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Hello and welcome to Noon Conferences hosted by MRI Online.

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In response to the changes happening around the

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world right now in the shutting down of in person

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events, we have decided to provide free daily

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Today we are joined by Dr. Darlene Metter.

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She is a professor of radiology and family and

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community medicine at UT Health San Antonio.

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She was board certified by the American

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Board of Radiology and Nuclear Medicine.

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Dr.Metter is actively involved in organized medicine

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and regulatory entities at the Local is a

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multi invited lecturer and visiting professor.

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A reminder that there will be some time at

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the end of this hour for a Q& A session.

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Please use the Q& A feature to ask all of your questions.

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We'll get to as many as we can before our time is up.

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That being said, thank you so much for joining us today, Dr. Metter.

0:42

I will let you take it from here.

0:44

Thank you very much and good afternoon.

0:48

I'm Darlene Mitter and today I'll be

0:49

speaking on hepatobiliary imaging.

0:52

I have nothing to disclose.

0:54

So the learning objective today will be that

0:56

after this presentation, you'll be able to

0:58

describe the four phases of hepatobiliary scan.

1:02

You'll be able to list three indications

1:04

for syncolide or CCK administration.

1:08

You'll be able to list three causes of a false

1:11

positive scan for cystic duct obstruction.

1:14

And lastly, we'll be looking at biliary leaks where

1:17

you'll be able to evaluate for a biliary leak.

1:21

So the format of this presentation, we'll first

1:23

look at the radiopharmaceutical, then we'll look at

1:26

patient preparation and pharmacologic intervention.

1:30

We'll look at what a normal scan looks like,

1:32

and we'll lastly look at what an abnormal scan

1:34

looks like in four common clinical scenarios.

1:38

Cholecystitis, common bowel duct

1:40

obstruction, biliary atresia,

1:46

So let's start with the rate of pharmaceutical.

1:50

There are two immunodiacetic acid agents

1:52

to assess in hepatobiliary imaging.

1:56

These are organic ions that are similar to lidocaine.

1:59

And they're very, very stable complexes.

2:01

The two major agents are diastephenin,

2:04

or hepatolite, and mebephenin.

2:07

or Colatec.

2:10

So how are these Ida agents metabolized?

2:13

Well, they're very much like bilirubin and they use the very

2:16

same pathways in hepatic uptake, transport, and excretion.

2:22

So let's look at hepatic uptake.

2:25

Hepatic uptake is carrier mediated.

2:28

So in the event of high bilirubin, many of the

2:30

receptor sites at the liver are occupied, occupied by

2:34

bilirubin and therefore the rate of pharmaceutical has

2:38

competitive inhibition by the high bilirubin level.

2:41

And hence you need a higher dose of the

2:43

rate of pharmaceutical and generally

2:45

that can be up to 10 millicaries.

2:50

So which IDA agent should I use?

2:52

Mepifenin versus diacifenin.

2:55

While mepifenin has greater stability, it has a

2:59

greater hepatic extraction, 98 percent versus 90%.

3:04

It has less renal excretion, less

3:06

than 1 percent versus less than 9%.

3:10

And it's actually the preferred agent for

3:12

bilirubin levels that are greater than

3:14

10 in patients with severe liver disease.

3:20

So now, how much should I give?

3:22

Well, the general adult dose is 3 to 5

3:26

millicaries intravenously, but depending on the

3:27

bilirubin, we can give up to 10 millicaries.

3:31

In the pediatric patients, It's weight based, and

3:33

you can follow the current North American consensus

3:36

guidelines, but generally this is generally 0.

3:39

05 millicuries per kilogram, with a minimum of 0.

3:43

5 millicuries.

3:45

However, in neonatal jaundice, I recommend a

3:47

minimum dose of one millicury, because you'll

3:49

most often be like, We'd be doing delayed imaging.

3:55

So now let's look at patient preparation

3:57

and pharmacologic interventions.

4:01

The most important thing in patient preparation

4:04

is the patient needs to be fasting for

4:05

at least four hours prior to your study.

4:09

You can do a minimum of two hours, but really

4:11

ideally it should be four hours because you

4:13

do not want the gallbladder to be contracted.

4:16

Food in the small bowel will stimulate CCK and the degree of

4:21

gallbladder contraction is proportional to the fat content.

4:24

So if you eat this hamburger that's listed

4:26

here, that's shown here, you need to wait at

4:29

least four hours before you perform your study.

4:32

The gallbladder contraction is proportional to the fat

4:35

content of the meal and gives you a high percentage

4:38

of false positive if you don't wait long enough.

4:40

for four hours.

4:42

In non fasting normals, 64 percent of normal patients will

4:46

have non visualization of the gallbladder due to gallbladder

4:50

contraction and will give you a false positive study.

4:56

So now let's look at pharmacologic interventions.

4:58

Let's look first at Zincolide, a cholecystokinin CCK.

5:05

CCK is a polypeptide hormone.

5:07

It's a bioactive eight terminal peptide with a

5:09

very short half life of two and a half minutes.

5:12

The important thing I think you

5:13

need to know is what does CCK do?

5:16

So CCK is excreted when you eat a meal

5:20

because it helps to digest the meal content.

5:22

So think of this.

5:23

You want to have more bile to help digest the

5:27

food and pass the bile into the small bowel.

5:29

So with that, you contract the gallbladder.

5:32

To allow passage of bile into the small

5:34

bowel, you relax the sphincter of OD.

5:37

You increase and stimulate bowel secretion

5:39

and intestinal activity to move the bowel

5:42

path into the small bowel for digestion.

5:45

And with that, you inhibit gastric emptying.

5:50

So what type of infusions do we give?

5:52

Well, you can give a short or a long infusion of Zincolide.

5:55

The short or what we say bolus over one to three minutes

5:58

has a lot of side effects and the most common side effect

6:01

is going to be cramping related to gallbladder neck spas,

6:04

but more likely related to increased intestinal motility.

6:08

The problem with a short bolus is that

6:09

you'll have great variability if you're

6:11

trying to do a gallbladder ejection fraction.

6:13

And then you also have a high

6:15

false positive study for bolus.

6:19

So really the preferred method for zinc halide infusion

6:22

is going to be the long standardized method, which is 0.

6:26

02 micrograms per kilogram for 60 minutes.

6:30

It gives the gallbladder ejection fraction of normal

6:32

ex in the range equal to or greater than 38 percent.

6:36

And this just gives a more standardized

6:38

ejection fraction than that for a fatty meal.

6:41

The only requirement for the syncolide infusion is that

6:44

you have to have a notable amount of gallbladder activity.

6:47

You don't necessarily need to have GI activity.

6:53

So now let's look at indications for CCK.

6:56

Before the procedure, if the patient has not

6:58

been eating for over 24 hours, the gallbladder

7:01

is likely dilated and full of sludge.

7:03

And If you keep the gallbladder dilated, it

7:06

will not allow the tracer to get into the

7:09

gallbladder, and you may have a false positive.

7:12

Also, some people use CCK to

7:14

diagnose sphincter of OG dysfunction.

7:18

Now, post procedure, at 60 minutes after

7:21

the patibility study, you can use CCK.

7:23

CCK for gallbladder ejection fraction,

7:25

and some people also use CCK to assess for

7:28

functional or anatomic common bowel obstruction.

7:34

So the next pharmacologic agent

7:35

we can use is morphine sulfate.

7:39

So what are the actions of morphine silicate?

7:42

Well, it increases sphincter of

7:43

constriction and decreases peristalsis.

7:47

And the main reason it tends to increase

7:50

common bile duct pressure to hopefully

7:52

reflux your radiotracer into the cystic duct.

7:57

The dose is 0.

7:59

04 micrograms per kilogram intravenously

8:01

and you image for 30 minutes.

