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Jaundice (icterus) is a yellow discoloration of the skin, mucous membranes, and the whites of the eyes caused by increased amounts of bilirubin in the blood. Jaundice is considered a sign of an underlying disease process. Jaundice is detectable clinically when the serum bilirubin is greater than 50μmol/L (3mg/dL). Aims: the objectives were to assess the accuracy of ultrasound U/S and Endoscope Retrograde Cholangio-Pancratography ERCP , to diagnose site and cause of biliary obstruction. Methodology: Prospective, analytical, study deal with the Comparison between U/S and ERCP to diagnose obstructive jaundice. The study was performed by abdominal U/S and ERCP for thirty patients with signs and symptoms of obstructive jaundice. Results: The study found that obstructive jaundice was the most common in elderly ages especially over 65 years. Females were forming (53.3%) VS (46.7%) males. Abdominal U/S of showed that (77.7%) of the patients had dilated common bile duct CBD but ERCP showed (76.7%). Abdominal U/S showed that (50%) of the patients had stone in CBD and (20%) carcinoma head of pancreas while ERCP showed (36.7%) of the patients with stone and (23.3%) had carcinoma head of pancreas. Accuracy of ERCP in diagnosing obstructive jaundice was (80%) while U/S accuracy was (70%). Conclusion :U/S examinations should be done before ERCP. ERCP procedure is needed for treatment only, however good sterilization and safety considerations must be achieved to avoid the complications. INTRODUCTION Jaundice (icterus) is detectable clinically when the serum bilirubin is greater than 50μmol/L (3mg/dL). The usual division of jaundice into prehepatic, hepatocellular and obstructive (cholestatic) is an over simplification as in hepatocellular jaundice there is invariably cholestasis and the clinical problem is whether the cholestasis is intrahepatic or extra hepatic [1]. Jaundice will therefore be considered under the following headings: haemolyticjaundiceincreased bilirubin load for the liver cells, congenital hyperbilirubinaemias defects in conjugation, cholestatic jaundice, including hepatocellular (parenchymal) liver disease and large duct obstruction [1]. The principal role of imaging in the jaundiced patient is the identification and detailed assessment of major bile duct obstruction. The clinical suspicion is based on a variable combination of dark urine, pale stools, pruritus, cholangitis and cholestatic liver function tests. Ultrasound U/S is the preferred initial imaging investigation, but will usually be supplemented with a combination of computed tomography CT, magnetic resonance cholangiopancreatography MRCP, direct cholangiography and, in some centers, endoscopic and/ or intraoperativ U/S [2]. U/S has replaced Oral cholecystography OCG for the diagnosis of gallstones and in many centers the oral contrast agents are no longer available. When extracorporeal shockwave lithotripsy was popular OCG was used to prove cystic duct patency, which was necessary for the passage of stone fragments. More recently oral contrast agents have been used for computed tomography CT cholangiography, although most centers use intravenous cholangiography IV biliary contrast agents[2]. Endoscopic retrograde cholangiopancreatography ERCP: ERCP provides direct opacification of bile ducts and pancreatic ducts with success rates of 92–97 per cent. It provides dynamic information during contrast medium introduction and drainage. It allows visual assessment of the duodenum and ampulla of Vater and provides an option for biopsy and brushings, as well as interventional procedures such as sphincterotomy and stone extraction, biliary stenting and biliary stricture dilatation [2]. Complication rates vary depending on the indication for the procedure, the presence of co-existing disease and the experience of the endoscopist, with severe complication rates of 0.9 per cent to 2.3 per cent, and total complication rates of 8.4–11.1 per cent, the most common significant complication being pancreatitis. The main diagnostic pitfall with ERCP is the under filling of ducts above a stricture [2]. The biliary system is one of the main systems in body, any problem in bile duct such as obstruction in Taif University College OF Applied Medical Science TaIF KSA P O BOX 2425 Post Code 21944 common bile duct may be effect on the liver which formed the largest gland in the body and filter any toxic substance before turn to the blood circulation, may be extend effect the biliary system to the pancreas [3]. The current study mainly aimed to assess the accuracy of U/S and ERCP in determining biliary obstruction. METHODOLOGY Prospective, analytical, study deal with the U/S and ERCP procedures for diagnosing obstructive jaundice. The target population of this study were consecutive patients

The radiological features of lobar and segmental liver atrophy and compensatory hypertrophy associated with biliary obstruction are important to recognise for diagnostic and therapeutic reasons. Atrophied lobes/segments reduce in volume and usually contain crowded dilated bile ducts extending close to the liver surface. There is often a “step” in the liver contour between the atrophied and non-atrophied parts. Hypertrophied right lobe or segments enlarge and show a prominently convex or “bulbous” visceral surface. The atrophied liver parenchyma may show lower attenuation on pre-contrast computed tomography (CT) and CT intravenous cholangiography (CT-IVC) and lower signal intensity on T1-weighted magnetic resonance imaging (MRI). Hilar biliary anatomical variants can have an impact on the patterns of lobar/segmental atrophy, as the cause of obstruction (e.g. cholangiocarcinoma) often commences in one branch, leading to atrophy in that drainage region before progressing to complete biliary obstruction and jaundice. Such variants are common and can result in unusual but explainable patterns of atrophy and hypertrophy. Examples of changes seen with and without hilar variants are presented that illustrate the radiological features of atrophy/hypertrophy.

Following oral cholecystography in 100 patients, the conventional "fatty meal" was replaced by an intramuscular injection of Ceruletid in a dose of 0.4 microgram/kg body weight. The synthetic decapetide Ceruletid is a substance with a hormone-like effect on the gastro-intestinal tract. It contracts smooth muscle in the gut and stimulates secretion in the stomach and the exocrine pancreas. Compared with other substances producing contraction which are given orally, Ceruletid acts more quickly and more powerfully in producing contraction of the gall bladder muscle. In 86% of positive cholecystograms, this resulted in satisfactory demonstration of the bile duct, 66% better than for oral substances. Many abnormalities, particularly localised adenomyomatosis, can only be diagnosed after good contraction of the gall bladder. Side effects, such as nausea, dizziness and a feeling of heat were transitory. In three patients it led to vomiting. The rapid and certain effect of Ceruletid during oral cholecystography requires reassessment of the role of intravenous cholangiography in diagnosis. Particularly amongst out-patients, with a high proportion of normal gall bladders, it is possible to complete the examination in one stage by demonstrating the bile duct with Ceruletid.

