cholecystokinin and Cholecystitis

Several cases of cholelithiasis and cholecystitis have been reported in patients treated with glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1RAs) and GLP-2 receptor agonists (GLP-2RAs), respectively. Thus, the effects of GLP-1 and GLP-2 on gallbladder motility have been investigated. We have provided an overview of the mechanisms regulating gallbladder motility and highlight novel findings on the effects of bile acids and glucagon-like peptides on gallbladder motility.. The articles included in the present review were identified using electronic literature searches. The search results were narrowed to data reporting the effects of bile acids and GLPs on gallbladder motility.. Bile acids negate the effect of postprandial cholecystokinin-mediated gallbladder contraction. Two bile acid receptors seem to be involved in this feedback mechanism, the transmembrane Takeda G protein-coupled receptor 5 (TGR5) and the nuclear farnesoid X receptor. Furthermore, activation of TGR5 in enteroendocrine L cells leads to release of GLP-1 and, possibly, GLP-2. Recent findings have pointed to the existence of a bile acid-TGR5-L cell-GLP-2 axis that serves to terminate meal-induced gallbladder contraction and thereby initiate gallbladder refilling. GLP-2 might play a dominant role in this axis by directly relaxing the gallbladder. Moreover, recent findings have suggested GLP-1RA treatment prolongs the refilling phase of the gallbladder.. GLP-2 receptor activation in rodents acutely increases the volume of the gallbladder, which might explain the risk of gallbladder diseases associated with GLP-2RA treatment observed in humans. GLP-1RA-induced prolongation of human gallbladder refilling may explain the gallbladder events observed in GLP-1RA clinical trials.

Topics: Bile Acids and Salts; Cholecystitis; Cholecystokinin; Cholelithiasis; Diabetes Mellitus, Type 2; Gallbladder; Gallbladder Emptying; Glucagon-Like Peptide 1; Glucagon-Like Peptide 2; Glucagon-Like Peptide-1 Receptor; Glucagon-Like Peptide-2 Receptor; Glucagon-Like Peptides; Humans; Muscle Contraction; Muscle, Smooth; Obesity; Postprandial Period

Since the early 1980s interventions have been used in conjunction with (99m)Tc-iminodiacetic acid (IDA) radiopharmaceuticals in many different clinical situations, eg, to prepare the patient for the study, to reduce the time of a study, to improve its diagnostic accuracy, and to make diagnoses not otherwise possible. Interventions all have underlying physiological rationales. Some of these interventions are as simple as having the patient fast before the study or eat a meal with high fat content. However, most are pharmacologic interventions, eg, morphine sulfate, cholecystokinin, and phenobarbital. Although these are probably the most common interventions used today, numerous other interventions have been used during the years and likely will be in the future. Interventions have aided in the diagnosis of acute cholecystitis, chronic cholecystitis, biliary obstruction, and sphincter of Oddi dysfunction. This review will discuss in detail the interventions commonly is use today and in somewhat less detail many that have been successfully used on an investigational basis and may have some larger role in the future.

Topics: Biliary Tract Diseases; Cholecystitis; Cholecystitis, Acute; Cholecystokinin; Chronic Disease; Gallbladder Emptying; Humans; Morphine; Radionuclide Imaging; Radiopharmaceuticals; Sincalide; Technetium Tc 99m Diethyl-iminodiacetic Acid

The gallbladder epithelium and smooth muscle layer are exposed to concentrated biliary solutes, including cholesterol and potentially toxic hydrophobic bile salts, which are able to influence muscle contraction. Physiologically, gallbladder tone is regulated by spontaneous muscle activity, hormones, and neurotransmitters released into the muscle from intrinsic neurons and extrinsic sympathetic nerves. Methods to explore gallbladder smooth muscle function in vitro include cholecystokinin (CCK) receptor-binding studies and contractility studies. In human and animal models, studies have focused on cellular and molecular events in health and disease, and in vitro findings mirror in vivo events. The interplay between contraction and relaxation of the gallbladder muscularis leads in vivo to appropriate gallbladder emptying and refilling during fasting and postprandially. Defective smooth muscle contractility and/or relaxation are found in cholesterol stone-containing gallbladders, featuring a type of gallbladder leiomyopathy; defects of CCKA receptors and signal transduction may coexist with abnormal responses to oxidative stress and inflammatory mediators. Abnormal smooth musculature contractility, impaired gallbladder motility, and increased stasis are key factors in the pathogenesis of cholesterol gallstones.

Topics: Animals; Bile Acids and Salts; Cholecystitis; Cholecystokinin; Cholecystolithiasis; Fasting; Gallbladder; Gallbladder Diseases; Gallbladder Emptying; Humans; Muscle Contraction; Muscle, Smooth; Postprandial Period; Receptors, Cholecystokinin

Topics: Cholecystectomy, Laparoscopic; Cholecystitis; Cholecystokinin; Cholelithiasis; Chronic Disease; Humans; Sensitivity and Specificity

We sought to determine whether a reduced gallbladder ejection fraction, (GBEF) ascertained by cholecystokinin-cholescintigraphy (CCK-CS), predicts symptomatic improvement after cholecystectomy.. Medical records of patients who had had CCK-CS as well as negative results of gallbladder ultrasonography were reviewed, and patients were contacted by telephone to determine whether they had benefited from cholecystectomy.. There were 35 patients (33 female, 2 male) who had a decreased GBEF. Cholecystectomy was done in 30, of whom 20 (67%) had resolution of pain, 8 (27%) had partial improvement, and 2 (7%) had no change. The 5 who declined cholecystectomy included none (0%) who were pain free, 2 (40%) who had partial improvement, and 3 (60%) who had no change. The clinical outcome of the two groups was significantly different. There were 14 patients (10 female, 4 male) with a normal GBEF. The 2 patients who had cholecystectomy were asymptomatic. Of the 12 patients who did not have cholecystectomy, 9 (75%) were asymptomatic, 1 (8%) had some improvement, and 2 (17%) had no change.. Cholecystectomy is indicated for patients with acalculous biliary pain and reduced GBEF, since symptoms will likely resolve with surgery and will persist without it. Cholecystectomy for patients with a normal GBEF should be considered only after failure of a nonoperative trial, since improvement usually occurs over time.

Topics: Adolescent; Adult; Aged; Child; Cholecystectomy; Cholecystitis; Cholecystokinin; Chronic Disease; Colic; Female; Follow-Up Studies; Forecasting; Gallbladder; Gallbladder Diseases; Gallbladder Emptying; Humans; Male; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Remission Induction; Retrospective Studies; Technetium Tc 99m Disofenin; Telephone; Treatment Outcome; Ultrasonography

Recent publications continue to refine the technique and interpretation of hepatobiliary scanning. Studies related to the evaluation of suspected acute cholecystitis have shown that morphine-augmented hepatobiliary imaging may not overcome the problem of false-positive study results in severely ill patients and the criterion for a normal study should be gallbladder visualization within 30 rather than 60 minutes. In patients with suspected acute cholecystitis, nonvisualized extrahepatic activity despite good hepatic uptake is highly predictive of acute cholecystitis, usually with biliary obstruction. The limitations of cholecystokinin-hepatobiliary imaging studies in patients with abdominal pain syndromes were defined and its use in evaluating common bile duct dynamics, and duodenogastric reflux was explored. Unusual findings and less-common uses of hepatobiliary scanning were reported, including assessment of conjoined twins, liver transplantation, primary biliary cirrhosis, gallbladder perforation, and persistent splenic visualization.

