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History: A 45-year-old female patient who was previously healthy presented after several weeks of fullness in the right upper quadrant of the abdomen. The patient did not experience pain, nausea, vomiting, or jaundice, and had no contributory past medical or surgical history, including no history of malignancy. Upon examination, vital signs were within normal limits and the patient appeared well, with soft palpable fullness in the right upper quadrant. The abdomen was nontender and nondistended. Laboratory investigation revealed no abnormalities, with a normal complete blood cell count and normal serum tumor markers that included α-fetoprotein (<2.0 ng/mL; reference, <8.3 ng/mL), cancer antigen 19-9 (21.6 U/mL; reference, <35 U/mL), and carcinoembryonic antigen (1.3 ng/mL; reference, <5 ng/mL). CT of the abdomen and pelvis was performed with intravenous contrast material in the emergency department. Subsequently, combined MRI and MR cholangiopancreatography of the abdomen was performed with and without intravenous contrast material for further evaluation. CT of the chest performed during the same encounter was unremarkable.

Gallbladder polyps (also known as polypoid lesions of the gallbladder) are a common incidental finding. The vast majority of gallbladder polyps smaller than 10 mm are not true neoplastic polyps but are benign cholesterol polyps with no inherent risk of malignancy. In addition, recent studies have shown that the overall risk of gallbladder cancer is not increased in patients with small gallbladder polyps, calling into question the rationale for frequent and prolonged follow-up of these common lesions. In 2021, a Society of Radiologists in Ultrasound, or SRU, consensus conference was convened to provide recommendations for the management of incidentally detected gallbladder polyps at US. See also the editorial by Sidhu and Rafailidis in this issue., (© RSNA, 2022.)

Gallbladder carcinoma is the most common cancer of the biliary system. It is challenging to diagnose because patients are often asymptomatic or present with nonspecific symptoms that mimic common benign diseases. Surgical excision is the only curative therapy and is best accomplished at early non-locally advanced stages. Unfortunately, gallbladder cancer often manifests at late locally advanced stages, precluding cure. Early tumors are often incidentally detected at imaging or at cholecystectomy performed for another indication. Typical imaging features of localized disease include asymmetric gallbladder wall thickening, polyps larger than 1.0 cm, and a solid mass replacing the gallbladder lumen. Advanced tumors are often infiltrative and can be confusing at CT and MRI owing to their large size. Determination of the origin of the lesion is paramount to narrow the differential diagnosis but is often challenging. It is important to identify gallbladder cancer and distinguish it from other benign and malignant hepatobiliary processes. Since surgical resection is the only curative treatment option, radiologist understanding and interpretation of pathways of nodal and infiltrative tumor spread can direct surgery or preclude patients who may not benefit from surgery. While both CT and MRI are effective, MRI provides superior soft-tissue characterization of the gallbladder and biliary tree and is a useful imaging tool for diagnosis, staging, and evaluation of treatment response. © RSNA, 2020.

Intraluminal pathologic conditions of the bile ducts and gallbladder are common, most frequently consisting of calculi and adenocarcinoma. In recent years, intraductal papillary neoplasm of the bile ducts (IPN-B), which is analogous to intraductal papillary mucinous neoplasm of the pancreas, has been recognized as a distinct pathologic entity and a precursor lesion to adenocarcinoma of the bile ducts. Intraductal tubulopapillary neoplasm (ITPN) of the bile duct was subsequently described as a distinct pathologic entity. With increased awareness and advances in imaging techniques, these lesions are diagnosed with increased frequency at preoperative imaging. A similar neoplasm in the gallbladder is referred to as intracholecystic papillary neoplasm. These lesions are often diagnosed at a preinvasive stage and have a better prognosis than invasive cholangiocarcinoma when treated with curative resection, underscoring the importance of an accurate imaging diagnosis. The most common causes of polypoid lesions of the gallbladder are cholesterol polyps and adenomyomatosis. These lesions need to be differentiated from the less common but clinically important adenocarcinoma of the gallbladder. Imaging is crucial to identify polyps that are at high risk for malignancy so that the appropriate management choice between imaging follow-up and cholecystectomy can be made by the treating physicians. Other less common gallbladder tumors, such as gallbladder adenomas, lymphoma, and metastases to the gallbladder, can manifest as intraluminal tumors; and awareness of these lesions is also important. In this article, the recent literature is reviewed; and the imaging appearances, histopathologic findings, and management of uncommon intraluminal tumors of the bile ducts and gallbladder and their mimics are discussed. © RSNA, 2019.

