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Background As the most common biliary malignancy, gallbladder cancer (GC) is an elderly-biased disease. Although extensive studies have elucidated the molecular mechanism of microRNA 182 (miR-182) and reversion-inducing-cysteine-rich protein with kazal motifs (RECK) in various cancers, the specific role of exosomal miR-182 and RECK in GC remains poorly understood. Aim To explore the relationship between exosomal miR-182/RECK and metastasis of GC. Methods Paired GC and adjacent normal tissues were collected from 78 patients. Quantitative polymerase chain reaction was employed to detect miR-182 and exosomal miR-182 expression, and Western blotting was conducted to determine RECK expression. In addition, the effects of exosomal miR-182/RECK on the biological function of human GC cells were observed. Moreover, the double luciferase reporter gene assay was applied to validate the targeting relationship between miR-182 and RECK. Results Compared with normal gallbladder epithelial cells, miR-182 was highly expressed in GC cells, while RECK had low expression. Exosomal miR-182 could be absorbed and transferred by cells. Exosomal miR-182 inhibited RECK expression and promoted the migration and invasion of GC cells. Conclusion Exosomal miR-182 can significantly promote the migration and invasion of GC cells by inhibiting RECK; thus miR-182 can be used as a therapeutic target for GC.

A 15-year-old boy underwent hepatobiliary scintigraphy for suspected acute cholecystitis. The initial images revealed an activity in the neighborhood of normal gallbladder fossa, suggestive of possible activity in the gallbladder, which would be inconsistent with a diagnosis of acute cholecystitis. However, after drinking 6 oz of water, the activity was no longer seen. Acute cholecystitis was confirmed pathologically after cholecystectomy.

In this pictorial essay, we review the 3-dimensional sonographic appearance of the normal gallbladder and biliary tree, as well as the appearance of congenital and acquired biliary tract disorders. Using examples, we demonstrate the advantage of 3-dimensional scanning compared with 2-dimensional sonography and, even in certain cases, magnetic resonance cholangiopancreatography.

A 25-year-old man was referred for chronic right upper quadrant abdominal pain for hepatobiliary scintigraphy to evaluate the gallbladder (GB) function. An unexpected GB contraction with ejection fraction (EF) of 90% was observed during the first hour of baseline imaging. Subsequent stimulation with sincalide produced GB EF of 99%. A similar case previously reported also showed normal unexpected GB EF that predicted similar post-sincalide GB EF. These examples support what should be evident: A normal unexpected GB EF is a sufficient evidence for a normal GB function and should obviate need for sincalide stimulation.

The purpose of the present study is to compare histological changes in the wall of human gallbladder in abnormal conditions like cholelithiasis & cholecystitis and find out the predominant risk factors for the development of cholelithiasis from primary stage like cholecystitis. To conduct case control study, 60 normal (control group) human gallbladders & 30 abnormal (case group) samples of human gallbladders having cholelithiasis and cholecystitis were obtained and processed & 9 slides were obtained and stained by H&E.. Different histological findings were noted in the various layers of gallbladders. Epithelial hyperplasia, dysplasia with erodification of mucosa and sub epithelial haemorrhages was denoted in both cholelithiasis & cholecystitis. On the behalf of statistical evidence, the present study shows both group case and control are highly significant. Predominant histological alterations were estimated in percentage by counting the number of sign and symtoms or alterations observed in various layers of diseased human gall bladder like cholecystitis and cholelithiasis and the percentage was evaluated by correlating with the normal gallbladder histological representation either/or minimal recessive histological alterations in the normal one. Predominant histological alterations were estimated and found maximum epithelial break was 62.5% in cholelithiasis where as 59.09% in cholecystitis

The aim of the current study was to investigate survivin expression in congenital choledochal cysts (CCCs), and its associations with clinical parameters of CCCs. In total, 121 children with CCCs were included in this study as the case group, and their cysts were staged according to the Todani classification system. Additionally, 49 normal gallbladder specimens from healthy children were included as the control group. Survivin detection was conducted using immunohistochemical staining. Associations between positive survivin expression and clinical parameters of CCCs were then analyzed. Positive survivin expression was observed in the cytoplasm, and was seen as granular with yellow or dark brown staining. In the case group, positive survivin expression was detected in most tissues. Specifically, compared to that of normal tissues, the cystic-shaped and fusiform-shaped CCC tissues had significantly higher positive survivin expression rates (all P < 0.05). Importantly, positive survivin expression was also shown to be significantly associated with gender and histological type (both P < 0.05). In conclusion, increased survivin expression was observed in CCC tissues, and was correlated with certain clinical parameters of CCCs, suggesting a possible prognostic value of survivin for CCC progression.

