The size of the normal common hepatic duct following cholecystectomy: an ultrasonographic study

CT evaluation of common duct dilation after cholecystectomy and with advancing age

PURPOSE

To evaluate common duct (CD) dilation by computed tomography (CT) in patients with intact gallbladders and diameter change over time in remote and interval cholecystectomy patients, frequency of visualization of the CD, and its relationship to age.

METHODS

This IRB-approved retrospective study evaluated baseline CD diameter, intrahepatic biliary dilation, and interval duct diameter change in patients with CTs ≥ 2 years apart (n = 324), in block-randomized order by two blinded board-certified radiologists. 272 patients were divided into three groups: (1) prior cholecystectomy before the first CT, (2) cholecystectomy between the first and last CTs, and (3) no cholecystectomy. A subset of 191 nonoperated patients was evaluated for age-related dilation.

RESULTS

Group 1 ducts were significantly larger than the other groups at both baseline and follow-up CTs (p < 0.001). Group 2 showed a greater increase in duct size than the other groups at follow-up (p < 0.001). The CD was measurable in 89% of the CT studies. In nonoperated patients, there was a statistically significant correlation between CD size and increasing age (p < 0.001), although the CD size remained within normal size limits.

CONCLUSION

Remote cholecystectomy patients have larger CD diameters than the nonoperated and interval cholecystectomy groups. Greater increase in ductal diameter occurred between studies in the interval cholecystectomy patients, suggesting that dilation occurs after cholecystectomy. Also, the CD dilates slightly with age in nonoperated patients.

Ultrasound measurements of the bile ducts and gallbladder: normal ranges and effects of age, sex, cholecystectomy, and pathologic states

OBJECTIVE

The objectives of this study were to determine the normal values and ranges for bile duct and gallbladder measurements, adjusted for demographic data, and to assess the effects of a variety of pathologic states on these values.

METHODS

Four thousand one hundred nineteen abdominal ultrasounds were retrospectively analyzed. The values for the extrahepatic bile duct (EHD), left (LIHD) and right (RIHD) intrahepatic ducts, gallbladder wall thickness, and gallbladder volume in "normal" patients were evaluated with respect to age, sex, ethnicity, and cholecystectomy status. These values were compared using multivariate analysis to those in a variety of diseased states, including cirrhosis, fatty liver, gallstones, sludge, cholecystitis, and biliary obstruction.

RESULTS

One thousand four hundred eighty-four of the 4119 examinations were classified as normal. The mean EHD, RIHD, LIHD, and gallbladder wall thickness and volume measurements in normal patients were 3.8 ± 1.6 mm, 1.9 ± 1.9 mm, 1.9 ± 1.1 mm, 2.6 ± 1.6 mm, and 242 ± 234 mL, respectively.There were small increases in EHD diameter with age (+0.02 ± 0.11 mm/y, P < 0.001), female sex (+0.3 ± 1.6 mm, P < 0.0001), and cholecystectomy (+1.0 ± 1.6 mm, P < 0.0001) and a small decrease with fatty liver (-0.4 ± 1.6 mm, P = 0.0003). The gallbladder wall was thicker in patients with gallstones (+0.4 ± 1.4 mm, P = 0.0049), sludge (+0.5 ± 1.4 mm, P = 0.0019), and acute cholecystitis (+3.1 ± 1.6 mm, P < 0.0001). With biliary obstruction, the mean EHD, RIHD, LIHD, and gallbladder volume measurements were 6.0 ± 2.1 mm, 4.2 ± 1.4 mm, 4.1 ± 1.4 mm, and 171 ± 207 mL, respectively (P < 0.0001 for all values).

CONCLUSIONS

This study clarifies normal values and ranges for bile duct and gallbladder measurements, adjusted for demographic data, and evaluates these measurements in a variety of common pathologic states.

The common duct dilates after cholecystectomy and with advancing age: reality or myth?

OBJECTIVES

To evaluate changes in the common duct diameter on sonography over time in patients with and without cholecystectomy.