8:03

Now this morphine augmentation was suggested by Choi in

8:07

1984 as an alternative to the delayed 4 hour imaging.

8:12

The specificity for delayed imaging was 68

8:15

percent and that of morphine was 84 percent.

8:19

Now, sometimes your patients who are undergoing

8:21

a patibility scan have been given morphine

8:24

sulfate, and if they have, you have to wait at

8:26

least six hours before you can start the study.

8:31

So now let's look at a normal scan.

8:36

The technical aspect is we first do 60 minutes of

8:39

dynamic imaging over the anterior right upper quadrant,

8:42

and depending whether or not we see the gallbladder,

8:44

I'll You do static LAO and right lateral views.

8:48

I typically do static and LAO and right lateral

8:50

views, um, for these studies, regardless whether I

8:53

see the gallbladder, because I like to just get an

8:55

idea of the differences in the orientation of the

8:59

different anatomic structures for these projections.

9:02

Optional components can be a radionuclide angiogram.

9:05

and delayed imaging.

9:08

Now when I look at a hepatobiliary scan, I like to describe

9:11

four phases and this follows a pattern or the physiologic

9:14

activity of bilirubin and therefore your radioactive tracer,

9:18

the vascular phase, hepatic, biliary, and enteric phases.

9:25

So let's start with the vascular phase.

9:27

Remember, The uptake by the liver is carrier mediated.

9:31

So normal vascular phase, you should

9:33

have blood pool clearance by 10 minutes.

9:35

And how do I assess that?

9:36

I look at cardiac activity, and cardiac

9:39

activity should be cleared by 10 minutes.

9:44

I mentioned a radionuclide angiogram, and

9:46

mainly that indication is for liver transplants.

9:49

And these are one to two second images

9:51

for the 60 seconds during the intravenous

9:54

administration of uratopharmaceutical.

9:57

And as you recall, the liver blood flow is by the

10:00

hepatic artery, 25%, but 75 percent by the portal vein.

10:06

Therefore, you see the liver generally 6

10:08

to 8 seconds after the spleen and kidney.

10:11

So here is an example of a pediatric liver

10:13

transplant patient in the anterior view.

10:16

And you can see here cardiac activity.

10:19

And then you see the spleen right here when

10:22

you first see the abdominal aorta remember that

10:25

20 percent of cardiac output is to the spleen.

10:28

Six to eight seconds later, you should start

10:30

seeing hepatic activity because of blood perfusion

10:34

to the liver 75 percent through the portal vein.

10:39

Now we're at the hepatic phase.

10:41

Hepatic distribution should be homogeneous, and then you

10:44

could also help to assess for the morphology of the liver.

10:48

Once the hepatic sites have taken up the

10:50

radiopharmaceutical, by tra uh, by Taken

10:55

up by the radioactive, um, material, it can

10:57

actively transport it into the biliary system.

11:01

Peak hepatic uptake is generally at 8 to 12 minutes, with

11:05

hepatic transit, or the T1 half, at 15 to 20 minutes.

11:09

And what that means is that by 20 minutes, half

11:11

of that hepatic activity should have been cleared.

11:14

Hepatitis clearance at 60 minutes should be minimal

11:17

activity at the time of the end of the study.

11:22

So we're back at this pediatric patient.

11:24

We see the vascular phase, the cardiac

11:26

activity here, and then you see the hepatic

11:29

activity, and then you look at your liver here.

11:32

in the hepatic phase.

11:32

It's nice and homogeneous, which is a normal hepatic uptake.

11:39

Now we're in the biliary to enteric phases.

11:41

The IDA excretion follows bowel flow.

11:44

It goes into the intra to extra hepatic bowel ducts

11:47

with two thirds of the bowel going through the

11:50

common duct, and one third into the cystic duct.

11:53

The final phase is the GI or enteric phase, where

11:56

generally you have biliary to bowel transit by 60 minutes.

12:02

So this is a normal hepatobiliary scan where you have The

12:06

vascular clays, you have normal clearance by 10 minutes.

12:09

You have hepatic uptake, which is homogeneous.

12:12

Now, in this particular patient, you see

12:13

an area of Fortopenia by the hepatic dome.

12:16

That's related to soft tissue

12:18

attenuation of the patient's breast.

12:20

And you see an area of crescentic increased activity

12:23

below that, which is related to Compton scatter.

12:28

Then you have the biliary gallbladder

12:30

activity, and then you have bile activity.

12:32

So this is a very normal study, and I like to report it

12:35

as a normal vascular, hepatic, biliary, and enteric basis.

12:42

So I'm now at 60 minutes.

12:44

What do I do?

12:45

Why, if I see gallbladder, I can

12:47

confirm gallbladder activity.

12:49

And we do that by doing two projections.

12:51

We do a left anterior oblique, or

12:53

LAO, to see how the gallbladder moves.

12:56

And in this projection, the gallbladder

12:58

should move lateral because it's anterior.

13:00

And if I forget, I just remember that it's left, So L is

13:05

also in laterals, so the gallbladder should move laterally.

13:09

I also can do a right lateral view knowing

13:11

that the gallbladder will be anterior.

13:13

So if I do an LAO and a right lateral

13:15

view, I can confirm gallbladder activity.

13:18

Sometimes you're not able to do these views, and

13:20

if you see, gallbladder activity that looks like

13:23

a gallbladder, it could be duodenal activity.

13:25

So you can have the patient drink water,

13:27

which will clear the duodenal activity.

13:29

And if you do a lateral view, the

13:31

duodenal activity should be posterior.

13:36

So here's a patient who had gallbladder activity

13:39

and we confirm it with the right lateral view.

13:41

This is the right lateral view.

13:42

This is anterior and the gallbladder is anterior.

13:46

Now, if he had duodenal activity, it would be posterior.

13:49

This is the LAO view and the gallbladder moved laterally.

13:55

At 60 minutes, you can also do

13:57

a gallbladder ejection fraction.

14:00

And we saw earlier, the Society of Nuclear Medicine

14:03

practice guidelines for palpabilary centigraphy,

14:07

the IV infusion of the standardized infusion of 0.

14:10

02 micrograms per kilogram for 16 minutes, 16 minutes

14:13

in saline with the normal gallbladder ejection

14:16

fraction equal to or greater than 38 percent.

14:19

The standardized effusion is recommended because

14:22

it has least variability, high specificity,

14:25

and few abnormal results in normal patients.

14:30

So this patient had a hepatobiliary study at

14:33

the end of 60 minutes, got the infusion of CCK.

14:36

And you can look at how the gallbladder decreases over time.

14:40

I generally tend to look at the first image and then

14:42

the last image, and then you can subtract that out.

14:45

And I believe that This gallbladder ejection

14:47

fraction is very high, and it is reported at 92%.

14:53

What about an abnormal gallbladder

14:55

ejection fraction, less than 38%?

14:58

Well, if I have gallstones, I will

15:00

call it chronic calculus cholecystitis.

15:03

If there are no gallstones, then I would call

15:06

it chronic acalculus cholecystitis, or other

15:09

people may also call biliary dyskinesia.

15:12

There's some rare sy So this

15:30

is a 33 year old female who had hepatocellular

15:34

carcinoma, chemoembolization with abdominal pain.

15:38

So the top image is her first 60 steps.

15:41

minute compatibility study before CCK, and at the end

15:45

of the study, you see what looks like the gallbladder.

15:48

So, they wanted to go ahead and assess

15:50

for her gallbladder ejection fraction.

15:52

This is her post CCK image, and if I see the first image and

15:56

I look at the last, there's really not much of a difference,

15:58

so I would suspect a low gallbladder ejection fraction.

16:02

And when they calculated out, it clearly is 8%, which is a

16:06

low gallbladder ejection fraction confirming your suspicion.

