HEPATOBILIARY IMAGING Presented by Yang Shiow-wen

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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 minutes     for 60 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

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Inject morphine (3-5 milligrams) and continue

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 More intense with time location 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/IRO CH/BiliaryNucs/BiliaryNucs.html (Virtual Hospital)  Chapter 38, Hepatobiliary Imaging, Darlene Fink-Bennett, P759-770

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The End

Thank for Your Attention !

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