Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Three-dimensional drip infusion CT cholangiography in patients with suspected obstructive biliary disease: a retrospective analysis of feasibility and adverse reaction to contrast material.

Three-dimensional drip infusion CT cholangiography in patients with suspected obstructive biliary... Background: Computed Tomography Cholangiography (CTC) is a fast and widely available alternative technique to visualise hepatobiliary disease in patients with an inconclusive ultrasound when MRI cannot be performed. The method has previously been relatively unknown and sparsely used, due to concerns about adverse reactions and about image quality in patients with impaired hepatic function and thus reduced contrast excretion. In this retrospective study, the feasibility and the frequency of adverse reactions of CTC when using a drip infusion scheme based on bilirubin levels were evaluated. Methods: The medical records of patients who had undergone upper abdominal spiral CT with subsequent three-dimensional rendering of the biliary tract by means of CTC during seven years were retrospectively reviewed regarding serum bilirubin concentration, adverse reaction and presence of visible contrast media in the bile ducts at CT examination. In total, 153 consecutive examinations in 142 patients were reviewed. Results: Contrast media was observed in the bile ducts at 144 examinations. In 110 examinations, the infusion time had been recorded in the medical records. Among these, 42 examinations had an elevated bilirubin value (>19 umol/L). There were nine patients without contrast excretion; 3 of which had a normal bilirubin value and 6 had an elevated value (25–133 umol/L). Two of the 153 examinations were inconclusive. One subject (0.7%) experienced a minor adverse reaction – a pricking sensation in the face. No other adverse effects were noted. Conclusion: We conclude that drip infusion CTC with an infusion rate of the biliary contrast agent iotroxate governed by the serum bilirubin value is a feasible and safe alternative to MRC in patients with and without impaired biliary excretion. In this retrospective study the feasibility and the frequency of adverse reactions when using a drip infusion scheme based on bilirubin levels has been evaluated. Page 1 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 Table 1: The infusion rate of iotroxate (Biliscopin ) was governed Background by the bilirubin level prior to the investigation. The same total For diagnosis of hepatobiliary disease, ultrasound and MR amount of Iodine (5 g) was given to all patients. cholangiography (MRC) are most frequently used. Endo- scopic Retrograde Cholangiography (ERC) is often Serum bilirubin Infusion time regarded as the gold standard for visualising biliary dis- ease. The latter modality is invasive, user-dependent and <20 µmol/ml 40–60 min 21–40 µmol/ml 1–3 hours may induce pancreatitis. It should therefore not be per- 41–99 µmol/ml 3–4 hours formed in patients where intervention is less certain. >100 µmol/ml 5 hours Ultrasound, on the other hand, is easily tolerated by the patients and cost effective. The modality is, however, user- dependent and the captured images are not easily under- stood by clinicians. MRC is superior in visualising the bil- patients with suspected obstructive biliary disease with iary system, and the images are appreciated by the respect to both feasibility and rate of adverse reactions surgeons at surgical planning. It does not require any con- after administration of the biliary contrast agent (iotrox- trast agent to visualise the bile ducts, and dilatation and ate). gallstones in the common bile duct are easily detected [1- 3]. Unfortunately, MRC cannot be performed in all Methods patients and hospitals due to limited availability of MRI This is a retrospective study in 142 consecutive patients or due to contraindications. MRC is also often inconclu- (68 men and 74 women, mean age 69 years, range 24 – 95 sive in patients with air in the biliary system, e.g. after pap- years) referred for investigation of biliary disease during illotomy or liver surgery with entero-hepatic anastomoses the period from January 1996 to January 2003. After (such as Whipple's operation and Billroth 2). Surgical approval by the ethics committee for the region, the med- clips after cholecystectomy may also give artefacts mim- ical records of all patients were retrospectively reviewed icking a ductal cancer or a stone [4,5]. An alternative non- regarding bilirubin level, infusion time and adverse invasive method to ultrasound and MRC is therefore events. Adverse events were defined as any signs of reac- required. tion to contrast media that occurred after the injection, such as anaphylaxis, urticaria and respiratory distress. Computed Tomography Cholangiography (CTC) is a fast and widely available technique to visualise hepatobiliary Administration of contrast media disease. Without contrast administration, multi detector The serum bilirubin concentration was measured before CT CT has been reported to have a sensitivity of 65%–88% examination using standard clinical laboratory methods and a specificity of 84%–97% to detect gallstones [6,7]. used at the hospital. 100 ml of meglumine iotroxate (Bili- Techniques to improve the sensitivity and specificity by scopin , Schering AG, Berlin, Germany) 50 mg I/ml was administering biliary contrast media orally [8] or intrave- administered by intravenous drip infusion. In order to nously [9,10] have been developed, but are not wide- allow longer infusion times, the solution volume was spread. Possible explanations for infrequent use of CTC increased by dilution with isotonic sodium chloride (500 might be the low resolution of single detector helical CT ml). The infusion time was determined by the measured and reports of an unacceptable high number of adverse bilirubin level according to a schematic protocol (Table 1). Following the guidelines from the manufacturer, the drip events after injection of meglumine iotroxate [11]. With the development of multidetector CT, the resolution of infusion was started at a low infusion rate (0.5 ml/min) CTC exceeds that of MR. The number of adverse reactions and increased to the desired infusion rate during the fol- with biliary contrast media has probably diminished by lowing 3–5 minutes. The CT scan was started immediately infusing the contrast media instead of injecting. after the infusion was completed. For distension of the dis- tal duodenum, the patients ingested two glasses of drinking The aim of this retrospective study was to evaluate pro- water immediately before the CT examination. To evaluate longed drip infusion CT cholangiography (CTC) in Table 2: CT acquisition parameters Type of scanner Collimation Pitch Increment mAs kV Number of examinations Single Slice 1 × 5.0 mm 1.5 1 mm 200 120 103 Multi-slice 4 × 2.5 mm 6 1 mm 130 120 46 Multi-slice 16 × 0.75 mm varying 0.5 mm 130 120 4 Page 2 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 Table 3: The bilirubin value, infusion time and final diagnosis in the nine cases where no secretion of contrast media was observed at DIC-CT. Bilirubin value, µmol/L Infusion time, minutes Reported findings in medical records, final diagnosis Reported findings at DIC-CT 133 120 Hepatitis Type B wide bile duct 1,2 120 240 Pancreatitis inconclusive 7,2,6 79 180 Intraductal stone in choledochus and pancreatitis Intraductal stone 1,2 73 120 Cholecystitis wide bile duct 1,2,3,6, 30 unknown Concrememt in choledochus Intraductal stone 25 unknown Concrement in choledochus, Total occlusion and Klatskin Intraductal stone, tumour 5,7 tumour 4,5,7 inconclusive 16 60 Distal stenosis in choledochus and pancreatitis 2,3 12 60 Total occlusion in choledochus, pancreas tumour wide bile duct 8 60 Post operative cholangitis/cholecystitis with bile fistula and fluid-filled cavity 1,6,7 leakage The method by which the final diagnosis was made is indicated by the superscript numbers where 1 = laboratory findings, 2 = ultrasound, 3 = ultrasound with fine needle biopsy, 4 = MRCP, 5 = operation, 6 = ERCP and 7 = PTC. Statistical methods