MEDLINE Abstracts: Cholescintigraphy: Diagnostic Applications
MEDLINE Abstracts: Cholescintigraphy: Diagnostic Applications
Dill JE
Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A. 8(6):361-5, 1998 Dec
The diagnosis of cholecystitis and cholelithiasis is often straightforward, particularly when transabdominal ultrasound (TUS) reveals gallstones or other abnormalities of the gallbladder. There remain many patients, however, with typical biliary pain and normal findings on TUS. This latter group of patients, in which women constitute a large majority, often undergo considerable suffering. Their medical care can also be quite costly. Cholecystokinin cholescintigraphy and stimulated biliary drainage (SBD) have been proposed for difficult-to-diagnose gallbladder disease, but they both have limitations. Cholecystokinin cholescintigraphy may not predict postoperative outcomes with a high degree of reliability. The processing and interpretation of bile drainage specimens is not standardized, and the sensitivity of SBD is less than that of endoscopic ultrasound (EUS). Combined endoscopic ultrasound and stimulated biliary drainage (EUS/SBD) offers a high degree of sensitivity in the diagnosis of cholecystitis and microlithiasis. Positive EUS/SBD is also highly correlated with long-term symptom resolution or relief following cholecystectomy.
Yao NS, Wu CW, Tiu CM, Liu JM, Whang-Peng J, Chen LT
Cardiovascular & Interventional Radiology 21(4):350-3, 1998 Jul-Aug
Two cases are reported of chronic, partial afferent loop obstruction with resultant obstructive jaundice in recurrent gastric cancer. The diagnosis was made by characteristic clinical presentations, abdominal computed tomography, and cholescintigraphy. Percutaneous transhepatic duodenal drainage (PTDD) provided effective palliation for both afferent loop obstruction and biliary stasis. We conclude that cholescintigraphy is of value in making the diagnosis of partial afferent loop obstruction and in differentiating the cause of obstructive jaundice in such patients, and PTDD provides palliation for those patients in whom surgical intervention is not feasible.
Gani JS
Australian & New Zealand Journal of Surgery 68(7):514-9, 1998 Jul
Background: Patients referred to general surgeons for the treatment of gall-bladder stones were studied to evaluate the role of sincalide cholescintigraphy as a gall-bladder stress test in an effort to identify a group of patients whose pain was non-biliary in origin and who would not be improved by cholecystectomy.
Methods: Ten asymptomatic controls and 57 patients with gallstones and abdominal symptoms were studied. All patients were interviewed by an independent assessor who identified a group of patients in whom the role of gallstones in their presentation was uncertain (clinically possibly biliary group). All patients and controls underwent sincalide cholescintigraphy. The surgeons remained blinded to the study results throughout the study period. All patients were re-evaluated 6-12 months later to establish the ultimate diagnosis based on their therapeutic response.
Results: Several parameters of gall-bladder function were studied from analysis of the sincalide cholescintigram. Lag time, ejection period, ejection rate and ejection fraction did not differ significantly among controls, patients proven to have non-biliary disease and patients proven to have biliary disease. There were significant differences in mean gall-bladder filling fraction between proven biliary and proven non-biliary groups. However, the group of patients with clinically possibly biliary symptoms could not accurately be separated into those who benefited from cholecystectomy and those who improved without surgery on the basis of this parameter.
Conclusions: Significant differences in gall-bladder filling fraction between symptomatic and asymptomatic gallstone patients were identified suggesting reduced gall-bladder compliance in symptomatic patients. However, the sincalide cholescintigram failed to emerge as a useful gall-bladder stress test. Even in the 1990s, assessment by an experienced surgeon appears to be the most appropriate way to select patients for cholecystectomy.