BACKGROUND AND OBJECTIVE The preoperative investigation for choledocholithiasis in patients undergoing elective laparoscopic cholecystectomy is still a matter of debate. PATIENTS AND METHODS In a prospective clinical trial the accuracy of intravenous cholangiography (IVC), ultrasonography and liver function tests in the preoperative diagnosis of choledocholithiasis was assessed in 98 patients undergoing elective cholecystectomy. Only patients with uncomplicated cholecystolithiasis considered to be at low risk for having bile duct stones were investigated. A 2-year follow-up clinical survey (mean) was performed in 92 of the 98 patients to investigate the occurrence of postoperative choledocholithiasis (gold standard: clinically manifest choledocholithiasis). RESULTS In this patient cohort the incidence of choledocholithiasis was found to be 5.1%. Among the three diagnostic tests IVC proved to be more accurate with higher sensitivity and a better positive predictive value than ultrasonography and liver function tests. The sensitivity for IVC was 100% compared to 20% for ultrasonography and 40% for liver function tests, respectively. The positive predictive value for IVC was 83.3% in comparison to 20% for ultrasonography and 25% for liver function tests. Mild side effects caused by intravenous contrast media were observed in 2.0%. During a mean postoperative follow-up of 2 years no clinically manifest and initially overlooked choledocholithiasis could be detected in the 92 investigated patients. CONCLUSION IVC is a reliable method to detect unsuspected common bile duct stones and should be used in the preoperative diagnosis prior to elective laparoscopic cholecystectomy. IVC may play a role in decreasing the rate of preoperative ERCP or intraoperative cholangiography in these patients.

Background Endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography (IOC) are tests used in the diagnosis of common bile duct stones in people suspected of having common bile duct stones. There has been no systematic review of the diagnostic accuracy of ERCP and IOC. Objectives To determine and compare the accuracy of ERCP and IOC for the diagnosis of common bile duct stones. Search methods We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov to September 2012. To identify additional studies, we searched the references of included studies and systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects (DARE)), Health Technology Assessment (HTA), Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. Selection criteria We included studies that provided the number of true positives, false positives, false negatives, and true negatives for ERCP or IOC. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct, or symptom-free follow-up for at least six months for a negative test as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones; with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors screened abstracts and selected studies for inclusion independently. Data collection and analysis Two authors independently collected data from each study. We used the bivariate model to summarise the sensitivity and specificity of the tests. Main results We identified five studies including 318 participants (180 participants with and 138 participants without common bile duct stones) that reported the diagnostic accuracy of ERCP and five studies including 654 participants (125 participants with and 529 participants without common bile duct stones) that reported the diagnostic accuracy of IOC. Most studies included people with symptoms (participants with jaundice or pancreatitis) suspected of having common bile duct stones based on blood tests, ultrasound, or both, prior to the performance of ERCP or IOC. Most studies included participants who had not previously undergone removal of the gallbladder (cholecystectomy). None of the included studies was of high methodological quality as evaluated by the QUADAS-2 tool (quality assessment tool for diagnostic accuracy studies). The sensitivities of ERCP ranged between 0.67 and 0.94 and the specificities ranged between 0.92 and 1.00. For ERCP, the summary sensitivity was 0.83 (95% confidence interval (CI) 0.72 to 0.90) and specificity was 0.99 (95% CI 0.94 to 1.00). The sensitivities of IOC ranged between 0.75 and 1.00 and the specificities ranged between 0.96 and 1.00. For IOC, the summary sensitivity was 0.99 (95% CI 0.83 to 1.00) and specificity was 0.99 (95% CI 0.95 to 1.00). For ERCP, at the median pre-test probability of common bile duct stones of 0.35 estimated from the included studies (i.e., 35% of people suspected of having common bile duct stones were confirmed to have gallstones by the reference standard), the post-test probabilities associated with positive test results was 0.97 (95% CI 0.88 to 0.99) and negative test results was 0.09 (95% CI 0.05 to 0.14). For IOC, at the median pre-test probability of common bile duct stones of 0.35, the post-test probabilities associated with positive test results was 0.98 (95% CI 0.85 to 1.00) and negative test results was 0.01 (95% CI 0.00 to 0.10). There was weak evidence of a difference in sensitivity (P value = 0.05) with IOC showing higher sensitivity than ERCP. There was no evidence of a difference in specificity (P value = 0.7) with both tests having similar specificity. Authors' conclusions Although the sensitivity of IOC appeared to be better than that of ERCP, this finding may be unreliable because none of the studies compared both tests in the same study populations and most of the studies were methodologically flawed. It appears that both tests were fairly accurate in guiding further invasive treatment as most people diagnosed with common bile duct stones by these tests had common bile duct stones. Some people may have common bile duct stones in spite of having a negative ERCP or IOC result. Such people may have to be re-tested if the clinical suspicion of common bile duct stones is very high because of their symptoms or persistently abnormal liver function tests. However, the results should be interpreted with caution given the limited quantity and quality of the evidence.

This study aimed to assess the ability of CT-i.v. cholangiography to show the perihilar biliary and cystic duct anatomy and to assess the relative performance of axial, maximum intensity projection and surface rendered displays. We also assessed the correlation between serum bilirubin levels and adequacy of biliary opacification. Spiral CT was carried out following infusion of 100 mL of Biliscopin in 181 patients with suspected biliary disease. The display of biliary anatomy was of high quality, with 91% of patients having good opacification of at least first-order bile ducts and 84% having good opacification of at least third-order right and left hepatic ducts. The quality of biliary opacification correlated inversely to serum bilirubin levels, with levels above two to three times the normal value being associated with lower rates of good opacification. Maximum intensity projection and surface rendered reformats aided anatomical interpretation to a similar degree. The relative frequency of types of perihilar branching patterns and cystic duct junctional anatomy correlated closely to those reported from previous anatomical studies.

症例は34歳の男性で, 以前より心窩部痛を自覚していた. 2001年9月健康診断で胆嚢結石症と診断され, 手術目的で入院した. 理学所見, 血液検査は正常であった. 超音波・単純CTでは胆嚢結石および腺筋症を示唆する均一な胆嚢底部壁肥厚を認めた. 経静脈胆道造影下CT (以下, DIC-CT) で胆嚢管合流部が高位に存在し, 胆嚢管合流部の左側から尾側に総胆管と並走する重複総胆管と疑われる構造が判明した. ERCPでは, 胆嚢管合流部付近の総胆管から重複総胆管が造影され, 続いて主膵管が造影された. これらの所見から, 胆嚢結石・腺筋症および膵胆管合流異常を有する重複総胆管症と診断した. 腹腔鏡下胆嚢摘出時, 術中造影で, 細い肝外胆管が太い総胆管の左側直近を並走することを捉え, 腹痛の原因・発癌の可能性などを考慮し, 腹腔鏡補助下に細い肝外胆管の結紮術を並施した. 摘出胆嚢に悪性所見は認めず, 症状は寛解し, 再燃は認めていない.

