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The incidence of gallstones and gallbladder sludge is higher in patients after total gastrectomy than in general population. Formation of gallstones after gastrectomy is multifactorial. Here, we investigate the changes in gallbladder and biliary tract functions by cholescintygraphy and monitored changes in cholecystokinin (CCK) release in long-term survivors after total gastrectomy for gastric carcinoma.Patients had undergone total gastrectomy for gastric carcinoma at least five years ago. The final study population consisted of 25 patients.Eight patients had undergone cholecystectomy before or at the time of gastrectomy. Gallstone formation was observed in seven of the remaining 17 patients during follow-up (41%). Maximum uptake of radioactivity and gallbladder maximum uptake was significantly delayed in the gastrectomy group than in the control group. There was no significant difference in CCK levels after the overnight fasting and at 60 minutes after stimulation among patients with or without stones in situ compared with healthy volunteers, but 30 minutes after the energy-rich drink patients had higher CCK levels than the control group.In gastrectomy patients, technetium isotope visualisation of the gallbladder and time for maximum activity was significantly delayed. This may indicate impaired gallbladder function. On the contrary, CCK release was not impaired.

To determine if the minimum administered radiopharmaceutical activity for hepatobiliary scintigraphy can be reduced while preserving diagnostic image quality using enhanced planar processing (EPP).A total of 40 infants between 10 and 270 days old (body mass 2.2 - 6.5 kg) had hepatobiliary scintigraphy during the period 2004 - 2010 following the intravenous administration of either (99m)Tc-mebrofenin (18 patients) or (99m)Tc-disofenin (22 patients). Due to the small size of these patients, they all received the minimum administered activity of 18.5 MBq consistent with the North American Consensus Guidelines. Six nuclear medicine physicians subjectively graded the acceptability of the image quality for clinical interpretation using a four-point scale (not acceptable, fair, good, excellent). Each physician independently graded seven image sets including the original study (full activity) and simulated reduced activity studies using binomial subsampling (50% of full activity, 25% of full activity and activity reduced by weight), with and without EPP.For full-activity studies, 98% were deemed acceptable by the six physicians for clinical interpretation. The percentages of acceptable 50% reduced activity studies with and without EPP were not significantly different from the percentage of acceptable full-activity studies (P = 0.193 and P = 0.998, respectively). The percentage of acceptable 25% reduced activity studies without EPP was significantly different from the percentage of acceptable full-activity studies (P0.001); however, this difference vanished when EPP was applied (P = 0.482). The activity reduced by weight ranged from 1.85 to 4.81 MBq (10% to 26% of full dose) and the percentages of acceptable studies with and without EPP were significantly different from the percentage of acceptable full-activity studies (P0.001 and P = 0.02, respectively).Clinically interpretable hepatobiliary scintigraphy images can be obtained in infants when the minimum administered activity is substantially reduced. Without EPP, clinically acceptable images may be produced with a reduction of 50%, and with EPP, a reduction of 75% or more may be possible.

Obesity is associated with nonalcoholic fatty liver disease (NAFLD), which is improved by bariatric surgery. Hepatobiliary scintigraphy with 99m.-Tc diisopropylacetanilido iminodiacetic acid (99mTc-DISIDA) has proved to be highly effective for the assessment of bile flow, representing an indirect measurement of hepatocyte and cholangiocyte function. The objective of this study was to assess the effects of Roux-en-Y gastric bypass (RYGB) on bile flow in obese subjects by hepatobiliary scintigraphy. This study was conducted in a public university hospital in Brazil. Twenty obese patients and five nonobese patients (with no hepatic or biliary disease) were studied. The obese patients were submitted to anthropometric evaluation and biochemical exams when they arrived at the service, during the immediate preoperative period and 3, 6, and 12 months after surgery. They were also submitted to abdominal ultrasound and hepatobiliary scintigraphy with 99mTc-DISIDA during the preoperative period and 12 months after RYGB. Tmax (time of maximum marker uptake) and T1/2 (half time between peak uptake and disappearance of the marker) were determined and compared between obese patients and controls, before and after surgery. The results were compared to those obtained with an intraoperative liver biopsy. A weight loss of 12.2 ± 4.3 % was observed during preparation for surgery, and a loss of 30.4 ± 5.6 % was observed 1 year after RYGB. Ultrasound hepatic analysis revealed some degree of NAFLD in the operated patients. Obese patients showed a prolonged T1/2 compared to control, with a reduction to normal levels after RYGB. We concluded that NAFLD compromises bile excretion, a process that can be reversed by treatment with RYGB.

We present a case study of a 56-y-old man who was admitted with acute abdominal pain and was found to have retroperitoneal hematoma from a ruptured duodenal aneurysm. 99mTc-diisopropyliminodiacetic acid cholescintigraphy showed incidental absent transit of radiotracer into the distal duodenum and severe enterogastric reflux, thought to be secondary to duodenal obstruction from the hematoma. Findings were confirmed on esophagogastroduodenoscopy, and the patient improved after subsequent gastrojejunostomy.

Background & Aims Portal vein ligation (PVL) is increasingly employed prior to major hepatectomy in order to enhance the volume of the future liver remnant (FLR) and to avoid post-hepatectomy liver failure. The efficacy of PVL on subjects with non-alcohol fatty liver disease (NAFLD) is largely unknown. Methods Sprague–Dawley rats fed with normal diet (control) and methionine-choline deficient diet (MCD) were used. The animals underwent PVL and were sacrificed at indicated time points. Results Livers from MCD rats exhibited a decreased BrdU and Ki-67 labelling index, and an increased apoptotic index after PVL compared to normal rats; as a net effect, MCD rats exhibited a decrease in their restituted liver mass and redistributed volume ratio, compared to normal rats. Normal rats displayed similar serum levels of ICG15-R before and after PVL; whereas MCD rats displayed reduced ICG15-R after PVL. Using 99m Tc-DISIDA scintigraphy examination, livers from MCD rats exhibited decreased HEF and prolonged TE 1/2 of FLR after PVL, indicating deteriorating hepatocyte function despite the shift in volume. The basal level of plasma TNFα, IL-1α, IL-1β, and IL-10 of MCD rats was significantly increased before PVL compared to normal rats; however their plasma level did not increase in response to PVL as in normal rats. Hepatic adiponectin mRNA surged in MCD rats after PVL, whereas its receptors, AdipoR1 and AdipoR2, were paradoxically down-regulated. PPARα, a down-stream molecule of AdipoR2 axis, was also decreased in MCD rats. Conclusions Reduced regenerated liver mass and deteriorated hepatocyte function of the FLR from steatotic rats after PVL may be associated with deranged Kupffer cell-mediated cytokine expression and disrupted adiponectin signalling.

