Hepatobiliary Iminodiacetic Acid Scan Research Articles

A Rare Case of Biliary Atresia with Biliary Ascites on a (Hepatobiliary Iminodiacetic Acid) HIDA Scan

AbstractBiliary atresia is one of the most challenging conditions in pediatric surgery even when it is the only finding. Here we present a rare case of biliary atresia complicated with biliary ascites due to ductal perforation identified on a hepatobiliary iminodiacetic acid (HIDA) scan.

The impact of cholecystectomy on the symptom relief and quality of life of patients with gallbladder dysmotility.

The aim of this study was to demonstrate the impact of laparoscopic cholecystectomy on the physical and mental health of patients with gallbladder dysmotility. Retrospective data was collected from 314 patients who had undergone a hepatobiliary iminodiacetic acid (HIDA) scan between June 2012 and June 2022 in a District General Hospital in South East England. Sixty-three patients who were diagnosed with gallbladder dysmotility were then contacted and asked to participate in a telephone interview regarding their symptoms. We measured their health-related quality of life using the HRQoL SF-12 v2 (Health Related Quality of Life Short Form-12 version 2) questionnaire. Differences in the resolution of symptoms between those that had undergone a cholecystectomy and those who did not, were assessed using a chi square test. The two groups were then compared using the student t-test to assess statistically significant differences. 94% (n=31/33) of the participants in the non-cholecystectomy group demonstrated persistent biliary pain symptoms as opposed to the 6% (n=2/30) in the cholecystectomy group. A statistically significant improvement in five out of the eight domains of the HRQoL SF-12 questionnaire was demonstrated. These domains include PCS (physical component summary), MCS (mental component summary), mental health, general health and bodily pain. The results of our retrospective analysis demonstrate an improvement in both the physical and mental health-related quality of life symptoms in patients who underwent laparoscopic cholecystectomy. These findings support the use of laparoscopic cholecystectomy as an effective method for managing gallbladder dysmotility.

Use of a Hepatobiliary Iminodiacetic Acid scan in the Diagnosis of Enterocutaneous Fistula: A Case Report

Enterocutaneous fistulas (ECFs) are abnormal connections between epithelium of the intestinal lumen and skin. The diagnosis and characterization of an ECF is vital to determine the appropriate treatment approach. Diagnosis of ECFs are typically made by visualization of succus drainage from a surgical incision. However, when diagnosis is unclear, various radiological modalities are available to aid diagnosis. We report a case of incidental application of nuclear medicine hepatobiliary iminodiacetic acid scan which led to the diagnosis of an ECF.

OGBN P32 Outcomes of patient with Biliary Dyskinesia undergoing laparoscopic cholecystectomy - A multicentre cohort study

Abstract Background Biliary dyskinesia (BD) is a benign disorder characterized by recurrent episodes of biliary pain in the absence of gallstones on ultrasound, normal liver function tests and an ejection fraction (EF) of <35% on hepatobiliary iminodiacetic acid (HIDA) scan. Laparoscopic cholecystectomy (LC) remains the only known effective treatment for BD. However, many surgeons are reluctant to offer LC in such patients due to the fear of non-resolution of symptoms. Our aim was to analyse the outcome of patients who underwent LC for BD in terms of resolution of the biliary symptoms. Methods Multicentre retrospective cohort study of patients who have BD proven on HIDA scan from January 2015 to December 2022. BD was defined as EF ≤35% on HIDA scan. Those with EF ≤35% but had evidence of gallstones, microlithiasis or post op leak were excluded from the study. Electronic case notes were reviewed for demographic details, duration of symptoms, body mass index (BMI), liver function test (LFT), radiological investigations, endoscopy report and histopathology results of cholecystectomy. Rome IV criteria of functional gastrointestinal (GI) disorders was used to confirm symptoms were biliary in origin. Results Of the 222 patients who had HIDA scan, 35 (15.7%) patients had BD. 26 (74.2%) were female and median age was 42 years (IQR 33-55). Median time from the onset of symptoms and HIDA scan was 18 months. 19 (54.2%) patients had LC preformed, 9 (25.7%) were discharged with decision of LC not required, 4 (11.4 %) had no further review and 2 (5.7%) still having LC under consideration. Histopathology of LC was, chronic inflammation in 10 (52.6%), cholesterosis in 3 (15.8%) and 4 (20.1%) had normal gallbladder. 13 (68.4%) patients who underwent LC were symptom free 12 months post-surgery. Conclusions BD although painful and potentially lifestyle limiting, does not progress to more serious consequences if untreated. Diagnosis is usually difficult, and patients go through extensive investigations before they have HIDA scan. LC improves the symptoms in two thirds of patients and should be offered to all patients with BD with appropriate counselling.

