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Stratification in the gallbladder with a radiolucent zone of nonopacified bile may be a physiologic phenomenon during intravenous cholangiography, and should not be confused with floating cholesterol gravel or sludge. A post-fatty-meal and/or delayed films may aid in the differentiation of these two conditions. If a fatty stimulus is given at least 1 hr. prior to the X-ray study, the stratification phenomenon may be avoided.

Oral cholecystography is the method of choice for the visualization and radiological study of the function of the gallbladder. In 10 per cent of cases, however, the gallbladder is not visualized although the cystic duct is patent. This may be due to inadequate absorption of contrast medium from the intestine. Alternatively, if the contrast medium is absorbed, it may not be concentrated sufficiently in the gallbladder to cast a radiographic shadow, possibly because of reabsorption of the medium from an inflamed gallbladder mucosa (2, 18, 22). When there is failure to outline the gallbladder at oral cholecystography, intravenous cholangiography is indicated. With the conventional injection technic, contrast is quite often poor or insufficient for accurate diagnosis, and the examination is usually unsuccessful in the presence of a serum bilirubin of 3.0 mg∕100 ml or higher. A method of cholangiography is here described whereby iodipamide is administered by controlled slow intravenous infusion. It is felt tha...

Diagnosis of acute cholecystitis usually can be established firmly on the basis of an accurate history and physical examination and routine laboratory studies. Occasionally, however, typical findings may lead to errors in diagnosis. In other cases the exact cause of upper abdominal pain may remain in doubt after completion of the routine diagnostic evaluation. Intravenous cholangiography has become a well-established diagnostic procedure for the detection of biliary tract disease. 1-5 In an attempt to confirm the usefulness and determine the accuracy of this procedure as an aid in the evaluation of acute abdominal pain, case records were reviewed of 211 consecutive patients in whom intravenous cholangiography was employed in the emergency room of the city-county charity hospitals of Houston and Harris County, Texas. Final diagnoses were established either by operative removal of the diseased tissue and pathological examination, or, as was the case with illnesses not requiring surgical intervention, adequate

SUMMARY The value of intravenous cholangiography accompanied by morphineinduced blockage of the sphincter of Oddi and tomography, and the value of operative cholangiography, are discussed in relation to acquired and congenital diseases of the intrahepatic biliary tree. The techniques permit the classification of these diseases into a number of aetiologically different groups: Congenital: stenosis and dilatation. Neoplastic: papillomatosis and epitheliomas. Stones: primary isolated intrahepatic lithiasis. Secondary displacement: malignant or benign tumours; simple or parasitic cysts. The most important clinical details are described and the therapeutic problems are discussed in the light of published experience.

The authors have investigated 72 patients referred for intravenous cholangiography using doses of Biligrafin forte ranging from 0·5 to 1 ml./kg body weight, diluted in 250 ml. of normal saline or hypertonic dextrose solution, and infused over half an hour. Increasing the dose of Biligrafin forte leads to considerable improvement in the degree of opacification of the bile-ducts. Using 1·0 ml. Biligrafin forte per kilogram gave a good demonstration of the bile-ducts in 80 per cent of patients with normal liver function tests compared with only 40 per cent using smaller doses. The use of a drip infusion technique virtually eliminates the problem of nausea and vomiting and provides a simple technique for the slow administration of larger quantities of Biligrafin. No difference could be detected in the quality of the result when using either normal saline or hypertonic dextrose as the diluent; and it is unlikely that the quality of the examination is affected by the diluent, whether it is saline, hypertonic de...

Summary The experience with intravenous cholangiography in evaluating thirty-one patients with suspected acute cholecystitis is reviewed. Certain pitfalls in the technic and evaluation of the radiographic films are mentioned. Visualization was noted in 71 per cent of the patients and a definitive decision concerning the presence or absence of acute cholecystitis was made in all of these patients. Nonvisualization occurred in 29 per cent of the patients and the majority of these patients were noted to have significant surgical diseases. This test has been found to be a reliable adjunct in the work-up of patients with suspected acute cholecystitis.

