ERCP

ERCP stands for endoscopic retrograde cholangiopancreatography. As hard as this is to say, the actual exam is fairly simple. A dye is injected into the bile and pancreatic ducts using a flexible, video endoscope.

Then x-rays are taken to outline the bile ducts and pancreas.

The liver produces bile, which flows through the ducts, passes or fills the gallbladder and then enters the intestine (duodenum) just beyond the stomach. The pancreas, which is six to eight inches long, sits behind the stomach. This organ secretes digestive enzymes that flow into the intestine through the same opening as the bile. Both bile and enzymes are needed to digest food.

EquipmentThe flexible endoscope is a remarkable piece of equipment that can be directed and moved around the many bends in the upper gastrointestinal tract. The newer video endoscopes have a tiny, optically sensitive computer chip at the end. Electronic signals are then transmitted up the scope to the computer which then displays the image on a large video screen. An open channel in the scope allows other instruments to be passed through it to perform biopsies, inject solutions, or place stents.

Reasons for the ExamDue to factors related to diet, environment and heredity, the bile ducts, gallbladder and pancreas are the seat of numerous disorders. These can develop into a variety of diseases and/or symptoms. ERCP helps in diagnosing and often in treating the condition.

ERCP is used for:

Gallstones, which are trapped in the main bile duct Blockage of the bile duct Yellow jaundice, which turns the skin yellow and the urine dark Undiagnosed upper-abdominal pain Cancer of the bile ducts or pancreas Pancreatitis (inflammation of the pancreas)

PreparationThe only preparation needed before an ERCP is to not eat or drink for eight hours prior to the procedure. You may be asked to stop certain medications such as aspirin before the procedure. Check with the physician.

The ProcedureAn ERCP uses x-ray films and is performed in an x-ray room. The throat is anesthetized with a spray or solution, and the patient is usually mildly sedated. The endoscope is then gently inserted into the upper esophagus. The patient breathes easily throughout the exam, with gagging rarely occurring. A thin tube is inserted through the endoscope to the main bile duct entering the duodenum. Dye is then injected into this bile duct and/or the pancreatic duct and x-ray films are taken. The patient lies on his or her left side and then turns onto the stomach to allow complete

visualization of the ducts. If a gallstone is found, steps may be taken to remove it. If the duct has become narrowed, an incision can be made using electrocautery (electrical heat) to relieve the blockage. Additionally, it is possible to widen narrowed ducts and to place small tubing, called stents, in these areas to keep them open. The exam takes from 20 to 40 minutes, after which the patient is taken to the recovery area.

ResultsAfter the exam, the physician explains the results. If the effects of the sedatives are prolonged, the physician may suggest an appointment for a later date when the patient can fully understand the results.

BenefitsAn ERCP is performed primarily to identify and/or correct a problem in the bile ducts or pancreas. This means the test enables a diagnosis to be made upon which specific treatment can be given. If a gallstone is found during the exam, it can often be removed, eliminating the need for major surgery. If a blockage in the bile duct causes yellow jaundice or pain, it can be relieved.

Alternative TestingAlternative tests to ERCP include certain types of x-rays (CAT scan, CT) and sonography (ultrasound) to visualize the pancreas and bile ducts. In addition, dye can be injected into the bile ducts by placing a needle through the skin and into the liver. Small tubing can then be threaded into the bile ducts. Study of the blood also can provide some indirect information about the ducts and pancreas.

Side Effects and RisksA temporary, mild sore throat sometimes occurs after the exam. Serious risks with ERCP, however, are uncommon. One such risk is excessive bleeding, especially when electrocautery is used to open a blocked duct. In rare instances, a perforation or tear in the intestinal wall can occur. Inflammation of the pancreas also can develop. These complications may require hospitalization and, rarely, surgery.

Due to the mild sedation, the patient should not drive or operate machinery for six hours following the exam. For this reason, a driver should accompany the patient to the exam.

ERCP Endoscopic retrograde cholangiopancreatography During this procedure an X-ray is taken of the pancreatic duct and bile ducts. These ducts drain secretions from the pancreas and liver respectively. Obtaining such pictures requires that an endoscope be placed in the mouth through the esophagus and stomach, then into the duodenum.

Procedure: The patient is sedated and given potent pain relievers (opiate) after on overnight fast. A local anesthetic is sprayed to the back of the throat. Frequently, muscle relaxants are used to relax the duodenum and ampulla (an anticholinergic drug, or glucagon, nitroglycerin). During the test patients are monitored to ensure that they are not oversedated. The monitoring includes a pulse oximeter (a probe fastened to the patient's finger that measures blood oxygen concentration) and a heart rate monitor. During the ERCP, the degree of sedation is much greater than that used for an EGD, so often the patient is asleep.

Using a modified endoscope, the investigator visualizes the duodenum on a monitor and finds the small opening where the bile duct and pancreatic duct empty into the duodenum (the ampulla of Vater). A thin catheter is passed through an opening in the endoscope and through the ampulla. Once the catheter has been placed through the opening (cannulated), a dye is injected into the pancreatic and bile ducts. This enables images of these ducts to be obtained. X-rays are taken of the abdomen over the area of the pancreas and are examined by the attending physicians on screen.

Despite the medication, occasionally the patient may feel discomfort and may retch. If discomfort occurs additional pain relief is usually provided. Symptoms arising from complications may also rarely occur.

Accuracy: • Will show the indirect effects of pancreatic cancer such as blockage or dilatation of the ducts and inflammation of the tissue. Similar symptoms can be caused by conditions such as chronic pancreatitis or stones in the pancreatic or bile ducts. By examining the pattern of these changes, it is possible to predict with a high degree of certainty if an abnormality is a cancer.

