral and intravenous cholangiography are also ineffective when the serum bilirubin is greater than 2-3 mg./100 ml. In such circumstances percutaneous transhepatic cholangiography may be useful, since this method can demonstrate the dilated intra hepatic biliary system which develops in chronic extrahepatic obstruction ; while a negative result may remove the need for laparotomy in a patient with hepatocellular disease. Since Atkinson et al. (1960) remarked on the revival of interest in this investigation numerous authors (Santos et al., 1960 ; Kaplan, et al., 1961 ; Shaldon et al., 1962 ; Arner et al., 1962 ; Flemma et al., 1963) have agreed on its value. Only one of these reports has come from this country, and the British Medical Journal (1964) suggests that percutaneous transhepatic cholangiography has still to gain general acceptance in Great Britain. This report of a small series with a case history and a brief survey of recent studies may be of interest.

The clinical course of 123 patients with acute cholecystitis is reviewed. Fifty-eight per cent of the patients were more than sixty years of age and 65 per cent of the fatalities occurred in women. With increasing age there was a relative increase in the percentage of male patients. The diagnosis was usually quite clear. A mass was palpable in 40 per cent of the patients. Subsiding symptoms with persistence of the mass were thought to be indicative of progressing inflammation. Intravenous cholangiography was helpful in the diagnosis. Of sixteen patients with acute cholecystitis, the common duct was clearly demonstrated in seven. Common duct stones were found in 8.7 per cent of the patients. Progression of the inflammation of acute cholecystitis was more severe and rapid in elderly patients. This was thought to be due to the more advanced state of the chronic pathologic process in the gallbladder in the older patients which was caused by long-standing biliary tract disease. A sudden change in the clinical course of certain older patients was attributable to cholangitis. At operation for acute cholecystitis, a biopsy specimen of the liver was taken in ten recent patients. Microscopic evidence of cholangitis was found in six patients. Cholecystectomy was possible in 60 per cent of the patients and exploration of the common duct was carried out in four, at the time of operation. Cholecystostomy was the operation of choice in the remainder of the patients. Among 123 patients with acute cholecystitis there were six deaths (mortality 4.8 per cent). All the patients who died were more than sixty-five years of age and had been ill for several days before entry. The deaths were related to peritonitis or aggravation of pre-existing unrelated diseases.

A case of melanoma of the gallbladder has been presented. The tumor was polypoid, was attached by a pedicle to the gallbladder mucosa, and partially filled the gallbladder lumen. There was no evidence of other organ involvement. The tumor was demonstrated in the gallbladder by intravenous cholangiography. It was successfully removed.

Exploration of the bile ducts is an operative procedure generally recognized to be fraught with difficulties. Instrumentation of the ducts is done blindly and, therefore, is often not definitive. Particularly difficult is the differentiation between tumor, stone, "spasm," and fibrosis at the sphincter of Oddi. Various diagnostic adjuncts, including intravenous cholangiography, operative cholangiography, and choledochoscopy, have been proposed for investigation of the biliary tract. However, the significant incidence of stones retained in the biliary tree after common duct exploration attests to the need for further technical improvement. Duodenotomy with transampullary exploration of the bile ducts might be considered as one such technical improvement. This procedure is mandatory for the removal of many stones impacted at the ampulla of Vater and for visual inspection in the diagnosis of suspected tumors of this site. In addition it allows the surgeon to prove the passage of probes and dilators through the sphincter of

B-scan ultrasonography appears to be useful in cases of radiographic nonvisualization or where impairment of hepatobiliary function is severe enough to preclude attempts at oral cholecystography or intravenous cholangiography. Sonographic demonstration of a normal gallbladder is an excellent indicator of the absence of disease. When consistently abnormal echoes are found, the test is a reliable indicator of biliary calculi.

Summary The demonstration of a worm in the common bile duct by intravenous cholangiography and tomography is discussed. It is emphasised that the majority of cases respond to conservative treatment and operation can be avoided.

RECENTLY, at this institution, a patient with choledocholithiasis experienced an episode of acute biliary colic while being studied by intravenous cholangiography. The resulting radiologic phenomena form the basis for this communication. Case Report A 21-year-old woman was referred for intravenous cholangiography following several episodes of biliary colic. Thirty minutes after intravenous administration of iodipamide (Cholografin) 3 calculi were demonstrated within a common bile duct 12 mm in diameter (Fig. 1). Fifteen minutes later the patient experienced pain identical to her previous episodes. At 60 minutes repeat roentgenography revealed impaction of the distal-most calculus and dilatation of the common duct to . . .

SINCE ITS INTRODUCTION in 1952, intravenous cholangiography using sodium iodipamide (Cholografin) has become a valuable and reliable method for the diagnosis of biliary tract disease, particularly following cholecystectomy. However, besides the risk and inconvenience involved in any intravenous procedure, serious reactions with the use of iodipamide have been reported in up to 2.5% of examinations in some series, with lesser reactions ranging as high as 38.8%. Thus, an oral contrast medium which could offer comparable results to those obtained by the intravenous method would have obvious advantages. Ipodate (Oragrafin) is a new cholecystographic and cholangiographic medium for oral administration which is rapidly excreted by the liver in sufficient quantity to produce opacification in the cystic and common bile ducts. It is prepared as the sodium or calcium salt of 3-(dimethylaminomethylamino)-2, 4, 6-triiodohydrocinnamic acid, with an iodine content of 61%. The sodium salt is available in 0.5-gm. capsules, and the calcium