Radionuclide Cholescintigraphy Research Articles

Inferior Vena Cava Compression Due to Biloma: A Case Report

Purpose: Biloma is an uncommon but well known complication of cholecystectomy. It varies in sizes from very small inconsequential leaks to very large collections causing pressure symptoms such as in gastric outlet obstruction. However, biloma causing inferior vena cava compression leading to significant edema has not been reported so far. Case Report: We report the case of a 55 year old female presenting with abdominal distention and lower extremity edema, a month after an open cholecystectomy. Physical examination showed distended abdomen with hepatomegaly and pitting edema of bilateral lower extremities. Laboratory data revealed normal hepatic function test except for an elevated alkaline phosphatase. Contrast enhanced computed axial tomography scan (CAT scan) of the abdomen revealed a 15 cm × 20 cm fluid collection (open arrows) displacing the liver far to the left and compressing on the inferior vena cava (closed arrows). The diagnosis of biloma was established at percutaneous drainage with resolution and relief of her symptoms. Discussion: Biloma is a localized collection of bile usually from iatrogenic injury. Laparoscopic cholecystectomy is the most common cause of bile duct injury leading to biloma formation although it can also occur spontaneously when gall stones are impacted in the bile ducts leading to disruption. The incidence varies from 0–7%. Other causes include local infection, cholangiocarcinoma, transarterial chemoembolization of hepatic malignancy and endoscopic retrograde cholangiopancreatography. Postoperative biloma commonly manifests within one week after surgery characterized by abdominal pain, fever, vomiting and jaundice. CAT scan and magnetic resonance imaging are superior to ultrasonography. Continuity between fluid collection and biliary tree can be determined by radionuclide cholescintigraphy. Chemical analysis of the aspirate can confirm the diagnosis. Percutaneous drainage is the treatment of choice for large collections otherwise endoscopic sphincterotomy with or without stent placement is usually adequate. Occasionally surgery may be needed for a persistent biloma particularly if infection ensues.[figure1]Figure

Cholelithiasis and Cholecystitis

Gallstone disease remains one of the most common medical problems leading to surgical intervention. Every year, approximately 500,000 cholecystectomies are performed in the US. Cholelithiasis affects approximately 10% of the adult population in the United States. It has been well demonstrated that the presence of gallstones increases with age. An estimated 20% of adults over 40 years of age and 30% of those over age 70 have biliary calculi. During the reproductive years, the female-to-male ratio is about 4:1, with the sex discrepancy narrowing in the older population to near equality. The risk factors predisposing to gallstone formation include obesity, diabetes mellitus, estrogen and pregnancy, hemolytic diseases, and cirrhosis. A study of the natural history of cholelithiasis demonstrates that approximately 35% of patients initially diagnosed with having, but not treated for, gallstones later developed complications or recurrent symptoms leading to cholecystectomy. During the last two decades, the general principles of gallstone management have not notably changed. However, methods of treatment have been dramatically altered. Today, laparoscopic cholecystectomy, laparoscopic common bile duct exploration, and endoscopic retrograde management of common bile duct (CBD) stones play important roles in the treatment of gallstones. These technological advances in the management of biliary tract disease are not infrequently accomplished by a multidisciplinary team of physicians, including surgeons trained in laparoscopic techniques, interventional gastroenterologists, and interventional radiologists. With the evolution of laparoscopic cholecystectomy, there has been a global reeducation and retraining program of surgeons. However, the treatment of choice for gallstones remains cholecystectomy. In recognition of the revolutionary advances in the treatment of cholelithiasis, it is the purpose of this collective review to describe recent information on the following topics: types of gallstones, asymptomatic gallstones, symptomatic gallstones, chronic cholecystitis, acute cholecystitis, and other complications of gallstones. Gross and compositional analysis of gallstones allows them to be classified as cholesterol, mixed, and pigment gallstones. When asymptomatic gallstones are detected during the evaluation of a patient, a prophylactic cholecystectomy is normally not indicated because of several factors. Only about 30% of patients with asymptomatic cholelithiasis will warrant surgery during their lifetime, suggesting that cholelithiasis can be a relatively benign condition in some people. However, there are certain factors that predict a more serious course in patients with asymptomatic gallstones and warrant a prophylactic cholecystectomy when they are present. These factors include patients with large (>2.5 cm) gallstones, patients with congenital hemolytic anemia or nonfunctioning gallbladders, or during bariatric surgery or colectomy. Epigastric and right upper quadrant pain occurring 30-60 minutes after meals is frequently associated with gallstone disease. The diagnosis of chronic cholecystitis is made by the presence of biliary colic with evidence of gallstones on an imaging study. Ultrasonography is the diagnostic test of choice, being 90-95% sensitive. The surgical literature suggests that 3-10% of patients undergoing cholecystectomy will have CBD stones. Intraoperative laparoscopic ultrasonography has recently replaced cholangiography as the method of choice for detecting CBD stones. Ultrasonography and radionuclide cholescintigraphy (HIDA scan) are useful in establishing a diagnosis of acute cholecystitis. Laparoscopic cholecystectomy should also be used in the treatment of acute cholecystitis. Laparoscopic cholecystectomy is more likely to be successful when performed within 3 days of the onset of symptoms. It is important to remember that gallstones can lead to a variety of other complications including choledocholithiasis, gallstone ileus, and acute gallstone pancreatitis.