16:12

If she had gallstones, it's chronic calculus cholecystitis.

16:15

If she had no gallstones, it's chronic

16:17

acalculus cholecystitis or biliary dyskinesia.

16:22

Now, I'm sure you all saw that big photopenic

16:24

region near her hepatic dome, and that's

16:27

related to her HCC, her anechymal embolization.

16:33

So, notice that you can do it in 60 minutes.

16:35

We can do delayed imaging, and that's generally

16:38

performed if there's no biliary or gallbladder activity.

16:41

And you can do delayed imaging up to 24 hours.

16:44

Typically, we do it at four hours, but you can do it up

16:46

to 24 hours if you still did not see the gallbladder.

16:50

And this is mainly to assess the

16:52

cystic or common bile duct obstruction.

16:55

I'll show you examples of patients

16:57

with severe liver disease.

16:59

That you can do delayed imaging to

17:01

assess for patency of the cystic duct.

17:04

And that can also be done for intrapatic cholestasis.

17:08

And we also do delayed imaging for bowel leaks and

17:11

particularly if the patient has peritoneal drains.

17:15

So this is a patient who has a very abnormal study and

17:19

as you can already see, there's an abnormal prolonged

17:22

vascular phase and if you look at the first image and

17:25

the last image, the liver looks pretty much the same

17:28

or actually increased in activity at the last image

17:31

consistent with an ab abnormal prolonged vascular and

17:34

hepatic phase consistent with hepatocellular disease.

17:39

They were also looking for cystic duct obstruction.

17:42

So at four hours, at one hour, there was no

17:45

gallbladder, but we did the LAO on right lateral view.

17:48

And then the four hour delay, there's still no gallbladder.

17:52

So this patient had no gallbladder at four hours

17:54

consistent with cystic duct obstruction and liver disease.

17:58

And actually she had, uh, this patient had

18:01

enough GI activity that would, I believe that

18:05

this was not related to the liver disease but

18:07

more related to the cystic duct obstruction.

18:11

Another patient with the bowel leak, you see

18:14

activity in the patient's drain and bulb.

18:17

And unfortunately, you can't see it

18:18

here, but it was actually in the tubing.

18:24

This is a 55 year old male with

18:26

abnormal liver function test.

18:29

And you can see here, you have intense cardiac

18:32

activity that persists all the way to 60

18:35

minutes in addition to the liver activity.

18:39

And we do the 4 hour delayed study, and so this is

18:42

consistent with severe liver disease with persistent

18:45

cardiac and hepatic activity, and really minimal to

18:48

no GI activity, the patient has severe hepatitis.

18:53

And to assess for the cystic duct, you

18:55

really can't do that when you have either

18:58

no or minimal biliary to bowel activity.

19:01

You cannot assess for cystic duct obstruction.

19:06

So now let's look at, uh, further interpretations.

19:09

Let's look at abnormal studies.

19:12

In particular, cholecystitis, acute

19:14

or chronic, calculus or acalculus.

19:16

So cholecystitis or cholelithiasis, uh,

19:19

with cholelithiasis has, is very common.

19:24

25 million people report to have gallstones.

19:27

Many will never have symptoms in their lifetime.

19:30

However, in a 20 year old follow up, in the age when we

19:34

did oral cholecystograms, they followed these patients,

19:36

and 18 percent of them presented with acute colic.

19:40

For hepatobiliary imaging, the most common

19:42

indication is going to be acute colic.

19:44

calculus cholecystitis.

19:46

For positive compatibility scans, 95 percent will be

19:50

related to acute cystic duct obstruction, with about

19:53

20 percent having complications such as gangrene.

19:55

In chronic

19:58

cholecystitis, 75 percent of their obstruction

20:02

will resolve, resulting in fibrosis.

20:05

Recurrence of acute colic, about 25 percent

20:08

in one year, 60 percent in six years.

20:12

Ultrasound accuracy is 80 to 85 percent.

20:16

Hepatobiliary imaging, however, is the procedure

20:18

of choice to assess for cystic duct obstruction

20:21

with a very high sensitivity of over 95

20:24

percent and specificity of over 90 percent.

20:29

A normal hepatobiliary scan and gallbladder ejection

20:32

fracture pretty much excludes acute calculus.

20:36

And acute A calculus cholecystitis.

20:42

So let's review four syntagraphic patterns

20:43

that you can see in hepatobiliary scans.

20:46

The most common, as we all know, is going to be

20:47

normal in at least about 60 percent of patients.

20:51

So we reviewed what the normal study is.

20:53

We'll review them again, our four phases.

20:56

Vascular phase normal should have

20:57

clearance of the blood pool by 10 minutes.

20:59

And again, I look at cardiac activity.

21:02

Hepatic should be homogeneous

21:04

with the T1 half at 20 minutes.

21:06

Biliary activity, if we're looking for

21:09

cystic duct obstruction, generally we would

21:11

like to see gallbladder by 60 minutes.

21:13

And if you do see gallbladder, it excludes acute

21:16

cystic dust, cholecystitis related to acute cystic

21:19

dust obstruction with very rare false negatives.

21:23

This has high negative predictive value of 98%.

21:28

I'd like you to remember, however, up to 90 percent of

21:31

patients with chronic cholecystitis will have a normal

21:33

hepatobiliary scan and visualization of the gallbladder.

21:37

As far as GIA TB, we generally like to see it by 60 minutes.

21:41

In about 20 percent of normal people, you will not see

21:44

GI activity, and that can be related to a hypertonic

21:48

sphincter at OTI, but also it's really more variable on

21:50

the patient preparation and the patient's fasting state.

21:56

So this is a normal hepatobiliary scan.

21:58

We see the cardiac activity clearing by 10 minutes.

22:02

You see nice, homogeneous tissue.

22:04

distribution of the hepatic parenchyma,

22:07

you see the gallbladder and GI activity.

22:10

And you can confirm this gallbladder activity

22:13

with an LAO, which gallbladder should move

22:15

laterally, and you can also confirm it with the

22:17

right lateral, the gallbladder should be anterior.

22:22

So now let's look at the next pattern.

22:24

You have no gallbladder at one hour, no gallbladder

22:27

after morphine augmentation, or on for our delayed

22:30

image, which is in about 30 percent of patients.

22:34

And this means cystic duct obstruction.

22:36

You can have a false positive in a small

22:39

percentage of patients with chronic cholecystitis.

22:44

So this is a patient, you have the vascular phase clearance

22:49

is normal, hepatic, and you see biliary and enteric phases.

22:54

And at 60 minutes, we see no gallbladder.

22:57

So what we do, we give morphine sulfate.

23:00

no gallbladder seen, and morphine sulfate after.

23:04

These are at 30 minutes.

23:06

This is consistent with cystic duct obstruction.

23:11

And this is a CT scan showing a

23:13

large gallstone near the cystic duct.

23:18

So what's some of the false positives

23:20

for cystic duct obstruction?

23:22

Remember we talked about the non fasting patients?

23:25

that are normal.

23:26

The gallbladder can be contracted in 64 percent of normals.

23:29

And so, if the patient has not been fasting

23:32

as recently even, you can have a false

23:34

positive study for cystic death obstruction.

23:37

Prolonged fasting, remember those patients

23:39

have a gallbladder full of sludge.

23:41

And if you do not give them CCK, you'll have

23:43

a false positive for cystic death obstruction.

23:47

Severe liver disease.

23:48

You can have a false positive.

23:50

You might not have enough activity that gets into the

23:53

biliary system to visualize the cystic duct at gallbladder.

23:57

A high common bowel death obstruction.

24:00

Biliary sphincterotomy is an interesting entity.

