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Tomographic examination was carried out on 27 patients in whom there was no opacification of the gallbladder after routine cholecystography using a double dose of contrast medium. Decisive findings were present in 24 of these cases. The findings included the presence of radiolucent and opaque calculi within the gallbladder, or within the common bile duct, and dilatation of the common bile duct. In the three cases in which no information was gained by tomography, cystic duct obstruction was found at operation.

The objective of this study was to derive and test clinical scoring system in order to predict the presence of gallstones and to identify inappropriate referrals. The design of this scoring system comprised a prospective audit of all referrals with suspected gallstones and a prospective validation of the system on new patients. The subjects used in the study consisted of 300 inpatient, outpatient and general practitioner referrals to a radiology department with suspected gallstones during the period 1984-1986 (1st cohort) and 200 similar referrals from 1987 to 1988 (2nd cohort). The main outcome measures were gallstones as determined by oral cholecystogram and/or ultrasound of the gallbladder. 32.7% and 24.0% of referrals in the first and second cohorts, respectively, had gallstones. A scoring system to predict gallstones was derived on the first cohort based on age, Murphy's sign, duration and type of pain, presence or absence of flatulence, and source of referral. This scoring system discriminated well between those with and without stones in both cohorts. Low risk groups, comprising about 15% of the referrals in each cohort, were identified with a prevalence of gallstones of 4.5% (1st cohort) and 3.0% (2nd cohort). If these patients had not been referred the radiological workload would have dropped by 15%, with a very small reduction in diagnostic yield. We conclude that prior to radiological assessment it is possible, on the basis of source of referral and symptoms, to identify a group of patients with a low prevalence of gallstones. These cases, with a low diagnostic yield, contribute substantially to the workload of a radiological department.

Contact dissolution with MTBE is an effective and safe method to treat symptomatic patients with cholesterol gallstones. Personnel, time, and safety factors have limited widespread use of the procedure. With current competing methods to treat gallstones, it is likely that MTBE use will be reserved for those patients who elect percutaneous therapy due to fear of surgery or anesthesia and in those elderly patients who are compromised by underlying medical conditions.

Gallstone lithotripsy (LITHO) was performed on 52 patients who underwent 107 procedures. Two hundred sixty-seven gallstone patients were screened and 215 (81%) were excluded. Excessive stone burden and nonvisualization by oral cholecystogram (OCG) were the most common reasons for exclusion. The hospital course of 100 excluded patients who later underwent elective cholecystectomy was evaluated for length of hospital stay (2.3 days) and total cost of treatment ($3685.00). Successful fragmentation to less than 5 mm was achieved in 43 LITHO patients (83%). Five LITHO patients (10%) required conversion to operative management. Complications of LITHO included acute cholecystitis (1 of 52 patients) and biliary colic (17 of 52 patients, or 33%). Multiple procedures in one patient were common. Costs for LITHO were calculated in two ways: first the individual cost for each of the 52 candidates; second the cost for successful LITHO was calculated by excluding five patients who required operation as well as five patients (10%) who are predicted failures of LITHO. Including the preoperative evaluation, treatment, recovery room, and follow-up, the individual LITHO cost for 52 patients was $8275.00. If the same total expenditure is calculated after excluding patients who required operation and those predicted to fail, the cost per 'successful' LITHO procedure was $10,245. The cost of 1 year of bile acid therapy is $1949.00 or $2413.00 per 'successful' procedure. Follow-up costs were $1232.00 per patient or $1525.00 per 'successful' procedure. The added LITHO cost incurred by screening eventual noncandidates was $904.00 per successful procedure. The sum of these individual costs was $15,087.00 per success, as compared to $3685.00 for cholecystectomy. No allowance was made for cost of stone recurrence. Lithotripsy costs appear to be sufficiently high to render the procedure unlikely to emerge as the treatment of choice.

Imaging of the biliary tract can utilize a wide variety of different techniques: plain film, oral cholecystogram, ultrasound, percutaneous transhepatic cholangiogram — PTC, endoscopic retrograde cholangiography — ERCP(see Chap. 27), CT, radioisotope imaging, operative cholangiogram, T-tube cholangiogram, intravenous cholangiogram — IVC, MRI, biopsy and therapeutic procedures.