To determine the accuracy of computed tomographic intravenous cholangiography (CT-IVC) for detection of choledocholithiasis. Sixty-five patients undergoing endoscopic retrograde cholangiography (ERC) underwent CT-IVC prior to ERC, using a single detector helical CT following intravenous infusion of 100 ml iotroxate. Patients with bilirubin levels3 times normal were excluded. ERC was indeterminate in three patients (4.7%) and CT-IVC in four (6.3%). Twenty-three patients had ductal calculi at ERC, and CT-IVC was positive in 22, with two false positives and one false negative: sensitivity 95.6%, specificity 94.3%. Stones were multiple in nine and solitary in 14. Of the 14 solitary stones, ten wereor=5 mm and eight wereor=4 mm. The bilirubin level in positive cases was within normal in 20. Maximum intensity projection (MIP) reformats showed stones in only 27% of cases and surface rendered (SR) reformats in none. CT-IVC is highly accurate for detection of ductal calculi, including single small calculi, with a normal or near normal serum bilirubin. Axial images should be used for interpretation rather than MIP or SR reformats.

This study aimed to assess the clinical usefulness of magnetic resonance cholangiopancreatography (MRCP) as a postoperative diagnostic tool in children with choledochal cysts. Magnetic resonance cholangiopancreatography was performed postoperatively in 19 patients and image quality was compared with that obtained by intravenous cholangiography spiral computed tomography (IVC-SCT). While the detectability by MRCP was inferior to that by IVC-SCT, MRCP highly (84.2%) depicted the anastomotic site together with the reconstructed bowel and intrahepatic bile ducts. Magnetic resonance cholangiopancreatography also clearly delineated the postoperative condition of pancreaticobiliary maljunction (PBM), residual distal common bile duct, common channel, and pancreatic duct. Since MRCP is noninvasive and requires neither radiation exposure nor a contrast agent, and is useful for detecting both anastomosis and pancreatico-biliary ducts around PBM, MRCP might be superior to IVC-SCT as an imaging technique for outpatient clinics performing long-term follow-up studies in children with choledochal cysts.

Background: The purpose of this prospective study was to evaluate if a recently proposed score system based on six preoperative parameters [history of colic pain and/or jaundice, dyspepsia, cholecystitis, ultrasound (US), evidence of common bile duct stones (CBDS), number and size of gallbladder stones at US, level of serum glutamic oxalacetic transaminase and/or alkaline phosphatase is effective in the selection of patients undergoing laparoscopic cholecystectomy (LC) with asymptomatic CBDS and could allow a significant reduction of the total number of preoperative examinations. Methods: In the case group, 408 patients were categorized into low-, medium-, and high-risk classes and underwent, respectively, no further preoperative assessment of the bile duct, intravenous cholangiography (IVC), and endoscopic retrograde cholangiography (ERC). Intraoperative cholangiography (IOC) was performed whenever the surgeon was in doubt as to biliary anatomy or bile duct clearance. These patients were compared with 408 retrospectively matched patients (control group) undergoing routine preoperative IVC and/or ERC. Results: In the case group, significantly lower numbers of IVC (120 vs 392) and IOC (3 vs 16) were performed (p < 0.005), whereas no difference in the total number of ERCs was noted. One patient in the control group had retained CBDS detected during follow-up evaluation, whereas none occurred in the case group. Conclusion: The proposed scoring system allows selective use of IVC, ERC, and/or IOC in patients undergoing elective LC.

No procedure has yet been identified as the “gold standard” for the detection and treatment of common bile duct stones (CBDS) in patients undergoing laparoscopic cholecystectomy (LC). This prospective study involves 2137 patients undergoing elective laparoscopic cholecystectomy. The algorithm for diagnostic management in place until July 1997 involved routine intravenous cholangiography and selective endoscopic retrograde cholangiography (ERC). Subsequently, assessment of the bile duct was not routinely performed, but a scoring system was applied to single out those patients at risk of CBDS who should undergo intravenous cholangiography and/or ERC (see Fig. 2). Whenever bile duct stones were found, endoscopic sphincterotomy (ES) was performed, and LC was performed with a standardized four-cannula technique after endoscopic bile duct stone clearance. Common bile duct stones were suspected in 340 patients who were referred for preoperative ERC; 250 patients were referred for ES; 21 patients were referred for open surgery because of failure of ERC or sphincterotomy. Common bile duct stones, detected in 283 cases (13.2%), were removed before surgery in 250 cases (88.3%) and during surgery in 28 cases (9.9%). Self-limited pancreatitis occurred in 4.2% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.4% of the cases. The conversion rate was 8.3% if sphincterotomy had been performed previously and 3.4% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 4.5%; mortality, 0.09%. During follow-up five patients (0.2%) had retained stones endoscopically treated. Future trials of novel strategies for detecting and treating CBDS should compare the results of novel strategies with those of the strategy employed in this study, which includes selective ERC, preoperative ES, and LC.

