X-ray diagnostics of diseases of the gallbladder and biliary tract

Normal gallbladder is not available for x-ray study. It becomes visible only when pathological changes, accompanied by calcification of its walls, with some chronic inflammatory processes, which accompanies the seal of the walls, increasing its volume and in the presence of very concentrated bile. Gallstones are visible only in those cases when they have enable lime salts (Fig. 121). The most common pure cholesterol stones cannot be detected without the use of contrast media, because cholesterol is not delayed x-ray to a greater extent than the soft tissue adjacent organs surrounding the bladder.

Fig. 121. Multiple gall bladder stones that are visible without x-ray study (x-ray).

Indirect signs of the diseases of the gallbladder may be obtained in the study of the gastrointestinal tract changes from the pyloric portion of the stomach and duodenal ulcer. So, when pericholecystic onion very often drag up and right. When increases in the gall bladder on the lateral surface of the bulb may be formed depressions. Often onion expands and becomes great that, by M. I. Nemenov (1930) and Berg (1930), is one of the signs of gallbladder disease.
Direct diagnosis of diseases of the gallbladder was made possible with the introduction radiography, x-ray study. Cholecystography applies not only to recognize not visible under normal conditions of gallstones, but also for diagnostics of morphological changes of the gallbladder and functional disorders.
X-ray examination of the biliary tract is carried out in two ways: x-ray study and cholangiography.
Currently cholecystography is carried out by administration of contrast media through the mouth. Much less frequently used method of intravenous administration of contrast agent. By contrast agent for oral administration serves as a reliable domestic product bilitrast.
For successful conduct of x-ray study of the necessary preliminary preparation, which is essentially not much different from the preparation to the regular study of the gastrointestinal tract. The main concern is that the bowel was absolutely free of any content, especially gases.
Bilitrast is given in the amount of 3-4 g (depending on body weight analyzed) in powder 1 g, which the patient must take an hour, drinking mineral water or sweet tea, a 13 - 15 hours to a radiological examination. Snapshots are made every hour three times, then made a functional test for the study of contractile activity of the gallbladder.
To ensure the best possible visibility of the gallbladder was proposed method of saturation, the essence of which is that you enter an increased amount of contrast media (single or double dose). Contrast medium is given in three steps with a twelve-hour intervals. Unlike the conventional way of contrast when using the saturation studied not fast during the period from the beginning of reception of bilitrast and to the production of images and diet are excluded choleretic and gas-forming substances (fats, eggs, fibre). Applies also Express cholecystography proposed Antonuci (1932) with employees. This method is that intravenously injected 125 ml of 40% glucose and the contrast agent for intravenous injection (ceritfication-sodium). After 10 minutes subcutaneously injected 25 UNITS of insulin. Good cholecystogram obtained in 2 hours after injection of a contrast agent. A. N. Maksumov (1952) proposed an accelerated method of x-ray study using oral administration of bilitrast. After 4 hours after administration of bilitrast intravenous 100 ml of 40% glucose solution. After 1-2 hours after administration of glucose turn out quite satisfactory cholecystogram. However, neither Express cholecystography nor the method of saturation are not widely used, and in practice is mainly used standard method of x-ray study.
Cholecystography significantly enriched understanding of the morphological and functional characteristics of the gallbladder. She gave an opportunity to study the shape and position of the gallbladder that in the x-ray image is significantly different from the normal anatomical descriptions (Fig. 122).

Fig. 122. Cholecystography. Normal gallbladder.

The position of the gallbladder depends on constitutional features of the studied. In persons normostenichesky the Constitution of the gallbladder is located on level I-II lumbar vertebrae and 2-3 cm to the right of them. Astenikov it is also parallel to the spine, but is projected significantly lower, sometimes reaching as far as the level of the fifth lumbar vertebra. Giperstenikov bubble may go high in the upper quadrant and often takes angle position.
On the shape of the gallbladder heavily influenced by the tone of his. Normally toned gallbladder is a pear-shaped with a well-pronounced neck. Shadow bubble homogeneous, but increased slightly down. The gallbladder with a high tone is more elongated and narrowed the form at small sizes. If hypotension bladder happens Muscovite stretched and has a wide base.
Quite often there are excesses of the gallbladder, which is the summer Palace, Lindenbraten refers to variants of norm. According to him these extremes found in 14% of persons suffering from diseases of the gallbladder (Fig. 123).

Fig. 123. Cholecystography. The inflection of the gallbladder. Visible cystic duct.
Fig. 124. Cholecystography. Cloisonne gallbladder.