• An ERCP can detect an abnormality suspicious of cancer in about 9 out of 10 patients who are investigated for possible adenocarcinoma. Patients who have very small cancers, less than 2 cm, that currently do not alter the main ducts of the pancreas or the bile duct will not be visible.

• Occasionally, it can be very difficult to tell if an abnormality in the pancreatic duct is due to cancer or inflammation. Tissue biopsy provides confirmation of the presence of cancer (link to FNA and cytology). This test is not useful in detecting most endocrine types of pancreatic cancer.

Results: If the test results are abnormal, a sample of pancreatic fluid from the pancreatic duct or a sample of tissue by biopsy can be obtained if necessary. This can be done either during the ERCP by positioning a biopsy forceps while looking at it on screen. Alternatively, the fluid

or tissue sample can be obtained by visualizing the are of concern using other imaging techniques and performing a needle biopsy (FNA).

As a treatment: Most importantly, if a pancreatic cancer is present and the patient is not a candidate for curative surgery, therapeutic procedures can be performed using ERCP. These procedures can provide considerable relief for the patient with minimal inconvenience or risk. Pancreatic cancers frequently block the bile duct that prevents the proper flow of bile from the liver. The therapeutic intervention typically alleviates symptoms caused by duct blockage such as jaundice, generalized and progressive itching, liver damage, inadequate digestion of food, a risk of bacterial infection of the blood and severe pain. Placing a stent into the bile duct to allow bile drainage can extend an individual's life and improve their quality of life. The patient does not feel the presence of the stent in their bile duct or pancreatic duct.

Risks : The main complications of the ERCP as a diagnostic procedure are pancreatitis, infection and bleeding.

The insertion of a therapeutic stent can have complications such as bleeding, inflammation of the pancreas (pancreatitis), bile duct damage and leakage, and infection. Bleeding and pancreatitis is more likely if a large (wide-bore) stent is placed as it requires a cut to be made to enlarge the opening of the narrow ampulla where the bile and pancreatic fluid enters the duodenum (see figure). The cut primarily targets a small sphincter muscle surrounding the ampulla (hence, the procedure is termed a sphincterotomy).

Overall, less than 1 in 10 individuals will have such a complication and severe life-threatening complications are rarer (1-2%). The risk of a complication when a sphincterotomy is not performed is less (2-5%) and depends on the number and size of the stents inserted. Usually therapeutic ERCP can be done as a same day procedure without the need for an overnight hospital stay. If complications occur or are suspected hospitalization might be required. Biliary stents usually succumb to blockage after several months as a result of further cancer growth. This may require periodic stent replacement.

There is also a small risk of an allergic reaction to the dye, which contains iodine. Rarely, drugs used to relax the ampulla of Vater can have side effects such as nausea, dry mouth, flushing, urinary retention, rapid heart rate (sinus or supraventricular tachycardia), or a drop in blood pressure.

ERCP (Endoscopic Retrograde Cholangiopancreatography)

Endoscopic retrograde cholangiopancreatography (en-doh-SKAH-pik REH-troh-grayd koh-LAN-jee-oh-PANG-kree-uh-TAH-gruh-fee) (ERCP) enables the physician to diagnose problems in the liver, gallbladder, bile ducts, and pancreas. The liver is a large organ that, among other things, makes a liquid called bile that helps with digestion. The gallbladder is a small, pear-shaped organ that stores bile until it is needed for digestion. The bile ducts are tubes that carry bile from the liver to the gallbladder and small intestine. These ducts are sometimes called the biliary tree. The pancreas is a large gland that produces chemicals that help with digestion and hormones such as insulin.

ERCP is used primarily to diagnose and treat conditions of the bile ducts, including gallstones, inflammatory strictures (scars), leaks (from trauma and surgery), and cancer. ERCP combines the use of x rays and an endoscope, which is a long, flexible, lighted tube. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x rays.

For the procedure, you will lie on your left side on an examining table in an x-ray room. You will be given medication to help numb the back of your throat and a sedative to help you relax during the exam. You will swallow the endoscope, and the physician will then guide the scope through your esophagus, stomach, and duodenum until it reaches the spot where the ducts of the biliary tree and pancreas open into the duodenum. At this time, you will be turned to lie flat on your stomach, and the physician will pass a small plastic tube through the scope. Through the tube, the physician will inject a dye into the ducts to make them show up clearly on x rays. X rays are taken as soon as the dye is injected.

If the exam shows a gallstone or narrowing of the ducts, the physician can insert instruments into the scope to remove or relieve the obstruction. Also, tissue samples (biopsy) can be taken for further testing.

Possible complications of ERCP include pancreatitis (inflammation of the pancreas), infection, bleeding, and perforation of the duodenum. Except for pancreatitis, such problems are uncommon. You may have tenderness or a lump where the sedative was injected, but that should go away in a few days.

ERCP takes 30 minutes to 2 hours. You may have some discomfort when the physician blows air into the duodenum and injects the dye into the ducts. However, the pain medicine and sedative should keep you from feeling too much discomfort. After the procedure, you will need to stay at the hospital for 1 to 2 hours until the sedative wears off. The physician will make sure you do

The digestive system

not have signs of complications before you leave. If any kind of treatment is done during ERCP, such as removing a gallstone, you may need to stay in the hospital overnight.