GLUT-1 is a transmembrane glucose transport protein that allows the facilitated transport of glucose into cells, normally expressed in tissues which depend mainly on glucose metabolism. Enhanced expression of GLUT-1 can also be found in a large spectrum of carcinomas. This study aimed to investigate GLUT-1 expression in gallbladder tissue: from normal tissue samples, hyperplasias, low-grade and high-grade dysplasias to gallbladder carcinomas. In all, 115 archived samples of gallbladder tissue from 68 patients, presented after cholecystectomy, were immunohistochemically stained for GLUT-1. According to the intensity of GLUT-1 immunoreactivity, samples were divided into negative (stained 0–10% of cells stained), positive with weak to moderate (10–50%) and positive with strong (>50%) GLUT-1 expression. The GLUT-1 immunoreactivity of the samples showed a characteristic increase from premalignant lesions to carcinomas. Normal gallbladder tissue samples did not express GLUT-1 (100%). Weak expression was shown only focally in hyperplasias, but to a greater extent with low-grade dysplasias (20%), high-grade dysplasias (40%) and carcinomas (51.8%). Normal gallbladder tissue is GLUT-1 negative. GLUT-1 expression in carcinoma tissue is significantly higher than in dysplastic lesions. Strong GLUT-1 expression indicates 100% specificity for detecting gallbladder carcinomas. Therefore, GLUT-1 is a candidate as a diagnostic as well as a tissue prognostic marker in gallbladder carcinoma patients.

Particle induced X-ray emission, particle induced γ-ray emission studies has been carried out to analyse normal and carcinoma tissues and blood samples of gallbladder of both sexes and seventeen trace elements namely Na, Mg, Al, K, Ca, Ti, Cr, Mn, Fe, Co, Ni, Cu, Zn, As, Se, Br and Pb were estimated in the tissue and blood samples. In the present study, concentration of Zn in the carcinoma gallbladder tissue is less than that of the normal gallbladder tissue. Tobacco habit could be one of the important factors to decrease the elemental concentrations in blood and tissue samples.

70 patients clinically classified as n.a.d. were sonographically examined for evaluation of the gallbladder fossa within two weeks after cholecystectomy. Four marked signs were noted. In 35 patients (50%) we found homogeneous echogenic formations of triangular, band-like, or oval shape in the bed of the gallbladder. In 25 cases (35.7%) inhomogeneous structures were seen. In 6 cases (8.5%) cystic structures resembling the normal gallbladder were seen which were interpreted as representing seromas or liquified haematomas. In 4 patients (5.7%) the bed of the gallbladder was entirely normal. Whether the gallbladder bed was closed by sutures or not, had no statistically significant effect on ultrasound appearance.

Author(s): Yoo, Jeong-Hyun; Kwak, Hyun-Joo; Lee, Myung-Jun; Suh, Jeong-Soo; Rhee, Chung-Sik | Abstract: PurposeOur goal was to establish the range of sonographic measurements of normal gallbladders in children.MethodsSix hundred ten children aged 0-16 years (male:female ratio, 1.5:1) with normal clinical and laboratory findings were included in this study. The sonographic parameters were the length, width, and calculated volume of the gallbladder, and the clinical parameters were the age, height, weight, and body surface area of the children. Statistical significance was determined through correlation and regression analyses.ResultsThe length of the gallbladder showed significant positive correlations with age (r = 0.65), height (r = 0.67), weight (r = 0.63), and body surface area (r = 0.65; p l 0.01). The calculated volume of the gallbladder also showed moderate correlations with age (r = 0.53), height (r = 0.55), weight (r = 0.61), and body surface area (r = 0.57; p l 0.01). The gallbladder width showed modest but significant correlations with age (r = 0.48), height (r = 0.53), weight (r = 0.53), and body surface area (r = 0.55; p l 0.01). The highest correlation coefficients were found between the gallbladder length and subject age (r = 0.65; p l 0.01) and between the gallbladder length and subject height (r = 0.67; p l 0.01). For all correlations, statistical significance remained after regression analysis (p l 0.01).ConclusionsValues for the size of the normal pediatric gallbladder are defined and will be helpful in the diagnosis of gallbladder abnormalities.