Purpose: To determine the natural history of gallbladder (GB) polyps incidentally detected at ultrasonography (US) and to propose management guidelines for these lesions based on polyp size., Materials and Methods: The HIPAA-compliant study was approved by the institutional review board, and informed consent was waived. A database search for "polyp" in all US examinations of the GB between January 1, 1999, and December 31, 2001, at a single institution was performed. All subsequent US reports were reviewed to determine changes in GB polyp size. The electronic medical record was searched to obtain clinical and pathologic follow-up., Results: Three hundred forty-six patients (mean age, 51.6 years; range, 20-93 years) with GB polyps were included. There were 156 men (45%) and 190 women (55%). US follow-up (mean, 5.4 years; range, 2-11.5 years) was performed in 149 patients (43%). Polyp size was stable in 90 (60%) polyps, decreased in eight (5%), increased in one (1%), and resolved in 50 (34%). Forty-two patients (12%) underwent cholecystectomy, revealing 13 (31%) GBs with polypoid lesions, 24 (57%) with stones and no polyps, and five (12%) with neither a stone nor a polypoid lesion. Clinical follow-up (mean, 8 years; range, 5-10.4 years) was performed in 155 patients (45%). No patient had clinical evidence of GB-related disease. Overall, no cases of GB malignancy were identified in 346 patients. Mean polyp size was 5.0 mm (range, 1-18 mm). No neoplastic polyps were found at 1-6 mm, one neoplastic polyp was seen at 7-9 mm, and two neoplastic polyps were found at 10 mm or larger., Conclusion: The risk of GB malignancy resulting from incidentally detected polyps is extremely low. Incidentally detected GB polyps measuring 6 mm or less may require no additional follow-up. Data are inconclusive regarding polyps 7 mm or greater, and further studies are warranted., (© RSNA, 2010)

Purpose: To evaluate whether preoperative portal vein embolization (PVE) with polyvinyl alcohol (PVA) particles and coils is safe and effective for inducing lobar hypertrophy in patients with hepatobiliary malignancy., Materials and Methods: PVE was performed in 26 patients. All patients had malignancy: metastases (n = 11), cholangiocarcinoma (n = 9), hepatocellular carcinoma (n = 5), and gallbladder carcinoma (n = 1). One patient had underlying liver disease caused by hepatitis. PVE was performed if the future liver remnant (FLR) was estimated to be less than 25% of the total liver volume. PVE was performed with a percutaneous transhepatic approach (right, 25 patients; left, one patient). PVA particles and coils were used to occlude the right portal system and veins supplying segment IV to promote FLR hypertrophy (segments I-III +/- IV). FLR hypertrophy was assessed with comparison of computed tomographic scans obtained before and 2-4 weeks after PVE. Effectiveness evaluation was based on changes in absolute FLR size and ratio of FLR to total estimated liver volume (TELV). Safety of PVE and hepatic resection was determined with postprocedure complication rate and median hospital stay., Results: Sixteen patients underwent hepatic resection (right trisegmentectomy [n = 13], right lobectomy [n = 3]) without mortality. Ten patients did not undergo resection (complete remission after medical therapy [n = 1], lack of regeneration [n = 2], extrahepatic disease undetected prior to PVE [n = 7]). Six patients had biliary obstruction; five were treated percutaneously before PVE. No patient developed postembolization syndrome or signs of fulminant hepatic insufficiency after PVE or resection. Two patients had complications after PVE that did not preclude successful resection. Median hospital stays were 1 day (PVE) and 7 days (liver resection). Mean absolute FLR increased from 325.0 to 458.6 cm3 (increase, 41.1%). Mean TELV was 1,784.8 cm3. FLR/TELV ratio increase was 8%., Conclusion: Preoperative PVE with PVA particles and coils is safe and effective for inducing lobar hypertrophy in patients with advanced hepatobiliary malignancy.