compliance to the protocol, the medical records were reviewed regarding the given infusion time at the ward. Data are given as mean (± standard deviation). Frequen- cies are given with their 95% confidence interval, com- Scanning parameters puted with normal approximation. Patients were scanned in the right oblique position by means of thin-section single-breath-hold helical CT in the Results cranio-caudal direction. Specific scan protocols varied Out of 153 examinations performed in 142 patients, one depending on the CT scanner available at the time of subject experienced a minor reaction (pricking sensation examination (Table 2). Between December 1995 and in the face) following the administration of 70 ml of con- November 1999, 102 patients were scanned with a single- trast. In this patient, the pre-exam bilirubin value was nor- slice CT scanner (Somatom A; Siemens Medical Systems, mal (11 µmol/L) and the planned infusion time was 60 Forcheim, Germany). From December 1999 to November minutes. Four weeks later, the same patient successfully 2002, a 4-slice multi-detector CT scanner (Somatom Vol- underwent a repeated CT cholangiography using the same ume Zoom; Siemens Medical Systems, Forcheim, Ger- infusion rate without any adverse reactions. In the other many) was used in 44 exams. Between December 2002 141 patients (151 examinations), no adverse reaction was and January 2003, a 16-slice multi-detector CT scanner noted in the medical records. Thus, the observed fre- (Somatom Sensation16; Siemens Medical Systems, quency of adverse reactions in this material was 1/153 Forcheim, Germany) was used in 6 exams. (0.65%). Of the 153 examinations, 10 were performed in out-patients. These patients normally stay in the radiology Evaluation of contrast media excretion department one hour after the contrast injection has been The attenuation in choledochus and liver was obtained completed. Due to the retrospective nature of this study, retrospectively by measurement in the restored digital late mild adverse advents may not have been recorded in images in all examinations with bilirubin >19 µmol/L (n these 10 patients. More severe adverse reactions such as a = 42), as well as in 67 individuals also described in skin rash, itches, etc. are, however, usually reported to the another study [12], 19 of the latter with bilirubin >19 hospital by the patients and according to the routines of µmol/L. In total, attenuation values from 90 (= 42 + 67 - the hospital, adverse reactions are always noted in the 19) patients were obtained. medical records after an X-ray examination. The hospital is the only one in the district and no notes could be found Review of literature about adverse advents in the patients' files (files from A MEDLINE search was performed for all clinical studies departments of radiology, surgery and internal medicine in English published during the period 1975–2004 con- were reviewed). cerning iotroxate, using the words "Biliscopin" or "iotrox- ate". All articles were reviewed for reports regarding The mean bilirubin value was 20 (± 25) µmol/L. 42 adverse events. The pooled frequency of adverse events patients had an elevated bilirubin value (defined as >19 was calculated for all articles with a number of patients µmol/L). Information regarding the infusion time used at >100 where the contrast had been infused for 30 minutes the ward had been noted in the medical records in 110 out or more. of 153 examinations. The mean infusion time was 82 (± Page 3 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 The Figure 1 infusion time of iotroxate (Biliscopin ) in relation to bilirubin level prior to the investigation The infusion time of iotroxate (Biliscopin ) in relation to bilirubin level prior to the investigation. The recommended infusion times were followed in 103 out of the 110 cases (94%) where information on infusion time was found in the medical records. Cases in which the recommendations were not followed are encircled (n = 7). Unfortunately, none of the three (3/110) exam- inations with a bilirubin value >100 µmol/ml was performed according to the infusion scheme. The patient with the highest bilirubin value (159 µmol/ml) had good diagnostic excretion of contrast in the bile ducts, whereas the other two had no excre- tion. A Figure 2 ttenuation in choledochus and liver at DIC-CT as a function of serum bilirubin before the examination Attenuation in choledochus and liver at DIC-CT as a function of serum bilirubin before the examination. 42) minutes. Disregarding potential measurement errors of Page 4 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 Table 4: Published studies on the frequency of adverse reactions at infusion of iotroxate at intravenous cholangiography. Included are all studies with at least 100 patients using an infusion time of at least 30 min. The severity of the reactions is graded as reported. The number in superscript denotes the corresponding reference. No. of Patients Total Minor Intermediate Severe Fatal Nilsson 1987 1 446 49 (3.4%) 41 (2.9%) 5 (0.35%) 3 (0.21%) 0 286 4 (1.4%) 4 (1.4%) 0 0 0 Daly 1987 Joyce 1991 100 2 (2.0%) 2 (2.0%) 0 0 0 Wigmore 1993 100 00000 Patel 1993 113 3 (2.7%) 3 (2.7%) 0 0 0 Grunshaw 1993 137 4 (2.9%) 3 (2.2%) 1 (0.7%) 0 0 A 36 A Sacharias 1995 1 061 11 (1.0%) 11 (1.0%) 0 0 Kwon 1998 440 2 (0.5%) 2 (0.5%) 0 0 0 Kitami 2006 220 3 (1.4%) 3 (1.5%) 0 0 0 Okada 2005 432 4 (0.9% 4 (0.9%) 0 0 0 Hirao 2000 120 2 (1.7%) 2 (1.7%) 0 0 0 B 38 Takamatsu 2004 132 1 (0.8%) 1 (0.8%) 0 0 0 Total 4587 85 65 17 3 0 Frequency (95% 1.9% (1.5%–2.2%) 1.4% (1.1%–1.8% 0.4% (0.2%–0.5%) 0.1% (0–0.1%) 0 confidence limits) No difference was made between minor and intermediate adverse events. The infusion time was 25–30 min. The number of complications in the article was reported by personal communication. at most 2 µmol/L, seven infusions (5%) had not been per- time of 30 minutes or more are listed in Table 4 as well as formed according to the protocol. Five of these received the the pooled number of adverse events (2.27%). infusion too fast and 2 too slow (Fig. 1). All three patients with a bilirubin >100 µmol/L were among the seven Discussion patients who did not receive the correct infusion rate. The When the bile ducts are obstructed, excretion of bile and intended infusion rate (5 hours) could therefore not be contrast media is decreased. It has therefore been assumed evaluated. that CT cholangiography cannot be performed in patients with elevated serum bilirubin concentration [9,10]. In this Excretion of contrast media was observed in 93% (143/ study, the infusion rate of the contrast media was adjusted to 153) of all exams (one examination aborted due to poten- the bilirubin value (Table 1). The aim was to keep the con- tial contrast reaction). In patients with elevated serum centration within the excretory capacity of the hepatocytes in bilirubin (>19 µmol/L) contrast media in the bile was order to optimise the concentration in bile. By using this observed in 36 out of 42 patients (86%). No visible secre- scheme, contrast excretion into the bile ducts was observed tion of contrast was reported in 9 patients (Table 3). In in 93% of all exams. In patients with elevated serum three of these, the infusion protocol had not been fol- bilirubin (>19 µmol/L), contrast media in the bile was lowed, with too fast infusion (bilirubin 73–133 µmol/L). observed in 86%. Excretion of contrast media was noted The final diagnoses in the patients with no visible secre- even when the bilirubin concentration was as high as 159 tion are also shown in Table 3. Three of these had occlu- µmol/L (Fig. 3, 4). It has previously been recommended not sive intraductal stones, all of which were reported at the to perform CTC in patients with bilirubin >50 µmol/L (3 CTC. Two patients had a malignancy affecting the bile mg/dL) [14]. In this study, excretion was observed in four ducts. One of these was reported at CTC and the other out of eight patients with bilirubin >50 µmol/L. In three of showed signs of dilated bile ducts. those without contrast excretion, however, the infusion pro- tocol had not been followed (too fast infusion). Although The