24:02

When you After you have a sphincterotomy, you

24:04

decrease the pressure from the sphincter of OD

24:07

to reflux the bile into the cystic ducts and

24:10

there's preferential ability to enter a transit.

24:13

And then it's also been reported in severe illness.

24:18

So what about the other half?

24:19

The false negative study where

24:21

you think you see the gallbladder.

24:23

We do know that you can see the gallbladder

24:25

in acute acalculus cholecystitis, partially

24:27

related to partial cystic duct obstruction.

24:31

And we'll talk about that later on in this presentation.

24:34

Perhaps you can mistake duodenal or

24:36

renal activity as the gallbladder.

24:38

There's an entity called cystic duct or the

24:40

nubbins sign, which I'll talk about later.

24:43

You may have a biloma and then congenital abnormalities.

24:48

So this is a 36 year old patient that we saw in our clinic.

24:51

She had a history of cholecystectomy a few years

24:54

back, but she presented with abdominal pain

24:56

and we did this study and you can see at 60

24:58

minutes it really looks like the gallbladder.

25:01

And so we did our LAO and our right lateral

25:03

and it definitely looked like the gallbladder,

25:05

but she had a history of cholecystectomy.

25:07

So we did a SPECT CT and it still

25:10

looked like the gallbladder.

25:11

We went ahead and talked to the clinician, and

25:13

actually the patient had a gallbladder remnant.

25:17

So in some cases, patients have a fenestrated

25:19

cholecystectomy and they have a gallbladder remnant.

25:22

So sometimes if you have this scenario, you

25:24

might want to check the operative report.

25:28

The third stenographic pattern is you see the gallbladder

25:31

after your morphine or Morphine augmentation and

25:35

on delay damaging, and you'll see that in a small

25:37

percentage of patients, and what that generally

25:39

means is the patient has chronic cholecystitis.

25:42

Other entities, however, can be seen in

25:44

hepatocellular disease, partial common bowel

25:47

duct obstruction, acute calculus, um, disease.

25:51

Disease related to partial cystic duct

25:53

obstruction and a calculus cholecystitis.

25:58

So this is a 21 year old male with abdominal pain.

26:02

And here you have a normal vascular phase,

26:06

hepatic phase, and then you have the enteric

26:08

phase, but no gallbladder at 60 minutes.

26:12

So what do we do?

26:14

We go ahead and give morphine, and you see the

26:16

gallbladder image after morphine administration.

26:19

So this has a patent cystic duct, but you also

26:22

then look at the ultrasound, and You see that the

26:26

gallbladder wall is thickened and there's sludge.

26:29

So this patient had a patent assisted

26:31

death, but he had chronic cholecystitis.

26:35

Now the last pattern we'll look at is the obstructive

26:38

pattern, which is in a small percent of patients.

26:41

And mainly we're looking at common bowel death obstruction.

26:45

So in acute common bowel death obstruction,

26:47

you'll really have good hepatic uptake.

26:49

You have a nice vascular clearance because the

26:51

hepatic enzymes are not abnormal at this point.

26:55

The But maybe the bilirubin is elevated.

26:58

There's no bilirubin activity at

27:00

one hour or on delayed imaging.

27:03

So this is a patient we saw in our ER.

27:05

where she came in with acute abdominal pain.

27:07

And at 60 minutes, you see just liver activity,

27:11

which I kind of call like a liver scan.

27:14

And then we did delayed 24 hour imaging.

27:16

And what you see here is some bladder

27:18

activity from vicarious renal excretion.

27:21

So they did an MRI, and she had gallstones.

27:24

She had cholelithiasis and choledocholithiasis

27:26

with three common bile duct stones, one

27:29

lodged at the ampullae of the bladder.

27:33

So let's look at other problem scenarios.

27:36

We've covered this a few times,

27:37

abnormal vascular and hepatic phases.

27:39

And this is, remember, prolonged vascular phase.

27:41

The clearance is greater than 10 minutes.

27:44

Persistent cardiac activity.

27:45

You have a prolonged hepatic transit.

27:48

Delayed to no hepatic peak.

27:50

Increased urinary excretion.

27:51

And you may or may not have bilirubin to bowel transit.

27:54

And this is indicative of hepatocellular disease.

28:00

So what can you do if you know the

28:01

patient has hepatocellular disease?

28:03

Then I would use a Mebifan and Mebri has higher

28:06

hepatic extraction, greater stability, and

28:09

less renal excretion, and we can use the higher

28:11

administered activity up to 10 millicaries.

28:16

So this patient, you can see, has at 48 minutes

28:20

still has hepatic activity and, and cardiac

28:24

activity, a prolonged vascular and hepatic

28:25

phase consistent with severe liver disease.

28:31

So let's look at the biliary phase.

28:33

Normal, you should be sure the gallbladder is present,

28:36

the bowel must be flowing, and the ducts must be patent.

28:39

So what are some of the problems we can see with a false

28:42

positive palpability scan where the gallbladder is not seen?

28:46

Well, we talked about two different scenarios.

28:48

One when the gallbladder is full of bile.

28:50

And the second when the gallbladder is contracted.

28:53

Let's say the gallbladder is full of bowel.

28:55

Remember that was a patient who has been eating for over

28:57

24 hours and you have a dilated gallbladder full of sludge.

29:01

You can also see this, though, with

29:03

TPN or low fat diets or two feedings.

29:06

So what's the modification you can do?

29:08

We can give CCK, wait 30 minutes, and then

29:11

proceed with your hepatobiliary study.

29:14

If the gallbladder is contracted, usually that's going to

29:16

be related to a recent meal, and the only thing you can do

29:19

then is to wait four hours after the last meal was ingested.

29:25

So now we have no gallbladder at 60 minutes,

29:28

but we know the gallbladder is in, and the

29:30

concern is for acute cystic duct obstruction.

29:33

You do have GI activity, like you see on this image

29:36

on the right, so you can give morphine sulfate,

29:39

or you can wait four hours and do delayed imaging.

29:43

If you see no gallbladder at 60 minutes

29:46

augmentation with morphine or delayed imaging that's

29:49

consistent with acute cystic death obstruction.

29:52

If you do see the gallbladder, that's not acute cystic

29:55

death obstruction, but possible chronic cholecystitis.

30:01

So here we again, we see a patient who has nice clearance

30:04

of the, of the vascular phase, nice hepatic clearance.

30:07

You have GI activity, but no gallbladder at 60 minutes

30:11

and no gallbladder after morphine administration

30:14

consistent with cystic death obstruction.

30:19

So one scenario I think We need to be careful of

30:22

is the patient with severe liver disease and you

30:25

have no gallbladder and no GI activity at 24 hours.

30:28

You cannot assess the patency of the cystic duct.

30:35

So another problem scenario that I've seen is that at one

30:37

hour, you have no gallbladder, you have a faint amount

30:40

of liver activity left, and you have lots of GI activity.

30:44

So whatever you do, whether you give morphine augmentation

30:46

or wait for hours delayed, I suggest that you do a.

30:50

a booster dose of two to three millicaries

30:53

of Colatec and wait 15 to 20 minutes.

30:56

Then you can do your morphine administration or you can

30:59

just go on and proceed with it delayed for our imaging.

31:04

So this is an example of such.

31:06

This patient has very good hepatic function.

31:08

The heart Vascular clearance is very prompt.

31:12

You have hepatic clearance is very prompt.

31:14

You have a lot of GI activity.

31:16

And so they end up waiting for four hours, but you

31:20

see at four hours, there's hardly any liver activity.

31:23

This patient probably would have benefited from a

31:25

two to three millicary dose at 60 minutes of Colatec.

31:32

So normal GI activity, you can, we

31:35

generally like to see at one hour.

31:36

You can see a small amount of

31:38

intergastric reflux, which is normal.