METHODS

We retrospectively evaluated the common duct diameter, central biliary dilatation, and interval change in 1079 patients who underwent sonography at least 2 years apart over a 6-year period. A board-certified radiologist, blinded to clinical and laboratory data, measured the duct diameter. A total of 893 patients (568 female and 325 male) were divided into 3 groups: group 1, remote cholecystectomy before sonography (mean, 9.7 years before sonography; n = 117); group 2, interval cholecystectomy between the first and second sonographic examinations (n = 56); and group 3, no cholecystectomy (n = 720). All groups were stratified by age, and group 3 was also stratified by the absence (n = 528) or presence (n=192) of gallstones.

RESULTS

Duct diameters at baseline and follow-up averaged 4.5 and 5.2, 3.6 and 4.9, and 3.5 and 3.9 mm in groups 1, 2, and 3, respectively. Group 1 ducts were larger at baseline than in the other groups (P < .001). At follow-up, group 2 ducts showed a greater interval diameter increase than the other groups (P < .001). In a subanalysis of each group based on age, there was a mild increase in duct size with increasing age, although not clinically significant and within normal limits. In group 3 patients who never had gallstones, there was a significant small increase in duct size over decades (P < .001). The baseline duct sizes for patients with gallstones were not significantly different from those who never had gallstones (P = .15).

CONCLUSIONS

Patients with remote cholecystectomy have larger common duct diameters than those with no or interval cholecystectomy. Most asymptomatic patients with or without cholecystectomy have a normal common duct diameter.

Dilatation of the bile duct in patients after cholecystectomy: a retrospective study

PURPOSE

Retrospective assessment of impact of cholecystectomy, age, and sex on bile duct (BD) diameter.

MATERIALS AND METHODS

We retrospectively reviewed abdominal contrast-enhanced multidetector computed tomography and laboratory reports of 290 consecutive patients (119 men; mean age, 55.9 years) who presented without cholestasis to the emergency department of our institution between June 2009 and August 2010. BD diameters were measured in 3 locations, by 2 independent observers, twice, at 1-month intervals. Reproducibility and agreement were evaluated by intraclass correlation coefficients and Bland-Altman analyses. The effects of cholecystectomy, age, and sex on BD diameter were analysed with linear mixed models.

RESULTS

BD diameter inter-reader reproducibility and agreement were excellent at the level of the right hepatic artery (intraclass correlation coefficient, 0.94). Sixty-one patients (21.0%) had a history of cholecystectomy. Among them, the 95th percentile of BD diameters at hepatic artery level was 7.9 mm (<50 years) and 12.3 mm (≥50 years). Among those without cholecystectomy, BD diameter was 6.2 mm (<50 years) and 7.7 mm (≥50 years). Cholecystectomy was associated with significantly larger BD diameters in both age groups (P < .001). Older age was associated with larger BD diameters (P = .004). Sex had no impact on BD diameter (P = .842).

CONCLUSION

Patients after cholecystectomy may present with an enlarged BD unrelated to cholestasis. The BD diameter increases with age. Clinicians should rely on cholecystectomy status, age, and laboratory results to determine needs of further investigation.

Common bile duct dilatation after cholecystectomy: a one-year prospective study

PURPOSE

Bile duct dilatation after cholecystectomy continues to be a matter of controversy. We aimed determine the magnitude of common bile duct (CBD) dilatation after cholecystectomy followed up to 1 year.

METHODS

Sixty-four cases (age, 47.3 ± 11.7 years; men, 28; women, 36) enrolled in this study. They received laparoscopic cholecystectomy in Chungbuk National University Hospital for symptomatic cholelithiasis or gallbladder polyps with normal bile duct, less than 7 mm. The CBD diameter was measured by one radiologist using ultrasonography at the maximum point after full length evaluation of extrahepatic bile duct. Forty-five and thirty-one cases were followed at 6 months and 1 year, respectively.

RESULTS

The CBD was dilated slightly from 4.1 mm at baseline to 5.1 mm at 6 months and 6.1 mm at 12 months after cholecystectomy. The number of cases of CBD dilatation of more than 7 mm at 6 months and at 12 months after cholecystectomy were 11 (24.4%) and 9 (29.0%), respectively. Seven cases at 6 months and 5 cases at 12 months showed bile duct dilation of more than 3 mm compared to baseline. There were no cases having bile duct dilation of more than 10 mm.

CONCLUSION

Postcholecystectomy dilatation of the bile duct occured slightly in most cases. But some cases showed more than 3 mm dilatation over baseline. Asymptomatic bile duct dilatation of up to 10 mm can be considered as normal range in patients after cholecystectomy.