Gallbladder image density at oral cholecystography has been compared with histological grading of the severity of chronic cholecystitis in resulting cholecystectomy specimens. (i) There was a linear relationship between gallbladder opacification and the grade of chronic cholecystitis. (ii) Removal of patients with either non-opacified gallbladders or abnormal liver function did not alter the linear trend. (iii) The occurrence of gallstones was independent of the degree of gallbladder opacification. (iv) The presence of gallstones did not correlate with the severity of chronic cholecystitis. A standardised oral cholecystographic technique with a grading system for gallbladder image density can be used as an index of the severity of chronic cholecystitis.

Among more than 400 patients with gallstones examined in our department in the past 2 yr, calculi were seen to float in only 3 patients. In each of these cases the ultrasound examination was done during or shortly after the oral cholecystogram. This suggests that contrast material raised the specific gravity of the bile and caused the floating phenomenon. No cases of floating stones in the absence of contrast material were found.

Plain roentgenograms were taken prior to oral cholecystography in 100 children. Three children had their gallstones obscured by the oral cholecystographic agent. Consideration should be given to obtaining plain roentgenograms in children with a strong clinical suspicion of gallbladder disease and a normal oral cholecystogram.

To define the optimal diagnostic approach for suspected chronic cholecystitis comprehensive management strategies were developed. Using a computer model, the frequency of appropriate surgery, inappropriate surgery, complications, death, and medical costs were compared in populations of patients with various disease prevalences. The optimal strategy began with ultrasonography, followed by an oral cholecystogram when the ultrasonogram was inconclusive. Oral cholecystogram also was employed when additional diagnostic studies failed to provide another explanation for the patient's symptoms. Compared with strategies using only ultrasonography or oral cholecystography, the combination strategy lowered the frequency of inappropriate surgery from 7.1 to 4.4% and direct medical costs from $1,877 to $1,766 per patient in a population with a 20% prevalence of chronic cholecystitis. The differences persisted at higher prevalences of cholecystitis and when sensitivities and specificities of the tests were varied over ranges reported in the literature. Diagnostic accuracy and direct medical costs could be improved by a more frequent interpretation of subtle abnormal ultrasonographic findings as inconclusive and by a more liberal use of oral cholecystography. This analysis demonstrates that a strategy combining ultrasonography and oral cholecystography is superior to the use of either test alone and is cost-efficient.

Results of ultrasonic anc cholecystographic (oral or intravenous) gall-bladder studies were compared retrospectively. 302 radiological studies of the gall-bladder, 156 oral and 146 intravenous cholecystograms, had been performed on 223 patients tested by ultrasound within six months. The gall-bladder was visualised by ultrasound in 217 (97.3%), in the intravenous cholecystogram in 92 of 146 (63%) and the oral cholecystogram in 82 of 156 (53%). The diagnosis of cholelithiasis by ultrasound was made in 97 of 223 cases, confirmed in 96 by further studies or operation. There was only one false-positive result. 143 radiological studies in these 97 patients gave 87 negative cholecystograms, gall-stones being directly demonstrated radiologically in only 46. There was one false-positive intravenous cholecystogram. In a further 97 patients ultrasound studies failed to demonstrate any gall-bladder disease, but in three of them radiology demonstrated stone (2.9% false-negative results). Amond 49 normal intravenous cholecysto-cholangiograms 47 were confirmed; once the diagnosis was made by ultrasound and at surgery (2% false-negative results). Oral cholecystography was the least reliable study. In every fourth negative test ultrasound and intravenous contrast-medium injection demonstrated a normal gall-bladder (28% false-positive).

To define the relative merits of radiographic and ultrasonic cholecystography, we studied 208 randomly selected patients with possible cholelithiasis. The patients underwent both procedures, and the results were interpreted in blind fashion. Two hundred patients had satisfactory confirmation of their diagnosis, by either a well visualized radiographic cholecystogram or operation or both. The overall accuracy of the ultrasonic examination was 93 per cent, with a false-negative rate of 11 and an indeterminate rate of 4 per cent. The indeterminate rate was 24 per cent for the single-dose oral cholecystogram and 8 per cent for the double-dose oral cholecystogram. Both ultrasonic cholecystography and radiographic cholecystography are useful to detect gallstones. Our findings support using single-dose oral cholecystography as the routine first examination. If the gallbladder is not satifactorily visualized, ultrasonic cholecystography can be performed immediately. In an emergency or for patients who might be pregnant, ultrasonic cholecystography is available as the initial examination.

