NucMedNet Online Physicians’ Guide

Hepatobiliary Imaging
Clinical Synopsis

Robert E. Henkin, MD, FACNP, FACR, Editor

INTRODUCTION Clinically, ultrasound is often the first diagnostic test em-

Biliary tract disease occurs in approximately 20 million ployed. When gallstones are identified or dilatation of
Americans each year. As a result of this disease, ap- the common duct is noted, the diagnosis is considered to
proximately 15 million patients will develop obstruction be made. CT has an accuracy similar to ultrasound.
of the cystic duct. These patients may present with signs When one examines the specificity of these exami-
of epigastric or right-upper-quadrant pain, fever, and nau- nations, the nuclear medicine study has the highest value.
sea. Various blood tests may be abnormal in this group The specificity of ultrasound examinations is variously
as well. While the classical appearance of biliary tract reported as 60% to 64%. The specificity quoted in the
disease is well known, there are a number of other enti- literature for nuclear medicine hepatobiliary studies is 93%
ties that mimic this disease process. Heart disease, pneu- to 96%. The positive predictive value of the nuclear
monia, renal colic, and intestinal obstruction may present medicine examination is as high as 90% in some series.
with a similar symptom complex. For ultrasound examinations, in the
As with all clinical evalua- “When one examines the specificity same patient population, only a
tions, a complete history and 40% to 50% positive predictive
of these [CT, nuclear medicine, and
physical examination will permit value is reported. The negative
the exclusion of a number of the ultrasound] examinations, the predictive value of nuclear medi-
alternative diagnoses. Over the nuclear medicine study has the cine studies has been reported to
years, various laboratory and im- highest values.” be as high as 99%.
aging tests have been devised to
assist the clinician in separating those patients with bil- PATIENT PREPARATION
iary tract disease from those with other diseases. Ultra- Patient preparation involves keeping the patient in a fast-
sound studies of the gallbladder, computed tomography ing state for at least 4 to 8 hours prior to the study. Be-
(CT), and conventional x-rays have all been employed to ginning a study too soon after feeding may result in a
make a diagnosis in this patient group. With this array of false negative study since the gallbladder may recently
examinations available, many physicians make an arbi- have emptied and is not filling at the time of the study.
trary choice as to which technique they will employ. There Patients who have not eaten for more than 48 hours may
are significant differences between diagnostic ultrasound, also have a false negative study. The gallbladder, when
CT, and nuclear medicine examinations with regard to put at rest by fasting for 48 or more hours, may not be
the accuracy in various biliary tract conditions. visualized on the study. Hyperalimentation patients may
also have nonvisualization of the gallbladder. Some au-
COMPARISON OF DIAGNOSTIC TESTS thors have recommended the use of a CCK analog to
Nuclear medicine examinations are considered to have force the gallbladder to empty completely and then refill.
the highest sensitivity, in excess of 95%. In the same In some cases this may be of benefit.
patient population with gallbladder disease, ultrasonogra- There are a group of patients who have fasted for a
phy has a reported sensitivity of 80%. One of the fac- prolonged period in whom the gallbladder does not fill
tors that may lead to the use of ultrasound instead of the spontaneously. In this group of patients the use of intra-
nuclear examination, despite its increased sensitivity, is venous morphine may lead to gallbladder filling. Mor-
that ultrasound can image other abdominal organs as well. phine causes spasm of the sphincter of Oddi. This re-
sults in an increase in back pressure throughout the duct
system from the spasm and forces bile into the cystic
duct. This maneuver is generally performed at 15 to 30
minutes post injection so that sufficient activity remains
in the liver to fill the gallbladder. The use of morphine in
patients who do not have gallbladder visualization reduces
the false positive study rate. If the patient is unable to
receive morphine, repeated images should be performed
for at least four hours post injection. Failure to visualize
the gallbladder by four hours is considered evidence of
cystic duct obstruction in patients with otherwise normal
liver function. Fig 1. Normal nuclear medicine biliary tract study at 15
to 20 minutes post injection. IHBD–intrahepatic bile
THE NORMAL STUDY duct;GB–gallbladder; CBD–common bile duct.
Normal nuclear medicine biliary tract studies demonstrate
