HIDA Flashcards
(34 cards)
1
Q
Indications for HIDA
A
- Biliary leak
- biliary atresia
- biliary obstruction
- biliary stent function
- biliary diversion assessment
- hepatocellular carcinoma
- focal nodular hyperplasia
- enterogastric reflux
- sphincter of oddi dysfunction
- acute vs. chronic cholecystitis
2
Q
Risk factors for cholecystitis
A
- age
- weight: rapid gain or loss
- female
- pregnant
- diet high in fat and cholesterol
- family history
3
Q
Acute calculus cholecystitis
A
- > 95% most common reason for cholecystectomy
- Blood work: High white cells normal liver
- RUQ pain radiating to shoulder
- nausea
- vomiting
- fever
- chills
- If untreated may lead to: Hemorrhage, ulceration, necrosis, gangrene, abcess/perforation
4
Q
Acute acalculus cholecystitis
A
- 2-5% of cases, 55% chance of morbidity
- seriously ill patients
- severe trauma
- severe burns
- shock
- sepsis
- post-op (non-biliary)
- post-partum
- Caused by inflammatory debris, inflammation of thegall bladder wall caused byinfection, ischemia, toxemia
5
Q
Chronic calculus cholecystitis
A
- chronic inflammation of the gall bladder due to repeated acute episodes
- recurrent biliary colic, low grade fever
- subsides in 1-10 days
- u/s confirs galstones and thickened gall bladder wall
- cgolecystectomy
- cholescinitigraphy rarely used
- results may be delayed or normal, most will have poor contraction with cck
6
Q
Chronic acalculus cholecystitis
A
- indistinguishable from ccc symptoms
- no stones, biliary dyskinesia
- RUQ pain, biliary colic, poor GB contraction, GB spasm (5-10% symptomatic)
- NM study sincalide
- cholecystectomy
7
Q
Radiopharmaceutical
A
- 99m-Tc iminodiacetic acid (IDA)
- binds to protein in blood to liver
- follows same extraction and excretion as bilirubin but not conjugated
- when serum bilirubin is high, may compete with one another
8
Q
HIDA
A
- 85% hepatic
- 15% renal
- good visualization @ 5-7mg/dL bilirubin
- no longer in use
9
Q
DISIDA (hepatolite)
A
- 88% hepatic
- 10% renal
- Good visualization @ serum bilirubin levels 20mg/dL
10
Q
Br IDA (choletec)
A
- Most resistant to bilirubin extraction
- best for patients with poor liver function
- 98% hepatic
- 17 min T1/2 excretion
- Bilirubin levels as high as 30mg/dL
11
Q
Patient preparation
A
- NPO 4 hours, if longer than 24 hours, 0.02ug/kg infusion cck over 60 min required to empty GB
- DIscontinue morphine: produces partial function biliary obstruciton, sphincter of oddi dysfunction
12
Q
Patient interview
A
- Reason for study
- cck pretreatment
- weight for intervential meds
- last meal
- check TPN in hospital patients
- acute or chronic symptoms
- u/s results
- surgery (biliary drainage tubes open or closed?)
