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Hepatobiliary Scintigraphy
version 3.0, approved June 23, 2001
Authors: Helena R. Balon, MD (William Beaumont Hospital, Royal Oak, MI); David R. Brill, MD (Chambersburg Hospital,
Chambersburg, PA); Darlene M. Fink-Bennett, MD (William Beaumont Hospital, Royal Oak, MI); John E. Freitas, MD (St.
Joseph Mercy Hospital, Ann Arbor, MI); Gerbail T. Krishnamurthy, MD (Tuality Community Hospital, Hillsborough, OR);
Harvey A. Ziessman, MD (Georgetown University, Washington, DC); Otto Lang, MD (Charles University, Prague, Czech Re-
public); Phil J. Robinson, MD (St. James University, Leeds, United Kingdom)
on parenteral hyperalimentation, or have a se- orally in two divided doses daily for a mini-
vere intercurrent illness). Sincalide should be mum of 3–5 days prior to the hepatobiliary
administered slowly (over a 3–5 min dura- imaging study to enhance the biliary excre-
tion) to prevent biliary spasm and abdominal tion of the radiotracer and increase the speci-
cramps. A slower infusion (30–45 min) may ficity of the test. Mebrofenin may be preferred
also be used (see IV.F.3.). over Disofenin in suspected biliary atresia.
2. Morphine Sulfate: When acute cholecystitis is G. Processing
suspected and the gallbladder is not seen by 1. Gallbladder ejection fraction (GBEF): Using
40-60 min, morphine sulfate, 0.04–0.1 mg/kg, the immediate pre-sincalide and the post-sin-
may be administered intravenously over 2-3 calide data, regions of interest (ROI) are
min. If the cystic duct is patent, flow of bile into drawn around the gallbladder (taking into ac-
the gallbladder will be facilitated by morphine- count patient motion) and adjacent liver
induced temporary spasm of the sphincter of (background) using any standard nuclear
Oddi. The intrahepatic biliary tree and com- medicine software package. The liver back-
mon bile duct (CBD) must contain radioactive ground ROI is selected taking care to exclude
bile, and tracer activity should be present in the ductal activity. GBEF is calculated from the
small bowel at the time of morphine injection. gallbladder time-activity curve as:
A second injection of radiopharmaceutical
(booster dose of approximately 1 mCi) may be
(net GB ctsmax) – (net GB ctsmin)
necessary prior to morphine if the remaining GBEF (%) = x 100
Net GB ctsmax
liver/biliary tree activity appears insufficient
to permit gallbladder filling. Shielding the 2. Hepatocellular function may be assessed by
bowel activity with lead may also be helpful. deconvolution analysis from ROI over the
Imaging is usually continued for another 30 liver and heart (hepatic extraction fraction) or
min following morphine administration but by analysis of a heart ROI for tracer clearance
may be extended if desired. Contraindications from the blood pool.
to the use of morphine include respiratory de- H. Interpretation Criteria
pression in non-ventilated patients (absolute), 1. Normal: A normal hepatobiliary scan is char-
morphine allergy (absolute) and acute pancre- acterized by immediate demonstration of
atitis (relative). hepatic parenchyma, followed sequentially
3. Sincalide stimulation: Gallbladder contractility by activity in the intra- and extrahepatic bil-
may be evaluated by determining the gallblad- iary ductal system, gallbladder and upper
der ejection fraction (GBEF) response to sin- small bowel. All these structures should be
calide. The study involves an intravenous in- seen within one hour. Gallbladder filling im-
jection over a minimum of 3 min or a 30-45 min plies a patent cystic duct and excludes acute
infusion of 0.01- 0.02 µg/kg sincalide after the cholecystitis with a high degree of certainty.
gallbladder is maximally filled with radiophar- 2. Acute cholecystitis: The hallmark of acute
maceutical (usually 60 min after the injection) cholecystitis (acalculous as well as calculous) is
and there is minimal activity in the liver. Com- persistent gallbladder non-visualization 30 min
puter acquisition (1-2 frames/min) then con- post morphine or on the 3–4 hr delayed image.
tinues for 30 min. Various protocols can be em- A pericholecystic hepatic band of in-
ployed. When performing and interpreting creased activity (rim sign) is often associated
this procedure, the physician must adhere to a with severe phlegmonous/gangrenous acute
specific technique (i.e., total dose of sincalide, cholecystitis, a surgical emergency.
dose rate and duration of infusion) and normal 3. Chronic cholecystitis and clinical settings as-
values validated for that technique. sociated with physiologicfailure of the gall-
4. Fatty meal stimulation: Gallbladder ejection bladder to fill with radiotracer (e.g., pro-
fraction measurement using a fatty meal longed fasting for >24–48 hr, severely ill or
challenge instead of sincalide has also been post-operative hospitalized patients) may re-
described. If visual assessment of gallblad- sult in gallbladder non-filling within the first
der emptying is sufficient, a fatty snack may hour, but may be separated from acute chole-
be used. cystitis using low dose intravenous morphine
5. Phenobarbital: In jaundiced infants in whom (see above) or delayed imaging. In chronic
biliary atresia is suspected, pretreatment with cholecystitis the gallbladder will usually be
phenobarbital, 5 mg/kg/day, may be given seen within 30 min of morphine administra-
62 • HEPATOBILIARY SCINTIGRAPHY
tion or on 3–4 hr delayed images, while true 8. Duodenogastric bile reflux: During a hepato-
cystic duct obstruction (acute cholecystitis) biliary scan, activity may reflux from the duo-
will result in persistent gallbladder non-visu- denum into the stomach. If the bile reflux is
alization. Appearance of the gallbladder after marked and occurs in a symptomatic patient,
the bowel has a significant correlation with it may be abnormal, since it is highly corre-
chronic cholecystitis. In severely ill patients lated with bile gastritis, a cause of epigastric
and in those on total parenteral nutrition, fre- discomfort.
