The 8 Snowmass 2017: PET/CT & Nuclear Medicine in Clinical ...Chronic cholecystitis & functional...

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e 8 th | Snowmass 2017: PET/CT & Nuclear Medicine in Clinical Practice Tuesday, February 21, 2017 Westin Snowmass Resort • Snowmass Village, Colorado Educational Symposia

Transcript of The 8 Snowmass 2017: PET/CT & Nuclear Medicine in Clinical ...Chronic cholecystitis & functional...

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The 8 th | Snowmass 2017:

PET/CT & Nuclear Medicine in Clinical Practice

Tuesday, February 21, 2017Westin Snowmass Resort • Snowmass Village, Colorado

Educational Symposia

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TABLE OF CONTENTSTUESDAY, FEBRUARY 21, 2017

Renal Scintigraphy (Andrew T. Trout, M.D.) .................................................................................................................... 45

State of the Art Hepatobiliary Nuclear Imaging (Pradeep G. Bhambhvani, M.D.) ................................................................ 57

Communicating Risks of Radiation Exposure (Kevin J. Donohoe, M.D.) ............................................................................ 69

Standardized Solid Meal Gastric Emptying Study and Alternatives (Pradeep G. Bhambhvani, M.D.) .................................. 77

Neuroendocrine Imaging (Arif Sheikh, M.D.) ................................................................................................................... 89

SAVE THE DATES - 2018 Winter Symposia

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STATE OF ART NUCLEAR HEPATOBILIARY

IMAGING (HIDA SCAN)

PRADEEP BHAMBHVANI, MD

Associate Professor

Molecular Imaging & Therapeutics,

Department of Radiology

The University of Alabama at Birmingham

February 21, 2017

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Disclosures

  Honorarium from Educational Symposia

Page 3

Outline

  Introduction

  Indications

 Procedure

 CCK and other interventions

 Clinical scenarios and interpretation

  Cholecystitis (acute & chronic)

  Biliary obstruction

  Bile leak

  Biliary atresia

 Conclusion

 References

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Introduction

  Hepatobiliary scintigraphy (HIDA) is a diagnostic

functional imaging test that evaluates hepatocellular

function and the biliary system by tracing the production

of bile from the liver, and its passage through the biliary

system into the small bowel

  HIDA from hepatic IDA (iminodiacetic acid)

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Indications

  Right-upper-quadrant pain variants

  Acute cholecystitis

  Chronic cholecystitis & functional biliary pain syndrome

  Biliary obstruction

  Neonatal jaundice (biliary atresia/neonatal hepatitis)

  Sphincter of oddi dysfunction, choledochal cysts etc.

  Post operative biliary tract

  Bile leak

  Biliary stent patency

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Radiopharmaceuticals

  99mTc-disofenin (DISIDA, 2,6-diisopropylacetanilido

iminodiacetic acid) or

  99mTc-mebrofenin (CHOLETEC, bromo-2, 4,6-

trimethylacetanilido iminodiacetic acid)

  Dose:

 Adults: 111-185 MBq (3-5 mCi) (higher doses in

jaundice)

 Infants & children: 1.8-2.59 MBq/kg (0.05-0.07 mCi/

kg), minimum 18.5 MBq (0.5 mCi)

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Preparation

 Fasting: Minimum 2 hours (preferably 6 hours)

 If fasting >24 hours pre-treat with CCK (to empty GB)

 Fatty meal prior evening (≥10g of fat, to empty GB)

  Hold narcotics for 12-24 hours (4 half lives). Naloxone

reversal an option

  Hold drugs affecting GB contractility: atropine, nifedipine,

indomethacin, octreotide, theophylline, histamine blockers,

progesterone, isoproterenol, benzodiazepines, ETOH,

nicotine

  Gallbladder ejection fraction (GBEF) best done as an

outpatient exam

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Procedure

  Radiopharmaceutical injected IV while patient lies

supine on imaging table.

  NM camera placed anterior to the patient detects

gamma rays emitted to form images. Include drains &

catheters in field of view.

  Cine images are acquired initially for up to 60 minutes.

  Delayed images & interventions may be done to

improve diagnostic certainty.

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Normal HIDA Scan

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Normal HIDA Scan (Alternative view)

RIGHT LATERAL

Page 11 Anterior View

1 2 3 4

5 6 7 8

9 10 11 12

13 14 15

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Page 12 Anterior View

In anterior view the activity in the duodenum often

interferes with activity in the gallbladder region!

Slid

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Tu

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Anterior View

Slide Courtesy of Dr. Mark Tulchinsky Page 14

40o

Left Anterior Oblique view separates GB from duodenal

activity – makes good anatomical sense!