The clinicopathologic features in 40 individuals between the ages of 13 and 20 undergoing cholecystectomy were analyzed and found to be a blend of the dissimilar patterns seen in earlier and later years. Only 4 had an associated hemolytic anemia. Females predominated in a ratio of 3.4:1, and a third were parous. Pain and right upper-quadrant tenderness were usually present, but often mis-interpreted. The oral cholecystogram proved to be the most useful diagnostic test. The incidence of acalculous cholecystitis was higher and that of common bile duct stone, lower than we have observed in the adult age group.

Ultrasonic B-mode examinations were performed in 50 patients in whom shape, size, and pathology of the gallbladder were known. The gallbladder was demonstrated in 92% of patients. Gallstones appeared as clusters of linear echoes which were constant in position in multiple scans. Artifacts resembling gallstones were due to use of excessively high gain settings, failure to identify the limits of the gallbladder, or to respiratory motion. Oral cholecystography should precede cholecystosonography unless a specific reason for avoiding the oral cholecystogram exists, such as jaundice. In patients in whom the gall-bladder was positively identified, diagnosis of gallstones was over 80% accurate.

Summary Sixty-seven cases of chronic cholecystitis have been reviewed and a comparison made between variations in the gall bladder shadow after oral cholecystography and different histological parameters of disease. A strong correlation was found between the density of the cholecystogram and the normality of the epithelium, and inversely with the degree of thickness of the wall and fibrosis of the lamina propria. Oedema, inflammatory cellular infiltrate and the presence of Rokitansky-Aschoff sinuses were not obviously related to function. Provided that minor histological changes are disregarded both a normal cholecystogram and absence of a shadow are adequate reflections of the condition of the gall bladder wall in the respects stated. The subjective radiological estimation of a faint gall bladder shadow remains valid as an indication of disease, but fails to indicate its degree of severity.

The prevalence of sonographically detectable gallstones in patients with chest pain and normal coronary arteries was compared with the prevalence of gallstones in patients referred to sonography for nonbiliary disease. Among 545 patients with chest pain and normal coronary arteriograms, 101 (18.5%) were referred for sonographic examination of the gallbladder. This test group was compared to a matched control group (n = 101) undergoing abdominal sonography for nonbiliary disease. Six patients (5.9%) in the test group and eight patients (7.9%) in the control group were found to have gallstones by accepted sonographic criteria. Studies based on oral cholecystogram screening of healthy populations have claimed a prevalence of cholelithiasis of 2.3%-6.2% for males and 2.3%-12% for females. The authors were unable to demonstrate a higher prevalence of sonographically identified gallstones in patients with chest pain and normal coronary arteries than in patients examined for nonbiliary disease. The frequency of gallstones in this test group is comparable to that reported for a screened population of healthy men and women.

The prevalence of cholelithiasis in Jamaican adults with SS disease was studied by plain abdominal radiograph in 206 patients and by oral cholecystogram in 126 (61%) of these patients. Gallstones were found in 57 (28%) of patients, were more common in females than males, and increased with age and hemolytic rate. The majority of gallstones were visible on the plain abdominal radiograph, only 17% of patients with gallstones having only radiolucent stones. Nonfunctioning oral cholecystograms were common (10%) in agreement with observations by previous workers. Gallstones were noted in the common bile duct in 2 patients. In general there was no clear relationship between the presence of cholelithiasis and clinical symptomatology. Complications, such as pancreatitis and malignant change in the gall bladder, recognized to be associated with cholelithiasis in the general population, have not been clearly related to cholelithiasis in SS disease. More information is needed before a logical policy can be evolved for surgical intervention in cholelithiasis in SS disease.

A high-resolution real-time ultrasound sector scanner was used in the evaluation of patients with suspected gallbladder disease. This technique is noninvasive, requires minimal preparation, and takes less than five minutes for a thorough examination of the gallbladder and related anatomy. In 17 months, 959 patients were examined for suspected gallbladder disease and the gallbladder was adequately visualized in all but 5 patients. Follow-up information was obtained from surgery in 153 cases. There were 132 true-positive studies, 15 true-negative, 5 false-negative and one-false positive study. In a correlative study with oral cholecystography, calculi were detected ultrasonically in 5 cases that had been missed on the oral cholecystogram.

