Gallbladder function and recurrent stones of the biliary tract in patients after endoscopic sphincterotomy

Nuclear medicine tests for acute gastrointestinal conditions

Acute cholecystitis (AC) and lower-gastrointestinal (GI) bleeding are 2 emergencies commonly encountered in nuclear medicine. Evidence of AC on hepatobiliary scintigraphy (HBS) allows for confident diagnosis and provides support for definitive surgical treatment. Proper patient preparation is essential for HBS including fasting and the use of pharmacologic adjuncts is sometimes required. Pharmacologic adjuncts may also be administered during HBS to shorten the length of the examination and increase its specificity. In the interpretation of HBS, there are several sources of false-positive results to be aware of, most commonly chronic cholecystitis. False-negative results on HBS are usually the result of mistaking another structure, such as a dilated cystic duct, for the gallbladder. Abdominal ultrasound is the appropriate initial test in patients with suspected AC, but HBS is an excellent second tier test for the diagnosis of AC in the work-up of indeterminate cases by sonography. GI bleeding scintigraphy plays an important role in the evaluation and management of patients with acute lower-GI bleeding. Scintigraphy serves to localize sites of active GI bleeding and stratify those patients who would benefit from aggressive treatment (surgery or arteriography) vs those who can be managed medically. Pretest involvement of respective services is critical for successful bleeding site confirmation and therapy by interventional radiology or surgery or both. Single photon emission computed tomography/computed tomography erythrocyte scintigraphy has demonstrated superior accuracy and precision over planar scintigraphy in the diagnosis of acute GI bleeding. Additionally, single photon emission computed tomography/computed tomography scintigraphy of GI bleeding provides useful supplemental anatomical information that benefits patient management.

Hepatobiliary scintigraphy in acute cholecystitis

Hepatobiliary scintigraphy is a mature imaging technique for evaluation of patients with acute cholecystitis (AC). It is effective in calculous and acalculous forms of AC. The test is used in contemporary medical practice as the arbiter when the findings from screening abdominal ultrasound do not fit a clinical picture. It is also performed in severely ill patients who have AC suspected on other testing, but whose frail condition and high operative risk demand the highest level of certainty. This review, therefore, examines all technique variations of hepatobiliary scintigraphy, offering an approach that may best fit a variety of clinical situations and philosophies on AC.

Endoscopic management of recurrent primary bile duct stones

BACKGROUND

The management of recurrent choledocholithiasis today remains as challenging as in the pre-endoscopic era. Between 2 and 7% of affected patients have historically required surgical intervention for the treatment of recurrent or retained choledocholithiasis and of these, as many as 24% develop biliary complications. To avoid surgery, repeated endoscopic management of the problem has been suggested. In this study, we evaluate our policy of repeated endoscopic management of recurrent primary bile duct stones.

METHODS

This study examined a cohort of nine patients identified from a prospective database with recurrent choledocholithiasis. Demographic, clinical and investigative details were recorded and data were analysed. Complications were determined from a review of the patient's file.

RESULTS

There were nine patients and 66 procedures were carried out. Mean age at time of first endoscopy was 70.1 years (36-91 years). Three patients were of male sex (33.3%). The mean number of endoscopies carried out per patient was 7.3 (3-13). Failure to completely clear the duct occurred in 36.4% of all endoscopies. There were no periprocedural complications.

CONCLUSION

Repeated endoscopic stone extraction by endoscopic retrograde cholangiopancreatography when required is a safe policy. However, this technique will only provide temporary relief from primary duct stones and repeated endoscopic treatment, again safe, will be required.

Does cholecystectomy after endoscopic sphincterotomy prevent the recurrence of biliary complications?

BACKGROUND

The intact gallbladder after endoscopic sphincterotomy is thought to be a potential risk factor for recurrent biliary complications. The aim of this non-randomized prospective study was to investigate whether cholecystectomy soon after endoscopic sphincterotomy could prevent the recurrence of biliary complications.

METHODS

From January 1991 to October 1995, 140 patients with intact gallbladder underwent endoscopic sphincterotomy for clearance of stones in the bile duct. Of the 140 patients, 46 underwent elective cholecystectomy soon after sphincterotomy (group A) and 94 did not (group B). All 140 patients had quantitative cholescintigraphy after normalization of liver function and were followed on a regular basis with liver biochemistry, sonography, and/or computed tomography. Endoscopic retrograde cholangiography was also performed if a recurrent biliary problem was suspected.

RESULTS

After a median 43 months (range 23 to 80) of follow-up, 5 patients in group A developed bile duct stones whereas 12 patients in group B had recurrent stones; 4 patients in group A versus 6 patients in group B had recurrent biliary symptoms. One patient in group A and 5 patients in group B with recurrent biliary stones were without symptoms. In group B, the age, gender, diameter of the bile duct, preexisting cholelithiasis, abnormal filling of the gallbladder on quantitative cholescintigraphy, and presence of juxtapapillary diverticulum were not found to be the significant factors affecting the recurrence of biliary symptoms or stones. Endoscopic removal of recurrent biliary stones was successful in all patients. Three patients in group B underwent cholecystectomy after abatement of symptoms.

CONCLUSION

Elective cholecystectomy after endoscopic sphincterotomy does not reduce the incidence of recurrent biliary complications.