HPB P08 Is Biliary Hyperkinesia a true Pathology? Should cholecystectomy be considered? A prequel towards Pilot study

Abstract Background Biliary Hyperkinesia (BH) is defined as a condition where gallbladder contracts and empties more rapidly than usual causing recurrent biliary colic with no evidence of gallstones on ultrasound or MRCP. Hepatobiliary iminodiacetic acid (HIDA) scan is the investigation of choice and shows gallbladder ejection fraction (EF) of >80% in BH. A recent systematic review and meta-analysis suggested that laparoscopic cholecystectomy (LC) could alleviate the symptoms. Similar results have been highlighted in case reports published about this relatively new gallbladder dysmotility. This study investigates the number of patients with BH on HIDA scan who might qualify for LC. Methods This was a 7-year (2015 to 2022) retrospective cohort study of adult patients with biliary pain in the absence of gallstones who underwent HIDA scan. Patient with EF >80% on HIDA scan were included in the study. Electronic case notes were reviewed for demographics, body mass index (BMI), smoking status, liver function tests, duration of symptoms, radiology investigations and endoscopy result including endoscopic ultrasound (EUS). Results 225 patients had HIDA scan of which 37 (16.4%) patients had BH. Median age was 49 years (IQR 38-62) and 32 (86.4%) were female. Median BMI 28 (IQR 23.3-32.4) and 48.3% were smokers. 5 (13.5%) were referred for pH manometry and gastric emptying studies while 25 (67.5%) have been formally discharged from surgery clinic follow-up. 7 (18.9%) are still waiting for further review. Only two patients had LC; one 3 years post HIDA when repeat ultrasound eventually showed gall stones and histopathology confirmed chronic cholecystitis. The second patient had sludge seen on EUS and histopathology confirmed chronic cholecystitis. Conclusions The hypothesis that overactive emptying of gallbladder represented by a high EF on HIDA scan leads to pain is somewhat convincing. High biliary pressure in a short circuit bounded by gallbladder/cystic duct junction and sphincter of Oddi causes gallbladder mucosal damage and cholecystitis. However, could there be missed stones or sludge is something that still needs to be considered. EUS might be of additional value before diagnosing patient with biliary hyperkinesia. Surgeons should consider LC in patients with BH once other pathologies have been ruled out. Further studies are needed to understand the outcome of cholecystectomy in BH.

A retrospective cohort study to examine the association between the persistence of abdominal pain after cholecystectomy and ejection fraction on HIDA scan in patients with biliary dyskinesia

Background and aimsThe persistence of pain in patients who underwent cholecystectomy primarily for biliary dyskinesia has been associated with gall bladder ejection fraction (GBEF) found on hepatobiliary iminodiacetic acid (HIDA) scan. Cholecystectomy is a definitive treatment for cholelithiasis but is questionable in biliary dyskinesia. During the postoperative follow-up, gastroenterologists and surgeons often found that some patients with biliary dyskinesia continue to experience biliary pain even after surgery. This study aims to investigate whether the value of GBEF found on the HIDA scan predicts the persistence of pain after cholecystectomy in patients with biliary dyskinesia (EF <35% on HIDA scan). MethodsIt is a retrospective cohort study conducted at Kern Medical by recruiting patients from November 2019 to October 2022 in consecutive manner. It is a single sample study consisting of post-cholecystectomy biliary dyskinesia patients with dichotomous outcomes, i.e., persistent typical recurrent epigastric or right upper quadrant pain with/without meals versus no pain. The primary outcome was the presence of pain 30 days after the cholecystectomy. Univariate analysis was performed with some of the bivariate indicators and continuous predictors, which contained fewer missing elements and had more variation. ResultsUnivariate logistic regression suggested that HIDA GBEF as a continuous variable does not suggest a relationship with pain after surgery (p = 0.3951). A ROC analysis suggested a cutoff of HIDA GBEF = 16 (AUC = 0.60, Specificity = 0.5455, Sensitivity = 0.7333). ConclusionOur study does not support the relationship between GBEF found on HIDA scan to improved outcomes after the surgery. But larger controlled trials comparing outcomes of the patients with biliary dyskinesia who did and didn't undergo cholecystectomy are needed to look for other factors.