Slide Courtesy of Dr. Mark Tulchinsky

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Anterior View

LAO view separates GB from duodenal

activity – makes good functional

imaging sense!

Slide Courtesy of Dr. Mark Tulchinsky

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Post CCK

2 min/frame

40o LAO Projection

1 2 3 4

5 6 7 8

9 10 11 12

13 14 15

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Interventions

  Suspected acute cholecystitis: GB not seen in the first

hour

  IV Morphine Sulfate (preferred): 0.04 mg/kg or fixed

2 mg dose over 2-3 min or

 Delayed images at 3-4 hours

  Assessment of GBEF

 Fatty Meal: Inconsistent

 CCK (Gold standard)

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Normal GBEF

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GBEF Formula

GBEF(%) =(NetGBcountsmax− NetGBcountsmin)

NetGBcountsmax×100

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Cholecystokinin (CCK, Sincalide, Kinevac®)

  33 amino acid polypeptide made in the proximal small

bowel. Active component is the C-terminal octapeptide

  Can be safely used with gallstones

  Boluses cause abdominal pain and nausea (50%)

  Sincalide: Synthetic analog of the terminal octapeptide

  Dose: 0.02 µg/kg IV infusion in 30-50 ml NS

  Pretreatment (over 30-60 min) if:

  Prolonged fasting (>24h)

  Hyperalimentation

  GBEF (over 60 min)

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CCK Protocols, SNM practice guidelines for hepatobiliary

scintigraphy. J Nucl Med Tech 2010;38:210–218

  a. 0.04, 3, 43±26%, 15-88%, 12.

  b. 0.02, 3, 35±17%, 17-59%, 6.

  c. 0.02, 3, 56±27, 0-100%, 23.

  d. 0.01, 3, 46±20, 12-74%, 20.

  e. 0.01, 10, 76±16, 37-96%, 13.

  f. 0.02, 15, 76±22, 32-98%, 15.

  g. 0.02, 15, 57±29, -2-98, 60.

  h. 0.01, 30, 64±20, 26-95%, 14.

  i. 0.02, 30, 70±22, 17-97%, 23

  j. 0.02, 30, 71±25, 8-99%, 60.

  k. 0.015, 45, 75±12, >40% (95% confidence limits), 40.

  l. 0.01, 60, 68±16, 15-88%, 20.

  m. 0.02, 60, 84±16, 38-100%, 60.

Format: sincalide dose (μg/kg),

time of infusion (min), GBEF

(mean±SD), GBEF range, and

number of normals studied

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Bhambhvani P et al. Variability in cholescintigraphy protocols in hospitals

across the state of Alabama. J Nucl Med 2010; 51 (Supplement 2):597.

Hours NPO 2-4 hrs 4 or more hrs

18 45

Screening for

Opiate Use

No Yes

13 50

CCK Pretreatment if

NPO > 24hrs

No Yes

58 5

GBEF Determination

Method

CCK Fatty Meal Variable

57 5 1

CCK Dose 0.01-.02 µcg/kg > than 0.02 µcg/kg

53 4

Duration of CCK

infusion (5 sites

used a Fatty Meal)

<3 min 3- 5 min >5 but <30

min

30 min

12 3 24 18

Normal GBEF (≥) 30% 35% 40% 50%

6 47 7 3

Evaluation if GB not

seen at 1 hr

2 hr delay 3-4 hr

delay

Morphine

use

Variable

16 35 6 6

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J Nucl Med 2010; 51:277–281

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J Nucl Med 2010; 51:277–281

  60 volunteers (32-F, 28-M); Ages 20-62

  4 Institutions, 15 subjects each

  All got CCK 0.02 µg/kg over 15, 30 and 60 min

  Coefficient of variation: 52%, 35% & 19% for the 15, 30

& 60 min infusion (p<0.0007)

  Normal GBEF (lower end of normal) :

 15 & 30 min: ≥15% & ≥13%

 60 min: ≥38% (least variation & highest EF’s)

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J Nucl Med Technol. 2010 Dec;38(4):210-8.

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Clinical Gastroenterology and Hepatology 2011;9:376–384

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Unavailability of Sincalide: Options

  Generic Sincalide (QC concerns)

  Fatty meals (Normal GBEF)

 Whole milk, 300 mL (≥ 51%)

 Ensure Plus®, 237 mL (≥ 33%)

 Lipomul: Soybean oil emulsion 30 mL (≥ 20%)

Ziessman H, Petry NA. J Nucl Med. 2013 Aug;54(8):17N.

