Biliary Scanning Research Articles

Rib region detection for scanning path planning for fully automated robotic abdominal ultrasonography.

Scanning path planning is an essential technology for fully automated ultrasound (US) robotics. During biliary scanning, the subcostal boundary is critical body surface landmarks for scanning path planning but are often invisible, depending on the individual. This study developed a method of estimating the rib region for scanning path planning toward fully automated robotic US systems. We proposed a method for determining the rib region using RGB-D images and respiratory variation. We hypothesized that detecting the rib region would be possible based on changes in body surface position due to breathing. We generated a depth difference image by finding the difference between the depth image taken at the resting inspiratory position and the depth image taken at the maximum inspiratory position, which clearly shows the rib region. The boundary position of the subcostal was then determined by applying training using the YOLOv5 object detection model to this depth difference image. In the experiments with healthy subjects, the proposed method of rib detection using the depth difference image marked an intersection over union (IoU) of 0.951 and average confidence of 0.77. The average error between the ground truth and predicted positions was 16.5 mm in 3D space. The results were superior to rib detection using only the RGB image. The proposed depth difference imaging method, which measures respiratory variation, was able to accurately estimate the rib region without contact and physician intervention. It will be useful for planning the scan path during the biliary imaging.

The Role of Hepatobiliary Scintigraphy as the Initial Investigative Modality for Significant Bile Leak following Laparoscopic Cholecystectomy

Introduction: Currently, the rate of bile duct injury and leak following laparoscopic cholecystectomy (LC) is still higher than for open surgery. Diverse investigative algorithms were suggested for bile leak, shifting from hepatobiliary scintigraphy (HBS) toward invasive and more sophisticated means. We aimed to analyze the use of biliary scan as the initial modality to investigate significant bile leak in the drain following LC, attempting to avoid potential unnecessary invasive means when the scan demonstrate fair passage of nuclear substance to the intestine, without leak. Methods: We have conducted a prospective non-randomized study, mandating hepatobiliary scintigraphy first, for asymptomatic patients harboring drain in the gallbladder fossa, leaking more than 50 mL/day following LC. Analysis was done based on medical data from the surgical, gastroenterology, and the nuclear medicine departments. Results: Among 3,124 patients undergoing LC, significant bile leak in the drain was seen in 67 subjects, of whom we started with HBS in 50 patients, presenting our study group. In 27 of whom, biliary scan was the only investigative modality, showing fair passage of the nuclear isotope to the duodenum and absence of leak in the majority. The leak stopped spontaneously within a mean of 3.6 days, and convalescence as well as outpatient clinic follow-up was uneventful. In 23 patients, biliary scan that was interpreted as abnormal was followed by endoscopic retrograde cholangio-pancreatography (ERCP). However, ERCP did not demonstrate any bile leak in 13 subjects. In 17 patients, ERCP was used initially, without biliary scan, suggesting the possibility of avoiding invasive modalities in 7 patients. Conclusions: Based on a negative predictive value of 91%, we suggest that in cases of asymptomatic significant bile leak through a drain following LC, a normal HBS as the initial modality can safely decrease the rate of using invasive modalities.

S1664 Colonic Obstruction Caused by GB Stone

INTRODUCTION: Colonic gallstone ileus is one of the rare causes of intestinal obstruction. These stones usually require surgery although endoscopic removal by different methods; such as extracorporeal lithotripsy, Dormia baskets and polypectomy snares have been described. CASE DESCRIPTION/METHODS: A 69-year-old female with no significant past medical history presented with several days of lower abdominal pain, nausea, vomiting, constipation and abdominal distension. There was no h/o hematemesis, melena or jaundice. She reported no previous colonoscopy. On exam, the patient was found to be in abdominal discomfort. No icterus or pallor was present. Abdominal exam showed distension with tenderness present in the left iliac fossa. Lab results were WBC 19.6, hemoglobin 6.0, platelets 340, total bilirubin 0.9, alkaline phosphatase 84, AST 12, ALT 8, Lactate 8.6. Fecal occult blood was negative. CT abdomen showed significant edema of the proximal colon, pneumobilia with 3.7 cm lamellated calcified lesion resembling a large gallstone present in the distal sigmoid colon resulting in local mechanical obstruction. The patient was diagnosed with gallstone colonic ileus and cholecystocolonic fistula. She underwent attempted removal of stone with the help of rigid sigmoidoscopy and then flexible colonoscopy, but both failed. Finally, she underwent open laparotomy and extended sigmoid colectomy, Hartmann’s procedure and colostomy. The cholecystocolonic fistula was not disturbed. She had a good recovery and was discharged in stable condition after 5 days. At around 6 months, she underwent a biliary scan which showed that the cholecystocolonic fistula had closed spontaneously. She subsequently underwent reversal of the Hartmann procedure and cholecystectomy. Currently she is doing well with no recurrence. DISCUSSION: Large bowel ileus due to gallstone is a rare cause of obstruction. The stone reaches the colon most commonly through cholecystocolonic fistula. The impacted area is usually at a point of pathological narrowing, such as related to diverticular disease, as in our patient. The patient typically presents with abdominal distension, pneumobilia and ectopic stone all of which were present in our patient. CT abdomen is the investigation of choice. Endoscopic Dormia basket removal has been successfully used in the past by authors. But when the stone is too large, surgical removal of the stone may be necessary. The cholecystocolonic fistula also needs to be repaired at a later date which may require surgical re-exploration.Figure 1.: Colonoscopic view showing large Gall Bladder stone in Sigmoid colon.Figure 2.: CT scan abdomen showing the radio-opaque GB stone in the sigmoid colon.