Purpose: To evaluate the demonstration of the pearl necklace sign at magnetic resonance (MR) cholangiopancreatography (MRCP) in patients with proven adenomyomatosis and carcinoma of the gallbladder., Materials and Methods: MRCP findings and those of a combination of unenhanced and arterial phase computed tomography (CT) and arterial phase MR imaging were retrospectively compared in 29 patients who were pathologically proven to have adenomyomatosis of the gallbladder and in 18 patients with pathologically proven gallbladder carcinoma. Receiver operating characteristic (ROC) analysis was used with a five-point confidence scale. The relative sensitivity, specificity, and accuracy of each imaging modality were also calculated. The pearl necklace sign was defined on MRCP images as small round foci, with the same markedly high signal intensity as bile, within the thickened wall of the gallbladder., Results: The mean area under the ROC curve of MRCP alone and that of the combination of MRCP and arterial phase MR imaging was significantly higher than that of combined CT (unenhanced and arterial phase) and arterial phase MR imaging alone (P <.01). The relative sensitivities in the diagnosis of adenomyomatosis of the gallbladder were 24% for the combined CT, 29% for arterial phase MR imaging, 62% for MRCP, and 57% for the combination of MRCP and arterial phase MR imaging. The mean relative sensitivity, specificity, and accuracy of the pearl necklace sign on MRCP images were 62%, 92%, and 74%, respectively. In eight (28%) of 29 patients with adenomyomatosis of the gallbladder, the pearl necklace sign was not identified by all three readers on the MRCP images., Conclusion: The pearl necklace sign, which indicates the presence of Rokitansky-Aschoff sinuses within the thickened gallbladder wall, was specifically detected at MRCP for adenomyomatosis of the gallbladder.

Purpose: To evaluate the segmental anatomy of the right anterosuperior area (segment 8) of the liver by using helical computed tomography during arterial portography (CTAP)., Materials and Methods: Twenty-seven patients without lesions at segment 8 underwent helical CTAP. Three-dimensional portograms were reconstructed to verify the course of the portal veins. The number of subsegmental branches, in addition to the branching point and the distribution in segment 8, was assessed., Results: In 25 (93%) patients, the dorsal branch of segment 8 gave rise to dorsally directed branches posterior to the right hepatic vein. In only four (25%) of 16 patients in whom the medial branch of segment 8 arose near the porta hepatis, the long paracaval portal branch of the caudate lobe extended upward above the interval between the middle and right hepatic veins., Conclusion: In most of the patients, the dorsal branches of segment 8 supplied the dorsocranial area of the right lobe posterior to the right hepatic vein. The paracaval portion of the caudate lobe was limited to below the interval between the middle and right hepatic veins in the majority of patients who showed medial branches of segment 8 arising near the porta hepatis. Recognition of this vascular anatomy is clinically important for preoperative evaluation of hepatic tumors in segment 8 because it may contribute to a safer surgical approach.