During the National Cooperative Gallstone Study, therapy with chenodiol, 750 or 375 mg/d, for 2 years resulted in confirmed, complete gallstone dissolution in 14% and 5% of patients, respectively, and partial dissolution (greater than 50%) in 27% and 18%. The present study was done to determine the frequency with which complete dissolution occurs in patients having partial dissolution of gallstones who receive additional therapy. Eighty-six of one hundred thirty-eight eligible patients continued to receive 750 mg/d (61 patients) or 375 mg/d (25 patients) of chenodiol for 1 year. Patients whose oral cholecystogram at the end of the year showed further (greater than 50%) dissolution continued to receive chenodiol, (28 patients at 750 mg/d and 11 patients at 375 mg/d) for a second year (total duration of therapy, 4 years). A final oral cholecystogram was taken at the end of the fourth year. Complete dissolution occurred in 23% and 16% of patients receiving chenodiol, 750 or 375 mg/d, respectively, for an additional 1 or 2 years.

A review of 200 cases in which routine oral cholecystography was supplemented by tomography is presented. In 69 out of 82 non-visualised gallbladders (NVGB) definite confirmation of gallbladder pathology was obtained. In the poorly functioning gallbladder and the gallbladder obscured by bowel, further information was obtained in 32 out of 56 and 18 out of 26 cases respectively. Tomography proved helpful in localising small filling defects within the gallbladder. Tomography is unlikely to add any extra information to an oral cholecystogram in which a good after fatty meal (AFM) film has been obtained. It is concluded that tomography is a valuable addition to oral cholecystography and increases its accuracy.

Recent reports state that prolonged gallbladder opacification after an otherwise normal oral cholecystogram is abnormal and reliably indicates acalculous cholecystitis. In 122 patients on a variety of diets, the frequency with which prolonged gallbladder opacification is detectable one and two days after oral cholecystography was studied prospectively. Prolonged opacification was seen in 75% of patients and did not occur more commonly in those patients with documented gallbladder disease. Prolongation of gallbladder opacification after oral cholecystography is common and cannot be used as the sole criterion for the diagnosis of cholecystitis.

Three patients with relapsing gallstone pancreatitis and normal routine biliary radiology are reported and discussed. It is emphasized that when dealing with recurrent pancreatitis for which no cause is evident, normal conventional biliary radiology (oral cholecystogram and intravenous cholangiogram) should not necessariry be accepted as conclusive. The use of endoscopic cholangio-graphy in such a situation is encouraging.

ADIOGRAPHIC R study of the opacified gallbladder enjoys a reputation as one of the safest and most accurate of all contrast studies. Although newer contrast agents have been introduced and are still undergoing clinical trial, Telepaque@ (iopanoic acid, Winthrop Laboratories, Inc.) is the contrast agent used in the vast majority of these examinations. Berk et a1.3 stated in 1974 that more than 40 million doses of Telepaque have been administered since its introduction 20 years ago. A retrospective study of over 5000 patients during a period of 3 years” confirms the safety and reliability of Telepaque. The known factors that influence opacification of the gallbladder need to be applied to the technique and interpretation of the gallbladder examination. The correct method of conducting the examination requires emphasis, especially in view of observations regarding second dose studies when the initial standard 3 g of Telepaque results in an inadequate gallbladder visualization.2,4,‘0,‘5

• Although oral cholecystography is a highly accurate investigation for the diagnosis of gallbladder disease, false normal examinations do occur. In other patients, the presence of jaundice, nausea, or vomiting may preclude oral cholecystography. When there is clinical suspicion of gallbladder disease with a normal or equivocal oral cholecystogram, ultrasound examination is a highly accurate alternative imaging procedure. We describe in this article three patients with apparently normal oral cholecystography who were found to have obvious gallstones on ultrasound examination and at surgery. The relative accuracy of these diagnostic procedures is reviewed and their place in the diagnosis of biliary tract disease is discussed. ( Arch Surg 113:877-879, 1978)

A thirteen year old Negro girl was found to have thirteen stones in the gallbladder on multiple views of an oral cholecystogram taken shortly after recovery from an attack of severe biliary colic. At surgery five days later only two of the thirteen stones remained in the gallbladder. Thorough exploration of the bile ducts failed to demonstrate stones. The highly unusual but obvious conclusion is that the stones were passed unnoticed during the intervening five days.