Evidence of impaired gallbladder function in patients with liver cirrhosis by quantitative radionuclide cholescintigraphy.

The aim of this study was to understand gallbladder function in liver cirrhosis. Gallbladder function was measured in 45 patients with liver cirrhosis by Tc-99m-labeled imino-diacetic acid analog cholescintigraphy. Gallbladder function was represented by the filling fraction and the ejection fraction (EF). The patients were divided into three groups, based on cirrhotic severity, using the modified Child's classification: A = good, B = fair, and C = poor. Fifteen normal control subjects were selected for comparison. There were no significant differences in filling fraction among all of the study groups. Normal controls had significantly higher 60-min EF values than did liver cirrhosis patients. Among the liver cirrhosis patients, class A patients had the highest EF values, and class C patients had the lowest EF values. We found that liver cirrhosis may significantly impair the gallbladder emptying, based on the evidence of quantitative Tc-99m-labeled imino-diacetic acid analog cholescintigraphy findings.

Evidence of impaired gallbladder function in patients with liver cirrhosis by quantitative radionuclide cholescintigraphy

OBJECTIVE: The aim of this study was to understand gallbladder function in liver cirrhosis. METHODS: Gallbladder function was measured in 45 patients with liver cirrhosis by Tc-99m–labeled imino-diacetic acid analog cholescintigraphy. Gallbladder function was represented by the filling fraction and the ejection fraction (EF). The patients were divided into three groups, based on cirrhotic severity, using the modified Child’s classification: A = good, B = fair, and C = poor. Fifteen normal control subjects were selected for comparison. RESULTS: There were no significant differences in filling fraction among all of the study groups. Normal controls had significantly higher 60-min EF values than did liver cirrhosis patients. Among the liver cirrhosis patients, class A patients had the highest EF values, and class C patients had the lowest EF values. CONCLUSIONS: We found that liver cirrhosis may significantly impair the gallbladder emptying, based on the evidence of quantitative Tc-99m–labeled imino-diacetic acid analog cholescintigraphy findings.

The clinical significance of gall-bladder non-visualization in cholescintigraphy of patients with choledochal cysts.

Intravenous radionuclide cholescintigraphy (IVRC) provides a very specific picture for choledochal cysts. However, the clinical significance of the non-visualization of the gall-bladder (GB) activity in these cases is unclear. In this study, we reviewed 27 patients with choledochal cysts who underwent IVRC within 7 days prior to operation and correlated the GB findings on IVRC with the histopathological results. In 18 of the 27 patients (66.7%), there was non-visualization of the GB at 4 h post injection. Among these, two had histopathological features of acute cholecystitis (AC), 11 had chronic cholecystitis (CC), and five had normal GBs. In the other nine patients with visualization of the GB, there were five cases of CC and four normal GBs. If we apply the finding of non-visualization of the GB at 4 h post injection as the criterion for the diagnosis of AC, the diagnostic accuracy was only 40.7% (11/27). We concluded that: (1) GB disease (AC and CC) was common (66.7%: 7.4% and 59.3% respectively) in choledochal cyst patients. (2) Non-visualization of the GB on IVRC did not necessarily indicate AC in choledochal cyst cases, and the diagnostic accuracy was low. (3) GB disease is not the only cause of GB non-visualization on IVRC. A huge choledochal cyst causing a mass or reservoir effect may be a cause of GB compression and result in non-visualization of the GB.

