Incidentally evaluating the status of renal function in technetium-99m DISIDA hepatobiliary imaging

During hepatobiliary imaging studies, approximately 9% of Tc-99m DISIDA normally is excreted via the kidney. In routine 2, 5, 10, 15, 30, 45, and 60-minute images, the kidneys and urinary bladder are best visualized at 5-10 minutes and after 10-15 minutes, respectively. Nonvisualization of the kidney and/or urinary bladder may indicate renal dysfunction. To evaluate this hypothesis, Tc-99m DISIDA hepatobiliary images of 63 patients were correlated with concurrent serum BUN and creatinine levels (measured within 24 hours of the hepatobiliary study). Serum creatinine and BUN values were normal in patients with renal visualization. In patients without renal visualization, 17 of 19 had abnormal BUN and creatinine levels. The values of BUN and creatinine were significantly elevated (P less than 0.001) in patients without renal visualization when compared with those showing renal visualization. One patient had visualization of a single kidney due to a nephrectomy; in another, persistent visualization was due to hydronephrosis. Nonvisualization of the kidneys and/or urinary bladder suggests abnormal renal function, and asymmetric renal activity raises the possibility of renal disease.     

Technetium-99m DISIDA hepatobiliary agent in diagnosis of hepatocellular carcinoma: relationship between detectability and tumor differentiation

The present investigation was aimed to assess the usefulness of biliary agents scintigraphy in the diagnosis of hepatocellular carcinoma (HCC) and to ascertain the relationship between the uptake of these agents and the degree of HCC differentiation. Forty-four patients with this hepatic cancer were included in the study. Liver scans were performed 20 min and 3 hr after the administration of 99mTc diisopropyliminodiacetic acid (DISIDA). DISIDA scintigraphy could not be assessed in six cases. In 16 (42%) out of the remaining 38 patients, the tumor exhibited equal or greater radioactivity uptake than the surrounding liver. In six out of these 16 patients, tumor uptake was apparent in the early and delayed hepatic scans, while in the other ten subjects radioactivity uptake by the HCC could only be detected in the 3-hr delayed scans. In the remaining 22 patients, HCC appeared as a cold area. Tumor location by this technique did not differ from that observed by 99mTc-sulfur colloid scan or ultrasound. DISIDA uptake was significantly related to tumor differentiation: 70% of those well differentiated tumors exhibited DISIDA uptake, whereas it was found in only 30% of those moderately differentiated and in none of those poorly differentiated (p less than 0.05). These results show that DISIDA scintigraphy can be useful in the diagnosis of HCC. Since its sensitivity is related to the degree of tumor differentiation, it may be indicated when aspiration cytology is unable to distinguish between well differentiated HCC and reactive changes due to hepatic cirrhosis.     

Persistent splenic visualization on technetium-99m DISIDA hepatobiliary studies

Tc-99m DISIDA is widely used for studying a variety of biliary conditions. It is generally recognized that the spleen is normally visualized on DISIDA imaging only during the blood pool phase. Upon review of our experience with DISIDA, visualization of the spleen was found more common than generally acknowledged. All DISIDA examinations performed at our two institutions were retrospectively reviewed; 95 studies were performed at Institution #1 and 150 studies at Institution #2. There were 138 men and 107 women. Quality control to confirm radiochemical purity included sephadex gel column chromatography. Of 245 patient studies, persistent splenic visualization was identified in one patient (1.0%) at Institution #1 and in 11 patients (7.3%) at Institution #2. There was no correlation between age, sex or final diagnosis and persistent visualization of the spleen. It is suggested that persistent splenic visualization may be caused by an elevated concentration of reduced hydrolized technetium (colloid) in DISIDA.     

Diagnostic significance of unusual small intestinal pattern on technetium-99m DISIDA hepatobiliary imaging studies

During the intestinal phase of hepatobiliary imaging studies in four patients, unusual small intestinal abnormalities were noted. These findings were correlated with surgery in three patients. Recognition of these patterns gives additional clinical information of significant diagnostic value. Further attention to small intestinal pattern and/or radionuclide evaluation of small intestine is a promising method of noninvasive evaluation of clinically suspected small intestinal infarction and obstruction.     