Preparation

Your stomach and duodenum must be empty for the procedure to be accurate and safe. You will not be able to eat or drink anything after midnight the night before the procedure, or for 6 to 8 hours beforehand, depending on the time of your procedure. Also, the physician will need to know whether you have any allergies, especially to iodine, which is in the dye. You must also arrange for someone to take you home—you will not be allowed to drive because of the sedatives. The physician may give you other special instructions.

Percutaneous transhepatic cholangiography

Definition

Percutaneous transhepatic cholangiography (PTHC) is an x-ray test used to identify obstructions either in the liver or bile ducts that slow or stop the flow of bile from the liver to the digestive system.

Purpose

Because the liver and bile ducts are not normally seen on x rays, the doctor injects the liver with a special dye that will show up on the resulting picture. This dye distributes evenly to fill the whole liver drainage system. If the dye does not distribute evenly, this is indicative of a blockage, which may be caused by a gallstone or a tumor in the liver, bile ducts, or pancreas.

Precautions

Patients should report allergic reactions to:

anesthetics dyes used in medical tests iodine shellfish

PTHC should not be performed on anyone who has cholangitis (inflammation of the bile duct), massive ascites, a severe allergy to iodine, or a serious uncorrectable or uncontrollable bleeding disorder. Patients who have diabetes should inform their doctor.

Description

PTHC is performed in a hospital, doctor's office, or outpatient surgical or x-ray facility. The patient lies on a movable x-ray table and is given a local anesthetic. The patient will be told to hold his or her breath, and a doctor, nurse, or laboratory technician will inject a special dye into the liver as the patient exhales.

The patient may feel a twinge when the needle penetrates the liver, a pressure or fullness, or brief discomfort in the upper right side of the back. Hands and feet may become numb during the 30-60 minute procedure.

The x-ray table will be rotated several times during the test, and the patient helped to assume a variety of positions. A special x-ray machine called a fluoroscope will track the dye's movement through the bile ducts and show whether the fluid is moving freely or if its passage is obstructed.

PTHC costs about $1,600. The test may have to be repeated if the patient moves while x rays are being taken.

Preparation

An intravenous antibiotic may be given every 4-6 hours during the 24 hours before the test. The patient will be told to fast overnight. Having an empty stomach is a safety measure in case of complications, such as bleeding, that might require emergency repair surgery. Medications such as aspirin, or non-steroidal anti-inflammatory drugs that thin the blood, should be stopped three-seven days prior to taking the PRHC test. Patients may also be given a sedative a few minutes before the test begins.

Aftercare

A nurse will monitor the patient's vital signs and watch for:

itching flushing nausea and vomiting sweating excessive flow of saliva possible serious allergic reactions to contrast dye

The patient should stay in bed for at least six hours after the test, lying on the right side to prevent bleeding from the injection site. The patient may resume normal eating habits and gradually resume normal activities. The doctor should be informed right away if pain develops in the right abdomen or shoulder or in case of fever, dizziness, or a change in stool color to black or red.

Risks

Septicemia (blood poisoning) and bile peritonitis (a potentially fatal infection or inflammation of the membrane covering the walls of the abdomen) are rare but serious complications of this procedure. Dye occasionally leaks from the liver into the abdomen, and there is a slight risk of bleeding or infection.

Normal results

Normal x rays show dye evenly distributed throughout the bile ducts. Obesity, gas, and failure to fast can affect test results.

Abnormal results

Enlargement of bile ducts may indicate:

obstructive or non-obstructive jaundice cholelithiasis (gallstones) hepatitis (inflammation of the liver) cirrhosis (chronic liver disease) granulomatous disease pancreatic cancer bile duct or gallbladder cancers

Key Terms

Ascites Abnormal accumulation of fluid in the abdomen.

Bile ducts Tubes that carry bile, a thick yellowish-green fluid that is made by the liver, stored in the gallbladder, and helps the body digest fats.

Cholangitis Inflammation of the bile duct.

Fluoroscope An x-ray machine that projects images of organs.

Granulomatous disease Characterized by growth of tiny blood vessels and connective tissue.

Jaundice Disease that causes bile to accumulate in the blood, causing the skin and whites of the eyes to turn yellow. Obstructive jaundice is caused by blockage of bile ducts, while non-obstructive jaundice is caused by disease or infection of the liver.

What Is PTC?Percutaneous transhepatic cholangiography,or PTC, is a way of examining the bile ductsystem in the liver. This procedure is doneunder local anesthesia by a radiologist. Duringthe exam, a thin needle is inserted through theskin (percutaneous) and through the liver(transhepatic) into a bile duct. Then dye is injected,and the bile duct system is outlined onx-rays (cholangiography).Why Is PTC Done?Bile is a body fluid that helps your body digestfats. It is produced by the liver and collectedin tiny bile ducts that empty into increasinglylarger ducts. Finally, a main bile duct carriesbile to the small intestine. Bile also is stored inthe gallbladder.When one or more bile ducts narrows or has ablockage, bile may back up and cause problemssuch as jaundice, a yellowing of the skin.Or, a leak in a bile duct may allow bile to flowinto the abdominal cavity. PTC allows yourdoctor to see on the x-rays if the ducts are

partially or completely blocked. If necessary, athin, flexible tube (catheter) may be insertedto allow the bile to drain into a collection bagoutside the body, or into the small intestine.This procedure is called biliary drainage.The drawing below shows the liver with thebile duct (biliary) “tree,” and the PTC needleinserted into a bile duct.PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHYAND BILIARY DRAINAGEcontinuedliverneedle Bile duct (bile duct “tree”)UPMCHealth SystemInformationfor Patients

