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I i1p I This paper is the result of a panel of experts convened. at . As the right and left hepatic ducts join to form the common the annual meeting of the Society of Gastrointestinal RadiolJ hepatic duct, they arch anteriorly over the portal vein. The o ists in Hawaii, January 14-19, 1990, to discuss the current . common hepatic duct, portal vein, and hepatic artery all lie status of diagnostic radiology of the biliary tract and biliary within the hepatoduodenal ligament (Fig. 1). Although the intervention. The focus of discussion was to update and touch normal intrahepatic bile ducts are not seen on CT, the cornon the highlights of each area rather than to provide a corn-f , mon hepatic duct can readily be distinguished from the adjaprehensive review. . J #{149} cent contrast-enhanced blood vessels. An oblique sonograrn

A double blind, randomized, controlled trial has been conducted in 11 Veterans Administration hospitals during a 49-month period to compare the relative efficacies of immune serum globulin (ISG) and an albumin placebo for the prevention of post-transfusion hepatitis (PTH). A total of 2204 patients, of whom 1094 received ISG, participated in the study. The results indicate that ISG significantly reduced the incidence of icteric type non-B hepatitis only (inferred to be also type non-A hepatitis). Adverse reactions were rare, and the ISG did not significantly alter the incubation period or duration of the disease. The data suggest, however, that a similar reduction in type non-A, non-B hepatitis would have occurred had commercial blood been excluded from use. Analysis of the 241 patients who developed hepatitis indicates that type B hepatitis constituted less than 20% of the cases each year of the study. Furthermore, the efficacy of the ISG, manufactured in 1944, against apparent type non-A, non-B hepatitis suggests that this overlooked disease has existed from at least that time. Host- and transfusion-related factors that might have modified the development of PTH were examined. The use of commerical blood was observed to be the most important risk factor. It is concluded that the PTH incidence can be most effectively reduced by eliminating commercial donor blood, and continuing to screen volunteer donors for hepatitis B surface antigen (HBsAg) by sensitive procedures. Of prime importance is the need to define the agent(s) responsible for type non-A, non-B hepatitis.

After the application in vitro of (14)C amylopectin sulphate solution to frozen sections of human ulcer-bearing stomach, autoradiography demonstrates localization of amylopectin sulphate to the gastric surface. The affinity of amylopectin sulphate macromolecule for the gastric luminal surface would provide a substrate-bound pepsin inhibitor with a molecular sieve-like action to exclude proteolytic enzymes from the mucosal surface. This protective coating action may mimic the hypothetical role of endogenous gastric mucous substances and account for the action of amylopectin sulphate in human peptic ulcer.

The keto acid, gamma-oxo-gamma-(8-fluoranthene)butyric acid (Zanchol) markedly alters sterol metabolism in rats. It stimulates cholesterol and bile acid synthesis and decreases cholesterol absorption.

The hepatic circulation is unique in that high volumes of low pressure blood flow are supplied through a dual venous and arterial circulation. This vascular supply is modulated both by the gastrointestinal vascular bed and an intrahepatic microcirculation. This complex vascular system is influenced by pathologic processes within the liver. Alterations in the hepatic circulation reflect hepatic metabolic adaptation and injury. It seems reasonable to assume that in some circumstances hepatic circulatory alterations are inappropriate, exaggerated or inadequate and contribute to the initiation or perpetuation of hepatic injury. This paper attempts to focus on evidence derived from studies of the normal and abnormal hepatic circulation that provide insights into hepatic circulatory responses and their role in the initiation and perpetuation of hepatic injury. A possible relationship of these vascular changes to pathologic processes within the liver is proposed. Ultimately, precise measurement and understanding of hepatic vasculature changes may allow appropriate intervention to offset injury or stimulate maximum effective repair. ImagesFIG. 1BFIG. 1A