Much attention has been devoted in the literature to the importance of serum bilirubin measurements in patients undergoing oral cholecystography. It is suggested that serum bilirubin levels above 35 μmol/litre (2 mg%) (Scarrow, 1973), lead to failure of the oral examination. We would like to draw the attention of clinicians and radiologists to the importance of assessing other aspects of liver function in patients in whom the serum bilirubin levels are within normal limits.

In 1,250 consecutive patients with nondiagnostic first-dose oral cholecystograms (OCG), the authors performed an upper gastrointestinal series (UGI) that same day prior to repeating the gallbladder studies. The residual barium from the UGI obscured the gallbladder on the reinforced OCG in only 19 patients (1.5%). This approach can alleviate scheduling problems, shorten the hospital stay for patients, decrease the time lost from work for outpatients, and permit an earlier correct diagnosis when the major problem is upper gastrointestinal rather than biliary.

The pattern of use of the oral cholecystogram and ultrasonocholecystography in the investigation of 1014 patients prior to cholecystectomy was analysed. Three hundred and sixty-eight (36.3%) of our patients had both an oral cholecystogram and an ultrasound examination of the gall-bladder. In 193 (52.4%) of these the initial investigation was positive: the second test in this group was rarely helpful and sometimes confusing. Overall the predictive value of a positive first study was 98.5%. We conclude that the use of further investigation following an initially positive result is not justified. By these criteria 18.5% of patients had an unnecessary second investigation.

Forty-two morbidly obese patients underwent cholecystectomy at the time of gastroplasty, primarily for prophylactic reasons. Preoperatively, 37 patients underwent ultrasonography (US) of the gallbladder and oral cholecystography, four US only, and one oral cholecystography only. There was one indeterminate US study (2.4%) and one indeterminate oral cholecystogram (2.7%). At US study, gallstones were detected in six of the eight patients with gallstones (sensitivity = 75%), and the gallbladders of all 32 patients without gallstones were categorized as normal (specificity = 100%). The gallstones not identified measured 1-2 mm in diameter. Oral cholecystographic study enabled detection of gallstones in three of the seven patients with gallstones (sensitivity = 43%) and categorized as normal all 30 gallbladders without gallstones (specificity = 100%). The gallstones not seen were small and included those not detected by US. The results suggest that US is equal or superior to oral cholecystography for detection of cholelithiasis in obese patients.

Successful treatment of gallstones by oral dissolving agents depends upon a functioning gallbladder. Thirty-one patients were assessed by oral cholecystography and ultrasound before and after a fatty meal. A correlation was demonstrated between radiological opacification and contraction on ultrasound. It is suggested that assessment of gallbladder function may be made by ultrasound methods alone, and an oral cholecystogram is not necessary prior to dissolution therapy.

Pancreozymin is a preparation which is extracted from the duodenal mucosa and contains the hormone cholecystokinin, a powerful stimulator of gall bladder contraction. It also causes an increased output of enzymes by the pancreas. Adlercreutz, Jorpes, Mutt and Wegelius (1957), Broden (1958) and Duff Gray (1958) have used preparations of cholecystokinin in order to cause a rapid contraction of the gall bladder after an oral cholecystogram. When the contrast-laden bile is expelled in this way the bile ducts may be demonstrated.

To the Editor.— In the article entitled "Endoscopic Retrograde Cholangiopancreatography" (1983;249:758), Venu and co-workers contend that those patients with symptoms suggestive of cholelithiasis and abnormal liver function test results should have an endoscopic retrograde cholangiopancreatography (ERCP) examination despite normal oral cholecystogram and sonograms of the gallbladder. This study was based on a retrospective analysis of patients examined between 1975 and 1980. Of the 206 patients examined, only 30 had real-time ultrasonography. Of these, three patients, or 10%, had false-negative results. A 10% false-negative rate with real-time ultrasound is no longer an acceptable figure. It is interesting that of the 29 patients who did have gallstones at ERCP or cholecystectomy, only three were missed by real-time ultrasound, leaving the other 26 false-negative results caused by either oral cholecystography or static sonography. I agree with the results of Cooperberg and Burhenne 1 recording a specificity of about 95% in the diagnosis of