HBS is used in the management of liver transplantation, a significant complication of which is biliary stricture. Strictures may be intraparenchymal within segments and main duct (non-anastomotic) or at the biliary-enteric anastomosis (anastomotic). Strictures are definitively diagnosed, and often managed, by PTC. This is invasive, technically challenging, and requires general anesthesia in young children. HBS may allow early detection of these complications and is non-invasive. The aim of this study was to review the scintigraphic pattern of biliary strictures using 99mTcDISIDA HBS following pediatric orthotopic liver transplantation, and to assess its role in the diagnostic algorithm of suspected biliary strictures. All available hepatobiliary studies performed post-transplant in 101 episodes of liver transplantation in 92 pediatric patients were reviewed. Twenty-three (23%) patients had known biliary strictures. Twenty-two patients had adequate studies available for review; five had intrahepatic (non-anastomotic) strictures alone, nine had a stricture of the anastomosis alone, and eight had both intrahepatic and anastomotic strictures. HBS patterns (either segmental or global changes) correlated very highly with clinically significant biliary strictures. All patients with known strictures had abnormal HBS; hence, in patients with abnormal liver function tests post-liver transplant, a normal HBS makes strictures very unlikely. We propose that HBS can thus be used to determine if further investigation is required.

Background and Aims Biliary complications are common after liver transplantation. This study sought to assess the value of hepatic iminodiacetic acid (HIDA) scans (hepatobiliary iminodiacetic acid scan) to detect early posttransplantation biliary complications. Methods From April 2003 to June 2006, 34 liver transplantations (recipients of mean ± SD age of 43.0 ± 15.7 years) were performed in 25 (73.5%) males from 20 (58.8%) cadaveric donors and 14 (41.2%) living-related donors. The subjects underwent HIDA scans using a single head gamma camera Meridian (Philips) after intravenous (IV) administration of 185 MBq Tc-99m Disofenin. The mean time ± SD posttransplantation to HIDA scan was 14.6 ± 18.2 days (range, 0–74). The results were compared with endoscopic retrograde cholangio pancreatography, magnetic resonant cholangiopancreatography, percutaneous cholangiograhy, and/or liver biopsy. Results Twenty-four abnormalities were detected by HIDA scan in 16 patients (47.1%): 10 (29.4%) biliary leaks; 4 (11.4%) biliary obstruction or cholestasis; 1 (2.9%) delayed uptake; 5 (14.7%) delayed blood pool clearance; and 8 (23.5%) delayed transit to the bowel. The complications were more common among living-donor compared with deceased-donor graft recipients, albeit a not statistically significant difference (P = .066). Total and direct bilirubin levels were significantly higher in patients with abnormal than normal HIDA scans (P = .011 and P = .040, respectively). The sensitivity and specificity of HIDA scans to detect overall postoperative complications were 100% and 66.7%, respectively. Biliary leak results were false positives in 7/10 patients, and true in 3. Detection of obstruction was 75% sensitive by HIDA. Conclusion HIDA scans are a noninvasive, reliable modality for early exclusion of posttransplantation biliary complications. However, correlation with clinical status and imaging modalities is essential to confirm detected abnormalities.

Patients with upper abdominal pain, nausea, and vomiting are often evaluated with ultrasound to diagnose symptomatic cholelithiasis or cholecystitis. With a normal ultrasound, a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. The purpose of this study was to evaluate whether the HIDA scan with EF was appropriately utilized in considering cholecystectomy. Over 18 months, we performed 1533 HIDA scans with EF. After exclusion, 1501 were analyzable, 438 of whom underwent laparoscopic cholecystectomy. Patients were divided into two groups: those with typical and atypical symptoms of biliary colic. Our primary endpoint was symptom resolution of those who underwent laparoscopic cholecystectomy. Symptom resolution was assessed by chart review of postop visits or readmissions. In patients with typical symptoms, resolution occurred in 66 per cent of patients with positive HIDA and 77 per cent with negative HIDA (P = 0.292). In patients with atypical symptoms, resolution occurred in 64 per cent of patients with positive HIDA and 43 per cent with negative HIDA (P = 0.013). A HIDA scan with EF was not useful in patients with typical symptoms of biliary colic and negative ultrasounds, and should not be used to make a decision for cholecystectomy. However, this test can be helpful in patients with atypical symptoms, as it does predict symptom improvement in this group.

The aim of this study was to determine whether hepatobiliary scintigraphy using (99m)technetium based di-isopropryl-imino-diacetic acid correlated to clinical or laboratory status of patients with primary sclerosing cholangitis (PSC). We carried out a retrospective case-control study involving 15 patients with proven PSC. Fifty-seven hepatobiliary scintigraphic studies were reviewed by consensus of two experienced observers using a semiquantitative scheme to score liver size and degree of radiopharmaceutical uptake, intrahepatic or extrahepatic biliary stasis, segmental liver clearance half-times and gall bladder visualization. The results were compared with age; disease duration; weight loss; serum bilirubin, alkaline phosphatase and albumin levels; antipyrine clearance; number of biliary stents and episodes of cholangitis and history of transplantation. Sixteen age-matched and sex-matched individuals with PSC, who did not undergo hepatobiliary scans, were selected for comparison. Among the scintigraphic variables, right lateral and superior liver clearance half-time values showed a significant linear correlation with disease duration and serum alkaline phosphatase levels (P < 0.05) but not with other clinical or biochemical indices. Other scintigraphic variables showed no correlation. An abnormal, hepatobiliary scan liver clearance half-time in patients with PSC correlates to disease duration and increased serum alkaline phosphatase levels, and this variable may be used to identify some subjects with more advanced disease.

Purpose: To compare three-dimensional sonography (3D US) with quantitative cholescintigraphy for assessing gallbladder contractility. Methods: Gallbladder radioactivity was assessed in 35 patients with suspected gallbladder disease using a gamma camera 5, 30, 60, and 90 minutes after technetium 99m (Tc-99m) DISIDA injection and 30 and 60 minutes after ingestion of a high-fat meal. Immediate gallbladder images were obtained via 3D US. Gallbladder radioactivity at 120 minutes after injection of Tc-99m DISIDA was defined as 100%, and gallbladder contractility was calculated. Gallbladder volume on 3D US was calculated using a dedicated software. Pearson correlation analysis and simple linear regression analysis were used. Results: The mean gallbladder volume on 3D US was 25.3 ml after fasting and 6.6 ml after a high-fat meal. The mean gallbladder contractility index was 77.7% on cholescintigraphy (range, 18–99) and 73.4 on 3D US (range, 16.7–97.3). A linear correlation between cholescintigraphy and 3D US contractility indices was observed. The r value on Pearson analysis was 0.92 and R2 of the coefficient of determination was 0.85. The difference in measured contractility between the 2 methods ranged from +21.5% to −15.0% (mean ± SD, 4.4 ± 8.7%). Conclusions: 3D US is a reliable and easy method for clinical measurement of the volume of the gallbladder and its contractility. © 2006 Wiley Periodicals, Inc. J Clin Ultrasound 34:123–127, 2006

A 43-year-old man, previously submitted to right hepatectomy, right hepatic artery chemoembolization, and surgical resection of liver lesions, with well-differentiated and moderately differentiated hepatocellular carcinoma (HCC) confirmed by histopathology, underwent cholescintigraphy with Tc diisopropyliminodiacetic acid (Tc-DISIDA) due to recurrent cholangitis. The scintigraphic images and the coregistered CT images showed radiotracer uptake in an area of biliary ectasia near the hepatic surface (which may be associated with recurrent cholangitis), in a hepatic nodule, and in multiple pulmonary metastases.