Sclerosing Cholangitis with Ulcerative Colitis after Bariatric Surgery

Introduction: 48 years old Iraqi female presented in 2012 with 4 months upper abdominal pain with elevation of the liver enzymes and arthralgia, 1 year after sleeve gastrectomy for obesity with 25 kg weight loss. Labeled as auto immune hepatitis and was started on prednisolone 20 mg and azathioprine 100 mg, attended our center for second opinion. Her past history was impressive for gestational diabetes and ulcerative colitis diagnosed before 15 years and treated for 1 year with remission. Strong family history of diabetes including father, mother, brothers, and her uncle has ulcerative colitis. Investigations: Showed high liver enzymes, ALT 159, AST 286, ALP 455 and GGT 378, high eosinophil count. Imaging showed fatty liver with mild dilatation of the biliary system but CT scan, MRI, MRCP were not conclusive. ERCP showed features of sclerosing cholangitis with dominant stricture right hepatic duct, brushing and biopsy showed inflammatory changes. Colonoscopy showed pan colitis with ileal involvement, biopsy showed colitis with eosinophilic infiltration. She was treated with mesalazine, ursodiol, prednisolone and azathioprine. Regular follow over 4 years showed normal liver enzymes and last colonoscopy was reported as normal. Conclusion: A patient developed elevated liver enzymes after sleeve gastrectomy for obesity. Imaging and endoscopies showed typical sclerosing cholangitis with dominant right hepatic bile duct stricture, colonoscopy showed pan colitis with high eosinophilic infiltration. The problem was the evaluation of the dominant stricture and the exclusion of malignancy.

The urgent diagnosis of gallstones in acute pancreatitis: a prospective study of three methods.

Ultrasonography (US), radionuclide biliary scanning (RBS), and biochemical tests were performed within 72 h of admission in 83 patients with acute pancreatitis in an attempt to define those with gallstones as an aetiological factor. US was 92 per cent accurate in the 80 per cent of patients in whom the gallbladder was demonstrated. There were no false positives. Sixty-seven per cent of patients with gallstones were diagnosed although this improved to 78 per cent when US was repeated following the patients' clinical improvement. The pattern of RBS was completely normal in 46.5 per cent of patients with biliary pancreatitis and 64 per cent of patients with non-biliary pancreatitis. Biochemical tests completely separated 47 per cent of patients with gallstones from those without. Used in combination with US these two methods accurately identified 81 per cent of patients in the biliary group. In conclusion US was found to be a rapid and accurate method of gallstone detection but used alone it has limited usefulness. RBS can be time consuming and was found to be of doubtful value. Biochemical tests were helpful in indicating a proportion of patients who had gallstones which were not detected by US, and therefore have a practical application. Current methods of gallstone detection in patients with acute pancreatitis are far from ideal and further studies are indicated.

Should surgeons operate on the evidence of ultrasound alone in jaundiced patients?