A horseshoe kidney detected incidentally by Tc-99m DISIDA hepatobiliary scintigraphy

Horseshoe kidney is a common renal fusion anomaly that is usually asymptomatic in adults. A horseshoe kidney was detected incidentally on Tc-99m DISIDA hepatobiliary scintigraphy performed to evaluate acute cholecystitis. The diagnosis was first suggested on hepatobiliary scintigraphy and confirmed by computed tomography.     

The effect of prolonged fasting and total parenteral nutrition on hepatobiliary imaging with technetium-99m DISIDA

Prolonged fasting (NPO) and total parenteral nutrition (TPN) have been reported to result in an unacceptable number of false-positive hepatobiliary scintigrams for acute cholecystitis. Based on these reports, the clinical usefulness of the hepatobiliary scan in diagnosing acute cholecystitis in the critically ill postoperative patient who has been NPO or on TPN has been questioned. Patients who were either on prolonged fasting or total parenteral nutrition and who had no history of hepatobiliary disease were prospectively studied to assess the value of the Tc-99m diisopropyl-iminodiacetic acid (DISIDA) scan without pretreatment with cholecystokinin (CCK) in such a setting. Of the 17 persons studied, nine had been on total parenteral nutrition for at least five days and eight had been fasting for at least five days prior to imaging. Seven of the nine individuals on TPN (78%) and six of the eight individuals who were NPO (75%) had normal hepatobiliary scintigraphy. The results suggest that hepatobiliary imaging with Tc-99m DISIDA has a lower false-positive rate in individuals on TPN or NPO than previously has been reported and that it has clinical efficacy in ruling out the diagnosis of acute cholecystitis in these individuals.     

Technetium-99m HMPAO imaging in Sturge-Weber syndrome

The Tc-99m HMPAO brain imaging confirmed marked hypoperfusion secondary to anomalous cerebral venous drainage of the Sturge-Weber syndrome. Until now, this had been a hypothesis suggested by results obtained from conventional brain scans and cerebral arteriography.     

Technetium-99m DMSA imaging and the obstructed kidney

Although several authors have claimed that the function of an obstructed kidney could be overestimated on Tc-99m DMSA imaging, the clinical importance of such an overestimation has not been well documented. Partial obstruction of one ureter was created in a rat, and a relative Tc-99m DMSA uptake was obtained 4 hours after intravenous injection. By puncture of the isolated obstructed kidney, it was shown that the function of that kidney was overestimated by at least 17%.     

Technetium-99m labeled myocardial perfusion imaging agents

99mTc labeled myocardial perfusion tracers have significantly advanced the field of noninvasive diagnostic evaluation and risk stratification of patients with known or suspected coronary artery disease by providing comprehensive information about myocardial perfusion and function from a single study. Of various currently available invasive and noninvasive test modalities, myocardial perfusion imaging provides the most powerful prognostic information that is incremental to the information obtained from invasive evaluation. Future research should focus on the development of perfusion tracers that linearly track myocardial blood flow over a wide range and have minimal splanchnic uptake. Availability of an effective attenuation and scatter correction program would further eliminate some of the current limitations of this technique.     

Unusual appearance of a highly vascular lesion on Tc-99m DISIDA hepatobiliary scintigraphy

A lesion was identified on the late images of a hepatobiliary scintigraphic study, but was not detected on the very early images, due to its enlarged blood pool. This combination of scan findings has not been previously described. The implication of the observation is that one must examine all the images of the hepatobiliary study in an effort to detect space-occupying lesions of the liver.     