Among anomalies form bubble contain double and two gallbladder. Very often found cloisonne gall bladders (Fig. 124), which sometimes create a complex clinical syndrome that require operative intervention
(N. I Am Yazlovskaya, 1964). However, one cannot rule out that the excesses of the gallbladder may occur in the soil of pericholecystic that in each individual case requires clarification. We can say that if banners and exaggerations are accompanied by the persistence of its paintings during the change of body position investigated and such changes are accompanied by disorders of the function of the gall bladder emptying, especially functional probes, in such cases it is necessary to think not about anatomic variants, and pathological conditions for the most part inflammatory origin. The leading role in the final deciphering these changes remains for the clinic.
Based on the data of x-ray study, you can have an idea not only about the tone of muscles of a gall bladder, but also on the concentration and motor functions.
Concentration ability of the gallbladder is determined on cholecystogram degree of intensity of his shadow. Well concentrated bile creates conditions for better visibility of the gallbladder. Because bile from the liver flows occurring at different times depending on the cycle of digestion filled in the gall bladder, you can see the delimitation of concentrated and non-concentrated bile. Weak shadow intensity bubble cholecystogram testifies a low concentration of the gallbladder.
Contraction of the gallbladder represents active muscle act. Under normal contractile activity bubble decreases gradually and evenly in all directions.
Relaxation of the gallbladder is also active muscle act. The relaxation bubble noted a steady increase in its size. When changing reduction relaxation bubble is always some amount of bile, which represents a physiological phenomenon. Gallbladder emptying is depending on the tone of its walls and from the "game" of the sphincter of Oddi.
As the functional tests to identify contractility of the wall of the gallbladder and functions emptying his investigated give two egg yolks. After taking yolks shape of the bubble is changed. After 45 minutes after taking two egg yolks in a gall bladder remains approximately 1/4 of the number of bile, determined before cholecystogram. When the weak response of the gallbladder to the functional test with egg yolks the opportunity to speak about decrease in contractile function of the walls of the bladder.
Gall stones on cholecystogram look in the form of round or polygonal filling defects in the background contrastirovania gallbladder (Fig. 125). Small stones are "buried" in contrast bile, and to identify necessary to produce images with compression. Better visibility of gallstones is achieved at reduced gall bladder. In such cases, the stones kepleyts on the bottom of the bubble. Best of all stones are identified in vertical position, as they sink to the bottom, which is conducive to their discovery.

Fig. 125. Cholecystography. Multiple stones in the gall bladder.

The reliability of detection of gallstones in x-ray study is quite high. A positive diagnosis of the presence of bile stone depends on concentration of the bubble, because at low concentrations of bile stones do not produce the phenomenon of filling defect due to the low intensity of the shadow of weakly contrastirovania bubble. Identifying prevents stones also block the cystic duct stones.
Negative cholecystography may be due to the insufficient ability of liver cells to highlight contrast bile in degenerative processes and cirrhosis, the closing of the duct stones or swollen mucosa, inflammation and scar her changes associated with impaired concentration, and in the absence of absorbability of contrast in the gut. Often cholecystography does not work due to technical errors.
Direct diagnostics features cholecystitis almost impossible. Diagnosis of cholecystitis can be built only on the amount of indirect indicators. These characteristics can be attributed defined by probing and on radiographs gallstones and the image is enlarged gallbladder. In the study of the gastrointestinal tract can be detected change the position and shape of the stomach, duodenum and transverse colon as a result of pericholecystic, as well as the slow emptying of the duodenal bulb, and spastic phenomena in the stomach. When x-ray study is suspected cholecystitis can cause no shadow of a gall bladder or weak his shadow, the presence in it of stones, its deformation and disorders of the motor function (the summer Palace, Lindenbraten, 1953). Indirect sign of the presence of cholecystitis can serve as a long-term delay of contrast in the gall bladder under normal initial evacuation. This delay can last up to 24 hours.
Pericholecystic mostly recognized by the film deformation of the gallbladder. Often when pericholecystic gallbladder is jagged and sharp contours that are better represented at reduction of the bubble. Often on the grounds of pericholecystic formed the excesses of the bubble, which unlike the kinks, which is a variant of the norm, accompanied by motor disabilities.
Disturbances in motor function of the gall bladder is manifested in the form of various types of dyskinesias. In dyskinetic processes are essential violation of the tone bladder, resulting distinguish dyskinesia hypertension, hypotension and atonic (A. N. Maksumov, 1952). Based on the study of cholecystogram. especially after functional yolk samples, you can create views about the appropriate type of a dyskinesia of the gallbladder. This guidance can be not only time of the gallbladder emptying, but its form, which, as mentioned above, depends on the tone. In the differential diagnosis between hypertensive dyskinesia and organic delays the emptying of the gallbladder may be set to the use of subcutaneous injection of atropine. If you like the sample does not occur emptying of bladder, you should think about organic reason, the relevant changes.