quently the gallbladder will not be seen even 9. Post-cholecystectomy sphincter of Oddi
after morphine despite a patent cystic duct, dysfunction: Sphincter of Oddi dysfunction
and a larger dose of morphine (0.1 mg/kg) has the appearance of partial common bile
may be necessary to decrease the false posi- duct obstruction. Pretreatment with sin-
tive rate of the study. calide or morphine may improve the sensi-
4. Reduced gallbladder ejection fraction in re- tivity for its detection. Various visual, quan-
sponse to sincalide occurs in calculous and titative and semiquantitative scintigraphic
acalculous biliary diseases (i.e., chronic acal- parameters of bile clearance have been used
culous cholecystitis, cystic duct syndrome, in conjunction with image analysis. (e.g., a
sphincter of Oddi spasm). It may also be asso- scoring system, hepatic hilum-to-duodenum
ciated with various non-biliary diseases and transit time, % biliary emptying post-mor-
conditions, as well as caused by a variety of phine provocation, etc.).
medications (e.g., morphine, atropine, cal- I. Reporting
cium channel blockers, octreotide, proges- Aside from patient demographics, the report
terone, indomethacin, theophylline, benzodi- should include the following information:
azepines, histamine-2 receptor antagonists). 1. Indication for the study (e.g., suspected acute
5. Common bile duct obstruction: Delayed bil- cholecystitis, suspected common bile duct ob-
iary-to-bowel transit beyond 60 min raises the struction, suspected bile leak, etc.).
suspicion for partial common bile duct (CBD) 2. Procedure
obstruction, although this may be seen as a a. Radiopharmaceutical and dose adminis-
normal variant in up to 20% of individuals. tered
With high grade CBD obstruction, there is b. Other medications given and their dosage
usually prompt liver uptake but no secretion (e.g., pre-treatment with sincalide, mor-
of the radiotracer into biliary ducts. With pro- phine, post-treatment with sincalide)
longed obstruction, concomitant hepatic dys- c. Duration of imaging, special or delayed
function may be seen. With partial biliary ob- views obtained
struction, radiotracer fills the biliary system 3. Findings
but clears poorly proximal to the obstruction Include the appearance of the liver, the pres-
by 60 min or on delayed images at 2-4 hours ence and time of tracer appearance in the gall-
or with Sincalide. Clearance into the bowel bladder, small bowel, any unusual activity
may or may not be seen. Severe hepatocellular (e.g., bile leak, enterogastric reflux, etc.), any
dysfunction may also demonstrate delayed quantitative data generated (e.g., GBEF)
biliary-to-bowel transit. 4. Study limitations, patient reactions to drugs
6. Biliary leak: A bile leak is present when tracer administered
is found in a location other than the liver, gall- 5. Comparison/correlative imaging data
bladder, bile ducts, bowel or urine. This may 6. Impression
be seen more easily using a cinematic display This should be concise, as precise as possible,
or decubitus positioning (see above). should address the clinical question, provide
7. Biliary atresia: Biliary atresia can be excluded a differential diagnosis and make recommen-
scintigraphically by demonstrating transit of dations if appropriate.
radiotracer into the bowel. Failure of tracer to 7. Any urgent or unexpected findings should be
enter the gut is consistent with biliary atresia, directly communicated to the referring physi-
but can also be caused by hepatocellular dis- cian and this should be documented.
ease or immature intrahepatic transport J. Quality Control
mechanisms. Renal or urinary excretion of the None
tracer (especially in diaper) may be confused K. Sources of Error
with bowel activity and is a potential source 1. The causes of a false-positive study (gallblad-
of erroneous interpretation. der non-visualization in the absence of acute
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL MARCH 2003 • 63
Nuclear Medicine Annual 1999. Philadelpia: Lippincott spectrum of patients seen in a specialized practice
Williams & Wilkins; 1999: 99–119 setting may be quite different than the spectrum of
patients seen in a more general practice setting.
The appropriateness of a procedure will depend in
VIII. Disclaimer
part on the prevalence of disease in the patient
The Society of Nuclear Medicine has written and population. In addition, the resources available to
approved guidelines to promote the cost-effective care for patients may vary greatly from one medi-
use of high quality nuclear medicine procedures. cal facility to another. For these reasons, guide-
These generic recommendations cannot be applied lines cannot be rigidly applied.
to all patients in all practice settings. The guide- Advances in medicine occur at a rapid rate. The
lines should not be deemed inclusive of all proper date of a guideline should always be considered in
procedures or exclusive of other procedures rea- determining its current applicability.
sonably directed to obtaining the same results. The