Kalliafas S, Ziegler DW, Flancbaum L, Choban PS
American Surgeon 64(5):471-5, 1998 May
The objective of this study was to review the incidence, risk factors, methods of diagnosis, and outcome of acute acalculous cholecystitis (AAC) and to identify the sensitivity and limitations of current radiographic modalities used to establish the diagnosis. Our study was a retrospective chart review in a tertiary-care university hospital. Over a 53-month period, 27 cases of AAC (17 males, 10 females; mean age 50 years; mean Acute Physiology and Chronic Health Evaluation II score, 17) were encountered. Of these, 14 (52%) occurred in critically ill patients and 17 (63%) in patients recovering from non-biliary tract operations. AAC occurred in 0.19 per cent of surgical intensive care unit admissions and accounted for 14 per cent (27 of 188) of all cases of acute cholecystitis. Presenting symptoms and laboratory values were nonspecific. Twenty patients had radiographic studies before surgery. Among the various radiological studies used for AAC, morphine cholescintigraphy had the highest sensitivity (9 of 10; 90%), followed by computed tomography (8 of 12; 67%) and ultrasonography (2 of 7; 29%). Ten of the 20 patients had more than one study done preoperatively. All 27 patients had an open cholecystectomy. AAC was associated with a high incidence of gangrene (17 of 27 cases; 63%), perforation (4 of 27; 15%), and abscess (1 of 27; 4%). The mortality rate was 41 per cent (11 of 27). We conclude that AAC is a rare, but potentially lethal, disease occurring in critically ill patients and those recovering from non-biliary tract operations. The clinical presentation is nonspecific, and significant delays in diagnosis result in a high incidence of gangrene, perforation, abscess, and death. To improve outcome, a high index of suspicion with early radiographic evaluation, often employing multiple studies, is necessary. An algorithm for the evaluation of patients for suspected AAC is proposed.
Mishkind MT, Pruitt RF, Bambini DA, Hakenewerth AM, Thomason MH, Zuger JH, Novick T
American Surgeon 63(9):769-74, 1997 Sep
We retrospectively reviewed the medical records of 107 patients in two community hospitals who had undergone cholecystokinin-stimulated cholescintigraphy with ejection fraction to determine whether this test is reliable in identifying patients whose symptoms will improve following cholecystectomy. Patients with cholelithiasis or incomplete medical records and patients who could not be interviewed were excluded from the study. Forty-two of 58 study patients (72%) had an abnormal ejection fraction (defined as 35% or less); 27 of 42 patients (64%) underwent cholecystectomy. Twenty-six of 27 (96%) reported lessening of or resolution of symptoms following cholecystectomy. Sixty-seven per cent of the surgical specimens from the 27 patients demonstrated chronic cholecystitis. Fifteen of 42 patients (36%) with abnormal ejection fractions did not undergo cholecystectomy; 12 of 15 (80%) also reported lessening or resolution of symptoms. Of the 16 of 58 patients with a normal ejection fraction, 2 underwent cholecystectomy and reported resolution of symptoms. Five of 14 (36%) with normal ejection fractions who did not undergo cholecystectomy reported improvement. In this series, most patients with an abnormal ejection fraction had lessening of symptoms regardless of whether they underwent cholecystectomy.
Sandoval BA, Goettler CE, Robinson AV, O'Donnell JK, Adler LP, Stellato TA
American Surgeon 63(7):611-6, 1997 Jul
Bile leaks are a recognized complication of laparoscopic cholecystectomy (LC). Different diagnostic approaches have been employed when this condition is suspected. We present our experience with cholescintigraphy as a primary imaging technique for the detection of bile leaks. The medical records of all patients who had cholescintigraphy after LC during a 58-month period were reviewed. Patients were selected for cholescintigraphy if fever unusual abdominal pain, nausea, vomiting, or jaundice were present beyond 36 hours after LC. Bile leaks were suspected in 25 out of 744 patients (3.36%). The nuclear imaging study was true positive in 7 cases and true negative in 18 cases, for a 100 per cent sensitivity, specificity, and accuracy in the detection of bile leaks. Five patients were treated by endoscopic retrograde cholangiopancreatography with stent and/or sphincterotomy, and two patients underwent exploratory laparotomy. None of the patients who underwent endoscopic retrograde cholangiopancreatography required peritoneal drainage. We conclude that cholescintigraphy is sensitive and accurate in the diagnosis of bile leaks. Its use along with a high index of suspicion of a bile leak may prevent the development of bile peritonitis.