Diameters of the common bile duct in adults and postcholecystectomy patients: a study with 64-slice CT

This study aims to collect data by multidetector computed tomography (MDCT) on the diameter of the normal common bile duct (CBD) and the diameter of CBD after cholecystectomy. In this retrospective study, CBD measurements were performed on axial oblique images, perpendicular to the long axis of the distal CBD. The mean diameter of the normal CBD was measured in 604 patients without cholecystectomy. The patients were divided into 6 groups according to their age. Analysis of variance (ANOVA) was used to compare data obtained from the six age groups. The mean diameter of the CBD of 46 patients who had cholecystectomy was calculated. The results were compared with age matched control group by Student's t test. The largest diameter of CBD ranged from 1.8 to 11.8mm. The mean of the largest diameter of 604 subjects was 4.77 ± 1.81. The diameter of the CBD significantly increased with age. Mean largest CBD diameters of postcholecystectomy subjects (7.28 ± 2.37) were significantly greater than age matched control group. In conclusion the diameter of CBD shows a considerable increase with age. The largest diameter of the CBD is up to 6mm in most of the subjects. An upper limit of 8mm appears reasonable after the age of 50; and an upper limit of 10mm seems appropriate for cholescystectomized subjects.

What should be done with a dilated bile duct?

Current methods for imaging the biliary tree include ultrasound, CT, MRI, endoscopic retrograde cholangiography, and endoscopic ultrasound (EUS). Bile duct abnormalities may be identified during evaluation of patient symptoms or laboratory abnormalities, or incidentally during imaging for another problem. Biliary dilatation, when identified, may be separated into obstructive or nonobstructive causes. Clinical presentation should guide decisions on which, if any, additional investigations are necessary. Choledocholithiasis is the most common cause of obstructive dilatation and frequently requires decompression. Nonobstructive causes include cystic dilatation, aging, and possibly post-cholecystectomy state. Data are limited regarding the yield of further investigations in patients with incidentally identified modest ductal dilatation without symptoms or laboratory abnormalities. Additional investigations are more likely to identify clinically relevant findings in patients with more pronounced dilatation. EUS is highly accurate, low-invasive, and useful in this setting, whereas ERC should be reserved for cases likely to require therapeutic intervention.

Ultrasound of the extrahepatic bile duct: issues of size

Ultrasound is a pivotal study for evaluation of the biliary tree. In particular, the size of the extrahepatic bile duct is a critical measurement and has been a contentious issue since the early days of diagnostic ultrasound. This article reviews the history and ongoing issues regarding sonography of the normal-size duct and a variety of factors that may affect its size, including age, prior surgery, congenital abnormalities, anatomical variations, and medications. Other related sonographic issues are discussed including abnormal nondilated ducts and abnormal intraluminal contents such as sludge or air that make evaluation of the duct more difficult, particularly in patients with primary sclerosing cholangitis and prior liver transplantation. Ultimately, the luminal size of the extrahepatic duct should be considered as a single part of the entire assessment of the biliary tree that must also include the intrahepatic and pancreatic ducts, the pattern of dilatation (variable vs progressively dilated to a single point of obstruction), any wall thickening, intraluminal sludge, calculi or mass, and extraluminal compression. Clinical symptoms and abnormal laboratory values should prompt further evaluation despite a normal appearance of the bile duct, whereas pursuit of an isolated finding of an enlarged duct without supporting clinical data may not be warranted.

Does cholecystectomy status influence the common bile duct diameter? A matched-pair analysis

The common bile duct (CBD) diameter is one factor that clinicians use when deciding on invasive evaluation for intra-ductal pathology, e.g., endoscopic retrograde cholangiopancreatography. Previous studies and gastrointestinal and radiological textbook authors report disparate interpretations. These inconsistent interpretations likely result from methodological limitations in prior studies. The purpose of this work is to primarily compare the CBD diameter among patients with and without prior cholecystectomy and secondarily to compare proximal and distal CBD measurements. Among 40 matched pairs, post-cholecystectomy patients had larger mean CBD diameters at proximal (7.0 vs. 5.4 mm; P < 0.001) and distal (5.9 vs. 4.6 mm; P < 0.001) sites. Post-cholecystectomy patients were also more likely to exceed the 6-mm cut point for proximal (80 vs. 28%; P < 0.001) or distal (58 vs. 20%; P = 0.003) measurements. Incidental radiographic detection of enlarged CBDs among post-cholecystectomy patients is common; therefore, clinicians should use clinical determinants to guide decisions about additional costly or potentially harmful evaluation for intraductal pathology.