Topics: Biliary Tract; Cholecystitis; Cholecystokinin; Duodenogastric Reflux; Humans; Imino Acids; Liver; Liver Cirrhosis, Biliary; Liver Transplantation; Organotechnetium Compounds; Radionuclide Imaging; Twins, Conjoined

Topics: Acute Disease; Adult; Bile Duct Diseases; Bile Ducts; Child; Cholecystitis; Cholecystokinin; Cholestasis, Extrahepatic; Cystic Duct; Humans; Imino Acids; Iodine Radioisotopes; Radionuclide Imaging; Rose Bengal; Technetium; Technetium Tc 99m Lidofenin

This study was undertaken to test the effect of sequential administration of an opioid and intravenous cholecystokinin (CCK) on gallbladder ejection fraction.. Forty-nine patients who had received an opioid underwent quantitative cholescintigraphy with octapeptide of CCK (CCK-8). Gallbladder ejection fraction and CCK-8-induced paradoxical filling were calculated.. In the basal state, more of the hepatic bile entered the gallbladder (67%) than the small intestine (33%). After CCK-8 infusion, gallbladder ejection fraction was low in 37 (76%) of 49 patients and normal in 12 (24%). All 5 types of opioids lowered ejection fraction. CCK-induced paradoxical filling of the gallbladder was noted in 7 patients, but only one showed paradoxical filling of greater than 20% and none had a normal gallbladder ejection fraction. The lowering effect of opioids on gallbladder ejection fraction may last as long as 18 h after intake.. CCK-8 produced a normal gallbladder ejection fraction in 24% of patients who had received an opioid and thus could exclude both acute and chronic cholecystitis during a single hepatobiliary study.

Topics: Artifacts; Cholecystitis; Cholecystokinin; Drug Administration Schedule; Drug Combinations; Female; Gallbladder; Gallbladder Emptying; Humans; Male; Middle Aged; Narcotics; Pain; Radionuclide Imaging

Over 500,000 patients undergo cholecystectomy annually in the United States for symptoms of upper abdominal discomfort and pain ascribed to gallbladder disease. However, approximately 5%, or 25,000 of these cases do not have gallstones on ultrasound examination but typically present with chronic symptoms of biliary colic. These patients often present as challenging diagnostic dilemmas and are often treated as if their symptoms are secondary to peptic ulcer disease or other gastrointestinal-related disorders. In 1992, we began to use the cholecystokinin (CCK) challenge test on patients with normal ultrasound examinations of the gallbladder but who had chronic symptoms resembling biliary colic. The CCK test was considered positive if the identical symptoms of discomfort or pain, usually in the right upper quadrant of the abdomen, were reproduced. This study describes the first 24 patients who had a positive CCK challenge test and chose to undergo cholecystectomy for relief of their symptoms. No patient was lost to follow-up evaluation at 1 to 24 months after operation.

Topics: Abdominal Pain; Adult; Aged; Biliary Tract Diseases; Cholecystectomy; Cholecystitis; Cholecystokinin; Chronic Disease; Colic; Diagnosis, Differential; Female; Follow-Up Studies; Humans; Male; Middle Aged; Pain Measurement

Cholescintigraphy was performed after pharmacological manipulation in 60 patients with a clinical suspicion of acute cholecystitis and non-visualization of the gallbladder 1 h after 99Tcm-DISIDA cholescintigraphy. Thirty patients received an intravenous (i.v.) injection of morphine sulphate (group I) and the other 30 patients an i.v. injection of CCK (group II). The sensitivity, specificity, positive predictive value and negative predictive value were 94, 100, 100 and 93% in group I and 100, 84, 79 and 100% in group II, respectively. There was a significant difference between groups (P < 0.05). In conclusion, morphine-augmented cholescintigraphy could supply more reliable diagnostic information and is less time-consuming in patients with a clinical suspicion of acute cholecystitis.

Topics: Acute Disease; Adult; Aged; Cholecystitis; Cholecystokinin; False Negative Reactions; False Positive Reactions; Female; Humans; Imino Acids; Injections, Intravenous; Male; Middle Aged; Morphine; Organotechnetium Compounds; Radionuclide Imaging; Sensitivity and Specificity; Technetium Tc 99m Disofenin

Regular gall bladder contraction reduces bile stasis and prevents gallstone formation. Intraduodenal administration of exogenous pancreatic secretory trypsin inhibitor-I (PSTI-I, also known as monitor peptide) causes cholecystokinin (CCK) secretion.. We proposed that stimulation of CCK release by PSTI would produce gall bladder contraction and prevent gallstones in mice fed a lithogenic diet. Therefore, we tested the effect of overexpression of rat PSTI-I in pancreatic acinar cells on plasma CCK levels and gall bladder function in a transgenic mouse line (TgN[Psti1]; known hereafter as PSTI-I tg).. Importantly, PSTI tg mice had elevated fasting and fed plasma CCK levels compared to wild-type (WT) mice. Only mice fed the lithogenic diet developed gallstones. Both fasting and stimulated plasma CCK levels were substantially reduced in both WT and PSTI-I tg mice on the lithogenic diet. Moreover, despite higher CCK levels PSTI-I tg animals developed more gallstones than WT animals.. Together with the previously observed decrease in CCK-stimulated gall bladder emptying in mice fed a lithogenic diet, our findings suggest that a lithogenic diet causes gallstone formation by impaired CCK secretion in addition to reduced gall bladder sensitivity to CCK.

Topics: Acinar Cells; Animals; Cholecystitis; Cholecystokinin; Diet; Gallbladder; Gallbladder Emptying; Gallstones; Intercellular Signaling Peptides and Proteins; Lipid Metabolism; Male; Mice, Inbred C57BL; Organ Size; Pancreas; Rats; Trypsin Inhibitor, Kazal Pancreatic

Studies on biliary dyskinesia have been based on short-term surgical follow-up and do not take into consideration that most patients are discharged from surgical follow-up after the first postoperative visit and that for persistent or recurrent symptoms they are frequently seen by primary care providers and subsequently referred to gastroenterologists. We aimed to study this pattern and assess which factors predict patients that will benefit from cholecystectomy.. This is a retrospective analysis of medical records of patients who underwent cholecystectomy for biliary dyskinesia from February 2001 to January 2010 with a minimum postoperative follow-up of 6 months.. At initial surgical follow-up, 19 of 141 (13.4%) patients said they had persistent symptoms. However, when subsequent visits were analyzed, 61 of 141 (43.3%) patients with persistent or recurrent symptoms saw their primary care provider. These symptoms were epigastric or right upper quadrant pain in 43 patients or 30% of those undergoing cholecystectomy. The only factor that distinguished patients with and without resolution of symptoms after cholecystectomy was the pathologic finding of inflammation (p = 0.02).. Cholecystectomy does not appear to be as effective for biliary dyskinesia when long-term follow-up is evaluated.

Topics: Abdominal Pain; Adolescent; Adult; Aged; Biliary Dyskinesia; Child; Cholecystectomy; Cholecystitis; Cholecystokinin; Female; Follow-Up Studies; Gastroenterology; Humans; Male; Middle Aged; Patient Selection; Primary Health Care; Recurrence; Referral and Consultation; Retrospective Studies; Treatment Outcome; Young Adult

For children with upper abdominal pain and evaluation for acalculous biliary disease, laparoscopic cholecystectomy is an accepted treatment with inconsistent outcomes. The purpose of this study was to identify predictors of outcomes.. One hundred sixty-seven children underwent laparoscopic cholecystectomy at a single children's hospital. Radiographic findings, histopathology, family history, and demographics (sex, age, height, weight, body mass index-for-age percentile) were evaluated as predictors of postoperative symptomatic resolution using a binomial probability model. The data for radiologic studies and pathologic specimens were obtained via re-review in a blinded fashion.. Of 167 children, 43 (25.7%) had a preoperative diagnosis of biliary dyskinesia and 41 (95.3%) had documented follow-up. Mean follow-up was 8.4 months. Twenty-eight patients (68.3%) had symptom resolution. Ejection fraction less than or equal to 15%, pain upon cholecystokinin injection, and a family history of biliary disease were not predictors of symptomatic resolution. Nonoverweight patients (body mass index-for-age <85th percentile) were more likely to have symptom resolution than their overweight counterparts (odds ratio, 2.13). Most patients (68.3%) had a pathologic gallbladder on blinded review. However, this did not correlate with outcome.. Most gallbladders removed for biliary dyskinesia are pathologic. Being overweight can be considered a relative contraindication to cholecystectomy for biliary dyskinesia.