Use of morphine cholescintigraphy in the diagnosis of acute cholecystitis in critically ill patients

To determine the efficacy of morphine enhanced radionuclide cholescintigraphy (MC) in the diagnosis of acute cholecystitis (AC) in critically ill patients. Retrospective chart review. 2 university hospitals. Records of all ICU patients who underwent MC as part of an evaluation for AC over an 8 year period were reviewed (n = 45). All patients initially had standard radionuclide cholescintigraphy (RC) performed which showed nonvisualization of the gallbladder (GB) and were then given morphine sulfate (0.05-0.1 mg/kg i.v.). The mean age was 54 years (range 18-84 years). Risk factors for AC included fasting in 41 patients (mean 12.4 days) and total parenteral nutrition in 32 patients. Signs of biliary sepsis included temperature > 100 degrees F in 38 patients, WBC > 10,000/ml3 in 40 patients, abdominal pain in 29 patients, and abnormal liver function tests in 42 patients. 23 patients had GB ultrasonography, with 7 showing stones. MC was positive (non-visualization) in 16 patients and negative (GB visualized) in 29, including 4 with gallstones. All patients in whom the GB was visualized did so within 1 h. There were 13 patients with positive MC who underwent operation; 12 had AC (9 acalculous, 3 calculous). Three patients were treated medically and recovered (false positive). All 29 patients with negative MC were true negatives. Overall, MC had an accuracy of 91%, sensitivity of 100%, specificity of 88%, positive predictive value of 75%, and negative predictive value of 100%. MC is a useful test in the evaluation of critically ill patients for suspected AC, particularly in patients with known risk factors or documented gallstones.

11. Comparison of single- vs dual-head acquisition in quantitative radionuclide cholescintigraphy

11. Comparison of single- vs dual-head acquisition in quantitative radionuclide cholescintigraphy

Morphine cholescintigraphy in the evaluation of hospitalized patients with suspected acute cholecystitis.

The authors determined if the diagnosis of acute cholecystitis can be accurately made or reliably eliminated by the use of morphine-augmented radionuclide cholescintigraphy (morphine cholescintigraphy [MC]) in hospitalized patients in whom the diagnosis is in doubt. SUMMARY/BACKGROUND DATA: Diagnosis of acute cholecystitis, calculous or acalculous, may be difficult in patients hospitalized for abdominal pain or other illnesses. Clinical signs often are obscure, and routine imaging studies are nonspecific or associated with a high incidence of false-positive tests. The authors report the use of MC in the evaluation of 163 hospitalized patients for acute cholecystitis over an 8-year period. All patients suspected to have acute cholecystitis initially had standard cholescintigraphy performed, which showed nonvisualization of the gallbladder, and then were given morphine sulfate (0.05-0.1 mg/kg, intravenously). Patients were divided into the following three groups: I--acute abdominal pain (N = 53); II--hospitalized for associated illness (N = 49); and III--critically ill (N = 61). Overall, MC confirmed the diagnosis of acute cholecystitis in 75 patients (46%), including 23 cases of acalculous cholecystitis. Visualization of the gallbladder occurred within 60 minutes of intravenous administration of morphine sulfate in all patients. Cystic duct obstruction and, presumably, the diagnosis of acute cholecystitis was excluded in 79 patients, including 38 who were critically ill. There were eight false-positive and one false-negative studies. Morphine cholescintigraphy had a sensitivity of 99%, a specificity of 91%, a positive predictive value of 0.9, a negative predictive value of 0.99, and an overall accuracy of 94%. In hospitalized patients with nonvisualization of the gallbladder after standard cholescintigraphy, MC is highly accurate, especially in predicting the absence of acute cholecystitis in patients with known risk factors.

The significance of a positive test of morphine cholescintigraphy in hospitalized patients : Flancbaum L, Wilson GA, Choban PS (Department of Surgery, Ohio State University Medical Center, 410 10th Avenue, Columbus, OH 43210). Surg Obstet Gynecol 1993;177:227–230.