remaining 4 patients had hepatitis, pancreatitis, absence of contrast media in the bile ducts is more likely in cholangitis or cholecystitis. patients with greatly elevated bilirubin, CTC is not useless in these patients – only two of the nine examinations without The observed attenuation in choledochus and liver for dif- contrast excretion were inconclusive. In the other seven ferent serum bilirubin levels is shown in Fig. 2. cases, CTC findings could guide the referring physician to other examinations and the final diagnosis (Table 3). Review of literature In total, 42 original publications in English were found. The lack of excretion may also constitute valuable infor- Those with more than 100 patients and with an infusion mation. Patients without excretion are likely to have either a total occlusion of the main bile duct/choledochus Page 5 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 In spi tion can b Figure 3 te of an el e observ evated bil ed when a pr irubin value, olong a goo ed infusion t d contrast excre- ime is used A vast number of biliary ston duct Figure 4 es visualized in the choledochus In spite of an elevated bilirubin value, a good contrast excre- A vast number of biliary stones visualized in the choledochus tion can be observed when a prolonged infusion time is used. duct. Pre-examination bilirubin was 29 µmol/L (infusion time In this case, the bilirubin value was 78 µmol/L and the infu- not noted in the medical record). ERCP verified the bile duct sion time was 3 hours. Final diagnosis was status post stones. choledochoduodenostomy. or severely impaired hepatocyte function. The bilirubin concentration, if not already considerably elevated, is likely to increase in these patients. In this study, the lack of excretion could be explained by the final diagnosis in all patients (Table 3). The protein-binding characteristics essential for biliary contrast media increase the risk of adverse reactions [11,15]. In a previously published review of the literature on the frequency of adverse reactions in examinations with short injection time (<10 min), the pooled number of adverse events was three times higher (16% vs. 5%) than after infusion (>30 min) of the same amount of con- trast media [11]. The frequency of adverse events of iotroxate (Biliscopin ) at infusion has been reported to be as high as 3.4%, with a pooled frequency of 1.9% (Table 4). It has been proposed that the tolerance of intravenous biliary contrast media is improved when a slow infusion technique is used (up to one hour of infusion) [16,17]. Our study supports this proposal, as there was only one adverse reaction, which was mild, in 142 patients and 153 Traffic acciden bile duct Figure 5 t with a liver rupture and leakage from a small examinations (0.65%). Traffic accident with a liver rupture and leakage from a small bile duct. The DIC-CT examination led the surgeon correctly After an inconclusive ultrasound examination, MRC has the to the leaking bile duct (arrow). The diameter of the rup- tured bile duct was 1 mm. advantage of not exposing the patient to radiation and con- trast media. On the other hand, in many clinical situations Page 6 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 the availability of MRI examinations with short notice is lim- media. The disadvantage of infusion is the need of super- ited. The sensitivity and specificity of contrast enhanced CTC vision, which is impractical in a radiology department. In to detect choledocholithiasis are comparable to those of our setting, this problem was solved by admitting the MRC (sensitivity 86–93% and 80–95%, respectively, and patients to a ward for infusion prior to CTC. specificity 94–100% and 88–96%, respectively) [3,8,18,19]. CTC is also faster than MRC, which may be of importance in Conclusion patients with difficulties in lying in the supine position for a This study indicates that drip infusion CTC with an infu- prolonged time or when evaluating severely ill patients. sion rate of iotroxate governed by the serum bilirubin concentration is a feasible and safe tool in patients with CTC has been used to preoperatively evaluate aberrant and without impaired biliary excretion. In addition to bile ducts before laparoscopic cholecystectomy. The fre- those with inconclusive MRC or contraindications, CTC is quency of anatomic variants that may affect the outcome a diagnostic alternative in patients already admitted to the of laparoscopic cholecystectomy was estimated to be 15% hospital for whom a reliable diagnosis or mapping of the with CTC [16,20,21]. In clinical practise, the frequency of biliary tree is required within a limited time. In younger bile duct injuries is about 0.5–1.5% [22,23]. The potential patients, non-ionising methods (i.e. MRC or a repeated value of pre-operative mapping of the biliary system by ultrasound examination) should be preferred. using CTC must therefore be weighed against the cost and radiation. Competing interests The author(s) are not aware of any conflicts of interest With injection of contrast media via biliary drainage cath- relating to this article. For the linguistic revision of this eters, CTC has been successfully used to visualize the manuscript AP received from Schering AG a support extent of ductal invasion by hilar carcinoma [24]. equalling to 300 Euro. Whether administration of contrast media orally or intra- venously may achieve similar results in patients without Authors' contributions drainage has not been shown. AP was responsible for study design, data collection, was one of the viewers, performed literature search and man- In clinical practise, CTC has been reported to be the pre- uscript preparation. ND was one of the viewers. ÖS was ferred modality to evaluate living donors prior to liver responsible for study design and statistical analyses. TB transplantation [25]. The main reported advantage to MRI was responsible for study design, was one of the viewers, and MRC was the superior mapping of the biliary tree [26] performed literature search and finalized manuscript. All – in other respects the two modalities were considered authors contributed during manuscript preparation, and equivalent for the planning [25]. After introduction of read and approved the final manuscript. CTC, the use of an intraoperative cholangiogram has been reported to be significantly reduced at living donor liver References 1. Aube C, Delorme B, Yzet T, Burtin P, Lebigot J, Pessaux P, Gondry- transplantation [27]. After liver surgery, there is a risk of Jouet C, Boyer J, Caron C: MR cholangiopancreatography ver- biliary leaks. In these patients, and in patients with trau- sus endoscopic sonography in suspected common bile duct matic rupture of the biliary tree, CTC may be useful to lithiasis: a prospective, comparative study. Am J Roentgenol 2005, 184:55-62. demonstrate the leak (fig 5) [28]. Cholescintigraphy can 2. Boraschi P, Gigoni R, Braccini G, Lamacchia M, Rossi M, Falaschi F: also demonstrate biliary leaks [29], but the resolution is Detection of common bile duct stones before laparoscopic low compared to CT. To our knowledge, there is no other cholecystectomy. Evaluation with MR cholangiography Acta Radiol 2002, 43:593-598. non-invasive technique to visualise a leakage from the bil- 3. Kim YJ, Kim MJ, Kim KW, Chung JB, Lee WJ, Kim JH, Oh YT, Lim JS, iary tree (unless a functioning external biliary drainage is Choi JY: Preoperative evaluation of common bile duct stones in patients with gallstone disease. Am J Roentgenol 2005, present, enabling a secondary cholangiography). 184:1854-1859. 