HEPATOBILIARY IMAGING Presented by Yang Shiow-wen 11/26/2001
Dec 19, 2015
HEPATOBILIARY IMAGING
Presented by
Yang Shiow-wen
11/26/2001
11/26/2001
Hepatobiliary Imaging
Evaluates hepatocellular function and patency of the biliary system Tracing the production and flow of bile from
the liver through the biliary system into the small intestine
Sequential images of the liver, biliary tree and gut are obtained
A "HIDA" scan or a "DISIDA" scan
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Performed with a variety of compounds that share the common imminodiacetate moiety
Hepatobiliary Imaging
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Structures of IDA derivates
Blue color: A polar component (the diacetate)
Red: A lipophilic component
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IDA-chelated Tc-99m
A magnification of two imminodiacetate compounds
Polar components chelated a Tc-99m molecule
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The lipophilic component : binding to hepatocyte receptors for bilirubin
Transported through the same pathways as bilirubin, except for conjugation
Excretion decreased with increasing bilirubin levels
Pathways of IDA derivates
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HIDA Little used today
HIDA
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DISIDA (Disofenin)
85% extracted by the hepatocytes
Visualization of gallbladder and CBD when bilirubin > 8 ng/dl
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BRIDA (Mebrofenin)
98% extracted by the
hepatocytes (bilirubin <1.5 mg/dL)
Visualization of gallbladder and CBD when bilirubin > 30 ng/dl
Higher hepatic extraction
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BRIDA (Mebrofenin)
Rapid biliary to bowel transit time Taken into consideration when evaluating acute
cholecystitis
Mebrofenin may be preferred over Disofenin in suspected biliary atresia
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Indications
Functional assessment of the hepatobiliary system
Integrity of the hepatobiliary tree Evaluation of suspected acute cholecystitis Evaluation of suspected chronic biliary tract
disorders Evaluation of common bile duct obstruction Detection of bile extravasation Evaluation of congenital abnormalities of the
biliary tree
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Contraindications
Hypersensitivity to IDA derivative Local anesthetics of the amide type
With disturbances of cardiac rhythm or conduction
Pregnancy Category: C
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Requirements for DISIDA Scan
Patient preparation: fasted for 2-4 hours Otherwise delayed or non-visualization Fasted for > 24 hrs or on TPN, a false-positive study
may occur
Radiotracer Adult
1.5-5 mCi Tc-99m IDA compounds i.v. 3 – 10 mCi for hyperbilirubinemia
Children 0.05 – 0.2 mCi/kg minimum of 0.3 – 0.5 mCi
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Requirements for DISIDA Scan
Additional information
History of previous surgeries, especially biliary and gastrointestinal
Time of most recent meal
Current medications esp. opioid compounds Delaying the study for 4 hr after the last dose
Bilirubin and liver enzyme levels
Results of ultrasound
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Requirements for DISIDA Scan
Gamma cameraA large field of view with a low energy all
purpose or high resolution collimatorA smaller field of view with a diverging
collimator
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Requirements for DISIDA Scan
Serial anterior views for 60 minutes Until activity is seen in both the gallbladder (patency of the cystic
duct) and the small bowel (patency of the common bile duct) Every 5 minutes for 30 minutes Once at 45 minutes Once at 1 hour
Right lateral views At 30, 60 minutes
Oblique views Separate gallbladder from small bowel activity
Delayed views At 2 hours, 4 hours, 6 hours or 24 hours after injection Severely ill patient, suspected CBD obstruction, suspected biliary
atresia
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Interventions
CCK (0.01-0.02 ug/kg) Fasting for >24-48 hours, or on TPN Empty the gall bladder (low resistance to bile flow state)
Preferential gallbladder filling Delayed biliary to bowel transit
Injection 30 min prior to the test Administered slowly (3 – 5 min)
Prevent biliary spasm and abdominal cramps
Water (5-10 cc) Distinguish transient duodenal activity from gallbladder
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Interventions
Morphine sulfate (0.04-0.1 mg/kg) When acute cholecystitis is suspected
and the GB is not seen by 60 min & Radiotracer within the small intestine Enhancing sphincter of Oddi tone
Increasing pressure within the CBDDiverting bile away from the sphincter of
Oddi & into functionally obstructed sludge filled gallbladder
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Interventions
Fatty meal stimulation Gallbladder ejection fraction measurement
Phenobarbital When biliary atresia is suspected 5 mg/kg/day (orally) for 3 – 5 days prior to
the study Enhancing the biliary excretion of the
radiotracer
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Processing
Gallbladder ejection fraction (GBEF) Using the immediate pre-CCK and the post-
CCK data Regions of interest (ROI) are drawn around
the GB and adjacent liver (background)
Hepatic extraction fraction (HEF) Index of hepatocellular function Deconvolution analysis from ROI over the
liver and heart
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Normal Study
Immediate demonstration of hepatic parenchyma
Prompt clearance of the blood pool within the first 5 minutes
Biliary excretion should commence within 20 minutes (5-10 min)
Biliary ducts would visualize followed the gallbladder
Gallbladder and small bowels are visualized within 1 hour
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Acute Cholecystitis
The most common indication
S\S Nausea, vomiting, fever Right upper quadrant pain post-prandially Mild to moderate leukocytosis Abnormal liver function test Pain radiates to the back (scapula)
Obstruction of cystic duct By a gallstone Inflammation, edema, gallbladder mucous, or a tumor
(5%)
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Acute Cholecystitis
