Hepatobiliary scintigraphy in the assessment of biliary obstruction after hepatic resection with biliary-enteric anastomosis

We investigated the usefulness of hepatobiliary scintigraphy (HBS) for diagnosing biliary obstruction after curative hepatic resection with biliary-enteric anastomosis. The study population consisted of 54 patients who underwent surgery for benign (n=18) or malignant (n=36) biliary disease. We analysed 68 technetium-99m DISIDA scintigrams which were performed at least 1 month after the surgery (median: 9 months). Final diagnosis was made by operative exploration, other invasive radiological studies or clinical and radiological follow-up for at least 6 months after the surgery. Diagnostic accuracy was analysed according to the pretest likelihood of biliary obstruction. There were two total and 15 segmental biliary obstructions. In patients with symptoms of biliary obstruction and abnormal liver function, HBS always allowed correct diagnosis (two instances of total obstruction, seven of segmental obstruction and seven of non-obstruction). Among the patients with non-specific symptoms or isolated elevation of serum alkaline phosphatase, HBS diagnosed segmental biliary obstruction in seven of the eight instances, and non-obstruction in 22 of 23 instances. There were no cases of biliary obstruction and no false-positive results of HBS in 21 instances with no clinical signs or symptoms of biliary obstruction. The diagnostic sensitivity and specificity of HBS for biliary obstruction were 94% (16/17) and 97% (50/51), respectively. In conclusion, HBS is a highly accurate modality for the diagnosis of segmental biliary obstruction during long-term follow-up after hepatic resection with biliary-enteric anastomosis. Received 1 August and in revised form 14 October 1999     

Hepatobiliary scintigraphy in the assessment of biliary obstruction after hepatic resection with biliary-enteric anastomosis

We investigated the usefulness of hepatobiliary scintigraphy (HBS) for diagnosing biliary obstruction after curative hepatic resection with biliary-enteric anastomosis. The study population consisted of 54 patients who underwent surgery for benign (n=18) or malignant (n=36) biliary disease. We analysed 68 technetium-99m DISIDA scintigrams which were performed at least 1 month after the surgery (median: 9 months). Final diagnosis was made by operative exploration, other invasive radiological studies or clinical and radiological follow-up for at least 6 months after the surgery. Diagnostic accuracy was analysed according to the pretest likelihood of biliary obstruction. There were two total and 15 segmental biliary obstructions. In patients with symptoms of biliary obstruction and abnormal liver function, HBS always allowed correct diagnosis (two instances of total obstruction, seven of segmental obstruction and seven of non-obstruction). Among the patients with nonspecific symptoms or isolated elevation of serum alkaline phosphatase, HBS diagnosed segmental biliary obstruction in seven of the eight instances, and non-obstruction in 22 of 23 instances. There were no cases of biliary obstruction and no false-positive results of HBS in 21 instances with no clinical signs or symptoms of biliary obstruction. The diagnostic sensitivity and specificity of HBS for biliary obstruction were 94% (16/17) and 97% (50/51), respectively. In conclusion, HBS is a highly accurate modality for the diagnosis of segmental biliary obstruction during long-term follow-up after hepatic resection with biliary-enteric anastomosis.     

Preoperative assessment of postoperative remnant liver function using hepatobiliary scintigraphy.

Hepatic resection is the therapy of choice for malignant and symptomatic benign hepatobiliary tumors. The concept of remnant liver volume (RLV) has been introduced and can be assessed with CT. However, inhomogeneous liver function distribution and a lack of correlation between morphologic hypertrophy and functional recovery fuelled the enthusiasm for functional imaging. The aim of the present study was to assess liver function reserve (LFR) and remnant liver function (RLF) before and after major liver surgery with hepatobiliary scintigraphy (HBS) and to compare scintigraphic results with volumetric CT data and indocyanine-green (ICG) clearance test results. Furthermore, HBS was used to assess functional recovery of liver function, and results were compared with volumetric data. METHODS: Fifteen patients with a partial liver resection were included. HBS was performed before, 1 d after, and 3 mo after surgery. ICG clearance and CT were performed before and 3 mo after surgery. Liver function determined with HBS was compared with ICG and volumetric data. RESULTS: Liver function determination using HBS was highly reproducible. A strong positive association (r = 0.84) was found between LFR determined with HBS and ICG clearance. Little or no association (r = 0.27) was found between CT volumetric analysis and corresponding ICG clearance. A strong positive association (r = 0.95) was found between the RLF determined preoperatively on HBS and the actually measured value postoperatively. A weak positive association (r = 0.61) was found between functional liver regeneration and liver volume regeneration in the 3 mo after partial liver resection. CONCLUSION: HBS offers a unique combination of functional liver uptake and excretion with the ability to assess the preoperative LFR and to estimate the RLF preoperatively. Determination of the RLF instead of the RLV might clarify some of the discrepancies observed in the literature between RLV and clinical outcome in patients with an inhomogeneous liver function. Finally, liver function regeneration can be monitored using HBS.     