Before Your PTC ProcedureOn the morning of your procedure, you mayhave a clear liquid breakfast, such as ginger aleor tea. Do not eat any solid foods. You willnot be allowed solid food until after your PTCis over. You may continue to drink clear liquids.Before your procedure, a radiologist will visityou and describe the PTC procedure to you.He or she also will discuss biliary drainagewith you in case you need to have this proceduredone during the PTC. You will be askedto sign a consent form that gives your permissionto have the procedures.You also will be asked if you are allergic to anymedications, especially antibiotics or iodine. Besure to tell your doctor and nurse if you havethese allergies or if you have had anyreactions to antibiotics or x-ray dye. This informationwill help your doctor and nurse toplan your care during the procedure. An intravenous(IV) line will be placed in a vein inyour arm so that you can receive medicationsduring the procedure.PTC is done in the Vascular and InterventionalRadiology Laboratory on the first floorof Presbyterian University Hospital. You willbe taken to the lab on a wheeled stretcher, anda nurse will help you get on the examinationtable. Patches will be placed on your chest anda blood pressure cuff will be placed on yourarm so that staff may monitor your heart rateand blood pressure during the procedure.You will receive medications through your IVto help you relax. You will be awake duringthe procedure and will be able to talk withthose around you.The PTC Procedure

The skin on the right side of your abdomenwill be cleaned with special soap, and the areawill be draped with sterile cloths. Your skinwill then be numbed with a local anesthetic.Once the area is numb, the doctor will insertduodenum (first part of small intestine)liverstomachcommon bile ductskincatheterUPMCHealth SystemInformationfor Patientscontinueda thin needle through your skin, between theribs, through the liver, into a bile duct. As theneedle is withdrawn, a small amount of dyewill be injected and x-rays will be taken. If youhave any discomfort, please tell your doctor ornurse. He or she can give you medication torelieve any discomfort you may feel.If the PTC results show a problem, such as ablockage in the bile duct, the doctor may replacethe thin needle with a small drainagetube (catheter) that will be threaded into thesmall intestine (see illustration). A smallpouch may be attached to the end of the catheteroutside your body to collect bile.PTC usually takes about one hour to perform.If a drainage tube needs to be inserted, theprocedure may take longer, depending onhow easily the tube can be threaded throughthe bile duct.After the ProcedureFollowing the procedure, your heart rate,temperature, breathing, and blood pressurewill be checked frequently. The bile in thecollection pouch also will be checked for color,amount, and presence of blood, and you willreceive several more doses of antibiotic medicationthrough your IV to prevent infection.Going Home With a Catheterin PlaceIf you are to be discharged with a catheter inplace, your nurse will teach you how to carefor the catheter at home. You will learn howto change the bandage around the catheter,how to do daily irrigations through the tube(flushing the catheter with water), and whatto do about showering or bathing.Bandage ChangesThe bandage around the catheter will need tobe changed every day, or any time it becomes

soiled or wet. To change your bandage, firstgather all the materials you will need andplace them near you. Then wash your handsthoroughly with warm water and soap. Tochange the bandage, do the following steps:1. Remove the old bandage.2. Soak a cotton swab in hydrogen peroxideand clean carefully under the blue plasticdisc that helps to secure the catheter. Becareful not to put any pressure on the catheterand not to pull on it at any time.3. Inspect the skin around the catheter forredness, tenderness, or drainage. Also checkto see that the catheter has not changedposition. Call your doctor if you notice anyof these signs.4. Slit a 4-inch by 4-inch gauze square fromone side to the middle of the gauze andplace it around the catheter on top of thedisc. Slit a second 4-inch-square gauze padin the same way and place it around thecatheter on top of the first bandage. Makesure the slits are on opposite edges whenthe pads are on top of each other. Do notplace a gauze bandage under the disc; thiscould cause the catheter to pull out.5. Cover the bandage completely with stripsof sterile tape.IrrigationsYour doctor may want your catheter to becapped. A cap, rather than a collection bag, onthe outside end of the catheter will allow bileto flow directly into the small intestine. If thecatheter is to be capped, you may need to flush(irrigate) the catheter periodically to keep itfrom becoming clogged. Your doctor will tellyou if the catheter is to be capped. Ask yourdoctor if you will need to irrigate the catheter.UPMCHealth SystemInformationfor PatientscontinuedYour doctor or nurse will tell you how to irrigateyour catheter if it is capped. If fluid willnot go into the catheter when you try to irrigateit, you should stop trying to irrigate thecatheter and call your doctor immediately.ShoweringYou may shower with the catheter in place, butyou will need to cover the gauze bandage. Tocover the bandage, place a piece of plastic wrapover the bandage and tape all the edges of theplastic wrap to prevent water from seeping in. Ifthe bandage becomes wet or damp, follow the

steps listed previously to change the bandage.QuestionsPlease share this information with your family,and ask your doctors and nurses any questionsyou or your family may have.The institutions of UPMC Health System prohibit and will not engage in discrimination or harassment on the basis of race, color, religion, nationalorigin, ancestry, sex, age, marital status, familial status, sexual orientation, disability, or status as a disabled veteran or a veteran of the Vietnamera. Further, the institutions will continue to support and promote equal employment opportunity, human dignity, and racial, ethnic, and culturaldiversity. This policy applies to admissions, employment, and access to and treatment in UPMC Health System programs and activities. This is acommitment made by the institutions of UPMC Health System in accordance with federal, state, and/or local laws and regulations.200 Lothrop StreetPittsburgh, PA15213-2582© UPMC Health System 2000SYS10251 JS/NM ORIG 2/00Form # 4868-7660-0200

For assistance in finding a doctor or health service that suits your needs, call the UPMC ConsumerReferral Service at (412) 647-UPMC (8762).