Acute cholecystitis is one of the most common diseases requiring emergency surgery. Ultrasonography is an accurate test for cholelithiasis but has a high false-negative rate for acute cholecystitis. The Murphy sign and laboratory tests performed independently are also not particularly accurate. This study was designed to review the accuracy of ultrasonography for diagnosing acute cholecystitis in a regional hospital.We studied all emergency cholecystectomies performed over a 1-year period. All imaging studies were reviewed by a single radiologist, and all pathology was reviewed by a single pathologist. The reviewers were blinded to each other's results.A total of 107 patients required an emergency cholecystectomy in the study period; 83 of them underwent ultrasonography. Interradiologist agreement was 92% for ultrasonography. For cholelithiasis, ultrasonography had 100% sensitivity, 18% specificity, 81% positive predictive value (PPV) and 100% negative predictive value (NPV). For acute cholecystitis, it had 54% sensitivity, 81% specificity, 85% PPV and 47% NPV. All patients had chronic cholecystitis and 67% had acute cholecystitis on histology. When combined with positive Murphy sign and elevated neutrophil count, an ultrasound showing cholelithiasis or acute cholecystitis yielded a sensitivity of 74%, specificity of 62%, PPV of 80% and NPV of 53% for the diagnosis of acute cholecystitis.Ultrasonography alone has a high rate of false-negative studies for acute cholecystitis. However, a higher rate of accurate diagnosis can be achieved using a triad of positive Murphy sign, elevated neutrophil count and an ultrasound showing cholelithiasis or cholecystitis.La cholécystite aiguë est l’une des maladies les plus répandues exigeant une chirurgie d’urgence. L’échographie est un test précis pour le dépistage de la cholélithiase, mais elle s’accompagne d’un taux élevé de diagnostics faux-négatifs de cholécystite aiguë. Le signe de Murphy et les analyses de laboratoire effectuées indépendamment ne sont pas non plus particulièrement précis. Cette étude a été conçue pour vérifier la précision de l’échographie dans le diagnostic de la cholécystite aiguë dans un hôpital régional.Nous avons passé en revue toutes les cholécystectomies d’urgence effectuées sur une période d’un an. Toutes les épreuves d’imagerie ont été examinées par un seul radiologue et toutes les analyses d’anatomopathologie, par un seul anatomopathologiste. Les examinateurs n’étaient pas au courant de leurs conclusions respectives.En tout, 107 patients ont eu besoin d’une cholécystectomie d’urgence au cours de la période de l’étude; 83 ont subi une échographie. La concordance d’opinion entre les radiologues a été de 92 % en ce qui concerne l’échographie. Pour la cholélithiase, l’échographie a présenté une sensibilité de 100 %, une spécificité de 18 %, une valeur prédictive positive (VPP) de 81 % et une valeur prédictive négative (VPN) de 100 %. En ce qui concerne la cholécystite aiguë, l’échographie a présenté une sensibilité de 54 %, une spécificité de 81 %, une VPP de 85 % et une VPN de 47 %. Tous les patients souffraient de cholécystite chronique et 67 % présentaient une cholécystite aiguë à l’examen histologique. Alliée à un signe de Murphy positif et à une élévation de la numération des neutrophiles, une échographie révélant une cholélithiase ou cholécystite aiguë offrait une sensibilité de 74 %, une spécificité de 62 %, une VPP de 80 % et une VPN de 53 % pour ce qui est du diagnostic de la cholécystite aiguë.L’échographie seule a donné lieu à un taux élevé de diagnostics fauxnégatifs de la cholécystite aiguë. Toutefois, la précision diagnostique augmente lorsque l’on observe simultanément un signe de Murphy positif, une augmentation de la numération des neutrophiles et des signes de cholélithiase cholécystite aiguë à l’échographie.

Laparoscopic cholecystectomy (LC) has become the standard approach for cholecystectomy despite relatively scant evidence that it is superior to open cholecystectomy (OC) in several prospective randomized studies [1‐ 4]. The overwhelmingly fast spread of the laparoscopic technology and the purported lower invasiveness and quicker recovery after LC as opposed to OC have led to important modifications in the management of biliary disease and especially in the attitude of many surgeons toward common bile duct (CBD) stones. Despite consensus that only symptomatic gallbladder stones require surgery [5], the general enthusiasm for laparoscopic surgery has lowered the threshold for LC. In most developed countries, the total number of cholecystectomies performed has increased by 14 ‐24% during 1991‐1993 [6, 7]. Data from Scandinavia suggest that the number of procedures has remained stable [6]. When cholecystectomy was performed for symptomatic cholelithiasis, the prevalence of CBD stones was 8 ‐15% in patients younger than 60 years and 15‐ 60% in patients older than 60 [5]. Performing LC in an increasing number of patients with little or only short-lasting symptoms has decreased the prevalence of CBD stones in the surgical population. Because the predictive values of any diagnostic test are directly related to the prevalence of the disease in the population tested, it is more than likely that the currently available preoperative diagnostic tools have lower positive predictive values than in populations with truly symptomatic cholelithiasis. Although LC is relatively safe (mortality rate ,0.1%), it is associated with a 0.36 ‐ 0.7% incidence of CBD injuries, which is almost twice the incidence for OC [6 ‐ 8]. Obviously, the increasing absolute number of cholecystectomies has increased the overall number of operative CBD injuries. The increasing number of cholecystectomies has also been responsible for the rising number of preoperative biologic and radiologic tests currently performed for the detection of CBD stones. A large variety of morphologic diagnostic investigations are available to the present-day clinician: conventional or endoscopic ultrasound, intravenous cholangiography, spiral computed tomographic (CT) cholangiography, magnetic resonance (MR) cholangiography, endoscopic retrograde cholangiography (ERC), and laparoscopic ultrasound. In addition to their variable efficiency for the detection of CBD stones, these techniques differ in terms of invasiveness, cost, and availability. Standardized and cost-efficient diagnostic strategies for CBD stones are required more than ever to limit the performance of diagnostic tests that may not only be noncontributive for most patients referred for cholecystectomy but also potentially harmful.

Introduccion, material y metodos Con la sospecha clinica o radiologica de coledocolitiasis, realizamos en el periodo de un ano, 32 tomografias computarizadas (TC) convencionales tras la administracion de contraste intravenoso de eliminacion biliar (Bilisergol). Los resultados obtenidos fueron contrastados mediante la realizacion de CPRE y/o cirugia. Resultados La sensibilidad y especificidad de la colangiografia intravenosa con TC convencional fue del 95%. Conclusiones Demostramos que la realizacion de un estudio protocolizado con cortes finos en fases de apnea, se demuestra como una tecnica muy util, al alcance de cualquier servicio de radiologia y con una altisima sensibilidad y especificidad en el diagnostico de las coledocolitiasis.

Consensus has never been reached regarding the need or the imaging technique for evaluating the common bile duct (CBD) in patients considered for cholecystectomy. With the advent of laparoscopic cholecystectomy there has been a resurgence of interest in the role of preoperative intravenous cholangiography (IVC) as an alternative for evaluating the CBD. The purpose of this audit was to assess whether a diagnostic workup based on IVC, which permits selective use of intraoperative cholangiography (IOC) and endoscopic treatment of CBD stones before surgery, could be useful in patients undergoing laparoscopic cholecystectomy (LC). In patients without jaundice, gallstone pancreatitis, a prior diagnosis of CBD stones, a prior history of contrast allergy, or a risk of contrast-associated acute renal failure, IVC was performed routinely. Patients suspected to have CBD stones based on IVC results or with inconclusive IVC and patients with a strong clinical suspicion of CBD stones were referred for endoscopic retrograde cholangiography (ERC). IOC was carried out in patients who had a history of contrast allergy or risk of contrast-associated acute renal failure and whenever the surgeon was in doubt as to the biliary anatomy or CBD clearance. IVC was carried out in 1155 patients, ERC in 225, and IOC in 54. IVC was conclusive in 1132 patients, with a diagnostic accuracy of 99%. Our workup permitted the sequential endoscopic-laparoscopic treatment of cholecystocholedocholithiasis in 162 cases. During the follow-up period residual CBD stones were detected in four patients. Our diagnostic workup showed that routine IVC exposes the population to a large radiation burden, and the cost is high for the small number of patients who benefit. Moreover, it does not seem helpful in reducing the incidence of CBD injuries during LC.