The biliary ultrasound scans of 132 patients having a laparotomy for jaundice have been reviewed to assess the role of ultrasound in the selection of patients for surgery. When scans were technically satisfactory the finding of a dilated extrahepatic duct (EHD) indicated obstructive jaundice in all cases, but the obstructing lesion in 5 per cent of such cases was too proximal for jaundice to be relieved by direct surgical decompression. Scans were further classified on the basis of abnormalities detected in the gallbladder. When EHD dilation was associated with gall bladder findings 'typical' of distal common bile duct (CBD) obstruction due to gall stones (small gallbladder with multiple gallstones) or tumour (dilated gallbladder without gallstones), surgically remediable obstruction was always present. Although ultrasound identified the obstructing lesion itself in a minority of cases, the cause of obstruction could be correctly inferred in 95 per cent of 'typical' scans. These results suggest that it is safe to proceed directly to surgery only when an experienced ultrasonographer demonstrates findings 'typical' of distal CBD obstruction due to gallstones or tumour.

Acute Abdomen Secondary to Ascaris lumbricoides Infestation of the Small Bowel

Ascariasis is a helminthic infection commonly found in tropical climates. It often propagates in communities of low socioeconomic status secondary to contamination of the soil and water supply with human feces. We present a case report of a 42-year-old Asian-Indian female presenting with a long-standing history of severe recurrent postprandial epigastric pain, requiring multiple hospital admissions. Ultrasound, computed tomography (CT), and nuclear biliary scan were negative. She underwent esophagogastroduodenoscopy that suggested ischemia. Magnetic resonance angiography (MRA) and mesenteric angiography were inconclusive. As conservative treatment had been unsuccessful, a small bowel series was performed. The radiographs demonstrated characteristic findings of Ascaris lumbricoides infestation. Although the prevalence, diagnosis, and subsequent treatment of an acute abdomen secondary to Ascaris lumbricoides infestation is commonly seen in developing countries, clinicians in developed countries may not consider this entity when faced with a patient with similar symptoms. We frequently care for immigrants from developing countries and our own citizens who visit the countries where ascariasis is endemic. Therefore, heightened awareness of Ascaris lumbricoides infection (ALI) presenting as an acute abdomen is necessary. The diagnosis requires an experienced radiologist and knowledge by the clinician of treatment options and of when a surgeon should be involved.

Treatment Of Gallbladder Dyskinesia In Children With Acupuncture

Figeroa I, Russe J. Treatment of Gallbladder Dyskinesia in Children with Acupuncture. Medical Acupuncture 2005; 16 (3)Background Gallbladder dyskinesia is a presumptive diagnosis of a gallbladder dysfunction that presents with gallstone-free biliary type of abdominal pain in patients who have delayed gallbladder emptying on cholecystokinin-stimulated hepatobiliary scans. In view of the high incidence of residual and recurrent symptoms reported in these patients after cholecystectomy, acupuncture may be an initial alternative prior to surgical management. Objective To determine if medical acupuncture in patients with gallbladder dyskinesia would alleviate their symptoms and postpone the need for urgent surgery.Design, Setting, and Patients A retrospective review of 10 patients (9 girls and 1 boy; mean age, 16 years), with a mean duration of symptoms of 11 months, who fulfilled the diagnostic criteria by biliary scan and had a minimum of 4 treatment sessions of acupuncture. All patients were considered surgical candidates by a referring pediatric gastroenterologist.Intervention The treatment sessions were scheduled at weekly intervals with a mean of 5 sessions per patient. Treatment consisted of 3-6 acupuncture points, based on the specific alteration according to Chinese syndromes. The needles were placed unilaterally and De Qi was obtained prior to sedation or tonification. The most frequently used were LR 3 and GB 34 for dispersing the liver; SP 6, ST 36, SP 4, SP 3, and CV 12 for tonifying the stomach and spleen; CV 12, ST 21, and SP 9 for dispersing Qi, and damp and food stagnation; and PC 6, ST 36, CV 10, and CV 13 for controlling the countercurrent Qi of the stomach.Main Outcome Measures Subjective symptom improvement and the parents' objective assessment of their children's clinical signs after acupuncture. Further hospitalizations and any surgical management were determined.Results All 10 patients improved significantly after the 1st 2 treatments and were asymptomatic within 4-7 treatments. Two patients within 12 months presented with recurrent moderate symptoms, but both responded rapidly with 2 additional treatments. At 2 years of follow-up, 8 patients were symptom-free and none required surgical intervention.Conclusions The results of this small series of cases suggest that acupuncture could be an initial alternative to cholecystectomy for gallbladder dyskinesia in children. Further clinical and laboratory research should be performed to confirm these findings and to determine the physiologic basis of the harmonizing effects on the gastrointestinal tract.

