99mTc-HIDA Cholescintigraphy Research Articles

PTH-033 Detection of duodeno-gastric reflux during routine 99mTc-hida scintigraphy

Introduction Duodeno-gastric reflux (DGR) is an incidental finding on 99mTc-HIDA studies but its detection often yields useful clinical information. Present study was carried out to determine the rate of detection as well as incidence of DGR in patients undergoing routine HIDA imaging over a 5-year-period. Methods One hundred and eighty-three sequential patients (52 males, 131 females, mean age 46 years old) who underwent 99mTc-HIDA cholescintigraphy over a 5-year-period between 2004 and 2008 have been retrospectively reviewed. Age, sex, previous surgery, clinical indications for the study, presence or not of DGR and clinical reports were subjected to analysis. Results Biliary dyskinesia (n=135; 74%), post-surgical symptoms (n=33; 18%) and sphincter of Oddi dysfunction (n=15; 8%) were the main indications for the study. 33/183 (18%) patients had DGR of which 21 (64%) were present in 117 patients with otherwise normal studies while 12 (36%) were seen in 66 patients with abnormal results (p=0.87). All except one case of DGR was detected and mentioned in the original clinical report. 25/132 (19%) and 8/51(18%) patients, respectively, with normal and abnormal biliary tract anatomy were found to have DGR (p=0.76). Occurrence of DGR had no significant relationship with age, sex or gall bladder ejection fraction. Conclusion DGR is an easily detected common finding on routine cholescintigraphy and may be the cause of presenting symptoms in patients who may have an otherwise normal HIDA study. The occurrence of DGR does not appear to have any significant relationship with age and sex of patients, biliary tract anatomy, or gall bladder function.

Development and validation of a comprehensive new hepatobiliary software. Part II: segmental liver function

This study was undertaken to develop comprehensive new hepatobiliary software to quantify segmental and lobar liver function and to obtain FDA approval. Hepatobiliary software written on JAVA platform and loaded on to a PC accepts 99mTc-HIDA dicom image data transferred from a gamma camera. Liver boundary was determined by threshold-based auto edge detection and liver height at right midclavicular (RMCL) line. Geometric mean area of the physiologic right lobe, physiologic left lobe and total liver area were measured. Segmental liver function was determined using the 5th minute frame as the default (100%). In 24 control participants, mean (+/-SD) liver height at RMCL was 14.7+/-0.12 cm. Geometric mean area of the physiologic right lobe was 116+/-3 cm2, left lobe 96+/-4 cm2, and total liver area 212+/-3 cm. Right upper lobe (segments 7 and 8) contributed 31+/-0.7%, right lower lobe (segments 5 and 6) 34+/-0.6%, left medial (segments 4A and 4B) 24+/-1%, left lateral (segments 2 and 3) 10+/-2%, and caudate lobe (segment 1) 1+/-0.02% of total liver function. In 23 patients, contrast three-dimensional computerized tomographic volume of the right lobe was 1194+/-419 ml, left lobe 434+/-221 ml, and total liver volume 1628+/-490 ml. Right lobe area was 120+/-30 cm2, left lobe (plus caudate) 88+/-29 cm2 with total liver area of 208+/-51 cm. Right upper lobe (segments 7 and 8) contributed 33+/-10%, right lower lobe (segments 5 and 6) 34+/-7%, left medial (segments 4A and 4B) 23+/-6%, left lateral (segments 2 and 3) 9+/-3%, and caudate lobe (segment 1) 1+/-0.4% of total liver function. There was good correlation of RMCL height, and area of right lobe and total liver with computerized tomographic liver volume. Correlation of percentage volume with percentage function was excellent. New FDA approved software provides quantitative assessment of segmental, lobar, and total liver size and function from a planar 99mTc-HIDA cholescintigraphy and may enable universal standardization in nuclear hepatology. Quantification may aid surgeons in the determination of the amount of tissue resection during liver surgery.

Is bile flow reduced in patients with hypothyroidism?

Background. Disturbances in the sphincter of Oddi (SO) function may prevent normal bile flow and thus enhance the probability of common bile duct stone (CBDS) formation. We have previously shown increased prevalence of diagnosed hypothyroidism in CBDS patients, thyroxine (T4) -induced inhibition of the SO contractility both in animal and in human experiments ex vivo, and reduced bile flow to duodenum in hypothyroid rats. The aim of the present study was to investigate human biliary dynamics in relation to altered thyroid gland function. Methods. Eight female patients, 1 with diagnosed untreated hypothyroidism and 7 with total thyroidectomy performed due to thyroid cancer, were studied in hypothyroid stage and again after thyroxine replacement therapy in euthyroid stage, with quantitative 99mTc HIDA cholescintigraphy (QC), biliary ultrasonography, and serum determinations. Each patient served as her own control in the 2 stages of the study. Results. In QC, maximal uptake of 99mTc HIDA was not changed in hypothyroidism compared to euthyroidism. The first appearance of radioactivity to large bile ducts at the hepatic hilum remained unchanged in the 2 stages of the study. Hepatic clearance of 99mTc HIDA was decreased at 45 minutes (28% [11-38] vs 50% [33-54]; P =.028; median and range) and at 60 minutes (55% [28-80] vs 69% [61-79]; P =.028; median and range) and hilum-duodenal transit time increased by 31% compared to euthyroid stage. In US no changes were seen in gall bladder or bile ducts in the 2 stages of the study. Serum hypercholesterolemia was observed in the hypothyroid stage. Conclusions. We conclude that hypothyroidism may result in delayed emptying of the biliary tract, as studied with QC. In addition to the changes in bile composition and excretion rate suggested before to take place in hypothyroidism, according to the present study changes in biliary emptying also may be included in the probable causes for the increased prevalence of CBDS in hypothyroidism. This may be due to the absence of the prorelaxing effect of thyroxine on SO, which we have shown before to exist ex vivo. (Surgery 2003;133:288-93)