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Acute Cholecystitis

  Most common indication for HIDA

  US is the initial test of choice (sufficient in 80% patients)

  HIDA is more accurate

 Sensitivity 95-98%, specificity 90% (HIDA) versus

70% & 86% (US)

  Detects the pathophysiologic event (GB/CD obstruction)

seen as persistent non-visualization of the GB

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Acute Cholecystitis

  Calculous (90-95%)

  Acalculous (5-10%)

 Elderly

 Critically ill (burns, sepsis, immunosuppressed, DM)

 Postpartum

 Vasculopathy

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Acute Cholecystitis: GB Non-visualization

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Acute Cholecystitis: GB Non-visualization

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Pitfalls

  False Positives

 Chronic cholecystitis

 Prolonged or no fasting

 Poor liver function

 Congenital/surgical absence of GB

  False Negatives

 GB mimics (bowel, diverticulum, cystic duct & rim signs)

 Intermittent GB obstruction

 Acalulous cholecystitis (sensitivity 70-80%)

  Cystic duct is less often obstructed

  CCK challenge & WBC scan

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Cystic Duct Sign

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Rim Sign

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  Recurrent biliary colic with gallstones seen on US &

relieved with cholecystectomy

  If symptoms atypical, HIDA with CCK GBEF very useful.

 Abnormal suggests CCC. Refer for cholecystectomy

 Normal consider other etiologies

Chronic Calculous Cholecystitis (CCC)

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Chronic Cholecystitis: HIDA findings

  1) Delayed GB filling (after 1 hour) with normal biliary to bowel transit

  2) Delayed/disparate GB filling relative to small bowel in the 1st hour

  3) Delayed biliary to bowel transit with normal GB filling

  4) Unusually slow GB filling

  5) Irregular or eccentric GB filling

  6) Faint or very small contracted GB

  7) Band or septa across GB

  8) Photopenic defects in GB

  9) GB non-visualization

  10) Poor response to sincalide (Low GB ejection fraction)

  11) Combinations of the above

  12) Normal hepatobiliary scan with prompt GB and small bowel activity

Chamarthy M, Freeman LM. Hepatobiliary Scan Findings in Chronic Cholecystitis

Clin Nucl Med 2010;35: 244–251

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Chronic Cholecystitis: Low GBEF

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GB non-visualization in an outpatient without acute symptoms:

Chronic Cholecystitis

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Chronic Acalculous Cholecystitis (CAC)

  5-10% of chronic cholecystitis

  CT/US not useful as no gallstones. HIDA has a role

  Synonyms

 Gallbladder/biliary dyskinesia

 Functional gallbladder disorder

 Chronic acalculous gallbladder disease

 Acalculous gallbladder dysfunction

 Gallbladder spasm

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Chronic Acalculous Cholecystitis

  Recurrent biliary colic

  No gallstones

  Low GBEF

  Symptoms improve with cholecystectomy

  Pathology reveals chronic inflammation

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Chronic Acalculous Cholecystitis

  CCK 0.02 mcg/kg over 45 min (EF measured at 60 min)

  103 patients, 21 with GBEF <40%

  11 randomized to cholecystectomy

 10 became asymptomatic

  1 improved

  No surgery group (10) remained symptomatic, 2 had

cholecystectomy with symptom resolution

  12/13 GB had chronic inflammation on histopathology

Yap L et al. Acalculous biliary pain: cholecystectomy alleviates symptoms in

patients with abnormal cholescintigraphy. Gastroenterology 1991;101:786–793.

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Enterogastric Reflux

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High Grade Biliary Obstruction (Persistent Liver Scan)

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Partial Obstruction & Sphincter of Oddi Dysfunction

  Good hepatic uptake, prompt secretion into the biliary

ducts, and gallbladder filling; however, clearance from

the biliary ducts is delayed

  Biliary to bowel transit does not exclude partial

obstruction. Poor clearance from biliary ducts is

characteristic

  CCK infusion can help differentiate from functional

delays (prompt transit after CCK)

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Bile Leak: Post MVA Liver Laceration

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Bile Leak-Post Cholecystectomy: SPECT-CT

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Biliary Atresia

  Progressive, idiopathic, fibro-obliterative disease of the

extrahepatic biliary tree. Presents as neonatal jaundice

  Early diagnosis is critical to prevent irreversible liver failure

  HIDA: Persistent hepatogram and no biliary-to-bowel

transit over 24 hours

  Preparation to prime liver enzymes:

 Phenobarbital: 5mg/kg/d for 3-5d or

 Ursodeoxycholic Acid: 20 mg/kg/d for 2-3d prior

  Treatment:

 Palliative hepatoportoenterostomy (Kasai procedure)