Biliary imaging: a review

For practitioners of endoscopic retrograde cholangiopancreatography (ERCP), the times are certainly “a-changin.” Until recently, ERCP was the gold standard for imaging the bile ducts. Noninvasive imaging was confined to transcutaneous ultrasound (TUS), computed tomography (CT) scanning, and radionuclide gallbladder and biliary scans, with percutaneous transhepatic cholangiography (PTC) and IOC (formerly T-tube cholangiography) being the other invasive options. In the last decade, however, “young pretenders” to the ERCP “throne” have emerged: specifically, magnetic resonance imaging (MRI), multidetector helical CT (MDCT) cholangiography, and endoscopic ultrasound (EUS). It is not so long ago that MRI was considered to have no future in the abdominal cavity. However, the abdominal MRI naysayers failed to anticipate the exponential growth of this fledgling technology. Magnetic resonance cholangiopancreatography (MRCP) now rivals ERCP in sensitivity and specificity in many situations. ERCP remains the principal nonsurgical therapeutic approach for mechanical obstruction of the biliary and pancreatic ducts, with PTC and allied techniques (e.g., percutaneous biliary drainage [PBD]) being reserved for ERCP failures and situations in which ERCP is not attempted (e.g., after Roux-en-Y biliary diversion). In most endoscopy units, ERCP has evolved into a mainly therapeutic modality, with a variety of noninvasive (or less invasive) imaging techniques being used for diagnosis. This review will explore the changing face of biliary imaging, with particular emphasis on ERCP, MRCP, and MDCT cholangiography.

Use of 99mTc-DISIDA biliary scanning with morphine provocation for the detection of elevated sphincter of Oddi basal pressure

BACKGROUNDEndoscopic biliary manometry is useful in the assessment of patients with types II and III sphincter of Oddi dysfunction, but it is time consuming and invasive.AIMTo investigate the role of...

Cholecystectomy in Patients with AIDS: Clinicopathologic Correlations in 107 Cases

The etiologic and clinical features of cholecystisis in infection due to human immunodeficiency virus (HIV) were studies retrospectively. The charts and histopathologic specimens of 136 HIV-infected patients who underwent cholecystectomy between February 1987 and May 1993 at a large tertiary care center were reviewed. Opportunistic pathogens infecting the 107 patients with AIDS included microsporidia (eight cases-- Enterocytozoon bieneusi in six and Septata intestinalis in two); cytomegalovirus alone (six cases); Cryptosporidium alone (eight cases); cytomegalovirus plus Cryptosporidum (15 cases); and Pneumocystis carinii and Isospora belli (one case each). In addition, histopathologic changes characteristic of Kaposi's sarcoma were seen in one case. Thirty-eight patients with AIDS had acalculous cholecystitis for which no etiologic agent was found. Twenty-eight AIDS patients had cholelithiasis, six with coexistent opportunistic gallbladder infection. In the 107 AIDS patients, no specific symptom was found to be predictive of opportunistic infection of the gallbladder, but such infection was significantly associated with an abnormal abdominal ultrasound (P = .017) and with nonvisualization of the gallbladder by radionucleotide biliary scan (P < .001).

Symptomatic interleukin-2-induced cholecystopathy in patients with HIV infection.

This study reports the clinical and radiologic findings in seven patients infected with HIV who had 10 consecutive episodes of symptomatic cholecystopathy induced by infusion of interleukin-2. Ten episodes of right upper quadrant pain associated with gallbladder wall thickening were seen in seven of 29 HIV-infected patients who received IV interleukin-2. Patients received 6-18 million IU/day of continuous interleukin-2 infusion for 5 days. Patients with right upper quadrant pain underwent sonographic examinations, which were interpreted prospectively. Medical records and previous sonographic studies were reviewed retrospectively. Follow-up was obtained through outpatient visits and sonography. Right upper quadrant pain during these 10 episodes of cholecystopathy usually developed 4-5 days after starting infusion of interleukin-2. Sonography during that time showed gallbladder wall thickening (mean thickness, 12.4 mm; range, 5-18 mm) and a wide variety of sonographic appearances. Tenderness during sonography was focal in six episodes, diffuse in one, and absent in three. Sludge was identified in one episode; calculi were not seen. Findings on radionuclide biliary scans were normal in three cases. Symptoms abated rapidly in every case after infusion of interleukin-2 was reduced or stopped. No surgery was necessary. When treatment was repeated, three patients had recurrent episodes, with clinical courses and sonographic aberrations showing little variance from the initial episodes. Follow-up sonography in three episodes showed a maximal thickness of the gallbladder wall of 4 mm. No patient had a history or laboratory evidence of intrinsic biliary disease. Symptomatic thickening of the gallbladder wall during infusion of interleukin-2 can exactly mimic other forms of acalculous cholecystitis, except that when associated with interleukin-2 the thickening is rapidly reversible and surgery is not required. Radionuclide scans can be useful in clinical decision making. The process appears to be benign, and cessation of interleukin-2 therapy, along with close clinical observation, appears to be the appropriate treatment.