ROENTGEN OENTGEN VISUALIZATION of the common bile duct can be useful in evaluating symptoms of biliary tract disease after cholecystectomy. This report is based on the study of 139 patients who had been subjected to cholecystectomy and subsequently were examined by means of intravenous cholangiography. Of these, 111 had been virtually asymptomatic following operation and appeared to be in good health. The remaining 28 patients had significant symptoms or signs of persistent or recurrent disease such as intermittent abdominal pain, nausea, vomiting, jaundice, dark urine, and clay-colored stools. Four patients without a history of jaundice but with an elevated serum bilirubin were included in this group. Patients who had a common duct exploration at the time of cholecystectomy were excluded from this study. It was felt that exploration and T-tube drainage might alter the duct. Technique Prior to the examination fluids were withheld. Meglumine iodipamide (Cholografin *) 20 cc was then

Nonvisualization of the gallbladder followingoral cholecystography is an indication for intravenous cholangiography; however, the gallbladder may be only faintly opacified. The immediate use of supplemental calcium ipodate may provide a simple, safe, and reliable method of facilitating a definite diagnosis.

1. Two cases of gas bubbles demonstrated during intravenous cholangiography mimicking duct stones are recorded. 2. The origin of the gas bubbles is usually from intestinal gas and the routes by which the gas enters the bile duct system are discussed. 3. The radiological appearances of the gas bubbles and their differentiation from duct stones are described and discussed.

A double-blind study comparing cholangiograms obtained by conventional intravenous injection of 20 ml Cholografin with cholangiograms made after injection of 40 ml Cholografin diluted in 250 ml 20% glucose in water infused over a one hour period was performed. When technical factors were not changed, there was no significant difference in the visualization ratings. When technical factors were changed to include low voltage, routine tomography, precise collimation, and patient immobilization, there was marked improvement in visualization. From the results of this study, it was concluded that technical factors are more important for good intravenous cholangiography than increasing the amount of contrast material or prolonging the injection time.

THE NEW method of visualizing the bile ducts by the oral administration of radiopaque material has proved of diagnostic value in two types of biliary tract conditions previously resistant to any form of roentgenologic diagnostic procedure.1These are (1) the apparently nonfunctioning gall bladder, as shown by routine cholecystography, and (2) the postcholecystectomy syndrome,2in which only the recently devised intravenous cholangiography with sodium iodipamide (sodium N, N1-adipyl-bis[3-amino-2, 4, 6-triiodobenzoate]; Biligrafin; Cholografin) has been of diagnostic value.3-3e In patients showing no visualization of the gall bladder in the cholecystograms, oral cholangiograms have shown in some cases visualization of the gall bladder, at times with stones. In the nonvisualized gall bladder with cystic duct obstruction, it has been possible by oral cholangiography to visualize pathologic common bile ducts, sometimes with stones. In the postcholecystectomy syndrome, there have been revealed pathologic dilated common bile ducts, common duct

The phenomenon of delayed opacification of gallstones following cholegraphy was described and investigated by Salzman et al. in 1959 (3). They found that most biliary contrast media are absorbed at the periphery of pigment stones, producing a rim of radiopacity. Opacification was demonstrated with iopanoic acid (Telepaque), iodoalphionic acid (Priodax), tetraiodophenolphthalein (iodophthalein), and iophenoxic acid (Teridax) (3). The phenomenon has not previously been described following iodipamide (Cholografin). Indeed, Salzman and Watkins state that delayed opacification does not occur following iodipamide, either in vivo or in vitro (3, 6). Case Report Mrs. F. L., a 69-year-old female, had a long history of rheumatic heart disease and chronic urinary tract infection with cicatricial urethritis. Eight years ago acute cholangitis developed. Roentgenograms showed multiple radiopaque gallbladder calculi. Cholecystectomy was performed, and a single opaque stone was also removed from the common duct. T-tube c...

The author has investigated 25 patients with drip infusion cholangiography using 250 ml. of 30% dextrose and 60 ml. of Biligrafin Forte administered intravenously over the course of one hour. The results are compared with 25 patients investigated by conventional intravenous cholangiography with 20 ml. of the same contrast medium. The author concludes that this drip infusion technique provides superior opacification of the biliary tract, and often delineates the gall bladder when other methods have failed to do so.