the gallbladder and common duct by 30 to 60 minutes to that he or she had noted previously, the test is consid-
post injection. Ideally, activity should be identified in the ered to be positive. In addition to the clinical observation,
GI track within one hour of the intravenous administra- a computation is performed to measure the gallbladder
tion of the radiopharmaceutical. (Figure 1) Between 1 ejection fraction.
and 2 hours post injection normal patients will show es- In a normal patient, greater than 50% of the
sentially complete emptying of the liver. Retained activ- gallbladder’s contents will be ejected by 15 minutes after
ity in the liver beyond two hours suggests hepatic dys- CCK injection. In those patients who fail to eject 40% or
function. Diseases such as hepatitis and cholestasis may more of its contents after CCK, it is highly likely that they
present with retained activity in the liver. When the dis- will benefit from surgery (Figure 2).
ease process is moderate to mild, further delayed imag- Ejection fractions between 40% and 50% are indetermi-
ing may demonstrate the gallbladder and duct system. nate. However, if the clinical symptoms were replicated
At times, imaging as late as 24 hours may be required. and the ejection fraction is below 50%, there is high prob-
ability the patient will benefit from a cholecystectomy.
NONOBSTRUCTIVE BILIARY TRACT DISEASE The literature has demonstrated that as high as an 80%
While the nuclear medicine hepatobiliary study is highly to 90% success rate is achieved in patients with positive
accurate at determining acute cholecystitis, it is often CCK nuclear studies.
used to evaluate a different patient group. Some pa-
tients present with right-upper-quadrant pain that mimics
the symptoms of gallbladder disease. However, the ul-
trasound and x-ray examinations reveal no evidence of
gallstones in these patients. This entity has been vari-
ously dubbed acalculous cholecystitis or biliary dyskine-
sia. This is felt to represent an end organ defect with
regard to CCK response. The surgical literature con-
tains patient outcome data that shows when a blind chole-
cystectomy is performed, only 50% of these patients ex-
perience relief of symptoms.
In order to evaluate this patient population an
interventional hepatobiliary tract study is performed. Once
the gallbladder is clearly visualized, the patient is given a
small dose, .02 to .04 micrograms per kilogram, of CCK.
The nuclear scan continues after the injection. The pa- Fig 2. Abnormal gallbladder ejection fraction after
tient is observed for replication of the clinical symptoms. CCK analog administration. This patient should
If the patient experiences abdominal discomfort similar benefit from surgery.
BILE LEAKAGE Patients with biliary
Patients who have experienced blunt abdominal trauma dyskinesia are routinely
or who may have undergone recent abdominal surgery identified by a CCK-aug-
mented nuclear scan. A
can develop bile leaks. Such leaks are clinically devas-
higher percentage of pa-
tating. Often, surgical inspection of the abdomen can- tients with biliary dyski-
not accurately localize the leak. One of the applications nesia will benefit from
of hepatobiliary imaging is the detection of such leaks. surgery if they are se-
Because the radiopharmaceutical administered mimics lected using the
the bile pathway, it is excreted in the bile. By continu- ç hepatobiliary scan crite-
ous imaging post injection, the site of leakage can be ria. Patients with sus-
identified (Figure 3). Correlation with anatomic imag- pected bile leaks or fistu-
ing modalities, such as ultrasound or CT, is suggested to las may have the site of
identify the location of the gallbladder. leakage localized by the
nuclear study. Nuclear
Fig 4. Patient with a fistula hepatobiliary studies are
between the gallbladder and available in virtually any
colon. (Arrow–colon) hospital offering acute
care services.

Fig 3. Automobile accident victim who suffered
a hepatic laceration. Postop he developed bile
peritonitis. Note the leakage of bile from the
laceration site in the dome of the right lobe.
In some patients spontaneous or postoperative fistu-
las from the gallbladder may result. Hepatobiliary imaging
may be used in this population to demonstrate the precise
site of communication. The information obtained is used to
plan the corrective surgical procedure (Figure 4).
SUMMARY
Hepatobiliary imaging is a highly accurate nuclear medi-
cine technique for vizualizing the gallbladder and bile duct
system. Clinically, the ultrasound examination is usually
the first procedure employed in evaluating the gallblad-
der. However, inconclusive ultrasound examinations
should be followed by a nuclear medicine study.
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