Hepatobiliary scintigraphy in liver transplant patients: the "blind end sign" and its differentiation from bile leak

PURPOSE: Hepatobiliary scintigraphy is commonly performed on liver transplant patients to exclude biliary complications such as obstruction or leak. Biliary reconstruction in these patients is performed using either a direct duct-to-duct anastomosis (choledochocholedochostomy) or a biliary-enteric anastomosis (Roux-en-Y hepaticojejunostomy). The authors have observed a finding in scans performed on the latter group of patients that often simulates a bile leak. They postulate this finding to represent retention of activity in the blind end of the Roux limb (the "blind end sign"). The purpose of this study was to determine characteristics of this blind end activity, which may help differentiate it from true bile leaks. METHODS: Two nuclear medicine physicians reviewed 36 Tc-99m mebrofenin hepatobiliary scans (31 patients). Biliary reconstruction was performed in 25 patients with a Roux-en-Y hepaticojejunostomy, and in 6 patients with a choledochocholedochostomy. Each scan was evaluated regarding whether there was focal, persistent retention of activity in the anastomotic region, and, if so, various features of the activity were noted. Activity was concluded to represent a true bile leak based on subsequent surgical confirmation, and if there was no such confirmation, the activity was concluded to represent blind end retention in patients with Roux-en-Y hepaticojejunostomies. RESULTS: There were 8 total examples of blind end activity and 3 examples of bile leak activity. Useful discriminators between the 2 types of activity included the following: fluctuation in size and/or intensity with time (8 of 8 blind end cases vs. 0 of 3 bile leak cases); size comparable with bowel (8 of 8 vs. 1 of 3); tubular (4 of 8 vs. 0 of 3), round (4 of 8 vs. 1 of 3), or irregular (0 of 8 vs. 2 of 3) shape; and movement into bowel (3 of 8 vs. 0 of 3). Delayed imaging was performed in 3 cases at 1.5 hours, but was only conclusive in 1 case in which diffuse extravasation was seen consistent with bile leak. CONCLUSION: Retention of activity in the blind end of the Roux limb in patients with Roux-en-Y hepaticojejunostomies may simulate bile leak, but certain typical features, as well as delayed imaging, may aid in distinguishing the two.     

Posttraumatic bile leaks: role of diagnostic imaging and impact on patient outcome

The aim of this study was to evaluate the impact of bile leaks on patient morbidity and hospital course following blunt and penetrating liver trauma. Forty patients who underwent hepatobiliary scintigraphy after trauma were included. Scintigraphic results were classified as follows: free intraperitoneal bile leak, contained bile leak, and no bile leak. Outcomes measured were length of hospital stay, number of procedures required, and number of subsequent imaging studies. Bile leaks were identified in 25% of patients. Eight percent had free intraperitoneal leaks, 18% contained bile leaks, and 73% had no bile leak. One study was nondiagnostic due to poor hepatic function. Mean hospitalization was as follows: free bile leak group, 53 days; contained bile leak group, 10 days; no bile leak group, 14 days. Patients with free intraperitoneal bile leak had more imaging studies and procedures than patients without free bile leak. Patients with liver injury and free intraperitoneal bile leak have longer hospitalizations and undergo more therapeutic procedures than those without, who respond to conservative management.     

Hepatobiliary scintigraphy. An effective tool in the management of bile leak following laparoscopic cholecystectomy

Bile leaks and bile duct injury has been the major postoperative complications described after laparoscopic cholecystectomy. In this study, we evaluated the role of hepatobiliary scintigraphy (HBS) in patients who underwent laparoscopic cholecystectomy, and there was a clinical suspicion of bile leak in postoperative period. METHOD: Twenty-five patients (M/F=11:14, mean age 39+/-8 years; range 24-58 years) with suspected bile leak postlaparoscopic cholecystectomy underwent sequential HBS. RESULTS: Thirteen patients had normal hepatobiliary scintigraphic studies. Five patients had small bile leak in gall bladder fossa with primary route of bile flow into the gut. All these 18 patients improved on conservative management alone. Significant bile leak from the cystic stump region was demonstrated in four patients. All of them were subjected to endoscopic cholangiography (ERCP), which confirmed the site of leak. All patients had stenting and sphincterotomy. One patient showed bile leak and obstruction at the lower end of common bile duct, he improved spontaneously. Another patient showed poor hepatocytes function and no excretion of radiotracer and underwent ERCP followed by hepaticojejunostomy for common hepatic duct ligation. One patient had frank bile leak in the right paracolic gutter and had to undergo hepaticojejunostomy. CONCLUSIONS: HBS is a valuable noninvasive method of investigating possible bile leaks or other biliary disruptions in postlaparoscopic cholecystectomy patients. Negative study for significant bile leak can assure the surgeon to manage the patient conservatively. However, it cannot be relied on absolutely when determining the need for reoperation for a significant bile leak in early postoperative period.     