Dubin Johnson Syndrome Masquerading as Biliary Atresia in a Neonate

Biliary atresia (BA), a surgical cause of neonatal cholestasis, needs timely intervention. A term male neonate presented with yellowish discoloration and pale stool on the third week of life, suspected as BA based on the liver function test and hepatobiliary iminodiacetic acid (HIDA) scan. His intraoperative cholangiogram was normal and finally diagnosed as a case of Dubin-Johnson syndrome (DJS) by whole exome sequencing. The baby became anicteric with the cholestasis regimen. DJS is one of the differential diagnoses of BA; genetic evaluation may be considered prior to an invasive cholangiogram in such cases.

Dose finding study for unilobar radioembolization using holmium-166 microspheres to improve resectability in patients with HCC: the RALLY protocol

BackgroundHigh dose unilobar radioembolization (also termed ‘radiation lobectomy’)—the transarterial unilobar infusion of radioactive microspheres as a means of controlling tumour growth while concomitantly inducing future liver remnant hypertrophy—has recently gained interest as induction strategy for surgical resection. Prospective studies on the safety and efficacy of the unilobar radioembolization-surgery treatment algorithm are lacking. The RALLY study aims to assess the safety and toxicity profile of holmium-166 unilobar radioembolization in patients with hepatocellular carcinoma ineligible for surgery due to insufficiency of the future liver remnant.MethodsThe RALLY study is a multicenter, interventional, non-randomized, open-label, non-comparative safety study. Patients with hepatocellular carcinoma who are considered ineligible for surgery due to insufficiency of the future liver remnant (< 2.7%/min/m2 on hepatobiliary iminodiacetic acid scan will be included. A classical 3 + 3 dose escalation model will be used, enrolling three to six patients in each cohort. The primary objective is to determine the maximum tolerated treated non-tumourous liver-absorbed dose (cohorts of 50, 60, 70 and 80 Gy). Secondary objectives are to evaluate dose–response relationships, to establish the safety and feasibility of surgical resection following unilobar radioembolization, to assess quality of life, and to generate a biobank.DiscussionThis will be the first clinical study to assess the unilobar radioembolization-surgery treatment algorithm and may serve as a stepping stone towards its implementation in routine clinical practice.Trial registrationNetherlands Trial Register NL8902, registered on 2020–09-15.

GALLBLADDER AGENESIS – A RARE CASE REPORT

Gallbladder agenesis is a rare congenital entity. The incidence is around 1 per 6500 live births. Around 50-70% patients are asymptomatic and the rest are symptomatic with symptoms mimicking biliary colic. Right upper quadrant ultrasound (US) is usually either misleading or inconclusive. Also advanced diagnostic studies such as hepatobiliary iminodiacetic acid (HIDA) scan and endoscopic retrograde cholangio-pancreatography (ERCP) may show nonvisualization of the gallbladder and erroneously lead providers to a diagnosis of cystic duct obstruction rather than Gallbladder Agenesis. So some patients are only finally diagnosed intraoperatively. Surgery in these patients becomes risky because unnecessary dissection while looking for the non-existent gallbladder can result in injury of the biliary tree, hepatic vasculature, or small bowel. Therefore, clinicians should keep Gallbladder Agenesis on their differential diagnosis list and imaging modalities such as magnetic resonance cholangiopancreatography (MRCP) should be obtained when other tests are inconclusive. We report a 48-year-old female presenting with chronic symptoms consistent with biliary colic and an equivocal US reported as cholelithiasis. She underwent laparoscopy during which the absence of the gallbladder was noted.