 Often, ultimately, liver transplantation

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Biliary Atresia (Absent Bowel Activity)

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Neonatal Hepatitis (+ Bowel Activity). No Biliary Atresia

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Conclusions

  HIDA is a valuable time tested imaging modality of the

hepatobiliary tract

  Its main advantage over other modalities is that it permits

physiologic imaging of liver function and biliary patency

  Morphine augmented HIDA allows for rapid diagnosis of acute

cholecystitis

  CCK (0.02 µg/kg infusion over 60 min) has the least variability

& may be considered the GBEF method of choice

Page 51

References

  Ziessman HA. Hepatobiliary Scintigraphy in 2014. J Nucl Med 2014; 55:1–9

  Ziessman HA. Nuclear Medicine Hepatobiliary Imaging. Clinical

Gastroenterology and Hepatology 2010;8:111–116

  Tulchinsky M et al. SNM practice guidelines for hepatobiliary scintigraphy. J

Nucl Med Tech 2010;38:210–218

  Ziessman HA. Sincalide Cholescintigraphy-32 Years Later: Evidence-Based

Data on Its Clinical Utility and Infusion Methodology. Semin Nucl Med 42:79-83

  Ziessman HA et al. Cholecystokinin Cholescintigraphy: Methodology and

Normal Values Using a Lactose-Free Fatty-Meal Food Supplement. J Nucl Med. 2003; 44: 1263-1266.

  Covington MF et al. Classification Schema of Symptomatic Enterogastric Reflux

Utilizing Sincalide Augmentation on Hepatobiliary Scintigraphy. J Nucl Med

Technol 2014; 42:198–202

  Tulchinsky M et al. Hepatobiliary Scintigraphy in Acute Cholecystitis. Semin

Nucl Med 42:84-100

  Chamarthy M, Freeman LM. Hepatobiliary Scan Findings in Chronic

Cholecystitis. Clin Nucl Med 2010;35: 244–251

Page 52

Thank You

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Disclosures/Disclaimers

 I have no conflicts of interest.

Three Things to Learn

•  Communication includes listening.

•  You must be trustworthy.

•  Don’t expect to win many people to your side,

no matter how good your evidence.

Why Think About Radiation Risk?

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What do people fear?

•  Unknown

•  Can’t see

•  Can’t smell

•  Can’t taste

•  Can’t touch

Risk Communication

 Who you will communicate with

 Medical colleagues

 Patients

 Research subjects

 Hostile groups

 Intentional exposures

 Unintentional exposure

Fear vs. Risk

  Rank hazard mortality

  Rank fear of hazard

 Correlation between fear and risk is ~ .2

How to Communicate Risk

 Know your audience

 Educational level

 Study subject?

 What are their concerns?

 Health

 Property

 Financial

Your Audience – Who is More Fearful?

Listen to your audience before you speak

 What is their concern?

 Health effects?

 Economic concerns?

 Family?

 Assess understanding as you go along.

 Summarize

 Ask them what they think about what you have

told them

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Assess Level of Education and Understanding

•  Listening helps

•  Know what vocabulary to use

•  Chest X-ray or .?

•  Background

•  Have they already made up their mind?

•  Where do they get their information?

•  What is worrying them?

Speaking to Specific Groups

•  Anti-nuclear

•  Regulators

•  General Public

•  Medical Professionals

•  Disaster drills

•  Consumers of radiological services

Educating Medical Professionals

• • 

• 

• 

• 

• 

• 

• 

• 

• • 

• 

Intentional vs Unintentional Exposures

•  Intentional

•  Medical

•  Radiation worker

•  Unintentional

•  Accidents

•  Terrorist attacks

•  Power Plants

Besides Speaking

•  Written communication

•  Web-based

• Blogs

• Social media

• Wiki articles

•  Newspapers

• Editorials

• Letters

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What if you Don’t Know?

•  Say:

•  “I don’t know”

•  Do not lose credibility with your

audience. You need to remain a

trusted source.

Ultimate Goal

•  In speaking to patients –

•  You are an advocate for the patient

•  We are adding risk to their lives, we are

damaging their tissues

•  What is the risk of NOT doing the scan?

•  In speaking to Physicians –

•  You are an advocate for the patient AND

physician

•  In speaking to regulators –

•  You are an advocate for the patient

•  Is something not working well?

