Post on 16-Oct-2021
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