Clinical, Laboratory, Radiological, and Genetic Characteristics of Pediatric Patients with Alagille Syndrome.

Alagille syndrome (ALGS) is an autosomal dominant disease caused by JAG1 or NOTCH2 mutation. It is diagnosed by the presence of three out of five features: characteristic facies, posterior embryotoxon, peripheral pulmonary stenosis, vertebral defects, and interlobular bile duct paucity. This study aimed to review the prevalence, clinical presentations, diagnosis, treatment, and outcome of patients with ALGS. This is a retrospective review of patients with ALGS at the Pediatric Department, Salmaniya Medical Complex, Bahrain, between August 1994 and October 2022. The diagnosis was based on clinical, laboratory, radiological, histopathological, and genetic findings. Five patients were found to have ALGS. The prevalence of ALGS in Bahrain was 1.04 patients per 100,000 (0.001%). Four were Bahraini and three were females. Median birth weight was 2.3 (2.3-2.5) kg. All patients presented at the time of birth with low birth weight, cholestatic jaundice, clay-colored stool, heart murmur, and dysmorphic facial features. All had congenital heart diseases, two had butterfly vertebrae, and one had posterior embryotoxon. All had elevated liver enzymes and normal abdominal ultrasound. Three had positive hepatobiliary iminodiacetic acid scan and one had bile duct paucity in liver biopsy. Three had intraoperative cholangiogram. Four were positive for JAG1 mutation. All received ursodeoxycholic acid and fat-soluble vitamins. Two required liver transplantation. ALGS is a rare disorder in Bahrain. Diagnosis is challenging as the disease can be associated with or misdiagnosed as biliary atresia. Patients with ALGS are at high risk of morbidity either by unnecessary intraoperative cholangiogram or unavoidable liver transplantation.

S1726 Eosinophilic Infiltration Causing Biliary Tree Obstruction Without Stricture

Introduction: We present an exceedingly rare case of eosinophilic cholangitis (EC) without stricture. Of the 40 cases of EC reported in the literature, fewer than 10 cases did not involve a stricture. Case Description/Methods: A 60-year-old female with no significant past medical history presented with symptoms of biliary colic for 2 days. Laboratory results were significant for elevated hepatobiliary enzymes including alkaline phosphatase of 300 IU/L and total bilirubin of 3.8 mg/dL. A hepatobiliary iminodiacetic acid scan was performed with an absence of radiotracer excretion into the biliary tract. However, a magnetic resonance cholangiopancreatography showed no obstructing stone, stricture, or lesion. A broad workup including hepatitis and autoimmune serologies was negative. The patient underwent an uncomplicated laparoscopic cholecystectomy, and direct inspection of the gallbladder confirmed significant edema. Histopathology of the gallbladder showed acute and chronic acalculous cholecystitis with eosinophilic rich infiltrates. Notably, the patient had an absolute eosinophil count of 1.2 cells/µL. She was diagnosed with eosinophilic cholangitis and treated with corticosteroids. At her one-month follow-up, her symptoms had resolved. Discussion: Eosinophilic cholangitis is a rare, self-limiting condition featuring eosinophilic invasion of the biliary tree. Laboratory values in EC reflect an obstructive process, but diagnosis is frequently delayed as both symptoms and imaging mimic multiple other biliary conditions including malignancy, primary strictures, primary sclerosing cholangitis, amongst others. Endoscopic dilation of strictures often provides a surprising diagnosis when pathology demonstrates dense infiltration of eosinophils. Although a majority of EC is associated with stricture, EC may also present with obstructive features in the absence of stricture. Likewise, peripheral eosinophilia may or may not be present. Risk factors for EC have not been established. Literature suggests that patients with pre-existing eosinophilic processes such as eosinophilic esophagitis and asthma are more likely to develop EC than the general population. There is no standard treatment, but corticosteroids have demonstrated empiric efficacy, similar to the other eosinophilic processes mentioned. Increased physician awareness of eosinophilic cholangitis will help prevent delays in diagnosis and initiation of effective medical therapy.