Patency of anastomoses after bilio-intestinal bypass: radioisotope demonstration.

Bilio-intestinal bypass (BIB) is effective for the treatment of refractory obesity. BIB permits bile flow into the non-functional jejunum, whereas food transit occurs via the remaining intestine. We used the radioisotope method of 99mTc-Hida cholescintigraphy (HC) in the follow-up of patients. 21 patients were studied 3 months to 3 years after BIB with HC. After 3 hours acquisition, images were reviewed by two independent observers. Regions of interest (ROIs) were drawn on images: liver parenchyma, cholecysto-jejunal anastomosis (CC), choledochus (COL). Radioactivity taken up by liver was compared with radioactivity of CC and COL. % radioactivity passing through CC (%CC) and through COL (%COL) were determined. The final parameter, -COL, indicates the radioactive bile which does not pass through the choledochus. Anastomoses were found patent a few months to 3 years after operation. -COL showed linear correlation with the decrease in cholesterolemia and in body weight in the 1st year after BIB. HC shows passage of radioactive bile through anastomoses and provides semiquantitative evaluation of bile flux diversion. Bile flux towards the gallbladder and non-functional jejunal limb far exceeds flux directed towards the duodenum via the choledochus.

Cholecystokinin and morphine pharmacological intervention during 99mTc-HIDA cholescintigraphy: A rational approach

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.

Biliary lipid mass in the gallbladder in health and in cholesterol gallstone disease

Objectives: A high cholesterol saturation index of gallbladder bile is an essential prerequisite for cholesterol gallstone formation. This could be due to a high cholesterol mass, or to a low bile acid and/or phospholipid mass in gallbladder bile, or to a combination of these abnormalities. The conventional method of measuring the saturation index cannot distinguish between these alternatives. Our aim was to distinguish between these alternatives in patients with cholesterol gallstones by measuring biliary lipid masses, and to study the effect of gender and obesity within this gallstone population. Methods: We have developed a simple technique for the measurement of total biliary lipid masses in the gallbladder. This involves a combination of 99mTcHIDA cholescintigraphy and of nasoduodenal intubation with intravenous cholecystokinin infusion to obtain a bile sample. We validated this technique by comparing it with direct measurement of biliary lipid masses following cholecystectomy; we studied 19 male non-obese healthy controls and a total of 45 gallstone patients, who were further subdivided into male non-obese (n = 13), female non-obese (n = 17) and obese (n = 15) gallstone patients. Results: The validation studies showed close agreement for all three biliary lipids between our technique and the direct measurements. The male non-obese gallstone patients had a significantly higher saturation index than the male non-obese healthy controls. This was due to a reduction in bile acid mass (2.73 versus 4.79 mmol, P < 0.005), with no difference in the masses of phospholipid or cholesterol. There were no differences between male and female non-obese gallstone patients; and obese patients had a reduced phospholipid mass as well as a reduced bile acid mass. There was no increase in cholesterol mass within the gallbladder in any of the groups. Conclusions: We conclude that 99mTcHIDA scintigraphy together with nasoduodenal intubation provides a simple valid technique for measuring biliary lipid masses in the gallbladder; that the main defect in gallstone disease is a reduction in bile acid mass; that within the gallstone population, gender has no effect on biliary lipid masses, but that obese gallstone patients have a reduction in phospholipid mass also. There was no increase in cholesterol mass in the gallbladder in any of the gallstone groups, presumably because this was prevented by the low bile acid mass.

The effect of a progestin on gallbladder function in young women

Female sex hormones have been considered to be a risk factor for the development of cholesterol gallstone disease, because of increased cholesterol saturation of bile. Impaired gallbladder function is an additional factor which is suspect but unproved. We investigated gallbladder function in 10 young women on two occasions: first during the follicular phase of the menstrual cycle, when endogenous progesterone is low, and again after the ingestion of medroxyprogesterone acetate, 10 mg/day for 10 days, just prior to the next menstrual period. Another group, 15 young women, was studied during their luteal phase, when endogenous progesterone is high. Gallbladder filling and emptying in response to cholecystokinin (0.02 U/kg-min) was quantitated by 99mTc-HIDA cholescintigraphy. Gallbladder filling and emptying were no different in women in the follicular phase than in women in the luteal phase of the menstrual cycle. In both menstrual phases, the administration of the exogenous progestin significantly (p < 0.05) reduced the fraction of hepatic bile entering the gallbladder. Gallbladder emptying was also depressed: the total amount ejected was less, the time to empty half the contents was prolonged, and the rate was slower (p < 0.05). Thus, different phases of the normal menstrual cycle do not appear to have any effect on gallbladder function. Administration of an exogenous progestin, however, significantly impairs both gallbladder filling and emptying, factors which could predispose to the formation of cholesterol gallstones.