We performed a retrospective study on 163 patients for evaluation of the benefit of intravenous cholangiography prior to laparoscopic cholecystectomy. Radiographic evaluation of the various areas of the biliary system was classified regarding resolution of anatomic structures: well detailed (excellent), impaired image but reliable interpretation possible (good), insufficient contrast with limited assessment (poor), no reliable judgment possible (insufficient). The common bile duct could be described as "good" in 96.3%, whereas the cystic duct could be described as "good" in only 54.6%. Concrements of the gallbladder were recognized in 72.4%, and common bile duct stones were diagnosed in only two of three patients. A distal junction of the cystic duct was found in nine cases, but there was no influence on the following operative procedure. Only one of two patients with a short cystic duct was identified. We found no improvement after routine use of intravenous cholangiography concerning the evidence of common bile duct stones or the avoidance of lesions of the common bile duct. Hence routine use of intravenous cholangiography prior to laparoscopic cholecystectomy is not justified.

The Mirizzi syndrome is often undiagnosed before surgery and can carry a high risk of iatrogenic damage to the common bile duct when encountered during open or, especially, laparoscopic surgery. Endoscopic management has recently been reported, but this treatment can be performed only when there is a high index of suspicion based on clinical criteria that the condition is present and therefore suggests the indication for endoscopic retrograde cholangiopancreatography (ERCP). This is not always the case. Consequently, in a considerable percentage of patients, the syndrome is discovered only after the bile ducts have been damaged during surgery. Three cases of Mirizzi's syndrome were observed in our experience of 896 laparoscopic cholecystectomies (0.3%). All patients were without typical symptoms, and the syndrome was unsuspected in spite of preoperative intravenous cholangiography. All patients required conversion to an open procedure, with two injuries of the common bile duct (a complete transection and a tear) being promptly repaired. We conclude that when this syndrome is suspected or found during surgery, the surgeon should follow these guidelines: (1) perform intraoperative cholangiography when possible, even through the gallbladder wall; and (2) dissect the gallbladder from above and, if necessary, open it to extract the stone. Dissection of Calot's triangle should never be attempted. Great expertise is required to complete the operation laparoscopically. The reported cases in the literature refer to a high percentage of conversion, underlining the technical difficulties and making this syndrome, when undiagnosed and unsuspected, a real challenge for laparoscopic surgeons.

A 21-year-old woman who for more than one year had had epigastric pain which was unrelated to food and radiated belt-like, was found to have a marked increase in gamma-GT, slightly elevated phosphatase activity, and increased erythrocyte sedimentation rate. The diagnosis of choledochal cyst, type Ia, was confirmed by sonography, endoscopic retrograde pancreatography and intravenous cholangiography. A choledochocystojejunostomy with a Y-Roux anastomosis was constructed to stop the cholestasis and prevent complications. The patient became symptom-free after the operation.

Purpose The work was aimed at presenting the indications, techniques and results of the percutaneous transjejunal approach to the biliary tree in patients with hepatobiliary complications due to surgery. Patients and methods Ten patients, 7 males and 3 females, mean age 50 years (range, 10–62) with hepatico-jejunostomy, who developed cholangitis together with jaundice or bile leakage, underwent this procedure, performed through the anastomotic loop that was not surgically anchored to the abdominal wall in all cases but one. The transjejunal approach was chosen because of non-dilated bile ducts in 3 patients, complex pathologic situations in 5 patients and to avoid complications to a transplanted liver in 2 patients. The jejunal loop was identified using CT, US and fluoroscopy in 4 patients and after its opacification in the remaining 6 (by percutaneous transhepatic or intravenous cholangiography or fistulography). Results The procedure was technically and diagnostically successful in all cases. Therapeutic procedures (stenting, dilation, litholysis) were also performed using the transjejunal approach in 7 patients and in 6 of them complete pathological resolution was achieved. There were no complications. Conclusions Different pathologies of the biliary tree, in patients with bilio-enteric anastomoses, have been identified and treated by this technique; they were fistulas, anastomotic and/or multiple segmental benign or malignant stenoses of the bile duct, and diffuse intrahepatic lithiasis. The procedure was safe and reliable.

OBJECTIVE: The authors aimed to study the safety and accuracy of infusion cholangiography in patients undergoing laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: Intravenous cholangiography is a theoretically attractive method of screening the common bile duct for stones. However, there still remain serious reservations regarding its safety and accuracy, despite some reports in the literature to the contrary. METHODS: A personal series of 1000 patients undergoing routine preoperative infusion cholangiography was reviewed. RESULTS: The cholangiograms detected bile duct stones with a sensitivity of 93.3% and a specificity of 99.3%. There were no serious contrast reactions, and the minor contrast reaction rate was 0.7%. CONCLUSIONS: The authors conclude that infusion cholangiography is indeed safe and accurate and should play a substantial role in preoperative screening for incidental common bile duct stones.

SUMMARY Indications for direct visualization of the bile ducts include bile duct dilatation demonstrated by ultrasound or CT scanning, where the cause of the bile duct dilatation is uncertain or where the anatomy of bile duct obstruction needs further clarification. Another indication is right upper quadrant pain, particularly in a post-cholecystectomy patient, where choledocholithiasis is suspected. A possible new indication is pre-operative evaluation prior to laparoscopic cholecystectomy. The bile ducts are usually studied by endoscopic retrograde cholangiopancreatography (ERCP), or, less commonly, trans-hepatic cholangiography. The old technique of intravenous cholangiography has fallen into disrepute because of inconsistent bile-duct opacification. The advent of spiral CT scanning has renewed interest in intravenous cholangiography. The CT technique is very sensitive to the contrast agent in the bile ducts, and angiographic and three-dimensional reconstructions of the biliary tree can readily be obtained using the CT intravenous cholangiogram technique (CT IVC). Seven patients have been studied using this CT IVC technique, between February 1995 and June 1996, and are the subject of the present report. Eight further studies have since been performed. The results suggest that CT IVC could replace ERCP as the primary means of direct cholangiography, where pancreatic duct visualization is not required.