Topics: Abdominal Pain; Adolescent; Biliary Dyskinesia; Body Mass Index; Child; Cholecystectomy, Laparoscopic; Cholecystitis; Cholecystokinin; Cohort Studies; Colic; Contraindications; Dietary Fats; Female; Gallbladder; Humans; Imino Acids; Male; Overweight; Radiography; Risk Factors; Single-Blind Method; Stroke Volume; Treatment Outcome; Young Adult

This study examines the hypothesis that cholecystitis down-regulates Guinea pig gallbladder (GPGB) smooth muscle cholecystokinin (CCK)-stimulated prostaglandin (PG) release. Guinea pig gallbladder from Control and 48 h bile duct ligated (BDL) animals were placed in cell culture and grown to confluence. The cultures underwent Western Blot analysis for smooth muscle cell content of COX-1, COX-2, Prostacyclin Synthase (PS), or were incubated with CCK at 10(-8)M or 10(-6)M with and without indomethacin for 1h and analyzed for release of 6-keto-PGF1alpha, PGE2 and TxB2 by EIA. BDL increased Guinea pig gallbladder cell culture basal PGE2 and PGI2 release which was in part due to increased COX-2 content. CCK incubation down-regulated BDL Guinea pig gallbladder cell culture release of 6-keto-PGF1alpha and PGE2 and down-regulated COX-2 content but did not alter the Control group. The decrease in CCK-mediated BDL cell Guinea pig gallbladder release may be an endogenous mechanism to limit physiologic derangements induced by increased endogenous gallbladder PG synthesis during early acute cholecystitis.

Topics: Animals; Cells, Cultured; Cholecystitis; Cholecystokinin; Cytochrome P-450 Enzyme System; Dinoprostone; Down-Regulation; Eicosanoids; Epoprostenol; Gallbladder; Guinea Pigs; Intramolecular Oxidoreductases; Myocytes, Smooth Muscle

We studied the influence of the inflammatory state of the gallbladder with gallstones on its response to cholecystokinin (CCK). Responses to CCK were evaluated in isolated human gallbladder strips incubated with pharmacological antagonists. Gallbladders from patients with gallstones were classified as having mild and severe chronic cholecystitis. Healthy gallbladders were collected from liver donors. In donor gallbladders, the CCK contraction was abolished with the CCK-A receptor antagonist, L-364718, and significantly reduced by indomethacin. In gallbladders with gallstones, only mild cholecystitis showed a decreased contraction to CCK. In gallbladders with gallstones, no involvement of prostaglandins in the CCK response was observed. In severe cholecystitis, CCK contractile effect was reduced by the serotonin receptor antagonist methysergide. In healthy gallbladder, the contraction provoked by CCK is mediated by CCK-A receptors and modulated by prostaglandins. The presence of gallstones in the gallbladder is correlated with a loss of prostaglandins-modulated CCK contraction. However, the excessive release of serotonin in advanced cholecystitis normalizes the contraction to CCK, suggesting that the state of cholecystitis affects the pool of inflammatory mediators responsible for gallbladder CCK-altered motility.

Topics: Acetylcholine; Adult; Atropine; Cholecystectomy; Cholecystitis; Cholecystokinin; Cholelithiasis; Drug Interactions; Female; Gallbladder Emptying; Histamine; Humans; Indomethacin; Male; Middle Aged; Muscle Contraction; Organ Culture Techniques; Probability; Propranolol; Sensitivity and Specificity; Serotonin; Severity of Illness Index; Tetrodotoxin

Acute acalculous cholecystitis remains a diagnostic challenge in critically ill trauma patients. Laboratory studies are nonspecific and associated injuries or mental status changes may mask clinical signs and symptoms. We conducted a retrospective study to assess the utility of ultrasound in the diagnosis of acute acalculous cholecystitis. We hypothesized that ultrasound is inadequate as a screening tool for acute acalculous cholecystitis. The abdominal ultrasounds of all patients undergoing evaluation for acute acalculous cholecystitis in a 40-month period at our Level I trauma center were reviewed. Thickened gallbladder wall, pericholecystic fluid and emphysematous gallbladder were considered positive sonographic criteria. Sludge, cholelithiasis, and hydrops were considered suggestive. Patients who did not undergo cholecystectomy had their gallbladders evaluated either during subsequent laparotomy or at autopsy or they were discharged from the hospital without need for intervention. Sixty-two patients were included. Twenty-one patients underwent cholecystectomy for presumed acute acalculous cholecystitis. The data revealed a sensitivity of 30 per cent (6/20) and a specificity of 93 per cent (39/42) for ultrasound evaluation. Twenty patients had subsequent hepatobiliary scans [hepato-iminodiacetic acid (HIDA)] with a sensitivity of 100 per cent (12/12) and specificity of 88 per cent (7/8). Our data do not support ultrasound as a reliable routine screening tool for acute acalculous cholecystitis. Despite its convenience as a bedside procedure ultrasound has insufficient sensitivity to justify its use and a more sensitive diagnostic tool should be used.

Topics: Acute Disease; Adult; Cholecystectomy; Cholecystitis; Cholecystokinin; Comorbidity; Critical Illness; Humans; Imino Acids; Middle Aged; Radionuclide Imaging; Retrospective Studies; Ultrasonography; Wounds and Injuries

Patients with symptoms consistent with biliary colic who do not demonstrate calculi on routine sonography present a diagnostic dilemma for clinicians. For those patients in whom other disease entities have been excluded and in whom the history and physical examination exemplify classic signs and symptoms of biliary disease we show in this study that cholecystokinin cholescintigraphy with calculation of gallbladder ejection fraction is a predictor of pathology as well as subsequent symptom relief after cholecystectomy. The spectrum of pathology that makes up chronic acalculous biliary disease lacks a distinct definition, yet this review shows that cholecystokinin cholescintigraphy offers the surgeon the means to better counsel his or her patient with regard to surgical indications, options, and benefits. We reviewed 26 patients who had no gallstones detectable, had gallbladder ejection fraction <35 per cent, and were status postlaparoscopic cholecystectomy for suspected chronic acalculous biliary disease. Our results show histopathologic evidence of chronic cholecystitis in 100 per cent, and 92 per cent of the patients had improvement of symptoms and satisfaction with the operation to the point that they would undergo the surgery again without reservation.

Topics: Cholecystectomy, Laparoscopic; Cholecystitis; Cholecystokinin; Chronic Disease; Humans; Predictive Value of Tests; Radionuclide Imaging; Retrospective Studies; Treatment Outcome

Topics: Adult; Cholecystitis; Cholecystokinin; Chronic Disease; Female; Gallbladder; Humans; Radionuclide Imaging

Numerous publications have reported that a low gallbladder ejection fraction (GBEF) determined by cholecystokinin (CCK) cholescintigraphy has a high positive predictive value for the diagnosis of chronic acalculous cholecystitis (CAC). Clinicians and surgeons have found this test to be clinically useful as an objective method to confirm their clinical diagnosis. However, an abnormally low GBEF is not specific for CAC. For example, numerous other diseases have been associated with a low GBEF, and various therapeutic drugs can cause poor gallbladder contraction. Importantly, improper CCK infusion methodology can result in an erroneously low GBEF. More than one third of healthy subjects and patients who receive sincalide, 0.02 microg/kg infused over 1-3 min, will have an erroneously low GBEF but will have a normal GBEF with a slower infusion (30-60 min) of the same total dose. Because of enthusiastic acceptance of CCK cholescintigraphy by clinicians, the types of patients referred for this test have changed over time. Patients investigated in publications confirming the usefulness of CCK cholescintigraphy had a high pretest likelihood of disease. They underwent extensive workup to rule out other diseases and were followed up for months or years before CCK cholescintigraphy was performed, allowing other diseases to become manifest or symptoms to resolve. However, CCK cholescintigraphy is now being used by clinicians to shorten the workup and follow-up time based on the rationale that CCK cholescintigraphy can quickly confirm or exclude the diagnosis. This new group of referral patients has a lower likelihood of the disease. Many will ultimately be diagnosed with diseases other than CAC. The positive predictive value of this test will likely be lower and the false-positive rate will likely be higher. Nuclear medicine physicians must work to minimize false-positive studies to maintain the confidence of referring clinicians. First, we can educate referring physicians as to the proper use of this study. Next, we must perform CCK cholescintigraphy using optimal methodology that will result in the lowest possible false-positive rate. And finally, we must interpret CCK cholescintigraphy in light of the patient's history, prior workup and clinical setting.

