Diagnostic value of the reflux sign in cholescintigraphy after administration of a gallbladder contracting agent--a comparison with X-ray cholangiography

This study reviewed 25 patients with the reflux sign in cholescintigraphy to assess its diagnostic value in evaluating biliary passage. After at least 4-hour fasting 5 mCi of 99mTcPMT or p-butyl IDA was injected intravenously and serial images were recorded before and after intramuscular injection of 10 micrograms of ceruletide diethylamine (caerulein). The reflux sign was determined positive when increased radioactivities in the left hepatic duct (minor reflux; MIR) or more peripheral intrahepatic ducts (major reflux; MAR) were recognized after injection of caerulein. The reflux sign was found in 28 of 237 (12%) studies. Direct and/or indirect X-ray cholangiograms were available in 25 (MIR; 15, MAR; 10). They included common bile duct (CBD) stone in 4, dilated CBD in 4, biliary dyskinesia (BD) in 4, chronic pancreatitis (CP) in 4, gallbladder (GB) stone in 3, duodenal ulcer (DU) in 2, CBD adenoma, pancreatic pseudocyst (PP), duodenal diverticle (DD), and acute cholangitis (AC) in 1 each. Their serum bilirubin levels were within normal limit in all but 2 at the time of cholescintigraphy. Transit time of radionuclides to the duodenum was found prolonged more than 60 min in 17 (68%) patients and persistent pooling in the CBD was found in 8 (28%) patients on scintigrams. The diameter of the CBD on X-ray cholangiogram was ranged 4 to 17 mm. Dilated CBD of more than 10 mm was found in 13 (52%) patients and apparent stenosis of the CBD in 6 (24%) patients. MAR seemed to correspond to increased diameter of the common hepatic more than 2 mm after caerulein injection in DIC. No abnormal findings in X-ray cholangiography was found in 10 (40%) patients including 3 with BD, 2 with GB stone, 2 with DU, 1 each with CP, PP, and AC. All those patients demonstrated MIR. We concluded that major reflux (MAR) sign was helpful in detecting an incomplete obstruction of the CBD, especially in patients with slightly to mildly dilated CBD.     

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.     

Variable bile retention on cholescintigraphy after morphine administration

Intravenous morphine sulfate has been used in conjunction with cholescintigraphy. We studied the variations in the degree and duration of the effects of 2 mg morphine on biliary kinetics in patients with gallbladder nonvisualization and undertook a comparison with biliary kinetics in patients not given morphine. Of 24 morphine-augmented cholescintigrams that were obtained without additional injection of technetium-99m diisopropyl-iminodiacetic acid (DISIDA), 19 showed continued gallbladder nonvisualization. Time-activity curves (TACs) of the liver parenchyma and common bile/hepatic duct (CD) of the entire study (before and after morphine) were obtained. In two patients, the CD was not sufficiently visualized to define a region of interest. In 17 patients, the peak CD activity was observed between 14 and 47 min after injection of^99mTc-DISIDA. In these 17, the TAC of the CD was declining essentially in parallel with the TAC of the liver parenchyma at the end of the first hour before morphine. After morphine injection, CD activity slowly increased for a variable duration in nine patients, while it continued to decrease in eight. CD activity between 1 h and 2 h showed a continuously decreasing pattern in another group of 20 patients who did not receive morphine despite gallbladder nonvisualization at 1 h. In summary, no significant effect of 2 mg of intravenous morphine on biliary kinetics was detected scintigraphically in a considerable proportion of patients. Also, there was considerable variation in the duration of the effect of morphine, when such an effect was present. This observation may have significant clinical implications for morphine-augmented cholescintigraphy.     

False-negative morphine-augmented cholescintigraphy: a case of subacute gallbladder perforation.

The gallbladder and an infected pericholecystic biloma secondary to subacute perforation were visualized during morphine-augmented cholescintigraphy. Perforation of the gallbladder may relieve cystic duct obstruction and contribute to false-negative visualization in the setting of acute cholecystitis.     