Background The advent of laparoscopic cholecystectomy has resulted in an increasc in common bile duct (CBD) injuries. Routine intraoperative cholangiography has been advocated to prevent these injuries. This study describes an alternative management strategy applied to a consecutive series of 1000 patients having laparoscopic cholecystectomy. Methods In patients with no history of contrast allergy and no suspicion of CBD stones, preoperative intravenous cholangiography (IVC) was performed routinely. Patients with suspected or detected CBD stones were referred for endoscopic retrograde cholangiography. This strategy was supplemented by selective intraoperative cholangiography. Results Overall 782 of the 1000 patients had successful preoperative IVC, allowing detection of 30 CBD stones and providing useful information about anatomical variation in CBD anatomy. Patients with inconclusive IVC studies, or those with a history of contrast allergy, had intraoperative cholangiography, which demonstrated a further 19 CBD stones. There were no contrast reactions and no damage to the biliary system which might have been obviated by intraoperative cholangiography. In the 724 patients who did not require complimentary intraoperative cholangiography, there has been no clinical evidence of missed CBD stones. Conclusion Routine preoperative IVC, with reservation of intraoperative cholangiography for indeterminate IVC examinations or the need for anatomical clarification, is a safe strategy for laparoscopic cholecystectomy.

A 46-year-old woman who had upper abdominal pain 10 years after cholecystectomy, and who had incidental sclerosing cholangitis (SC), was investigated by three-dimensional helical computed tomographic (3-DHCT) cholangiography with contrast medium, because endoscopic retrograde cholangiography (ERC) was unsuccessful and a second ERC was not permitted by the patient. The cholangiogram demonstrated annular strictures of the bilateral hepatic duct at the confluence of the common hepatic duct, and dilatation of the left intrahepatic biliary duct. Although we could not clarify the cause of the biliary tract deformity at the time of the 3-DHCT, the tentative diagnosis of postcholecystectomy deformity of the biliary tree led to successful treatment by right liver lobectomy and hepaticojejunostomy. Histologic findings were compatible with SC. From this experience and the literature, we suggest that 3-DHCT cholangiography with contrast medium can contribute to the preoperative diagnosis of morphological changes in the biliary tree in patients with postcholecystectomy symptoms.

In the open cholecystectomy era, the established principle for treating biliary calculi was to perform intraoperative cholangiography to diagnose and treat the concomitant common duct stone at the time of cholecystectomy. To reduce unnecessary cholangiograms, a selective cholangiogram policy based on preoperative and operative criteria was sometimes used. Although both time and cost were saved, a 4% to 10% chance of missing unsuspected common duct stones was associated with this policy. The introduction of laparoscopic cholecystectomy in Australia initially led to an abandonment of the principles of biliary surgery. Rates of intraoperative cholangiography declined as stones were either ignored or diagnosed preoperatively by endoscopic retrograde cholangiopancreatography and/or intravenous cholangiography. When stones were identified, they were treated by preoperative endoscopic sphincterotomy. This decline in cholangiography was associated with a twofold to fourfold rise in serious bile duct injury as wel...

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for radiological visualization of the common bile duct. In addition to its diagnostic applications, ERCP, along with sphincterotomy, is a standard therapy for bile duct calculi. The advent of laparoscopic cholecystectomy (LC) has focused much attention on the role of ERCP in the management of bile duct calculi. The use of ERCP before LC should be selective, with ERCP restricted to patients with a high risk of bile duct calculi. ERCP should be performed after LC in patients with continuing symptoms suggestive of bile duct calculi or when operative cholangiography has demonstrated calculi. Intravenous cholangiography (IVC) has no role as a screening test for bile duct calculi, and percutaneous transhepatic cholangiography (PTC) should be restricted to those patients in whom bile duct calculi is highly suspected and in whom ERCP has failed. Elderly and frail patients with bile duct calculi may be satisfactorily managed by ERCP alone. Although a "minimally invasive" procedure, ERCP is not without risks. Local practice will depend to a great extent on the availability of ERCP expertise.

During intraoperative cholangiography, cystic duct stones were diagnosed in 79 of 898 consecutive patients (8.8%) who underwent laparoscopic cholecystectomy over a 45-month period. The stones were successfully removed laparoscopically. In addition, it should be mentioned that the stones were identified and retrieved before the cholangiography was started in all but 8 of the 79 cases. Of these 79, only 27 cases (34.2%) had been diagnosed as having cystic duct stones preoperatively by intravenous cholangiography and/or endoscopic retrograde cholangiography. From the results obtained, it can be concluded that intraoperative cholangiography is mandatory to detect unsuspected retained stones not only in the common duct but also in the cystic duct during laparoscopic cholecystectomy, and also provides vital information as to biliary anatomic variations, the proximity of the cystic duct to the common duct, and the confirmation of inadvertent bile duct injury.

The gallbladder and the biliary tract are structures in close connection with the adjacent organs and may show a number of variations and anomalies. It is therefore important for surgical purposes to know their anatomy and variations in detail. Various methods are used in the imaging of the variations of the biliary tract and its pathologies, including ultrasonography, computed tomography; direct cholangiographic methods like endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, intravenous cholangiography and T-tube cholangiography, as well as indirect methods like magnetic resonance cholangiopancreatography (MRCP) or cholescintigraphy. The aim of this study is to investigate the frequency of the anatomic variations of the biliary tract using 3-T MRCP and to compare the findings with the data in the literature. For the purposes of this study, patients who underwent MRCP at our hospital (Dicle University Hospital) between November 2009 and February 2012 were investigated retrospectively. A total of 590 patients (between 6 and 88 years of age; mean age: 51 ± 9 years) were included in the study. The MRCP imaging was carried out with an magnetic resonance imaging (MRI) device supplied with 3-T magnetic power and by obtaining T2-weighted images through the single-shot fast spin echo technique using the standard body coil. The axial and coronal source images and the reformatted images were evaluated together in terms of the possible anatomic variations. Among the 590 patients included in the study, of 233 (39.5 %) showed anatomic variations at different levels in the intra- and extrahepatic biliary tracts. Among these variations, a right posterior hepatic duct insertion to the left hepatic duct at the level of the bifurcation has been observed in 71 patients (12.1 %), trifurcation was observed in 30 patients (5.1 %) and insertion into the main hepatic duct at the proximal aspect of the cystic duct was observed in 18 patients (3.1 %). At the level of the cystic duct, medial insertion of the cystic duct was viewed in 58 patients (9.8 %), distal medial insertion was seen in 40 patients (6.8 %), a short cystic duct was detected in 10 patients (1.7 %), pancreatobiliary junction anomaly was viewed in two patients (0.4 %) and duplicate anatomic variations have been observed in 42 patients (7.2 %). MRCP studies conducted using 3-T MRI devices may reveal similar or greater numbers of variations when compared to the existing MRCP studies in the literature. 3-T MRI shows a couple of variations. Pointing out these anatomical variations before the surgical intervention may prevent possible iatrogenic traumas. Donors with unsuitable variations for liver transplant may be spotted out at an early phase through the MRCP and certain operations with a high morbidity rate may thus be avoided.