13
Q
Protocol
A
- Dose: adults 11-185 MBq, children 1.85-37 MBq
- supine
- anterior
- LEAP or LEHR
- flow: 1 sec/frame 1 min
- dynamin: 1 min/frame 59 min
- LAO views at 60 min
- No GB @ 60 min inject morphine
- 75 MBq if insufficient liver activity
14
Q
Normal hepatobiliary uptake
A
- 5 min: liver activity exceed blood pool
- 10 min: cardiac blood pool gone
- 15 min: biliary tree
- 30 min: gall bladder
- 60-90 min: small bowel
15
Q
Morphine
A
- aids in acute cholecystitis
- increases interbiliary pressure
- dose: 0.04 mg/kg over 3min in 10 ml of saline, 2-3mg max
- Indications:
1. 45-60 min no GB
2. 75 MBq 99m-Tc IDA before if insufficient liver uptake - Results
1. CAC: GB seen within 30 min
2. AAC: cystic duct obstruction, no gallbladder
16
Q
Sincalide/CCK/Kinevac
A
- interacts with sphincter of oddi and GB wall
- GB contraction, bile release
- colonic motility
- sphincter of oddi relaxation
- Dose: 0.02 ug/kg over 30-60 min, effects seen in 15 min
17
Q
Indications for CCK before study
A
- NPO 24 hrs, empties full GB
- Severe medical conditions
- TPN
- Sphincter of oddi dysfuntions
18
Q
Indications for CCK during study
A
- When GB vizualization required at 30-60 min
- normal GB EF >38%
19
Q
Indications for CCK after study
A
- Differentiate common duct obstruciton from functional causes
- Diagnosis of CAC
- R/O AAC if gall bladder fills
20
Q
Acute cholecystitis results
A
- vizualization of the biliary system
- GB not full at 60 min, non-diagnostic (consistent with obstruction)
- 3-4 hour delay image, no GB at 3-4 hours diagnostic
- Morphine injection:
- GB fills 5-30 min, chronic cholecystitis
- No GB, acute cholecystitis
- Sensitivity: 96-100%
- Specificity: 81-100%
- More accurate than ultrasound
21
Q
Calculus cholecystitis results
A
- Cholescintigraphy not commonly used, ultrasound confirms diagnosis
- Study usually shows normal GB contraction but is poor with CCK
22
Q
Chronic acalculus cholecystitis results
A
- Bowel seen
- Delayed GB at 1-4 hours
- CCK can confirm
- Normal EF rules out acalculus disease
23
Q
Rim sign
A
Appearance:
- curvilinear band of increased activity along hepatic margin above GB fossa
- Increased pericholecystic hepatic activity without GB
Identification:
- Early appearanceas tracer clears the liver
- increased flow and/or imparied hepatocyte radionuclide excretion
- caused by liver inflammation adjacent to the GB wall
- severe acute cholecystitis specific: very ill, at risk for gagrene, abcess and possible rupture
24
Q
False positives
A
- Rapid biliary to bowel transit
- NPO too long
- NPO too short
- hyperalimentation (TPN)
- chronic cholecystitis
- hepatic dysfuntion
- concurrent severe illness
25
False negatives
- acute acalculus cholecystitis
- partial cystic duct obstruction
- accessory cystic duct
- dialated cystic duct
- biliary leak
- duodenal diverticula stimulation (GB)
- renal stimulation on GB
26
What are factor that impact GB contraction?
- Diabetes, IBS, pregnancy, chrons, celiac, cirrhosis
27
What are medications that interfere with GB contraction?
- Opiates
- Indmethicin
- Theophymine
- Benzodiazapines
- Birth control
- Atropine
- calium channel blockers
- nicotine, alcohol
28
Image analysis
- Background subtracted for GB EF
- Hepatocellular function assessed for with ROI around liver and heart (optional)
- GBEF= max counts- min counts/ max counts
29
Complete obstruction
- Obstructs bile flow leading to biliary cirrhosis
- Symptoms: Abdominal pain, jaundice, elevated bilirubin and alkaline phosphatase levels
30
Partial obstruction
- Gallstones
- bilirubin may be normal, no dialation
- intermittent recurrent abdominalpain
31
High grade obstruction
- hepatic uptake
- no biliary tree
- no bowel uptake @ 24 hrs when complete
- Some bowel uptake @ 24 hrs when complete
32
Low grade obstruction
- Hepatic uptake
- rapid secretion into biliary ducts
- bowel seen @ 60 min
- complete clearance @ 2 hrs
33
Enterogastric reflux
- scatter and overlying loops of small bowel seen
- often associated with CCK or morphine
- caused by gastritisand post-op gastric retention surgery
34