A retrospective analysis of complications arising from 300 consecutive attempts at endoscopic retrograde cholangiopancreatography (ERCP) in 278 patients was undetaken to determine the rate and severity of complications. An over-all complication rate of 5% (15 cases) was documented. Complications were categorized in terms of those arising from endoscopy itself or from the administration of pharmacological agents (7 cases), and those observed after the injection of radioopaque contrast into the biliary tree or pancreas (8 cases). Complications which might be considered coincidental to a patient's underlying illness were not excluded. Complications were significantly more frequent after injection of diseased duct systems. Brief, self-limited pancreatitis after retrograde pancreatography occurred in 5 of 90 patients with pancreatic disease. No cases of pancreatitis were observed after retrograde pancreatography in 102 patients without pancreatic disease X2 = 5.82, P less than 0.025). Sepsis occurred after retrograde cholangiography in 3 of 56 patients with extrahepatic biliary obstruction. In the absence of extrahepatic obstruction, cholangiography was performed without complication in 85 cases (X2 = 3.62, P less than 0.1), although 25 of these had intense cholestasis due to hepatic parenchymal disease. This analysis provides the basis for modifications of ERCP technique and management that may reduce the future incidence of complications. This study suggests that the incidence and severity of complications that arise from ERCP compare favorably with procedures of equivalent diagnostic yield.

A case of traumatic pancreatitis with a radiopaque calculus producing pain by obstructing the distal pancreatic duct is presented. Preoperative ductal anatomy was defined by a percutaneous pancreatogram that established the presence of mechanical duct obstruction as the cause of pain, and the potential for operative relief of duct obstruction. A remission from pain resulted from pancreatic duct decompression by a lateral pancreaticojejunostomy. The potential value of percutaneous pancreatography is discussed.

Hepatitis B immune globulin (HBIG) and immune serum globulin (ISG) were examined in a randomized, double-blind trial to assess their relative efficacies in preventing type B hepatitis after needle-stick exposure to hepatitis B surface antigen (HBsAG)-positive donors. Clinical hepatitis developed in 1.4% of HBIG and in 5.9% of ISG recipients (P = 0.016), and seroconversion (anti-HBs) occurred in 5.6% and 20.7% of them respectively (P less than 0.001). Mild and transient side-effects were noted in 3.0% of ISG and in 3.2% of HBIG recipients. Available donor sera were examined for DNA polymerase (DNAP) and e antigen and antibody (HBeAg; anti-HBE). Both DNAP and HBeAg showed a highly statistically significant correlation with the infectivity of HBsAg-positive donors. Hepatitis B immune globulin remained significantly superior to ISG in preventing type B hepatitis even when the analysis was confined to these two high-risk subgroups. The efficacy of ISG in preventing type B hepatitis cannot be ascertained because a true placebo group was not included.

The combination of upper gastrointestinal endoscopy and endoscopic retrograde cholangiopancreatography was evaluated as a primary diagnostic procedure in 91 consecutive patients suspected of pancreatic or biliary tract disease. In 77 (85%) of the patients, the origin, nature, or extent of disease was established by endoscopy (13 patients), pancreatography (25 patients), or cholangiography (39 patients). This combined technique compares favorably with other means of diagnosing pancreatic or biliary tract disease.

A randomised, double-blind, controlled trial has been undertaken to compare the efficacy of hepatitis B immune globulin (H.B.I.G.) with that of immune serum globulin (I.S.G.) for the prophylaxis of viral hepatitis. Participants in the trial were individuals exposed accidentally to material infectious for hepatitis (primarily viral B hepatitis). Preliminary evaluation of the first 302 of the 561 individuals entered into the study indicates that H.B.I.G. significantly reduced the frequencies of both clinical and subclinical hepatitis during the first 3--4 months after the injection. Less than 10% of H.B.I.G. recipients had detectable anti-HBs at the sixth month after the injection, suggesting that H.B.I.G. might need to be given every 3--4 months to continually exposed individuals. Further long-term evaluation is required in order to define more clearly those most likely to benefit from H.B.I.G.

Evolution in the diagnosis and non-surgical management of biliary tract disease is outlined and analyzed. The relative roles of endoscopic and percutaneous techniques are weighed in terms of risk, technical difficulty and clinical value. Initial diagnosis and treatment should be by endoscopic retrograde cholangiopancreatography (ERCP) when feasible because of lower diagnostic and treatment risk. When technical or clinical circumstances dictate, a prompt shift to percutaneous techniques is indicated. The complimentary roles of endoscopic, percutaneous and surgical methods are emphasized. Therapy by nonsurgical methods is closely linked to diagnosis by direct cholangiography. Close coordination reduces hazard and improves likelihood of successful resolution in these difficult clinical problems.

A case of choledochocele, missed during exploratory laparotomy but managed by endoscopic biliary surgery, is presented.