With the advent of laparoscopic cholecystectomy a trend toward more extensive preoperative diagnostic study of the biliary tree by intravenous cholangiography or ERCP has been observed. However, both exams have technical limitations and are not without risk. We report our experience with 500 consecutive routine dynamic intraoperative cholangiographies during laparoscopic cholecystectomy, 97% of which were successful. No lesions from cholangiography were observed. In ten patients clips on the cystic artery appeared on intraoperative cholangiogram to be too close to the hepatic duct and were removed. Anomalies of surgical importance were discovered in 11 patients (2.3%). Unsuspected stones were found in 18 cases (3.7%) and suspected stones confirmed in 12 (2.4%). In our experience routine dynamic intraoperative cholangiography provided important information in 51 cases out of 500 (10.2%). We conclude that routine dynamic intraoperative cholangiography is extremely useful for safer laparoscopic cholecystectomy and cost containment.

In the present work we recount our experience in handling common bile duct stones (CBDS) in our first 100 cases of laparoscopic cholecystectomy. In the first 50 cases our diagnostic procedures involved the use of ultrasound exploration and intravenous cholangiotomography 48 h before laparoscopic surgery. We found three cases of residual CBDS. One of the cases was treated by means of ERCP. The other two cases were resolved by carrying out a transparietohepatic cholangiography after the ERCP procedure failed. After this experience, we changed our strategy, introducing the intraoperative cholangiography in the cases with an unclear diagnosis. With this new approach, no residual CBDS occurred in the following 50 cases. These findings demonstrate the following: (1) In our hands, intravenous cholangiography is not more effective than ultrasound exploration in resolving dubious cases. (2) These dubious cases are more effectively diagnosed by means of selective intraoperative cholangiography. (3) When CBDS is treated by transparietohepatic cholangiography it proves to be less uncomfortable for the patient than ERCP and, as we found, even more efficient in removing the stones, although our experience is based on only two cases.

To determine whether helical computed tomography (CT) performed during intravenous cholangiography can provide useful images of the biliary tree and to compare this technique with endoscopic retrograde cholangiography (ERC).Eighteen adult patients with clinically suspected biliary disease who were referred for ERC were first examined with helical CT cholangiography performed 75 minutes after intravenous infusion of 100 mL of 10.3% iodipamide meglumine.Helical CT cholangiography revealed good opacification of the biliary tree in 13 of 14 patients with serum bilirubin levels less than 2 mg/dL (34 mumol/L) and poor opacification in three of four patients with levels greater than 2 mg/dL. In six of seven patients with choledocholithiasis, the diagnosis was made by means of helical CT cholangiography.Helical CT cholangiography may be a clinically useful method for visualization of the biliary tree in some patients with suspected biliary disease with normal bilirubin levels and in patients in whom attempts at ERC fail.

With the advent of laparoscopic cholecystectomy (LCH) various strategies have been proposed for the management of common bile duct (CBD) stones. In a consecutive series of 1140 patients subjected to LCH, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was attempted in 128 patients (11.2%) and successfully accomplished in 121 (94.5%). Based on the prediction of CBD stones by laboratory tests, ultrasonography, and intravenous cholangiography, prelaparoscopic ERCP was performed in 106 patients (9.3%). CBD stones were identified in 56 patients and benign papillary stenosis in 5 patients (57.5%). Of these 61 patients, 58 (95%) were treated by endoscopic sphincterotomy (ES) and stone extraction followed by LCH after a mean interval of 1.6 days. Three patients with failure of endoscopic ductal stone extraction required open CBD exploration. In 39 of the 106 patients (36.8%) ERCP was negative for ductal stones but revealed unexpected ampullary and pancreatic cancer in two cases. Six patients (of the 106) with preoperative ERCP cannulation failure (5.7%) were managed either by LCH and intraoperative cholangiography or by open CBD exploration. In 22 of the 1140 total patients (1.9%) ERCP was performed at various intervals after LCH. Retained CBD stones were found in eight patients, and ES and ductal clearance was achieved in all eight. There was no mortality among the entire surgical group who underwent perioperative ERCP/ES. Including two cases of ES-related pancreatitis, the overall morbidity was 5.5% (7 of 128). Perioperative ERCP/ES in conjunction with LCH is an attractive approach for patients with cholecystocholedocholithiasis, at least until laparoscopic ductal clearance becomes a standard procedure.

Volumetric computed tomography (CT) scans ("spiral CT") were performed after intravenous (i.v.) cholangiography followed by additional 3D surface reconstructions of gallbladder and biliary ducts. 34 patients were investigated prior to cholecystectomy. No allergic adverse reactions were observed. The scan time was 24 s. Contrast enhancement in the extrahepatic bile duct and gallbladder were measured. All CT image series were reviewed independently by four experienced physicians (two radiologists, two surgeons) and compared for quality with conventional cholangiography on a three-point scale. The average rating for the demonstration of the biliary tract was significantly better for spiral CT than for conventional cholangiography (p < 0.01). In all cases sufficient contrast was found in the common bile duct (mean 315 HU). 3D imaging was considered to be helpful for intraoperative orientation during laparoscopic surgery. Cholangiography prior to hepatobiliary surgery is important, particularly if minimally invasive laparoscopic techniques are used. The most important questions for the radiologist concern: (1) obstructions or calculi in the ductal system and the gallbladder; (2) the anatomy of the right hepatic duct and the cystic duct (Gotz et al, 1991). To answer these questions, intravenous cholangiography employing conventional tomography is usually performed. The quality of the examination can be diminished by superposition of faeces or gas and small intraductal calculi may be

Patients who continue to have or who develop abdominal pain after apparently successful cholecystectomy pose diagnostic difficulties. This study reports 384 such patients, investigated by endoscopic retrograde cholangiopancreatography (ERCP). There were 146 patients with abdominal pain alone with no previous history of common bile duct (CBD) exploration, of whom only 17 (11.6 per cent) had CBD stones on ERCP. Bile duct calculi were present in 76 of 140 patients (54.3 per cent) with abnormal biochemical findings (raised alkaline phosphatase and/or amylase level) and in 34 of 57 (60 per cent) with an abnormality detected on ultrasonography or intravenous cholangiography. A combination of biochemical and radiological abnormalities was present in 37 patients and was associated with CBD stones in 28 (76 per cent). Patients who had undergone CBD exploration represented a special group, of whom the majority (75 per cent) had common duct stones at ERCP even in the absence of biochemical and radiological abnormalities. ERCP is a useful investigation in patients with persistent postcholecystectomy symptoms. Other features in addition to pain or a history of CBD exploration may be relevant to the decision to perform ERCP in the investigation of these patients.