When upper abdominal symptoms persist or recur after cholecystectomy, the possibility of stones being present in the common bile duct usually arises. Examination which will give positive evidence as to the presence or absence of such stones is obviously valuable. Both diagnostic transduodenal biliary drainage and intravenous cholangiography are of real help in this problem, but each has certain limitations. It is often necessary, therefore, to correlate data from both of these tests with the clinical evaluation of the patient before a reasonable decision can be reached regarding the advisability of surgery. Our experience with these two diagnostic examinations forms the basis of this report. Diagnostic Transduodenal Biliary Drainage To determine the diagnostic value of biliary drainage in detecting postcholecystectomy biliary lithiasis, we reviewed the records of all patients on whom exploration of the common bile duct was carried out from 1935 through 1955. Of this group of 580 patients

At the present time there are conflicting reports concerning the efficacy of large-dose slow-infusion cholangiography (1, 2). The large-dose slow-infusion method has been compared with the common direct-injection method. In a consecutive completely unselected study, 53 patients were examined by the large-dose infusion method and 53 by the common direct-injection technic. All cases for which intravenous cholangiography was requested were included in this study. There were no exceptions. Technic In both groups the patients were given nothing orally from midnight on. In the direct injection group 20 cc meglumine Cholografin (methylglucamine iodipamide) was injected over a one- to two-minute period. In the infusion group 40 cc of meglumine Cholografin was diluted with 50 cc of saline and infused over a fifteen-minute period. Films were made every fifteen minutes from the onset of administration of medium for a two-hour period unless interrupted by zonography. Single-film examination was done at four hours and...

A safe and effective intravenous Cholangiographie agent has been available to radiologists since the introduction in Europe of Biligrafin as a 20 per cent solution of sodium iodipamide in 1953 and its successor in this country, the methylglucamine salt Cholografin.2 Through the twelve-year period, 1953 to 1965, clinical investigators using the recommended 20 cc injection have published widely divergent results on the success of this contrast agent (1–6). In their review of the literature, Floch and Geffen (7) noted that the incidence of nonvisualization was as high as 34 per cent, but with improved patient selection and experience the degree of failure is generally in the 6 to 15 per cent range. The duct was satisfactorily visualized in 83.5 per cent of the 237 cases in their series. Wise (8) indicated in his monograph that, with proper patient selection based on preliminary liver function evaluation, successful visualization of the common duct in the cholecystectomized patient might be improved from his ...

Endoscopic retrograde choledochopancreatography (ERCP) was employed in 52 patients symptomatic after cholecystectomy in whom barium meal studies and intravenous cholangiography had failed to yield a diagnosis. Cannulation of the papilla of Vater was carried out in 50 of the patients in a mean time of 10 min. Diagnostic information demonstrating a pathological lesion or a normal biliary and pancreatic ductal system was obtained by means of endoscopy and ERCP in 48 cases. There were no serious complications. A pathological lesion was demonstrated in all but one of the patients presenting with jaundice, cholangitis or pancreatitis but the diagnostic yield was not as high in patients with vague upper abdominal symptoms. Endoscopy and ERCP are the investigative procedures of first choice in complex post-cholecystectomy cases in whom intravenous cholangiography fails, gives incomplete information or suggests normality in the face of continuing symptoms or clinical evidence of residual biliary disease.

The following case illustrates clearly that absorption of a contrast agent Reno-M-60® (Meglumine diatrizoate), indeed, can occur. CASE REPORT A 42 year old woman was referred for the evaluation of recurrent bouts of midepigastric pain. Cholecys­ tectomy had been performed 4 years previously for cholecys­ titis and cholelithiasis. The serum and urine amylase, as well as serum lipase determinations, were normal. Intravenous cholangiography performed during the present hospitaliza­ tion revealed a common bile duct 12 mm in diameter with relatively poor distal visualization but suggestive of a distal stricture or small stone. In this context, ERCP was performed. After the pharynx was anesthetized with Cetacaine® (Ben­ zocaine) topical anesthetic, the patient was sedated with 10 mg of intravenous Valium ® (Diazepam). The Olympus )FB side-viewing duodenoscope was then passed into the duodenum. Glucagon, 1 mg intravenously, established duodenal paralysis. The ampulla was identified, and free cannulation was accomplished. Reno-M-60® was injected by hand pressure, and opacification of the main pancreatic duct was obtained. With slow withdrawal and continuous gentle injection, opacification of the common bile duct was accom­ plished. Both ductal systems were interpreted as being nor­ mal. During the injection the patient experienced mild, midepigastric discomfort while an intense pancreatic acinari­