Clinical and radionuclide evaluation of bile diversion by Braun enteroenterostomy: prevention and treatment of alkaline reflux gastritis. An alternative to Roux-en-Y diversion.

OBJECTIVE AND SUMMARY BACKGROUND: Symptomatic, medically resistant postgastrectomy patients with alkaline reflux gastritis (ARG) have increased enterogastric reflux (EGR) documented by quantitative radionuclide biliary scanning. Even asymptomatic patients after gastrectomy have increased EGR compared with nonoperated control patients. Roux-en-Y biliary diversion, although successfully treats the clinical syndrome of ARG, has a high incidence of early and late postoperative severe gastroparesis, Roux limb retention (the Roux syndrome), or both, which often requires further remedial surgery. As an alternative to Roux-en-Y diversion, this review evaluates the efficacy of the Braun enteroenterostomy (BEE) in diverting bile away from the stomach in patients having gastric operations. Based on previous pilot studies, the BEE is positioned 30 cm from the gastroenterostomy. Thirty patients had the following operations and were evaluated: standard pancreatoduodenectomy (8), vagotomy and Billroth II (BII) gastrectomy (6), BII gastrectomy only (10), and palliative gastroenterostomy to an intact stomach (6). All anastomoses were antecolic BII with a long afferent limb and a 30-cm BEE. Four symptomatic patients with medically intractable ARG and chronic gastroparesis had subtotal BII gastric resection with BEE rather than Roux-en-Y diversion. Eight control symptomatic patients and six asymptomatic patients with previous BII gastrectomy and no BEE were evaluated. Radionuclide biliary scanning was performed within 30 days in all patients and at 4 to 6 months in 14 patients. Bile reflux was expressed as an EGR index (%). After operation, 18 of 34 patients (53%) had no demonstrable EGR while in the fasting state for as long as 90 minutes. The range of demonstrable bile reflux (EGR) in the remaining 16 patients was from 2% to 17% (mean, 4.5%). Enterogastric reflux in the 14 control patients (with no BEE) ranged from 5% to 82% (mean, 42%). The four patients with ARG and chronic gastroparesis treated by subtotal gastrectomy and BEE had postoperative EGR of 0%, 2%, 2%, and 4%, respectively. They are asymptomatic with no evidence of bile reflux gastritis. In the 14 patients who had late evaluation, EGR ranged from 0% to 16% (mean, 5.5%). No patient had signs or symptoms of ARG after operation. Braun enteroenterostomy successfully diverts a substantial amount of bile from the stomach. The ARG syndrome might be prevented by performing BEE during gastric resection or bypass in a variety of operations. Conversion to a BII with BEE may be an alternative to Roux-en-Y diversion in treating medically resistant ARG and subsequent may avoid the Roux syndrome.

The Diagnostic Value of Grading Hyperperfusion and the Rim Sign in Cholescintigraphy

Biliary scans of 84 hospitalized patients believed to likely have acute cholecystitis, including 55 scans that had a radionuclide angiography phase, were retrospectively evaluated to determine the frequency of the rim sign and hyperperfusion, and to test the hypothesis that more intense hyperperfusion or rim sign is associated with a greater severity of gallbladder pathology ("complicated" acute cholecystitis). In 65 of the 84 cases there was surgical intervention (including 43 from the 55 cases whose scans had a radionuclide angiography phase). "Complicated" acute cholecystitis was considered present if there was gangrene, perforation, empyema, necrosis, ulceration, or fibrous exudation. Each scan was evaluated for the presence of a rim sign and arterial hyperperfusion to the region of the gallbladder fossa. The intensities of these secondary signs of acute cholecystitis were then graded as "mild" or "marked." Subdividing the rim sign and hyperperfusion into a "marked" category considerably improved the specificity, positive predictive value, and likelihood ratio (positive) for the diagnosis of acute cholecystitis, but even more so for the complicated subgroup when marked hyperperfusion or marked rim sign were the criteria used for a positive study. Approximately 50% of the patients with acute cholecystitis had hyperperfusion and a rim sign, and approximately 15% had marked hyperperfusion and a marked rim sign. Of the patients with acute cholecystitis, the only ones with marked hyperperfusion or a marked rim sign were those who had complicated acute cholecystitis. The data demonstrate an association between greater intensity of the rim sign or hyperperfusion and greater severity of gallbladder pathology in patients with acute cholecystitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of Surgical Therapy for Biliary Dyskinesia