Topics: Cholecystitis; Cholecystokinin; Chronic Disease; False Positive Reactions; Female; Gallbladder; Gallbladder Emptying; Humans; Male; Radionuclide Imaging; Sincalide

Cholelithiasis is a common disorder occurring in over 20 million people in the United States and resulting in approximately 600,000 cholecystectomies annually. Although over 95% of biliary tract disease is caused by gallstones, the vast majority (>80%) of cholelithiasis cases are asymptomatic. The purpose of this study is to evaluate the utility of quantitative cholescintigraphy in detecting symptomatic biliary tract disease and predicting clinical relief after cholecystectomy.. Fifty-two patients with clinical symptoms of chronic cholecystitis were evaluated by cholescintigraphy with a gallbladder ejection fraction calculated after the intravenous administration of cholecystokinin. A gallbladder ejection fraction of > or =35% was considered a normal physiologic response. Forty-one of the patients subsequently underwent cholecystectomy, whereas the remaining 11 subjects were diagnosed and treated for non-biliary disorders that did not require cholecystectomies. After clinical follow-up including histopathological gallbladder findings, all subjects' final diagnoses were established and correlated with their quantitative cholescintigram study.. Twenty-six of twenty-eight patients who had an abnormal quantitative cholescintigram demonstrated evidence of chronic cholecystitis by histopathologic criteria after cholecystectomy. Furthermore, 27 of these 28 patients (96%) experienced complete relief of their clinical symptoms after surgery.. Functional cholescintigraphy is a safe, accurate, and useful test for detecting symptomatic gallbladder disease, and appears reliable in predicting symptomatic relief after cholecystectomy.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cholecystectomy; Cholecystitis; Cholecystokinin; Cholelithiasis; Chronic Disease; Female; Follow-Up Studies; Forecasting; Gallbladder; Gastrointestinal Agents; Humans; Injections, Intravenous; Male; Middle Aged; Muscle Contraction; Predictive Value of Tests; Radionuclide Imaging; Remission Induction; Reproducibility of Results; Safety; Sensitivity and Specificity

The diagnosis of cholecystitis and cholelithiasis is often straightforward, particularly when transabdominal ultrasound (TUS) reveals gallstones or other abnormalities of the gallbladder. There remain many patients, however, with typical biliary pain and normal findings on TUS. This latter group of patients, in which women constitute a large majority, often undergo considerable suffering. Their medical care can also be quite costly. Cholecystokinin cholescintigraphy and stimulated biliary drainage (SBD) have been proposed for difficult-to-diagnose gallbladder disease, but they both have limitations. Cholecystokinin cholescintigraphy may not predict postoperative outcomes with a high degree of reliability. The processing and interpretation of bile drainage specimens is not standardized, and the sensitivity of SBD is less than that of endoscopic ultrasound (EUS). Combined endoscopic ultrasound and stimulated biliary drainage (EUS/SBD) offers a high degree of sensitivity in the diagnosis of cholecystitis and microlithiasis. Positive EUS/SBD is also highly correlated with long-term symptom resolution or relief following cholecystectomy.

Topics: Bile; Cholecystitis; Cholecystokinin; Cholelithiasis; Endosonography; Female; Gallbladder; Humans; Male; Radionuclide Imaging; Treatment Outcome

The purpose of this study was to determine if a combination of cholecystokinin (CCK) pretreatment followed by morphine augmentation improved the detection of cystic duct patency compared with CCK pretreatment only.. One hundred fifty-five patients with suspected acute cholecystitis had scintigraphy performed with 185-481 MBq (5-13 mCi) 99mTc-mebrofenin adjusted to the patients' total bilirubin levels. All patients were pretreated with 0.02 microgram/kg sincalide injected intravenously over 3-5 min. Sequential imaging was performed until gallbladder activity was identified or up to 90 min postinjection of mebrofenin. If no gallbladder was identified, a second dose of mebrofenin was given as necessary to have tracer in the biliary system. Then, 0.04 mg/kg intravenous morphine sulfate was administered, followed by imaging for up to 30 min or until gallbladder visualization.. Twenty-eight percent (43/155) of the patients pretreated with CCK had nonvisualization of the gallbladder at 90 min postinjection of radiotracer. After intravenous morphine, the gallbladder was identified in 42% (18/43) of these patients (p = 0.0001).. Hepatobiliary imaging with CCK pretreatment and imaging for 90 min was insufficient to identify all patent cystic ducts. Morphine augmentation significantly increased the frequency of gallbladder visualization in patients pretreated with CCK.

Topics: Acute Disease; Adolescent; Adult; Aged; Aged, 80 and over; Aniline Compounds; Cholecystitis; Cholecystokinin; Cystic Duct; Female; Gallbladder; Gallbladder Emptying; Glycine; Humans; Imino Acids; Male; Middle Aged; Morphine; Organotechnetium Compounds; Prospective Studies; Radionuclide Imaging; Sensitivity and Specificity

Recent data and reanalysis of the literature suggest that nonvisualization of the gallbladder on the delayed images of cholescintigraphy is a nonspecific finding. Morphine augmentation has a reasonably good, though imperfect, specificity and positive predictive value, that are significantly better than for delayed imaging, in addition to its logistical advantage (shortening the imaging time). The technique is recommended, therefore, for routine clinical use in patients with nonvisualization of the gallbladder at 1 hr. Further study seems to be necessary to assess the effect of variable or no visible effect of low-dose morphine among patients on the efficacy of morphine-augmented cholescintigraphy. Sincalide pretreatment, when administered at the physiologic rate, is helpful in conditions in which functional resistance to tracer flow into the gallbladder are present. The results from the series by Chen et al. and by Kim et al. suggest that morphine augmentation can further improve the efficacy of the test even after CCK pretreatment. A comparison between the efficacy of delayed imaging and that of imaging for 60-90 min after CCK pretreatment is not available. Therefore, the latter does not obviate the need for delayed imaging when the morphine augmentation technique is not used. Finally, the nuclear medicine physician should use the most optimal technique for the pharmacologic intervention, in other words, the dose and the rate of administration. Certain conditions and medications may affect gallbladder contraction. It is also important to be aware of the various physiologic and pharmacologic effects on imaging findings, not only those findings that are normal but also the undesirable variants. Failure to recognize such effects can lead to incorrect interpretations.

Topics: Acute Disease; Cholecystitis; Cholecystokinin; Cystic Duct; Gallbladder Emptying; Humans; Morphine; Radionuclide Imaging; Sincalide

Pharmacological intervention with either cholecystokinin-8 (CCK-8) or morphine during 99mTc- hepatoiminodiacetic acid (HIDA) cholescintigraphy is required primarily for the assessment of the diseases affecting the gallbladder, the common bile duct, or the sphincter of Oddi. For imaging, the patient should be prepared by an overnight fast, or with 4 hours of minimum fast. Pre-emptying with CCK-8 is probably undesirable and should either be avoided or one should wait for at least 4 hours after CCK-8 to begin the 99mTc-HIDA study to achieve higher specificity of the test for acute cholecystitis. When he gallbladder is not observed by 60 mins in a clinical setting of acute cholecystitis, a dose of 0.04 mg/kg of morphine is administered intravenously and imaging continued for an additional 30 mins. Nonvisualization of the gallbladder by 90 mins with morphine in an appropriate clinical setting is diagnostic for acute cholecystitis. When the gallbladder is not observed by 60 min but is seen with morphine administered after 60 mins, a positive diagnosis of abnormal gallbladder function can be made. When the gallbladder is observed in a clinical setting of biliary pain or chronic calculous or acalculous cholecystitis, CCK-8 at a dose rate of 3.3 ng/kg/min is infused intravenously for 3 mins (10 ng/kg/3 min) for the measurement of the ejection fraction. An ejection fraction value of less than 35% is indicative of calculous or acalculous chronic cholecystitis. The gallbladder emptying is directly related to the total number of cholecystokinin receptors in the smooth muscle. The ejection fraction can be controlled to any desired level simply by controlling the dose rate or the duration of infusion of CCK-8. Morphine and other opiate metabolites circulate for many hours in blood and act on the sphincter of Oddi and decrease the gallbladder ejection fraction. Careful drug history, especially that of opiates, is very critical in all subjects with a low ejection fraction before assigning an abnormality to the gallbladder motor function.

