HEPATOBILIARY IMAGING

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HEPATOBILIARY IMAGING

• Presented by
• Yang Shiow-wen
• 11/26/2001

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Hepatobiliary Imaging

• The function of the biliary tree and gall bladder
• A "HIDA" scan or a "DISIDA" scan

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Hepatobiliary Imaging

• Performed with a variety of compounds that share
  the common imminodiacetate moiety

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Structures of DISIDA

• Blue color A polar component (the diacetate)
• Red A lipophilic component

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Structures of DISIDA

• HIDA
• Little used today
• DISIDA
• Imaging the gall bladder better when liver
  function is poor

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Pathways of DISIDA

• The lipophilic component binding to hepatocyte
  receptors for bilirubin
• Transported through the same pathways as
  bilirubin, except for conjugation

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IDA-chelated Tc-99m

• A magnification of two imminodiacetate compounds
• Polar components chelated a Tc-99m molecule

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Indications

• Acute cholecystitis
• Chronic cholecystitis
• Bile leakage
• Biliary atresia

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Requirements for DISIDA Scan

• Patient preparation fasted for 4 hours
• Radiotracer Tc-99m IDA compounds i.v.
• Imaging serial anterior/lateral views for 60
  minutes
• Every 5 minutes for 30 minutes
• Once at 45 minutes
• Once at 1 hour
• Delayed views of the gall bladder 2 hours, 4
  hours, 6 hours or 24 hours after injection

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Requirements for DISIDA Scan

• Morphine
• Injection at one hour to help force the gall
  bladder to fill
• Water
• CCK
• Injection prior to the test to empty the gall
  bladder
• Suspected chronic cholecystitis
• Injection to measure how well the gall bladder
  empties.

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Normal Study
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Acute Cholecystitis

• The most common indication
• S\S
• Nausea, vomiting, fever
• Right upper quadrant pain post-prandially
• Mild to moderate leukocytosis
• Abnormal liver function test
• Pain radiates to the back (scapula)
• Usually blockage of the cystic duct by a gallstone

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Acute Cholecystitis

• If hepatic scintigraphy reveals adequate filling
  of the gallbladder, acute cholecystitis is
  effectively excluded.
• Within 30 minutes, the gallbladder fails to
  visualize
• Wait for one whole hour
• Differential diagnosis for non-visualization of
  the gallbladder
• Relaxation of the sphincter of Oddi
• Inject morphine (3-5 milligrams) and continue the
  study for another half an hour

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Non-Visualization of Gallbladder
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Non-Visualization of Gallbladder
Negative study after injection of morphine
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Re-injected DISIDA Morphine
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Chronic Cholecystitis

• Ultrasound is the primary modality of choice
• S\S
• Usually having gall stones
• The cystic duct is not blocked
• More chronic pain
• Delayed visualization of the gall bladder
• Biliary dyskinesia in response to administration
  of CCK

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Bile leaks

• Most appropriate non-invasive imaging technique
  for evaluation of bile leaks
• Sensitivity 87, Specificity 100 (2-3 ml of
  labeled bile)
• Radiopharmaceutical activity
• In an extrahepatic and extraluminal location
• More intense with time
• Differentiating intraluminal activity from a leak
• Ingestion of water
• Standing views in addition to anterior oblique
  views

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Reflux into Stomach
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Radioactivity in Left Subphrenic Space-I
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Bile Leak Post-cholecystectomy-II
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No Excretion from Liver

• No excretion up to 6 hours
• This pattern is commonly seen in
• Ascending cholangitis
• Pancreatitis
• Hepatitis

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Pseudo Gallbladder
Radionuclide in C-loop of the Duodenum
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Pseudo Gallbladder
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Pseudo Gallbladder
Disappear after ingestion of water
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Obstruction at Ampulla
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Irregular Uptake in Liver-I
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Metastatic Deposits in Liver-II
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References

• http//www.vh.org/Providers/Lectures/IROCH/Biliary
  Nucs/BiliaryNucs.html (Virtual Hospital)
• Chapter 38, Hepatobiliary Imaging, Darlene
  Fink-Bennett, P759-770

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The End

• Thank for Your Attention !