Hepatobiliary scintigraphy in detecting lesser sac bile leak in postcholecystectomy patients: the need to recognize as a separate entity

Cholecystectomy is one of the most commonly performed abdominal surgeries in which bile duct injury and bile leaks are the most important complications. Imaging plays an important role in the prompt diagnosis and management of bile leaks. The more common sites of bile leak are the gallbladder bed, subhepatic, in a bilioma, right paracolic gutter, or diffusely in the peritoneal cavity. Bile leak into the lesser sac (LS) is uncommon but is a special entity posing difficult problems in management. We have described in this study the clinical presentation, imaging findings, and management of 6 patients with biliary leakage into the LS postcholecystectomy. The clinical presentation of this condition was varied, ranging from patients with asymptomatic or with vague complaints resulting in difficulties in clinical suspicion or symptomatic but minimal enough not to be detected by ultrasonogram. Hepatobiliary scintigraphy played an important role in the diagnosis and management, and all patients required definitive therapeutic drainage procedures. Any persistent focal radiotracer activity in the anatomy of the LS, increasing with time and not diffusing into the general peritoneal cavity is diagnostic of bile leak into the LS.     

Various presentations of postcholecystectomy bile leak diagnosed by scintigraphy

Hepatobiliary scintigraphy is an established method for the diagnosis of a bile leak from the biliary system. A bile leak should be considered in any patient after cholecystectomy who has unexplained abdominal pain after operation. Three patients with bile leak diagnosed by scintigraphy are described, one of whom had an unusual pattern of hepatic subcapsular collection of the bile. The second patient had a bile leak through the postsurgical drainage tube, whereas the third patient had a more typical pattern of leakage into the peritoneal cavity.     

Value of MRCP with Mangafodipir Trisodium (Teslascan) injection in the diagnosis and management of bile leaks

PURPOSE: To assess the value of MRCP with Mangafodipir Trisodium (Teslascan) injection in the diagnosis and management of bile leaks. PATIENTS AND METHODS: Retrospective study of 25 patients (18 males, 7 females) with a mean age of 49.7 years and high clinical suspicion of bile leak who underwent MRCP with Mangafodipir Trisodium (Teslascan) injection between 2002 and 2006. The suspected etiology for bile leak was surgical (n=17), traumatic (n=7) or medical (n=1). The clinical suspicion was based on a combination of clinical, laboratory and imaging findings. RESULTS: MRCP with Teslascan injection demonstrated a bile leak in 20 patients. The site of leak was depicted in 17 cases: second order of smaller bile duct, (n=9), hepatic duct (n=3), confluence (n=2), cystic duct (n=1), bilioenteric anastomosis (n=2). Management based on MR findings included biloma drainage (n=7), biliary drainage (n=5), endoscopic management (n=2), repeat surgery (n=3), expectant management (n=1), and medical management (n=1). Outcome was favourable in 18 cases. Two patients died from infectious complications. CONCLUSION: In addition to confirming a diagnosis of bile leak, MRCP with Teslascan injection depicts the site of leak allowing optimal management.     

TIPS术中胆汁漏出：刺激平滑肌细胞增生?