4. Irie H, Honda H, Kuroiwa T, Yoshimitsu K, Aibe H, Shinozaki K, Mas- CTC has been shown to provide kinetic and functional uda K: Pitfalls in MR cholangiopancreatographic interpreta- tion. Radiographics 2001, 21:23-37. information [30]. This is also possible in contrast 5. Watanabe Y, Dohke M, Ishimori T, Amoh Y, Okumura A, Oda K, enhanced MRC when hepatocyte specific contrast media Koike S, Dodo Y: Diagnostic pitfalls of MR cholangiopancrea- tography in the evaluation of the biliary tract and gallblad- is used (Gd-BOPTA and Gd-EOB-BOPTA). Further studies der. Radiographics 1999, 19:415-429. are required to evaluate whether contrast enhanced MRC 6. Soto JA, Alvarez O, Munera F, Velez SM, Valencia J, Ramirez N: Diag- or CTC should be preferred to evaluate biliary kinetics. nosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography, and MR cholangiography. Am J Roentgenol 2000, 175:1127-1134. The main disadvantages of CTC compared to MRC are the 7. Neitlich JD, Topazian M, Smith RC, Gupta A, Burrell MI, Rosenfield use of radiation and contrast media. In our study, includ- AT: Detection of choledocholithiasis: comparison of unen- hanced helical CT and endoscopic retrograde cholangiopan- ing the literature review, the frequency and severity of creatography. Radiology 1997, 203:753-757. adverse reactions was low when infusing the contrast Page 7 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 8. Soto JA, Velez SM, Guzman J: Choledocholithiasis: diagnosis with tion: evaluation at CT cholangiography – initial experience. oral-contrast-enhanced CT cholangiography. Am J Roentgenol Radiology 2005, 235:899-904. 1999, 172:943-948. 28. Dinkel HP, Moll R, Gassel HJ, Knupffer J, Timmermann W, Fieger M, 9. Stockberger SM, Wass JL, Sherman S, Lehman GA, Kopecky KK: Schindler G: Helical CT cholangiography for the detection and Intravenous cholangiography with helical CT: comparison localization of bile duct leakage. Am J Roentgenol 1999, with endoscopic retrograde cholangiography. Radiology 1994, 173(3):613-7. 192:675-680. 29. Sandoval BA, Goettler CE, Robinson AV, O'Donnell JK, Adler LP, 10. Van Beers BE, Lacrosse M, Trigaux JP, de Cannieri L, De Ronde T, Stellato TA: Cholescintigraphy in the diagnosis of bile leak Pringot J: Noninvasive imaging of the biliary tract before or after laparoscopic cholecystectomy. Am Surg 1997, 63:611-6. after laparoscopic cholecystectomy: use of three dimen- 30. Eracleous E, Genagritis M, Papanikolaou N, Kontou AM, Prassopoul- sional spiral CT cholangiography. Am J Roentgenol 1994, los P, Chrysikopoulos H, Allan P, Gourtsoyiannis N: Complemen- 162:1331-1335. tary role of helical CT cholangiography to MR 11. Nilsson U: Adverse reactions to iotroxate at intravenous cholangiography in the evaluation of biliary function and cholangiography. A prospective clinical investigation and kinetics. Eur Radiol 2005, 15:2130-2139. review of the literature. Acta Radiologica 1987, 28:571-575. 31. Daly J, Fitzgerald T, Simpson CJ: Pre-operative intravenous 12. Persson A, Dahlstrom N, Smedby O, Brismar TB: Volume render- cholangiography as an alternative to routine operative ing of three-dimensional drip infusion CT cholangiography in cholangiography in elective cholecystectomy. Clin Radiol 1987, patients with suspected obstructive biliary disease: a retro- 38:161-163. spective study. Br J Radiol 2005, 78(936):1078-85. 32. Joyce WP, Keane R, Burke GJ, Daly M, Drumm J, Egan TJ, Delaney PV: 13. Breen DJ, Nicholson AA: The clinical utility of spiral CT cholan- Identification of bile duct stones in patients undergoing giography. Clin Radiol 2000, 55:733-739. laparoscopic cholecystectomy. Br J Surg 1991, 78:1174-1176. 14. Takahashi M, Saida Y, Itai Y, Gunji N, Orii K, Watanabe Y: Reevalu- 33. Wigmore SJ, Wood K, Rainey JB, Macleod DA: Intravenous ation of spiral CT cholangiography: basic considerations and cholangiography in preoperative assessment of patients con- reliability for detecting choledocholithiasis in 80 patients. J sidered for laparoscopic cholecystectomy. Surg Laparosc Endosc Comput Assist Tomogr 2000, 24:859-865. 1991, 4:254-257. 15. Pasanen P, Partanen K, Pikkarainen P, Alhava E, Pirinen A, Janatuinen 34. Patel JC, McInnes GC, Bagley JS, Needham G, Krukowski ZH: The E: Ultrasonography, CT, and ERCP in the diagnosis of role of intravenous cholangiography in pre-operative assess- choledochal stones. Acta Radiol 1992, 33:53-56. ment for laparoscopic cholecystectomy. Br J Radiol 1993, 16. Kwon AH, Inui H, Imamura A, Uetsuji S, Kamiyama Y: Preoperative 66:1125-1127. assessment for laparoscopic cholecystectomy: feasibility of 35. Grunshaw ND, Lansdown MRJ, Milkins RC: The intravenous using spiral computed tomography. Ann Surg 1998, cholangiogram – time for reappraisal in the age of laparo- 227:351-356. scopic cholecystectomy. Minimally invasive Therapy 1993, 17. Okada M, Fukada J, Toya K, Ito R, Ohashi T, Yorozu A: The value 2(Suppl):35. of drip infusion cholangiography using multidetector-row 36. Sacharias N: Safety of Biliscopin. Australas Radiol 1995, 39:101. helical CT in patients with choledocholithiasis. Eur Radiol 37. Kitami M, Takase K, Murakami G, Ko S, Tsuboi M, Saito H, Higano S, 2005, 15:2140-5. Nakajima Y, Takahashi S: Types and frequencies of biliary tract 18. Gibson RN, Vincent JM, Speer T, Collier NA, Noack K: Accuracy of variations associated with a major portal venous anomaly: computed tomographic intravenous cholangiography (CT- analysis with multi-detector row CT cholangiography. Radiol- IVC) with iotroxate in the detection of choledocholithiasis. ogy 2006, 238(1):156-66. Eur Radiol 2005, 15:1634-42. 38. Takamatsu S, Goseki N, Nakajima K, Teramoto K, Iwai T, Arii S: Dis- 19. Boraschi P, Gigoni R, Braccini G, Lamacchia M, Rossi M, Falaschi F: tributing pattern of the bile duct of the caudate lobe on com- Detection of common bile duct stones before laparoscopic puted tomography with drip infusion cholangiography and cholecystectomy. Evaluation with MR cholangiography. Acta its surgical significance. Hepatogastroenterology 2004, 51:29-32. Radiol 2002, 43:593-598. 20. Izuishi K, Toyama Y, Nakano S, Goda F, Usuki H, Masaki T, Maeta H: Pre-publication history Preoperative assessment of the aberrant bile duct using mul- The pre-publication history for this paper can be accessed tislice computed tomography cholangiography. Am J Surg 2005, 189:53-55. here: 21. Hirao K, Miyazaki A, Fujimoto T, Isomoto I, Hayashi K: Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. Am http://www.biomedcentral.com/1471-2342/6/1/prepub J Roentgenol 2000, 175:713-20. 22. Soderlund C, Frozanpor F, Linder S: Bile duct injuries at laparo- scopic cholecystectomy: a single-institution prospective study. Acute cholecystitis indicates an increased risk. World J Surg 2005, 29:987-993. 23. MacFadyen BV Jr, Vecchio R, Ricardo AE, Mathis CR: Bile duct injury after laparoscopic cholecystectomy. The United States experience. Surg Endosc 1998, 12:315-321. 24. Kim HJ, Kim AY, Hong SS, Kim MH, Byun JH, Won HJ, Shin YM, Kim PN, Ha HK, Lee MG: Biliary ductal evaluation of hilar cholangi- Publish with Bio Med Central and every ocarcinoma: three-dimensional direct multi-detector row scientist can read your work free of charge CT cholangiographic findings versus surgical and pathologic results – feasibility study. Radiology 2006, 238:300-8. "BioMed Central will be the most significant development for 25. Schroeder T, Malago M, Debatin JF, Goyen M, Nadalin S, Ruehm SG: disseminating the results of biomedical researc h in our lifetime." "All-in-one" imaging protocols for the evaluation of poten- Sir Paul Nurse, Cancer Research UK tial living liver donors: comparison of magnetic resonance imaging and multidetector computed tomography. Liver Your research papers will be: Transpl 2005, 11(7):776-87. available free of charge to the entire biomedical community 26. Yeh BM, Breiman RS, Taouli B, Qayyum A, Roberts JP, Coakley FV: Biliary tract depiction in living potential liver donors: com- peer reviewed and published immediately upon acceptance parison of conventional MR, mangafodipir trisodium- cited in PubMed and archived on PubMed Central enhanced excretory MR, and multi-detector row CT cholan- giography – initial experience. Radiology 2004, 230:645-51. yours — you keep the copyright 27. Wang ZJ, Yeh BM, Roberts JP, Breiman RS, Qayyum A, Coakley FV: BioMedcentral Living donor candidates for right hepatic lobe transplanta- Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Medical Imaging Springer Journals

Three-dimensional drip infusion CT cholangiography in patients with suspected obstructive biliary disease: a retrospective analysis of feasibility and adverse reaction to contrast material.

Download PDF
8 pages

Loading next page...