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

High Incidence of Cholelithiasis in Older Patients with Homozygous Beta-Thalassemia

The records of 48 patients with homozygous beta-thalassemia were reviewed for evidence of cholelithiasis by abdominal ultrasonography or plain abdominal X-ray. The presence of cholelithiasis was reported in 25 patients (52%). The incidence increased with age to 83% in patients over 31 years of age. Gallstones were more frequent among patients with beta-thalassemia intermedia and with less blood transfusion requirements. Eleven patients with cholelithiasis (44%) became symptomatic. Eight received operations on an elective or semielective basis. Another patient had incidental cholecystectomy during splenectomy. The preoperative evaluation included abdominal ultrasonography, nucleotide biliary scan and evaluation of the cardiopulmonary status. Due to the longer survival of patients with homozygous beta-thalassemia, the problem of cholelithiasis is becoming more frequent.

Diagnostic Studies in Patients With Sickle Cell Anemia and Acute Abdominal Pain

Twenty-eight patients with sickle cell disease who presented with acute abdominal pain were evaluated with clinical laboratory, ultrasound, and biliary scintigraphic studies to determine their predictive capabilities for differentiating veno-occlusive disease (sickle cell crisis) from acute biliary disease. Eleven patients were treated surgically and 17 medically. Gallstones were demonstrated in 25 (90%) of the patients studied by ultrasound, and biliary scans were abnormal in nine patients (32%). Abnormal laboratory and radiological studies (ultrasound, biliary scintigraphy) were not significantly different in the two groups and had a low positive predictive value for detection of acute biliary disease. Nevertheless, normal biliary scintigraphy had high negative predictive value in that, if normal, it gave assurance that the cystic duct was patent and unnecessary surgery could be obviated in this high-risk category of patients.

Radionuclide Biliary Scanning in the Diagnosis of Gallstone Pancreatitis

The ability of hepatobiliary scanning (99mTc HID A) to distinguish gallstone (GS) from non-gallstone (NGS) pancreatitis was investigated in 29 patients. 4 patients had repeat scans during a

A blinded prospective study comparing four current noninvasive approaches in the differential diagnosis of medical versus surgical jaundice

A prospective study was undertaken to compare the diagnostic accuracy of clinical evaluation, ultrasound, computed tomography, and technetium 99m-HIDA or -PIPIDA biliary scans in distinguishing between intrahepatic and extrahepatic jaundice. A final diagnosis was established in each of the 50 patients who completed the study, among whom 29 had intrahepatic cholestasis and 21 had extrahepatic obstruction. In the diagnosis of extrahepatic obstruction, the sensitivities of clinical evaluation, ultrasound, computed tomography, and nuclear medicine biliary scan were 95%, 55%, 63%, and 41%, respectively; the specificities were 76%, 93%, 93%, and 88%; and the overall accuracies were 84%, 78%, 81%, and 68%. These data support the conclusion that when the clinical evaluation is carefully performed, it is the single most effective noninvasive means of detecting extrahepatic biliary obstruction in a jaundiced patient. Although ultrasound, computed tomography, and radionuclide biliary scan are less sensitive, they are highly reliable if they indicate that extrahepatic obstruction is present. A flow chart of invasive and noninvasive approaches for evaluation of the jaundiced patient is presented.

Biliary scintigraphy in acute pancreatitis.

A prospective study was carried out in 60 patients to determine the efficacy of 99mTc-PIPIDA scintigraphy in differentiating biliary pancreatitis from nonbiliary pancreatitis. Forty patients were classified as having biliary pancreatitis and 20 patients as having the nonbiliary type. Scintigraphic scans were divided into five main types according to the time to visualization of the gallbladder and the time to excretion of 99mTc-PIPIDA into the intestinal tract. Normal scans were obtained on 95% of patients (19/20) with nonbiliary pancreatitis; 22.5% of patients (9/40) with biliary pancreatitis had normal scans. It is concluded that elevated amylase levels together with an abnormal biliary scan, as defined by the criteria presented here, indicate biliary pancreatitis, while a normal scan largely excludes such diagnosis.