Radiation Doses and Dose Limits Dose Examples

Source Dose – mSv (mrad)

Torso CT (w/wo) 40 (4,000)

PET/CT 8 – 25 (800 – 2,500)

Myocardial perfusion (R/S) 7 (700)

Chest CT 7 – 1.5 (700 – 150)

Natural background (per

year)

3.5 (350)

Chest x-ray 0.1 (10)

Dental X-rays 0.005 (0.5)

Flying 0.003 (0.3) /hr

Radiologyinfo.org

Physical

Radionuclide Half-Life Activity Use

Cesium-137 30 yrs 1.5x106 Ci Food Irradiator

Cobalt-60 5 yrs 15,000 Ci Cancer Therapy

Plutonium-239 24,000 yrs 600 Ci Nuclear Weapon

Iridium-192 74 days 100 Ci Industrial Radiography

Hydrogen-3 12 yrs 12 Ci Exit Signs

Strontium-90 29 yrs 0.1 Ci Eye Therapy Device

Iodine-131 Therapy 8 days 0.015 Ci Nuclear Medicine

Technetium-99m 6 hrs 0.025 Ci Diagnostic Imaging

Americium-241 432 yrs 0.000005 Ci Smoke Detectors

Radon-222 4 days 1 pCi/l Environmental Level

Examples of Radioactive Materials Communication in Radiation Disaster

•  The “worried well” are going to require a large

amount of resources.

•  Emphasize medical care over radiation

exposure concerns.

•  Communication of reliable and accurate

information is very important and very

unlikely.

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Decontamination

• 

• 

• 

• 

• 

• 

Max Mussel

Tammy Tech

References

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RADIONUCLIDE GASTRIC EMPTYING STUDY

Standard Solid-Meal & Alternatives

PRADEEP BHAMBHVANI, MD

Associate Professor

Molecular Imaging & Therapeutics,

Department of Radiology

The University of Alabama at Birmingham

February 21, 2017

Page 2

Disclosures

  Honorarium from Educational Symposia

Page 3

Outline

  Introduction

  Consensus Guideline and Standardized Meal

  Patient Preparation

  Interpretation

  Rapid Emptying

  Alternative Meal

  Shortened Protocol

  Liquid Emptying

  Conclusions

Page 4

Radionuclide Gastric Emptying

GOLD STANDARD

Page 5

Radionuclide Gastric Emptying

Most comprehensive & physiologic studies of gastric

motor function

  Widely available

  Simple, noninvasive & quantitative

  Uses a physiologic meal (solids with or without

liquids)

  Can determine therapy effectiveness

Page 6

Scintigraphy Alternatives

Not routinely done as more studies needed

  13C Octanoic acid breath testing

  Wireless motility capsule

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Page 7

Normal Stomach Physiology

Antrum: - Phasic contractions, grind solid

food particles

Controls Solid Emptying

Fundus: - Tonic reservoir which

undergoes receptive relaxation

- Constant pressure gradient

Controls Liquid Emptying

Page 8

Liquid Emptying: Exponential Solid Emptying: Linear

Lag Phase

Gastric Emptying: Time Activity Curves

Page 9

Introduction

  Gastroparesis is a syndrome of objectively delayed

gastric emptying in the absence of mechanical

obstruction and with symptoms of nausea, vomiting, early

satiety, bloating and/or upper abdominal pain

  The radionuclide study cannot differentiate functional

delay from anatomic obstruction (e.g. tumor or ulcer).

EGD or CT or barium study can aid with that

  More symptoms with delays in solid emptying versus

liquid emptying

Page 10

Etiology of Gastroparesis

  Idiopathic (50%)

  Diabetes Mellitus

  Post-surgical (vagus injury): Bilroth II, heart & lung

transplants, fundoplication

  Medications

  Viral

  Dysautonomia

  CNS: MS, Brainstem CVA/tumor, PD, SCI

  Infiltrative disorders: Scleroderma, Amyloid etc.

Page 11

Factors Affecting Gastric Emptying

  Meal related (fat, protein, acid, osmolality, volume,

weight, caloric density, particle size)

  Patient position (standing, sitting, supine)

  Incomplete meal or emesis

  Stress, Exercise

  Medications

  Tobacco smoking

  Hyperglycemia

  Menstrual cycle

Page 12

Effect of increasing liquid calorie content on liquid (a) and solid (b) emptying

Collins PJ et al., Gut, 1983, Dec;24(12):1117-25.