31:41

If you look at the enteric phases, you

31:43

generally don't see any bowel activity if

31:45

you have common bowel duct obstruction.

31:48

Sometimes you can see bowel obstruction.

31:50

Um, biliary activity, biliary to bowel transit

31:53

with sphincter of OD contraction, and then severe

31:55

liver disease, depending how severe the liver

31:57

disease, you may or may not see bowel activity.

32:01

The entity I want to focus on, though, is moderate

32:03

to severe enterogastric reflux, because that can

32:06

cause biliary gastritis and biliary esophagitis.

32:11

Well, let's look at this patient.

32:13

She's a 41 year old female with postprandial chest pain.

32:18

And you can see she has a normal hepatobiliary scan, except

32:20

she has a mild to moderate degree of enterogastric reflux.

32:24

So while we were talking to her in the room,

32:26

she said, Oh, I feel that pain in my chest.

32:29

So we took the camera and we imaged her chest,

32:32

and you can see that activity on the bottom

32:34

right here, activity in her metesophagus.

32:38

So she had gastroesophageal reflux and enterogastric.

32:42

She had biliary Okay, and.

32:45

Enterobiliary gastric and gastroesophageal

32:47

reflux resulting in irritation, and this can

32:51

also cause some biliary, um, esophagitis.

32:57

So, let's see, we have another problem scenario.

32:59

We have no GI activity at 60 minutes.

33:02

And your clinical question is cystic duct obstruction.

33:06

And you do see the gallbladder.

33:08

Really, technically, you're done

33:09

because the cystic duct is patent.

33:11

And you don't really need to see GI

33:13

activity because you wouldn't see it.

33:15

have cystic duct obstruction if you have

33:17

prompt visualization of the gallbladder.

33:19

So really if you're looking for acute

33:21

cystic duct obstruction, once you see

33:22

the gallbladder, you're, you're done.

33:25

However, if you don't see the gallbladder, you have

33:27

no GI activity, then you need to do the 4 to 24

33:30

hour delayed imaging and again, assess your liver

33:33

because you may need a booster dose of Colatept.

33:39

This is a cholelithiasis and abdominal pain.

33:44

So you see here, she has normal clearance of

33:48

her vascular hepatic phase, and you see the

33:50

gallbladder is seen quite, uh, immediately.

33:54

And then you see here, this little

33:55

photopenic area, you see all her gallstones.

33:57

She has photopenic gallstones and her gallbladder fundus.

34:01

So technically, we're, we're done

34:03

because of Cystic Ductus patent.

34:05

But if you want to see the GI activity to be complete,

34:08

you can give that patient a little CCK to move things

34:11

on and, uh, be complete to see the GI activity.

34:19

So what about delayed bilirubib transit?

34:21

No GI activity at 60 minutes.

34:24

Remember I said that can be normal depending

34:26

on the patient preparation and fasting state.

34:29

Remember we mentioned the patient that had we've not

34:31

been eating for over 24 hours and we gave a pre HIDA CCK.

34:36

Delayed bilirubinal transit is very common in these patients

34:39

and about half of these patients you won't see bowel

34:42

activity at one hour because most of the activity will tend

34:46

to go up into the gout that have like in a negative sex

34:50

toxic section that that's of the gallbladder, where the

34:53

activity goes up into the gallbladder rather than the bowel.

34:57

You can have no ability to buy transit

34:59

and partial common ballot instruction.

35:01

severe hepatobiliary disease, and then you can

35:04

also look at spring porogedons, um, spring type O

35:08

dysfunction and ototitis and with opiate administration.

35:13

Now I'm all, I'm sure you all have heard of the

35:16

REM sign of pericolohepatic increased activity.

35:19

You often see this better as the liver clears.

35:22

It's really not diagnosis of acute cholecystitis.

35:26

It has been reported to have seen in up to 70 to

35:28

85 percent of patients with acute cholecystitis.

35:31

40 percent have been reported to be complicated

35:34

with gangrene and perforation, but it's

35:36

also reported in chronic cholecystitis.

35:40

So this is a patient that, uh, Did a study on, and

35:43

you can see it's a faint brim of activity here,

35:47

a scented activity of hepatic activity in the

35:49

region of adjacent to a photopenic gallbladder.

35:53

The patient has the gallbladder removed.

35:55

This is her CTP4 and the pathology showed acute

35:59

cholecystitis with an adherent inflamed liver.

36:03

So that was probably the cause of that, uh, brim sign.

36:09

So I mentioned cystic duct or nubbin sign.

36:12

So you can see this in cystic duct obstruction.

36:14

It's the nubbin of cystic duct

36:16

activity distal to the obstruction.

36:19

When you see the cystic duct remnant

36:21

sign, do not give morphine sulfate.

36:23

The cystic duct is partially obstructed.

36:27

And so this is, I don't know if it projected

36:30

well, but this is a little nubbin of

36:31

activity in the region of the cystic duct.

36:37

Now you need to be very careful for

36:39

this entity in very, very sick patients.

36:41

Acute acalculus cholecystitis.

36:43

It's reported in up to 10 percent of acute cholecystitis.

36:46

I think that's a little high, but I still think

36:49

you need to remember this entity in very sick

36:52

patients because morbidity is 55%, mortality is 30%.

36:58

The mechanism most commonly reported is

37:00

cystic duct debris with partial obstruction.

37:05

Uncommonly, you can have a patient's cystic duct with an

37:08

inflamed gallbladder wall, and I actually had a patient

37:10

who had gallbladder ischemia related to the cystic artery.

37:15

You can exclude acute achalcoscolitis if you do

37:19

an ejection fraction, and it's normal because,

37:22

uh, an inflamed gallbladder will not have a normal

37:26

ejection fraction of equal to or greater than 38%.

37:30

So, if you can exclude acute achalcococcystitis,

37:33

I think that would be clinically helpful.

37:37

So, now let's take a word on chronic disease.

37:40

Chronic cholecystitis gallstones cause pain.

37:43

can cause chronic gallbladder inflammation and fibrosis.

37:47

With chronic cholecystitis, up to 95 percent

37:49

will have a normal hepatobiliary study.

37:51

Now, there are cases that report that with chronic

37:54

cholecystitis, you'll see GI activity before

37:56

gallbladder activity, and that the longer the

37:59

delay in seeing the gallbladder activity, the

38:01

higher the specificity for chronic cholecystitis.

38:04

Now, that's just an observation, and, uh, uh,

38:07

It may be a pattern you see, but I'd like you to

38:10

remember that 95 percent of chronic cholecystitis

38:12

will have a normal hepatobiliary study.

38:17

This is a 34 year old female with abdominal pain.

38:20

We saw prompt GI activity at 12 minutes, and then at

38:23

60 minutes, she did not have any gallbladder activity.

38:26

So we brought her back, no gallbladder, 60 minutes.

38:30

So we brought her back at two hours, and you

38:32

can see gallbladder activity at two hours.

38:34

LAO, the gallbladder went lateral, the

38:36

right lateral, the gallbladder's anterior.

38:39

Her ultrasound, though, showed gallstones and a

38:41

thickened wall consistent with chronic cholecystitis.

38:47

This is another patient.

38:48

She's 36 show with abdominal pain.

38:50

You see a nice shadowing gallstone.

38:54

So you see her, A powder belly study.

38:57

She sees gallbladder at 60 minutes,

38:59

so she has a patent cystic duct.

39:02

You can see her ultrasound with the

39:03

photopenia gallstone at the, near the fundus.

39:08

And you do her ejection fraction, which is less than 38%.

39:11

It's 13%.

39:13

So this is consistent with chronic calculus cholecystitis.

39:16

She has a gallstone and a low gallbladder ejection fraction.

