Oral Cholecystography

ORAL CHOLECYSTOGRAPHY
Oral cholecystography is a radiological procedure used to visualize the gallbladder and biliary

channels. In the last decade, it has been found that cholecystography is the most important single
objective aid in the diagnosis of dysfunction or disease of the gallbladder. A radiopaque cholegraphic
(contrast) agent, usually iopanoic acid (Telepaque) or its sodium or calcium salt, is orally administered,
which is absorbed by the intestine. This excreted material will collect in the gallbladder, where
reabsorption of water concentrates the excreted contrast. Since only 10% of gallstones are
radiopaque, the remaining 90% will appear as translucent on an opaque background in an abdominal
X-ray.
While sonography is the preferred method for demonstrating gallstones, and CT and MRI scans are
also commonly used to evaluate the gallbladder, cholecystography is still occasionally used because of
its ability to demonstrate both stones and gallbladder function. The gallbladder may be examined
using an orally administered contrast medium in the form of tablets (Telepaque, Bilopaque, or
Oragrafin) or Oragrafin granules.
INDICATIONS
This is an investigation which has largely become redundant over the last decade with the widespread
use of US and, to a lesser extent, of other more sophisticated imaging tools such as endoscopic
retrograde cholangiography (ERCP) and magnetic resonance cholangiography (MRCP). The indication for
its use now is to demonstrate suspected pathology in the gallbladder when ultrasound is not available or
has failed to demonstrate the gallbladder. 1,2
The cystic duct and common bile duct may also be seen. The examination is unlikely to be successful
when the serum bilirubin is greater than 34 μmol/l.
However, the following had been the indications in the past:
Gallstones (cholelithiasis)
Stones of the Bile duct (choledocholithiasis)
Cholangitis
Ca of the bile duct
Cholecystitis etc
CONTRA-INDICATIONS
1. Severe hepatic or renal disease
2. Acute cholecystitis
3. Dehydration
4. Intravenous cholangiography within the previous week (although this is now a rarely undertaken
investigation)
5. Previous cholecystectomy.
Contrast medium
1. Sodium ipodate (Biloptin); 6 capsules each containing 500 mg. This is the most widely used agent.
2. Iopanoic acid (Telepaque); 6 capsules each containing 500 mg.
Patient preparation for Biloptin
1. A laxative 2 days prior to the examination.
2. Light, fat-free diet on the day before the examination.
3. No food from 18:00 h on the day before the examination until after the examination has been
completed. Liquids (without milk) are allowed. The cholecystographic agent is taken with water after the
last meal prior to the patient's appointment.
Preliminary film
Prone 20° LAO, centred 7.5 cm to the right of the spinous processes, 2.5 cm cephalad to the lower costal
margin.
Position of patient and cassette
• The patient lies prone on the X-ray table. The right side is raised, rotating the median sagittal plane
through an angle of 20 degrees; the coronal plane is now at an angle of 20 degrees
to the table. The arm on the raised side is flexed so that the right hand rests near the patient’s head,
while the left arm lies alongside and behind the trunk. The patient is moved across the table until the
raised right side is over the centre of the table, and a compression band is applied.
A 24 _ 30-cm cassette is placed longitudinally in the Bucky tray with its centre 2.5 cm above the lower
costal margin to include the top of the iliac crest.
Direction and centring of the X-ray beam
• The vertical central ray is directed to a point 7.5 cm to the right of the spinous processes and 2.5 cm
above the lower costal margin and to the centre of the cassette. The exposure is made on arrested
respiration after full expiration.
Note
An additional image can be taken on arrested respiration after full inspiration to show the relative
movement of the gallbladder and overlying calcifications that are suspected to be outside the
gallbladder, e.g. within costal cartilages.
Films
1. Prone 20° LAO - contrast medium fills the fundus of the gallbladder.
2. Supine 20° RPO - contrast medium fills the neck and Hartmann's pouch.
3. Erect 20° LAO - may demonstrate floating gallstones.
4. Overlying bowel shadows may be removed by rotating the patient under fluoroscopic control or by
tomography.
5. Prone 20° LAO, 30 min after a fatty meal (chocolate or a proprietary fat emulsion). The value of this
film was found to be:
a. essential for the cholecystographic diagnosis of adenomyomatosis and cholesterolosis
b. occasionally helpful in diagnosing small stones
c. of little value in assessing the biliary ducts or separating the gallbladder from overlying bowel gas
d. of no value in the diagnosis of functional biliary tract disorders.
If the gallbladder is not seen on the first film, the patient is asked the following questions:
1. What time were the tablets taken? (Sufficient time is needed for absorption and concentration in the
gallbladder.)
2. How many tablets were taken?
3. Did diarrhoea or vomiting develop after the tablets were taken?
If the tablets have been taken, a 35 x 43-cm supine abdominal film is taken. This may demonstrate:
a. a gallbladder in an abnormal position, or
b. unabsorbed contrast medium. This has a flakey appearance and can be distinguished from esterified
contrast medium that has passed through the liver and biliary tract, which causes a more uniform,
fainter opacification.
If the gallbladder is only poorly seen, the patient is given a further standard dose to be taken that
evening and repeat films are taken the following day.
Additional techniques
For better visualization of the ducts, manufacturers make the following recommendations:
1. Biloptin - (i) 12 capsules at the usual time or (ii) 6 capsules 10-12 h before the examination plus
another 6 capsules 3 h before.
2. Telepaque - 3-6 tablets are taken 4 h after a fatty lunch on the day preceding the examination, and
then a full dose of 6 tablets after a fat-free meal in the evening.
Aftercare
None.
Complications
Side-effects, even of a trivial nature, are rare with sodium ipodate. Mild gastrointestinal disturbances -
nausea, with or without vomiting and diarrhoea - may occur. The incidence of diarrhoea is greatest with
iopanoic acid. Skin reactions - urticaria, vasodilatation and pruritus - have been recorded.
Cholecystographic agents have a uricosuric action and alteration of serum urate may precipitate an
attack of gout.
T- Tube and Surgical Cholangiography