Purpose: To describe the computed tomographic (CT) appearance of recurrent gallbladder carcinoma along port tracks after laparoscopic cholecystectomy and to assess the effect of recurrence on patient care., Materials and Methods: Seventeen abdominal CT scans in 16 of 19 consecutive patients who underwent hepatic resection for gallbladder carcinoma diagnosed at laparoscopic cholecystectomy were reviewed retrospectively. Medical records were reviewed to determine the clinical effect of tumor recurrence along a port track., Results: CT revealed 12 tumor recurrences along laparoscopic port tracks in six (32%) patients (mean, two recurrences per patient; range, one to four per patient). Eight (67%) CT-depicted recurrences appeared homogeneous, and nine (75%) directly involved subjacent omental fat. The mass was the only site of recurrence at CT in two (33%) patients. The presence of an abdominal wall tumor recurrence affected patient care in four (67%) of six patients. Histopathologic examination results confirmed recurrent tumor in all five (100%) patients who underwent biopsy., Conclusion: Tumor recurrence along port tracks is a potential complication of laparoscopic cholecystectomy when gallbladder carcinoma is present, even after subsequent hepatic resection is performed for attempted cure. Recurrences appear as a new or enlarging abdominal wall mass, often involving subjacent omental fat, and may be the only site of recurrent disease at CT. Demonstration of abdominal wall tumor recurrence affects patient care.

Purpose: To assess the value of computed tomography (CT), cholangiography, ultrasonography (US), and magnetic resonance (MR) imaging in the demonstration of biliary tract carcinoma complicating primary sclerosing cholangitis (PSC)., Materials and Methods: Thirty patients were studied who had PSC and biliary tract carcinoma. Twenty-six patients had cholangiocarcinoma, and four had gallbladder carcinoma. Sixty-four CT scans, 41 cholangiograms, 40 US studies, and seven MR studies were reviewed retrospectively for evidence of tumor and PSC. Imaging results were correlated with pathologic findings from whole liver specimens and biopsies. Presence of mass was rated as definite, probable, possible, or doubtful or absent., Results: On CT scans, cholangiocarcinomas produced hypoattenuating masses in 17 of 23 cases, delayed contrast enhancement in six of 12, progressive biliary dilatation in five of 15, and thickened bile duct wall in two of 23. On cholangiograms, dominant strictures were present in 18 of 21 cases of cholangiocarcinoma; 13 were malignant, and five were benign. Cholangiocarcinoma formed polypoid bile duct masses in two of 21 cases. Biliary dilatation was caused by cholangiocarcinoma in 10 of 12 cases and by benign stricture in two. Gallbladder carcinomas demonstrated masses on CT scans, cholangiograms, and US images, and wall thickening on CT and US images. Overall, definite or probable tumor was demonstrated in 25 of 30 patients (83%)., Conclusion: Most biliary tract carcinomas complicating PSC can be demonstrated on imaging studies.

Purpose: To evaluate the frequency, location, and appearance of transient increased attenuation in the liver during arterial-phase helical or incremental computed tomography (CT) in patients with gallbladder disease without hepatic extension., Materials and Methods: Findings in dynamic CT examinations in 31 patients with surgically proved gallbladder disease not extending into the liver and in 31 control patients without gallbladder disease were retrospectively reviewed and correlated with findings in other imaging examinations., Results: Areas of transient increased hepatic attenuation (n = 27) were identified in 22 of 31 patients with gallbladder disease and in only one of 31 control patients. The difference in these findings was statistically significant (P < .001). In the 27 areas of transient increased hepatic attenuation, these findings were categorized as curvilinear or nodular attenuation adjacent to the gallbladder fossa in 13 (48%), segmental or subsegmental attenuation in segment IV and/or V in seven (26%), lobar attenuation in the left lobe (segments II-IV) in four (15%), and nodular attenuation seen as an early enhancing "pseudolesion" in segment IV in three (11%). Hepatic angiography performed in 10 of the 22 patients showed early depiction of the dilated cystic vein (n = 8) and direct communication with the portal branches (n = 2)., Conclusion: Transient increased attenuation in the liver had a variable appearance at dynamic arterial-phase CT in most patients with gallbladder disease. This attenuation was most likely due to increased blood flow from the hepatobiliary system.

