Gastrointestinal

System Nuclear
Medicine
Par t 3

Hepatobiliary Imaging
 Physiology

Hepatic cells secrete about 1 liter of bile

per day. Bilirubin is the final degradation
product of porphyrin metabolism, and its
principal source is the catabolism of
hemoglobin. Bilirubin is extracted from the
plasma by the hepatocyte, conjugated with
glucuronic acid, and excreted into the bile
biliary tree .
 Conjugated hyperbilirubinemia
usually indicates the presence of biliary
obstruction. Common bile duct flow is
solely passive, but the cystic duct may
function as a variable resistor that
actively regulates flow into and out of the
gallbladder.
 The biliary canals permit the passage of
bile from the liver to the duodenum.The
right and left hepatic ducts join at the
porta hepatis to form the common hepatic
duct,which in turn combines with the
cystic duct to form the common bile duct
.This is 10-15cm long, and is joined at its
distal end by the main pancreatic duct;
 They enter the wall of the duodenum at
the ampulla of Vater.. The gall- bladder
is attached to the inferior surface of the
liver. It is usually about 10cm in length
and 3-5cm in diameter .It serves as a
reservoir of bile and renders it more
concentrated .It connects with bile biliary
tree through the cystic duct.
胆 胆

道 道

系 系

统 统
肝 脏 解 剖
后 位
 Principle

The hepatic parenchymal (polygonal) cells

constitute 85% of the hepatic mass. Their
function can be studied by radiotracers such as
Tc-99m labelled iminodiacetic acid (IDA) or its
derivatives which are selectively extracted by the
liver polygonal cells and excreted into the bile.
 Biliary imaging has become the procedure
of choice in evaluating patients with
suspected acute cholecystitis because in
virtually all cases of acute cholecystitis
there is obstruction of the cystic duct with
no passage of radionuclide into the
gallbladder.
 The test can also be used to detect
enterogastric reflux of bile and neonatal
biliary atresia as well as to assess biliary
kinetics (gallbladder ejection fraction) in
suspected chronic cholecystitis.
 Indications:
• 1. Diagnosis of acute cholecystitis and
differentiate between acute cholecytitis and
pancreatitis
• 2. Diagnosis of biliary atresia,
• 3.Demonstration of patency of cystic and
common bile duct whenever oral or
intravenous cholecystograms are not
applicable.
4. Detection of bile leak,
5. Evaluation of bile duct obstruction.
6.Work-up of patients with biliary dyskinesis.
7. Study of bile reflux, postoperative gastroduodenal
reflux.
 Radiopharmaceuticals

A variety of radiopharmaceuticals have

been synthetized with the specific aim of
imaging the biliary system. An important
advance was achieved in the early 1970s
with the introduction of compounds which
reach high concentration in bile and are
produced by standard 99mTc-lablling techniques
of the 99mTc -lablled compounds,
 The iminodiacetic acid derivatives are
the most promising and also the most
widely used. They fulfil basic
requirements for hepatobiiary
radiopharmaceuticals, their molecular
weight varies from 300 to 1000dt.
and all compounds are organic anions,
bind to serum albumin, and usually
contain two ring structures in opposite
planes in the molecule. They are
responsible for chelation with 99mTe on the
one end and biliary excretion properties
on the other end of the molecule.
The commonly 99mTe-iminodiacetic(IDA)
derivatives used for hepatohiliary
imaging are:
99m
Te -HIDA, 99mTe -EHIDA, 99mTe -DISIDA .
They are transported to the liver bound
to albumin and are actively taken up by
the hepatocytes following the same
anionic pathway as bilirubin.
• HIDA: 85% excreted by the liver, 15%
by the kidneys
• Good visualization at bilirubin levels of
5-7 mg/dl
 Patient Preparation
• The patient should fast for 4 hours before
the study commences but not more than 12
hours
• The patient should fast and not eat within
4 hours of the study as the ingestion of
food may result in gallbladder
contraction and consequently a false
positive diagnosis ;
 If the patient has fasted for more
than 12 hours or has not eaten in
many days then HIDA may have
delayed filling of gallbladder
because it is filled with bile.
 Acquisition Parameters
• Imaging can be performed in either of 2
ways:
• 1.Sequential statics: After injection the
patient then take 3 minute anterior images
at 5 min,l5min,20 min,30 min,40 min,50 min.
and 60 min intervals. If the gallbladder has
delayed filling then arrange for the patient to
have a meal and reimage 3 hours later and
see if the gallbladder has filled.
• 2. Continuous acquisition:
If you use the continuous acquisition method
then the patient is positioned under the
gamma camera and the computer acquisition is set
up to erect for a dynamic phase (1 frames/min
for 60mins).The patient is asked to lay down in
the supine position.
 Normal Imaging
After intravenous administration of 99mTe
-HIDA:
There is rapid uptake of the tracer by the
liver. Then 99mTc-HIDA passes from the liver
towards the porta hepatis and hepatic
ducts. The common bile duct and cystic duct
become visible and the gallbladder normally
fills ( or seen) within 30 minutes after
injection.
 At this time the loops of the duodenum are
seen. Clearance of the activity from the
liver starts within 10-15 minutes and is only
just visible at the end of the study.
 And that means that the tracer
pass out of the liver.
The gallbladder is still visible at
60 minutes post injection and it
should be cleared from the liver.
Clinical Usage
 1.Acute cholecystitis

