Intravenous administration of morphine sulfate in hepatobiliary imaging for acute cholecystitis: a review of clinical efficacy

Morphine sulfate has been used by several investigators in the cholescintigraphic diagnosis of acute cholecystitis. A review of the available literature indicates that morphine sulfate significantly reduces the total time required for the hepatobiliary examination, while retaining both high sensitivity (98.8%) and specificity (88.9%).     

Efficacy of morphine sulfate-augmented hepatobiliary imaging in acute cholecystitis

OBJECTIVE: A review of the English language literature was performed to determine the sensitivity and specificity of morphine sulfate-augmented hepatobiliary imaging for acute cholecystitis. Twenty publications, involving 914 patients, were reviewed from journals published between 1984 and 1999. The analysis of these patients has resulted in the largest combined review study to date. The sensitivity and specificity of morphine-augmented hepatobiliary imaging were calculated to be 96.1% and 88.6%, respectively. After reading this paper, the nuclear medicine technologist should be able to: (a) discuss the clinical use of morphine augmentation during hepatobiliary imaging; and (b) state the sensitivity and specificity of morphine sulfate-augmented hepatobiliary imaging.     

Cholescintigraphy in acute cholecystitis: use of intravenous morphine

Conventional cholescintigraphy (60 patients) and a modified protocol (59 patients) were compared in 74 females and 45 males with acute cholecystitis. In the modified protocol, intravenous morphine (0.04 mg/kg) was administered whenever the gallbladder was not seen 40 minutes after injection of Tc-99m-pyridoxylideneglutamate (36/59). Accuracy was 98% with morphine, compared with 88% for the conventional protocol; specificity improved from 83% to 100% with no loss of sensitivity (96% in both groups). Low doses of morphine are well tolerated and can result in a highly accurate diagnosis of acute cholecystitis without the need for delayed imaging.     

Hepatic hot spot on both radiocolloid and hepatobiliary imaging in acute cholecystitis

A focal hot spot in the liver, seen on radiocolloid imaging, has been reported in several conditions. A patient with acute cholecystitis who had a hot spot in the liver on both radiocolloid and hepatobiliary scintigraphy is described. The hepatobiliary finding disappeared following cholecystectomy.     

Early morphine administration to expedite gallbladder visualization during cholescintigraphy for acute cholecystitis

A 58-year-old woman underwent emergent hepatobiliary imaging for evaluation of possible acute calculous cholecystitis. Intravenous morphine was administered 10 minutes after small bowel activity was first seen. The gallbladder visualized promptly after morphine administration, effectively excluding cystic duct obstruction and acute cholecystitis. The entire imaging procedure was completed and a final diagnosis made within 30 minutes.     

Two false-negative results using morphine sulfate in hepatobiliary imaging

Morphine sulfate has been used in hepatobiliary imaging to cause contraction of the sphincter of Oddi, thereby increasing pressure in the biliary tree. If the cystic duct is patent, the increased pressure usually causes bile to flow into the cystic duct with filling of the gallbladder. Using this technique, the authors have encountered two false-negative cases. Both patients received 0.04 mg/kg of morphine sulfate intravenously, 40 minutes after the intravenous administration of 5 mCi of technetium 99m-DISIDA. Although both patients filled their gallbladders within 1 hour, they both underwent surgical exploration because of high clinical suspicion of acute cholecystitis. Both were found to have acute cholecystitis.     

胆囊炎及结石性胆囊炎^99Tc^m—EHIDA肝胆显像研究

目的探讨胆囊炎及结石性胆囊炎胆囊显像特点.方法对14例无肝胆疾病的正常对照者和均经手术病理检查证实的包括胆囊炎患者27例、结石性胆囊炎患者38例2个疾病组进行了99Tcm-二乙基乙酰苯胺基亚氨二乙酸(EHIDA)肝胆显像及半定量分析.结果与对照组比较,2个疾病组潜伏期(LP)延长,胆囊排胆分数(EF)及排胆率(ER)均明显降低,差异均有高度显著性(P均<0.01).胆囊平均排空曲线示2个疾病组脂餐后胆囊排空潜伏期延长,呈"再充盈”现象.急性胆囊炎及慢性胆囊炎急性发作6例、慢性胆囊炎8例以及结石性胆囊炎20例胆囊未见显影.结论核素肝胆显像可早期预测胆囊疾病的发生并指导治疗.     

胆囊炎及结石性胆囊炎99Tcm-EHIDA

目的　探讨胆囊炎及结石性胆囊炎胆囊显像特点。方法　对 14例无肝胆疾病的正常对照者和均经手术病理检查证实的包括胆囊炎患者 2 7例、结石性胆囊炎患者 38例 2个疾病组进行了99Tcm 二乙基乙酰苯胺基亚氨二乙酸 (EHIDA)肝胆显像及半定量分析。结果　与对照组比较 ,2个疾病组潜伏期 (LP)延长 ,胆囊排胆分数 (EF)及排胆率 (ER)均明显降低 ,差异均有高度显著性 (P均 <0 0 1)。胆囊平均排空曲线示 2个疾病组脂餐后胆囊排空潜伏期延长 ,呈“再充盈”现象。急性胆囊炎及慢性胆囊炎急性发作 6例、慢性胆囊炎 8例以及结石性胆囊炎 2 0例胆囊未见显影。结论　核素肝胆显像可早期预测胆囊疾病的发生并指导治疗     

Gallbladder perforation seen on hepatobiliary imaging following morphine sulfate injection

A case of gallbladder perforation imaged during morphine-augmented cholescintigraphy is presented. Tc-99m DISIDA imaging dramatically demonstrated the bile leak. Whether morphine sulfate contributed to the perforation of the gallbladder is debatable.     