Imaging in Pediatric Obstructive Jaundice

Cholestatic jaundice characterized by elevated conjugated bilirubin can be due to multitude of factors in neonates and childhood. Extrahepatic biliary atresia (EHBA), choledochal cyst, neonatal hepatitis, cytomegalovirus (CMV), and biliary plug are some of the common causes in neonate and early infancy. Causes in late infancy and childhood comprises viral hepatitis, choledochal cyst, cholelithiasis, worm infestation, and biliary compression secondary to extrinsic causes (node, collection, tumor). Some serious disorders like biliary atresia must be considered with the emphasis on early diagnosis of treatable causes. In the modern era, with multiple diagnostic modalities available including high-resolution ultrasonography, magnetic resonance imaging (MRI), CT scan, and nuclear imaging [hepatobiliary iminodiacetic acid (HIDA) scan], rapid diagnosis can be made in many surgically treatable cases. The authors will discuss the imaging modality available with advantages, disadvantages, and common indications of each modality, and overview of obstructive jaundice discussing the wide spectrum of causes in neonates and late childhood. Combining available knowledge with careful and meticulous search can help narrow down the diagnosis and initiate prompt treatment.

Pathology Out of Place

Question: A 41-year-old woman with no significant past medical history presents with a year-long history of intermittent abdominal pain associated with constipation, nausea, and vomiting. Her initial evaluation 1 year ago included an esophagogastroduodenoscopy, gallbladder ultrasound examination, and hepatobiliary iminodiacetic acid scan, which were all unremarkable. She was started on proton pump inhibitor therapy and sucralfate (Carafate) without improvement in her symptoms.

Pediatric Normokinetic Biliary Dyskinesia: Pain with Cholecystokinin on Hepatobiliary Iminodiacetic Acid Scan Predictive of Symptom Resolution After Cholecystectomy.

Introduction: Biliary dyskinesia is typically defined as a gallbladder ejection fraction (EF) <35% on hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (CCK-HIDA) testing. Cholecystectomy often leads to resolution of associated biliary colic symptoms. Alternatively, there is a subset of symptomatic patients with normal gallbladder EF on CCK-HIDA. It has been proposed that pain with CCK injection is more predictive of symptom resolution after cholecystectomy than low gallbladder EF. We reviewed our experience with pediatric patients with positive CCK provocation testing and a normal gallbladder EF in the absence of gallstones. Materials and Methods: We retrospectively reviewed the records of all pediatric patients with normal hepatobiliary iminodiacetic acid EFs (35%-80%) and pain with CCK injection at a tertiary care center between 2016 and 2020. Age, gender, body mass index (BMI), CCK-HIDA results, and pathology analysis were noted. Short- and long-term resolution of symptoms was determined by patient self-reporting at a mean of 3 weeks and 46 months, respectively. Results: Seventeen patients met inclusion criteria. Average age was 15.1 years (range, 12-17 years) with median BMI 24.9 (± 4.9 kg/m2). Mean CCK-HIDA EF was 56.3% (± 11.4%). In total, 62.5% of patients had evidence of chronic cholecystitis and/or cholesterolosis on pathology analysis. Of patients available for short-term and long-term postoperative follow-up, 80% and 83% reported complete or near complete resolution of symptoms, respectively. Conclusions: Normokinetic biliary dyskinesia is poorly understood but appears to be associated with chronic inflammation and cured by surgical intervention. Laparoscopic cholecystectomy results in resolution of symptoms for a majority of patients and should be considered in those with pain with CCK injection despite normal imaging studies. Clinical Trial Registration Number: 1657640-2.

Internal herniation of the right colon through the foramen of Winslow: A case report.