Purpose: To evaluate the computed tomographic (CT) features of xanthogranulomatous cholecystitis (XGC) and to distinguish it from gallbladder carcinoma., Materials and Methods: Retrospective analysis was performed in 11 patients with XGC and 17 patients with gallbladder carcinoma in which the wall was thickened. The following CT features were analyzed: maximum wall thickness, intramural hypoattenuated nodules, mucosal line, patterns of wall thickening and enhancement, and the presence of stones. The changes outside the gallbladder were also compared., Results: The mean thickness of the gallbladder wall was 1.8 cm in patients with XGC and 2.1 cm in patients with gallbladder carcinoma. Intramural hypoattenuated nodules were seen in all patients with XGC but in only seven patients with gallbladder carcinoma (P = .008). The mucosal line was observed in nine patients with XGC and in six with gallbladder carcinoma (P = .02). The gallbladder wall was more diffusely thickened in patients with XGC (10 of 11 patients) than in patients with gallbladder carcinoma (seven of 17 patients) (P = .01). The occurrence of changes outside the gallbladder did not differ statistically significantly., Conclusion: Because of a statistically significant overlap of CT features, only when intramural hypoattenuated nodules occupy a large area of the thickened gallbladder wall can the diagnosis of XGC be highly suggestive. The diagnosis of XGC at CT may indicate a less aggressive surgical approach.

The ipsilateral approach was used at preoperative portal vein embolization in 38 patients with hepatobiliary malignancy. The right anterior portal branch was punctured. Two different 5.5-F triple-lumen balloon catheters were used, and fibrin glue and iodized oil were injected. Portal vein embolization was successful in all cases (right lobe, 24 patients; left lobe and right anterior segment, six; right lobe and left medial segment, three; right posterior segment, two; right anterior segment, one; left lobe, one; and right and caudate lobes, one).

Purpose: To identify ultrasonographic (US) features of large cholesterol polyps (> 10 mm in diameter) of the gallbladder in the differential diagnosis of polypoid lesions., Materials and Methods: Sixty-seven patients underwent US (n = 67) and endoscopic US (n = 33). Fourteen patients had large cholesterol polyps. Findings in these patients were compared with those in patients with small cholesterol polyps (< or = 10 mm in diameter; n = 34) or other polypoid lesions (n = 19)., Results: US demonstrated the large cholesterol polyps as pedunculated masses with granular surfaces. In 94% of patients, all small cholesterol polyps were echogenic whereas the large cholesterol polyps tended to have decreased echogenicity. Endoscopic US showed complete or partial aggregation of echogenic spots in all cholesterol polyps-but not in other polypoid lesions, which included carcinomas., Conclusion: Aggregation of echogenic spots seems to be a US feature characteristic of both large and small cholesterol polyps. Routine use of endoscopic US is recommended for differential diagnosis of polypoid lesions because of its high resolution.

Although carcinoma of the gallbladder has a low overall prevalence, it is the most common malignant tumor of the biliary tract. Retrospectively, 59 cases of histologically proved gallbladder carcinoma were reviewed. The series consisted of 42 women and 17 men, ranging in age from 35 to 86 years. Clinical manifestations of gallbladder carcinoma include right upper quadrant pain, anorexia, weight loss, and jaundice. Radiologic findings included focal or diffuse thickening of the gallbladder wall (49%), a mass in the gallbladder fossa (37%), and an intraluminal mass (14%). Associated findings were cholelithiasis (64%), biliary duct dilatation (38%), invasion of the adjacent structures (67%), distant metastases other than those of the liver (3%), and porcelain gallbladder (4%). The histologic diagnoses were adenocarcinoma (90%) and squamous cell carcinoma (10%). Differential diagnoses include all conditions in which the gallbladder wall appears thickened. A general awareness of the radiologic features of gallbladder carcinoma enhances preoperative diagnoses.

Ultrasonically (US) guided fine-needle aspiration biopsy was performed in 88 patients who had gallbladder masses. All masses were less than 4.8 cm in diameter. A 22- or 23-gauge, Teflon-coated needle was placed into the mass with the transhepatic or transperitoneal route. By means of this technique, gallbladder malignancy was confirmed in 69 of the 78 cases of malignancy (88.5%). Ten of 10 benign lesions were properly categorized. One patient developed bile peritonitis following a single needle pass with the transperitoneal approach. Pain, a minor complication of the procedure, was noted in four cases. No instances of hemorrhage or vasovagal reactions occurred. From their experience in this large series, the authors conclude that US-guided fine-needle aspiration biopsy of gallbladder masses is a safe, reliable, and accurate technique for the diagnosis of malignancy.