 
/lp/springer-journals/three-dimensional-drip-infusion-ct-cholangiography-in-patients-with-dqHtVfNwGN

References (38)

Publisher
Springer Journals
Copyright
Copyright © 2006 by Persson et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Imaging / Radiology
eISSN
1471-2342
DOI
10.1186/1471-2342-6-1
pmid
16630362
Publisher site
See Article on Publisher Site

Abstract

Background: Computed Tomography Cholangiography (CTC) is a fast and widely available alternative technique to visualise hepatobiliary disease in patients with an inconclusive ultrasound when MRI cannot be performed. The method has previously been relatively unknown and sparsely used, due to concerns about adverse reactions and about image quality in patients with impaired hepatic function and thus reduced contrast excretion. In this retrospective study, the feasibility and the frequency of adverse reactions of CTC when using a drip infusion scheme based on bilirubin levels were evaluated. Methods: The medical records of patients who had undergone upper abdominal spiral CT with subsequent three-dimensional rendering of the biliary tract by means of CTC during seven years were retrospectively reviewed regarding serum bilirubin concentration, adverse reaction and presence of visible contrast media in the bile ducts at CT examination. In total, 153 consecutive examinations in 142 patients were reviewed. Results: Contrast media was observed in the bile ducts at 144 examinations. In 110 examinations, the infusion time had been recorded in the medical records. Among these, 42 examinations had an elevated bilirubin value (>19 umol/L). There were nine patients without contrast excretion; 3 of which had a normal bilirubin value and 6 had an elevated value (25–133 umol/L). Two of the 153 examinations were inconclusive. One subject (0.7%) experienced a minor adverse reaction – a pricking sensation in the face. No other adverse effects were noted. Conclusion: We conclude that drip infusion CTC with an infusion rate of the biliary contrast agent iotroxate governed by the serum bilirubin value is a feasible and safe alternative to MRC in patients with and without impaired biliary excretion. In this retrospective study the feasibility and the frequency of adverse reactions when using a drip infusion scheme based on bilirubin levels has been evaluated. Page 1 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 Table 1: The infusion rate of iotroxate (Biliscopin ) was governed Background by the bilirubin level prior to the investigation. The same total For diagnosis of hepatobiliary disease, ultrasound and MR amount of Iodine (5 g) was given to all patients. cholangiography (MRC) are most frequently used. Endo- scopic Retrograde Cholangiography (ERC) is often Serum bilirubin Infusion time regarded as the gold standard for visualising biliary dis- ease. The latter modality is invasive, user-dependent and <20 µmol/ml 40–60 min 21–40 µmol/ml 1–3 hours may induce pancreatitis. It should therefore not be per- 41–99 µmol/ml 3–4 hours formed in patients where intervention is less certain. >100 µmol/ml 5 hours Ultrasound, on the other hand, is easily tolerated by the patients and cost effective. The modality is, however, user- dependent and the captured images are not easily under- stood by clinicians. MRC is superior in visualising the bil- patients with suspected obstructive biliary disease with iary system, and the images are appreciated by the respect to both feasibility and rate of adverse reactions surgeons at surgical planning. It does not require any con- after administration of the biliary contrast agent (iotrox- trast agent to visualise the bile ducts, and dilatation and ate). gallstones in the common bile duct are easily detected [1- 3]. Unfortunately, MRC cannot be performed in all Methods patients and hospitals due to limited availability of MRI This is a retrospective study in 142 consecutive patients or due to contraindications. MRC is also often inconclu- (68 men and 74 women, mean age 69 years, range 24 – 95 sive in patients with air in the biliary system, e.g. after pap- years) referred for investigation of biliary disease during illotomy or liver surgery with entero-hepatic anastomoses the period from January 1996 to January 2003. After (such as Whipple's operation and Billroth 2). Surgical approval by the ethics committee for the region, the med- clips after cholecystectomy may also give artefacts mim- ical records of all patients were retrospectively reviewed icking a ductal cancer or a stone [4,5]. An alternative non- regarding bilirubin level, infusion time and adverse invasive method to ultrasound and MRC is therefore events. Adverse events were defined as any signs of reac- required. tion to contrast media that occurred after the injection, such as anaphylaxis, urticaria and respiratory distress. Computed Tomography Cholangiography (CTC) is a fast and widely available technique to visualise hepatobiliary Administration of contrast media disease. Without contrast administration, multi detector The serum bilirubin concentration was measured before CT CT has been reported to have a sensitivity of 65%–88% examination using standard clinical laboratory methods and a specificity of 84%–97% to detect gallstones [6,7]. used at the hospital. 100 ml of meglumine iotroxate (Bili- Techniques to improve the sensitivity and specificity by scopin , Schering AG, Berlin, Germany) 50 mg I/ml was administering biliary contrast media orally [8] or intrave- administered by intravenous drip infusion. In order to nously [9,10] have been developed, but are not wide- allow longer infusion times, the solution volume was spread. Possible explanations for infrequent use of CTC increased by dilution with isotonic sodium chloride (500 might be the low resolution of single detector helical CT ml). The infusion time was determined by the measured and reports of an unacceptable high number of adverse bilirubin level according to a schematic protocol (Table 1). Following the guidelines from the manufacturer, the drip events after injection of meglumine iotroxate [11]. With the development of multidetector CT, the resolution of infusion was started at a low infusion rate (0.5 ml/min) CTC exceeds that of MR. The number of adverse reactions and increased to the desired infusion rate during the fol- with biliary contrast media has probably diminished by lowing 3–5 minutes. The CT scan was started immediately infusing the contrast media instead of injecting. after the infusion was completed. For distension of the dis- tal duodenum, the patients ingested two glasses of drinking The aim of this retrospective study was to evaluate pro- water immediately before the CT examination. To evaluate longed drip infusion CT cholangiography (CTC) in Table 2: CT acquisition parameters Type of scanner Collimation Pitch Increment mAs kV Number of examinations Single Slice 1 × 5.0 mm 1.5 1 mm 200 120 103 Multi-slice 4 × 2.5 mm 6 1 mm 130 120 46 Multi-slice 16 × 0.75 mm varying 0.5 mm 130 120 4 Page 2 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 Table 3: The bilirubin value, infusion time and final diagnosis in the nine cases where no secretion of contrast media was observed at DIC-CT. Bilirubin value, µmol/L Infusion time, minutes Reported findings in medical records, final diagnosis Reported findings at DIC-CT 133 120 Hepatitis Type B wide bile duct 1,2 120 240 Pancreatitis inconclusive 7,2,6 79 180 Intraductal stone in choledochus and pancreatitis Intraductal stone 1,2 73 120 Cholecystitis wide bile duct 1,2,3,6, 30 unknown Concrememt in choledochus Intraductal stone 25 unknown Concrement in choledochus, Total occlusion and Klatskin Intraductal stone, tumour 5,7 tumour 4,5,7 inconclusive 16 60 Distal stenosis in choledochus and pancreatitis 2,3 12 60 Total occlusion in choledochus, pancreas tumour wide bile duct 8 60 Post operative cholangitis/cholecystitis with bile fistula and fluid-filled cavity 1,6,7 leakage The method by which the final diagnosis was made is indicated by the superscript numbers where 1 = laboratory findings, 2 = ultrasound, 3 = ultrasound with fine needle biopsy, 4 = MRCP, 5 = operation, 6 = ERCP and 7 = PTC. Statistical methods compliance to the protocol, the medical records were reviewed regarding the given infusion time at the ward. Data are given as mean (± standard deviation). Frequen- cies are given with their 95% confidence interval, com- Scanning parameters puted with normal approximation. Patients were scanned in the right oblique position by means of thin-section single-breath-hold helical CT in the Results cranio-caudal direction. Specific scan protocols varied Out of 153 examinations performed in 142 patients, one depending on the CT scanner available at the time of subject experienced a minor reaction (pricking sensation examination (Table 2). Between December 1995 and in the face) following the administration of 70 ml of con- November 1999, 102 patients were scanned with a single- trast. In this patient, the pre-exam bilirubin value was nor- slice CT scanner (Somatom A; Siemens Medical Systems, mal (11 µmol/L) and the planned infusion time was 60 Forcheim, Germany). From December 1999 to November minutes. Four weeks later, the same patient successfully 2002, a 4-slice multi-detector CT scanner (Somatom Vol- underwent a repeated CT cholangiography using the same ume Zoom; Siemens Medical Systems, Forcheim, Ger- infusion rate without any adverse reactions. In the other many) was used in 44 exams. Between December 2002 141 patients (151 examinations), no adverse reaction was and January 2003, a 16-slice multi-detector CT scanner noted in the medical records. Thus, the observed fre- (Somatom Sensation16; Siemens Medical Systems, quency of adverse reactions in this material was 1/153 Forcheim, Germany) was used in 6 exams. (0.65%). Of the 153 examinations, 10 were performed in out-patients. These patients normally stay in the radiology Evaluation of contrast media excretion department one hour after the contrast injection has been The attenuation in choledochus and liver was obtained completed. Due to the retrospective nature of this study, retrospectively by measurement in the restored digital late mild adverse advents may not have been recorded in images in all examinations with bilirubin >19 µmol/L (n these 10 patients. More severe adverse reactions such as a = 42), as well as in 67 individuals also described in skin rash, itches, etc. are, however, usually reported to the another study [12], 19 of the latter with bilirubin >19 hospital by the patients and according to the routines of µmol/L. In total, attenuation values from 90 (= 42 + 67 - the hospital, adverse reactions are always noted in the 19) patients were obtained. medical records after an X-ray examination. The hospital is the only one in the district and no notes could be found Review of literature about adverse advents in the patients' files (files from A MEDLINE search was performed for all clinical studies departments of radiology, surgery and internal medicine in English published during the period 1975–2004 con- were reviewed). cerning iotroxate, using the words "Biliscopin" or "iotrox- ate". All articles were reviewed for reports regarding The mean bilirubin value was 20 (± 25) µmol/L. 42 adverse events. The pooled frequency of adverse events patients had an elevated bilirubin value (defined as >19 was calculated for all articles with a number of patients µmol/L). Information regarding the infusion time used at >100 where the contrast had been infused for 30 minutes the ward had been noted in the medical records in 110 out or more. of 153 examinations. The mean infusion time was 82 (± Page 3 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 The Figure 1 infusion time of iotroxate (Biliscopin ) in relation to bilirubin level prior to the investigation The infusion time of iotroxate (Biliscopin ) in relation to bilirubin level prior to the investigation. The recommended infusion times were followed in 103 out of the 110 cases (94%) where information on infusion time was found in the medical records. Cases in which the recommendations were not followed are encircled (n = 7). Unfortunately, none of the three (3/110) exam- inations with a bilirubin value >100 µmol/ml was performed according to the infusion scheme. The patient with the highest bilirubin value (159 µmol/ml) had good diagnostic excretion of contrast in the bile ducts, whereas the other two had no excre- tion. A Figure 2 ttenuation in choledochus and liver at DIC-CT as a function of serum bilirubin before the examination Attenuation in choledochus and liver at DIC-CT as a function of serum bilirubin before the examination. 42) minutes. Disregarding potential measurement errors of Page 4 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 Table 4: Published studies on the frequency of adverse reactions at infusion of iotroxate at intravenous cholangiography. Included are all studies with at least 100 patients using an infusion time of at least 30 min. The severity of the reactions is graded as reported. The number in superscript denotes the corresponding reference. No. of Patients Total Minor Intermediate Severe Fatal Nilsson 1987 1 446 49 (3.4%) 41 (2.9%) 5 (0.35%) 3 (0.21%) 0 286 4 (1.4%) 4 (1.4%) 0 0 0 Daly 1987 Joyce 1991 100 2 (2.0%) 2 (2.0%) 0 0 0 Wigmore 1993 100 00000 Patel 1993 113 3 (2.7%) 3 (2.7%) 0 0 0 Grunshaw 1993 137 4 (2.9%) 3 (2.2%) 1 (0.7%) 0 0 A 36 A Sacharias 1995 1 061 11 (1.0%) 11 (1.0%) 0 0 Kwon 1998 440 2 (0.5%) 2 (0.5%) 0 0 0 Kitami 2006 220 3 (1.4%) 3 (1.5%) 0 0 0 Okada 2005 432 4 (0.9% 4 (0.9%) 0 0 0 Hirao 2000 120 2 (1.7%) 2 (1.7%) 0 0 0 B 38 Takamatsu 2004 132 1 (0.8%) 1 (0.8%) 0 0 0 Total 4587 85 65 17 3 0 Frequency (95% 1.9% (1.5%–2.2%) 1.4% (1.1%–1.8% 0.4% (0.2%–0.5%) 0.1% (0–0.1%) 0 confidence limits) No difference was made between minor and intermediate adverse events. The infusion time was 25–30 min. The number of complications in the article was reported by personal communication. at most 2 µmol/L, seven infusions (5%) had not been per- time of 30 minutes or more are listed in Table 4 as well as formed according to the protocol. Five of these received the the pooled number of adverse events (2.27%). infusion too fast and 2 too slow (Fig. 1). All three patients with a bilirubin >100 µmol/L were among the seven Discussion patients who did not receive the correct infusion rate. The When the bile ducts are obstructed, excretion of bile and intended infusion rate (5 hours) could therefore not be contrast media is decreased. It has therefore been assumed evaluated. that CT cholangiography cannot be performed in patients with elevated serum bilirubin concentration [9,10]. In this Excretion of contrast media was observed in 93% (143/ study, the infusion rate of the contrast media was adjusted to 153) of all exams (one examination aborted due to poten- the bilirubin value (Table 1). The aim was to keep the con- tial contrast reaction). In patients with elevated serum centration within the excretory capacity of the hepatocytes in bilirubin (>19 µmol/L) contrast media in the bile was order to optimise the concentration in bile. By using this observed in 36 out of 42 patients (86%). No visible secre- scheme, contrast excretion into the bile ducts was observed tion of contrast was reported in 9 patients (Table 3). In in 93% of all exams. In patients with elevated serum three of these, the infusion protocol had not been fol- bilirubin (>19 µmol/L), contrast media in the bile was lowed, with too fast infusion (bilirubin 73–133 µmol/L). observed in 86%. Excretion of contrast media was noted The final diagnoses in the patients with no visible secre- even when the bilirubin concentration was as high as 159 tion are also shown in Table 3. Three of these had occlu- µmol/L (Fig. 3, 4). It has previously been recommended not sive intraductal stones, all of which were reported at the to perform CTC in patients with bilirubin >50 µmol/L (3 CTC. Two patients had a malignancy affecting the bile mg/dL) [14]. In this study, excretion was observed in four ducts. One of these was reported at CTC and the other out of eight patients with bilirubin >50 µmol/L. In three of showed signs of dilated bile ducts. those without contrast excretion, however, the infusion pro- tocol had not been followed (too fast