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Medications and Gastric Emptying

  ACCELERATE

  Metoclopramide

  Erythromycin

  Domperidone

  Cisapride

  DELAY

  Narcotics (Morphine, Percocet, Vicodin)

  Alpha-2-adrenergic agonists (Clonidine), Atropine

  Tricyclic antidepressants, Benzodiazepines & Phenothiazines

  Calcium channel blockers, Progesterone, Theophylline

  Anticholinergics (Bentyl, Levsin, Donnatal)

  Octreotide

Page 14

Study to Establish Normal Values

Page 15

Tougas G et al. Am J Gastroenterol. 2000;95:1456-1462

  11 sites in 4 countries (US, Canada, Italy, Netherlands)

  123 volunteers (60-F, 63-M); ages 19-73

  No GI illness/surgery, no ongoing medical condition &

no medications

  All had a 99mTc-labeled low fat egg meal. 20 patients

also had the 99mTc-labeled liver meal

  1 min images and gastric retention at 60, 120 and 240

minutes

Page 16

Tougas G et al. Am J Gastroenterol. 2000;95:1456–1462

Percent Retention Median 95th Percentile

1 hour 69 90

2 hour 24 60

4 hour 1.2 10

T-50 (min) 83 132

Lag phase (min) 21 49

Results N=123

Page 17

Tougas G et al. Am J Gastroenterol. 2000;95:1456–1462

Other Results

 No significant difference in emptying between meals,

except 3h retention was higher with the liver meal

 Gender: There was more gastric retention in women at

1 and 2h but no difference from men at 4h

 Age: Greater retention in younger patients

 BMI: No relationship with gastric emptying

Page 18

Consensus Recommendations

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Page 19

SNMMI Guideline

J Nucl Med Technol. 2009 Sep;37(3):196-200

Page 20

Patient Preparation

  Minimum 4 hour fasting

  Fasting blood sugar less than 200 mg%

  Insulin & oral medications OK with standardized meal

  Stop Narcotics, Prokinetics, Anticholinergics for 2 days

  If nausea or vomiting, Zofran use is safe

  Women are ideally studied on days 1-10 of menstrual cycle

  Avoid smoking on day of test

Page 21

Standardized Meal: Egg Whites Sandwich (255 kcal)

  EGG-BEATERS (118 ml/4 oz. 60 kcal), 0.5-1 mCi 99mTc sulfur

colloid mixed with egg whites, scrambled or omelet

  2 toasted white bread slices (120 kcal)

  30g strawberry jam (75 kcal)

  120 ml water

  Meal eaten separately or as sandwich in <10 minutes

  At least 50% of the meal should be consumed

Page 22

Imaging

  Anterior & posterior 1 minute images after meal & hourly up

to 4 hours

  Calculate gastric retention from geometric mean after region

of interest (ROI) drawn around stomach

  Geometric mean = √ anterior counts x posterior counts

  ROI should avoid small bowel

  Higher sensitivity at 4 hours

Page 23

Interpretation

Normal Values for Low Fat Egg-Whites Gastric Emptying Study

Am J Gastroenterol. 2007;102:1–11

Time Point Lower Normal Limit for

Gastric Retention

Upper Normal Limit for

Gastric Retention

0 min A lower value suggests

rapid emptying

A greater value suggests

delayed emptying

1 hour 30% 90%

2 hour 60%

3 hour 30%

4 hour 10%

Page 24

Interpretation

  Delayed Emptying

 2 hour retention >60% and/or

 4 hour retention of ≥10%

  Rapid Emptying

 1 hour retention <30%

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Page 25

NORMAL EMPTYING

GASTRIC RETENTION

1 HOUR: 69%

2 HOUR: 25%

3 HOUR: 17%

4 HOUR: 2%

4 HOUR

Page 26

SEVERE DELAYED EMPTYING

GASTRIC RETENTION

1 HOUR: 76%

2 HOUR: 64%

3 HOUR: 47%

4 HOUR: 40%

Page 27

Severity of Gastroparesis

  No correlation between severity and symptoms

  Severity scale (% gastric retention)

 11-15%: Mild

 16-35%: Moderate

 >35%: Severe

Camilleri M. N Engl J Med 2007;356:820-9.

Page 28

Rapid Gastric Emptying

  Usually seen

 After peptic ulcer surgery (pyloroplasty)

  In early type 2 DM

 Zollinger-Ellison syndrome

 Hyperthyroidism

  Symptoms: Diarrhea, abdominal pain, bloating, nausea (early

dumping syndrome), diaphoresis, palpitations, weakness, fainting

(late dumping syndrome)

  Symptoms often similar to gastroparesis

Page 29

Rapid Gastric Emptying

Page 30

Alternative Meal (Ensure Plus®)

Use of a High Caloric Liquid Meal (Ensure Plus®) as

an Alternative to a Solid Meal for Gastric Emptying

Scintigraphy

 20 healthy volunteers

 Egg-whites sandwich (EWS) and Liquid Nutrient Meal

(LNM) GE exams on separate days

Sachdeva et al: Dig Dis Sci July 2013, Volume 58, Issue 7, 2001-6

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Page 31

EWS versus Ensure Plus®

Egg Whites Sandwich

(EWS)