To facilitate early detection of carcinoma of the gallbladder, a comparative study of macroscopic forms and ultrasonographic (US) features of stage I (TNM staging system) gallbladder cancer was carried out retrospectively in 71 cases of such carcinomas that were resected surgically. Macroscopic forms of the lesions were classified into four types: pedunculated (eight cases), sessile (15 cases), superficial raised (25 cases), and flat (23 cases). Among 71 cases, only 20 were diagnosed preoperatively by means of US. US patterns of the lesions were also classified into four types: fungating mass, lumen filling, smooth raised, and thickening of mucosa. US features corresponded well to the macroscopic forms. No flat lesion was identified preoperatively. For early detection of carcinoma of the gallbladder, it seemed essential to pay careful attention to mild mucosal change, as more than 50% of early cancers did not show apparently protruding lesions.

A case of primary carcinoma of the gallbladder with nodal metastases, diagnosed by ultrasound examination in a nonjaundiced patient, is described. The gallbladder mass was also visualized on oral cholecystography. The ultrasonic and pathologic findings are correlated.

The authors report their experience with 24 patients who underwent a variety of percutaneous procedures involving the gallbladder. Twenty diagnostic and 13 therapeutic procedures were performed under sonographic, computed tomographic (CT), or fluoroscopic guidance; these procedures included biopsy of the gallbladder, diagnostic cholecystography, diagnostic aspiration of bile, gallstone dissolution and removal, cholecystostomy for drainage, and gallbladder abscess drainage. The indications for percutaneous cholecystostomy (performed in 11 patients) included relief of hydrops and empyema, gallstone dissolution, mechanical gallstone removal, and drainage for malignant obstruction. Each procedure was successful. There was one complicating episode of cholecystitis and four previously described episodes of vagal hypotension. Bile peritonitis did not occur in any of the patients. The authors discuss the various percutaneous gallbladder procedures and specific technical considerations in performing them.

Twenty-seven gallbladder carcinomas were examined by computed tomography (CT). All patients had abnormal CT findings, suggesting a gallbladder lesion in 26. Based on the major CT findings, gallbladder cancer was classified as "massive," "thickened wall," or "intraluminal." Twenty cases were diagnosed correctly as cancer: on retrospect, definite findings of gallbladder cancer were observed in 24 and equivocal or misleading signs in 3. Some cases of chronic cholecystitis and liver tumor were difficult to differentiate from gallbladder cancer. Direct hepatic extension was easily seen, but lymph-node metastases and bile-duct extension were difficult to distinguish.

Ultrasonography and CT have been used to diagnose carcinoma of the gallbladder, since in most patients the diagnosis cannot be made through radiography alone. Ultrasonography was performed on 14 patients and CT on 7. Ultrasonographic findings are classified into four types. Frequently, there are gallstones, dilated bile ducts, or metastatic lesions in the liver or retroperitoneal lymph nodes. The diagnosis was made or suggested by ultrasonography in 84.6% of patients. Findings on CT correlated well with the ultrasonographic features.

Nine patients with calcification of the gallbladder wall (porcelain gallbladder) were analyzed by ultrasound and the appearance correlated with the CT, radiographic, clinical, and surgical findings. Three distinct patterns were identified: (a) a hyperechoic semilunar structure with acoustic shadowing posteriorly, simulating a stone-filled gallbladder devoid of bile, which was seen in 5 patients; (b) a biconvex , curvilinear echogenic structure with variable acoustic shadowing, seen in all 3 patients with carcinoma of the gallbladder; and (c) an irregular clump of echoes with posterior acoustic shadowing, seen in 1 patient. Potential pitfalls in the diagnosis of gallbladder calcification are presented, and the association between calcification and cancer is emphasized.