Risk assessment of posthepatectomy liver failure using hepatobiliary scintigraphy and CT volumetry.

A major part of morbidity and mortality after liver resections is caused by inadequate remnant liver function leading to liver failure. It is therefore important to develop accurate diagnostic tools that can predict the risk of liver resection-related morbidity and mortality. In this study, preoperative hepatobiliary scintigraphy of the future remnant liver and CT volumetric measurement of the future remnant liver were performed on patients who were to undergo liver resection. The accuracy of risk assessment for postoperative morbidity, liver failure, and mortality was evaluated. METHODS: Forty-six patients who were scheduled for liver resection because of hepatobiliary tumors, including 17 patients with parenchymal disease (37%) and 13 patients with hilar cholangiocarcinoma (28%), were assessed preoperatively. Hepatobiliary scintigraphy was performed by drawing regions of interest around the future remnant to calculate (99m)Tc-mebrofenin uptake in it. CT volumetry was used to measure the volume of the total liver, the tumors, and the future remnant. Receiver-operating-characteristic analysis was performed to assess cutoff values for risk assessment of morbidity, liver failure, and mortality. Furthermore, univariate and multivariate analyses were performed to determine factors related to morbidity and mortality. RESULTS: Morbidity and mortality rates were 61% and 11%, respectively. Liver failure occurred in 6 patients (13%). Significantly decreased uptake in the future remnant was found in patients in whom liver failure and liver failure-related mortality developed (P=0.003 and 0.02, respectively). The volume of the future remnant was not significantly associated with any of the outcome parameters. In receiver-operating-characteristic analysis, uptake cutoff values for liver failure and liver failure-related mortality were 2.5%/min/body surface area and 2.2%/min/body surface area, respectively. In multivariate analysis, uptake was the only significant factor associated with liver failure. CONCLUSION: Preoperative measurement of (99m)Tc-mebrofenin uptake in the future remnant liver on hepatobiliary scintigraphy proved more valuable than measurement of the volume of the future remnant on CT in assessing the risk of liver failure and liver failure-related mortality after partial liver resection.     

MR cholangiography with manganese dipyridoxyl diphosphate in the evaluation of biliary-enteric anastomoses: preliminary experience

OBJECTIVE: The purpose of our study was to assess the usefulness of manganese dipyridoxyl diphosphate (Mn-DPDP)-enhanced T1-weighted MR cholangiography for evaluating patients with biliary-enteric anastomoses. CONCLUSION: Mn-DPDP-enhanced T1-weighted MR cholangiography may provide useful functional information and may aid in the assessment of the patency of biliary-enteric anastomoses.     

Phrygian cap simulating mass lesion in hepatobiliary scintigraphy

Hepatobiliary imaging has been used to demonstrate that defects in the region of the gallbladder fossa in sulfur colloid studies correspond to normal gallbladder and not tumor. We report a case of delayed filling of a portion of the gallbladder due to a Phrygian cap anomaly. The case demonstrates that without delayed images incomplete filling of the gallbladder can be confused with a mass lesion in the liver.     

Value of hepatobiliary scintigraphy and ultrasonography in the differential diagnosis of jaundice

In order to compare the reliability of hepatobiliary scintigraphy using DISIDA (DHS) and ultrasonography (US) in the diagnosis of obstructive jaundice, 36 consecutive patients clinically suspected for obstruction were examined with both methods. Sixteen patients who were definitively shown to have obstruction, were all correctly detected with DHS; US was positive in 15 cases, revealing the cause of the obstruction in four cases. The site of obstruction was predicted in eight cases by DHS and in 11 cases by US. Associated gallbladder diseases were evaluated better by US than by DHS, but a perforation was only demonstrated clearly by DHS. In the 20 patients with nonobstructive disease the false positive results were found in one case using DHS and in two cases using US. In this series of patients DHS and US showed high sensitivity and specificity, which were further increased when the two techniques were combined.     