A double blind, randomized, controlled trial has been conducted in 11 Veterans Administration hospitals during a 49-month period to compare the relative efficacies of immune serum globulin (ISG) and an albumin placebo for the prevention of post-transfusion hepatitis (PTH). A total of 2204 patients, of whom 1094 received ISG, participated in the study. The results indicate that ISG significantly reduced the incidence of icteric type non-B hepatitis only (inferred to be also type non-A hepatitis). Adverse reactions were rare, and the ISG did not significantly alter the incubation period or duration of the disease. The data suggest, however, that a similar reduction in type non-A, non-B hepatitis would have occurred had commercial blood been excluded from use. Analysis of the 241 patients who developed hepatitis indicates that type B hepatitis constituted less than 20% of the cases each year of the study. Furthermore, the efficacy of the ISG, manufactured in 1944, against apparent type non-A, non-B hepatitis suggests that this overlooked disease has existed from at least that time. Host- and transfusion-related factors that might have modified the development of PTH were examined. The use of commercial blood was observed to be the most important risk factor. It is concluded that the PTH incidence can be most effectively reduced by eliminating commercial donor blood, and continuing to screen volunteer donors for hepatitis B surface antigen (HBsAg) by sensitive procedures. Of prime importance is the need to define the agent(s) responsible for type non-A, non-B hepatitis.

Endoscopy combined with endoscopic retrograde cholangiopancreatography is a unique tool providing a broad, precise yield of diagnostic information about diseases of the upper gastrointestinal tract. In the absence of gross anatomic disease, its diagnostic accuracy should exceed 90 per cent and risk be minuscule. The incidence of complications and, therefore, risk to the patient and proportional to the magnitude and remedial nature of the disease processes found. In the absence of diagnostic procedures for diseases of the biliary tree and pancreas that are riskless, the relationship of endoscopic retrograde cholangiopancreatography risk to diagnostic value and patient salvage emphasizes the value of endoscopy combined with endoscopic retrograde cholangiopancreatography as the diagnostic procedure of choice for patients with suspected disease of the biliary tract or pancreas. The unique value of endoscopic retrograde cholangiopancreatography in providing rapid visualization of diseases of the upper gastrointestinal tract mucosa combined with cholangiography and pancreatography is dramatized in the patient with upper abdominal pain syndrome with or without jaundice. In the face of a rapidly evolving illness and the potential need for early surgical intervention, barium studies are relatively contraindicated and have a poor diagnostic yield. By contrast, endoscopic retrograde cholangiopancreatography combined with endoscopy rapidly rules out, or, in the presence of disease of the upper gastrointestinal tract, permits the immediate use of subsequent diagnostic procedures. An experience with more than 1,000 procedures reveals that endoscopic retrograde cholangiopancreatography is an invaluable tool for the diagnosis and management of disease of the pancreas and biliary tract.

The transport of plasma albumin and newly made albumin into ascitic fluid was studied in eight patients with cirrhosis and ascites. The thoracic duct was cannulated in two patients and lymph collected over a period of 2 hr. Simultaneously albumin-(131)I and carbonate-(14)C were injected intravenously. The albumin-(131)I measured the transfer of plasma albumin into ascites and into thoracic duct lymph. The carbonate-(14)C, by labeling newly formed albumin, permitted the estimation of the transfer of newly formed albumin into plasma, ascites, and lymph. If the newly synthesized albumin entering ascites and thoracic duct lymph is delivered initially into the plasma, then the ratios of the albumin-(14)C and -(131)I in ascites and lymph compared with the content of albumin-(14)C and -(131)I in plasma would be identical. However, if some newly formed albumin is delivered directly into ascites or lymph, the ratio for albumin-(14)C would be higher than that for albumin-(131)I in lymph or ascites. The ratios of both labeled albumins found in ascites or lymph are expressed as per cent of the total plasma pool. In the eight patients studied 4.2-11.7% of the albumin-(14)C in plasma was found in ascites in 2 hr whereas only 0.4-2.2% of plasma albumin-(131)I entered in this same period. In the two patients studied during thoracic duct lymph drainage 6.1 and 13.5% of newly made albumin-(14)C appeared in lymph in 2 hr whereas only 2.8 and 3.8% of plasma albumin-(131)I was found in the lymph. In cirrhosis with ascites some newly formed albumin entered ascites and thoracic duct lymph by a direct pathway from the liver bypassing the systemic circulation.