Undifferentiated (embryonal) sarcoma of the liver (USL) is a rare malignant mesenchymal tumor principally affecting patients of pediatric age. Bronchobiliary fistula is a very rare complication in patients with liver tumor. To the authors' knowledge, this is the first report of a bronchobiliary fistula resulting from tumor invasion in a child with liver sarcoma. A 12-year-old boy was diagnosed to have USL of the right liver lobe, invading the diaphragm. An extended right hepatectomy and total resection of the mass was performed, leaving patchy tumoral invasion of the anterior diaphragmatic surface followed by combined chemotherapy regimen. Six months after the operation, the presence of bilious sputum suggested a bronchobiliary fistula, which was confirmed by hepatobiliary scintigraphy. The patient underwent a right thoracotomy and fistula division. Although bronchobiliary fistula is a very rare complication in patients with hepatic tumors, suspicion in the appropriate clinical setting is necessary to recognize this problem. Hepatobiliary scintigraphy is the useful diagnostic procedure to define bronchobiliary fistula in children with liver tumor and clinical suspicion of bronchobiliary fistula.

Biliary diversion procedures are performed during gastric surgery to decrease bile reflux. A 1-day dual-radionuclide examination was studied to determine its potential in the evaluation of the effectiveness of the Braun enteroenterostomy in reducing bile reflux and its effects on gastric emptying. Orally ingested gallium 67–labeled egg and intravenously administered technetium 99m diisopropyl-imino-diacetic acid were imaged simultaneously. This provided a way to depict both bile reflux and gastric emptying on the same day in patients who underwent gastric surgery. Overall, the Braun enteroenterostomy trades bile reflux, a symptomatic and premalignant disease, for gastroparesis, a less severe and often treatable disease. © RSNA, 2003

The purpose of this study is to evaluate the influence of kibble shape and fiber content of commercial dry foods on gastric emptying in healthy cats. Eight healthy cats were used to evaluate four different diets which varied in shape of kibble (round versus triangle) or fiber content (low versus high). Diets were labeled with 99mTc-mebrofenin and gastric emptying was evaluated with nuclear scintigraphy. There was a significant difference between the kibble shapes at both T50 and T20. The triangle shaped kibble required significantly longer time than the round kibble to reach T50 (P = 0.02) and T20 (P = 0.001). Diet fiber content did not have a significant influence on T50, and T20. The influence of caloric and water intake was assessed with division of cats into high, medium, and low intake groups. The caloric intake had its main effect at T50 with the lowest quartile of caloric intake requiring significantly less time to reach T50 than the middle group and upper quartile (P = 0.05). Water intake did not have a significant effect on gastric emptying in this study. There was no relationship or correlation between the surface area of the food (cm2/kg) and T90, T50, and T20.

Interferon (IFN) provides effective treatment in some patients with chronic hepatitis. The clarification of factors predictive of therapy response would be helpful in identifying patients who would benefit from treatment. In this study, we evaluated the potential utility of Tc-99m sulfur colloid liver/spleen and Tc-99m-disofenin hepatobiliary scintigraphy to predict therapy response to IFN in patientswith chronic active hepatitis. The study group consisted of ten patients with chronic viral hepatitis B who were treated with 4.5 units of interferon alpha for 12 months. Prior to the start of the therapy, sulfur colloid scintigraphy was obtained by which the liver/spleen ratios were derived. Hepatobiliary scintigraphy was performed on a separate day and time-activity curves were generated from regions of interest drawn over the liver, heart and gall-bladder. The index of blood and liver clearance time was calculated. Histological grading and laboratory values were obtained for clinical correlation. Responders (n = 6) to IFN were defined as those who improved clinically with normalized transaminase levels and had HBeAg seroconversion. On SC scintigraphy, the liver/spleen ratio of non-responders was significantly lower than responders (median values: 0.69 vs. 1.16, p = 0.01) but on hepatobiliary scintigraphy no statistically significant parameters were found to predict response to interferon therapy.

Opioid-mediated contraction of the distal common bile duct (CBD) may delay tracer passage during nuclear hepatobiliary imaging (NHI), mimicking pathologic obstruction. We sought to determine if opioid administration before NHI delays CBD visualization and prolongs imaging. The records of 198 Emergency Department patients who underwent NHI were reviewed (after excluding those with evidence for pathologic CBD obstruction). Opioids were administered before NHI in 56 cases. Delayed CBD visualization occurred in 28.6% of subjects who had received opioids and in 12.0% of those who had not (p < 0.01). Delayed imaging was performed in 77.8% of those who had received opioids and in 53.5% of those who had not (p < 0.01). The relative risk of delayed CBD visualization was 1.46 [95%CI 0.65-3.28] for meperidine, 4.18 [95%CI 2.00-8.82] for morphine, and 2.38 [95%CI 1.29-4.39] for any opioid. We conclude that opioids given before NHI are associated with delayed CBD visualization and more imaging sessions.

We describe a 41-year-old man with a 1-week history of nausea and vomiting 1 month after chemoembolization of a liver metastasis. The patient subsequently became febrile and developed right upper quadrant abdominal and midback pain. Findings of initial laboratory and imaging studies (a noncontrast computed tomographic [CT] scan and ultrasound) were not remarkable. Hepatobiliary scintigraphy, performed to rule out cholecystitis, revealed an abnormal area in the right lobe of the liver consistent with a focal bile leak into an abscess cavity. The patient was subsequently treated for liver abscess. In conclusion, hepatobiliary scintigraphy should be considered as a first-line test in the work-up of patients whenever a postchemoembolization complication is considered likely.