The investigation of unexplained biliary dilatation

The investigation of biliary dilatation forms a routine part of gastroenterology practice. In developed countries, biliary dilatation is usually the result of obstruction of bile flow by either stones or mitotic lesions of the pancreas or biliary tree, and standard radiologic and endoscopic techniques are used to identify and relieve the obstruction. In the absence of an obvious cause, however, the investigation and management of biliary dilatation can prove challenging, particularly while trying to minimize invasive studies. This review examines factors thought to influence bile duct size in the absence of obvious obstructing pathology and looks at some causes of biliary dilatation that are unusual and potentially difficult to diagnose.

The non-dissociative clunking wrist: a personal view

Clunking of the wrist is often the result of a combined radiocarpal and midcarpal ligament insufficiency, coupled with inadequate neuromuscular coordination. When symptomatic, these wrists may benefit from splinting, isometric exercising of specific muscles and advice on activity modification. Failing this, different surgical strategies have been proposed, depending on the location of dysfunction. When the clunking derives from an isolated injury of one joint, reconstruction of its inadequate ligaments may be an effective solution. However, soft tissue procedures tend to fail when clunking results from multilevel instability. In these cases, partial carpal arthrodesis is an alternative. Although effective in eliminating the clunking, midcarpal fusion is associated with alteration of the so-called "dart-throwing" motion, the most common rotation in daily activities, and hence is not recommended. Radiolunate fusion, by contrast, appears to be a less morbid alternative, with the benefit of eliminating the painful clunking while preserving a good range of dart-throwing motion.

The role of sonography in imaging of the biliary tract

Sonography is the recommended initial imaging test in the evaluation of patients presenting with right upper quadrant pain or jaundice. Dependent upon clinical circumstances, the differential diagnosis includes choledocholithiasis, biliary stricture, or tumor. Sonography is very sensitive in detection of mechanical biliary obstruction and stone disease, although less sensitive for detection of obstructing tumors, including pancreatic carcinoma and cholangiocarcinoma. In patients with sonographically documented cholelithiasis and choledocholithiasis, laparoscopic cholecystectomy with operative clearance of the biliary stone disease is usually performed. In patients with clinically suspected biliary stone disease, without initial sonographic documentation of choledocholithiasis, endoscopic ultrasound or magnetic resonance cholangiopancreatography is the next logical imaging step. Endoscopic ultrasound documentation of choledocholithiasis in a postcholecystectomy patient should lead to retrograde cholangiography, sphincterotomy, and clearance of the ductal calculi by endoscopic catheter techniques. In patients with clinical and sonographic findings suggestive of malignant biliary obstruction, a multipass contrast-enhanced computed tomography (CT) examination to detect and stage possible pancreatic carcinoma, cholangiocarcinoma, or periductal neoplasm is usually recommended. Assessment of tumor resectability and staging can be performed by CT or a combination of CT and endoscopic ultrasound, the latter often combined with fine needle aspiration biopsy of suspected periductal tumor. In patients whose CT scan suggests hepatic hilar or central intrahepatic biliary tumor, percutaneous cholangiography and transhepatic biliary stent placement is usually followed by brushing or fluoroscopically directed fine needle aspiration biopsy for tissue diagnosis. Sonography is the imaging procedure of choice for biliary tract intervention, including cholecystostomy, guidance for percutaneous transhepatic cholangiography, and drainage of peribiliary abscesses.