Krishnamurthy S, Krishnamurthy GT
Seminars in Nuclear Medicine 26(1):16-24, 1996 Jan
Pharmacological intervention with either cholecystokinin-8 (CCK-8) or morphine during 99mTc- hepatoiminodiacetic acid (HIDA) cholescintigraphy is required primarily for the assessment of the diseases affecting the gallbladder, the common bile duct, or the sphincter of Oddi. For imaging, the patient should be prepared by an overnight fast, or with 4 hours of minimum fast. Pre-emptying with CCK-8 is probably undesirable and should either be avoided or one should wait for at least 4 hours after CCK-8 to begin the 99mTc-HIDA study to achieve higher specificity of the test for acute cholecystitis. When he gallbladder is not observed by 60 mins in a clinical setting of acute cholecystitis, a dose of 0.04 mg/kg of morphine is administered intravenously and imaging continued for an additional 30 mins. Nonvisualization of the gallbladder by 90 mins with morphine in an appropriate clinical setting is diagnostic for acute cholecystitis. When the gallbladder is not observed by 60 min but is seen with morphine administered after 60 mins, a positive diagnosis of abnormal gallbladder function can be made. When the gallbladder is observed in a clinical setting of biliary pain or chronic calculous or acalculous cholecystitis, CCK-8 at a dose rate of 3.3 ng/kg/min is infused intravenously for 3 mins (10 ng/kg/3 min) for the measurement of the ejection fraction. An ejection fraction value of less than 35% is indicative of calculous or acalculous chronic cholecystitis. The gallbladder emptying is directly related to the total number of cholecystokinin receptors in the smooth muscle. The ejection fraction can be controlled to any desired level simply by controlling the dose rate or the duration of infusion of CCK-8. Morphine and other opiate metabolites circulate for many hours in blood and act on the sphincter of Oddi and decrease the gallbladder ejection fraction. Careful drug history, especially that of opiates, is very critical in all subjects with a low ejection fraction before assigning an abnormality to the gallbladder motor function.
Dill JE
Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A. 8(6):361-5, 1998 Dec
The diagnosis of cholecystitis and cholelithiasis is often straightforward, particularly when transabdominal ultrasound (TUS) reveals gallstones or other abnormalities of the gallbladder. There remain many patients, however, with typical biliary pain and normal findings on TUS. This latter group of patients, in which women constitute a large majority, often undergo considerable suffering. Their medical care can also be quite costly. Cholecystokinin cholescintigraphy and stimulated biliary drainage (SBD) have been proposed for difficult-to-diagnose gallbladder disease, but they both have limitations. Cholecystokinin cholescintigraphy may not predict postoperative outcomes with a high degree of reliability. The processing and interpretation of bile drainage specimens is not standardized, and the sensitivity of SBD is less than that of endoscopic ultrasound (EUS). Combined endoscopic ultrasound and stimulated biliary drainage (EUS/SBD) offers a high degree of sensitivity in the diagnosis of cholecystitis and microlithiasis. Positive EUS/SBD is also highly correlated with long-term symptom resolution or relief following cholecystectomy.
Yao NS, Wu CW, Tiu CM, Liu JM, Whang-Peng J, Chen LT
Cardiovascular & Interventional Radiology 21(4):350-3, 1998 Jul-Aug
Two cases are reported of chronic, partial afferent loop obstruction with resultant obstructive jaundice in recurrent gastric cancer. The diagnosis was made by characteristic clinical presentations, abdominal computed tomography, and cholescintigraphy. Percutaneous transhepatic duodenal drainage (PTDD) provided effective palliation for both afferent loop obstruction and biliary stasis. We conclude that cholescintigraphy is of value in making the diagnosis of partial afferent loop obstruction and in differentiating the cause of obstructive jaundice in such patients, and PTDD provides palliation for those patients in whom surgical intervention is not feasible.