In 3,600 patients evaluated with technetium-99m sulfur colloid for metastatic liver disease, 40 had equivocal scans due to a solitary defect in the interior margin of the right lobe. In these patients, the authors differentiated the gallbladder fossa from a metastatic focus using one of two new hepatobiliary agents: technetium-99m labeled pyridoxylideneglutamate and paraisopropylacetanilido iminodiacetic acid. In 31 patients, the focal defect filled with radioactive bile, showing that the solitary defect in the radiocolloid scan was a prominent gallbladder fossa. On laparoscopic biopsy, eight of nine patients whose focal defects were not due to the gallbladder were found to have metastatic disease. The ninth patient had carcinoma of the gallbladder. The need for laparoscopic biopsy was obviated in a majority (78%) of the patients by identifying the gallbladder fossa.

Fifty-three patients with documented primary biliary carcinoma were studied with computed tomography. Twenty-six patients had gallbladder carcinoma and 27 patients had carcinoma of the biliary ductal system. Ninety percent of patients with gallbladder cancer had an intraluminal mass. Local invasion into the liver was common. The majority of patients with biliary ductal carcinoma had dilated bile ducts, while only 50% of patients with gallbladder cancer had biliary ductal dilatation. The most common location of tumor involving the extrahepatic biliary ductal system was the distal common bile duct. This occurred in eight patients out of 27, or 30% of the cases.

Comparison has been made between slow infusion hepatic angiographic studies obtained before and after the intra-arterial injection of prostaglandin F2 alpha. The prostaglandin injection resulted in increased caliber of the hepatic arteries, increased opacification of the parenchyma of the liver and improved visualization of the wall of the gallbladder. Poorly vascularized metastatic lesions were better shown on the prostaglandin studies, and carcinoma of the gallbladder was diagnosed in two instances. The demonstration of highly vascularized metastatic tumor was enhanced on the prostaglandin studies, but further improved after the injection of angiotensin.

Eight cases of choledochal cyst associated with biliary malignancy (gallbladder carcinoma in three and bile duct carcinoma in five) were reviewed to evaluate the roles and limitations of computed tomography (CT) (n = 8), ultrasound (US) (n = 6), cholangiography (n = 8), and angiography (n = 6). In cases of gallbladder carcinoma, both CT and US revealed mass lesions in the gallbladder consistent with cancer. CT also depicted either a mass lesion or an irregular thickened wall in all cases of bile duct carcinoma; however, US failed to demonstrate a thickened wall in one of three cases in which CT findings were positive. Cholangiography universally revealed malunion of the pancreatico-biliary duct, and the findings were suggestive of malignancy in seven cases in which CT depicted abnormalities. Angiography showed tumor stain in three of six cases. Lymph node metastases were present in four cases but were detected preoperatively in only one. One case showing a thickened bile duct wall was erroneously diagnosed as malignancy among 27 cases of choledochal cyst unassociated with biliary malignancy.

A fatty meal was given to 231 patients who had a well-visualized gallbladder with no stones. The radiological diagnoses on fluoroscopic spot films made before and after the fatty meal were compared. Only one case was diagnosed differently after the fatty meal. In 4 patients the post-fat film was useful in confirming a suspected diagnosis. Indications for administration of a fatty meal include (a) overlying gas shadows, (b) differentiation of a stone from a polyp, (c) adenomyomatosis, (d) a distended gallbladder, and (e) suspected common bile duct obstruction. In the absence of these indications, the time, effort, and cost involved in making the post-fat film are not justified by the additional diagnostic information obtained.

Three new angiographic features of cholangiocarcinoma are bile duct dilatation, venous obstruction and arterio-arterial collaterals. Differentiation of the lucencies of dilated bile ducts (cylindrical in shape) from those due to metastases (spherical) is discussed. Because of its high reliability and the difficulties of operative diagnosis, angiography can play an important diagnostic role in patients with suspected cholangiocarcinoma.