39:22

Now let's look at biliary atresia.

39:24

The etiology of biliary atresia is unknown.

39:28

Most often it's seen in full term infants with

39:30

an elevated bilirubin and hepatospinal megaly.

39:33

The differential diagnosis is neonatal hepatitis.

39:37

And the importance of making this diagnosis

39:40

is because the patient with bilirubin atresia

39:42

should get a CASI procedure by 60 days.

39:46

You've all known about pre treating these patients

39:48

to increase therapeutic enzyme with phenobarbital.

39:51

That was not done in the past.

39:52

Now they use, uh, urosaldeoxycholic

39:55

acid, which is less sedative.

39:59

So the minimum dose is 0.

40:01

05 millicuries per kilogram.

40:02

I recommend a minimum dose, though, of one millicary.

40:06

Prompt diagnosis is extensional.

40:09

And the hepatobiliary study may prove

40:11

the only clue for biliary atresia.

40:14

A patent extra hepatobiliary system, where you see GI

40:18

activity, excludes biliary atresia in jaundiced neonates.

40:24

Bowel activity excludes biliary atresia.

40:27

If you have no biliary to bowel transit, even

40:30

on delayed imaging, you really can't tell.

40:33

In little children and neonates, neonate, you

40:35

need to be aware of renal activity, and if

40:38

you're not sure, I would recommend you SPECT.

40:40

You can do SPECT CT, but then you'll add further

40:42

radiation, and oftentimes we need to do delayed

40:45

imaging in the clinical scenario of biliary atresia.

40:53

So this was a patient we had with real atrial

40:54

atresia, and you can see that at the end of, these

40:58

are two minute image, at the end of one hour, we just

41:00

have liver activity, No GI activity at 60 minutes.

41:06

And then we did 24 hour delayed imaging.

41:09

And you can see she has vicarious

41:11

excretion into the urinary bladder.

41:13

So is this activity here, is this kidney or is this GI?

41:17

Tried to do right lateral, she couldn't tell.

41:20

We suspected there was GI activity, but we didn't know,

41:24

so we went ahead and did a spec study on the patient.

41:27

And if you look in here, this is axial

41:30

views and this is the left lobe anteriorly.

41:33

And we looked here and we saw that these two things

41:36

images, we thought that was GI activity, which it

41:38

was, and we excluded biliary atresia, and the patient

41:43

had neonatal hepatitis and, uh, recovered from that.

41:49

This is another patient who had biliary atresia, severe

41:52

hepatocellular disease, no GI activity at 24 hours.

41:57

You can't tell severe liver disease, you can't differentiate

42:00

between neonatal hepatitis versus biliary atresia.

42:05

The last section we'll look at will be

42:07

biliary leaks after cholecystectomy.

42:10

liver transplant and patients with Roux en Y procedures.

42:14

Let's look at the post operative ability scan.

42:17

Cholecystectomy we can assess for common bowel patency.

42:20

Or biliary leaks.

42:22

You can do sphincter autotomies and patients

42:24

can have biliary stents, and we can use

42:26

hepatobiliary scans to confirm the patency.

42:29

In other clinical scenarios, they use HEPA scans to assess

42:32

for sphincter of ary dysfunction and ENT loop syndrome.

42:36

I won't discuss the two last

42:37

entities during this presentation.

42:41

So this is 28-year-old female who was 10 years

42:44

post cholecystectomy and had abdominal pain, and

42:46

the clinicians wanted to assess her aary system.

42:49

So this is a normal post cholecystectomy.

42:52

Now,

42:56

when looking for bile leaks, I really recommend

42:58

delayed imaging and usually 18 to 24 hour imaging.

43:02

And if the patient has drains, I'd be

43:05

sure, you know, where the drains are.

43:07

And if they're in the peritoneal cavity,

43:08

where in the peritoneal cavity they are.

43:11

Any progressive extraluminal activity on imaging

43:15

is going to be suspicious for a biliary leak.

43:18

Sometime this, this leak is very, uh, very subtle, and

43:22

so I generally recommend that you do a cinematic display.

43:26

If the patient has cholecystectomy, usually

43:28

that leak will begin in the gallbladder fossa.

43:31

You might have an entity called reappearing liver

43:33

sign, where as the liver clears, you have more activity

43:37

that reaccumulates under the, gallbladder fossa.

43:39

Diaphragm of the liver, which is the bile

43:41

leak, that could be the reappearing liver sign.

43:44

I'll show you an example of a tail sign of Rencio.

43:47

Most often we like to see it on the right lateral view.

43:50

And again, if there are peritoneal drains,

43:52

you need to image the peritoneal drain.

43:56

So this is a patient who they worried about a biliary

43:59

leak and what I do is I like to look at the first image

44:01

that gives me the anatomy of the patient at the time

44:05

and then you can see there's increasing activity in the

44:07

region of the porta that's really not anatomic following

44:11

or intraluminal and you get concerned and then you look

44:15

at On subsequent imaging, the patient has a lot of non

44:19

anatomic activity actually flowing freely into the abdomen.

44:22

This patient had a large biliary leak.

44:26

This is another patient who we saw that in

44:28

the first hour, this was a very large leak.

44:31

You can see a tail of activity below the right

44:34

hepatic lobe, and this is the tail sign of Renzio.

44:37

This patient went back to the OR.

44:40

This is another patient who had drains,

44:42

and this was in the perineal cavity.

44:45

This activity here, this activity is in the drain.

44:48

This patient had a coercive tetanus, had a large

44:51

leak and had to be taken back to the operating room.

44:58

So now let's look at liver transplants.

45:00

You can have whole versus split liver transplants.

45:03

And really, mainly the reason in the split liver transplant,

45:06

they tend to leak at the cut edge and that is very common.

45:10

They try to bovine the, cut edge site, um, in the

45:13

operating room, but most often you'll have a little

45:16

leak and a lot of times they'll just observe that.

45:19

The other area that you'll have a leak

45:21

is the extrapatic biliary anastomosis.

45:24

These are of two types.

45:25

You can have a duct to duct or an end

45:27

to end or an end to side anastomosis.

45:30

And so these are demonst cartoon demonstrations of

45:33

patibility, uh, That can occur with the palpability

45:37

scans as far as leaks and the anastomosis.

45:39

This is the liver transplant.

45:41

This is an orthotopic.

45:42

This is the IVC.

45:44

The hepatic artery and portal vein anastomosis.

45:46

And this is the biliary anastomosis.

45:48

This is an end to end anastomosis.

45:50

The blue is the, um, donor common bowel duct,

45:55

and the green is the recipient of common bowel

45:58

duct, and this is the biliary anastomosis.

46:02

This here is an end to side anastomosis on a split liver

46:05

transplant, and they tend to, this is the cut edge, and

46:08

this is where they tend to have a mild biliary leak.

46:12

So what type of leaks can occur?

46:14

With the end to end anastomosis, acutely you can get,

46:18

the most common problem is going to be an asthmatic

46:20

edema or a stricture, followed by biliary leak.

46:24

Late complications is, uh, an asthmatic stricture

46:28

at the site of, um, um, um, um, um, surgery.

46:32

All of these are generally treated with

46:35

an endobiliary stent placed during ERCP.

46:39

An end to side anastomosis, the most common

46:41

complication is going to be a biliary leak.

46:45

So here we are again, end to end anastomosis,

46:48

most common is going to be anastomotic edema and

46:50

stricture followed by a leak, and the most common

46:53

for an end to side is going to be, uh, a leak.

46:58

So it's very important in liver transplants

47:00

to know what type of liver transplant

47:01

and what type of biliary anastomosis.

47:05

Issue here is you have a biliary leak, and if they

47:07

can't fix it with an endobiliary stent, you can

47:09

always convert this to an endocyte anastomosis.