We propose a new method to help physicians assess, using a hepatobiliary iminodiacetic acid scan image, whether or not there is bile reflux into the stomach. The degree of bile reflux is an important index for clinical diagnosis of stomach diseases. The proposed method applies image-processing technology combined with a hydrodynamic model to determine the extent of bile reflux or whether the duodenum is also folded above the stomach. This condition in 2D dynamic images suggests that bile refluxes into the stomach, when endoscopy shows no bile reflux. In this study, we used optical flow to analyze images from Tc99m-diisopropyl iminodiacetic acid cholescintigraphy (Tc99m-DISIDA) to ascertain the direction and velocity of bile passing through the pylorus. In clinical diagnoses, single photon emission computed tomography (SPECT) is the main clinical tool for evaluating functional images of hepatobiliary metabolism. Computed tomography (CT) shows anatomical images of the external contours of the stomach, liver, and biliary extent. By exploiting the functional fusion of the two kinds of medical image, physicians can obtain a more accurate diagnosis. We accordingly reconstructed 3D images from SPECT and CT to help physicians choose which cross sections to fuse with software and to help them more accurately diagnose the extent and quantity of bile reflux. We used optical flow to ascertain the direction and velocity of bile flow to help physicians diagnose bile reflux exact.We combined image processing technology and hydrodynamic models to quantify bile reflux.We reconstructed 3D images from SPECT and CT to help physicians diagnosis.

The purpose of this study was to determine the efficacy of CT to predict the development of bile leaks in hepatic trauma. This HIPAA-compliant retrospective study was IRB approved and consent was waived. All patients who sustained hepatic trauma between January 1, 2006, and January 31, 2012, and who underwent CT and hepatobiliary scans during the same hospital admission were included. One hundred and thirty-two patients met the inclusion criteria. Comparison between the presence of biliary injury relative to American Association for the Surgery of Trauma (AAST) hepatic injury grade and mean distance of the hepatic laceration to the inferior vena cava (IVC) was made. The ability of free fluid to predict bile injury was analyzed. Forty-one (31 %) of the 132 patients had positive hepatobiliary scans. Of these 41 patients, seven (17 %) sustained low-grade and 34 (83 %) sustained high-grade hepatic injury compared with the 37 (41 %) low-grade and 54 (59 %) high-grade hepatic injuries in the negative hepatobiliary scan group. The mean distance to the IVC was 2.4 cm (SD 2.9 cm) and 3.6 cm (SD 3.3 cm) in patients with and without bile leaks, respectively. A statistically significant difference in the proportion of high-grade injuries and the mean distance from the IVC between the two groups was identified. The presence of free fluid on CT is sensitive, but not specific, for detecting a bile leak. CT findings, including AAST liver injury grade and location of the liver laceration, are able to predict which patients are at risk for developing bile leaks as seen on hepatobiliary scintigraphy, whereas the presence of free fluid is not.

Hepatobiliary scintigraphy is an established method for the diagnosis of a bile leak from the biliary system. A bile leak should be considered in any patient after cholecystectomy who has unexplained abdominal pain after operation. Three patients with bile leak diagnosed by scintigraphy are described, one of whom had an unusual pattern of hepatic subcapsular collection of the bile. The second patient had a bile leak through the postsurgical drainage tube, whereas the third patient had a more typical pattern of leakage into the peritoneal cavity.

BACKGROUND Endoscopic biliary manometry is useful in the assessment of patients with types II and III sphincter of Oddi dysfunction, but it is time consuming and invasive. AIM To investigate the role of 99m Tc-DISIDA scanning, with and without morphine provocation, as a non-invasive investigation in these patients compared with endoscopic biliary manometry. SUBJECTS AND METHODS A total of 34 patients with a clinical diagnosis of type II (n=21) or III (n=13) sphincter of Oddi dysfunction were studied. Biliary scintigraphy with 100 MBq of 99m Tc-DISIDA was carried out with and without morphine provocation (0.04 mg/kg intravenously) and time/activity curves were compared with the results of subsequent endoscopic biliary manometry. RESULTS Eighteen (nine type II, nine type III) of the 34 (53%) patients had sphincter of Oddi basal pressures above the upper limit of normal (40 mm Hg). In the standard DISIDA scan without morphine, no significant differences were observed in time to maximal activity (Tmax) or percentage excretion at 45 or 60 minutes between those with normal and those with abnormal biliary manometry. However, following morphine provocation, median percentage excretion at 60 minutes was 4.9% in those with abnormal manometry and 28.2% in the normal manometry group (p=0.002). Using a cut off value of 15% excretion at 60 minutes, the sensitivity for detecting elevated sphincter of Oddi basal pressure by the morphine augmented DISIDA scan was 83% and specificity was 81%. Also, 14 of the 18 patients with abnormal manometry complained of biliary-type pain after morphine infusion compared with only two of 16 patients in the normal manometry group (p=0.001). CONCLUSIONS 99m Tc-DISIDA with morphine provocation is a useful non-invasive investigation for types II and III sphincter of Oddi dysfunction to detect those with elevated sphincter basal pressures who may respond to endoscopic sphincterotomy.

Clinically significant changes in hepatic haemodynamics accompany the development of portal hypertension, hepatocellular carcinoma, liver metastases and liver cirrhoses, and after major liver resection. Hepatic blood flow parameters, such as hepatic arterial flow (HAF), hepatic portal flow (HPF), total hepatic blood flow (THBF) and hepatic perfusion index (HPI), are useful adjuncts to the diagnosis of liver pathology, the evaluation of disease progress and prognostication. Here, we describe a non-invasive method that combines the measurement of these parameters in a single study in real time. Red blood cells from eight pigs were labelled with 99Tc(m) using an in-vitro method and re-injected into the pigs. Data acquisition over the heart, lungs, liver and kidneys was started immediately and a blood sample was obtained 15 min post-injection. Hepatic arterial flow was determined from the ratio of the maximum gradients between the integrated time-activity curve of the left ventricle and the first-pass time-activity curve of the liver before the peak of the kidneys time-activity curve. The hepatic perfusion index was determined by comparing the slope of the liver time-activity curve before and after the kidney peak. Hepatic portal flow was determined from the hepatic arterial flow and the hepatic perfusion index, and total hepatic blood flow was determined as the sum of arterial and portal flow. The results were compared against those obtained from a clearance method using 99Tc(m)-DISIDA. The average hepatic perfusion index was 0.38, and the average hepatic arterial flow and hepatic portal flow were 168.3 +/- 52.9 and 274.6 +/- 60.1 ml x min(-1) respectively. The average total hepatic blood flow was 442.8 +/- 53.5 ml x min(-1), while the total hepatic flow determined by 99Tc(m)-DISIDA clearance was 419.7 +/- 62.6 ml x min(-1). No significant difference in total hepatic blood flow was found between the two methods. The results of this study show that it is possible to obtain all hepatic haemodynamics data in a single study using a non-invasive method.