After surgical cholecystectomy, (removal of the gall bladder), a tube is sometimes left temporarily in the
patient. This flexible rubber tube is about the size of a drinking straw in the shape of a T. The crossbars
of the T extend into the hepatic and common bile ducts.
The base of the T passes through the stump of the cystic duct or a tiny surgical opening in the common
bile duct and exits through a small opening left in the original incision.
The T tube serves primarily as a drain for bile until the postsurgical edema in the common bile duct sub•
sides and bile can pass normally into the duodenum. It also serves as an avenue for the administration
of a contrast agent if it is necessary to examine the biliary system postoperatively. This study may be
performed to detect residual calculi in the hepatic or common bile duct, but it is most frequently used to
determine the patency of the ducts before removing the drain.
A surgical T-tube cholangiogram may be performed in conjunction with cholecystectomy to ensure that
any calculi remaining in the ducts are detected and removed before closing the incision (Fig. 10-8).
Following an operative study, the T tube may or may not be left in place when the incision is closed.
During surgery the radiographer's duties are strictly technical. Patient care is accomplished by the
anesthesiologist, and contrast injection is performed by the surgeon with assistance from the surgical
staff.
Endoscopic Retrograde Cholangiopancreatography (ERCP)

ERCP is a fiber-optic examination of the common bile duct performed with an endoscope. The patient is
sedated and the back of the throat anesthetized. The tubular portion of the endoscope is then passed
through the patient's mouth, down the throat, and through the stomach into the duodenum under
fluoroscopic control. A small catheter is passed through the endoscope into the distal end of the
common bile duct through the papilla of Vater. Contrast is injected through the catheter, and spot films
or digital images record the cholangiogram radiographically.
Attachments for the gastroscope include a "stone basket" for the removal of biliary calculi.

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ORAL CHOLECYSTOGRAPHY

Oral cholecystography is a radiological procedure used to visualize the gallbladder and biliary

However, the following had been the indications in the past:

Stones of the Bile duct (choledocholithiasis)

Ca of the bile duct

1. Severe hepatic or renal disease

2. Iopanoic acid (Telepaque); 6 capsules each containing 500 mg.

Patient preparation for Biloptin

1. A laxative 2 days prior to the examination.

2. Light, fat-free diet on the day before the examination.

Position of patient and cassette

Direction and centring of the X-ray beam

3. Erect 20° LAO - may demonstrate floating gallstones.

a. essential for the cholecystographic diagnosis of adenomyomatosis and cholesterolosis

b. occasionally helpful in diagnosing small stones

d. of no value in the diagnosis of functional biliary tract disorders.

2. How many tablets were taken?

3. Did diarrhoea or vomiting develop after the tablets were taken?

a. a gallbladder in an abnormal position, or

T- Tube and Surgical Cholangiography

Endoscopic Retrograde Cholangiopancreatography (ERCP)

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