• A retrospective study of all patients who underwent splenectomy during the 20-year period, 1960 to 1979, for hereditary spherocytosis at the Johns Hopkins Hospital, Baltimore, identified 58 patients, of whom 20 (33%) were 15 years of age or older. Accessory splenic tissue was located in ten (17%) of the patients. Although cholelithiasis was present in only 12 (21%) of the total cohort, when analyzed for patients 10 years of age or older the incidence was 41% (11/27). Because of the positive association between advancing age, cholelithiasis, and hereditary spherocytosis, it is recommended that any patient 10 years of age or older undergo an oral cholecystogram as part of the routine preoperative evaluation. ( Arch Surg 1981;116:306-308)

History A 59-year-old woman was first admitted to the hospital in March 1960 with an acute illness of two days' duration manifested by vomiting and progressive right upper quadrant pain. Blood pressure was 183/100 mm Hg. Tenderness, with a questionable palpable mass, was present in the right upper quadrant. The white blood cell count was 22,500/cu mm with 78% neutrophils. An oral cholecystogram (Fig 1) demonstrated a nonfunctioning gallbladder with large calcifications in the right upper quadrant. An upper gastrointestinal series was normal. The patient responded to conservative management and was discharged. On June 29, 1964, she was readmitted with a four-day history of nausea and vomiting. An upper gastrointestinal series demonstrated incomplete obstruction in the pyloroduodenal region (Fig 2). She again responded rapidly to conservative management and was discharged. On August 6, 1964, she was admitted to the hospital for the third time with an abrupt onset of epigastric

• A 68-year-old woman had reversible nonoliguric acute renal failure and yellow pigmentation of her skin and sclerae after ingesting phenazopyridine hydrochloride, 200 mg four times a day for six weeks. Although she began to recover renal function promptly after the drug therapy was discontinued, there was a further decline in her glomerular filtration rate after an oral cholecystogram and intravenous pyelogram. Phenazopyridineinduced acute renal failure is rare, but its early recognition is important so that additional nephrotoxicity from studies using roentgenographic contrast material may be avoided in patients with this problem. ( Arch Intern Med 1981;141:784-786)

We read with interest the article by Watson and Wild (1986), as we have been carrying out a similar study in Aberdeen. During 1983–84, every person attending the outpatient department of the Aberdeen Royal Infirmary for an oral cholecystogram (OCG) also had an ultrasound scan of the gallbladder.

Hospitals' patterns of ancillary service use were examined to determine whether new technologies replace older, more outmoded technologies, and to explore the factors associated with adoption of newer services and abandonment of older services. Annual inpatient use of five pairs of ancillary services was measured for 1978 through 1980 at 63 hospitals in five regions. The diagnostic test pairs consisted of one well-established diagnostic test and one newer service that could largely substitute for the older one and included (1) oral cholecystogram and gallbladder ultrasound; (2) brain scan and computed tomographic head scan; (3) skull roentgenogram and brain scan; (4) bone survey and bone scan; and (5) blood type/cross and type/screen. Use of gallbladder ultrasound increased significantly after its adoption, with small decreases in the use of oral cholecystogram, its paired test. For the other newer tests examined, increased use was not accompanied by significantly decreased use of the paired older service. The strongest predictors of change in patterns of test use were hospital size, number of residencies, occupancy, urban location, and the proportion of specialists on staff. We conclude that diffusion of new diagnostic services occurs gradually and often without concomitant decrease in older, outmoded services; new services generally seem to complement rather than substitute for older ones. Larger hospitals with a greater teaching commitment make a faster transition to the use of new technologies and the abandonment of older ones. ( JAMA . 1989;262:1196-1200)

Rotor syndrome is a rare disease of hereditary hyperbilirubinemia transmitted with autosomal recessive trait. In general, Rotor syndrome shows direct hyperbilirubinemia and there has been several reports since Sons's report in 1966, in Korea. A 34-year-old female with admitted with the chief complaint of intermittent icteric sclera for 24 years. There was no family history of jaundice. Rotor syndrome was diagnosed by oral cholecystogram, BSP retention test, -DISIDA scan, liver biopsy and electromiuoscopy study of liver biopsy specimen. We report this case with brief review of the literature.