Nonoperative imaging techniques in suspected biliary tract obstruction

Evaluation of suspected biliary tract obstruction is a common clinical problem. Clinical data such as history, physical examination, and laboratory tests can accurately identify up to 90% of patients whose jaundice is caused by extrahepatic obstruction. However, complete assessment of extrahepatic obstruction often requires the use of various imaging modalities to confirm the presence, level, and cause of obstruction, and to aid in treatment plan. In the present summary, the literature on competing technologies including endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiopancreatography (PTC), endoscopic ultrasound (EUS), intraductal ultrasonography (IDUS), magnetic resonance cholangiopancreatography (MRCP), helical CT (hCT) and helical CT cholangiography (hCTC) with regards to diagnostic performance characteristics, technical success, safety, and cost-effectiveness is reviewed. Patients with obstructive jaundice secondary to choledocholithiasis or pancreaticobiliary malignancies are the primary focus of this review. Algorithms for the management of suspected obstructive jaundice are put forward based on current evidence. Published data suggest an increasing role for EUS and other noninvasive imaging techniques such as MRCP, and hCT following an initial transabdominal ultrasound in the assessment of patients with suspected biliary obstruction to select candidates for surgery or therapeutic ERCP. The management of patients with a suspected pancreaticobiliary condition ultimately is dependent on local expertise, availability, cost, and the multidisciplinary collaboration between radiologists, surgeons, and gastroenterologists.

Imaging the spectrum of biliary tract disease

An understanding of underlying biliary pathology and the corresponding subtle changes reflected at imaging can greatly improve imaging accuracy in evaluating the biliary tract. The optimal demonstration of biliary tract imaging findings requires attention to specific imaging and contrast techniques, regardless of the modality used.

Transabdominal sonography of bile ducts

Ultrasound is considered to be the initial imaging modality of choice for evaluation of bile ducts. In this article, sonographic anatomy of the bile ducts and ultrasound findings in congenital, inflammatory, neoplastic, and other abnormalities of bile ducts are described. Roles of color Doppler ultrasound and newer applications, such as harmonic imaging and three-dimensional ultrasound, in evaluation of bile ducts are discussed.

Noninvasive imaging approach to patients with suspected hepatobiliary disease

Technologic advances in ultrasound, computed tomography (CT), and magnetic resonance imaging over the past decade have greatly improved the noninvasive evaluation of the liver and biliary tree. Each imaging modality offers unique and valuable information that aids in the evaluation of the liver and biliary tree. Improved spatial resolution, harmonic imaging, and color and power Doppler have transformed hepatobiliary ultrasound such that it is often the initial examination for many patients. Helical CT permits the characterization of the hepatic parenchyma during multiple phases of contrast enhancement. New rapid magnetic resonance sequences allow images of the liver to be obtained without motion artifact. The multiplanar techniques of magnetic resonance cholangiography allow noninvasive visualization of the biliary and pancreatic ducts. This article reviews the noninvasive imaging approach to patients with suspected hepatobiliary disease.

Diagnosis and treatment of sphincter of Oddi dysfunction

BACKGROUND Sphincter of Oddi dysfunction is a challenge from both the diagnostic and therapeutic point of view. There is much ongoing debate about the accuracy and usefulness of various diagnostic tests, as there is about the effectiveness of proposed therapeutic alternatives.

METHODS

A comprehensive review of the past 15 years' literature was undertaken, using the Medline database and cross-referencing of major articles on the subject.

RESULTS AND CONCLUSION

Endoscopic and surgical treatments result in similar outcomes, with considerable failure rates. The latter reflect the difficulties in accurate diagnosis and a lack of sound objective criteria for selecting patients for intervention. In addition, in some patients sphincter of Oddi dysfunction may be only part of a generalized motility disorder of the gastrointestinal tract.

Ultrasound and cholangiography for the diagnosis of biliary complications after orthotopic liver transplantation: a comparative study

The ability of ultrasound to detect biliary obstruction, bile leakage and generalized ductal changes after orthotopic liver transplantation (OLT) was compared to cholangiography. Cholangiography was considered to be the gold standard. Adequate opacification of the biliary tree was achieved in 139 cholangiograms. Biliary obstruction, intermediate or large bile leakage, and generalized ductal changes were diagnosed with cholangiography in 15% (21/139), 14% (20/139), and 16% (22/139), respectively. Normal ultrasound findings could not exclude biliary stricture, generalized ductal changes, or bile leakage, and fluid collections were not correlated with bile leakage. Abnormal ultrasound findings were highly predictive of the cholangiographic diagnosis of biliary obstruction or generalized ductal changes (specificity of 98% and 100%, respectively). An irregular appearance of the bile ducts and increased periductal echogenicity proved to be characteristic features for generalized ductal changes.