Topics: Acute Disease; Bile; Biliary Tract; Cholecystitis; Cholecystokinin; Gallbladder Emptying; Humans; Imino Acids; Morphine; Organotechnetium Compounds; Radionuclide Imaging; Technetium Tc 99m Lidofenin

We investigated the effect of intravenous infusions of the therapeutically available amino acid solutions Moripron and Morihepamin (Roussel Morishita, Osaka, Japan) on gallbladder contraction and cholecystokinin (CCK) release in healthy male volunteers. Plasma CCK levels were measured by radioimmunoassay, using the antibody OAL-656, which is specific for the aminoterminus of CCK-8 and thus recognizes biologically active forms of all CCKs. The volume of the gallbladder was calculated by ultrasonographic measurements. Intravenous infusion of Moripron at the rate of 3.33 ml/min for 60 min, caused gallbladder contraction, with a peak response of 31.3 +/- 8.6% of the fasting volume at 45-60 min, and a significant increase in plasma CCK concentration, from 1.8 +/- 0.2 pmol/l to a peak of 9.9 +/- 1.5 pmol/l, at 30-45 min. The maximum gallbladder contraction and the peak CCK release during the Moripron infusion were not significantly different from findings after a test meal. There was a close relationship between the peak plasma CCK concentration and the maximal gallbladder contraction during the administration of Moripron, and this agent, even when infused at the rate of 1.67 ml/min, significantly increased plasma CCK levels and gallbladder contraction. Intravenous infusion of Morihepamin had no significant influence on gallbladder volume or plasma CCK levels. The discrepancy in responses appeared to be related to differences in composition between Moripron and Morihepamin, and not to the total dose of amino acid. Intravenous infusions of amino acids appear to have different effects on gallbladder contraction and plasma CCK secretion depending on the amino acids composition. Our findings suggest that an intravenous infusion of Moripron could be used for the prophylaxis of acute acalculous cholecystitis and sludge formation due to reduced biliary motility in patients on total parenteral nutrition.

Topics: Adult; Amino Acids; Cholecystitis; Cholecystokinin; Food, Formulated; Gallbladder; Gallbladder Emptying; Humans; Infusions, Intravenous; Male; Parenteral Nutrition, Total; Radioimmunoassay; Ultrasonography

Topics: Adult; Cholecystitis; Cholecystokinin; False Negative Reactions; Female; Gallbladder; Gallbladder Emptying; Humans; Radionuclide Imaging; Time Factors

Between April 1, 1989, and January 1, 1994, 38 patients with chronic acalculous cholecystitis underwent an advanced (3-puncture) laparoscopic cholecystectomy at our institution. The 30 women and 8 men had a mean age of 39 years (range, 23 to 65 years) and represented 4.5% of our overall gallbladder patient population. In each case, the disease produced typical biliary colic, but no gallstones were visualized on ultrasound examination; cholecystokinin-stimulated cholescintigraphy revealed a dysfunctional gallbladder, as evidenced by an ejection fraction of < or = 35% or nonvisualization or nonemptying of the organ. In all 38 cases, cholecystectomy resulted in the complete relief of symptoms. Although an increasing number of physicians are recommending this operation for acalculous gallbladder disease, it should not be performed on the basis of clinical history alone. Rather, objective criteria confirming the need for surgical intervention should be obtained by means of appropriate preoperative testing, including cholecystokinin-stimulated cholescintigraphy.

Topics: Adult; Aged; Biliary Dyskinesia; Cholecystectomy, Laparoscopic; Cholecystitis; Cholecystokinin; Chronic Disease; Female; Humans; Imino Acids; Male; Middle Aged; Organotechnetium Compounds; Technetium Tc 99m Lidofenin; Ultrasonography

The incidence of acute acalculous cholecystitis (AAC) is increasing and associated mortality is high. Biliary stasis and sludge formation are probably important factors in the pathogenesis of this disease. No data concerning the dynamics of these changes in the early phase of intensive care therapy are available. The gallbladders of 20 patients treated after major abdominal surgery in the surgical intensive care unit (SICU) with mechanical ventilation and without enteral feedings were therefore observed sonographically during the first 5 postoperative days in a prospective observational study. 20 patients treated on a regular ward after major abdominal surgery also not receiving any enteral nutrition served as control group. 24 hours after admission to the intensive care unit and on all subsequent days of observation the gallbladders of the patients in the SICU-group were significantly larger than in the control group. Sludge also appeared earlier and more frequently in the gallbladders of the SICU-patients. Lack of enteral feedings alone cannot explain these results. Positive-pressure ventilation and medications used in SICU are most likely responsible for the observed differences. Besides the necessity to make the diagnosis of AAC as early as possible, it appears to be worthwhile to investigate measures of prophylaxis. Since gallbladder distension in patients treated in SICU can be already observed on the first postoperative day it seems to be reasonable to initiate a regimen of prophylactic measures (e.g. with cholecystokinin or ceruletide) early in the course of ICU-therapy.

Topics: Abdomen; Acute Disease; Aged; Biliary Dyskinesia; Ceruletide; Cholecystitis; Cholecystokinin; Critical Care; Female; Humans; Male; Middle Aged; Parenteral Nutrition, Total; Positive-Pressure Respiration; Postoperative Complications; Prospective Studies; Risk Factors; Ultrasonography

The relationship of bradykinin and cholecystokinin (CCK) to inflamed gallbladder prostanoid synthesis and release was examined in rabbits treated with common bile duct ligation (BDL) for 24 or 72 h. Gallbladders removed from control and BDL groups were incubated in oxygenated Krebs buffer at 37 degrees C (pH 7.4) for 60 min. The slices were then placed every 20 min in vials containing increasing doses of bradykinin (30-3000 ng) or CCK (30-1000 ng). Incubation fluid was analyzed by RIA for 6-keto-prostaglandin (PG)F1 alpha (PGI2 metabolite), PGE2 and thromboxane (TX) B2. Bradykinin stimulated control gallbladder 6-keto-PGF1 alpha and PGE2 release was modest. Gallbladders from 24- and 72-h BDL groups released 3- to 10-fold higher levels of 6-keto-PGF1 alpha and PGE2 (not TXB2) following bradykinin stimulation when compared to controls, which was abolished with indomethacin pretreatment. CCK did not stimulate gallbladder prostanoid release in the control or BDL groups. These data show that bradykinin and not CCK stimulated PGI2 and PGE2 release from inflamed rabbit gallbladder. Increased BDL gallbladder PGI2 release may be prolonged or augmented by bradykinin as gallbladder distention and progressive acute inflammation stimulate local bradykinin formation.

Topics: Acute Disease; Animals; Bradykinin; Cholecystitis; Cholecystokinin; Dinoprostone; Epoprostenol; Gallbladder; In Vitro Techniques; Male; Prostaglandins; Rabbits

One hundred eighty-seven patients who presented with symptoms consistent with biliary colic but had no ultrasonic evidence of cholelithiasis were observed in an effort to identify those with a functional gallbladder disorder that might benefit from surgical intervention. All patients underwent quantitative evaluation of gallbladder emptying using cholecystokinin biliary scanning, and ejection fractions less than 35% were considered abnormal. One hundred twenty-nine patients (69%) had abnormal ejection fractions, and 88 (68%) of these subsequently underwent cholecystectomy. Sixty of the surgical specimens revealed pathologic changes. Eighty-four percent of patients successfully contacted for follow-up experienced complete relief, and another 13% had partial relief of preoperative symptoms. Only two patients reported no change in symptom complex. Twenty-nine patients with abnormal ejection fractions elected not to undergo surgery. Fifty-nine percent of these patients continued to experience symptoms of biliary colic at a mean follow-up of 22 months. Of the 44 patients with normal ejection fractions, 35 (80%) reported resolution of symptoms during follow-up of medical treatment. Cholecystokinin biliary scanning can help identify patients with acalculous, functional gallbladder disease who may benefit from cholecystectomy.