A very rare case of multiple advanced carcinoma of the gallbladder in the different histological types was experienced.The patient was a 69-year-old man. Ultrasonography revealed a 3×3×cm elevated lesion and wall thickness. The lesion was diagnosed as carcinoma of the gallbladder. Intravenous cholangiography showed no visualization of the gallbladder. Possible coexistence of some lesion in the neck was suspected, but no lesion was found by US and CT. Simple cholecystectomy was made.Gross examination of the excised specimen showed carcinomas of 4×4×4 cm in the fundus, and 1×1×cm in the neck. No abnormal findings were not found between two lesions. Microscopic examination revealed adenosquamous cell carcinoma in the fundes and adenocarcinoma in the neck. Both lesions were advanced carcinoma in the same level (ss).There was no intramucosal invasion nor vessel invasion between two lesions. Preoperative examination, operative findings, and examination of excised specimen, there were no direct invasion, lymphnode metastasis, nor distant metastasis. So we could not find no biological differentiation between two lesions.

We experienced a case of traumatic neuroma incidentally noted in the gallbladder resected for choledo-cholithiasis. Ultra-sonography, computed tomography, and intravenous cholangiography indicated stones in the common bile duct in an 85-year-old female and operation was performed. Many stones were found din the dilated common bile duct. The gallbladder was atrophic and its wall thickened and hardend. Microscopically, thickening of the gallbladder wall was due mainly to nodular proliferation of peripheral nerve fascicles. A diagnosis of traumatic neuroma was made over.Traumatic neuroma in the gallbladder is very rare and a review of the literature disclosed only two cases of it. This paper presents the third case of traumatic neuroma of the gallbladder, with some discussion of its symptoms and pathogenesis.

Hydatid disease is a common medical problem in some areas of the world. In fact, it is the main zoonosis affecting the human population in southern Chile.1,2 The incidence in this country has been approximately 600 to 800 new cases per year. Among patients harboring the disease, the liver is the most commonly affected organ with an infestation rate of 60% to 74%. Cyst rupture into the biliary tree is a common complication, with the right hepatic duct more commonly involved (55% to 60%).3 Communications are usually small, occurring as result of tears between the cyst wall and biliary radicles. Large tears involving main bile ducts are less frequent (7% to 9%). Obstructive jaundice and cholangitis occur when daughter cysts and fragmented membranes obstruct the biliary tree (5% to 10%).4-6 Biliary fistula develops after surgical drainage of the cyst when intracystic pressure decreases.7,8 The involvement of the bile ducts is not easy to detect. CT and US generally fail to show involvement. Intravenous cholangiography rarely shows a well-defined image of the biliary tree, and percutaneous transhepatic cholangiography is contraindicated because of the chance of causing intraabdominal spread of echinococcal contents and subsequent anaphylactic shock.9,10 Because of the relative high morbidity and mortality rates associated with surgical therapy, nonoperative methods of treatment for biliary fistulas have been developed. The use of ERCP is considered effective in detecting biliary involvement from the cyst, and it also provides an effective approach to therapy.11,12 We report here our experience in the management of four cases of hydatid cysts communicated with the biliary tree using ERCP and biliary stent insertion. CASE REPORTS

Choledochocele, or type III choledochal cyst, is a rare anomaly. Two children with choledochocele, both younger than any previously reported patient, were recently cared for at the University of Michigan Medical Center and prompted a literature review of this subject. Since 1974, 40 cases of choledochocele have been reported with enough clinical information for critical review. Ten of these patients were 21 years of age or younger. Presenting symptoms were not specific for choledochocele; they were generally interpreted to result from other biliary or gastrointestinal disorders that are more common for each age group. In pediatric patients the most frequent signs and symptoms of choledochocele were abdominal pain (70%), nausea and/or vomiting (60%), jaundice (30%), and acute pancreatitis (30%). While two-thirds of adult patients with choledochocele had undergone prior cholecystectomy (with stones rarely found), this was observed only once in children. Obstructive symptoms led to evaluation of the stomach and duodenum with either barium upper GI series or endoscopy in all children. These demonstrated an extrinsic mass effect in 90% of the patients. Endoscopic retrograde cholangiopancreatography identified a choledochocele in all cases in which the study was successfully executed. Intravenous cholangiography was sensitive in children, but less so in the adult patients reviewed. Other imaging efforts (computerized tomography, ultrasound, radionuclide scanning) were less dependable. Transduodenal marsupialization is the treatment of choice for patients of all ages and was provided in both of these newly reported children.

Cholecystoenteric fistulas are often not diagnosed preoperatively and delineation of fistula can have an influence on surgical planning. We report a case of cholecystocolonic fistula diagnosed preoperatively using CT-i.v. cholangiography and review the published reports.

Aim. To determine the possibility of preoperative evaluation of the feasibility of laparoscopic cholecystectomy based on the standard preoperative examinations and findings. Methods. During 1997, 100 consecutively operated patients with the diagnosis of chronic calculous cholecystitis were followed up. Sex and age, and the results of blood count, sedimentation rate, ultrasonography (US), and intravenous cholangiography (IVC) were monitored. Based on adhesions, fibrosis in Calot?s triangle and pericholecystitis, surgical interventions were classified as minor and major. Results. Minor operations were performed in 57, and major in 43 patients. Earlier surgical interventions had been carried out in 8 (18.6%) patients from the major surgery group, while 9 (15.79%) patients had undergone minor surgery. Out of 57 patients with minor surgery, IVC verified the contrast medium filling of the gallbladder in 55 (96.49%) of the patients. Tense gallbladder or wall stratification was not revealed by ultrasonography in any of the patients from this group. Out of 43 patients with major surgery, the gallbladder was not filled with the contrast medium during IVC in 34 (79.07%) patients, while the stratified and tense gallbladder was found by US in 2 (4.65%) patients. The mean sedimentation rate was 14.3 in the patients with minor surgery, and 23.5 in major surgery group. Mean WBC in the patients with minor surgery was 7.4 ? 109. The patients with major surgery had slightly increased mean value of the white cell count. It was 8.3 ? 109. Conclusion. Statistically significant difference (p ? 0.05) was found between the variables of the IVC, sedimentation rate, the white blood count, and the earlier operations. No significant difference was found between other analyzed variables.