Morphine-augmented radionuclide cholescintigraphy (MC) is a useful adjunctive diagnostic tool for the identification of acute cholecystitis (AC) in patients who are hospitalized and critically ill with occult sepsis. The results of previous studies have demonstrated a reduction in false-positive rates, that is, nonvisualization, from 40 percent with standard radionuclide cholescintigraphy to 5 percent with MC in these high-risk patient groups, with an overall accuracy of 92 percent. This study was performed to determine the significance of a positive test result from MC in patients with occult sepsis. We reviewed the records of all 20 patients at high risk in whom MC was positive during the 35-month period ending 31 May 1992. AC was confirmed by laparotomy in all 16 patients who underwent surgical treatment. There were two patients who recovered with antibiotic therapy alone (considered false-positives) and two additional patients who died without operation or a confirmed diagnosis of AC (excluded from analysis). Thus, in this series, MC was associated with a positive predictive value of 0.89, confirming that it is a valuable adjunct in establishing the diagnosis of AC in patients who are seriously ill and hospitalized with occult sepsis.

The evaluation of gallbladder function by quantitative radionuclide cholescintigraphy in patients with noninsulin-dependent diabetes mellitus.

Twenty-nine patients (24 males, 5 females; aged 62.8 +/- 10.1 years) with noninsulin-dependent diabetes mellitus (NIDDM) without gallstones and impaired liver function were included in our study. The patients were categorized by blood sugar control and disease duration. Twelve normal controls (10 males, 2 females; aged 62.8 +/- 12.4 years) were also studied for comparison. The gallbladder filling fraction (FF) and ejection fraction (EF) were calculated following the method of Krishnamurthy et al. The results showed no significant difference (P > 0.5) between (1) NIDDM and normal controls in FF (69.1 +/- 29.4 versus 67.5 +/- 24.0%) and EF (45.0 +/- 23.5 versus 54.8 +/- 10.0%) by a t-test, (2) good and poor blood sugar control in FF (64.9 +/- 30.9 versus 73.7 +/- 26.4%) and EF (42.0 +/- 25.4 versus 54.8 +/- 10.0%) by a Mann-Whitney U test, (3) long and short disease durations in FF (70.9 +/- 29.7 versus 67.9 +/- 28.7%) and EF (37.9 +/- 20.7 versus 50.0 +/- 24.1%) by a Mann-Whitney U test. In conclusion, the results challenge some previous reports and warrant further research.

The evaluation of gallbladder function by quantitative radionuclide cholescintigraphy before and after ESWL for gallstones: preliminary report.

We assessed changes of gallbladder function including concentration and contraction in patients with gallstones after extracorporeal shockwave lithotripsy (ESWL). The abilities of concentration and contraction were expressed as filling fraction (FF) at 90 min and ejection fraction (EF) at 30 min after a fatty diet by Tc-99m DISIDA cholescintigraphy. A total of 12 patients who had symptomatic gallstones without cholecystitis were included in our study. ESWL failed in three cases: FF decreased in two of three cases and increased in one of three cases, whereas EF decreased in two of three cases and increased in one of three cases. In another nine cases, ESWL was successful and the gallstones were fragmented. One month after ESWL, in three of these nine cases, the gallstones had completely disappeared. In the three cases at 1 month after ESWL, FF decreased in two of three cases and increased in one of three cases, whereas EF decreased in one of three cases and increased in two of three cases. In the remaining six cases after ESWL, there were still some residual stone fragments in the gallbladder. In these six cases after 6 months, no fragments were found in the gallbladders, the third Tc-99m DISIDA cholescintigraphy was performed. In these six cases, the changes of FF and EF, before ESWL, 1 month after ESWL, and 6 months after ESWL, were irregular and fluctuant. However, no significant improvement of gallbladder function was demonstrated even when ESWL was successful.(ABSTRACT TRUNCATED AT 250 WORDS)

Radionuclide Hepatobiliary Scanning in Patients with AIDS-Related Sclerosing Cholangitis

Biliary disease, primarily manifesting as papillary stenosis or sclerosing cholangitis, is being increasingly recognized as a problem in the acquired immunodeficiency syndrome (AIDS) and may be amenable to specific treatment. Ultrasound, followed by endoscopic retrograde cholangiopancreatography (ERCP) for definitive diagnosis, is currently the prime mode of investigation of suspected hepatobiliary diseases in AIDS. There are few published reports of the use of radionuclide cholescintigraphy in the assessment of these patients. This report presents Tc-99m DISIDA cholescintigraphy data from three patients with AIDS-related hepatobiliary disease confirmed by ERCP. Radionuclide cholescintigraphy was abnormal in all three patients. In two of the subjects, there was focal duct dilation with strictures in the biliary tree. The third patient demonstrated diffuse hepatic parenchymal retention with marked delay in tracer washout. Two of the subjects, treated with specific anticryptosporidial therapy, subsequently underwent progress cholescintigraphy. In one of these patients with initial diffuse parenchymal retention, there was marked improvement in scan appearances. The second patient with initial duct dilation had no significant change in scan appearances, but quantitative analysis did demonstrate improvement in hepatobiliary tracer clearance rate. In conclusion, although ERCP remains the gold standard in the diagnosis of AIDS-related biliary disease, radionuclide cholescintigraphy may be a useful modality in these patients as a screening test before proceeding to more expensive and invasive techniques. In addition, quantitative analysis of cholescintigraphy may allow assessment of patient response to specific antimicrobial or surgical intervention.