Common bile duct caliber following cholecystectomy: a two-year sonographic survey

The aim of this study was to evaluate the size of the common bile duct (CBD) in patients with gallstones, before and after cholecystectomy. Ten female patients (22-61 years) were examined in whom gallstones were shown by ultrasound. The caliber of CBD was measured before cholecystectomy and then 6, 12, 18, and 24 months after cholecystectomy. No significant change of CBD caliber in each interval prior to or following cholecystectomy was observed.

Abdominal ultrasonography following laparoscopic cholecystectomy: a prospective study

Laparoscopic cholecystectomy has gained widespread acceptance as the operation of choice for symptomatic gall-stones. We prospectively performed ultrasonography on 100 consecutive patients after laparoscopic cholecystectomy to determine the effect of this procedure on common bile duct diameter. This study also examines the incidence and clinical significance of intra-abdominal fluid collections after laparoscopic cholecystectomy. Our results show that 24% of patients had dilatation of the common duct (greater than 6 mm) when scanned 48 h post-operatively. The incidence of dilated common ducts fell to 9% when the patients were scanned 1 month later. This transient dilatation of the common duct, occurring post-operatively, has not been previously described. Intra-abdominal fluid collections were demonstrated in 10% of our patients but were clinically significant in only 1%. This study suggests that routine ultrasonography has a low yield immediately after laparoscopic cholecystectomy.

Efficacy of nifedipine therapy in patients with sphincter of Oddi dysfunction: a prospective, double-blind, randomized, placebo-controlled, cross over trial

1. Twenty-eight patients who fulfilled entry criteria for sphincter of Oddi dysfunction were randomly allocated to receive nifedipine and placebo in a cross over design with 12 week treatment periods separated by a 2 week wash-out. 2. All patients had episodic pain resembling biliary pain, had previously undergone cholecystectomy, had elevated alkaline phosphatase during episodes of pain and had elevated basal pressure on sphincter of Oddi manometry. 3. Compared with placebo, significant decreases in cumulative pain score, number of pain episodes, oral analgesic tablets consumed and emergency room visits were observed during nifedipine treatment. 4. Overall 21 patients improved during nifedipine therapy while seven patients did not. None of the following predicted response to nifedipine therapy: enzyme levels, morphine-Prostigmine test, fatty meal sonography, common duct diameter and pressure, sphincter of Oddi phasic pressure, frequency and duration of phasic waves and maximal fall in the basal pressure at sphincter of Oddi manometry after sublingual administration of nifedipine. However patients with predominant antegrade propagation of phasic contractions of sphincter of Oddi did significantly better on nifedipine than those with abnormal propagation of phasic contractions. 5. Nifedipine therapy orally in maximal tolerated doses relieves pain in patients with sphincter of Oddi dysfunction who have elevated basal pressure and sphincter of Oddi phasic contractions of predominantly antegrade nature.

The thick common bile duct in pyogenic cholangitis

The paper describes thickening of the wall of the common bile duct in acute pyogenic cholangitis demonstrated by ultrasound. The abnormality appears as a hypoechoic stripe lying internal to the echogenic line of the normal common bile duct. The clinical features of acute cholangitis may be atypical and this new sign should be of value in these difficult cases.

Bile duct size after cholecystectomy: an endoscopic retrograde cholangiopancreatographic study

Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 43 patients before and 4-14 months after cholecystectomy. All patients had a normal common bile duct and were asymptomatic after the operation. Preoperative and postoperative films of adequate quality were available for scrutiny in 35 patients. The largest mean(s.d.) diameter of the common duct, after correcting for magnification, was 0.96(0.27) cm before cholecystectomy and 1.16(0.29) cm after surgery (P less than 0.0001). Thirty-one of the 35 patients showed increased duct size after cholecystectomy, and the difference was 1 mm or more in 26 patients. There was a positive correlation between the increase in bile duct size and the time interval after cholecystectomy. After cholecystectomy a small but significant increase in bile duct diameter is demonstrable on ERCP.