DISIDA scan Sensitivity: 95%, specificity 93-96% Positive predictive value: 92.1%, negative
predictive value: 99%
Adequate filling of the gallbladder Acute cholecystitis is effectively excluded
Cystic duct obstruction Failure to visualize the gallbladder up to 4 hours
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Acute Cholecystitis
When acute cholecystitis is suspected and the gallbladder is not seen within 40–60 min 3 – 4 hr delayed images should be
obtained Rule out chronic cholecystitis Premedication with CCK Morphine augmentation
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Acute Cholecystitis
Premedication with CCK Same sensitivity and specificity Disadvantages
Not differentiated chronic cholecystitis from normal Nausea, vomiting, exacerbation of bladder pain Missed acute cholecystitis exhibiting delayed
gallbladder visualization Without delayed views
Malrotaion, enterogastric reflux, masses displacing or inflammatory processes of the small bowel
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Acute Cholecystitis
Ingestion of morphine sulfate More accurately, less complication Differential diagnosis for non-visualization of
the gallbladder Relaxation of the sphincter of Oddi Imaging is usually continued for another 30 min
Contraindications Absolute: Respiratory depression in non-ventilated
patients, morphine allergy Relative: acute pancreatitis
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Acute Cholecystitis
The hallmark of acute cholecystitis (acalculous as well as calculous)
Persistent gallbladder non-visualization 30 min post-morphine or on the 3 – 4 hr delayed image
Rim sign A band or rim of increased activity adjacent to
gallbladder fossa Associated with severe phlegmonous/gangrenous
acute cholecystitis, a surgical emergency Cystic duct obstruction, acute cholecystitis
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Chronic Cholecystitis
Ultrasound is the primary modality of choice
S\S Usually having gall stones The cystic duct is not blocked More chronic pain
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Common Bile Duct Obstruction
Delayed visualization of the gall bladder Clinical settings associated with physiologic failure of the
gallbladder to filling e.g. fasting for >24 – 48 hr, severely ill or post-operative patients
may result in GB non-visualization within the first hour A larger dose of morphine (0.1 mg/kg) decrease the false positive
rate
Separated from acute cholecystitis using morphine or delayed imaging
Reduced gallbladder ejection fraction in response to CCK Indicative of chronic cholecystitis, gallbladder dyskinesia or
the cystic duct syndrome Visualization of the GB after the bowel
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Common Bile Duct Obstruction
S\S Hyperbilirubinemia (> 5 mg/dl) Dilation of CBD (sonography, >3 days) A history of pancreatitis (serum amylase)
DISIDA scan High grade or a total CBD obstruction Sensitivity: 95% Detection immediately
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Common Bile Duct Obstruction
Delayed biliary-to-bowel transit beyond 60 min raises the suspicion
Activity in the small bowel seen within 60 min does not entirely exclude partial CBD obstruction
When neither the gallbladder nor the small bowel are seen within 18–24 hrs Suspected High grade CBD obstruction Severe hepatocellular dysfunction may appear
similar
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Bile Leaks
Most appropriate non-invasive imaging technique for evaluation of bile leaks
Sensitivity: 87%, Specificity: 100% (2-3 ml of labeled bile)
Radiopharmaceutical activity In an extrahepatic and extraluminal location More intense with time
Differentiating intraluminal activity from a leak Standing views in addition to decubitus views Cinematic display 3 – 4 hrs delayed imaging
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Biliary Atresia
Excluded by demonstrating transit of radiotracer into the bowel
Failure of tracer to enter the gut Hepatocellular disease Immature intrahepatic transport mechanisms Biliary atresia CBD obstruction
Urinary excretion of the tracer (especially in diaper) may be confused with bowel activity
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Duodenogastric Bile Reflux
Highly correlated with bile gastritisCause of epigastric discomfort
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False Positive Study
Gallbladder non-visualization in the absence of acute cholecystitis
Insufficient fasting (<2 – 4 hr) Prolonged fasting (>24 – 48 hr), especially total parenteral
nutrition (despite CCK pre-treatment and Morphine augmentation)
Severe hepatocellular disease High grade common bile duct obstruction Severe intercurrent illness (despite CCK pre-treatment and
Morphine augmentation) Pancreatitis (rare) Rapid biliary-to-bowel transit (insufficient tracer activity
remaining in the liver for delayed imaging) Severe chronic cholecystitis Previous cholecystectomy
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False Negative Study
Gallbladder visualization in the presence of acute cholecystitis
Bowel loop simulating gallbladder (drinking water may help to clarify anatomy)
Acute acalculous cholecystitis The presence of the "dilated cystic duct" sign
simulating GB. (Morphine should not be given) Bile leak due to GB perforation Congenital anomalies simulating gallbladder Activity in the kidneys simulating gallbladder or small
bowel (may be clarified by a lateral image)
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Reflux into Stomach
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Radioactivity in Left Subphrenic Space-I
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Bile Leak Post-cholecystectomy-II
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References
http://www.vh.org/Providers/Lectures/IROCH/BiliaryNucs/BiliaryNucs.html (Virtual Hospital)
http://www.cancerboard.ab.ca/about/ercdocs/diiso.html
http://www.nuclearonline.org/PI/Bracco%20mebrofenin%20doc.pdf
http://www.snm.org/pdf/hb2.pdf
http://www.vh.org/Providers/Textbooks/ElectricGiNucs/Text/Hepatobiliary.html
Chapter 38, Hepatobiliary Imaging, Darlene Fink-Bennett, P759-770
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The End
Thank for Your Attention !