目的经颈内静脉肝内门腔静脉分流术（ＴＩＰＳ）中胆道损伤并胆汁漏出，可能是引起ＴＩＰＳ术后支架内平滑肌细胞（ＳＭＣ）增生和狭窄的重要因素。本研究以离体ＳＭＣ培养和ＴＩＰＳ猪模型实验评价胆汁对ＳＭＣ的作用。材料与方法离体ＳＭＣ培养分为三组：Ⅰ组＝１．０％血清＋１．０％胆汁；Ⅱ组＝１０．０％血清＋１．０％胆汁；Ⅲ组＝１０．０％血清。细胞收获点分别为３、１０、１４天。动物实验组共用４５只猪建立ＴＩＰＳ模型，术后处死时间为１０～１６天。结果此前预试验结果：使用２．５％、５．０％、１０．０％胆汁的培养基，ＳＭＣ在３天内全部死亡。离体细胞培养（１．０％胆汁）实验组（Ⅰ、Ⅱ组）中的脱氧核糖核酸（ＤＮＡ）和总蛋白量明显较对照组（Ⅲ组）少（Ｐ＜０．０５），且随着培养时间的延长其差异增加。动物实验组：２８．８９％的标本证实有胆汁漏出。定量分析示胆汁漏组中的ＳＭＣ增殖量较无胆汁漏组少。组织学检查发现有新生胆管在支架内生长。结论２．５％～１０．０％胆汁杀死ＳＭＣ，１．０％胆汁可抑制ＳＭＣ生长。动物实验示胆汁漏出导致ＳＭＣ增生减少，但血栓形成增加，从而使支架闭塞率增高。     

Bile leakage, bile ascites and bilioma--nuclear medicine diagnosis--demonstration of typical cholescintigraphic findings

Cholescintigraphy (hepatobiliary sequential scintigraphy) with 99m Tc-marked IDA derivatives results in a specific identification of bile in free intraperitoneal fluids (bile ascites) or encapsulated intraperitoneal fluids (bilioma). To detect or exclude a biliary leak, cholescintigraphy was performed in 42 patients. In contrast to sonography and CT ("anatomical imaging"), which are capable of detecting an intraperitoneal accumulation of fluid with high sensitivity, cholescintigraphy ("functional imaging"), alone can help to identify the presence of bile in such fluids, both specifically and on a non-invasive basis. Modern gamma cameras are of such high sensitivity that they can identify even the most minute of activity (bile) quantities with satisfactory anatomic allocation.     

Bile duct disruption and biloma after laparoscopic cholecystectomy: imaging evaluation.

Disruption of the biliary tree after laparoscopic cholecystectomy has been reported in 0-7% of cases, and likely represents the most significant postoperative complication. Documenting the presence and extent of a bile leak is often difficult. We reviewed the first 264 laparoscopic cholecystectomies performed at our institution and found seven cases of bile extravasation and/or biloma formation (prevalence, 2.7%). All patients were first seen in the early postoperative period with abdominal pain and low-grade fever. Sonography was performed in five of seven, CT in five of seven, hepatobiliary scintigraphy with diisopropyliminodiacetic acid in five of seven, and ERCP in four of seven cases. While sonography and CT were initially helpful in determining the presence of abdominal fluid collections, they were unable to differentiate between postoperative seroma, lymphocele, hematoma, and bile leak. Hepatobiliary scintigraphy was useful in demonstrating continuity of these fluid collections with the biliary tree and guiding further therapy. Four cases were managed with endoscopic biliary decompression, with the use of sphincterotomy or nasobiliary stent placement, with good clinical result. The other three cases were treated surgically with T-tube or external drainage. All patients did well clinically, without evidence of bile reaccumulation. Our experience suggests that sonography and CT are useful in detecting postoperative fluid collections, but cannot differentiate bile from other fluids. Hepatobiliary scintigraphy is valuable as a noninvasive means of investigating possible bile leaks and in guiding further therapy.     

Bile ascites in adults. Diagnosis using hepatobiliary scintigraphy and paracentesis

Hepatobiliary scintigraphy has been recognized as a useful diagnostic tool in detecting the presence and site of bile leaks. The authors report a case of bile ascites secondary to a postsurgical biliary leak, the scintigraphic findings in bile ascites, and the potential use of paracentesis, in combination with hepatobiliary scintigraphy, in confirming the presence of bile ascites and a bile leak.     