Changes in bile duct diameter after cholecystectomy: a 5-year prospective study

In this prospective study, we have measured with ultrasound the diameter of the common hepatic duct and the common bile duct in a series of 24 patients having elective cholecystectomy. Preoperative measurements by ultrasound were compared with measurements taken directly from operative cholangiograms and excellent correlation was observed (r = 0.938). Studies were repeated 1 mo, 12 mo, and 5 yr after operation. Of 21 patients returning for study at 5 yr, there were 4 patients with 1-mm ducts before surgery who showed an increase in the size of the common hepatic duct but in none was the final measurement greater than 4 mm. Mean common hepatic duct diameter (n = 21) increased from 3.95 mm before to 4.48 mm 5 yr after surgery (p = 0.24, paired t-test). Common bile duct was more easily seen after cholecystectomy and of 13 ducts satisfactorily measured 1 and 5 yr after surgery, 7 showed an increase in size (mean common hepatic duct 1 yr = 4.77 mm, 5 yr = 5.92 mm, p = 0.059, paired t-test). Significant dilatation of the common hepatic duct was seen in only 2 of 21 patients, but a strong trend to minor dilatation was observed in the common bile duct after cholecystectomy.

Unexpected dilatation of the common bile duct after methyl tertiary butyl ether (MTBE) in rabbits. Possible implications to findings in man

Methyl tertiary butyl ether (MTBE) rapidly dissolves cholesterol gall stones in vitro and in vivo. To further characterise tolerability and safety of this aliphatic ether, either MTBE (1 ml/kg body wt daily for two days) or an equal amount of saline was infused into the common bile duct (CBD) of eight cholecystectomised rabbits. Transient vomiting, dyspnoea and somnolence developed during MTBE instillation. Post-treatment values of serum transaminases and alkaline phosphatase were significantly higher in MTBE than in saline treated animals. Cholangiography one week after the last intraductal infusion showed a five-fold increase of CBD size in MTBE v control rabbits. At autopsy histological signs of chemical cholangitis and mild duodenitis were noted in MTBE treated animals. Prompted by these findings, we performed a cholangiography in two patients who had received intraductal MTBE (about 0.2 ml/kg body wt daily for one or two days) one year before: an abnormal dilatation of the CBD was present, which might represent a specific, hitherto undescribed permanent sequela of MTBE administration.

Sphincter of Oddi dysfunction: a clinical controversy

This report analyzes the literature on sphincter of Oddi dysfunction as it applies to biliary-type pain. The sensitivities and specificities of the tests used to diagnose this condition (e.g., size of bile duct, drainage time of bile duct, provocative tests with morphine, sphincter of Oddi manometry) are poorly defined. Recent studies suggest that noninvasive tests such as quantitative nuclear scintigraphy and fatty meal sonography may aid in diagnosing functional common bile duct obstruction. Continuous manometry of the biliary tree with microtransducer technologies may allow a greater understanding of the causes of pain in this group of patients. Only 1 case report of pharmacologic management for this disorder exists in the literature. Endoscopic sphincterotomy may be helpful in relieving the pain that occurs in this condition but is associated with increased risks. There is no consensus in the literature as to the best test that will predict response to sphincterotomy. Controlled trials of medical therapies are needed.

Prospective study of clinical and biochemical features of symptomatic choledocholithiasis

One hundred consecutive patients were prospectively studied to assess the clinical and biochemical features of symptomatic choledocholithiasis. Biochemical tests were performed during the three days following the onset of symptoms. Pain was the most frequent symptom of choledocholithiasis, observed in 75% of the patients, but rarely occurred alone (12%). Clinical symptoms were not different according to age. High serum gamma glutamyl transpeptidase and alkaline phosphatase were the most frequent biochemical abnormalities in patients with symptomatic choledocholithiasis: they were increased in 94 and 91% of cases, respectively. Only one patient had no biochemical abnormality. Serum transaminases could reach very high levels just as in hepatitis. Biochemical data did not differ regardless of whether the common bile duct was enlarged or not. Biochemical abnormalities had been studied over the first 10 days of spontaneous evolution in 25 patients while choledocholithiasis persisted: serum bilirubin and transaminases significantly decreased while serum gamma glutamyl transpeptidase, alkaline phosphatase, and amylase remained unchanged. These results indicate that, in patients with suggestive symptoms, choledocholithiasis is unlikely in the absence of biochemical abnormalities in the first three days following the onset of symptoms.

