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

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

4. 11/26/2001  Performed with a variety of compounds that share the common imminodiacetate moiety Hepatobiliary Imaging

5. 11/26/2001 Structures of DISIDA  Blue color: A polar component (the diacetate)  Red: A lipophilic component

6. 11/26/2001  HIDA Little used today  DISIDA Imaging the gall bladder better when liver function is poor Structures of DISIDA

7. 11/26/2001  The lipophilic component : binding to hepatocyte receptors for bilirubin  Transported through the same pathways as bilirubin, except for conjugation Pathways of DISIDA

8. 11/26/2001 IDA-chelated Tc-99m  A magnification of two imminodiacetate compounds  Polar components chelated a Tc-99m molecule

9. 11/26/2001 Indications  Acute cholecystitis  Chronic cholecystitis  Bile leakage  Biliary atresia

10. 11/26/2001 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

11. 11/26/2001 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.

12. 11/26/2001 Normal Study

13. 11/26/2001 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

14. 11/26/2001 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

15. 11/26/2001 Non-Visualization of Gallbladder

16. 11/26/2001 Non-Visualization of Gallbladder Negative study– after injection of morphine

17. 11/26/2001 Re-injected DISIDA & Morphine

18. 11/26/2001 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

19. 11/26/2001 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

20. 11/26/2001 Reflux into Stomach

21. 11/26/2001 Radioactivity in Left Subphrenic Space-I

22. 11/26/2001 Bile Leak Post-cholecystectomy-II

23. 11/26/2001 No Excretion from Liver  No excretion up to 6 hours  This pattern is commonly seen in Ascending cholangitis Pancreatitis Hepatitis

24. 11/26/2001 Pseudo Gallbladder Radionuclide in C-loop of the Duodenum

25. 11/26/2001 Pseudo Gallbladder

26. 11/26/2001 Pseudo Gallbladder Disappear after ingestion of water

27. 11/26/2001 Obstruction at Ampulla

28. 11/26/2001 Irregular Uptake in Liver-I

29. 11/26/2001 Metastatic Deposits in Liver-II

30. 11/26/2001 References  http://www.vh.org/Providers/Lectures/IRO CH/BiliaryNucs/BiliaryNucs.html (Virtual Hospital)  Chapter 38, Hepatobiliary Imaging, Darlene Fink-Bennett, P759-770

31. 11/26/2001 The End Thank for Your Attention !