Transabdominal duplex Doppler ultrasonography (TDDU) is commonly used for measuring hepatic blood flow (HBF) in clinical practice. Flow velocity and the cross-sectional area (CSA) of vessels are obtained separately and used to compute blood flow. Respiration and changes in portal pressure are known to cause variations in the CSA of the portal vein, but the impact of these parameters on TDDU measurement of portal blood flow is unclear. Eight Yorkshire pigs (20.7–25.1 kg) were used for the study. TDDU determination of portal blood flow was carried out using CSA of the portal vein obtained at inspiration (maximal) and at expiration (minimal) for computation, and the differences obtained were compared. Determination of HBF was carried out simultaneously on the same animals using diisopropyliminodiacetic acid (DISIDA) clearance. A physiological increase in portal pressure was then created by 50% hepatectomy and TDDU measurement similarly carried out on the second postoperative day. Computing portal blood flow in the intact liver using maximal and minimal CSA gave rise to a mean difference of 7.0 ml kg−1 min−1 (P < 0.001). A significant correlation was obtained between HBF and portal flow computed from maximal CSA (Pearson's correlation = 0.85, P < 0.033). The respiratory index of the portal vein (maximal CSA/minimal CSA) decreased from 1.5 to 1.2 after hepatectomy, which also caused a 90% increase in portal pressure. Respiration and portal pressure thus significantly impact on TDDU determination of HBF, and in this porcine model, computation using maximal CSA more accurately reflects HBF.

Gastric emptying in 18 healthy cats was assessed simultaneously using scintigraphy and barium-impregnated polyethylene spheres (BIPS®). Canned Prescription Diet(r) Feline c/d(r) (Hill's Pet Nutrition, Inc., Topeka, KS) labeled with 99mTc-disofenin (Hepatolite, DuPont Merck Pharmaceutical Co., Billerica, Mass.) was fed on four separate days, Scintigraphic images were obtained at time 0 and then every 30 minutes to 6 hours. On the fourth scan day, 30 small (1.5 mm) and 10 large (5 mm) BIPS® (Chemstock Animal Health Ltd., Christchnrch, New Zealand) were mixed with the labeled meal, and in addition to scintigraphy, radiographs were made at 60-minute intervals for 6 hours. Gastric emptying was 11 to 15% slower on the day of simultaneous radiography as compared with the 3 days when only scintigraphy was performed (p≤ .05). Percentage retention of 1.5 mm BIPS® in the stomach was significantly greater than the percentage retained gastric activity at hours 1, 2, 3, 4, 5, and 6 (p≤ .05).BIPS® were clustered in the pyloric region of the stomach by 3 hours in all cats. In 10/18 animals, all BIPS® were retained in pyloric region of the stomach at 6 hours, despite observable decreased size of the gastric silhouette and ≤15% retained gastric activity. In conclusion, gastric emptying of 1.5-mm BIPS® does not parallel gastric emptying of 99mTc-disofenin labeled canned Prescription Diet(r) Feline c/d(r). Stress associated with radiography may delay gastric emptying. Diet type should be considered when evaluating clinical radiographic studies where BIPS® have been used.

Hepatobiliary scintigraphy evaluates the biliary clearance of Tc-99m-labeled iminodiacetic acid agents (Tc-99m IDA) and has a high sensitivity and specificity for the diagnosis of acute cholecystitis. False-negative studies are extremely rare. We describe an apparently normal nonmorphine-augmented hepatobiliary study in gangrenous acalculous cholecystitis. Based on clinical findings, computed tomography, and ultrasound demonstration of a dilated gallbladder, a cholecystectomy was performed. Pathologic examination of the gallbladder revealed acute gangrenous cholecystitis with culture positive for Klebsiella pneumoniae.

Our purpose was to identify clinical or radiologic features predictive of response to percutaneous cholecystostomy performed for the treatment of acute cholecystitis.The clinical records and radiologic images of patients who underwent percutaneous cholecystostomy for suspected acute cholecystitis between January 1987 and July 1994 were retrospectively reviewed. A response to percutaneous cholecystostomy was defined as an improvement in clinical symptoms and signs or reduction in fever and WBC to normal within 72 hr of percutaneous cholecystostomy. The number and type of radiologic investigations were reviewed by two radiologists. The presence of gallstones, gallbladder wall thickening, distention, and pericholecystic fluid was recorded. The clinical and radiologic findings were analyzed for their relationship to response to percutaneous cholecystostomy.Sixty-one percutaneous cholecystostomies were performed in 37 male and 24 female patients and were technically successful in 59. Thirty-one patients had gallstones, 28 did not. Thirty-one patients were in the intensive care unit, and 15 were ventilated. Complications occurred in six (10%): misplacement of the percutaneous cholecystostomy catheter in the colon (one), exacerbation of sepsis (three), and bile leakage (two). The mortality rate was 2%--one of the patients with septic shock succumbed to a cardiac arrest 3 days after the procedure. Forty-three patients (73%) responded to percutaneous cholecystostomy. Patients with gallstones and symptoms and signs localized to the right upper quadrant of the abdomen were more likely to respond (p = .006). The only individual radiologic feature predictive of a positive response was the presence of pericholecystic fluid in patients with gallstones (p = .03). The presence of all four radiologic findings was also associated with a positive response (p = .039). The results of bile cultures were not predictive of response. Of the 16 nonresponders, six had documented biliary sepsis and cholecystitis.Clinical symptoms and signs referable to the gallbladder, the presence of pericholecystic fluid in patients with gallstones, and the presence of an increasing number of radiologic findings in any one patient are predictive of a positive response to percutaneous cholecystostomy.

The functional nature of nuclear medicine procedures makes them especially valuable in the management of patients undergoing intensive care. However, the severe nature of the patient's condition invariably prevents him or her from attending the nuclear medicine department for diagnostic investigations. We have piloted a bedside nuclear medicine service using a four-probe detector system linked to an IBM computer with curve processing software. Protocols for a range of radionuclide probe investigations, including renal, hepatobiliary, gastric outflow and lung vascular permeability, using 99 Tc m and 111 In radiopharmaceuticals have been established. The measurement of lung vascular permeability in patients with clinical symptoms of adult respiratory distress syndrome was considered to be a valuable procedure on the intensive care unit. Due to the poor availability of 113 In m , which had previously been used for the measurement of lung permeability, we used a technique based on in vivo labelling of serum transferrin with ll1 In-chloride together with 99 Tc m -red blood cells for the calculation of the plasma protein accumulation index. Other procedures include the measurement of gastric outflow in patients previously on parenteral feeding, and the assessment of hepatobiliary and renal function. The equipment proved to be reliable and convenient for use at the bedside, although ultrasound imaging was essential for the correct positioning of the probe detectors over smaller organs such as the kidneys and the gallbladder. The high sensitivity of the probe detectors required only low administered amounts of activity, minimizing radiation protection measures for patients and staff. The administration of radiopharmaceuticals via indwelling lines and tubes presented particular problems and we recommend that parenteral injections should not be given through manifold giving sets, or via Teflon cannulae.