Ultrasound detection of choledocholithiasis: prospective comparison with ERCP in the postcholecystectomy patient

The role of ultrasound as a screening test for choledocholithiasis was prospectively assessed by comparing the results of upper abdominal ultrasound with direct cholangiography in 59 unselected symptomatic postcholecystectomy patients. Ultrasound detected duct stones in 13 of 29 patients (sensitivity, 45%) and their absence in 29 of 30 (specificity, 97%). A positive ultrasound diagnosis of choledocholithiasis was correct 13 times out of 14 (predictive value, 93%) whereas a negative diagnosis was correct on only 29 of 45 occasions (predictive value, 64%). No significant learning effect was seen. Intestinal gas obscuring the distal common duct was the most important factor limiting the ability of ultrasound to detect duct stones. Duct stones were present in 25 of 35 patients shown to have a dilated common duct on ultrasound, and in 4 of 24 with nondilated ducts; the predictive value of duct dilatation at ultrasound for duct stones was therefore 71% and that of nondilatation in excluding stones was 83%. Dilated intrahepatic bile ducts were demonstrated at ultrasound in only 17% of patients with choledocholithiasis. We conclude that ultrasound cannot reliably diagnose or exclude bile duct stones and is an inadequate screening test for the symptomatic postcholecystectomy patient.

Ultrasound in the diagnosis of jaundice--a review

A retrospective study of 92 jaundiced patients undergoing ultrasound examination was undertaken to assess the clinical utility of this test. The patients were graded according to the likelihood of biliary obstruction. In those in whom biliary obstruction was proven to be present, the sensitivity of ultrasound to detect the obstruction was 91% and the test specificity was 100%. In patients who had undergone cholecystectomy no increase in the diameter of the common duct was observed. Liver function tests proved to be unreliable in discriminating between extrahepatic obstructive jaundice and other forms of jaundice. Ultrasound scanning is a useful screening test in the diagnosis of the jaundiced patient. However, follow-up is suggested for those with a negative result of this test but in whom biliary obstruction is suspected. An approach to the investigation of the jaundiced patient should include early ultrasound examination in those with possible biliary obstruction.

Endoscopic retrograde cholangiograms of the normal and post-cholecystectomy biliary tree

The diameter of extrahepatic and intrahepatic bile ducts was measured on 50 normal retrograde cholangiograms and on the cholangiograms of 109 post-cholecystectomy patients undergoing endoscopic retrograde cholangiopancreatography: 70 of the post-cholecystectomy patients had a normal cholangiogram and 39 had retained stone or biliary stricture, of whom 17 were jaundiced. Biliary diameter at all points measured was greater in the post-cholecystectomy patients with no biliary lesion than in normals, and further increased in the presence of pathology (e.g. retained stone). The extent of overlap in biliary diameter between all these three groups is so great that measurement of bile duct calibre cannot separate patients with retained stone from post-cholecystectomy patients without retained stone, or from patients with an entirely normal biliary tree, even in the presence of obstructive jaundice. Methods of evaluating the biliary tract which rely on the measurement of bile duct diameter (e.g. ultrasound) are therefore of limited value in the investigation of post-cholecystectomy patients.

Evaluation of the postoperative patient with 99mTc-IDA cholescintigraphy

In order to assess the role of 99mTc-iminodiacetic acid (IDA) cholescintigraphy in evaluating postoperative patients, a total of 213 studies were performed in 189 patients over a 3-year time period. Of these, 130 studies were obtained in 125 cases with signs and/or symptoms suggesting postcholecystectomy syndrome. A normal sized duct that emptied within an hour ruled out significant pathology with a high degree of accuracy (97%). A less reliable finding of normalcy was the combination of ductal dilatation with functional patency in that three of 20 patients (15%) who exhibited this pattern were proven to have nonobstructing calculi in their common bile duct. AZ spectrum of abnormal findings was encountered. Ductal dilatation was a most significant indicator of partial or intermittent ductal obstruction when it was associated with altered time-activity dynamics in the ducts and secondarily, delayed biliary-to-bowel transit time of the radiotracer. Patterns indicating complete common duct obstruction, cystic duct remnants, and bile leaks also proved to be very sensitive. Seventy-three studies in 56 patients very accurately evaluated the integrity of biliary-enteric bypass anastomosis. Complete and partial obstructive patterns were similar in appearance to those encountered in postcholecystectomy syndrome. Several leaks were also detected in this patient population. Ten studies were performed in eight patients who underwent Billroth II gastroenterostomies primarily to see if afferent loop obstruction was present. Three of these patients did demonstrate dilated A-loops with stasis, thereby making a positive diagnosis possible.