Ultrasonography and scintigraphy of the liver in focal and diffuse disease

In a clinical series the accuracy of standard colloid scintigraphy and gray-scale ultrasonography in investigations for liver disease was evaluated. The results of 246 investigations in which both methods were utilized were reviewed and classified according to diagnosis and follow-up. In focal disease the sensitivity was 0.90 for scintigraphy, and 0.83 for ultrasonography; ultrasonography had the higher specificity, 0.94 compared with 0.77 for scintigraphy. In diffuse disease the sensitivity was found to be low for both methods, about 0.60, while specificity was high, 0.86 for scintigraphy and 0.92 for ultrasonography. Decreased liver function in diffuse liver disease as reflected by bone marrow uptake at scintigraphy was not found to have any influence on the degree of sensitivity of ultrasonography.     

Ursodeoxycholic acid-augmented hepatobiliary scintigraphy in the evaluation of neonatal jaundice.

Early differentiation of extrahepatic biliary atresia from intrahepatic cholestasis is important. Hepatobiliary scintigraphy is an excellent noninvasive investigation for ruling out extrahepatic biliary atresia. This study aimed at identifying the role of ursodeoxycholic acid (UDCA), a choleretic agent, in conjunction with hepatobiliary scintigraphy in differentiating extrahepatic biliary atresia from neonatal hepatitis. METHODS: Fifty-one infants (42 male, 9 female) aged 0.3-5.5 mo (mean, 2.9 mo) presenting with neonatal jaundice underwent 99mTc-mebrofenin hepatobiliary scintigraphy. For patients who did not show any excretion of tracer into the intestine till 24 h, the study was repeated after oral administration of UDCA (20 mg/kg every 12 h) for 48-72 h. Ultrasonography and, if required, liver biopsy and intraoperative cholangiography were used with clinical data such as stool color and serologic and other etiologic investigations to form a final diagnosis. RESULTS: Of 51 patients, 19 showed biliary excretion in the first study, ruling out extrahepatic biliary atresia. Neonatal hepatitis was the final diagnosis in these. Of the remaining 32 patients, 12 nonexcretors converted to excretors after UDCA treatment, whereas 20 still showed no biliary drainage. Four nonexcretors on scintigraphy had a final diagnosis of neonatal hepatitis with galactosemia; the remaining 16 had extrahepatic biliary atresia. The specificity of hepatobiliary scintigraphy in ruling out extrahepatic biliary atresia improved from 54.3% to 88.6% (P < 0.001) after UDCA treatment. None of the patients experienced any ill effects from UDCA administration. CONCLUSION: Pretreatment with UDCA significantly improves the specificity of hepatobiliary scintigraphy in ruling out extrahepatic biliary atresia as a cause of prolonged neonatal jaundice.     

Diagnosis of gallbladder dyskinesia by quantitative hepatobiliary scintigraphy

AIM: The aim of the present study was to develop a new pharmacologic method during hepatobiliary scintigraphy by which patients with functional and organic forms of gallbladder (GB) dysfunction can be differentiated. METHODS: Quantitative hepatobiliary scintigraphy (QHBS) was performed on 31 patients with impaired GB motility selected by cerulein-augmented ultrasonography. Nineteen patients had acalculous biliary pain (ABP) and suspected GB dyskinesia, 6 patients had celiac disease, and 6 patients had type II diabetes mellitus. Sixty minutes after the isotope administration, 1 ng/bwkg/min cerulein (CCK10) was infused for 10 minutes, and then from the 90th minute, an equivalent dose of CCK10 was infused in the presence of 0.5 mg sublingual glyceryl trinitrate (GTN) in 12 or placebo in 7 consecutive patients. The GB ejection fraction (GBEF) was calculated repeatedly in time periods from 60 to 90 and from 90 to 120 minutes. RESULTS: In the majority of patients with ABP and suspected GB dyskinesia, CCK10 and GTN coadministration normalized the previously impaired GB-emptying. When the cumulative results of all 12 patients were calculated, we demonstrated significant differences (P=0.003) in the GBEF between the first (CCK10) versus the second (CCK10 plus GTN) stimuli: 19+/-11% versus 40+/-17%, respectively. In contrast, in 12 patients with celiac sprue and diabetes mellitus, no differences in the GBEF were detected when the first (CCK10 alone) versus the second (CCK10 plus GTN) stimuli was compared: 21+/-10% versus 22+/-13%, respectively. Finally, placebo and CCK10 coadministration in 7 consecutive patients with ABP and suspected GB dyskinesia did not influence the GBEF as compared with CCK10 alone: 13+/-9% versus 15+/-10%, respectively. CONCLUSION: GTN and CCK10 coadministration induces a significant improvement of the GBEF in patients with GB dyskinesia. The application of this new pharmacologic test during QHBS permitted the noninvasive separation of those patients with secondary impaired GB-emptying as a result of GB dyskinesia from those with primary forms of GB hypokinesia.     