A 71-year-old lady was admitted with the sudden onset of right upper quadrant pain. It had begun the previous evening, about half an hour following a small meal of pork and beans. Pain was located in the right upper quadrant, was crampy, gradually worsened, and was associated with intermittent vomiting. She received two injections of demerol Pethedine without relief. There was no previous history of fatty food intolerance or jaundice. She had had previous admissions for typical left ureteral colic in 1955 and low back pain in 1960. She was in acute distress and holding her right upper quadrant. On physical examination, there was much voluntary guarding at this site. Rebound and palpation tenderness were elicited in the same area. The bowel sounds were reduced but present. The temperature was 101·4. A W.B.C. was 15,400 with a shift to the left. Urinalysis and rapid amylase were normal, and the alkaline phosphatase was 2·3, the bilirubin 0·4 total. A chest radiograph showed a raised diaphragm with right low...

Enterogenous cysts are developmental defects of gut which may arise anywhere in the gastrointestinal tract but are rare in the duodenum. The embryological mechanism is probably the failure of complete coalesence of fetal vacuoles of the .primitive gut. They may communicate with the bowel lumen and may receive the bile and pancreatic ducts. Sex distribution is equal; one third of the cases are in adults (1, 3, 4). The symptoms are usually those of duodenal obstruction, but ulceration, bleeding, jaundice, and pancreatitis may occur (8, 9). The most common physical finding is a movable, non-tender mass in the right epigastrium where a fluid-density mass may be seen on radiographs. A sharply defined mass attached to the concave border of the duodenum is typically observed on barium study. It is usually not possible to differentiate the lesion from lipoma, leiomyoma, aberrant pancreas, or other intramural tumefactions that also occur in this area (2, 3, 6). Case Report This 14-year-old Caucasian female became ...

Intravenous cholangiography in a 27-year-old woman with a postcholecystectomy bile pseudocyst revealed a hepatogram effect and showed the interface between the liver and the mass. Recognition of the hepatogram may yield a diagnostic bonus by providing information about the liver parenchyma.

Since its introduction in the early 1950's, Cholografin has become widely accepted and is being used with increasing frequency. Although its primary indication is in the postcholecystectomy patient, certain conditions necessitate its use for the initial evaluation of the biliary system. Cholografin methylglucamine2 provides 52 per cent iodipamide methylglucamine and the bound iodine content of the solution is about 26 per cent (5.2 gm. per 20 c.c.). Approximately 90 per cent of the Cholografin injected is excreted by the liver and the remaining 10 per cent by the kidneys. It appears in the bile almost immediately after injection; however, the best ductal visualization is obtained in twenty to thirty minutes. Filling of the bladder is produced by an overflow of the contrast-laden bile from a tightly filled common bile duct. The medium passes concentrically around the wall of the gallbladder with subsequent diffusion and mixing into the nonopacified bile. This is a passive filling and does not reflect on th...

Polycystic disease of the liver may clinically mimic diseases of the gallbladder. The presence of extrinsic masses deforming the gallbladder on oral cholecystography or intravenous cholangiography, especially in patients with a previous history of polycystic kidney disease, should suggest the correct diagnosis. Gray-scale ultrasonography can confirm the diagnosis, precluding the need for invasive studies or surgery. (JAMA1981;246:864-866)

These monographs are the combined efforts of two gastroenterologists and a radiologist. The stated purpose is to acquaint the physician with the numerous diagnostic modalities available and offer guidance to their use. This goal is accomplished, and, in addition, anatomy, pathophysiology, clinical presentation, and laboratory findings are included. The end result is a compact review of the diseases of these organs, with a slight emphasis on diagnostic imaging. The writing is unusually clear and succinct. The illustrations are clear and adequate. The text and bibliography are current. The single adverse criticism is that some of the diagnostic techniques, such as intravenous cholangiography and hypotonic duodenography, are not properly downgraded as to their need and efficacy in current clinical practice. Any physician who wishes to review the current status of diseases of these organs and their diagnosis will find these volumes time effective.

A retrospective review of the records of 1,507 patients with a diagnosis of cholecystitis was conducted for the five-year period, 1972 to 1977. Of this group of patients, a histopathologic diagnosis of acute cholecystitis was established in 154 patients (10.2%). Common duct calculi were detected in 17 of these 154 patients, an incidence of 11%. Preoperative evaluation by means of serum bilirubin and alkaline phosphatase levels and intravenous cholangiography was unsatisfactory for consistent demonstration of choledocholithiasis in the presence of acute cholecystitis. Intraoperative cholangiography was found to be the most reliable method for detection of common duct calculi and was successfully employed in 14 of 17 patients with choledocholithiasis. The remaining three patients had palpable stones.