47:15

So other GI, biliary anastomosis trauma we can

47:19

assess the patency of the biliary system, system

47:22

and then the integrity of the anastomosis.

47:25

A lot of times the clinicians know that there's a biliary

47:27

leak, but they just want to assess is this a slow or small

47:30

leak or a rapid bile leak for management decisions and if

47:34

they need to take the patient back to the operating room.

47:37

So this is a patient who had seven days post op after

47:40

an orthotopic liver transplant and abdominal pain.

47:44

You see here free fluid in the abdomen,

47:46

some ascites, no focal fluid collection.

47:49

They wanted to know about a bowel leak

47:51

and this here is the IBC anastomosis.

47:56

So you see here in the first 60 see free

47:59

flowing, um, um, tracer within the peritoneal

48:02

cavity consistent with the notable leak.

48:06

This patient had a large bowel leak after cholecystectomy

48:10

and went straight back to the operating room.

48:14

This is another patient who had an orthotopic liver

48:16

transplant, and you can see the initial images at

48:20

four hours show persistent cardiac and liver activity.

48:23

Patient had severe liver disease.

48:25

What we do with our patients, um, we

48:27

put a lead shield over the abdomen.

48:30

Um, Most all the time these patients will have a

48:33

subdiaphragmatic drain and then a biliary and asthmatic

48:36

drain and we tend to put these drains on the Lead

48:40

shield to assess for any minute amount of activity.

48:43

So at four hours We don't see any activity, but

48:46

we brought the patient back at 24 hours and you

48:48

can see that on the in the, over the lead shield.

48:51

You can see there's a small amount of

48:52

activity in the bulb consistent with a small

48:55

leak, but the patient was just observed.

48:59

This is another patient who had a trisegmentectomy and

49:02

a hepatogenosomy, and they wanted to rule out a biloma.

49:05

You can see a large localated air fluid level near the

49:09

surgical site, and they were concerned for a biloma.

49:13

You can see this on the coronal image.

49:16

And so the patient had a normal rule on why, and

49:19

so at 60 minutes here, you see a You don't see any

49:24

biliary leak, but you see that large area of phonopenia

49:27

that corresponded to that loculated air fluid level.

49:30

So at 60 minutes, we didn't see any leak.

49:33

So what do we do?

49:33

We bring the back of four hours and clearly

49:36

you see this area of extraluminal accumulation.

49:40

We did a SPECT CT.

49:42

You can see the air fluid level co registering to this

49:44

large biloma and the patient was aspirated 95 cc's of fluid.

49:51

So, during this presentation, we've looked at and

49:54

described the four phases of a normal hepatobiliary scan.

49:58

Remember the vascular phase, clearance by 10

50:01

minutes, hepatic, biliary, and enteric phases.

50:05

We've looked at three indications

50:07

for syncolyte or CCK administration.

50:09

Fasting patient MPO for over 24 hours,

50:12

that gallbladder is full of sludge.

50:14

We do CCK for gallbladder ejection fraction.

50:16

And some, um, Indications are used to

50:19

assess for sphincter of OD dysfunction.

50:22

Explain three causes of a false positive

50:25

scan for cystic death obstruction.

50:27

Non fasting patients, remember 64 percent

50:30

of non fasting normals can have a positive

50:32

scan because the gallbladder is contracted.

50:35

If the patient's been fasting, their gallbladder is

50:37

full of sludge and they can have a false positive scan.

50:40

And then you've seen a false positive scan

50:42

and high grade common bowel death obstruction.

50:46

And lastly, to be able to evaluate for a

50:48

biliary leak, remember to do delayed imaging.

50:51

We like to do anterior and right lateral views,

50:53

and particularly in patients after cholecystectomy.

50:55

If there are any peritoneal drains, image the drains.

50:59

And do cinematic displays if you have small amount

51:03

of activity to look for extra luminal activity.

51:08

So in summary, we've looked at the rate of pharmaceutical

51:10

mevaphenin, the pharmacologic interventions with CCK

51:13

and morphine sulfate, apalobiter scans, remember to look

51:17

at the vascular, hepatic, biliary, and enteric phases.

51:21

We've looked at four patterns of hepatobiliary study.

51:24

We've looked at acute acalcus cholecystitis, which is

51:27

excluded with the normal gallbladder ejection fraction.

51:30

Chronic colitis status up to 95 percent

51:32

can have a normal hepatobiliary scan, and

51:35

biliary atresia is excluded with GI activity.

51:39

We've looked at post op immunications and

51:41

liver transplant, mainly looking for leaks.

51:45

Thank you.

51:47

Perfect.

51:48

Thank you so much.

51:48

I do see a couple of questions for you in the Q& A feature.

51:51

Before we move there, I just want to thank all

51:53

of you on behalf of MRI Online for participating

51:55

in this new conference today and remind you that

51:56

it will be made available on demand at mrinline.

51:59

com in addition to all previous new conferences.

52:01

This is complimentary.

52:02

Uh, and join us tomorrow.

52:04

Dr. Rakesh Harris and Gani will be with us for a noon

52:06

conference on MR imaging of urinary bladder and the urethra.

52:10

Um, if you can open up that Q& A feature,

52:13

Dr. Metter, it should be at the top of your screen.

52:18

Okay.

52:20

I know you have a time crunch, so

52:21

as many as you can get through.

52:22

Okay.

52:24

Thank you.

52:27

Okay, so the question is, um, In India,

52:29

we don't have Sankalites, so we're forced

52:31

to do fatty meal using bread and butter.

52:34

In some cases, the bread offer quadrant pain,

52:36

dyspepsia, no gallbladder, no gallstones.

52:38

On ultrasound, gallbladder is seen on delayed imaging

52:41

more than 60 minutes, and smaller but with good emptying.

52:46

How do you interpret that?

52:48

Well, it depends.

52:48

If you, if you're looking for acute cystic

52:50

death obstruction, and you see the gallbladder,

52:52

there's no cystic death obstruction.

52:54

Unfortunately, to look for a gallbladder ejection

52:56

fraction, it's going to be very variable with very, Okay.

52:59

Bye.

53:00

degrees of fat content in a meal.

53:02

So I really, you know, it's very hard to say on that.

53:06

I think if you have a fatty meal and

53:09

the ejection fraction is greater than 38

53:11

percent, I think you could say that's normal.

53:12

If it's less than that, I think it's indeterminate.

53:14

The second question, could you please

53:20

Explain gallbladder moving laterally and

53:22

anteriorly in different views one more time.

53:24

Yes, so when you see the gallbladder and if you

53:27

look at an anterior view, it's going to tend

53:29

to be in the region of the gallbladder fossa.

53:31

It's really important to see how it looks like on

53:34

an ultrasound or really like a CT where it lies.

53:37

And what happens is it's generally more kind of like in

53:39

the mid part of the liver when you look at anteriorly.

53:42

So when you do a right lateral view, depending, I mean

53:44

an LAO view, I think it's really the most helpful view.

53:47

If you do, An LAO view, and I'd probably

53:50

probably do like a 45 degree steep LAO view.

53:53

You can see the gallbladder moving laterally

53:56

towards the abdominal wall, and if it

53:58

moves laterally it's going to be anterior.

54:00

And the main reason you see that is because you want

54:03

to differentiate the gallbladder from the duodenum,

54:05

and the duodenum will not move laterally, it will move

54:08

medially because it's posteriorly, it's posterior.

54:13

What is the role of morphine sulfate?

54:16

Well, the morphine sulfate helps to,

54:18

um, increase gallbladder pressure.

54:20

Remember, it contracts the sphincter of OD

54:22

to increase the common bowel duct pressure.

54:24

And with one third of the bowel in the biliary system going

54:28

into the cystic duct, so it helps to encourage more, um,

54:34

activity, actually more activity to go into the cystic duct.