Introduction and importanceHerniation through the Foramen of Winslow, also known as the epiploic foramen, is an extremely rare phenomenon with less than 200 cases reported in medical literature. Internal hernias account for less than 1% of all hernias and roughly 8% of all internal hernias occur through the foramen of Winslow. We present a case of a foramen of Winslow hernia that was not detected until direct visualization with laparoscopy.Presentation of caseA 52 year-old healthy female with a surgical history of a Caesarean section presented to the ER with severe epigastric pain radiating to her back. Physical exam was positive for abdominal tenderness and guarding. Vital signs were within normal limits. Murphy’s sign and Rovsing’s sign were negative. Initial imaging studies, including a CT scan of the abdomen, and laboratory findings were unremarkable. A hepatobiliary iminodiacetic acid (HIDA) scan was performed and demonstrated non-visualization of the gallbladder suggestive of acute vs. chronic cholecystitis. Following these results the patient elected to undergo exploratory laparoscopy with potential cholecystectomy. Intra-operatively, the colon was noted to be herniated through the foramen of Winslow. The procedure was converted to an open laparotomy. The hernia was manually reduced, and a right hemicolectomy was performed to prevent recurrence of the hernia.DiscussionReports list an enlarged foramen of Winslow, excessive viscera mobility (i.e., persistent ascending mesocolon or long small bowel mesentery), and an increase in intra-abdominal pressure as potential risk factors for this particular hernia. In our case, the patient was noted to have excessive mobility of the viscera with the presence of persistent ascending mesocolon and an abnormally long right mesentery. Physical exam is usually nonspecific and laboratory findings are typically unremarkable, posing a diagnostic challenge. Additionally, radiological findings indicating presence of an internal hernia were missed in the initial CT scan read by the radiologist. Internal hernias need to be managed surgically as there is a risk of strangulation with bowel ischemia.ConclusionThis rare radiographic phenomenon is difficult to diagnose radiographically and warrants further workup due to the potential risk of bowel strangulation despite negative clinical and laboratory findings.

Percutaneous Cholecystostomy Tube for Acute Cholecystitis: Quantifying Outcomes and Prognosis

Percutaneous cholecystostomy tubes (PCT) are utilized in the management of acute cholecystitis in patients deemed unsuitable for surgery. However, the drive for these decisions and the outcomes remain understudied. We sought to characterize the practices and utilization of PCT and evaluate associated outcomes at an urban medical center. Patients undergoing PCT placement over a 12-y study period ending May 2019 were reviewed. Demographics, clinical presentation, labs, imaging studies, and outcomes were abstracted. The primary and secondary outcomes were 30-d mortality and interval cholecystectomy, respectively. Two hundred and four patients met inclusion criteria: 59.3% were male with a median age of 67.5 y and a National Surgical Quality Improvement Program (NSQIP) risk of serious complication of 8.0%. Overall, 57.8% of patients were located in an intensive care unit setting. The majority (80.9%) had an ultrasound and 48.5% had a hepatobiliary iminodiacetic acid scan. The overall 30-d mortality was 31.9%: 41.5% for intensive care unit and 18.6% for ward patients (P < 0.01). Of patients surviving beyond 30 d (n=139), the PCT was removed from 106 (76.3%), and a cholecystectomy was performed in 55 (39.6%) at a median interval of 58.0 d. A forward logistic regression identified total bilirubin (Adjusted Odds Ratio: 1.12, adjusted P < 0.01) and NSQIP risk of serious complication (Adjusted Odds Ratio: 1.16, adjusted P < 0.01) as the only predictors for 30-d mortality. Patients selected for PCT placement have a high mortality risk. Despite subsequent removal of the PCT, the majority of surviving patients did not undergo an interval cholecystectomy. Total bilirubin and NSQIP risk of serious complication are useful adjuncts in predicting 30-d mortality in these patients.

