Cholangiography and Biliary Regurgitation

Cholangiography, the roentgen study of the biliary tract by means of the direct introduction of a contrast medium, may be accomplished in a number of ways and with a number of contrast substances. The material may be injected directly into the gallbladder or the common duct—immediate cholangiography—at the time of a surgical exploration of the biliary tract. Roentgenograms are then made on the operating table (Fig. 1). More commonly the injection is made postoperatively through a drainage tube previously inserted into the gallbladder or the common duct—delayed cholangiography. Recently some efforts have been made to inject a radiopaque substance into the gallbladder before operation. This can be accomplished by either of two procedures. A catheter can be placed in the gallbladder through a simple abdominal incision. Cholangiography is then done and the situation of the biliary tract determined (Fig. 2). The information obtained will govern the exact type of surgery to be undertaken. Another method is that suggested by Horan (1) and Marcel Royer (2). Under the guidance of a peritoneoscope introduced into the peritoneal cavity, a needle is thrust into the gallbladder and the biliary tract is thus injected with the contrast medium. Roentgenograms may then be obtained and the presence or absence of calculi, strictures, tumors or other abnormalities may be determined. In the first attempts at cholangiography, Carnot and Blamoutier (3) used a barium suspension as a contrast medium but the medium was unsatisfactory, so the effort was unsuccessful. The first satisfactory result was accomplished by Lanari and Squirru (4), using lipiodol. A clear delineation of the major biliary ducts was obtained. This medium is still used by many radiologists, notably in South America. In this clinic, iodized oil as a contrast medium for cholangiography was abandoned many years ago because of its viscosity, its tendency to form globules, and the uneven distribution which resulted (Fig. 3). Following this we used thorotrast (thorium dioxide sol), finding it a most satisfactory substance because of its great opacity to x-rays and its ready miscibility with aqueous solutions. An unfortunate experience led us to discontinue its use. A patient, in whom a tube had been placed in the common duct during the course of a cholecystectomy, was given an injection of thorotrast through this opening. The tube, however, had been diverted from the duct and the inner end was lying in the peritoneal cavity. The contrast medium was therefore introduced into the peritoneal space. The result was a violent reaction, high fever, and evidences of peritoneal irritation. Recovery eventually occurred, but the thorium dioxide remained in the sinusoids of the peritoneum and in the lymph nodes for many years.