Tests & Procedures

Cholecystography

(Gallbladder Series, GB Series, Oral Cholecystography, Oral Cholecystogram, X-rays of the Gallbladder)

Procedure Overview

What is cholecystography?

Cholecystography is an x-ray procedure used to examine the gallbladder when gallstones are suspected. A contrast dye is swallowed prior to the procedure. The contrast dye allows for better visualization of gallstones and other abnormalities of the gallbladder that cannot be seen on a standard x-ray of the abdomen.

X-rays use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film. X-rays are made by using external radiation to produce images of the body, its organs, and other internal structures for diagnostic purposes. X-rays pass through body structures onto specially-treated plates (similar to camera film) and a "negative" type picture is made (the more solid a structure is, the whiter it appears on the film).

Contrast dye, when swallowed prior to the cholecystogram, causes the gallbladder to appear opaque on a cholecystogram x-ray film. Gallstones will appear as dark spots within the gallbladder or bile ducts. Depending on how well the contrast dye has been absorbed, polyps and tumors may also be visible on the x-ray film.

Due to the development of improved technology, cholecystography is no longer performed routinely. Ultrasound and computed tomography (CT scans) are faster and often more accurate in diagnosing conditions of the gallbladder.

Other related procedures that may be used to diagnose problems of the gallbladder include abdominal x-rays, CT scan of the liver and biliary tract, abdominal ultrasound, endoscopic retrograde cholangiopancreatography (ERCP), and gallbladder nuclear scans. Please see these procedures for additional information.

What are gallstones?

Gallstones form when bile stored in the gallbladder hardens into stone-like material. Too much cholesterol, bile salts, or bilirubin (bile pigment) can cause gallstones. Slow emptying of the gallbladder can also contribute to the formation of gallstones.

When gallstones are present in the gallbladder itself, it is called cholelithiasis. When gallstones are present in the bile ducts, it is called choledocholithiasis. Gallstones that obstruct bile ducts can lead to severe or life-threatening infection of the bile ducts, pancreas, or liver. Bile ducts can also be obstructed by cancer or trauma.

There are two types of gallstones: cholesterol stones and pigment stones. Eighty percent of gallstones are cholesterol stones. The size of gallstones varies from a grain of salt to golf-ball size. A person can develop a single stone or several stones.

What are the symptoms of gallstones?

At first, most gallstones do not cause symptoms. However, when gallstones become larger, or when they begin obstructing bile ducts, symptoms or "attacks" begin to occur. Attacks of gallstones usually occur after a fatty meal and at night. The following are the most common symptoms of gallstones. However, each individual may experience symptoms differently. Symptoms may include, but are not

click image to enlarge

limited to, the following:

← pain that comes and goes in the abdomen ← nausea and/or vomiting ← fever and/or chills ← jaundice - yellowing of the skin and eyes ← abdominal bloating ← intolerance of fatty foods ← belching or gas, and indigestion

The symptoms of gallstones may resemble other medical conditions or problems. Always consult your physician for a diagnosis.

Reasons for the Procedure

Cholecystography may be performed when signs and symptoms of gallbladder disease, such as right upper quadrant abdominal pain, jaundice, and intolerance of fat in the diet are present. These symptoms may indicate the presence of gallstones or other obstructions in the gallbladder and/or bile ducts.

In addition to gallstones and obstruction of the bile ducts, other conditions that may be detected by cholecystography include, but are not limited to, polyps, tumors, inflammation, infection, and nonfunctioning gallbladder.

There may be other reasons for your physician to recommend cholecystography.

Risks of the Procedure

The amount of radiation used during a cholecystography is considered minimal; therefore, the risk for radiation exposure is very low.

If you are pregnant or suspect that you may be pregnant, you should notify your physician. Radiation exposure during pregnancy may lead to birth defects.

If contrast dye is used, there is a risk for allergic reaction to the dye. Patients who are allergic to or sensitive to medications, contrast dye, iodine, or shellfish should notify their physician.

Patients with kidney failure or other kidney problems should notify their physician. In some cases, the contrast dye can cause kidney failure, especially if the person is taking Glucophage (a diabetic medication).

Patients with liver disease or other liver damage should notify their physician, as impaired liver function decreases the usefulness of the contrast dye.

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Certain factors or conditions may interfere with the results of the test. These factors include, but are not limited to, the following:

← inadequate absorption of the contrast dye due to liver disease or damage, vomiting and/or diarrhea after swallowing the dye, intestinal malabsorption, or gallbladder inflammation

← barium within the intestines due to a recent barium x-ray procedure

Before the Procedure

← Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

← You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear.

← Notify the radiologic technologist if you have ever had a reaction to any contrast dye, or if you are allergic to iodine or seafood.

← Notify your physician if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).

← Your physician will give you instructions regarding fasting prior to the procedure. Generally, you will be instructed to eat a fat-free meal the night before the procedure, then withhold food and liquids after midnight. You may also be instructed to withhold cigarettes and chewing gum as well.

← Notify the radiologic technologist if you are pregnant or suspect you may be pregnant.

← Your physician will give you the contrast dye to swallow the night before the procedure. It is very important that you follow the instructions exactly as given in order to obtain adequate contrast visualization of the gallbladder.