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.

Nuclear medicine can provide useful data when monitoring the organ function of patients undergoing intensive care. Test procedures involve the administration of radiopharmaceuticals and external monitoring using gamma cameras or nuclear probes. The radiopharmaceuticals required may be given at lower doses than normally used in routine nuclear medicine imaging, are ideally available 24 h a day and are preferably administered via indwelling cannulae and giving sets. Three radiopharmaceuticals have been studied; a renal function agent, a hepatobiliary function agent and a product used for in vivo labelling of protein for lung permeability studies. Under conditions of storage, dilution and passage through giving sets (simulating conditions found during administration in the intensive care setting), some instability can be demonstrated in each product, which could result in the tests giving rise to wrong or misleading data. It is recommended that radiopharmaceuticals are not diluted excessively, and that where possible, parenterally-administered products are given by direct intravenous injection and not through giving sets.

Hepatobiliary scintigraphy using iminodiacetic (IDA) radiopharmaceuticals provides clinically useful information on the function of the biliary tract in a variety of pathological processes in children, including neonatal jaundice, gallbladder dysfunction, trauma, and liver transplantation. Phenobarbital premedication (5 mg/kg per day for a minimum of 5 days in divided doses) is used in infants who are being examined for neonatal jaundice to increase the accuracy of 99mTc-IDA scintigraphy in differentiating extrahepatic biliary atresia from neonatal hepatitis. Biliary atresia can be ruled out in an infant if a patent biliary tree is shown with passage of activity into the bowel. If no radiopharmaceutical is noted in the bowel on imaging up to 24 hours, distinction between severe hepatocellular disease and biliary atresia cannot be made. The literature reports 91% accuracy, 97% sensitivity, and 82% specificity for hepatobiliary imaging in the diagnosis of biliary atresia. The impairment of both intrahepatic and extrahepatic biliary drainage is an important cause of liver disease in cystic fibrosis. Hepatobiliary scintigraphy in cystic fibrosis has shown characteristic patterns of dilatation of mainly the left hepatic duct, narrowing of the distal common bile duct, gallbladder dysfunction, and delayed bowel transit. Cholecystitis in children may be acalculous. Sensitivity and specificity for the scintigraphic diagnosis of acute acalculous cholecystitis is reported to range from 68% to 93% and 38% to 93%, respectively. Cholescintigraphy in a suspected bile leak provides information generally not available with other techniques, except for direct cholangiography. If the amount of intraperitoneal accumulation of the tracer is greater than that entering the gastrointestinal tract, surgery is usually indicated. Hepatobiliary imaging in children who have undergone liver transplantation will assess graft vascularity, parenchymal function, biliary drainage, presence of a leak, and obstruction.

Drug related false-positive hepatobiliary imaging is uncommon. The authors present a case of a 54-year-old woman who was treated with intravenous ceftriaxone for bacterial meningitis. Symptoms of acute cholecystitis subsequently developed and a sonogram revealed a gallstone. A Tc-99m DISIDA hepatobiliary study was positive for cystic duct obstruction. After discontinuation of ceftriaxone, the patient's clinical condition improved and, 2 weeks later, a repeat hepatobiliary scan was normal. High doses of ceftriaxone and prolonged administration may lead to formation of pseudocholelithiasis and signs of acute cholecystitis. Although this condition is usually benign and reversible, discontinuation of the drug is warranted when symptoms of acute cholecystitis are accompanied by a positive hepatobiliary scan.

The partition coefficients (log P) of theoretically possible alkyliodinated iminodiacetic acid (IDA) derivatives and commercial IDA derivatives were calculated using two computer programs: ChemSketch Log P and ChemOffice Ultra. Newly synthesized ligands (DIETHYLIODIDA and DIISOPROPYLIODIDA) with the highest calculated log P were labeled with technetium-99m. The biodistribution and the influence of bilirubin on their biokinetics were investigated in rats and compared to corresponding results for commercial Tc-99m-BROMIDA. Log P of Tc-99m-complexes of synthesized ligands were determined experimentally as well as the protein binding. In comparison to Tc-99m-BROMIDA, Tc-99m-DIETHYLIODIDA has: (a) better biliary excretion (2.76 +/- 0.15%ID/g versus 1.83 +/- 0.10%ID/g); (b) faster hepatic clearance (2.90 +/- 0.21%ID/g versus 7.47 +/- 0.70%ID/g) and decreased biliary excretion (for 14% versus 22%) in conditions of hyperbilirubinemia after 15 min. It is proved that Tc-99m-DIISOPROPYLIODIDA has a prolonged hepatic transit time and decreased biliary excretion. (c) 2012 Elsevier Ltd. All rights reserved.

Cholescintigraphy was performed after pharmacological manipulation in 60 patients with a clinical suspicion of acute cholecystitis and non-visualization of the gallbladder 1 h after 99Tcm-DISIDA cholescintigraphy. Thirty patients received an intravenous (i.v.) injection of morphine sulphate (group I) and the other 30 patients an i.v. injection of CCK (group II). The sensitivity, specificity, positive predictive value and negative predictive value were 94, 100, 100 and 93% in group I and 100, 84, 79 and 100% in group II, respectively. There was a significant difference between groups (P < 0.05). In conclusion, morphine-augmented cholescintigraphy could supply more reliable diagnostic information and is less time-consuming in patients with a clinical suspicion of acute cholecystitis.

Classically, the "rim sign" has been described throughout the hepatobiliary scan. The authors present a case of a late rim sign visualized at 25 minutes postinjection that proved to be acute upon chronic acalculous cholecystitis without gangrene.