391 Routine Hatobiliary Iminodiacetic Acid Scan of All Suspected Cases of Acute Cholecystitis

Cholecystitis is the second-most common surgical admission from emergency departments and represents a large health burden. Different imaging modalities are utilized to evaluate this disease while hepatobiliary iminodiacetic acid (HIDA) scans are reported to be more sensitive and specific for acute cholecystitis because it is a functional evaluation of the gallbladder and can demonstrate cystic duct obstruction. Most emergency departments obtain a HIDA scan when the clinical diagnosis is equivalent. At our center, the primary general surgery group requires routine HIDA scans on all suspected cases of acute cholecystitis before deciding operative management. The purpose of this study was to perform a retrospective review of all HIDA scans performed in 2018 among emergency department cases of suspected cholecystitis. The specific aim was to evaluate the agreement between ultrasound (US) and HIDA scan findings and their association with operative decision-making. Secondary objectives were to evaluate discrepancies, insurance status, age, sex, ED length-of-stay, operative outcomes, and costs. HIDA scans were identified from our imaging record system from January 1, 2018 to December 31, 2018. An abnormal US (US+) was defined as the presence of gallstones plus either of the following: gallbladder wall thickening, pericholecystic fluid, sonographic Murphy’s, or common bile duct dilatation. An abnormal HIDA (HIDA+) scan was defined as cystic duct obstruction and/or failure to visualize the gallbladder. Qualitative reviews of specific cases were summarized. STATA (College Station, TX) was used for statistical analysis. N = 550 patients who received both HIDA scan and gallbladder US. There were 348 cases of US+ and 234 cases of HIDA+. There was a 59.3% agreement between US and HIDA findings. n = 169 of US+ and HIDA- and n = 55 of US- and HIDA+. Pairwise correlation 0.236 (p<0.001). There was a net decrease in operative care of 114 cases by adding HIDA. 550 HIDA scans have an estimated aggregate charge of $773,300 whereas 114 fewer laparoscopic cholecystectomies would have an aggregate savings of $2,101,932. This is the largest single-center study of comparison between HIDA and US in emergency department patients. The use of HIDA scans suggested 49% of patients with US+ findings may not require urgent surgery whereas 27% of patients with non-diagnostic US demonstrated the need for surgical intervention. The routine use of HIDA scans may have a significant impact on costs and reimbursements for this common etiology. The clinical suspicion is the main driver of resource utilization and routine HIDA scans increase immediate costs, ED length-of-stay, and can result in a net decrease of costs for urgent operative care.

CHEST IN CRISIS: A CASE OF BRONCHOBILIARY FISTULA

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bronchobiliary fistula (BBF) is a rare occurrence of altered anatomy of the biliary duct system in which it connects to the lungs. Biliptysis is pathognomonic for this condition. Predisposing factors include malignancy, bile duct obstruction, trauma, and surgery. Our case highlights a patient who presented with several months of non-resolving right middle lobe (RML) pneumonia who was later found to have a BBF. CASE PRESENTATION: Our patient is a 43-year-old male with a history of colon cancer with liver metastasis on palliative chemotherapy who presented after multiple episodes of RML pneumonia. He had endoscopic retrograde cholangiopancreatography (ERCP) with stent placement for malignant biliary obstruction. Three months later, he had fever, cough, and scant yellow sputum with chest x-ray (CXR) findings of RML consolidation. He received appropriate antibiotics for community-acquired pneumonia. His symptoms recurred two weeks later. During that admission, the CT chest showed consolidation of the RML. Sputum culture grew Klebsiella pneumoniae and was treated appropriately. He had two more similar episodes. Bronchoscopy showed erythematous endobronchial mucosa in the RML with carbapenem-resistant Enterobacteriaceae (CRE) and Klebsiella pneumoniae on culture. Transbronchial lung biopsy was negative for malignancy. After seven months from the initial ERCP, he presented with copious bilious sputum and right pleuritic chest pain. Repeat CT chest showed persistent RML consolidation and 4 cm fluid collection along the hepatic capsule which grew CRE and Klebsiella pneumoniae. This raised suspicion for bronchobiliary fistula. A hepatobiliary iminodiacetic acid (HIDA) scan done did not demonstrate the presence of a fistula. Magnetic resonance cholangiography (MRC) was done which showed a small sinus tract that represented a BBF. He underwent right anterior sectionectomy of the liver with diaphragm repair and ERCP with replacement of biliary stent. DISCUSSION: The most common cause of acquired BBF is liver malignancy likely through obstruction which produces inflammation in the subdiaphragmatic space with subsequent rupture into the bronchial system. Patients can present with pneumonia, while it is rare, it is the most common comorbidity associated with BBF. Our patient presented with biliptysis and recurrent pneumonia with multidrug-resistant organisms. MRC and HIDA are preferred studies as they are non-invasive. Our patient's HIDA scan was not diagnostic but the MRC showed the BBF. Our patient underwent segmental hepatectomy and ERCP with stent replacement with subsequent symptom resolution. CONCLUSIONS: A high index of suspicion is required to diagnose BBF when the presentation is atypical such as in the case of recurrent RML pneumonia. Early diagnosis is important to prevent progressive antibiotic resistance. Non-invasive modalities like HIDA and MRC are preferred for making the diagnosis. REFERENCE #1: Liao G-Q. Management of acquired bronchobiliary fistula: A systematic literature review of 68 cases published in 30 years. World J Gastroenterol. 2011;17(33):3842. doi:10.3748/wjg.v17.i33.3842 REFERENCE #2: Aduna M, Larena JA, Martín D, Martínez-Guereñu B, Aguirre I, Astigarraga E. Bile duct leaks after laparoscopic cholecystectomy: value of contrast-enhanced MRCP. Abdom Imaging. 2005;30(4):480-487. doi:10.1007/s00261-004-0276-2 DISCLOSURES: No relevant relationships by Tundun babalola, source=Web Response No relevant relationships by Afoma King, source=Web Response No relevant relationships by Nirvi Shah, source=Web Response No relevant relationships by susan waitimu, source=Web Response