Three-dimensional cholangio-spiral CT demonstration of a post-traumatic bile leak in a child

Bilioma is a rare complication of traumatic liver injury, and the precise site of bile leak is often difficult to demonstrate with a non-invasive technique. We report a case of post-traumatic bile leak in a 15-year-old girl in whom spiral CT after intravenous cholangiography allowed excellent preoperative demonstration of the extent of the liver rupture and an exact location of the bile leak. We think that spiral-CT cholangiography could be an accurate, non-invasive technique to investigate the biliary system in cases of paediatric liver trauma. Received: 2 December 1997; Revision received: 3 April 1998; Accepted: 6 May 1998     

Pneumoperitoneum Caused by Transhepatic Air Leak After Metallic Biliary Stent Placement

A self-expanding metallic biliary stent was placed for palliation of a common bile duct obstruction in a 68-year-old male with unresectable pancreatic head cancer 3 days after initial percutaneous right transhepatic catheter decompression. The stent crossed the ampulla of Vater. Three days later, the stent was balloon-dilated and the percutaneous access was removed. At removal, a small contrast leak from the transhepatic tract was seen. Three days later, pneumoperitoneum was found with symptoms of peritoneal irritation and fever. A widely open sphincter of Oddi caused by the metallic stent, accompanied by delayed sealing of the transhepatic tract, may have caused the air and bile leakage into the peritoneal space. This case shows that pneumoperitoneum may occur without ductal tear or bowel injury, with a biliary stent crossing the ampulla of Vater.     

Effect of narcotic premedication on scintigraphic evaluation of gallbladder perforation

A case of gallbladder perforation is presented in which a small bile leak was demonstrated by cholescintigraphy while the patient was receiving meperidine, but not after meperidine was discontinued. The scintigrams obtained during meperidine therapy also showed a pattern of bile-duct obstruction. It is suggested that increased biliary pressure secondary to meperidine administration permitted visualization of the leak. Use of narcotic drugs may be a useful pharmacologic intervention in cases of peritonitis due to small or obscure bile leaks.     

Biliary leaks: treatment by means of percutaneous transhepatic biliary drainage

PURPOSE: To evaluate the efficacy of percutaneous transhepatic biliary drainage in the treatment of biliary leaks. MATERIALS AND METHODS: Sixteen patients with a biliary leak involving either the common bile duct (n = 12), the biliary confluence (n = 2), or a hepaticojejunal anastomosis (n = 2) were treated by means of percutaneous transhepatic biliary drainage. The biliary leak was due to severe acute necrotizing pancreatitis in six patients, while 10 patients had postoperative leak. Percutaneous transhepatic biliary drainage was performed with a 12-F catheter, with two series of side holes positioned on both sides of the extravasation to divert bile flow away from the defect. RESULTS: In 13 patients, the biliary leak healed after drainage (mean duration, 78 days). In four of these patients, a slight residual narrowing of the bile duct was treated by means of either balloon dilation (n = 2) or balloon dilation followed by insertion of a metallic stent (n = 2). All 13 patients remained cured (mean follow-up, 38 months). Two patients with severe acute necrotizing pancreatitis died of complications unrelated to the biliary leak. Vascular complications occurred in two patients, one of whom died after surgical drainage of a subcapsular hematoma. CONCLUSION: Biliary leaks can be treated successfully by means of percutaneous transhepatic biliary drainage. The procedure is particularly useful when surgical or endoscopic management has failed.     

Refractory biliary leak from intrahepatic biliary-enteric anastomosis treated by selective portal vein embolization

A 66-year-old woman underwent partial hepatectomy and pylorus-preserving pancreaticoduodenectomy for advanced Klatskin-type cholangiocarcinoma, and five intrahepatic biliary-enteric anastomoses were created. One anastomosis between the anterior-superior segmental bile duct and the jejunum developed a refractory biliary leak. Selective portal venous embolization with use of ethanol was performed in the anterior-superior portal branch to eliminate the production of bile by the target segment. The patient's clinical course was uneventful and the leak resolved after portal vein embolization.     

Acetic acid sclerotherapy for treatment of a bile leak from an isolated bile duct after laparoscopic cholecystectomy

Bile leak after laparoscopic cholecystectomy is not uncommon, and it mainly occurs from the cystic duct stump and can be easily treated by endoscopic techniques. However, treatment for leakage from an isolated bile duct can be troublesome. We report a successful case of acetic acid sclerotherapy for bile leak from an isolated bile duct after laparoscopic cholecystectomy.     

Standing views to differentiate gallbladder or bile leak from duodenal activity on cholescintigrams

Confusing a gallbladder or bile leak with duodenal activity is a common source of error in the interpretation of cholescintigrams. Techniques such as supplementary oblique views, delayed views, the "water test," dynamic display and combined cholescintigraphy and ultrasound have been used with varying degrees of success. As illustrated in two cases, supplementary standing views provide a simple alternative method to differentiate gallbladder from small bowel activity.     