Topics: Adult; Biliary Dyskinesia; Cholecystectomy; Cholecystitis; Cholecystokinin; Cholelithiasis; Diagnosis, Differential; Female; Follow-Up Studies; Gallbladder; Gallbladder Diseases; Humans; Imino Acids; Male; Middle Aged; Organotechnetium Compounds; Prospective Studies; Radionuclide Imaging; Technetium Tc 99m Disofenin

Chronic acalculous cholecystitis represents 5 to 20 per cent of electively treated diseases of the gallbladder. A 70 per cent success rate in relieving these patients of chronic pain was reported when surgical treatment was recommended based on symptoms alone. The cholecystokinin ejection fraction, which is a quantitative measure of emptying of the gallbladder, was 95 per cent accurate in predicting which patients would be relieved of symptoms by surgical treatment. In this study, we report our consecutive experience during a 20 month period with 83 patients.

Topics: Adult; Cholecystectomy; Cholecystitis; Cholecystokinin; Evaluation Studies as Topic; Female; Gallbladder; Humans; Male; Middle Aged; Muscle Contraction; Predictive Value of Tests; Radionuclide Imaging; Rheology; Stroke Volume

Topics: Cholecystitis; Cholecystokinin; Gallbladder; Humans; Imino Acids; Intestines; Morphine; Organotechnetium Compounds; Radionuclide Imaging; Retrospective Studies; Technetium Tc 99m Disofenin

The authors assessed the influence of cholecystokinin (CCK), administered before cholescintigraphy, on the biliary-to-bowel transit time (BBTT) of technetium-99m disofenin. Fourteen healthy volunteers underwent two separate cholescintigraphic studies with and without CCK treatment. BBTT was less than 1 hour in all 14 studies of subjects not treated with CCK. In 14 subjects treated with CCK, there was no tracer activity in the bowel up to 2 hours in seven (50%) (P = .006). Eighty-three cholescintigrams obtained in patients with suspected acute cholecystitis were also retrospectively analyzed. In 53 of 83 patients in whom the gallbladder was visualized within 1 hour, significantly delayed BBTT was found in 14 of 29 (48%) who received CCK, compared with the BBTT in one of 24 patients (4%) who did not receive CCK (P less than .001). In the 30 patients in whom the gallbladder was never visualized (n = 28) or was visualized after 1 hour (n = 2), BBTT was less than 30 minutes, regardless of whether patients were treated with CCK. Results show that CCK treatment causes significantly delayed BBTT in many cases, and this finding should not be interpreted as abnormal.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cholecystitis; Cholecystokinin; Female; Gallbladder; Humans; Imino Acids; Intestines; Male; Middle Aged; Organotechnetium Compounds; Radionuclide Imaging; Retrospective Studies; Technetium Tc 99m Disofenin; Time Factors

The cholecystographic pattern and the contractile response of the gallbladder (GB) to cholecystokinin (CCK) were studied in 101 consecutive patients with uncomplicated chronic cholecystitis confirmed by pathology. Sequential GB images were obtained after administration of 5 mCi 99mTc-Disofenin and the ejection fraction was determined following a 15 min infusion of CCK. Sixteen of 101 (16%) GB failed to visualize up to 4 h; of the remaining patients, 3/85 (4%) showed delayed visualization beyond 1 h, and 82/85 visualized within 1 h. The mean ejection fraction (EF) in 67 patients was 56.9% +/- 27.5% compared to 74.8% +/- 19.8% in a normal control group of 27 subjects (P less than 0.005). However, there was a large overlap as 76% of chronic cholecystitis patients had EF values falling within the full normal range. GB disease could be identified with confidence when the EF was less than 35%, i.e. below the 2 standard deviation range of normal. On the basis of radionuclide kinetic studies alone, the majority of patients with chronic cholecystitis cannot be distinguished from normal.

Topics: Adult; Aged; Cholecystitis; Cholecystokinin; Chronic Disease; Female; Gallbladder; Humans; Imino Acids; Male; Middle Aged; Organometallic Compounds; Radionuclide Imaging; Technetium Tc 99m Disofenin

The motor activity of the gall bladder was studied using cholescintigraphy with 99m Tc-HIDA in 57 patients with chronic cholecystitis and chronic hepatitis and in 9 controls. A comparative analysis of the curves activity-time based upon the elements of images of the external contour and the entire zone of the gall bladder, made it possible to reveal differences in the type of reaction of the gall bladder to the use of cholagogic stimulators (cholecystokinin i.v. and cholagogic breakfast). A method of the processing of the results made it possible to determine the number of contraction phases of the gall bladder during its emptying as well as the true latent period and the period of primary reactions of the biliferous apparatus after taking a food stimulus.

Topics: Cholagogues and Choleretics; Cholecystitis; Cholecystokinin; Gallbladder; Hepatitis; Humans; Imino Acids; Peristalsis; Radionuclide Imaging; Technetium; Technetium Tc 99m Lidofenin

We reviewed 57 patients, who during the last four years had cholecystokinin cholecystography during evaluation of abdominal pain, and found this test to be reliable for diagnosing chronic acalculous cholecystitis. Eighty-eight percent of the patients in whom abdominal pain was reproduced during cholecystokinin cholecystography and who had less than 50% contraction of the gallbladder were cured or improved after cholecystectomy.

Topics: Adult; Aged; Cholecystectomy; Cholecystitis; Cholecystography; Cholecystokinin; Chronic Disease; Evaluation Studies as Topic; Female; Follow-Up Studies; Humans; Male; Middle Aged

The use of ERCP to identify cystic duct syndrome is reported for the first time herein. Nine patients with obscure biliary colic were further investigated with fat meal or CCK, cholecystogram or ERCP, or both, to identify the partial obstruction in the cystic duct. Cholecystectomy is curative in this disease. Because about one-third of the patients with disease of the gastrointestinal or biliary tracts or pancreas have two of these diseases simultaneously, it is essential that a thorough evaluation both preoperatively and at operation be performed so that a single well designed operation can be performed. ERCP has been helpful in defining the nature and extent of this disease.

Topics: Adult; Aged; Cholangiopancreatography, Endoscopic Retrograde; Cholecystectomy; Cholecystitis; Cholecystography; Cholecystokinin; Cholestasis, Extrahepatic; Colic; Cystic Duct; Female; Humans; Male; Middle Aged; Syndrome

Topics: Acute Disease; Adult; Aged; Amino Acids; Cholecystitis; Cholecystokinin; Female; Humans; Male; Middle Aged; Trypsin Inhibitors

Topics: Adolescent; Adult; Aged; Cholagogues and Choleretics; Cholecystitis; Cholecystokinin; Cholelithiasis; Chronic Disease; Female; Humans; Kinins; Male; Middle Aged

A review of gallbladder scintigraphy in patients with potentially compromised hepatobiliary function revealed two groups in whom cholecystitis might be mistakenly diagnosed. In 200 consecutive hospitalized patients studied with technetium-99m-PIPIDA for acute cholecystitis or cholestasis, there were 41 alcoholics and 17 patients on total parenteral nutrition. In 60% of the alcoholics and 92% of those on parenteral nutrition, absent or delayed visualization of the gallbladder occurred without physical or clinical evidence of cholecystitis. A cholecystagogue, sincalide, did not prevent the false-positive features which presumably are due to altered bile flow kinetics related to alcoholism and parenteral nutrition. Four patients on parenteral nutrition undergoing cholecystectomy for suspected cholecystitis had normal gallbladders filled with jellylike viscous thick bile. A positive (nonvisualized or delayed visualized) gallbladder PIPIDA scintigram in these two populations should not be interpreted as indicating a need for cholecystectomy.