Non-Surgical Treatment of Gallbladder Stones With rare exceptions, treatment is recommended only in the symptomatic stage of gallstone disease. Normal gallbladder ejection function

A wide range of normal gallbladder variations are seen on gallbladder imaging. This essay illustrates the major variations that may be encountered, including anomalies in location, number, and form.

Endoscopic retrograde sphincterotomy may be done without sequelae in the presence of a normal gallbladder. Endoscopic removal of common bile duct stones as a preoperative procedure is not routinely indicated. It is not clear whether it is beneficial for elderly high-risk patients. However, endoscopic retrograde sphincterotomy appears to be a valuable treatment for cholangitis and gallstone pancreatitis with or without intact gallbladder. When common bile duct stones are removed leaving cholelithiasis, patients develop symptoms at about the same rate as patients with asymptomatic cholelithiasis.

A 50-year-old man underwent routine cholescintigraphy with Tc-99m choletec for chronic abdominal pain. The cholescintigrams showed a large photopenic defect within the gallbladder suggesting an intraluminal mass. Sonography of the gallbladder revealed a normal gallbladder, and no intraluminal masses, gallstones, or sludge. These findings can be explained by nonuniform mixing of old and new bile.

Whole body iodine-131 scan is a well-established imaging method for the detection of metastatic or residual tumor sites in patients with well-differentiated thyroid cancer. Many false-positive iodine-131 scan findings mimicking metastatic thyroid cancer have long been reported. The authors describe a false positive uptake in normal gallbladder on post-ablative iodine-131 scan in a patient with papillary thyroid cancer. This finding should be considered to be another possible false-positive finding on iodine-131 whole body scan.

Gastric and gallbladder emptying in 113 patients with functional dyspepsia (FD) were evaluated by real-time ultrasonography (RUS) after a liquid-fat meal by the patients, and compared with 15 healthy volunteers. The results showed that in FD group 69 patients (61.06%) had delayed gastric emptying, and 28 patients (24. 77%) had gallbladder hypokinesia. Among them both delayed gastric emptying and gallbladder hypokinesia were found in 11 patients (9. 7%), 44 patients (38. 93%) had normal gastric emptying and 85 patients (75. 22%) had normal gallbladder emptying.

Though innumerable congenital anomalies related with gallbladder and biliary tree have been described but yet a surgeon may be taken by surprise due to presentation of a congenital anomaly during cholecystectomy totally unreported in textbook or biomedical literature. Here we report such one case of congenital anomaly, where a gallbladder look alike structure was found along with the normal gallbladder.

Laparascopic cholecystectomy is the current standard of care for acute cholecystitis. Biliary leak resulting from common or hepatic bile duct injuries is a well-know complication. The authors report an atypical appearance of a biliary leak into the gallbladder fossa, simulating the normal anatomy and physiology of the gallbladder, which in the absence of clinical history was initially interpreted as normal by a nuclear medicine physician. This case emphasizes the importance of obtaining accurate clinical history prior to interpreting scintigraphic studies.

A 16-year-old, 41 kg boy with chronic granulomatous disease presented with fever, chills, and diaphoresis. CT showed necrotising mediastinal lymphadenitis and a contracted but otherwise normal gallbladder (figure 1A). The patient was started on intravenous antibiotics and clinically improved. Culture of the lymphadenitis obtained by CT-guided aspiration grew Granulibacter bethesdensis. …

Organic phenolphthalein compounds had previously been injected intravenously into rabbits and dogs and observed to be concentrated into bile fluid. Graham and Cole identified a compound (the calcium salt of tetrabromphenolphthalein) that when given intravenously to patients resulted in “definite and cleanly cut shadows of the gallbladder” in radiographs of the abdomen obtained a few hours later.Their preliminary results suggested that a normal gallbladder is usually visualized, while a pathologic gallbladder is more difficult to observe, and predicted an important diagnostic role for this new roentgenologic examination.See PDF for full text of the original JAMA article.