Liquid Nutrient Meal

(LMN) Ensure Plus®

Calories (kcal) 255 350

Fat % 2 28

Protein % 24 15

Carbohydrate % 72 57

Fiber % 2 0

Sachdeva et al: Dig Dis Sci July 2013, Volume 58, Issue 7, 2001-6

Page 32

Alternative Meal (Ensure Plus®)

  Ensure Plus® gastric emptying is overall similar to EWS

  Ensure Plus® meal empties without a lag phase and

takes slightly longer to empty from the distal stomach,

likely due to its higher fat content

  Reasonable alternative to the EWS meal

Sachdeva et al: Dig Dis Sci July 2013, Volume 58, Issue 7, 2001-6

Page 33

Shortened Protocol

  174 patients (123-F, 51-M)

  Abnormal Emptying: >65% retention at 2 hours

  Normal Emptying: <45% retention at 2 hours

  Very accurate

  <25% patients needed 4 hour imaging

Bonta V et al: Clin Nucl Med; Vol 36(4), Apr 2011, p 283-285

Page 34

Shortened Protocol

J Nucl Med 2015; 56:873–876

Page 35

  4 academic institutions; 431 patients

  At 2 hours:

  261 (60.6%) had gastric retention <45%, i.e. normal

  62 (14.4%) had gastric retention >65%, i.e. delayed emptying; and

  108 (25.1%) had intermediate values requiring imaging through 4 hours

  Bonta criteria had a sensitivity, specificity, and accuracy of 92.4%, 96.9%,

and 95.8%. False negative results seen in 8 patients (1.9%).

  Bonta criteria shortened the study duration in most patients,

resulting in an effective compromise between reduced resource use,

improved patient convenience, and preserved accuracy.

J Nucl Med 2015; 56:873–876

Shortened Protocol

Page 36

Sources of Error

  Vomiting after meal or Incomplete meal or prolonged

meal ingestion time

  Non-standard meal

  Poor labeling

  Slow meal passage from the mouth/esophagus into

the stomach

  Gastroesophageal reflux

  Overlap of small-bowel activity with the stomach ROI

  Lack of decay correction etc.

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Issues Requiring Clarification

  Pediatric GES (no standards yet)

  Post-surgical (Bariatric, Billroth-no normal values)

  Value of other emptying metrics:

 Fundal–antral and antral-pyloric coordination

 Gastric accommodation

 Regional muscular contraction patterns

 Antral motility

 Fundal accommodation response

 Separate fundal and antral emptying curves

 Effect of varying meal composition on emptying etc.

Page 38

Liquid Gastric Emptying

  Conventional belief: There is good correlation between

solid & liquid emptying, so the latter is not done routinely

  Alternative to solid meal or part of a solid-liquid study

 Post-operative states

 Solid meal intolerance

 Dumping syndrome or

 Research study

Page 39

  “Solid gastric emptying is more sensitive than liquid emptying

for detection of Gastroparesis liquid emptying is preserved

until the disorder is advanced” Tadataka Yamada, Textbook of

Gastroenterology 4th edition

  “Liquid emptying is always normal when solid emptying is

normal” and “A liquid only study should be reserved for those

who cannot tolerate solids” The Requisites: Nuclear Medicine 3rd

Edition. Harvey Ziessman, Janis P O’Malley & James H Thrall

  “Liquid GE studies are by themselves of limited clinical value

because liquid emptying usually is not abnormal until

gastroparesis is far advanced” Update on GI Scintigraphy,

Seminars in Nuclear Medicine, 2006, 36, 110-118, Alan H Maurer,

Henry P Parkman

Liquid Gastric Emptying

Page 40

Ziessman HA et al. J Nucl Med 2009 50: 726-731.

101 symptomatic patients (24-M 77-F) had sequential liquid solid GES

7 patients were diabetic

Liquid GES with 111In DTPA and solid GES with EWS

Normal liquid GES: <19 min (mean ± 2SD) or <22 min (mean ± 3 SD)

Page 41

Ziessman HA et al. J Nucl Med 2009 50: 726-731.

A Normal liquid

GES

Delayed

liquid GES

Total

Normal solid

GES

58 27 85

Delayed solid

GES

4 12 16

Total 62 39 101

B Normal liquid

GES

Delayed

liquid GES

Total

Normal solid

GES

61 24 85

Delayed solid

GES

4 12 16

Total 65 36 101

Normal liquid GES

T1/2 <19 min

Normal liquid GES

T1/2 <22 min

Page 42

Ziessman HA et al. J Nucl Med 2009 50: 726-731.