Prognostic value and pathophysiologic significance of the rim sign in cholescintigraphy

This study reviews 27 patients with nonvisualization of the gallbladder on cholescintigraphy. The preoperative diagnosis of acute cholecystitis was confirmed pathologically in 23. A rim of increased hepatic activity (RIHA) adjacent to the gallbladder fossa was seen throughout the study in 35% with acute cholecystitis and in no patients with chronic cholecystitis. Nine patients with "complicated" cholecystitis (defined pathologically as a late stage of the spectrum of acute cholecystitis) had a positive RIHA in contrast to no patients with "noncomplicated acute cholecystitis" (p less than 0.05). The sensitivity/specificity of the RIHA for "complicated" acute cholecystitis was 45%/100% and the positive/negative predictive value was 100%/39%. Liver tissue that was attached to the gallbladder by adhesions and removed at surgery was reviewed histologically and correlated with the presence or absence of a RIHA. The RIHA seems to be a useful indicator of patients presenting at a later stage of the pathologic spectrum of acute cholecystitis and perhaps at increased risk for complications.     

Morphine-augmented cholescintigraphy with a false-negative result and an apparent ectopic gallbladder.

Morphine-augmented cholescintigraphy has been shown to be a highly sensitive and specific means of evaluating acute cholecystitis. False-negative results do occur infrequently, however, and such a case is reported. In addition, this case initially demonstrated an apparent ectopic gallbladder, and thus anomalies in location of the gallbladder will be discussed.     

Use of CCK cholescintigraphy to differentiate choledochal cyst from gallbladder

A 17-year-old girl presented with right upper quadrant pain and was found to have a subhepatic cyst by ultrasound and CT. A DISIDA scan showed prompt filling of both the gallbladder and a very dilated common bile duct consistent with a choledochal cyst. Following intravenous administration of cholecystokinin, there was immediate emptying of the gallbladder into the cyst. Quantitative cholecystokinin cholescintigraphy may be a useful adjunct in the differentiation of choledochal cyst from gallbladder activity.     

The contracting cord sign of multiple sclerosis

Summary A new sign of multiple sclerosis, the contracting cord sign, is described. The myelographic demonstration of a large cord that subsequently decreases in size may suggest multiple sclerosis. Multiple sclerosis must be considered in the differential diagnosis of an enlarged spinal cord. Distinguishing between the collapsing cord and the contracting cord is discussed.     

Differential gallbladder contractility in fundal adenomyomatosis: demonstration by cholecystokinin cholescintigraphy

The cholecystokinin cholescintigraphic findings of fundal adenomyomatosis in a 29-yr-old male with severe post-prandial pain are presented. Planar cholescintigraphy demonstrated a trilobed gallbladder contour. Following the administration of 0.02 micrograms/kg of cholecystokinin at maximal gallbladder filling, fundal dyskinesia was observed. Regional gallbladder ejection fractions were: whole gallbladder, 43%; proximal two-thirds of the gallbladder, 70%; and gallbladder fundus, 32%. First harmonic Fourier phase and amplitude images demonstrated: (a) decreased fundal amplitude values, and (b) a phase shift of the pixels in the gallbladder fundus.     

Cholecystokinin cholescintigraphy: detection of abnormal gallbladder motor function in patients with chronic acalculous gallbladder disease

CCK cholescintigrams were performed in 374 patients with recurrent postprandial right upper quadrant pain, biliary colic, and a normal gallbladder sonogram and/or cholecystogram. The results of these examinations were correlated with the patients' final medical/surgical diagnoses. Twenty-seven patients recruited as control volunteers without objective clinical evidence of biliary disease also underwent CCK cholescintigraphy to determine if the degree of gallbladder contraction post-CCK differs in symptomatic versus asymptomatic subjects. Decreased gallbladder motor function was identified (maximal gallbladder ejection fraction response to CCK less than 35%) in 94% of patients with histopathologically confirmed chronic acalculous cholecystitis or the cystic duct syndrome and in 88% of patients clinically believed to have chronic acalculous biliary disease. Decreased gallbladder motor function does not distinguish symptomatic from asymptomatic gallbladder disease.     