Acute acalculous cholecystitis. A review.

Acute acalculous cholecystitis is an uncommon but very serious illness, that, if undiagnosed, may lead to gallbladder perforation and death. The condition has numerous causes that result in bile stasis and ischemia leading to inflammation and infection in the gallbladder wall. The bedside diagnosis may be difficult, especially in critically ill patients. Current imaging techniques including ultrasonography, computer tomography, and radionuclide cholescintigraphy are very helpful. Depending on the clinical situation, the gallbladder should either be drained by a surgical or percutaneous cholecystostomy under local anesthesia or removed.

Intestinal Obstruction Diagnosed by Cholescintigraphy

Radionuclide cholescintigraphy provides useful information about the dynamics of bile flow through the liver, gallbladder, bile ducts, and intestines. Besides helping to diagnose acute cholecystitis, it may provide other meaningful information to effectively alter the patient's management. Preoperative diagnosis of intestinal obstruction was made on routine cholescintigraphy and was proved subsequently at surgery.

Nifedipine inhibits cholecystokinin-induced gallbladder contraction

Nifedipine is a calcium channel blocker which results in relaxation of smooth muscle. Although it has been utilized clinically to treat cardiovascular disease, and more recently spastic disorders of the esophagus and colon, its effects on gallbladder contractility have not been clearly defined. We tested the effects of nifedipine on gallbladder contraction stimulated by cholecystokinin (CCK) in a conscious guinea pig model and in healthy human volunteers. Gallbladder contraction was measured in response to repeated injections of CCK before and after intravenous nifedipine given to groups of five guinea pigs in a dose of 100, 200, or 300 μg. Nifedipine virtually abolished spontaneous interdigestive gallbladder contractile activity and decreased resting gallbladder tone. The mean amplitude of gallbladder contraction in response to CCK was decreased by 45, 73, and 67% ( P < 0.01), in response to the nifedipine doses of 100, 200, and 300 μg, respectively. The integrated gallbladder contractile response and the rate of rise of gallbladder pressure in response to CCK were also significantly decreased by nifedipine. In nine healthy human volunteers, gallbladder emptying was measured by radionuclide cholescintigraphy in response to CCK infusion; on another day the study was repeated after oral administration of 10 mg nifedipine. Ejection fraction was significantly decreased by nifedipine from 72 ± 5 to 51 ± 5% ( P < 0.001). These data demonstrate that nifedipine is a potent inhibitor of gallbladder contractility in guinea pigs and man. This may provide the basis for the use of nifedipine clinically in the treatment of biliary colic and also raises questions about the potential effect of longterm nifedipine use on gallstone formation and cholecystitis.

Impairment of gallbladder emptying in diabetes mellitus

Individuals with diabetes mellitus are reported to have a twofold to threefold increase in the incidence of cholesterol gallstones. A frequently cited but unproven pathophysiologic mechanism for this phenomenon is reduced gallbladder muscle function, which results in stasis and allows for cholesterol gallstone crystal formation and gallstone growth. To date, gallbladder motor function has not been investigated in a well-characterized diabetic population. Therefore, using radionuclide cholescintigraphy, gallbladder filling and subsequent emptying produced in response to an infusion of the octapeptide of cholecystokinin in 30 diabetic patients and 20 control individuals were studied. No difference in any parameter used to assess gallbladder filling was demonstrated in the diabetics when compared with controls. In contrast, gallbladder emptying induced with cholecystokinin-octapeptide (20 ng/kg body wt · h) was reduced in diabetics compared with controls (55% ± 5% vs. 74% ± 4%, p < 0.01). The peak emptying rate in the diabetics was also decreased (5.0% ± 0.5% per minute) compared with the controls (7.0% ± 0.6% per minute, p < 0.02). The observed decreased gallbladder emptying found in diabetics was not related to obesity, type of diabetes, diabetic control, or presence or absence of peripheral neuropathy. The most severe impairment of gallbladder emptying occurred, however, in diabetics with an associated autonomic neuropathy. This subgroup demonstrated a significant reduction in the percentage of gallbladder emptying (40% ± 8% vs. 62% ± 5%, p < 0.04) and the peak ejection rate (3.5% ± 0.5% per minute vs. 5.6% ± 0.6%, p < 0.02) compared with the diabetics without autonomic neuropathy.