infusion). Although The remaining 4 patients had hepatitis, pancreatitis, absence of contrast media in the bile ducts is more likely in cholangitis or cholecystitis. patients with greatly elevated bilirubin, CTC is not useless in these patients – only two of the nine examinations without The observed attenuation in choledochus and liver for dif- contrast excretion were inconclusive. In the other seven ferent serum bilirubin levels is shown in Fig. 2. cases, CTC findings could guide the referring physician to other examinations and the final diagnosis (Table 3). Review of literature In total, 42 original publications in English were found. The lack of excretion may also constitute valuable infor- Those with more than 100 patients and with an infusion mation. Patients without excretion are likely to have either a total occlusion of the main bile duct/choledochus Page 5 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 In spi tion can b Figure 3 te of an el e observ evated bil ed when a pr irubin value, olong a goo ed infusion t d contrast excre- ime is used A vast number of biliary ston duct Figure 4 es visualized in the choledochus In spite of an elevated bilirubin value, a good contrast excre- A vast number of biliary stones visualized in the choledochus tion can be observed when a prolonged infusion time is used. duct. Pre-examination bilirubin was 29 µmol/L (infusion time In this case, the bilirubin value was 78 µmol/L and the infu- not noted in the medical record). ERCP verified the bile duct sion time was 3 hours. Final diagnosis was status post stones. choledochoduodenostomy. or severely impaired hepatocyte function. The bilirubin concentration, if not already considerably elevated, is likely to increase in these patients. In this study, the lack of excretion could be explained by the final diagnosis in all patients (Table 3). The protein-binding characteristics essential for biliary contrast media increase the risk of adverse reactions [11,15]. In a previously published review of the literature on the frequency of adverse reactions in examinations with short injection time (<10 min), the pooled number of adverse events was three times higher (16% vs. 5%) than after infusion (>30 min) of the same amount of con- trast media [11]. The frequency of adverse events of iotroxate (Biliscopin ) at infusion has been reported to be as high as 3.4%, with a pooled frequency of 1.9% (Table 4). It has been proposed that the tolerance of intravenous biliary contrast media is improved when a slow infusion technique is used (up to one hour of infusion) [16,17]. Our study supports this proposal, as there was only one adverse reaction, which was mild, in 142 patients and 153 Traffic acciden bile duct Figure 5 t with a liver rupture and leakage from a small examinations (0.65%). Traffic accident with a liver rupture and leakage from a small bile duct. The DIC-CT examination led the surgeon correctly After an inconclusive ultrasound examination, MRC has the to the leaking bile duct (arrow). The diameter of the rup- tured bile duct was 1 mm. advantage of not exposing the patient to radiation and con- trast media. On the other hand, in many clinical situations Page 6 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 the availability of MRI examinations with short notice is lim- media. The disadvantage of infusion is the need of super- ited. The sensitivity and specificity of contrast enhanced CTC vision, which is impractical in a radiology department. In to detect choledocholithiasis are comparable to those of our setting, this problem was solved by admitting the MRC (sensitivity 86–93% and 80–95%, respectively, and patients to a ward for infusion prior to CTC. specificity 94–100% and 88–96%, respectively) [3,8,18,19]. CTC is also faster than MRC, which may be of importance in Conclusion patients with difficulties in lying in the supine position for a This study indicates that drip infusion CTC with an infu- prolonged time or when evaluating severely ill patients. sion rate of iotroxate governed by the serum bilirubin concentration is a feasible and safe tool in patients with CTC has been used to preoperatively evaluate aberrant and without impaired biliary excretion. In addition to bile ducts before laparoscopic cholecystectomy. The fre- those with inconclusive MRC or contraindications, CTC is quency of anatomic variants that may affect the outcome a diagnostic alternative in patients already admitted to the of laparoscopic cholecystectomy was estimated to be 15% hospital for whom a reliable diagnosis or mapping of the with CTC [16,20,21]. In clinical practise, the frequency of biliary tree is required within a limited time. In younger bile duct injuries is about 0.5–1.5% [22,23]. The potential patients, non-ionising methods (i.e. MRC or a repeated value of pre-operative mapping of the biliary system by ultrasound examination) should be preferred. using CTC must therefore be weighed against the cost and radiation. Competing interests The author(s) are not aware of any conflicts of interest With injection of contrast media via biliary drainage cath- relating to this article. For the linguistic revision of this eters, CTC has been successfully used to visualize the manuscript AP received from Schering AG a support extent of ductal invasion by hilar carcinoma [24]. equalling to 300 Euro. Whether administration of contrast media orally or intra- venously may achieve similar results in patients without Authors' contributions drainage has not been shown. AP was responsible for study design, data collection, was one of the viewers, performed literature search and man- In clinical practise, CTC has been reported to be the pre- uscript preparation. ND was one of the viewers. ÖS was ferred modality to evaluate living donors prior to liver responsible for study design and statistical analyses. TB transplantation [25]. The main reported advantage to MRI was responsible for study design, was one of the viewers, and MRC was the superior mapping of the biliary tree [26] performed literature search and finalized manuscript. All – in other respects the two modalities were considered authors contributed during manuscript preparation, and equivalent for the planning [25]. After introduction of read and approved the final manuscript. CTC, the use of an intraoperative cholangiogram has been reported to be significantly reduced at living donor liver References 1. Aube C, Delorme B, Yzet T, Burtin P, Lebigot J, Pessaux P, Gondry- transplantation [27]. After liver surgery, there is a risk of Jouet C, Boyer J, Caron C: MR cholangiopancreatography ver- biliary leaks. In these patients, and in patients with trau- sus endoscopic sonography in suspected common bile duct matic rupture of the biliary tree, CTC may be useful to lithiasis: a prospective, comparative study. Am J Roentgenol 2005, 184:55-62. demonstrate the leak (fig 5) [28]. Cholescintigraphy can 2. Boraschi P, Gigoni R, Braccini G, Lamacchia M, Rossi M, Falaschi F: also demonstrate biliary leaks [29], but the resolution is Detection of common bile duct stones before laparoscopic low compared to CT. To our knowledge, there is no other cholecystectomy. Evaluation with MR cholangiography Acta Radiol 2002, 43:593-598. non-invasive technique to visualise a leakage from the bil- 3. Kim YJ, Kim MJ, Kim KW, Chung JB, Lee WJ, Kim JH, Oh YT, Lim JS, iary tree (unless a functioning external biliary drainage is Choi JY: Preoperative evaluation of common bile duct stones in patients with gallstone disease. Am J Roentgenol 2005, present, enabling a secondary cholangiography). 184:1854-1859. 