Demonstration of a bronchobiliary fistula by 99mTc-HIDA cholescintigraphy

A case of bronchobiliary fistula diagnosed by 99mTc-HIDA cholescintigraphy is presented. The fistula caused by a stenosing tumor of the left hepatic duct would probably have been missed without the use of delayed views and body fluids counting which increased the specificity of scintigraphic findings.

99mTc-HIDA cholescintigraphy in Dubin-Johnson and Rotor syndromes.

99mTc-HIDA cholescintigraphy was performed in 6 patients with Dubin-Johnson syndrome and 1 patient with Rotor syndrome. In the patients with Dubin-Johnson syndrome, the cholescintigrams had a characteristic pattern of delayed visualization or nonvisualization of the gallbladder and bile ducts in the presence of intense, homogeneous, and prolonged visualization of the liver. In the patient with Rotor syndrome, the hepatobiliary system was not visualized at all. It is concluded that 99mTc-HIDA cholescintigraphy may be helpful in the diagnosis of Dubin-Johnson syndrome and Rotor syndrome and in the differential diagnosis between these two conditions.

Demonstration of traumatic bile leakage with cholescintigraphy and ultrasonography

Technetium-99m HIDA cholescintigraphy and ultrasonography are noninvasive, safe, simple procedures that can document the presence, location, and extent of a bile leak. Early detection of posttraumatic or postoperative biliary tract disruption can significantly reduce morbidity and mortality. The possibility of biliary tract disruption should be considered in any patient who has had blunt or penetrating abdominal trauma. In two cases reported, the new hepatobiliary radiotracer 99mTc dimethyliminodiacetic acid (HIDA) was quite useful in detecting such leaks. Sonography was particularly useful in detecting small intra- or perihepatic bile collections which no longer communicate with the biliary tree. An active bile leak at a surgical anastomosis may also be documented by 99mTc-HIDA cholescintigraphy and can yield information of potential prognostic importance. Serial cholescintigraphy is also useful in evaluating the response to medical or surgical treatment.

Rapid and accurate diagnosis of acute cholecystitis with 99mTc-HIDA cholescintigraphy.

Technetium-99m dimethyl acetanilide iminodiacetic acid (HIDA) cholescintigraphy was performed on 90 patients with suspected acute cholecystitis. Visualization of the gallbladder established patency of the cystic duct and excluded the diagnosis of acute cholecystitis in 50 of 52 patients. Nonvisualization of the gallbladder with visualization of the common bile duct was diagnostic of acute cholecystitis in 38 patients, all subsequently proven at surgery. The observed accuracy of this procedure is 98% and specificity is 100%. The false negative rate is 5% and false positive rate is zero. Technetium-99m-HIDA has many advantages which make it the procedure of choice in evaluating a patient for suspected acute cholecystitis. It is a rapid, simple, safe examination which provides functional as well as anatomic information about the hepatobiliary system in individuals with a serum bilirubin level up to 8 mg/100 ml.

Cholescintigraphy, ultrasonography and computerized tomography in the evaluation of biliary tract disorders

Newer modalities available for the evaluation of hepatobiliary disease include cholescintigraphy, ultrasonography, and computerized tomography. We have examined the relative strengths and weaknesses of each of these noninvasive techniques and developed a rational diagnostic approach for the evaluation of acute cholecystitis, chronic cholecystitis, and cholestasis. The procedure of choice for suspected acute cholecystitis is 99m Tc-HIDA cholescintigraphy because it is a highly accurate method for obtaining functional information with regard to cystic duct patency. In suspected chronic cholecystitis, the oral cholecystogram is the best screening procedure, followed by ultrasound for confirmation of gallbladder disease as the cause of nonvisualization. The role of 99m Tc-HIDA cholescintigraphy in suspected chronic cholecystitis is limited to those cases where the oral cholecystogram and sonogram yield disparate results, or where a patient is known to have chronic gallbladder disease and superimposed acute exacerbation is suspected. Ultrasonography is recommended as the initial procedure for evaluation of the patient with cholestasis. It is highly accurate in distinguishing hepatocellular disease from obstructive jaundice, and when dilated biliary radicles are visualized, ultrasonography is frequently capable of identifying the cause of obstruction. If the patient's body habitus or gaseous distention makes ultrasonographic evaluation difficult, then computerized tomography is recommended, followed by endoscopic retrograde cholangiopancreatography or transhepatic cholangiography, when needed.