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Gastrointestinal

System Nuclear
Medicine
Par t 3

Hepatobiliary Imaging
Physiology

◆ Hepatic cells secrete about 1 liter of bile per


day. Bilirubin is the final degradation
product of porphyrin metabolism, and its
principal source is the catabolism of
hemoglobin. Bilirubin is extracted from the
plasma by the hepatocyte, conjugated with
glucuronic acid, and excreted into the bile
canuliculi.
◆ Conjugated hyperbilirubinemia usually
indicates the presence of biliary
obstruction. Common bile duct flow is
solely passive, but the cystic duct may
function as a variable resistor that
actively regulates flow into and out of the
gallbladder.
◆ The biliary canals permit the passage of
bile from the liver to the duodenum.The
right and left hepatic ducts join at the
porta hepatis to form the common
hepatic duct,which in turn combines with
the cystic duct to form the common bile
duct .This is 10-15cm long, and is joined
at its distal end by the main pancreatic
duct;
◆ They enter the wall of the duodenum at
the ampulla of Vater.. The gall- bladder
is attached to the inferior surface of the
liver. It is usually about 10cm in length
and 3-5cm in diameter .It serves as a
reservoir of bile and renders it more
concentrated .It connects with bile biliary
tree through the cystic duct.
肝 脏 解 剖
后 位
胆 胆

道 道

系 系

统 统
Principle
The hepatic parenchymal (polygonal)
cells constitute 85% of the hepatic
mass. Their function can be studied by
radiotracers such as Tc-99m labelled
iminodiacetic acid (IDA) or its
derivatives which are selectively
extracted by the liver polygonal cells
and excreted into the bile.
◆ Biliary imaging has become the procedure
of choice in evaluating patients with
suspected acute cholecystitis because in
virtually all cases of acute cholecystitis
there is obstruction of the cystic duct with
no passage of radionuclide into the
gallbladder.
◆ The test can also be used to detect
enterogastric reflux of bile and neonatal
biliary atresia as well as to assess biliary
kinetics (gallbladder ejection fraction) in
suspected chronic cholecystitis.
Indications:
◆ 1. Diagnosis of acute cholecystitis and
differentiate between acute cholecytitis
and pancreatitis
◆ 2. Diagnosis of biliary atresia,
◆ 3.Demonstration of patency of cystic and
common bile duct whenever oral or
intravenous cholecystograms are not
applicable.
◆ 4. Demonstration of improvement of
bile flow after relieve of obstruction,
◆ 5. Demonstration of complete obstructive
jaundice.
◆ 6.Work-up of patients with biliary
dyskinesis.
◆ 7. Study of bile reflux, postoperative
gastroduodenal reflux.
Radiopharmaceuticals

◆ A variety of radiopharmaceuticals have been


synthetized with the specific aim of imaging the
biliary system.An important advance was
achieved in the early 1970s with the
introduction of compounds which reach high
concentration in bile and are produced by
standard 99mTc-lablling techniques of the
99mTe -lablled compounds,
◆ Theiminodiacetic acid derivatives are
the most promising and also the
most widely used. They fulfil basic
requirements for hepatobiiary
radiopharmaceuticals, their molecular
weight varies from 300 to 1000.
◆ and all compounds are organic
anions,bind to serum albumin,and
usually contain two ring structures in
opposite planes in the molecule.They are
responsible for chelation with 99mTe on the
one end and biliary excretion
properties on the other end of the
molecule.
◆ The commonly 99mTe-iminodiacetic(IDA)
derivatives used for hepatohiliary
imaging are:
◆ 99mTe -HIDA, 99mTe -EHIDA, 99mTe
-DISIDA . They are transported to the
liver bound to albumin and are actively
taken up by the hepatocytes following the
same anionic pathway as bilirubin.
◆ HIDA: 85% excreted by the liver, 15%
by the kidneys
◆ Good visualization at bilirubin levels of
5-7 mg/dl
Patient Preparation
◆ The patient should fast for 4 hours
before the study commences but not more
than 12 hours
◆ The patient should fast and not eat within
4 hours of the study as the ingestion of
food may result in gallbladder contraction
and consequently a false positive
diagnosis ;
◆ If the patient has fasted for more than
12 hours or has not eaten in many
days then HIDA may have delayed
filling of gallbladder because it is
filled with bile.
Acquisition Parameters.
◆ Imaging can be performed in either of 2
ways:
◆ 1.Sequential statics: After injection the
patient then take 3 minute anterior images at
5 min,l5min,20 min,30 min,40 min,50 min. and
60 min intervals. If the gallbladder has delayed
filling then arrange for the patient to have a
meal and reimage 3 hours later and see if the
gallbladder has filled.
◆ 2. Continuous acquisition:
◆ If you use the continuous acquisition
method then the patient is positioned
under the gamma camera and the computer
acquisition is set up to erect for a dynamic
phase (frames/min for 60mins).The patient is
asked to lay down in the supine position.
Normal Imaging

◆ After intravenous administration of 99mTe


-HIDA:
There is rapid uptake of the tracer by the
liver. Then 99mTc-HIDA passes from the liver
towards the porta hepatis and hepatic ducts.
The common bile duct and cystic duct become
visible and the gallbladder normally fills ( or
seen) within 30 minutes after injection.
◆ At this time the loops of the duodenum
are seen. Clearance of the activity from
the liver starts within 10-15 minutes
and is only just visible at the end of the
study.
◆ And that means that the tracer pass
out of the liver.
◆ The gallbladder is still visible at 60
minutes post injection and it should
be cleared from the liver.
Clinical Usage
1.Acute cholecystitis

◆ Cholelithiasis is the formation of


stones in the biliary tree and is a
relatively common disease . If the
stone become s wedged in the cystic
duct , this can cause acute
cholecystitis.
◆ A confident diagnosis of acute
cholecystitis can be made with a
clinical picture of acute upper
abdominal pain associated with fever,
an acutely tender and usually palpable
gall bladder, and transient jaundice.
◆ In more difficult cases investigation
is required, and 99mTc-labelled
hepatobiliary pharmaceuticals have been
shown to have a place in the diagnosis,
and the test is a very easy , harmless ,
high sensitivity and high specificity
method.
◆A silent gallbladder, especially
persistent non visualization at 4
hours post injection is virtually
diagnosis of acute cholecystitis.