Why not choledochal cyst?

With excision as a standard procedure for treating choledochal cyst, early diagnosis becomes a central issue in reducing morbidity and mortality from that disorder. In a retrospective analysis of 35 patients treated over a 10-year period, we found the diagnosis was delayed for an average of 11.9 months from the beginning of presenting symptoms. Three factors were responsible: (1) a random combination of non specific presenting symptoms such as pain and vomiting or jaundice and hepatomegaly frequently led to a diagnosis such as acute pancreatitis or hepatitis, in which conservative treatment was considered most appropriate; (2) the three parameters commonly used to diagnose acute pancreatitis (serum amylase, lipase, and Cam/Ccr) may all be elevated in patients with a choledochal cyst; and (3) a combination of several noninvasive examinations such as radionuclide cholescintigraphy, ultrasonography, and upper gastrointestinal X-rays may fail to diagnose some difficult cases of choledochal cyst. To obviate such problems, we recommend a routine ultrasound examination of biliary tract in children with recurrent or progressive obstructive jaundice or unexplained acute pancreatitis. When these noninvasive examinations fail to solve the problem, endoscopic retrograde cholangiopancreatography should be considered.

Acute cholecystitis: diagnosis with radionuclide angiography.

Radionuclide angiography and cholescintigraphy were performed with a bolus injection of technetium-99m disofenin in 65 patients with suspected acute cholecystitis. Acute cholecystitis was surgically confirmed in 23 of 25 cases in which radionuclide angiographic findings were positive (i.e., showed focal increased flow to the gallbladder region) (positive predictive value, 92%). Sensitivity and specificity of radionuclide angiography for detecting acute cholecystitis were 72% and 94% for cholescintigraphy. Three patients with scintigraphically visible gallbladders (at 45 minutes, 2.4 hours, and 4.5 hours) and positive angiograms had severe acute cholecystitis and abscess. All 20 patients with positive radionuclide angiographic and scintigraphic results had transmural acute cholecystitis. None of the nine patients with acute cholecystitis and false-negative angiograms had abscess or gangrene of the gallbladder. Use of radionuclide angiography may enable the prediction of the severity of acute cholecystitis, as nine of 25 patients with positive findings had either gangrenous cholecystitis or pericholecystic abscess. Positive findings on radionuclide angiograms may preclude the need to obtain delayed (beyond 1 hour) cholescintiscans.

Diagnosis of Intrahepatic Stone by Endoscopic Retrograde Intrahepatic Cholangiography A Comparative Study with Intravenons Radionuclide Cholescintigraphy and Ultrasonography

Diagnosis of Intrahepatic Stone by Endoscopic Retrograde Intrahepatic Cholangiography A Comparative Study with Intravenons Radionuclide Cholescintigraphy and Ultrasonography

The significance of nonvisualization of extrahepatic bile duct in intravenous radionuclide cholescintigraphy with special reference to acute suppurative cholangitis.

Intravenous radionuclide cholescintigraphy using Tc-99m HIDA was performed in 386 consecutive patients with suspected biliary disease. Among 365 patients with prompt hepatic uptake, the common bile duct was not visualized in 19 (5.2%). Biliary calculi with infection, especially suppurative cholangitis, is the most frequent condition responsible for this cholescintigraphic pattern. Conditions involving the common bile duct from extrinsic causes may also present this pattern. This pattern is a specific indicator of pathology in the common bile duct. In addition, it is diagnostic for acute suppurative cholangitis, with a sensitivity of 66.7%, a specificity of 90.5%, an accuracy of 88.3%, a positive predictive value of 42%, and a negative predictive value of 96.3%. Aside from mechanical obstructions, functional obstruction of a normal sized common duct that contained no calculi could also be detected by this pattern.