Introduction and aim: Endoscopic ultrasonography (EUS) plays a major role in diagnosis of the gallbladder lesions. The normal gallbladder wall has been demonstrated to consist of 3 layers on EUS images. It is generally accepted that the 2nd and the 3rd layers include the muscularis propria and subserosal fibrous tissue, and the subserosal adipose tissue, respectively. However these 3 layers cannot be seen in some normal gallbladder by EUS images. Therefore this study was aimed to clarify the cause of these 2 different EUS images seen normal gallbladder by histological study of the gallbladder wall performed simultaneously. Materials and methods: Gallbladder specimens from 12 autopsy cases without biliary tract disorders, 6 with the three EUS layers (goup A) and 6 with one uniform layer (group B), were enrolled in this study. Two needles were stabbed into the gallbladder wall from the mucosa to perform EUS and histological study for the same area of the specimen. For this study an Olympus GFUMQ 240 with a frequency of 7.5MHz was used. Results: Histology of the specimens were summarized in the table. The thickness of the muscularis propria and fibrous layer showed no significant differences between group A and B. While the thickness of the adipose layer of group B was determined to be one half of group A. Conclusions: This study indicates that the one uniform layer seen in normal gallbladder on EUS images reflects a thin subserosal adipose layer.

Visualization of the gallbladder wall during intravenous infusion of diatrizoate has been equated with cholecystopathy. However, a large control group of patients without biliary tract symptoms has not been studied. The authors examined a group of 2,867 such patients who underwent excretory urography; the results suggest that visualization of the normal gallbladder wall occurs frequently enough to severely limit the usefulness of infusion tomography of the gallbladder in the diagnosis of cholecystopathy.

The immediate pattern of nuclear labeling with tritiated thymidine has been investigated in the guinea pig, in both the normal gallbladder and in the gallbladder 24 hr after common duct ligation. In the normal gallbladder, nuclear labeling was sparse and without detectable relation to any anatomic feature. In the cystic duct, the surface epithelium, the ductules, and the gland acini all showed occasional early labeling. After common duct ligation, label was avidly and uniformly incorporated in cell nuclei in all structures, except the glands of the gallbladder itself. It is concluded that there are no proliferative compartments in the gallbladder of the guinea pig.

Nonvisualization of the gallbladder is the primary finding in cholescintigraphy for acute cholecystitis. Recent investigators have described a useful secondary finding of increased pericholecystic hepatic activity (PCHA). A case of acute cholecystitis is presented in which the PCHA was round in configuration and appeared in the first 5 minutes of the study. This may be a source of diagnostic error if it is interpreted as visualization of the normal gallbladder. Appearance of the PCHA has not been previously described before 30 minutes. This case of early appearance raises the possibility that hyperemia may play a role as the cause in some forms of the PCHA. The phantom gallbladder was correctly identified as PCHA by observing the peak of activity of the PCHA occurring before the appearance of intrahepatic biliary radicals.

In vivo and in vitro studies indicate that the rate of absorption of Telepaque from the intestine is dependent on the pH of the gastrointestinal contents. An increase in intestinal pH in animal experiments accelerates the rate of absorption of Telepaque.Consideration of solubility properties leads to the hypothesis that the rate of absorption is limited by the rate of solution of Telepaque.Impaired radiographic visualization of the normal gallbladder may result from poor intestinal absorption of Telepaque due to low pH in the gastrointestinal tract.

SummaryImmunodiffusion of bile against specific antisera revealed 17 serum proteins in 10 normal gallbladder bile samples. Seven were common to all 10 samples. Five others were present in at least 50% of the biles. Analytical disc electrophoresis gave a mean of 12 bands staining with amido-schwarz with a range of 8-20. Because of the variability of bile patterns no uniform DEP pattern for normal gallbladder bile could be established, although relative relationships of major bands usually were recognizable. By use of DEP-immunodiffusion it was possible to identify and locate 12 specific serum proteins in the polyacrylamide electrophoretic patterns of bile.

1. The unusual association of a few grossly minute gallstones, not detected by usual radiographic technics, with recurrent acute pancreatitis is recorded for 6 patients.

Ten normal persons underwent a study to compare the effects of a fat-free diet and a conventional pre-examination diet on the visualization of the normal gallbladder. Iopanoic acid was the contrast medium employed. The results support the concept that cholecysto-cholestasis is a cause of cholecystographic error.

Although we may not be fully aware that each discovery in science is dependent upon another of equal importance, we realize this fact when we undertake a study of the development of any significant idea. Since this is true, we often wonder why the author of one discovery does not capitalize on it and proceed with the development of the other which appears to follow so obviously. It is amazing how seldom this progression is made by one man or group of men. The concept of cholecystography was developed by Evarts Graham and was based upon two previous discoveries. One of these was the demonstration by Abel and Rowntree (1), in 1910 that phenoltetrachlorphthalein was excreted almost entirely in the bile. The other was the demonstration by Rous and McMaster (2), in 1921, that the normal gallbladder was able to concentrate bile eight to ten times by absorbing water (Fig. 1). Abel and Rowntree were searching for a cathartic which could be given by hypodermic injection, hoping also for one which had a prolonged a...