Percutaneous Biliary Interventions: Inside and Outside the Box: The Role of the Interventional Radiologist in Bile Leak Diagnosis and Management

Bile leaks are rare but potentially devastating iatrogenic or posttraumatic complications. This is being diagnosed more frequently since the advent of laparoscopic cholecystectomy and propensity toward nonsurgical management in select trauma patients. Timely recognition and accurate characterization of a bile leak is crucial for favorable patient outcomes and involves a multimodal imaging approach. Management is driven by the type and extent of the biliary injury and requires multidisciplinary cooperation between interventional radiologists, endoscopists, and hepatobiliary/transplant surgeons. Interventional radiologists have a vital role in both the diagnosis and management of bile leaks. Percutaneous interventional procedures aid in the characterization of a bile leak and in its initial management via drainage of fluid collections. Most bile leaks resolve with decompression of the biliary system which is routinely done via endoscopic retrograde cholangiopancreaticography. Some bile leaks can be definitively treated percutaneously while others necessitate surgical repair. The primary principle of percutaneous management is flow diversion away from the site of a leak with the placement of transhepatic biliary drainage catheters. While this can be accomplished with relative ease in some cases, others call for more advanced techniques. Bile duct embolization or sclerosis may also be required in cases where a leaking bile duct is isolated from the main biliary tree.     

The usefulness of hepatobiliary scintigraphy in the diagnosis of complications after adult-to-adult living donor liver transplantation

Living donor liver transplantation has become an accepted procedure to overcome the shortage of adult donor organs. The aim of this study was to evaluate the usefulness of hepatobiliary scintigraphy in the diagnosis of complications after adult-to-adult living donor liver transplantation. We analysed 82 hepatobiliary scintigraphy studies performed using technetium-99m DISIDA in 60 adult patients (44 males, 16 females) who had been transplanted with a living donor's hepatic lobe (right lobe, 32; left lobe, 28). Indications for hepatobiliary scintigraphy were abnormal symptoms and/or liver function tests ( n=54) or suspected bile leak or biloma ( n=28). Median interval between transplantation and scintigraphy was 69 days (9 days to 23 months). Scintigraphic findings were classified into hepatic parenchymal dysfunction, total biliary obstruction, segmental biliary obstruction, bile leak and normal graft. Scintigraphic findings were confirmed by liver biopsy in 17 cases, and by radiological and clinical follow-up in 65 cases. There were 29 events relating to biliary complications (six total biliary obstructions, eight segmental biliary obstructions and 15 bile leaks) and 19 relating to non-biliary complications (15 cases of rejection, two of infection and two of vascular compromise) in 38 patients. Hepatobiliary scintigraphy provided the correct diagnosis in all eight segmental and five of six total biliary obstructions, and in all 15 cases of bile leak. Of the 19 non-biliary complications, 16 showed parenchymal dysfunction regardless of the aetiology and three showed total biliary obstruction on scintigraphy. All but three of 34 normally functioning grafts were normal on scintigraphy. The diagnostic sensitivity and specificity of scintigraphy for biliary obstruction in the 54 patients with abnormal symptoms or liver function tests were 93% (100% for segmental, 83% for total) and 88% (35/40), respectively. The sensitivity and specificity were each 100% (15/15, 13/13) for bile leak in the 28 patients with suspected bile leak or biloma. Hepatobiliary scintigraphy is an accurate diagnostic modality in the evaluation of biliary complications after adult-to-adult living donor liver transplantation, although it has limitations as a means of differential diagnosis of non-biliary complications.     

Percutaneous management of biliary leaks: biliary embosclerosis and ablation

Biliary leaks after hepatobiliary surgery are not uncommon. In certain situations minimal invasive percutaneous techniques may result in avoidance or reduction of the extent of surgery. Minimal invasive percutaneous techniques include (1) percutaneous bile collection (biloma) drainage, (2) percutaneous transhepatic biliary drainage, (3) biliary leak site embolization/sclerosis, and (4) leaking biliary segment ablation. There are two clinical applications for biliary ablation. The first is actual bile leak site ablation or embosclerosis to reduce an aperture or ablate a fistula (block a hole). The second is ablating an entire biliary segment to cease bile production and induce hepatic segmental atrophy (cease bile production). This article discusses the techniques used for biliary leak site embosclerosis/ablation (including biliary-cutaneous tract ablation) and biliary segmental ablation.