To evaluate the role of intravenous cholangiography (IVC), ultrasound and oral cholecystography in the diagnosis of gallstone pancreatitis, 20 patients with acute pancreatitis were studied during the first three days of an attack. The IVC successfully demonstrated the common bile duct and gallbladder in 17 (85%) of 20 patients. The ultrasound studies showed the gallbladder in all 18 patients in whom the gallbladder was present. The common duct was not seen by ultrasound in any patient and the pancreas was abnormal in all patients. In the three patients with gallbladder stones these were identified on both IVC and ultrasound. Common duct stones in three patients were seen only by IVC (two of these patients had concurrent gallbladder stones and one after cholecystectomy). Oral cholecystography was of limited usefulness, although the 50% visualization rate was higher than the literature suggests. (JAMA242:342-343, 1979)

THE RAPID and accurate diagnosis of biliary disease is an important medical problem. Sixteen million Americans are estimated to have gallstones, and they will develop in an additional 800,000 persons each year. 1 Cholelithiasis and its complications are the fourth most common cause for surgical hospitalization and the most common indication for abdominal surgery in adults. 2 More than 500,000 operations are performed annually for gallbladder disease at a cost of more than $1 billion. 1,2 In view of the magnitude of the problem, it is not surprising that numerous diagnostic procedures have evolved for the evaluation of hepatobiliary disease, including oral cholecystography, intravenous cholangiography, ultrasonography, transhepatic cholangiography, computed tomography (CT), and endoscopic retrograde pancreaticoduodenography. Since more than 95% of cases of acute cholecystitis are associated with cystic duct obstruction, this finding is the major hallmark of the imaging diagnosis of acute inflammatory disease. The ideal method for diagnosing acute

To the Editor.— In regard to the report of a hepatotoxic reaction (228:1420, 1974), we recently presented at the annual meeting of the Radiologic Society of North America the results of a comparison study of differing dosage regimens in intravenous cholangiography. One interesting finding was elevation of the serum glutamic oxaloacetic transaminase (SGOT) level after cholangiography. Of 149 patients who received the single dose recommended by the manufacturer, 13 (8.7%) developed an elevated SGOT level. Of 126 patients who received the double dose advocated recently in the literature, 1-3 23 (18.3%) developed abnormal SGOT levels after cholangiography. A 77% incidence in elevated SGOT levels is mentioned in the German literature when a double dose of a mixture of ioglycamate meglumine and ioglycamate sodium (Bilivistan) was used for cholangiography. 4 Other German authors have also noted elevations of SGOT values when doses of this mixture or iodipamide meglumine injection (Biligrafin) larger

A case of agenesis of the gallbladder and cystic duct and the cholangiographic findings are presented. We believe this to be the first case documented by intravenous cholangiography.

• The clinical diagnosis of acute cholecystitis may sometimes be difficult. We compared the accuracy of abdominal ultrasound and intravenous cholangiography in patients with acute cholecystitis. Forty patients with histories and physical findings of acute cholecystitis had intravenous cholangiography and grayscale abdominal ultrasonography soon after admission. Thirty-four of the 40 patients had surgically and pathologically proved acute cholecystitis. Thirty-one of the 34 patients had positive ultrasound findings. The intravenous cholangiographic findings were present in 27 of the 34 patients with acute cholecystitis. We describe the sonographic findings of acute cholecystitis. Ultrasound of the abdomen is recommended as the initial screening procedure in patients suspected of having acute cholecystitis. (Arch Surg115:158-160, 1980)

• We reviewed our experience with intravenous cholangiography in the evaluation of 70 patients with suspected acute cholecystitis. Twenty-one of these patients had visualization of the biliary ducts without opacification of the gallbladder, a roentgenographic finding that was considered diagnostic of acute cholecystitis. Twenty of the 21 patients were noted to have acute cholecystitis during exploratory laparotomy. The remaining patient had a normal gallbladder, but was found to have a liver abscess. Opacification of the gallbladder with evidence of gallstones was found in eight patients; all had acute cholecystitis. Visualization of the gallbladder without gallstones was found in 22 patients, revealing no acute cholecystitis in this group. Many of these patients were admitted to the hospital with a primary diagnosis of acute cholecystitis and were spared an unnecessary surgical exploration. Nineteen patients had nonvisualization of the gallbladder and biliary ducts. This roentgenographic finding may be caused by acute intra-abdominal conditions other than cholecystitis and caution is warranted in its interpretation. This test has been found to be a reliable adjunct in the work-up of patients with suspected acute cholecystitis. ( Arch Surg 113:568-570, 1978)