← Notify the radiologic technologist if you have any vomiting or diarrhea after taking the contrast dye, because the procedure may have to be rescheduled if too much contrast dye was lost.

← Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

Cholecystography may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your physician's practices.

Generally, cholecystography follows this process:

1. You will be asked to remove any clothing or jewelry that may interfere with the exposure of the body area to be examined.

2. If you are asked to remove clothing, you will be given a gown to wear.

3. You may be given an enema prior to the procedure to clear the intestines of gas or feces that may interfere with imaging of the gallbladder.

4. You will be positioned in a manner that carefully places the part of the abdomen that is to be x-rayed between the x-ray machine and a cassette containing the x-ray film. You may be asked to stand erect, to lie flat on a table, or to lie on your side on a table, depending on the x-ray view your physician has requested. You may have x-rays taken from more than one position.

5. Body parts not being imaged may be covered with a lead apron (shield) to avoid exposure to the x-rays.

6. Once you are positioned, the radiologic technologist will ask you to hold still for a few moments

while the x-ray exposure is made.

7. It is extremely important to remain completely still while the exposure is made, as any movement may distort the image and even require another x-ray to be done to obtain a clear image of the body part in question.

8. The x-ray beam will be focused on the area to be photographed.

9. The radiologic technologist will step behind a protective window while the image is taken.

10. Several x-rays will be taken while you are in various positions.

11. If testing of the gallbladder’s ability to contract is requested, you will be given some type of fatty intake to stimulate gallbladder contraction. You may be given a fatty meal, or you may be given a fatty synthetic substance either by mouth or by intravenous (IV) injection. Additional x-rays will be taken after you have consumed the fatty intake.

The radiologist will look at the x-ray films before you leave to ensure that the gallbladder was adequately visualized during the procedure. If the x-rays are inadequate, the test may need to be repeated.

After the Procedure

Generally, there is no special type of care following cholecystography. However, your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.

Because the contrast dye is excreted from the body through the kidneys, you may feel some slight discomfort with urination for a day or so.

Gallbladder Mucocele

Last Updated: June 15, 2005

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Synonyms and related keywords: hydrops of the gallbladder, gallstone disease, overdistended gallbladder filled with mucoid or clear and watery content, outlet obstruction of the gallbladder, cholecystitis, Mirizzi syndrome, common bile duct obstruction, cholangitis

  AUTHOR INFORMATION Section 1 of 10   

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Author: Rajagopalan Vijayaraghavan, MBBS, MS, MMed, FRCSEd, FICS, Consulting Surgeon, Department of Surgery, RMV Hospital, Bangalore, India Rajagopalan Vijayaraghavan, MBBS, MS, MMed, FRCSEd, FICS, is a member of the following medical societies: International College of Surgeons, and Royal College of Surgeons of England Editor(s): Oscar Joe Hines, MD, Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michael A Grosso, MD, Department of Cardiothoracic Surgery, St Francis Hospital; Paolo Zamboni, MD, Chair of Surgical Methodology, Assistant Professor, Department of Surgical, Anesthesiological, and Radiological Sciences, University of Ferrara Medical Center, Ferrara, Italy; and John Geibel, MD, DSc, Director, Professor, Departments of Surgery and Cellular and Molecular Physiology, Yale-New Haven Hospital, Yale University School of Medicine

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  INTRODUCTION Section 2 of 10   

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Gallstone disease is the most common affliction of the biliary system, affecting 15-20% of the US population, with nearly 1 million new cases reported annually.

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Problem: Mucocele or hydrops of the gallbladder describes an overdistended gallbladder filled with mucoid or clear and watery content. This usually noninflammatory distension results from an outlet obstruction of the gallbladder and is commonly caused by an impacted stone in the neck of the gallbladder or in the cystic duct.

Frequency: About 3% of all pathologic gallbladders in adults are mucoceles. The true prevalence may be higher because of the varying criteria used by different authors to define the condition.

Reports indicate that an association could exist between mucoceles and solitary stones of the gallbladder.

Etiology: Causes include the following:

Impacted stone in the gallbladder neck or cystic duct Spontaneously resolved acute cholecystitis Tumors - Polyps or malignancy of the gallbladder Extrinsic compression of the neck or cystic duct by

lymph nodes or inflammatory fibrosis or adjacent malignancies in the liver, duodenum, or colon

Prolonged total parenteral nutrition or ceftriaxone therapy

Congenital narrowing of the cystic duct Parasites such as Ascaris (occasionally) In children and infants, acute, acalculous,

noninflammatory hydrops of the gallbladder may be associated with the following:

o Kawasaki syndrome (mucocutaneous lymph node syndrome)

o Streptococcal pharyngitis o Mesenteric adenitis o Typhoid o Leptospirosis o Hepatitis o Familial Mediterranean fever o Nephrotic syndrome o Fibrocystic disease

Other problems to be considered include the following:

Hepatomegaly, choledochal cyst Courvoisier gallbladder due to simultaneous

obstruction of the gallbladder and common bile duct Pseudocyst of the pancreas Renal mass Right suprarenal gland mass

Gallstones Treatment

Mesenteric cysts Parasitic cysts - Hydatid cyst Ascending colon mass

Pathophysiology: Long-standing obstruction to the outflow from the gallbladder results in overdistension of the gallbladder; occasionally, the gallbladder assumes massive proportions and the volume may be as much as 1.5 liters. The bile or bile pigment is slowly resorbed, and continuing secretion from the mucosa of the gallbladder results in clear and watery or mucoid content (white bile). The wall may be of normal thickness, or, in long-standing cases, the mucosa atrophies and the wall becomes thin, sometimes even transparent. Wall thickening can occur with recurrent attacks of cholecystitis. The contents are usually sterile, and any bacterial contamination ends in empyema of the gallbladder. Gross overdistension may result in gangrene and/or perforation of the gallbladder, with ensuing pericholecystic collection or peritonitis. The severity of the inflammatory episode dictates the clinical presentation.