Indium-111-leukocyte imaging in acute cholecystitis

Eleven patients with suspected acute cholecystitis underwent sequential 99mTc-iminodiacetic derivative (IDA) and 111In-white blood cell (WBC) imaging to determine if 111In-WBCs accumulate within an acutely inflamed hemorrhagic gallbladder wall and, thus, could be employed as a reasonable alternative to 99mTc-IDA scintigraphy in detecting acute cholecystitis. Seven patients had surgically confirmed acute cholecystitis. Of these cases, five had a true-positive 99mTc-IDA and 111In-WBC, one an indeterminate 111In-WBC and true-positive 99mTc-IDA, and one a true-positive 111In-WBC and false-negative 99mTc-IDA scan. The remaining four patients did not have acute cholecystitis. All visualized their gallbladder within 1 hr after 99mTc-IDA administration and none had 111In-WBC gallbladder wall uptake. Both 111In-WBC and 99mTc-IDA scintigraphy accurately detected acute cholecystitis: hepatobiliary scintigraphy demonstrated a cystic duct obstruction and 111In-WBC imaging detected the inflammatory infiltrate within the gallbladder wall. The sensitivity and specificity of each was 86% and 100%, respectively.     

Current trends in imaging evaluation of acute cholecystitis

This study was designed to retrospectively determine recent clinical trends of initial radiological evaluation in patients pathologically proven to have acute cholecystitis (AC) and to assess the methodology that led to its diagnosis. Over a 28-month period, the medical records and imaging studies of 117 consecutive patients who had pathologically confirmed AC were retrospectively analyzed. The sensitivities of ultrasound (US) and hepatobiliary ^99mTc-iminodiacetic acid (HIDA) were computed. The false-negative scans were retrospectively reviewed by a blinded radiologist to determine the limitations and advantages of each modality. The 117 patients were grouped into six categories based on the type of imaging examination they underwent prior to cholecystectomy: initial US evaluation only (n=80, 68.4%), initial US followed by HIDA (n=17, 14.5%), initial HIDA only (n=2, 1.7%), initial HIDA followed by US (n=3, 2.6%), initial CT (n=5, 4.3%), and no imaging evaluation (n=10, 8.6%). HIDA scan had a calculated sensitivity of 90.9% (20 true-positive, 2 false-negative) while US had a sensitivity of 62% (62 true-positive, 38 false-negative). Current practice in the initial radiological evaluation of acute cholecystitis remains outdated. The vast majority of patients in our study group were initially worked up using US, although HIDA scan has been shown to have greater sensitivity for the diagnosis of acute cholecystitis.     

Hepatobiliary imaging and the use of intravenous morphine

Thirty-one patients suspected of acute cholecystitis were studied prospectively using hepatobiliary imaging in conjunction with intravenous morphine. If persistent nonvisualization of the gallbladder occurred post-morphine, delayed 4 hour imaging was performed. Intravenous morphine correctly diagnosed acute cholecystitis in 94% of cases. Through the use of intravenous morphine, imaging time can be decreased from 4 to 1.5 hours.     

Radiopharmaceuticals for hepatobiliary imaging

Tests for liver function have by and large centered around clinical laboratory diagnostic procedures for a number of years. Besides these, radiographic imaging procedures, including oral cholecystography and intravenous cholangiography, serve a very useful purpose, but several of them are invasive and involve a certain degree of risk from the administered contrast media as well as discomfort to the patient. The cholescintigraphic procedures, though noninvasive, have not played a significant role in the evaluation of hepatobiliary disorders prior to the introduction of the currently available. 99mTc-labeled IDAs. These new hepatobiliary agents offer many advantages over the previously utilized radiopharmaceuticals (131I-rose bengal in particular) in terms of the high degree of specificity for localization in the gallbladder with rapid extraction rates by the polygonal cells of the liver and very low excretion via the GU tract. A detailed understanding of the structure distribution relationship of the various groups in the complex enable the design of agents with an improvement in hepatobiliary specificity and other desirable characteristics. In many clinical situations, even in patients with high bilirubin levels, the 99m-Fc-labeled IDAs offer far superior clinical information over the alternative diagnostic imaging modalities. Further, the absorbed radiation dose imparted to the critical organs is far lower than with the older agents. Thus, the introduction of the cholescintigraphic procedures with the 99mTc-labeled IDAs have ushered in a new phase in the diagnostic workup of patients with impaired hepatocellular function and other biliary disorders.     

Morphine-augmented cholescintigraphy: its efficacy in detecting acute cholecystitis

Cholescintigrams were performed in 158 patients suspected of having acute cholecystitis after administration of 185 Mbq (5 mCi) of 99mTc-mebrofenin or disofenin. Morphine sulfate, 0.04 mg/kg was given intravenously if there was nonvisualization of the gallbladder at 40-60 min provided that radiotracer was seen within the small bowel. Acute cholecystitis was deemed present if there was nonvisualization of the gallbladder 30 min post-morphine administration; no cystic duct obstruction was present if the gallbladder was demonstrated pre- or post-morphine administration. A final diagnosis was estimated in 51 postoperative patients histologically, the remainder having their final diagnosis gleaned from their medical records. The sensitivity, specificity, positive and negative predictive value of morphine-augmented cholescintigraphy in detecting acute cholecystitis was 94.6, 99.1, 97.2, and 98.3%, respectively. These findings indicate that morphine-augmented cholescintigraphy detects acute cholecystitis with as high a degree of accuracy as conventional hepatobiliary scintigraphy, yet requires only 1.5 hr to establish the diagnosis.