• A group of 47 children with homozygous sickle cell disease ranging in age from 2 to 18 years was studied for the prevalence of gallstones. All of these patients had oral cholecystogram and cholecystosonogram. Eight of the 47 patients (17%) had gallstones both on oral cholecystography and on cholecystosonography. These eight patients had a history of recurrent abdominal pain usually localized to the right upper quadrant. All were admitted on several occasions for sickle cell abdominal crises and four of these were admitted for acute hepatic crisis. These patients have undergone elective cholecystectomy and gallstones were found in every patient. The patients have been followed up from seven to 17 months after cholecystectomy and none have had abdominal symptoms or required hospitalization for abdominal crises. ( Am J Dis Child 133:306-307, 1979)

We do not oppose the performance of both an oral cholecystogram and an upper GI series in patients regarding whom differentiation between diseases involving the two systems is difficult. We would never suggest that a patient with classic peptic ulcer symptoms and gallstones not have a GI series. We did not conclude that a GI series is unnecessary in patients with gallstones. What we did was examine the films of 100 patients defined in a particular way and demonstrate a potentially important abnormality by upper GI series in only four of them. In our patients, the GI series had a relatively low yield of identifying abnormalities in patients with gallstones in the absence of GI bleeding or suspicion of GI cancer.

GALLBLADDER disease accounts for more than 500,000 operations annually in the United States and is the most common indication for abdominal surgery and the fourth most common cause of surgical hospitalization in adults. 1 For almost 60 years, since the introduction by Graham and Cole 2 of the oral cholecystogram (OCG) in 1924, it has remained the unchallenged method for investigation of gallbladder disease. Nevertheless, despite its accuracy, safety, and ease of performance, the future of the oral cholecystogram is presently in doubt, principally as a result of the recent advent of gray-scale ultrasound. Ultrasonic techniques, including realtime scanning, have demonstrated remarkable sensitivity and specificity for nearly the entire spectrum of gallbladder disease. In some centers, ultrasonography is now employed as the primary screening technique for detection of gallbladder pathology. Because cholecystosonography may lead to revisions in clinical approaches to diagnosis of gallbladder disease, this review of principles, results, and

Dr Janower's comments are both good news and bad news to us. The bad news is that we were indeed sloppy in our definitions of "normal" and "abnormal" gallbladders. By "normal gallbladder," we meant a gallbladder which did not contain gallstones. We are aware of the work by Mujahed et al; in their article, the definition of "not normal" included cases of "chronic cholecystitis." The value of these authors' conclusion that failure to visualize the gallbladder on two oral examinations indicates gallbladder disease is somewhat diminished by the fact that they had no surgical confirmation in more than half of their cases (193 out of 345). There is also some disagreement as to the clinical significance of "chronic cholecystitis." The good news is that ultrasound is now available as a useful tool for diagnosing gallstones. How this procedure is integrated with the oral cholecystogram is up to the

The pioneer efforts of Graham and Cole to produce a radiological examination of the gallbladder were prompted by a desire to enhance and refine the diagnosis of gallbladder disease beyond that achieved by history and physical examination. It is interesting to consider the background of the period in which the Graham-Cole test was designed. The specialty of radiology was not yet in formal existence (the American Board of Radiology was not organized until 1934). Drs Graham and Cole were not even radiologists. Both men, being members of the Department of Surgery at Washington University School of Medicine, undoubtedly felt ill at ease about exploring or removing a gallbladder without first ascertaining its pathological state. The hazards of surgery, particularly those of anesthesia, were, of course, much greater than they are today, so that proper indications for surgery were paramount. In addition to its relevance for surgeons, the article by Graham

To the Editor.— In the overtly jaundiced patient, the oral cholecystogram tends to be deemphasized as a means of elucidating the underlying disease, because jaundice is so often associated with hepatic dysfunction impeding excretion of contrast agents into the bile. 1 There are, however, diseases capable of producing severe jaundice due to an isolated and quite specific metabolic defect, such as diminished ability of the liver to convert bilirubin into bilirubin glucuronide, as in Gilbert's syndrome. 2 Becasue the hyperbilirubinemia of Gilbert's syndrome appears to be due to faulty bilirubin metabolism alone, one would expect to obtain a normal oral cholecystogram readily in a patient with this syndrome, even in the presence of marked icterus. This hypothesis was borne out in one patient. Report of a Case.— A 17-year-old man had had intermittent yellow discoloration of his sclerae and skin for several months, which was becoming more persistent and intense.