Microscopic examination reveals a flattened mucosa lined by low columnar or cuboidal cells; the increased intraluminal pressure results in plentiful Rokitansky-Aschoff sinuses. Inflammatory cells may be present either in small numbers or in abundance.

Clinical: Symptomatology includes right upper quadrant (RUQ) pain or epigastric pain and discomfort, nausea, and vomiting. Continuance of pain or persistence of tenderness longer than 6 hours indicates possible acute cholecystitis. Fever and chills suggest infected bile, with a possible empyema of the gallbladder. Jaundice is unusual except in coexisting obstruction of the common bile duct either by stones or by extrinsic compression (Mirizzi syndrome). A palpable, somewhat tender mass is usual; the gallbladder at times may even be felt down in the pelvis.

Diagnostic criteria

The diagnosis of a mucocele should be considered in the following:

Minimal acute inflammatory signs are present. A large, palpable, minimally tender gallbladder is found

on clinical examination. Laboratory test results are normal or just within the

upper limit of reference range values. Plain radiograph of the abdomen shows a soft tissue

density globular shadow in the subhepatic region.

Ultrasonography of the RUQ shows evidence of minimal wall thickening, an impacted stone in the neck, or infundibulum of an enlarged gallbladder and clear content.

Intraoperatively, the aspirate from the gallbladder is clear and watery or mucoid (white bile).

The gallbladder on opening shows a white wall; clear, watery, or mucoid content; a stone or stones impacted in the neck or the cystic duct; a narrowed cystic duct; or a tumor and/or polyp causing obstruction of the neck of the gallbladder.

  INDICATIONS Section 3 of 10   

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See Surgical therapy.

 RELEVANT ANATOMY AND CONTRAINDICATIONS

Section 4 of 10   

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Relevant Anatomy: See Pathophysiology.

Contraindications: The contraindications to surgical treatment of mucocele of the gallbladder obviously would include any associated medical conditions or illnesses that preclude surgery. No absolute contraindication exists.

Laboratory research has indicated that chemical ablation of the gallbladder mucosa might be an alternative in patients who are medically unfit, elderly, or critically ill. A combination of ethanol, sodium tetradecyl sulfate, and a mucosal exfoliant has been tried successfully in rats.

  WORKUP Section 5 of 10   

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Lab Studies:

No single laboratory test is diagnostic of a mucocele. However, laboratory workup should include all tests performed for acute cholecystitis.

A mild leukocytosis with a shift to the left is common. Higher counts indicate the possibility of acute cholecystitis or infected bile. Bilirubin levels are usually within the reference range or may be mildly raised in

cases of Mirizzi syndrome or in those with associated common bile duct (CBD) obstruction or cholangitis. Liver enzymes are usually within the reference range, although a mild rise in alkaline phosphatase may be present. Any gross rise should raise the suspicion of an obstructed CBD. Serum amylase levels are generally within the reference range; any gross rise suggests the possibility of acute pancreatitis due to an obstruction close to the ampulla of Vater.

Imaging Studies:

Ultrasonography, although entirely operator dependent, is extremely sensitive in detecting stones in the gallbladder. A grossly distended thin-walled gallbladder measuring over 5 cm across anteroposteriorly, an impacted stone in the infundibulum or neck of the gallbladder or in the cystic duct, and clear fluid content indicate a possible mucocele. Sonographic Murphy sign may be positive. The wall may be thickened, and a small amount of pericholecystic fluid may be present in cases with acute cholecystitis. Gross wall thickening and murky, thick fluid with sediments and a pericholecystic collection suggest an empyema or pyocele of the gallbladder. Ultrasonography is also useful in identifying ductal obstruction and is extremely sensitive in identifying intrahepatic biliary tree dilatation.

Plain radiograph of the abdomen may show a soft tissue density shadow with an intraluminal calcific shadow in the subhepatic region. This finding alone is nonspecific and should only be used as a guideline in differential diagnosis.

Scintigraphy (hepato-iminodiacetic acid [HIDA] scan) may be indicated in obscure cases, although it can only offer indirect evidence. Nonvisualization of the gallbladder indicates an obstructed gallbladder and possible acute cholecystitis; nonvisualization in the small intestine indicates CBD obstruction.

CT scan may be indicated in cases where the diagnosis is unclear or where other associated conditions and/or complications must be assessed. The gallbladder is well visualized, and the wall and contents can be assessed; however, stones may be difficult to identify. Associated hepatic conditions, pancreatitis, and complications such as an abscess formation and perforation of the gallbladder may be better assessed with a CT scan.

Magnetic resonance cholangiopancreatography (MRCP) clearly shows the biliary-pancreatic tree, and it is being used increasingly instead of a diagnostic endoscopic retrograde choledochopancreatography (ERCP) to assess the biliary tree; cholecystokinin (CCK)-enhanced studies are more specific.

Occasionally, percutaneous injection of contrast into the mass may be

carried out to identify anatomical details.

  TREATMENT Section 6 of 10   

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Medical therapy: Do not consider a medical line of management with oral dissolution therapy in obstructed gallbladders. In acalculous hydrops observed in children as a part of a wider spectrum, expectant management may be considered.