To evaluate the efficacy of ultrasonographically (US)-guided percutaneous cholecystocholangiography (PCC) for early diagnosis and characterization of biliary atresia in infants with cholestatic liver disease.Institutional review board approval was obtained for this study. Parental informed written consent was obtained. From October 2003 to August 2010, 22 infants (12 male, 10 female; age range, 1-138 days) were referred to the radiology department for PCC. Indications for PCC were suspected biliary atresia at 24-hour delayed technetium 99m-diisopropyl-phenylcarbamoylmethyl-iminodiacetic acid (DISIDA) scintigraphy because no excretion was observed in the small bowel (n = 17) or when the results of the scan or liver biopsy could not be obtained within 3 days because of a delay in schedule (n = 5). A diagnosis of biliary atresia was excluded when there was contrast material visualized in the gallbladder, biliary system, and passage to the duodenum. Patients with biliary atresia underwent surgery as the reference standard.Among the 18 patients who underwent successful PCC, biliary atresia was excluded in 13, with diagnoses as follows: total parenteral nutrition-associated cholestasis (TPNAC) (n = 6), neonatal hepatitis (n = 4), congenital syphilis (n = 1), neonatal lupus (n = 1), and congenital cytomegalovirus hepatitis (n = 1). Biliary atresia was diagnosed in five patients (four with type IIIb and one with type IIIa) and was confirmed at surgery. In four infants in whom US-guided gallbladder puncture had failed, biliary atresia (n = 2) and TPNAC (n = 2) were diagnosed.PCC is a safe and useful technique for early exclusion when biliary atresia cannot be ruled out after traditional screening tests; in addition, it may be useful for preoperative type determination of biliary atresia. © RSNA, 2011.

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.

Laparoscopic cholecystectomy is widely accepted as an alternative to traditional open cholecystectomy. Its advantages are a shorter hospital stay, earlier return to normal activity, less pain, and improved cosmetic results. However, in the initial experience with this technique, biliary leaks were several times more frequent than in traditional cholecystectomy. Four cases of scintigraphic detection of biliary leaks after laparoscopic cholecystectomy are described. The results of the examination are compared in two cases with endoscopic retrograde cholangiography and in the remaining two with intraoperative findings. Hepatobiliary scintigraphy is suggested for early evaluation of postoperative complications involving the biliary system.

Background and objectives Reflux is one of the most common sequela after proximal gastrectomy (PG). The aim of this study was to find a predicting factor related to the character of esophageal reflux after PG. Methods Wireless ambulatory 24-hr pH monitoring (for acid reflux, AR) and diisopropyliminodiacetic acid hepatobiliary scan (for bile reflux, BR) were performed on 24 patients who had reflux symptoms after PG with esophagogastrostomy from July 2008 to March 2009. Endoscopic examination was done and the length of remnant stomach (LoRS) was measure by postoperative UGI series. Results Eleven patients (45.8%) had only BR, 7 (29.2%) had AR only, Two patients (8.3%) had both acid and BR, and 3 (12.5%) had neither. The LoRS along greater curvature was significantly shorter in patients with only BR (16.11 ± 2.87 cm) than in patients with only AR (23.69 ± 6.15 cm, P = 0.003). Severity of symptoms or esophagitis was not significantly correlated with the content of acid or BR. Conclusion Reflux symptom after PG is caused by either bile or acid rather than both. Character of reflux was related to the LoRS. J. Surg. Oncol. 2010; 101:626–633. © 2010 Wiley-Liss, Inc.

Technetium 99m-labeled diisopropyliminodiacetic (acid [99mTc]DISIDA) has been used extensively in the evaluation of hepatobiliary diseases. As a result of investigation into transport mechanisms of [99mTc]DISIDA, we undertook to determine precise concentrations of this compound in the standard clinical formulation. Calculations based on published formulas were used. These take into account column efficiency, the time since the previous elution of 99mTc from the 99Mo column, and the total quantity of 99mTc eluted. Primary cultures of rat hepatocytes were used to evaluate the transport of Na99mTcO4 and the 99mTc-labeled DISIDA monomer. Pertechnetate was not taken up by the hepatocytes, the amount of [99mTc]DISIDa taken up was not dependent on the concentration of DISIDA but rather on the concentration of technetium, when the DISIDA/99mTc ratio was varied in the culture medium. We conclude that calculation of the total technetium concentration is necessary to determine the amount of compound taken up by the liver, and to interpret kinetic studies of hepatocellular transport mechanisms.

One hundred and four adult patients with cystic fibrosis were evaluated for the presence of liver disease as defined by abnormal liver function tests of six months' duration, histological evidence of fibrosis or cirrhosis, or the presence of portal hypertension, or both. Twenty patients fulfilled these criteria and were evaluated further for the presence of biliary tract abnormalities with biliary scintigraphy using 99Tc diisopropylphenyl-carboxymethyl iminodiacetic acid (DISIDA) and endoscopic retrograde cholangiography. Clearance of 99Tc DISIDA from the liver and biliary tree was diminished at 45 (E45) and 60 (E60) minutes in the patients with liver disease compared with those without liver disease; E45 = 37.8% and 65.8%, p less than 0.01; E60 = 48.2% and 77.5%, p less than 0.01 respectively. Serial analogue images of the extrahepatic biliary tree were consistent with common bile duct obstruction with retention of DISIDA and tapering of the common bile duct in seven of 18 patients with and two of 10 patients without liver disease. Endoscopic retrograde cholangiography showed changes consistent with sclerosing cholangitis, with beading and stricturing of the intrahepatic ducts in 12 of the 14 patients. In all 14 patients, including those in whom biliary scintigraphy had suggested obstruction, no abnormality of the common bile duct was identified. These results indicate that abnormalities of the bile ducts in patients with cystic fibrosis related liver disease are confined to the intrahepatic biliary tree and that common bile duct strictures do not contribute to either the progression or development of liver disease in these patients.

We studied the size of the liver graft and the host liver in six consecutive patients undergoing auxiliary heterotopic liver transplantation for chronic endstage liver disease. In all cases, a liver reduced in size by left lateral hepatectomy was inserted. The sizes of the graft and host liver were estimated by planimetry of two-dimensional di-isopropyl iminodiacetic acid scintigrams taken 3, 7, 21, 90 and 180 days after surgery. Graft size increased from a mean of 12.2 cm2 (95% confidence interval = 10.2 to 14.1) on day 3 to a maximum of 14.8 cm2 (95% confidence interval = 13.4 to 16.1) on day 21 and remained stable thereafter; in contrast, the host liver decreased in size from 9.6 cm2 (95% confidence interval = 6.8 to 12.3) on day 3 to 3.9 cm2 (95% confidence interval = 3.0 to 4.8) at mo 6. We conclude that in patients with chronic liver failure, an auxiliary allograft reduced in size and placed adjacent to the host liver shows regenerative growth within 3 wk, whereas the host liver atrophies in 3 to 6 mo. (HEPATOLOGY 1992;15:54-57).

The hepato-enteric distribution of 99Tcm-labelled DISIDA and the hepato-splenic distribution of 99Tcm-labelled phytate were studied in controls and in mice with carbon tetrachloride-induced acute liver damage. The test group animals showed a diminished excretion of DISIDA to intestine with retention of this tracer in the liver and an increased splenic uptake of phytate. No changes in the hepatic uptake of phytate were found. The joint evaluation of both tracers in the study of diffuse liver disease is discussed.