The results of endoscopic retrograde cholangiography (E.R.C.) and intravenous cholangiography (I.V.C.) were compared in patients undergoing surgery for biliary calculi. E.R.C. gave a significantly higher rate of correct diagnosis of gallbladder calculi (p=0·026) and common bileduct calculi (P=0·002) than I.V.C. Biliary stones may thus frequently be present in patients with a normal I.V.C. and E.R.C. may reduce the rate of diagnostic errors in patients with symptoms of biliary disease.

The etiological factors accounting for symptoms persisting or following cholecystectomy for gallbladder disease can be classified as calculi in the biliary ducts, 1,2 stricture of the common duct, 3,4 surgical factors, 5 and re-formed gallbladder, with or without calculi. 6,7 Pericholedochal neuromata, 8 long cystic duct stump, 9 acute and recurring pancreatitis, 10 spasm, 10 fibrosis, 11 or anomalies of the sphincter of Oddi 12 have also been implicated. Other factors, namely, adhesions, 13 anomalies of the biliary and pancreatic ducts, 12 neoplasms of the ampulla of Vater, 14 bacterial sensitivity, 15 and psychosomatic elements 8 have also been mentioned. Upper abdominal symptoms following the use of sodium iodipamide (Cholagrafin) 16 in intravenous cholangiography have been reported. The purpose of this paper is to report an additional factor that may be classified as chemical, namely, the use of sodium o -iodohippurate, as Medopaque-H. This radiopaque material has been responsible for

THIS REPORT concerns an unusual adverse effect which has not been previously reported—the provocation of malarial relapse. Such cases may occur with increasing frequency as perplexing diagnostic problems in view of the large number of Americans who have been and are now being exposed to infection. Report of Cases Case 1. —Patient B.M., a 28-year-old Argentinian seaman, was admitted to the US Public Health Service Hospital, Baltimore, in August 1958, with a complaint of intermittent pain in the right-upperquadrant for the previous three months. He had been recently exposed to malaria in Brazil and had been taking an unidentified drug for suppression of malaria. Physical examination was unremarkable except for tenderness in the right-upper-quadrant and splenomegaly. The gallbladder did not visualize with orally administered contrast material. An intravenous cholangiogram revealed the presence of gallstones. Forty-eight hours after the cholangiogram he developed a temperature elevation to 101 F (38.3 C) with

The thesis is simple and not new. A mass in the child's abdomen can be accurately located by radiologic examination. Conventional, plain film study is used first. Barium gastrointestinal study and enemas, excretory and retrograde urography, and intravenous cholangiography follow if needed. These examinations, affording observations of the size of the mass, its contour, variation with change in position, presence of calcification, or other internal characteristics, can then be correlated with the clinical and laboratory findings and the sex and age of the patient to give an accurate diagnosis in the light of statistical probability. The more complicated less readily available radiographic techniques, such as presacral gas inflation and aortography, are only rarely needed. Simple and as obviously worthy as this thesis of Drs. Nice, Margulis, and Rigler may be, it needs reiteration. They have written a book limited in scope, yet their coverage of their subject is complete. Necessary

It is generally conceded that after cholecystectomy performed for cholelithiasis moderate to severe postoperative symptoms occur in from 10 to 25% of patients.1When cholecystectomy is performed for the so-called noncalculous gallbladder, symptoms persist in about 50% of the patients.2The possible causes for persistent or recurrent symptoms are many. They include calculi in the hepatic, common, or cystic ducts; stone or inflammation of the gallbladder stump; common duct stricture; residual cholangitis, hepatitis, and pancreatitis; neuromas about the common duct; postoperative adhesions; biliary dyskinesia; and, not infrequently, erroneous preoperative diagnoses or associated diseases, such as hiatal hernia, unrecognized malignant lesion, gastric or duodenal ulcer, arthritis of the spine, or psychoneurosis. These patients present a real challenge to the clinician.