Disorders of gallbladder function related to duodenogastric reflux in technetium-99m DISIDA hepatobiliary scintigraphy

Controversy exists over the relation between gallbladder dysfunction and the propensity for duodenogastric reflux. To evaluate this, Tc-99m DISIDA hepatobiliary imaging studies in 120 patients were reviewed, excluding patients who had had cholecystectomy or subtotal gastrectomy before scintigraphy. Serial images were obtained at 5, 10, 15, 30, 45, and 60 minutes and up to 24 hours, if indicated, after intravenous injection of 5-10 mCi of Tc-99m DISIDA. Normally, the liver, bile ducts, gallbladder, common bile duct, and bowel are visualized sequentially. Reversal of the normal sequence of gallbladder (GB) and bowel visualization indicates GB dysfunction; nonvisualization of the GB reflects cystic duct obstruction or absent GB function. Duodenogastric reflux is identified by radiotracer localized in the area just below or immediately adjacent to the tip of the left hepatic lobe. The intragastric location of the tracer may be verified by oral administration of 300 uCi of Tc-99m sulfur colloid. Twenty-nine patients had duodenogastric reflux between 10 and 60 minutes after injection. Of the 29 patients, 22 had a nonvisualized gallbladder, four had reversal of appearance of GB and bowel activity, and three had a normal study. GB dysfunction or nonfunction is more frequently demonstrated when duodenogastric reflux is present than with normal gallbladder function (P less than 0.001). In conclusion, gallbladder malfunction is closely associated with duodenogastric reflux, an abnormality that may be diagnosed noninvasively by Tc-99m DISIDA hepatobiliary scintigraphy.     

Technetium-99m HMPAO labeled leukocytes in inflammation imaging

Technetium-99m-HMPAO (Tc-99m-HMPAO) labeled leukocyte imaging was carried out in 19 patients at 3–5 hr after reinjection. There were no side effects noted. Tc-99m leukocyte images showed gall bladder, colon, kidney, and urinary bladder activity in normal distribution as a result of excretion of the eluted Tc-99m complex. They yielded a sensitivity of 93%, a specificity of 100% and an accuracy of 95%. They were correctly positive in 14 out of 19 cases. But one false negative case was seen in a patient with pyonephrosis showing a lack of renal function with decreased renal blood flow. It was concluded that they have some advantages over In-111 leukocyte images, but we have to consider the fact that the ureteral obstruction or the lack of renal function with decreased renal blood flow may result in a false positive or a false negative case.     

Technetium-99m benzimidazolyl iminodiacetic acid hepatobiliary radiopharmaceuticals: structure biodistribution studies

The biodistribution of fifteen structural variants of the hepatobiliary radiopharmaceutical, technetium-99m benzimidazolyl iminodiacetic acid (BIMIDA) were determined 1 h after i.v. injection into rats. The best compounds with respect to hepatobiliary excretion were those with halogen substituents in the benzene ring of the BIMIDA ligand. The cholescintigraphic properties of the BIMIDA compounds compared favourably with those of technetium-99m acetanilido iminodiacetic acid (HIDA) radiopharmaceuticals.     

Technetium-99m MDP imaging of acute radiation-induced inflammation

Tc-99m MDP three-phase bone imaging demonstrated the acute hyperemic inflammatory soft tissue phase of radiation injury to the hand in a patient receiving radiation therapy to bone lesions of multiple myeloma.     

Abnormal uptake of Technetium-99 m hydroxymethylene diphosphonate in the liver

Diffuse liver uptake on bone scintigraphy is a rare occurrence with only a few reports in the literature. A case of diffusely increased uptake in a patient with acute hepatitis is presented.     

Suprarenal abscess in the neonate. Technetium-99m glucoheptonate imaging

Although suprarenal abscess in a newborn is rare, a prompt diagnosis is essential for proper patient management. The findings obtained with Tc-99m glucoheptonate renal imaging in a newborn with a right adrenal abscess are reported. A radionuclide renal imaging sequence over a 15-hour period demonstrated a "rim sign" which can be used to suggest the diagnosis. Radionuclide and ultrasound imaging of neonatal adrenal masses is discussed.