Topics: Alcoholism; Bile; Cholecystitis; Cholecystokinin; Cholestasis; False Positive Reactions; Gallbladder; Humans; Imino Acids; Organotechnetium Compounds; Parenteral Nutrition; Parenteral Nutrition, Total; Peptide Fragments; Radionuclide Imaging; Sincalide; Technetium

Because the efficacy of cholecystokinin cholecystography in the detection of chronic acalculous cholecystitis remains in doubt, the procedure is rarely used in clinical practice. However, the ability to observe gallbladder contraction with sonography and 99mTc-para-isopropylacetanilido-iminodiacetic acid cholescintigraphy (PIPIDA) offers a possibility to improve the sensitivity of the test. To determine if the degree of gallbladder contraction after cholecystokinin is the same as measured by the three techniques and if it differs in symptomatic patients compared to the normal population, cholecystokinin cholecystography, cholecystokinin sonography, and cholecystokinin PIPIDA were performed in 10 symptomatic patients and 10 normal volunteers. The mean maximum contraction of the gallbladder during the three studies was 63%, 61%, and 68%, respectively, for the volunteers, and 72%, 63%, and 73%, respectively, for the patients. The mean maximum gallbladder contraction during all three procedures was 64% +/- 26% SD in the volunteers and 74% +/- 17% SD in the patients. The differences were not statistically significant. Although there was good correlation in the degree of maximum gallbladder contraction among cholecystokinin cholecystography, cholecystokinin sonography, and cholecystokinin PIPIDA, marked variation in both the volunteers and the patients makes it unlikely that the degree of contraction as observed by any of these techniques can be used to indicate the presence of chronic acalculous cholecystitis.

Topics: Biliary Dyskinesia; Cholecystectomy; Cholecystitis; Cholecystography; Cholecystokinin; Follow-Up Studies; Gallbladder; Humans; Imino Acids; Muscle Contraction; Organotechnetium Compounds; Radionuclide Imaging; Technetium; Ultrasonography

Two tests of cystic duct patency were compared in 37 patients with suspected acute cholecystitis. Ultrasound (US) measurement of gallbladder contraction induced by 40 Ivy dog units of cholecystokinin (CCK) was followed by the radionuclide (RN) test for cystic duct patency. In all 13 patients in whom US showed significant gallbladder contraction after CCK, the cystic duct was proved to be patent by the RN test. The gallbladder did not contract significantly in 24 patients. Eleven of these patients had acute cholecystitis, with evidence of cystic duct obstruction, and 12 had patent cystic ducts and final diagnoses other than acute cholecystitis. The measurement of contraction of the gallbladder in response to CCK is a valuable improvement over simple US when cystic duct obstruction is excluded; failure of contraction is not specific, and independent evaluation of cystic duct patency is required.

Topics: Adult; Aged; Bile Duct Diseases; Cholecystitis; Cholecystokinin; Cholelithiasis; Cystic Duct; Gallbladder; Humans; Middle Aged; Radionuclide Imaging; Ultrasonography

Topics: Adult; Cholecystitis; Cholecystokinin; Chronic Disease; Female; Humans; Longitudinal Studies; Male; Middle Aged; Pancreas; Pancreatitis; Recurrence; Remission, Spontaneous

Cholecystokinin (CCK) and its C-terminal octapeptide analog, Sincalide, have been utilized in two separate roles for the evaluation of gallbladder disease. These are: (1) prior to cholescintigraphy to evacuate the gallbladder and optimized subsequent filling with radiotracers, and (2) to study contractile function of visualizing gallbladders on cholecystography and cholescintigraphy. As a preparation for 99mTc-IDA studies, it clearly facilitates earlier gallbladder filling in patients with chronic cholecystitis, thereby ruling out complete cystic duct obstruction. The problem lies in the fact that the use of CCK as a premedication markedly decreases the sensitivity of the study to detect chronic cholecystitis, since the findings become indistinguishable from patients with normal gallbladders. For this reason, the authors prefer to obtain delayed images, since chronic cholecystitis is frequently associated with gallbladder filling beyond the first hour. The role of CCK in detecting abnormal gallbladder function in the normally visualizing gallbladder also is controversial. Other studies as well as the author's experience suggests that as much as one-forth of positive cases may be associated with normal gallbladders at surgery and often even on microscopic examination. However, most importantly, the great majority of these patients are relieved of their symptoms following surgery. It appears reasonable that CCK or Sincalide cholecystography or cholescintigraphy may be detecting functional abnormalities before anatomic changes occur and can, therefore, serve as a useful examination in selecting symptomatic patients who may benefit from cholecystectomy.

Topics: Acute Disease; Cholecystectomy; Cholecystitis; Cholecystography; Cholecystokinin; Common Bile Duct; Gallbladder; Humans; Imino Acids; Injections, Intravenous; Muscle Contraction; Muscle, Smooth; Peptide Fragments; Radionuclide Imaging; Sincalide; Technetium; Technetium Tc 99m Diethyl-iminodiacetic Acid

Topics: Biliary Tract Diseases; Child; Cholecystitis; Cholecystokinin; Chronic Disease; Enzyme Activation; Humans; Pancreas; Secretin

Changes in the radiological diagnosis of gallbladder disease are occurring at a remarkable rate. In this symposium, several recognized authorities place the various diagnostic modalities and their interrelation in modern perspective. The present and future roles of oral cholecystography and intravenous cholangiography, the radiological diagnosis of chronic acalculous cholecystitis, and the use of ultrasonography and cholescintigraphy are analyzed.

Topics: Acute Disease; Cholangiography; Cholecystitis; Cholecystography; Cholecystokinin; Chronic Disease; Gallbladder Diseases; Humans; Imino Acids; Radionuclide Imaging; Technetium; Technetium Tc 99m Diethyl-iminodiacetic Acid; Technetium Tc 99m Lidofenin; Tomography, X-Ray Computed; Ultrasonography

Topics: Acute Disease; Adult; Cholecystitis; Cholecystokinin; Chronic Disease; Cystic Duct; Humans; Liver Cirrhosis, Alcoholic; Male; Middle Aged; Radionuclide Imaging

Twenty-six patients who had typical symptoms of biliary tract disease, e.g. postprandial right upper quadrant pain, nausea and vomiting, fatty food intolerance and flatulence and who had had two or more normal oral cholecystograms were subjected to cholecytokinin cholescystography. Ten patients showed a normal response to the intravenous administration of cholecystokinin, namely prompt and complete emptying of the gallbladder without producing any adverse reaction or symptoms. Sixteen patients demonstrated either no contraction or incomplete contraction of the gallbladder in response to cholecystokinin; several patients had moderate contraction of the gallbladder accompanied by symptoms of biliary colic. This latter group underwent cholecystectomy and operative cholangiography. Fifteen of the 16 patients are asymptomatic or improved, and only one patient continues to have symptoms. All removed gallbladders had histologic evidence of chronic cholecystitis. It is concluded that in some individuals with continuing symptoms suggesting gallbladder disease but normal oral cholecystograms, cholecystokinin cholecystography may be helpful in identifying physiologic dysfunction of the gallbladder.

Topics: Adult; Aged; Cholecystectomy; Cholecystitis; Cholecystography; Cholecystokinin; Diagnosis, Differential; Esophageal Achalasia; Esophageal Neoplasms; Female; Gallbladder; Gallbladder Diseases; Gastritis; Humans; Male; Middle Aged

In a 5 year period, eight patients in whom acute acalculous cholecystitis developed during intravenous hyperalimentation are reviewed with emphasis on factors contributing to pathogenesis. Gallbladder distention, biliary stasis, and bile inspissation, thought to be important in the pathogenesis of this disease, are enhanced with the use of hyperalimentation, and this potential complication is being seen with increasing frequency in seriously ill or injured patients who are being fed parenterally. In addition to hyperalimentation, sepsis, hypotension, multiple transfusions (more than 10 units), prolonged fasting, and ventilatory support were frequent common denominators. Typical findings of pain, tenderness, and a mass in the right upper abdominal quadrant are infrequent, and the diagnosis rests on a high index of suspicion and ultrasonography. This syndrome may be preventable by the stimulation of gallbladder emptying with intermittent fat ingestion or parenteral infusion of cholecystokinin.