Previous results from tests on a limited number of patients suggested that the combination of relatively normal hepatocyte clearance, prolonged parenchymal transit time, and eventual passage of radiotracer into the intestine or gallbladder without evidence of biliary tract dilatation were relatively specific for intrahepatic cholestasis. We reevaluated the specificity of cholescintigraphy for the diagnosis of intrahepatic cholestasis in an unselected group of patients from a general hospital. Sixteen patients had the cholescintigraphic findings of intrahepatic cholestasis and an established diagnosis of biliary tract dilatation or nondilatation by ultrasound, ERCP, or intraoperative cholangiography. Using 6 mm as the upper limits of normal for the diameter of the common hepatic duct by ultrasonography resulted in a specificity of 63% (10 correct out of 16); using 6 mm plus 1 mm for for every decade over 60 years of age gave a specificity of 75% (12 correct out of 16); and using the more liberal criterion of 8 mm as the upper limits of normal increased the specificity to 81% (13 out of 16). The data suggest that cholescintigraphy alone is unreliable in differentiating intrahepatic cholestasis from extrahepatic obstruction, even when the obstruction is partial and radiotracer eventually passes through the extrahepatic biliary tract.

A 17-year-old girl presented with right upper quadrant pain and was found to have a subhepatic cyst by ultrasound and CT. A DISIDA scan showed prompt filling of both the gallbladder and a very dilated common bile duct consistent with a choledochal cyst. Following intravenous administration of cholecystokinin, there was immediate emptying of the gallbladder into the cyst. Quantitative cholecystokinin cholescintigraphy may be a useful adjunct in the differentiation of choledochal cyst from gallbladder activity.

The authors assessed the influence of cholecystokinin (CCK), administered before cholescintigraphy, on the biliary-to-bowel transit time (BBTT) of technetium-99m disofenin. Fourteen healthy volunteers underwent two separate cholescintigraphic studies with and without CCK treatment. BBTT was less than 1 hour in all 14 studies of subjects not treated with CCK. In 14 subjects treated with CCK, there was no tracer activity in the bowel up to 2 hours in seven (50%) (P = .006). Eighty-three cholescintigrams obtained in patients with suspected acute cholecystitis were also retrospectively analyzed. In 53 of 83 patients in whom the gallbladder was visualized within 1 hour, significantly delayed BBTT was found in 14 of 29 (48%) who received CCK, compared with the BBTT in one of 24 patients (4%) who did not receive CCK (P less than .001). In the 30 patients in whom the gallbladder was never visualized (n = 28) or was visualized after 1 hour (n = 2), BBTT was less than 30 minutes, regardless of whether patients were treated with CCK. Results show that CCK treatment causes significantly delayed BBTT in many cases, and this finding should not be interpreted as abnormal.

Rotor syndrome is a rare, benign familial disorder characterized by chronic fluctuating, nonhemolytic and predominantly conjugated hyperbilirubinemia with normal hepatic histology. In contrast to Dubin-Johnson syndrome, there is no liver pigmentation in Rotor syndrome. A 36-year-old man was admitted due to asymptomatic persistent jaundice. His siblings had jaundice with direct hyperbilirubinemia. Physical examination revealed icteric sclerae without hepatosplenomegaly. Laboratory findings showed increased serum bilirubin with direct bilirubinemia. Hepatic uptake and storage capacity of indocyanine green was markedly reduced, while excretion into bile was slightly suppressed. Markedly decreased hepatic uptake and poor visualization of the gallbladder and biliary tract were shown in 99mTc-DISIDA scan. Histology of the liver showed mild steatosis without pigmentation. We report a case with the review of literature.

Spinal cord injury (SCI) is associated with increased prevalence of gallstones and acute acalculous cholecystitis. A possible explanation for the increased prevalence of gallstones in SCI patients is decreased gallbladder motility causing gallbladder stasis. In this study, we investigated gallbladder function in patients with SCI.Eighteen normal controls, 16 trauma controls and 46 SCI patients were included in this study. Gallbladder function was measured by technium 99m-labeled imino-diacetic acid analogue ((99)Tc(m)-DISIDA) hepatobiliary imaging and represented by filling fraction (FF) and ejection fraction (EF). The data from SCI patients were analyzed according to old versus young, female versus male, heavy versus light body weight, ASIA AB versus ASIA CD classification, high- versus low-level injury, and long versus short injury duration.Fifty-two percent of SCI patients had abnormal FF and 59% had abnormal EF. Significantly decreased FF and EF values were found in SCI patients, especially in female patients with severe and high-level injuries.Quantitative (99)Tc(m)-DISIDA cholescintigraphy showed that SCI can significantly impair gallbladder function.

Bile leakage into the thoracic cavity is a rare complication of invasive cancer. A 12-year-old boy was diagnosed with undifferentiated sarcoma of the right lobe of the liver invading the diaphragm. An extended right hepatectomy and total resection of the mass was performed, leaving a patchy tumoral invasion at the anterior diaphragmatic surface. Surgery was followed with a combined chemotherapy regimen. In the sixth postoperative month, he was readmitted with bilious expectoration. Tc-99m mebrofenin hepatobiliary scintigraphy revealed radiotracer accumulation in the right hemithorax. Bile leakage into the right thoracic cavity was diagnosed based on the hepatobiliary scintigraphic findings. For this patient; hepatobiliary scintigraphy, which is routinely used to visualize the liver and biliary tree, provided a noninvasive mean for the precise diagnosis of a bronchobiliary fistula. The fistula was then confirmed and corrected with surgery. The patient recovered uneventfully.

We discuss the diagnostic value of nuclear scintigraphy in the management of infections after cochlear implantation. A 56-year-old female (Case 1) and a 46-year-old female (Case 2) developed complaints of diffuse headache, 4 and 5 months after cochlear implantation, without other signs of infection during examination, laboratorial testing and initial computed tomography. In Case 1 we performed a technetium 99 m-difosfate scintigraphy, which showed an increased uptake in the right petrosal bone, suggestive of chronic osteomyelitis. This case failed conservative treatment and underwent complete explantation, after which 67gallium-citrate single-photon emission computed tomography normalized during follow-up. In Case 2 inflammation at the site of the cochlear implant was confirmed by performing a positron emission tomography scan, which showed an increased uptake. Case 2 was treated successfully with antibiotics. Both have no signs of recurrent infection. Nuclear scintigraphy can be the single valuable tool in case of a late low-grade infection after cochlear implantation. Delayed low-grade chronic osteomyelitis of the petrosal bone is a rare but dramatic complication after cochlear implantation. It can develop with minimal signs of infection.