The role of morphine-augmented cholescintigraphy and real-time ultrasound in detecting gallbladder disease

OBJECTIVE: Rapid diagnosis of acute cholecystitis is essential to minimize morbidity and mortality. The purpose of this study was to assess the diagnostic utility of cholescintigraphy using morphine augmentation compared with ultrasound, in acute and chronic gallbladder disease. METHODS: Cholescintigrams were performed on 103 patients suspected of having acute cholecystitis. In 79 patients (Group A) morphine sulfate was administered to reduce the scintigraphic imaging time if the gallbladder was not visualized during the first hour. In 24 control patients (Group B) no morphine was administered. All patients were evaluated clinically and 93 patients had concurrent ultrasound examination. RESULTS: The clinical presentation was nonspecific. The ultrasound findings were sensitive in detecting gallbladder disease (100%), but had low specificity (24%). Only findings of sediments and pericholecystic fluid were specific for cystic duct obstruction. Morphine augmentation reduced the imaging time by 126 min in patients with chronic cholecystitis. CONCLUSION: Real-time ultrasound has low specificity for gallbladder disease. In the presence of an abnormal ultrasound, it is essential to perform a hepatobiliary scan, either to exclude gallbladder disease or distinguish acute from chronic cholecystitis. Low-dose morphine administration is a safe and useful adjunct to standard cholescintigraphy by substantially reducing the time required to obtain a diagnostic study.     

Choledochal cyst mimicking gallbladder in Tc-99m disofenin radionuclide cholescintigraphy

A 6-year-old girl suffered from intermittent abdominal pain and bile-stained vomiting after undergoing cholecystectomy for perforated gallbladder and bile peritonitis when she was 2 years old. The interesting finding of her choledochal cyst, which was visualized 5 minutes after the injection of Tc-99m disofenin and contracted well after an egg meal, is reported. This finding is inconsistent with those of early reports, which emphasized delayed filling and stasis of radioactivity in the dilated cyst. This case, together with more recent reports in this field, suggests that nuclear images of choledochal cyst, like its clinical presentation, may be quite variable.     

Gallbladder carcinoma. Another cause of the distended photon-deficient gallbladder in cholescintigraphy

A case report of an 82-year-old woman with carcinoma of the gallbladder is presented. Technetium-99m DISIDA cholescintigraphy demonstrated nonvisualization of the gallbladder, with a large photon-deficient region corresponding to the gallbladder fossa, with medial displacement of the common bile duct. Carcinoma of the gallbladder has not been previously described as a cause of this scintigraphic pattern.     

99mTc-HIDA,a gallbladder imaging agent

The molecule N-(2,6-dimethyl-phenyl-carbamoyl-methyl)-iminodiacetic acid (HIDA), capable of chelating reduced ^99mTc, was synthesized, characterized, labeled with ^99mTc, and studied in experimental animals.The results indicated that the new ^99mTc-radiopharmaceutical is rapidly cleared from the blood to the liver, then rapidly removed to the gallbladder and excreted into the duodenum through the common bile duct.A comparative kinetic study of ^99mTc-HIDA and ¹³¹I-Rose Bengal performed in rabbits demonstrated that both radiopharmaceuticals had a similar blood clearance rate, but cleared at a different rate from liver to gallbladder. ^99mTc-HIDA showed a faster accumulation in the gallbladder than ¹³¹I-Rose Bengal.These findings, combined with the advantage of the low acute toxicity of HIDA, were promising enough to encourage a further evaluation and clinical investigation of this new Tc-99m hepatobiliary agent.     

Delayed biliary-to-bowel transit in cholescintigraphy after cholecystokinin treatment

The authors assessed the influence of cholecystokinin (CCK), administered before cholescintigraphy, on the biliary-to-bowel transit time (BBTT) of technetium-99m disofenin. Fourteen healthy volunteers underwent two separate cholescintigraphic studies with and without CCK treatment. BBTT was less than 1 hour in all 14 studies of subjects not treated with CCK. In 14 subjects treated with CCK, there was no tracer activity in the bowel up to 2 hours in seven (50%) (P = .006). Eighty-three cholescintigrams obtained in patients with suspected acute cholecystitis were also retrospectively analyzed. In 53 of 83 patients in whom the gallbladder was visualized within 1 hour, significantly delayed BBTT was found in 14 of 29 (48%) who received CCK, compared with the BBTT in one of 24 patients (4%) who did not receive CCK (P less than .001). In the 30 patients in whom the gallbladder was never visualized (n = 28) or was visualized after 1 hour (n = 2), BBTT was less than 30 minutes, regardless of whether patients were treated with CCK. Results show that CCK treatment causes significantly delayed BBTT in many cases, and this finding should not be interpreted as abnormal.