Cholelithiasis is the formation of stones

in the biliary tree and is a relatively
common disease . If the stone becomes
wedged in the cystic duct , this can
cause acute cholecystitis.
 A confident diagnosis of acute
cholecystitis can be made with a
clinical picture of acute upper
abdominal pain associated with fever,
an acutely tender and usually palpable
gall bladder, and transient jaundice.
 In more difficult cases investigation
is required, and 99mTc-labelled
hepatobiliary pharmaceuticals have been
shown to have a place in the diagnosis,
and the test is a very easy , harmless ,
high sensitivity and high specificity
method.
 A silent gallbladder, especially
persistent non visualization at 4
hours post injection is virtually
diagnosis of acute cholecystitis.
 The reason is that the gallbladder is unable to
concentrate activity when the cystic duct is
inflamed and obstructed .
The sensitivity cholescintigraphy in making
this determination exceeds 95%, and the
specificity approaches 99 %, leading to an
overall accuracy of > 97% in the acute
situation..
 2. Chronic cholecystitis

Delayed visualization between 1-4

hours in a patient with normal liver
function is a reliable sign of chronic
cholecystitis
 Although delayed visualization of
the gallbladder beyond 1 hour
postinjection occurs most commonly
in patients with chronic
cholecystitis, the role of 99mTc-IDA
imaging in diagnosing chronic
cholecystistis is limited for many
reasons.
 The majority of patients with chronic
cholecystitis exhibit normal visualization of the
gallbladder (85-90%). Delayed visualization of
the gallbladder ( Between 1 to 4 hours of the
exam) is considered fairly characteristic for
chronic cholecystitis ， but delayed
visualization can also be seen in a very small
number of patients with acute cholecystitis
(3.5%).
 The longer the delay in visualization , the
higher the correlation with chronic cholecystitis.
Visualization of bowel activity prior to
visualization of the gallbladder is a non-
sensitive, but rather specific finding in patients
with chronic cholecystitis (In most normals, the
gallbladder is seen before bowel activity). This
sign indicates chronic cholecystitis about 75% of
the time.
 3. Jaundice
In jaundiced patients it is important
to distinguish between intrahepatic
(nonobstructive) and extrahepatic(obstructive)
cholestasis which are treated medically and
surgically respectively.
In specific instances, biliary scintigraphy may
be useful in cases of acute common bile duct
obstruction when functional stasis is detectable
before dilation, and occasionally even before
liver function tests become abnormal.
 Extrahepatic bile duct obstruction causes
an increase in the ductal hydrostatic pressure
until the point where further hepatocyte
excretion is no longer possible.
In acute common bile duct obstruction (0 to
24 hours) there is generally prompt hepatic
uptake of the tracer without visualization of the
biliary tree and no gastrointestinal activity
(unless obstruction is partial).
 Hepatic function remains normal
during this early period. Between 24 and
96 hours, there is a mild to moderate
decrease in hepatic function. Beyond 96
hours, there is very poor hepatic uptake
and the scintigraphic findings are
difficult to distinguish from hepatitis.
 If the bile ducts are visualized, tracer activity
within a normal common duct should be less on a
2 hour image, than on a 1.5 hour image. If ductal
activity is unchanged or more intense on later
images, some degree of obstruction is likely
present.
Intrahepatic cholestasis can produce a pattern
identical to complete CBD obstruction.
 4. Biliary Atresia:

In biliary atresia there is usually normal

prompt clearence of tracer from the blood and
normal hepatic concentration with a high liver
to heart ratio at 5 minutes. Subsequently,
there is NO EXCRETION from the liver (non-
visualization of the biliary tree and bowel).
 5. Neonatal hepatitis
Depending on the severity of cholestasis
and hepatocellular dysfunction, different
scan patterns may be noted. Typically,
patients with neonatal hepatitis will
demonstrate poor hepatic uptake (due to
hepatocellular dysfunction) of the tracer
with poor biliary excretion, delayed transit
into the bowel.
 6. Biliary leakage

99m
Tc- IDA provides a sensitive
means of identifying, localizing, and
permitting serial evaluation of biliary
leaks.
 After surgery, the preferential route
of bile flow can be traced , whether
through a surgical anastomosis or into a
abnorma1 collection, without introduction
of nonphysiologic artifacts from
pressure injection through catheters or
risk of infection and other complications.
 The scintigraphic finding diagnostic for a
bile leak is extravasation of tracer
activity into the peritoneal cavity.
 However up to 50% of bile leaks can be
missed, if delayed images (at 4 hours) are
not performed. Delayed images are helpful
because the bile leak activity will frequently
intensify over time. Most bile leaks will be
detected in 4 to 6 hours, but rarely a leak
may not be identified until 24 hours after
injection. Therefore, 24 hour delayed
images should be obtained.
 7. Choledochal cysts

The typical cholescintigraphic appearance

is a photon-deficient mass in the region of
the porta hepatis and it can fills on delayed
images (2- 4 hours post injection).
 Cho1edocha1 cysts are caused by
irregular development of the sphincter
of oddi and the junction of the
pancreatic and common bile ducts, which
permit the reflux of pancreatic juice into
the common bile duct to result in
inflammation, fibrosis, obstruction and
consequent dilation.
Normal Imaging
fast

breakfast
Acute cholecystitis
Acute cholecystitis
Chronic cholecystitis
Intrahepatic Obstuction
Extrahepatic Obstuction
Cholestasis
Neonatal Hepatitis Syndrome
Neonatal Hepatitis
Congenital biliary Atresia

24h
Cystic Duct Obstruction
Cystic Duct Cyst
Choledochal cysts

Sketch Map
Bile Leak
 The end
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