MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Hepatobiliary Scintigraphy

Erik Mittra, MD, PhD Stanford University

Division of Nuclear Medicine

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Outline n  What are the studies? n  For each study:

n  Tracer(s) n  Physiology n  Protocol n  Cases

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

What are the studies? n  HIDA scan n  Hemangioma scan n  Liver-spleen scan

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

What are the studies? n  HIDA scan

n  Acute cholecystitis n  Acute acalculous cholecysititis n  Chronic cholecystitis n  Biliary duct obstruction n  Sphincter of Oddi dysfunction n  Biliary atresia n  Postoperative biliary tract (i.e., biliary leak) n  Evaluation of liver lesions

n  Hemangioma scan

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

HIDA Scan

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

HIDA scan n  What is the isotope? n  What is the energy of the isotope? n  What is the half-life? n  What is the tracer?

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

HIDA - Radioisotopes

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Hepatobiliary Physiology

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

HIDA - Protocols n  Acute cholecystitis n  Acute acalculous cholecysititis n  Chronic cholecystitis n  Biliary duct obstruction n  Biliary atresia n  Postoperative biliary tract (i.e., biliary leak) n  Evaluation of liver lesions

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

HIDA – Key principles

n  Should be NPO > 4 hrs but < 24 hrs n  CCK causes gallbladder constriction n  Morphine (and other narcotics) cause Sphincter of

Oddi constriction n  Bilirubin should be < 27

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

HIDA – Normal times

n  Blood pool clearance: 5-10 min n  Gallbladder filling: 10-30 min (max 1 hr) n  Common bile duct filling: 20 min n  Common bile duct T1/2: 60 min n  Transit to small bowel: 60 min n  Transit to large bowel: 3 hrs

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Acute cholecystitis protocol

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Acute cholecystitis protocol Basic outline

CCK?

Administer Choletec

Morphine? Readminister Choletec?

Stop post Morphine

Stop if no Morphine

Hrs -0.5 0 1 2 3

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Acute acalculous cholecystitis protocol

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Acute acalculous cholecystitis protocol

Basic outline

CCK?

Administer Choletec

Morphine? Readminister Choletec?

Stop post Morphine

Stop if no Morphine

Hrs -0.5 0 1 2 3

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Acute acalculous cholecystitis protocol

CCK?

Administer Choletec

CCK? Tc-99m or In-111 WBC?

Administer tagged-WBCs

Re-image if Tc-99m WBC given

Hrs -0.5 0 1 2 3-4 6

Exclusion of false-negative outline

Re-image if In-111 WBC given

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Chronic cholecystitis protocol

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Chronic cholecystitis protocol Basic outline

Pre- treatment?

Administer Choletec

CCK? Morphine??? Readminister Choletec?

Stop post CCK or Morphine

Hrs -0.5 0 1 2

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Biliary obstruction protocol

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Biliary obstruction protocol Basic outline

Administer Choletec

Stop or continue dynamic imaging? CCK or alter pt. position?

Delayed static imaging

Delayed static imaging

Hrs -0.5 0 1 2 24

No CCK!

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Sphincter of Oddi dysfunction protocol

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Sphincter of Oddi dysfunction protocol

Basic outline

Administer Choletec

Stop dynamic imaging

Perform TAC analysis

Hrs -0.5 0 1 2

CCK

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Biliary atresia protocol

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Biliary atresia protocol Basic outline

Administer Choletec

Stop dynamic imaging Delayed static imaging

Hrs - 5 d 0 1 24

Phenobarbital 5mg/kg x 5 days

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Biliary leak protocol

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Biliary leak protocol Basic outline

Administer Choletec

Stop dynamic imaging Delayed static imaging

Hrs -0.5 0 1 2-24

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Evaluation of liver lesions

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Hemangioma scan n  What is the isotope? n  What is the energy of the isotope? n  What is the half-life? n  What is the tracer?

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Hemangioma scan – Key issues n  No preparation n  Sensitivity directly related to size n  SPECT/CT?

n  Size n  Location

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Hemangioma scan protocol

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Hemangioma scan protocol Basic outline

Administer Tc99m-RBCs

Start flow study (1 s/f x 60 sec)

Delayed static planar image, followed by SPECT(CT)

Min 0 1 60-120

Static planar image

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Hemangioma scan protocol

MIPS Stanford University Molecular Imaging Program at Stanford

School of Medicine Department of Radiology

Cases