◆ The reason is that the gallbladder is unable
to concentrate activity when the cystic
duct is inflamed and obstructed . the
sensitivity of 99mTc- IDE
cholescintigraphy in making this
determination exceeds 95%, and the
specificity approaches 99 %, leading to
an overall accuracy of > 97% in the
acute situation..
2. Chronic cholecystitis
◆ Delayed visualization between 1-4 hours in a
patient with normal liver function is a reliable
sign of chronic cholecystitis
◆ Although delayed visualization of the
gallbladder beyond 1 hour postinjection occurs
most commonly in patients with chronic
cholecystitis, the role of 99mTc-IDA imaging in
diagnosing chronic cholecystistis is limited for
many reasons.
◆ The majority of patients with chronic
cholecystitis exhibit normal visualization of the
gallbladder (85-90%). Delayed visualization of
the gallbladder ( Between 1 to 4 hours of the
exam) is considered fairly characteristic for
chronic cholecystitis when seen, but delayed
visualization can also be seen in a very small
number of patients with acute cholecystitis
(3.5%).
◆ The longer the delay in visualization , the
higher the correlation with chronic cholecystitis.
Visualization of bowel activity prior to
visualization of the gallbladder is a non-
sensitive, but rather specific finding in patients
with chronic cholecystitis (In most normals, the
gallbladder is seen before bowel activity). This
sign indicates chronic cholecystitis about 75% of
the time.
3. Jaundice
◆ In jaundiced patients it is important
to distinguish between intrahepatic
(nonobstructive) and extrahepatic(obstructive)
cholestasis which are treated medically and
surgically respectively. In specific instances,
biliary scintigraphy may be useful in cases of
acute common bile duct obstruction when
functional stasis is detectable before dilation,
and occasionally even before liver function
tests become abnormal.
◆ Extrahepatic bile duct obstruction causes
an increase in the ductal hydrostatic pressure
until the point where further hepatocyte
excretion is no longer possible. In acute
common bile duct obstruction (0 to 24 hours)
there is generally prompt hepatic uptake of the
tracer without visualization of the biliary tree
and no gastrointestinal activity (unless
obstruction is partial).
◆ Hepatic function remains normal during
this early period. Between 24 and 96
hours, there is a mild to moderate
decrease in hepatic function. Beyond 96
hours, there is very poor hepatic
uptake and the scintigraphic
findings are difficult to distinguish
from hepatitis.
◆ If the bile ducts are visualized, tracer
activity within a normal common duct
should be less on a 2 hour image, than on a
1.5 hour image. If ductal activity is
unchanged or more intense on later
images, some degree of obstruction is likely
present. Intrahepatic cholestasis can
produce a pattern identical to complete
CBD obstruction.
4. Biliary Atresia:
In biliary atresia there is usually normal
prompt clearence of tracer from the blood and
normal hepatic concentration with a high liver
to heart ratio at 5 minutes. Subsequently,
there is NO EXCRETION from the liver (non-
visualization of the biliary tree and bowel).
5. Neonatal hepatitis
◆ Depending on the severity of cholestasis
and hepatocellular dysfunction, different
scan patterns may be noted. Typically,
patients with neonatal hepatitis will
demonstrate poor hepatic uptake (due to
hepatocellular dysfunction) of the tracer
with poor biliary excretion, delayed transit
into the bowel, and renal excretion..
6. Biliary leakage

◆ 99mTc- IDA provides a sensitive


means of identifying, localizing, and
permitting serial evaluation of biliary
leaks. After surgery, the preferential
route of bile flow can be traced ,
◆ whether through a surgical anastomosis
or into a abnorma1 collection,without
introduction of nonphysiologic
artifacts from pressure injection
through catheters or risk of infection and
other complications.
◆ The scintigraphic finding diagnostic for a
bile leak is extravasation of tracer
activity into the peritoneal cavity. Up to 50% of
bile leaks can be missed, however, if delayed images
(at 4 hours) are not performed. Delayed images are
helpful because the bile leak activity will frequently
intensify over time. Most bile leaks will be detected
in 4 to 6 hours, but rarely a leak may not be
identified until 24 hours after injection. Therefore,
24 hour delayed images should be obtained
7. Choledochal cysts

◆ The typical cholescintigraphic appearance


is a photon-deficient mass in the region of
the porta hepatis and it can fills on delayed
images (2- 4 hours post injection).

◆ Cho1edocha1 cysts are caused by
irregular development of the sphincter
of oddi and the junction of the
pancreatic and common bile ducts,
which permit the reflux of pancreatic
juice into the common bile duct to
result in inflammation, fibrosis,
obstruction and consequent dilation.
Normal Imaging
Acute cholecystitis
Acute cholecystitis
Chronic cholecystitis
Intrahepatic Obstuction
Extrahepatic Obstuction
Cholestasis
Neonatal Hepatitis Syndrome
Cystic Duct Obstruction
Cystic Duct Cyst
Sketch Map
Bile Leak
Class is over , let’s
go home!!!