Following visualization of the gallbladder, we have routinely examined the patient at fifteen and thirty minutes after the ingestion of a fat meal2 in order to study the contraction phase and, if possible, to demonstrate the cystic and the common ducts. This method is considered by Sussman (11) of greater importance than the mere determination of the gallbladder emptying time, since “a demonstration of a normal cystic and common duct provides a valuable confirmation of a normal function of the gallbladder and the sphincter of Oddi.” Definite visualization of the hepatic ducts has also been accomplished by this method and has been interpreted as an indication of biliary dyskinesia (1, 3). The small size of the gallbladder, after partial emptying has occurred, often helps to bring into prominence small stones whose shadows might otherwise be obscured. With the use of tetraiodophthalein, contractions of the gallbladder after the fat meal occurred promptly and vigorously, so that in over half of the normal ca...

A bacteriologic analysis of the gallbladder bile in eighty patients who underwent operation was performed in a prospective study. In all twenty patients with a normal gallbladder as assessed by oral cholecystography and intraoperative palpation, cultured were negative. Among patients with chronic cholecystitis only 30 per cent had positive bile cultures and this rose to 47 per cent among patients with acute cholecystitis.

Hepatobiliary imaging has been used to demonstrate that defects in the region of the gallbladder fossa in sulfur colloid studies correspond to normal gallbladder and not tumor. We report a case of delayed filling of a portion of the gallbladder due to a Phrygian cap anomaly. The case demonstrates that without delayed images incomplete filling of the gallbladder can be confused with a mass lesion in the liver.

We reviewed a series of 25 patients whose cholecystosonograms showed ultrasonic nonvisualization of the gallbladder, high-amplitude echoes in the region of the gallbladder bed, and strong acoustical shadowing. These 3 findings have previously been thought to be a reliable indication of a small contracted gallbladder filled with stones. In our series, all 25 such patients did not have gallstones, but the size and number of the calculi were highly variable. Only a small minority of our patients had a contracted gallbladder in most, the volume of the gallbladder was either normal or greater than normal. Ultrasonic nonvisualization of the gallbladder accompanied by acoustical shadowing was not a reliable indicator of gallbladder wall thickness in our series. Of 25 patients, 20 had either a normal gallbladder wall or only slight thickening. When we reviewed our images to determine how many fit the "WES" criteria thought to be a specific manifestation of a contracted gallbladder filled with stones, we found that 14 of 25 individuals clearly showed this group of ultrasonic findings. We could not, however, correlate the presence or absence of the 'WES' triad with the number and size of stones, the gallbladder volume, or thickness of the gallbladder wall.

1. 1. A case is presented of traumatic rupture of an otherwise normal gallbladder in a young boy. 2. 2. The etiology, diagnosis and treatment are discussed.

This prospective study of 139 patients was performed for evaluation of the normal and abnormal distal cystic duct and cystic duct remnant after cholecystectomy. The normal distal cystic duct could be demonstrated in 51% of the patients with normal common bile duct and normal gallbladder. The average diameter of the normal distal cystic duct was 1.8 mm. In 95% of the patients, the distal cystic duct was located posterior to the common bile duct and, in 5% of the patients, anterior to the common duct. Echoes produced by cystic duct insertion into the common bile duct occasionally can be mistaken for stones in the common bile duct. These echoes, however, are not associated with acoustic shadowing. Sludge and stones could be demonstrated in the distal cystic duct as well as in the cystic duct remnant after cholecystectomy.

There is a little doubt that the spontaneous passage of gallstones occurs sometimes without pain or jaundice. This is probably more frequent than is realised. While the cholecystogram is a reliable investigation and of great assistance to the clinician, occasionally a normal gallbladder will be demonstrated, when it has previously been the resting place of small gallstones. Four cases are described in which patients suffering clinically from cholelithiasis are shown to have a normal cholecystogram, but on repeat examinations gallstones are demonstrated in each case over intervals of one or two years. It is suggested that gallstones had been present in all these cases at the time of the initial symptoms, but could well have passed prior to the first examination.