Gani JS
Australian & New Zealand Journal of Surgery 68(7):514-9, 1998 Jul
Background: Patients referred to general surgeons for the treatment of gall-bladder stones were studied to evaluate the role of sincalide cholescintigraphy as a gall-bladder stress test in an effort to identify a group of patients whose pain was non-biliary in origin and who would not be improved by cholecystectomy.
Methods: Ten asymptomatic controls and 57 patients with gallstones and abdominal symptoms were studied. All patients were interviewed by an independent assessor who identified a group of patients in whom the role of gallstones in their presentation was uncertain (clinically possibly biliary group). All patients and controls underwent sincalide cholescintigraphy. The surgeons remained blinded to the study results throughout the study period. All patients were re-evaluated 6-12 months later to establish the ultimate diagnosis based on their therapeutic response.
Results: Several parameters of gall-bladder function were studied from analysis of the sincalide cholescintigram. Lag time, ejection period, ejection rate and ejection fraction did not differ significantly among controls, patients proven to have non-biliary disease and patients proven to have biliary disease. There were significant differences in mean gall-bladder filling fraction between proven biliary and proven non-biliary groups. However, the group of patients with clinically possibly biliary symptoms could not accurately be separated into those who benefited from cholecystectomy and those who improved without surgery on the basis of this parameter.
Conclusions: Significant differences in gall-bladder filling fraction between symptomatic and asymptomatic gallstone patients were identified suggesting reduced gall-bladder compliance in symptomatic patients. However, the sincalide cholescintigram failed to emerge as a useful gall-bladder stress test. Even in the 1990s, assessment by an experienced surgeon appears to be the most appropriate way to select patients for cholecystectomy.
Kalliafas S, Ziegler DW, Flancbaum L, Choban PS
American Surgeon 64(5):471-5, 1998 May
The objective of this study was to review the incidence, risk factors, methods of diagnosis, and outcome of acute acalculous cholecystitis (AAC) and to identify the sensitivity and limitations of current radiographic modalities used to establish the diagnosis. Our study was a retrospective chart review in a tertiary-care university hospital. Over a 53-month period, 27 cases of AAC (17 males, 10 females; mean age 50 years; mean Acute Physiology and Chronic Health Evaluation II score, 17) were encountered. Of these, 14 (52%) occurred in critically ill patients and 17 (63%) in patients recovering from non-biliary tract operations. AAC occurred in 0.19 per cent of surgical intensive care unit admissions and accounted for 14 per cent (27 of 188) of all cases of acute cholecystitis. Presenting symptoms and laboratory values were nonspecific. Twenty patients had radiographic studies before surgery. Among the various radiological studies used for AAC, morphine cholescintigraphy had the highest sensitivity (9 of 10; 90%), followed by computed tomography (8 of 12; 67%) and ultrasonography (2 of 7; 29%). Ten of the 20 patients had more than one study done preoperatively. All 27 patients had an open cholecystectomy. AAC was associated with a high incidence of gangrene (17 of 27 cases; 63%), perforation (4 of 27; 15%), and abscess (1 of 27; 4%). The mortality rate was 41 per cent (11 of 27). We conclude that AAC is a rare, but potentially lethal, disease occurring in critically ill patients and those recovering from non-biliary tract operations. The clinical presentation is nonspecific, and significant delays in diagnosis result in a high incidence of gangrene, perforation, abscess, and death. To improve outcome, a high index of suspicion with early radiographic evaluation, often employing multiple studies, is necessary. An algorithm for the evaluation of patients for suspected AAC is proposed.