I hesitate to enter the discussion on the excellent paper by Nolan and Gibson (1970), but I feel that I should correct a misunderstanding for which I am responsible. While reviewing the literature on Biligrafin, I recalculated Fischer's results on the excretion of Biligrafin to produce a dose-response curve (Benness, 1970). This suggested that there was depression of the bile flow rate, Biligrafin concentration and Biligrafin output with a blood Biligrafin concentration above 0·2 mg I/ml.

TTHERE ARE FEW problems more perplexing than the differential diagnosis of the jaundiced patient. Oral and intravenous cholangiography are not applicable in the presence of jaundice, and if jaundice has been present for any prolonged period, the usual chemical tests are of limited value in differentiating extrahepatic obstructive from hepatocellular jaundice. Percutaneous transhepatic cholangiography, however, will reveal the pathologic anatomy of the biliary tree in the presence of jaundice. In some cases it can distinguish obstructive from hepatocellular jaundice, and obviate laparotomy on a patient with hepatitis. In those patients with extrahepatic obstruction, the precise pathologic anatomy of the biliary tree is demonstrated preoperatively, and thus may save valuable operative time. The indications for percutaneous cholangiography are:: I. (A) To investigate jaundice of obscure etiology; this may differentiate hepatocellular from extrahepatic obstructive jaundice and/or; (B) Locate the level of extrahepatic obstruction, and distinguish carcinoma of the head of the pancreas

Introduction Calculous disease of the biliary tree is a common affliction. Over 10% of our adult population harbors cholelithiasis. The successful treatment of this ailment depends upon the utilization of available diagnostic aids, proper understanding of the course of the disease, and judicious application of surgical therapy. Diagnosis by Intravenous Cholangiography Intravenous cholangiography allows radiographic visualization of the biliary tree without the concentrating action of the gallbladder, and where oral cholecystography fails. It helps evaluate the common duct prior to cholecystectomy; this tends to lessen the incidence of retained or overlooked common duct stones. It is of utmost value in appraising symptoms following cholecystectomy such as may be caused by a re-formed gallbladder, cystic duct stump, or overlooked and new-formed common duct stones. It may also be of aid in evaluating the acute abdomen when acute cholecystitis is suspected. Surgery Surgery cures cholelithiasis when performed during the early stages of

Fistulas of the biliary tract are infrequent but serious complications of biliary tract disease. The diagnosis of external fistulas is easy, but internal fistulas, when there has been no previous surgery, may be unsuspected because characteristic symptoms are lacking. Internal fistulas may be visible within the biliary tree in plain roentgenograms; they may become visible by reflux of barium from the gastrointestinal tract into the bile ducts; or they may be recognized by the finding of a characteristic "frothy" excretion pattern within the liver after intravenous cholangiography with methylglucamine iodipamide. This finding is here reported for the first time in connection with 9 cases of roentgenologically diagnosed spontaneous internal biliary fistulas.

Until recent years, plain abdominal films and regular gastroduodenal roentgen examination were essentially the only radiologic techniques applied to the diagnosis of diseases of the pancreas. 1-4 A great increase in interest in the problems of diagnosis of diseases of this organ has been evidenced of late by the development of a variety of techniques designed to investigate the pancreas. Among these techniques may be mentioned operative pancreatography, 5 pancreatic angiography, 6 pneumoretroperitoneal pancreatography, 7 intravenous cholangiography, 8 percutaneous direct cholangiography, 9 and splenoportography. 7 In addition, considerable research effort has been expended in the development—as yet unsuccessful—of compounds for the direct opacification of the pancreas. 10-12 Until these efforts are successful, we will be limited to the indirect methods of visualization, which are the basis both of the older and the more recent methods mentioned above and which are attended with great diagnostic difficulty, from the standpoint of both

Infusion techniques are an important advance in intravenous cholangiography, and I was therefore most interested to read the article by Drs. Nolan and Gibson in your September issue. I fear, however, that this paper may encourage the unnecessary and possibly harmful escalation of Biligrafin dosage. Some patients apparently received 90 ml. of Biligrafin Forte. This dose contains 45 g of the methylglucamine salt of Biligrafin with a total iodine content of 22·5 g. For comparison one might consider the oral preparation of Telepaque. A double dose (6 g) of this substance, which might be required for a very large patient, contains only 4g of iodine.