  Liquid gastroparesis seen in 30% of patients with

normal solid emptying

  Gastroparesis diagnosis increased from 16% with only

abnormal solid study to an additional 28-32% with

normal solid but abnormal liquid study

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Page 43 Page 44

Sachdeva P et al. Dig Dis Sci (2011) 56:1138–1146

  Retrospective study; 449 patients (346-F & 103-M)

  62 diabetics (15%)

  27% (60/228) had delayed liquid & normal solid emptying

Normal

solid GES

Delayed

solid GES

Rapid solid

GES

Total

Normal liquid

GES

168 90 11 269

Delayed liquid

GES (>50%

retention at 1h)

60 117 3 180

Total 228 207 14 449

Page 45

Added Value of Liquid Emptying

  Prior publications have found poor correlation between

symptoms and GES

  One reason may be that only antral function has been

studied

  Therapies specific for fundal dysfunction are needed

Page 46

Conclusions

  Solid-meal gastric emptying is standardized!

  Ensure Plus® is a viable alternative meal

  Shortened protocol maintains accuracy while improving

clinic workflow

  Liquid emptying has added diagnostic value

Page 47

References

  Abell TL, Camilleri M, Donohoe K, et al. Consensus recommendations for gastric emptying

scintigraphy: a joint report of the American Neurogastroenterology and Motility Society

and the Society of Nuclear Medicine. Am J Gastroenterol. 2008;103:753–763.

  Tougas G, Eaker EY, Abell TL, et al. Assessment of gastric emptying using a low fat meal:

establishment of international control values. Am J Gastroenterol. 2000;95:1456–1462.

  Ziessman HA. Goetze S, Bonta D, Ravich W. Experience with a new standardized 4-hr

gastric emptying protocol. J Nucl Med. 2007;48:568–572.

  Sachdeva P, Malhotra N, Pathikonda M, et al. Gastric emptying of solids and liquids for

evaluation for gastroparesis. Dig Dis Sci. 2011 Apr;56(4):1138-46.

  Ziessman HA, et al. The added diagnostic value of liquid gastric emptying compared with

solid Emptying alone. J Nucl Med 2009 50: 726-731.

  Bonta D, Lee H, Ziessman H. Shortening the 4 hour gastric emptying protocol. Clin Nucl

Med. 36(4), April 2011, pp 283-285.

  Donohoe KJ et al. Procedure Guideline for Adult Solid-Meal Gastric-Emptying Study 3.0. J.

Nucl. Med. Technol. 2009 Sep;37(3):196-200.

  Collins PJ, Horowitz M, Cook DJ et al. Gastric emptying in normal subjects-a reproducible

technique using a single scintillation camera and computer system. Gut. 1983 Dec;24(12):

1117-25.

  Sachdeva P, Kantor S, Knight LC, et al. Use of a high caloric liquid meal as an alternative

to a solid meal for gastric emptying scintigraphy. Dig Dis Sci. 2013 Jul;58(7):2001-6.

  Pelletier-Galarneau M, Sogbein OO, Pham X et al. Multicenter validation of a shortened

gastric-emptying protocol. J Nucl Med. 2015 Jun;56(6):873-6.

Page 48

Thank You

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NeuroendocrineImaging

NeuroendocrineImaginghasbeenoneofthefirstreceptorbasedimagingmodalitiesinNuclearMedicine.ItisnowbecomingincreasinglyimportantastheinvolvementofNuclearMedicineinthisfieldisgrowing.ThetalkwillreviewthebasicindicationsofimagingwithPentetreotideandmIBGimagingwithSPECT,anddiscussoptionsthathavebeenusedclinicallyinPET,includingthenewlyapprovedtracers.

1) ReviewofpathologieswithinNeuroendocrineImaging

2) ReviewofSPECTtracersusedforclinicalimaging

3) ReviewofPETtracersusedforclinicalimaginginNeuroendocrineDiseases

4) ComparisonofPETvs.SPECTtracers

5) ImplicationsofprognosisandtherapywithNuclearMedicine

References:

1) PfannenbergAC,etal.“BenefitofAnatomical-functionalImageFusionintheDiagnosticWork-upofNeuroendocrineNeoplasms”EurJNuclMedMolImaging.2003;30:835–43

2) BuchmannI,etal.“Comparisonof68Ga-DOTATOCPETand111In-DTPAOC(Octreoscan)SPECTinPatientswithNeuroendocrineTumours”EurJNuclMedMolImaging(2007)

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VailFebruary 4 - 9, 2018Vail Marriott Mountain Resort & SpaVail, CO

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*Snowmass February 18 - 23, 2018The Westin Snowmass ResortSnowmass Village, CO

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