HEPATOBILIARY IMAGING

1. HEPATOBILIARY IMAGING Presented by Yang Shiow-wen 11/26/2001

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

3. Hepatobiliary Imaging • Performed with a variety of compounds that share the common imminodiacetate moiety

4. Structures of DISIDA • Blue color: A polar component (the diacetate) • Red: A lipophilic component

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

6. Pathways of DISIDA • Thelipophilic component : binding to hepatocyte receptors for bilirubin • Transported through the same pathways as bilirubin, except for conjugation

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

8. Indications • Acute cholecystitis • Chronic cholecystitis • Bile leakage • Biliary atresia

9. 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

10. 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.

11. Normal Study

12. 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

13. 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

14. Non-Visualization of Gallbladder

15. Non-Visualization of Gallbladder Negative study– after injection of morphine

16. Re-injected DISIDA & Morphine

17. 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

18. 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

19. Reflux into Stomach

20. Radioactivity in Left Subphrenic Space-I

21. Bile Leak Post-cholecystectomy-II

22. No Excretion from Liver • No excretion up to 6 hours • This pattern is commonly seen in • Ascending cholangitis • Pancreatitis • Hepatitis

23. Pseudo Gallbladder Radionuclide in C-loop of the Duodenum

24. Pseudo Gallbladder

25. Pseudo Gallbladder Disappear after ingestion of water

26. Obstruction at Ampulla

27. Irregular Uptake in Liver-I

28. Metastatic Deposits in Liver-II

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

30. The End Thank for Your Attention !