Evaluation of hepatic perfusion and function with modified hepatobiliary scintigraphy

The quantitative relationship between changes in portal vein pressure and the perfusion index was studied, and hepatocellular function was evaluated. A modified protocol of hepatobiliary dynamic scintigraphy with Tc-99m-labeled ethylene hepatobiliary iminodiacetic acid (EHIDA) was performed in 37 patients with hepatic cirrhosis and 12 healthy controls. In 18 patients, the portal vein pressure (PVP) was measured intra-operatively during the portal vein bypass procedure. The portal vein perfusion index (PVI) was obtained by a two-compartment model of hepatic perfusion. A three-compartment model was applied in the hepatocellular extracted and excreted time-radioactivity curves, and the hepatic functional index was calculated including the hepatic uptake index (UI), the mean residual index (MRI), the uptake speed index (UsI), the descent speed index (DsI), the peak uptake (PU), and the peak time (PT) of hepatic uptake. These function indices in the cirrhotic patients were compared to the indices in the healthy controls with a two-sided t-test; specifically, the PU (18.94 ± 6.80 vs. 29.67 ± 18.98, P < 0.01), UI (0.84 ± 5.99 vs. 18.41 ± 13.87, P < 0.05), and UsI (0.58 ± 0.39 vs. 1.23 ± 0.81, P < 0.01) were slower in patients with hepatic cirrhosis compared with the healthy controls. The PT (16.83 ± 4.89 vs. 10.95 ± 2.79, P < 0.001) and MRI (5.93 ± 2.96 vs. 2.74 ± 0.97, P < 0.001) were more prolonged and the DsI (0.07 ± 0.09 vs. 0.18 ± 0.14, P < 0.01) was less compared to controls. The PVI were significantly higher in cirrhotic patients than in controls (46.17 ± 7.83 vs. 29.07 ± 5.71, P < 0.001), and the PVI correlated to the PVP (r = 0.79, P < 0.01).In conclusion, modified quantitative hepatobiliary dynamic scintigraphy can evaluate the changes of portal vein blood flow and monitor hepatocellular function, in which the portal vein blood flow can estimate portal vein pressure.     

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.     

Morphine-augmented hepatobiliary scintigraphy in the severely ill: caution is in order

Morphine augmentation in hepatobiliary scintigraphy has been reported as a useful tool to shorten imaging time. The technique has not been extensively evaluated in patients who are severely ill and receiving total parenteral nutrition, although the study of these patients with non-morphine-augmented hepatobiliary scintigraphy is problematic. The authors retrospectively analyzed 51 morphine-augmented hepatobiliary studies performed in a tertiary referral center on a population with a high proportion of severe intercurrent illness (18 patients, 14 of whom were receiving total parenteral nutrition) and hepatocellular dysfunction (eight patients). The overall sensitivity was 94%, specificity was 69%, and the false-positive rate was 40% for the diagnosis of acute cholecystitis. The majority of the false-positive cases occurred in the severely ill subgroup (false-positive rate, 60%). Morphine-augmented hepatobiliary studies may be advantageous because of shortened imaging time. However, patients who have severe intercurrent illness, whether or not they are receiving total parenteral nutrition, have a higher frequency of false-positive morphine-augmented hepatobiliary studies, and positive findings at scintigraphy in this patient group should be interpreted with caution.     

Functional diagnosis of biliary endoprostheses using hepatobiliary sequence scintigraphy

In 11 patients with biliary endoprosthesis, hepatobiliary scintigraphy with dimethyliminodiacetic acid (HIDA) was performed 16 times because of an increase in the serum bilirubin level. For the demonstration of dysfunction of the endoprosthesis, this method proved to have the same sensitivity as transhepatic cholangiography, which was performed as control examination. Therefore, hepatobiliary scintigraphy, a noninvasive and well-tolerated examination, can be recommended as a primary diagnostic tool in addition to ultrasonography for assessment of the drainage function of the biliary endoprosthesis.