Mishkind MT, Pruitt RF, Bambini DA, Hakenewerth AM, Thomason MH, Zuger JH, Novick T
American Surgeon 63(9):769-74, 1997 Sep
We retrospectively reviewed the medical records of 107 patients in two community hospitals who had undergone cholecystokinin-stimulated cholescintigraphy with ejection fraction to determine whether this test is reliable in identifying patients whose symptoms will improve following cholecystectomy. Patients with cholelithiasis or incomplete medical records and patients who could not be interviewed were excluded from the study. Forty-two of 58 study patients (72%) had an abnormal ejection fraction (defined as 35% or less); 27 of 42 patients (64%) underwent cholecystectomy. Twenty-six of 27 (96%) reported lessening of or resolution of symptoms following cholecystectomy. Sixty-seven per cent of the surgical specimens from the 27 patients demonstrated chronic cholecystitis. Fifteen of 42 patients (36%) with abnormal ejection fractions did not undergo cholecystectomy; 12 of 15 (80%) also reported lessening or resolution of symptoms. Of the 16 of 58 patients with a normal ejection fraction, 2 underwent cholecystectomy and reported resolution of symptoms. Five of 14 (36%) with normal ejection fractions who did not undergo cholecystectomy reported improvement. In this series, most patients with an abnormal ejection fraction had lessening of symptoms regardless of whether they underwent cholecystectomy.
Sandoval BA, Goettler CE, Robinson AV, O'Donnell JK, Adler LP, Stellato TA
American Surgeon 63(7):611-6, 1997 Jul
Bile leaks are a recognized complication of laparoscopic cholecystectomy (LC). Different diagnostic approaches have been employed when this condition is suspected. We present our experience with cholescintigraphy as a primary imaging technique for the detection of bile leaks. The medical records of all patients who had cholescintigraphy after LC during a 58-month period were reviewed. Patients were selected for cholescintigraphy if fever unusual abdominal pain, nausea, vomiting, or jaundice were present beyond 36 hours after LC. Bile leaks were suspected in 25 out of 744 patients (3.36%). The nuclear imaging study was true positive in 7 cases and true negative in 18 cases, for a 100 per cent sensitivity, specificity, and accuracy in the detection of bile leaks. Five patients were treated by endoscopic retrograde cholangiopancreatography with stent and/or sphincterotomy, and two patients underwent exploratory laparotomy. None of the patients who underwent endoscopic retrograde cholangiopancreatography required peritoneal drainage. We conclude that cholescintigraphy is sensitive and accurate in the diagnosis of bile leaks. Its use along with a high index of suspicion of a bile leak may prevent the development of bile peritonitis.
Krishnamurthy S, Krishnamurthy GT
Seminars in Nuclear Medicine 26(1):16-24, 1996 Jan
Pharmacological intervention with either cholecystokinin-8 (CCK-8) or morphine during 99mTc- hepatoiminodiacetic acid (HIDA) cholescintigraphy is required primarily for the assessment of the diseases affecting the gallbladder, the common bile duct, or the sphincter of Oddi. For imaging, the patient should be prepared by an overnight fast, or with 4 hours of minimum fast. Pre-emptying with CCK-8 is probably undesirable and should either be avoided or one should wait for at least 4 hours after CCK-8 to begin the 99mTc-HIDA study to achieve higher specificity of the test for acute cholecystitis. When he gallbladder is not observed by 60 mins in a clinical setting of acute cholecystitis, a dose of 0.04 mg/kg of morphine is administered intravenously and imaging continued for an additional 30 mins. Nonvisualization of the gallbladder by 90 mins with morphine in an appropriate clinical setting is diagnostic for acute cholecystitis. When the gallbladder is not observed by 60 min but is seen with morphine administered after 60 mins, a positive diagnosis of abnormal gallbladder function can be made. When the gallbladder is observed in a clinical setting of biliary pain or chronic calculous or acalculous cholecystitis, CCK-8 at a dose rate of 3.3 ng/kg/min is infused intravenously for 3 mins (10 ng/kg/3 min) for the measurement of the ejection fraction. An ejection fraction value of less than 35% is indicative of calculous or acalculous chronic cholecystitis. The gallbladder emptying is directly related to the total number of cholecystokinin receptors in the smooth muscle. The ejection fraction can be controlled to any desired level simply by controlling the dose rate or the duration of infusion of CCK-8. Morphine and other opiate metabolites circulate for many hours in blood and act on the sphincter of Oddi and decrease the gallbladder ejection fraction. Careful drug history, especially that of opiates, is very critical in all subjects with a low ejection fraction before assigning an abnormality to the gallbladder motor function.