54:38

It increases your, um, Pressure essentially

54:42

and kind of forces the Tracer to go into the

54:46

cystic duct if the cystic duct is patent.

54:51

What is your take on the use of Ensure plus Mule

54:54

for HIDAS studies in the view of difficulty?

54:58

You know, I I'm not familiar with that.

55:00

Um, I still think the standardized, uh, infusion of CCK.

55:05

I think if you take Ensure, you'd have

55:07

to do a big study in your population.

55:09

I really, uh, I think the same answer would be going

55:13

for Ensure as for the fatty meal is if you have a

55:15

greater than 38 percent, probably that's normal.

55:18

If it's less than that, I think it's indeterminate.

55:23

Another question, how we can actually

55:25

time the hepatic and biliary phases?

55:28

Well, it depends.

55:29

Hepatic phase and biliary phase, you don't really time it.

55:31

You actually just visually look at it.

55:33

In the sense of, if you're looking at timing, I

55:37

guess, it's when you inject the radiopharmaceutical

55:39

and you're having the patient under the camera.

55:42

As soon as you inject the pharmaceutical

55:45

and it's in the liver, that's time.

55:47

zero and you count from then from the time you

55:49

inject you can you um count for 60 minutes after you

55:53

complete the injection and Then that's when you look

55:56

at your t1 half at 20 minutes short half of your

55:59

radiopharmaceutical should have cleared from the liver

56:05

The next question in biliary atresia.

56:07

Do we need to do dynamic imaging

56:08

or can we take static imaging?

56:10

You can do static imaging really if you can just you know

56:14

You can do, you can inject the patient, you can take, if

56:16

the patient's up in the NICU, I think you can just take

56:19

your portable camera if you just want to take static images.

56:22

I think you should actually get at least an image

56:25

initially and then at 60 minutes and then you can take

56:28

interval imaging on delayed imaging for 24 hours later.

56:32

And if you really want to be, limited,

56:34

you can do one at 60 minutes, and you can

56:37

do one at four hours, and then 24 hours.

56:41

Okay, regarding ultrasound versus HIDA

56:43

scans and patient with right upper quadrant

56:45

pain, it depends what you're looking for.

56:47

If you're looking for acute cystic duct obstruction, I think

56:50

the HIDA scan is really physiologically what you'll see.

56:53

If you have a patient who has an ultrasound and

56:57

has a type of Has right upper quadrant pain, has

57:01

gallstones and a thickened gallbladder wall, and

57:03

pericholecystic fluid, and has a positive Murphy's.

57:06

I think you can call that acute cholecystitis.

57:08

It depends kind of what you're looking

57:10

at and what your clinical scenario is.

57:15

Any idea on reliability of a hiatus

57:17

scan, just a small bowel motility?

57:19

No, I don't have, uh, any information on HIDISCAN.

57:23

It relates to small bowel activity, and I think

57:26

that would probably maybe, you might want to do a

57:29

gastric emptying, and you can follow the small bowel.

57:31

You can, I know you can do small bowel trans at

57:33

times, but I'm not really familiar with that.

57:37

What is the appearance of I'm sorry.

57:40

What is the appearance of gallbladder

57:42

acute acalcosclosus thitis?

57:45

So sometimes, so the, when you talk about the appearance,

57:49

I assume you're talking about the compatibility scan.

57:51

Well, we know that acute acalcosclosus thitis can, you can

57:55

visualize the gallbladder in, acute achalicus colitisitis

58:00

because it's only partial common bowel duct obstruction

58:03

usually related to debris in the in the cystic duct and

58:08

so That would be the pattern you see the gallbladder And

58:11

so you say the cystic duct is patent and it is patent But

58:14

to exclude acute achalicus colitisitis and you have if you

58:18

have enough activity in the gallbladder not just a little

58:21

bit of activity, but if you have a a a moderate amount

58:24

of activity, and you do a gallbladder rejection fraction.

58:26

If you get a normal gallbladder rejection fraction, I

58:29

think it's unlikely that you'll have an inflamed, acutely

58:33

inflamed gallbladder related to achalclous cholecystitis.

58:38

But you have to have, be sure that you have enough activity,

58:40

just not a little bit of activity in the gallbladder.

58:42

You have to have enough activity to give you a

58:44

reliable, um, gallbladder rejection fraction.

58:49

Can you use hepatic extraction time in hepatic?

58:53

I'm not familiar with extract, hepatic extraction

58:56

times for quantification of liver function.

59:00

Um, I can just, I think most a lot of times, I think when

59:03

We start getting into numbers, sometimes you get into

59:05

trouble, but, um, usually by the end of 60 minutes for a

59:09

normal functioning liver, you should have minimal activity

59:13

at 60 minutes in the liver on a hepatobiliary scan.

59:18

Do you have a standardized meal you administer?

59:20

No, we don't.

59:21

We don't give meals for assessing

59:23

gallbladder ejection fraction.

59:24

We use the standardized sincalide infusion

59:27

that's recommended by the S& M guidelines.

59:33

Do you have an algorithm on palatability findings

59:35

that can aid you in the diagnosis and impression?

59:38

I'm not sure what you mean by that.

59:41

Um, I like to talk about the vascular,

59:43

hepatic, biliary, and enteric phases.

59:46

And if that study is normal, I call it patent cystic duct.

59:49

I do not call it no cholecystitis because you can have, um,

59:54

gallbladder wall ischemia, um, and causing cholecystitis.

59:59

So I say that we're looking physiologically

60:01

For patency of the cystic duct.

60:03

So this would be a patent cystic duct if I

60:05

see the gallbladder on the hepatobiliary scan.

60:10

Do you have a high gallbladder ejection fraction?

60:14

Um, no, I don't have any indication.

60:17

The thing is that these high gallbladder ejection

60:19

fractures, I'm wondering how they're infusing the

60:21

sincolide that they're giving, because you can

60:23

have a lot of variability in both seeing the CCK.

60:27

So, I think if you have a normal, uh, 0.

60:30

02 micrograms per kilogram, that standardized

60:32

infusion, that's going to give you a better thermometer

60:35

on what the normal should be for that patient.

60:39

Okay, there's all these questions here.

60:41

Do you have any?

60:42

Um, which is better, CCK or Morphine?

60:45

Um, these are looking at two different things.

60:47

Uh, and, uh, so, morphine, for CCK, you're looking

60:51

for a gallbladder, generally do that for a gallbladder

60:53

ejection fraction like we're talking about, and

60:55

morphine is when you don't see the gallbladder.

60:58

See, CCK, you have to see the gallbladder.

61:00

With morphine, you don't see the gallbladder, and

61:02

you're trying to see the gallbladder by refluxing

61:05

the radiopharmaceutical into the cystic duct.

61:09

What's the rate that you infused?

61:11

I had mentioned the standardized rate is that 02

61:14

micrograms per kilogram, um, for 60 minutes in saline.

61:18

02 Over an hour.

61:21

That's rate of infusion.

61:24

And I believe those are No other questions I

61:29

see in the queue.

61:31

Yep, that's perfect.

61:32

Does it bring us a close down to thank you

61:33

Dr. Metter for your time today?

61:34

We really appreciate it.

61:35

Thanks to all of you for participating

61:36

in this noon conference again It will be

61:38

made available on demand at MRIonline.

61:40

com in addition to all previous student conferences.

61:42

It's complimentary And join us tomorrow.

61:45

Dr. Mukesh, Harrison, Ghani will be with us for a

61:47

noon conference on MR imaging of urinary bladder

61:49

and the urethra Please follow us on social media

61:52

at the MRIonline for updates and reminders.

61:54

Thanks again.

61:55

Thank you.