S3576 Oddity of an Opiated Oddi: A Case of Sphincter of Oddi Dysfunction

Introduction: We present a case of recurrent right upper quadrant (RUQ) pain resulting from Sphincter of Oddi Dysfunction (SOD) in the setting of chronic opioid use. SOD is a functional gastrointestinal disorder that presents similarly to other disorders of the biliary tree. Understanding features of this disorder and its etiologies can streamline evaluation and treatment. Case Description/Methods: Our patient is a 77-year-old male, chronic opioid user, who had multiple Emergency Department (ED) visits and hospital admissions for RUQ pain in the setting of significantly elevated liver associated enzymes (LAEs). However, repeated imaging of the RUQ with CT, Ultrasound, and MRCP remained largely unremarkable. On a subsequent presentation, the patient experienced severe increase in pain after administration of morphine. Lab investigation showed an abrupt increase in LAEs and lipase after administration of morphine. Imaging was obtained, and was again inconsistent with cholecystitis. Interestingly, he attained analgesia with meperidine on admission. During a following ED visit, RUQ imaging showed non-specific gallbladder inflammation, and a Hepatobiliary Iminodiacetic Acid (HIDA) scan showed low gallbladder ejection fraction (GBEF). These findings suggested Functional Gallbladder Disorder and laparoscopic cholecystectomy was performed. Unfortunately, ten days later the patient had worsening RUQ pain with no signs of obstruction. With diagnostic criteria for SOD met and other etiologies ruled out, our patient was referred for sphincterotomy. Discussion: Opiate-induced SOD is theoretically well known, but there have been only few reported cases in literature. Furthermore, SOD is difficult to diagnose, as providers must first rule out other hepatobiliary disease. ROME IV Diagnostic Criteria for Functional Gastrointestinal Disorders was used in review of our case. Biliary pain, absence of bile duct stones or other structural abnormalities, and elevated LAEs fulfilled the criteria for this disorder. This case highlights the clinical evaluation and care of SOD. While all opioids have been shown to contract the Sphincter of Oddi (SO), morphine has been shown to strongly cause this contraction, and is one of the earliest reported causes of SOD in literature. Meperidine has been shown to have minimal effect on the SO contraction and is the ideal opioid to treat pain of biliary or pancreatic source.

Neonatal Hyperbilirubinemia and Cholestasis.

Neonatal Hyperbilirubinemia and Cholestasis.