The echographic appearance of the wall of normal well-filled and contracted gallbladders was studied prospectively in 25 persons. Using gray-scale equipment, the wall of the filled gallbladder appeared as a single reflecting structure, whereas during contraction, three different components could be distinguished. The exact recognition of this particular pattern is important in the differential diagnosis of real wall thickening and incomplete contraction.

Various factors extrinsic to the biliary system are known to interfere with the contrast opacification of a normal gallbladder. Some of these factors are rather infrequent, but as a group, they become significant. Unless ruled out, they may lead to the erroneous diagnosis of nonopacification because of a diseased condition, when the gallbladder is inreality normal.

Two hundred and twenty-seven patients were examined by oral cholecystography and ultrasound to compare the 2 methods and to decide which should be the first examination. Inadequate opacification at oral cholecystography occurred in 27% of patients at first examination and in 18% of this group on a repeat examination. Ultrasound, however, provided a diagnosis in all cases on first examination and we feel that where facilities allow ultrasound be the first examination in gallbladder disease.

The fundus of a normal gallbladder is rounded. Any deviation from this configuration should prompt a search for the nonfilled segment of a septate gallbladder. Three illustrative cases are presented in which the initial observation of a flat fundus led to further evaluation and visualization of the remaining portion of a septate gallbladder.

When faced with a patient with possible acute cholecystitis, technetium-99m-HIDA scintigraphy should be the primary diagnostic procedure performed. If scintigraphy reveals a normal gallbladder, acute cholecystitis is excluded. If the scintigram fails to visualize the gallbladder, ultrasonography is deemed advisable to exclude potential false-positive scintigrams and confirm the presence of cholelithiasis.

Sir .—We read with interest the clinical memorandum "Normal Gallbladder Appearing as Abdominal Mass in Neonates" by Liechty et al (Journal1982; 136:468-469), and we commend the authors on their clinical observations. However, we disagree with their conclusions concerning the pathogenesis of this problem. Virtually, all significantly ill neonates treated in tertiary centers have feedings withheld for hours to days. Therefore, if a lack of enteral feedings was the only or most significant factor in causing gallbladder distention, one would expect a more frequent occurrence of this relatively rare finding. Including the three cases reported by Liechty et al, there have been ten cases of transient neonatal gallbladder distention reported in the last two years. 1-3 Five of these cases were associated with group B streptococcal sepsis. 1,3 Three other cases had strong historical and clinical data suggestive of infection, 1,3 and the remaining two cases reported by Liechty et

A retrospective review of 5,000 patients studied over a period of three years showed that a second dose was necessary in 25% of gallbladder examinations; however, third and fourth doses gave no additional information. Nonopacification of the gallbladder after a second examination is diagnostic of disease when all extrinsic factors have been ruled out. Intravenous cholangiography may show calculi in a diseased gallbladder that was not opacified on the oral study, since it does not depend on the concentrating ability of the gallbladder for opacification; however, a radiographically normal gallbladder on intravenous cholangiography does not rule out nonobstructive cholecystitis or cholelithiasis.

To make the radiological diagnosis of cholecystosis, an understanding of the normal macroscopic and microscopic anatomy and some functional aspects is important.

Normal gallbladder scintigraphy occurs in 2 to 5% of reported patients with acute cholecystitis. Gallbladder visualization is found in patients with acalculous cholecystitis and in those with recent relief of cystic duct obstruction but persistence of inflammation. A patient is reported who had clinical and pathologic findings of acute cholecystitis but normal gallbladder visualization. This reemphasizes that the diagnosis of acute cholecystitis cannot be excluded by normal gallbladder scintigraphy.

The combination of a normal oral cholecystogram and ultrasound study of the gallbladder is considered adequate evidence to exclude cholelithiasis as a cause of biliarylike pain. We examined 206 patients with biliarylike pain and normal findings on cholecystogram and ultrasound study of the gallbladder by endoscopic retrograde cholangiopancreatography (ERCP). Of the 195 patients who had successful ERCP, 32 patients (group 1) had mild, transient abnormalities in liver function tests and 163 (group 2) had normal liver function test results. Small gallstones were demonstrated on ERCP examination in 25 of 32 group 1 patients and in four of 163 group 2 patients, all confirmed at surgery or endoscopic sphincterotomy. In conclusion, despite negative results on cholecystogram and ultrasound study of the gallbladder, patients with biliarylike pain and abnormal liver function test results should be evaluated further by diagnostic ERCP examination. ( JAMA 1983;249:758-761)

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