Topics: Abdominal Injuries; Adult; Aged; Cholecystectomy; Cholecystitis; Cholecystokinin; Cholestasis; Dietary Fats; Female; Humans; Male; Middle Aged; Parenteral Nutrition; Parenteral Nutrition, Total; Ultrasonography

The group of conditions variously termed biliary dyskinesia, acalculous cholecystitis, biliary pain without stones, or functional disorders of the biliary tract, is poorly defined clinically, and no consistent pathological abnormalities have been previously described in patients with this diagnosis. In this paper we report histological abnormalities encountered in operative live biopsies in such patients. The criteria for the diagnosis of a functional biliary tract disorders were: pain typical of biliary pain, negative results of investigations for organic biliary tract or other gastrointestinal disease, and reproduction of the patient's symptoms by cholecystokinin, or morphine, or both. Twenty of 45 patients with a presumptive diagnosis satisfied these criteria, and had a wedge liver biopsy at the time of operation. The 20 liver biopsy specimens were compared in a blind fashion with similar ones taken from patients having diagnostic laparotomies; patients with stones confined to the gallbladder; patients with gallstone pancreatitis; and patients with proven common bile duct stones. The biopsy findings were found to be similar to those in the latter two groups. Thus the abnormalities were similar to those found in partial or intermittent biliary obstruction, and it is suggested that they may be due to intermittent increases in biliary pressure.

Topics: Adult; Aged; Biliary Dyskinesia; Biliary Tract Diseases; Cholecystitis; Cholecystokinin; Cholelithiasis; Female; Humans; Liver; Male; Middle Aged; Morphine; Pain; Pancreatitis

Cholescintigraphy with N-substituted iminodiacetic acid (HIDA) labelled with technetium-99m is a new noninvasive technique for evaluation of the hepatobiliary system. The significance of nonvisualization of the gallbladder by this method in comparison with standard radiologic examinations was studied. In 43 healthy subjects the gallbladder was visualized by the two methods. By contrast, all 27 patients in whom the gallbladder was not visualized by cholescintigraphy had cholecystitis. When visualization failed to occur, a repeat cholescintigraphic study after an injection of cholecystokinin demonstrated the status of the cystic duct. Visualization excludes cystic duct obstruction and acute cholecystitis, whereas persistent nonvisualization indicates cystic duct obstruction.

Topics: Acetanilides; Acute Disease; Cholecystitis; Cholecystography; Cholecystokinin; Diagnosis, Differential; Gallbladder; Humans; Imino Acids; Methods; Radionuclide Imaging; Technetium

Now that the active fragment of the cholecystokinin molecule has been made available for use in clinical pracitce, reports on the value of cholecystokinin cholecystography must be re-evaluated to determine if the procedure is worthwhile in patients with persistent symptoms and a normal conventional oral cholecystogram. Such an analysis discloses that there is no uniform agreement on what consitutes an abnormal examination and raises serious questions concerning the scientific validity of much of the data. It is apparent that there is no immutable evidence to date to indicate that cholecystokinin cholecystography is an accurate technique to determine which patients in this category will benefit from cholecystectomy.

Topics: Adolescent; Adult; Biliary Tract Diseases; Cholecystectomy; Cholecystitis; Cholecystography; Cholecystokinin; Chronic Disease; Humans; Middle Aged

Topics: Adolescent; Child; Cholecystitis; Cholecystokinin; Duodenal Diseases; Duodenal Ulcer; Enteritis; Humans; Pancreatic Diseases; Pancreatitis

Topics: Acute Disease; Cholecystitis; Cholecystokinin; Humans; Imino Acids; Radionuclide Imaging

A procedure was devised to quickly and reliably determine the patency of the cystic duct in patients suspected of having acute cholecystitis. First the gallbladder was stimulated to empty by a cholecystokinin injection. Thirty minutes later a radiolabeled biliary marker, either 150 muCi 131-I rose bengal or 2 mCi 99-mTc dihydrothioctic acid, was injected, and the accumulation of radioactivity in the liver and gallbladder regions was monitored by external gamma emission imaging and recording devices. The images of diagnostic importance were obtained between 60 and 90 minutes after injection of the tracer. Thirty-nine patients with acute abdominal pain were studied. Ten patients who had acute cholecystitis failed to show gallbladder accumulation of radioactivity, reflecting the cystic duct obstruction that initiates this disease. Twenty-nine patients having a variety of other diseases all showed gallbladder accumulation of activity, indicating in each patient that the cystic duct was patent. No significant adverse effects were noted. We conclude that the procedure is a useful adjunct to the clinical and roentgenographic evaluation of patients with acute abdominal pain.

Topics: Acute Disease; Adolescent; Adult; Aged; Cholecystitis; Cholecystokinin; Chronic Disease; Cystic Duct; Female; Gallbladder; Gallbladder Diseases; Humans; Male; Middle Aged; Pancreatitis; Radionuclide Imaging; Rose Bengal; Stimulation, Chemical; Technetium

Topics: Adult; Aged; Amylases; Bicarbonates; Cholecystectomy; Cholecystitis; Cholecystokinin; Chronic Disease; Duodenal Ulcer; Female; Humans; Liver Cirrhosis; Male; Middle Aged; Pancreas; Pancreatitis; Postoperative Complications; Secretin; Syndrome

Topics: Adult; Aged; Cholecystitis; Cholecystography; Cholecystokinin; Cholesterol; Evaluation Studies as Topic; Female; Follow-Up Studies; Gallbladder; Gallbladder Diseases; Humans; Male; Methods; Middle Aged; Technology, Radiologic; Time Factors

Topics: Adolescent; Adult; Aged; Bilirubin; Cholecystitis; Cholecystokinin; Chronic Disease; Duodenum; Female; Humans; Intestinal Secretions; Male; Middle Aged; Stimulation, Chemical

Topics: Animals; Bile; Cholecystitis; Cholecystokinin; Cholelithiasis; Common Bile Duct; Swine; Vagotomy; Vagus Nerve

Topics: Acute Disease; Cholecystitis; Cholecystokinin; Chronic Disease; Gallbladder; Humans; Pancreas; Pancreatic Elastase; Pancreatitis; Phospholipases; Secretin; Trypsin

Topics: Adult; Aged; Cholecystitis; Cholecystography; Cholecystokinin; Cholelithiasis; Duodenal Ulcer; Female; Humans; Male; Middle Aged; Vagotomy; Vagus Nerve

Topics: Adolescent; Adult; Aged; Child; Cholecystitis; Cholecystography; Cholecystokinin; Cholelithiasis; Contrast Media; Female; Gallbladder Diseases; Gastrointestinal Motility; Humans; Intestine, Small; Male; Middle Aged; Time Factors

Topics: Amylases; Cholecystectomy; Cholecystitis; Cholecystography; Cholecystokinin; Common Bile Duct; Female; Gallbladder; Gallbladder Diseases; Humans; Injections, Intravenous; Male; Psychophysiologic Disorders; Spasm

Topics: Calcinosis; Cholecystitis; Cholecystokinin; Cholelithiasis; Cholesterol; Female; Gallbladder; Gallbladder Diseases; Humans; Male

Topics: Adult; Biliary Dyskinesia; Cholecystitis; Cholecystography; Cholecystokinin; Cystic Duct; Female; Humans; Injections, Intravenous; Male; Methods; Middle Aged; Technology, Radiologic

Topics: Biliary Dyskinesia; Cholecystectomy; Cholecystitis; Cholecystokinin; Cholelithiasis; Gallbladder Diseases; Humans

Topics: Adult; Aged; Amylases; Celiac Disease; Cholecystitis; Cholecystokinin; Cholelithiasis; Gastrointestinal Diseases; Humans; Infusions, Parenteral; Middle Aged; Pancreas; Pancreatitis; Proteins; Secretin; Secretory Rate

Topics: Biliary Dyskinesia; Cholecystitis; Cholecystokinin; Duodenum; Fats; Gastrins; Gastritis; Gastrointestinal Motility; Hepatitis A; Humans; Stomach

Topics: Amyloidosis; Biochemical Phenomena; Biochemistry; Cholangitis; Cholecystitis; Cholecystokinin; Colonic Neoplasms; Drug Therapy; Duodenum; Electrophoresis; Enteritis; Gastritis; Hemosiderosis; Humans; Intestinal Secretions; Leucyl Aminopeptidase; Liver Cirrhosis; Liver Diseases; Melanoma; Mucous Membrane; Nephrosis; Pancreatitis