4. Irie H, Honda H, Kuroiwa T, Yoshimitsu K, Aibe H, Shinozaki K, Mas- CTC has been shown to provide kinetic and functional uda K: Pitfalls in MR cholangiopancreatographic interpreta- tion. Radiographics 2001, 21:23-37. information [30]. This is also possible in contrast 5. Watanabe Y, Dohke M, Ishimori T, Amoh Y, Okumura A, Oda K, enhanced MRC when hepatocyte specific contrast media Koike S, Dodo Y: Diagnostic pitfalls of MR cholangiopancrea- tography in the evaluation of the biliary tract and gallblad- is used (Gd-BOPTA and Gd-EOB-BOPTA). Further studies der. Radiographics 1999, 19:415-429. are required to evaluate whether contrast enhanced MRC 6. Soto JA, Alvarez O, Munera F, Velez SM, Valencia J, Ramirez N: Diag- or CTC should be preferred to evaluate biliary kinetics. nosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography, and MR cholangiography. Am J Roentgenol 2000, 175:1127-1134. The main disadvantages of CTC compared to MRC are the 7. Neitlich JD, Topazian M, Smith RC, Gupta A, Burrell MI, Rosenfield use of radiation and contrast media. In our study, includ- AT: Detection of choledocholithiasis: comparison of unen- hanced helical CT and endoscopic retrograde cholangiopan- ing the literature review, the frequency and severity of creatography. Radiology 1997, 203:753-757. adverse reactions was low when infusing the contrast Page 7 of 8 (page number not for citation purposes) BMC Medical Imaging 2006, 6:1 http://www.biomedcentral.com/1471-2342/6/1 8. Soto JA, Velez SM, Guzman J: Choledocholithiasis: diagnosis with tion: evaluation at CT cholangiography – initial experience. oral-contrast-enhanced CT cholangiography. Am J Roentgenol Radiology 2005, 235:899-904. 1999, 172:943-948. 28. Dinkel HP, Moll R, Gassel HJ, Knupffer J, Timmermann W, Fieger M, 9. Stockberger SM, Wass JL, Sherman S, Lehman GA, Kopecky KK: Schindler G: Helical CT cholangiography for the detection and Intravenous cholangiography with helical CT: comparison localization of bile duct leakage. Am J Roentgenol 1999, with endoscopic retrograde cholangiography. Radiology 1994, 173(3):613-7. 192:675-680. 29. Sandoval BA, Goettler CE, Robinson AV, O'Donnell JK, Adler LP, 10. Van Beers BE, Lacrosse M, Trigaux JP, de Cannieri L, De Ronde T, Stellato TA: Cholescintigraphy in the diagnosis of bile leak Pringot J: Noninvasive imaging of the biliary tract before or after laparoscopic cholecystectomy. Am Surg 1997, 63:611-6. after laparoscopic cholecystectomy: use of three dimen- 30. Eracleous E, Genagritis M, Papanikolaou N, Kontou AM, Prassopoul- sional spiral CT cholangiography. Am J Roentgenol 1994, los P, Chrysikopoulos H, Allan P, Gourtsoyiannis N: Complemen- 162:1331-1335. tary role of helical CT cholangiography to MR 11. Nilsson U: Adverse reactions to iotroxate at intravenous cholangiography in the evaluation of biliary function and cholangiography. A prospective clinical investigation and kinetics. Eur Radiol 2005, 15:2130-2139. review of the literature. Acta Radiologica 1987, 28:571-575. 31. Daly J, Fitzgerald T, Simpson CJ: Pre-operative intravenous 12. Persson A, Dahlstrom N, Smedby O, Brismar TB: Volume render- cholangiography as an alternative to routine operative ing of three-dimensional drip infusion CT cholangiography in cholangiography in elective cholecystectomy. Clin Radiol 1987, patients with suspected obstructive biliary disease: a retro- 38:161-163. spective study. Br J Radiol 2005, 78(936):1078-85. 32. Joyce WP, Keane R, Burke GJ, Daly M, Drumm J, Egan TJ, Delaney PV: 13. Breen DJ, Nicholson AA: The clinical utility of spiral CT cholan- Identification of bile duct stones in patients undergoing giography. Clin Radiol 2000, 55:733-739. laparoscopic cholecystectomy. Br J Surg 1991, 78:1174-1176. 14. Takahashi M, Saida Y, Itai Y, Gunji N, Orii K, Watanabe Y: Reevalu- 33. Wigmore SJ, Wood K, Rainey JB, Macleod DA: Intravenous ation of spiral CT cholangiography: basic considerations and cholangiography in preoperative assessment of patients con- reliability for detecting choledocholithiasis in 80 patients. J sidered for laparoscopic cholecystectomy. Surg Laparosc Endosc Comput Assist Tomogr 2000, 24:859-865. 1991, 4:254-257. 15. Pasanen P, Partanen K, Pikkarainen P, Alhava E, Pirinen A, Janatuinen 34. Patel JC, McInnes GC, Bagley JS, Needham G, Krukowski ZH: The E: Ultrasonography, CT, and ERCP in the diagnosis of role of intravenous cholangiography in pre-operative assess- choledochal stones. Acta Radiol 1992, 33:53-56. ment for laparoscopic cholecystectomy. Br J Radiol 1993, 16. Kwon AH, Inui H, Imamura A, Uetsuji S, Kamiyama Y: Preoperative 66:1125-1127. assessment for laparoscopic cholecystectomy: feasibility of 35. Grunshaw ND, Lansdown MRJ, Milkins RC: The intravenous using spiral computed tomography. Ann Surg 1998, cholangiogram – time for reappraisal in the age of laparo- 227:351-356. scopic cholecystectomy. Minimally invasive Therapy 1993, 17. Okada M, Fukada J, Toya K, Ito R, Ohashi T, Yorozu A: The value 2(Suppl):35. of drip infusion cholangiography using multidetector-row 36. Sacharias N: Safety of Biliscopin. Australas Radiol 1995, 39:101. helical CT in patients with choledocholithiasis. Eur Radiol 37. Kitami M, Takase K, Murakami G, Ko S, Tsuboi M, Saito H, Higano S, 2005, 15:2140-5. Nakajima Y, Takahashi S: Types and frequencies of biliary tract 18. Gibson RN, Vincent JM, Speer T, Collier NA, Noack K: Accuracy of variations associated with a major portal venous anomaly: computed tomographic intravenous cholangiography (CT- analysis with multi-detector row CT cholangiography. Radiol- IVC) with iotroxate in the detection of choledocholithiasis. ogy 2006, 238(1):156-66. Eur Radiol 2005, 15:1634-42. 38. Takamatsu S, Goseki N, Nakajima K, Teramoto K, Iwai T, Arii S: Dis- 19. Boraschi P, Gigoni R, Braccini G, Lamacchia M, Rossi M, Falaschi F: tributing pattern of the bile duct of the caudate lobe on com- Detection of common bile duct stones before laparoscopic puted tomography with drip infusion cholangiography and cholecystectomy. Evaluation with MR cholangiography. Acta its surgical significance. Hepatogastroenterology 2004, 51:29-32. Radiol 2002, 43:593-598. 20. Izuishi K, Toyama Y, Nakano S, Goda F, Usuki H, Masaki T, Maeta H: Pre-publication history Preoperative assessment of the aberrant bile duct using mul- The pre-publication history for this paper can be accessed tislice computed tomography cholangiography. Am J Surg 2005, 189:53-55. here: 21. Hirao K, Miyazaki A, Fujimoto T, Isomoto I, Hayashi K: Evaluation of aberrant bile ducts before laparoscopic cholecystectomy: helical CT cholangiography versus MR cholangiography. Am http://www.biomedcentral.com/1471-2342/6/1/prepub J Roentgenol 2000, 175:713-20. 22. Soderlund C, Frozanpor F, Linder S: Bile duct injuries at laparo- scopic cholecystectomy: a single-institution prospective study. Acute cholecystitis indicates an increased risk. World J Surg 2005, 29:987-993. 23. MacFadyen BV Jr, Vecchio R, Ricardo AE, Mathis CR: Bile duct injury after laparoscopic cholecystectomy. The United States experience. Surg Endosc 1998, 12:315-321. 24. Kim HJ, Kim AY, Hong SS, Kim MH, Byun JH, Won HJ, Shin YM, Kim PN, Ha HK, Lee MG: Biliary ductal evaluation of hilar cholangi- Publish with Bio Med Central and every ocarcinoma: three-dimensional direct multi-detector row scientist can read your work free of charge CT cholangiographic findings versus surgical and pathologic results – feasibility study. Radiology 2006, 238:300-8. "BioMed Central will be the most significant development for 25. Schroeder T, Malago M, Debatin JF, Goyen M, Nadalin S, Ruehm SG: disseminating the results of biomedical researc h in our lifetime." "All-in-one" imaging protocols for the evaluation of poten- Sir Paul Nurse, Cancer Research UK tial living liver donors: comparison of magnetic resonance imaging and multidetector computed tomography. Liver Your research papers will be: Transpl 2005, 11(7):776-87. available free of charge to the entire biomedical community 26. Yeh BM, Breiman RS, Taouli B, Qayyum A, Roberts JP, Coakley FV: Biliary tract depiction in living potential liver donors: com- peer reviewed and published immediately upon acceptance parison of conventional MR, mangafodipir trisodium- cited in PubMed and archived on PubMed Central enhanced excretory MR, and multi-detector row CT cholan- giography – initial experience. Radiology 2004, 230:645-51. yours — you keep the copyright 27. Wang ZJ, Yeh BM, Roberts JP, Breiman RS, Qayyum A, Coakley FV: BioMedcentral Living donor candidates for right hepatic lobe transplanta- Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes)

Journal

BMC Medical Imaging – Springer Journals

Published: Apr 22, 2006

There are no references for this article.