Surgical therapy: Cholecystectomy is the definitive treatment for an obstructed gallbladder. Laparoscopic cholecystectomy is the criterion standard procedure. Open cholecystectomy may be performed in patients with very large gallbladders, those with greatly thickened walls, and those with an obliterated Calot triangle in whom laparoscopic dissection could be difficult and time consuming.

In some patients, percutaneous (ultrasound-guided) or open cholecystostomy may be used as a temporary measure; cholecystostomy is usually performed in very sick patients or when the dissection is technically very difficult. A subsequent completion cholecystectomy may be carried out once the initial condition improves.

Preoperative details: In patients with systemic signs and symptoms, preoperative management should include correction of hydration, nasogastric drainage (if necessary), and appropriate broad-spectrum antibiotic therapy. Preferably, cholecystectomy is carried out in the same admission.

Intraoperative details: Intraoperative aspiration of the large gallbladder helps to facilitate grasping the gallbladder for dissection.

Intraoperative cholangiography is indicated, depending on clinical and investigative features that may suggest CBD obstruction.

  COMPLICATIONS Section 7 of 10   

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Progressive inflammation leads to acute cholecystitis and all its attendant manifestations.

Bacterial contamination of the bile leads to an empyema of the gallbladder; the patient usually has a toxic and ill appearance. Gas-producing organisms may lead to an emphysematous gallbladder; air bubbles in the wall of the gallbladder are visualized on plain radiograph, ultrasound, or CT scan.

Perforation of the gallbladder with ensuing pericholecystic abscess or fluid collection and peritonitis is another complication; the diagnosis is usually strongly suspected on clinical grounds. Pseudomyxoma peritonei may result from the rupture of a true mucocele of the

gallbladder. Perforation of the gallbladder into the duodenum results in a

cholecystenteric fistula. This occurs when the stone erodes into adjacent bowel, usually the duodenum. Gas in the biliary tree may be evident on plain radiographs of the abdomen or on ultrasonography. If the stone is large, this may result in obstruction of the distal small bowel, leading to gallstone ileus.

Large gallbladders may compress on the pylorus or duodenum, causing gastric outlet obstruction.

  OUTCOME AND PROGNOSIS Section 8 of 10   

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The prognosis is excellent if diagnosis is correct and no complications have ensued.

For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center and Cholesterol Center. Also, see eMedicine's patient education article Gallstones.

  PICTURES Section 9 of 10   

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Caption: Picture 1. Gallbladder mucocele. This is the ultrasound picture of a 35-year-old woman presenting with recurrent episodes of right upper quadrant (RUQ) colic. Her most recent attack was 3 days ago. Note the gross wall thickening; this is usually measured on the anterior wall of the gallbladder on ultrasound examination. Also note the clear content, the stone in the neck of the gallbladder, and the absence of pericholecystic fluid. All favor a diagnosis of acute cholecystitis.

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Caption: Picture 2. Gallbladder mucocele. These pictures clearly show a stone in the neck of the gallbladder, with postacoustic shadowing. Also, the minimal wall thickening and a dilated gallbladder suggest a mucocele.

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Picture Type: CTCaption: Picture 3. Gallbladder mucocele. This transverse scan of the gallbladder shows a stone in the neck of the gallbladder, with postacoustic shadowing. Also, minimal wall thickening and a dilated gallbladder are visible (see Image 2).

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Picture Type: CTCaption: Picture 4. Gallbladder mucocele. These transverse scans of the gallbladder show layering of the gallbladder wall; this suggests edema and indicates an acute cholecystitis.

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Picture Type: CTCaption: Picture 5. Gallbladder mucocele. This longitudinal scan shows layering with fluid in the wall of the gallbladder and an impacted stone in the neck of the gallbladder. The intraluminal shadowing indicates sediments in the fluid; this image indicates acute cholecystitis with a possible pyocele of the gallbladder.

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Picture Type: CTCaption: Picture 6. This scan shows a cluster of impacted calculi in the neck of the gallbladder, minimal wall thickening, and clear content. This is indicative of a

mucocele of the gallbladder.

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Picture Type: CTCaption: Picture 7. This scan clearly shows a cluster of calculi with postacoustic shadowing in the neck of the gallbladder, normal wall, and clear content; this indicates a mucocele of the gallbladder.

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Picture Type: CTCaption: Picture 8. Gallbladder mucocele. This perioperative photograph of a gallbladder shows a distended gallbladder with evidence of adhesions on the wall of the gallbladder. The irregular surface indicates recurrent attacks of cholecystitis.

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Picture Type: PhotoCaption: Picture 9. Gallbladder mucocele. This intraoperative photograph shows a subserosal perforation of an acute, emphysematous, acalculous cholecystitis in a 58-year-old diabetic man. He presented with features suggestive of ileus. He had a high intrathoracic liver (and gallbladder), and clinical signs were atypical. The green color is unusual.

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Caption: Picture 10. Gallbladder mucocele. This perioperative photograph of a gallbladder shows the inflamed mucosa in a gallbladder; note the stones.

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Picture Type: PhotoCaption: Picture 11. Gallbladder mucocele. This perioperative photograph of a gallbladder in a patient with acute cholecystitis shows an inflamed, edematous gallbladder with areas of erythema and congestion.

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Picture Type: PhotoCaption: Picture 12. Gallbladder mucocele. This intraoperative photograph shows a yellowish aspirate from the gallbladder of a 28-year-old woman who presented with features of right upper quadrant peritonitis. The slightly yellowish fluid was sterile and was rich in cholesterol.

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