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GI · Hepatobiliary

Hepatobiliary Scintigraphy (HIDA)

Snapshot

HIDA (⁹⁹ᵐTc-mebrofenin) images hepatocyte extraction and biliary excretion. Its flagship use is acute cholecystitis: persistent non-visualisation of the gallbladder at 3–4 hours, or 30 minutes after morphine augmentation, is diagnostic (sensitivity ≈96%, specificity ≈90%). It also detects bile leaks and, in neonates, helps distinguish biliary atresia from neonatal hepatitis.

Read the full article →In-depth, fully referenced version

The tracer is extracted by hepatocytes and excreted into bile, so normal images show liver → bile ducts → gallbladder → bowel. A cystic-duct obstruction blocks gallbladder filling — the basis of the cholecystitis diagnosis.

GB non-fillAcute cholecystitis
MorphineAugmentation
NeonatalAtresia vs hepatitis
Simulated anterior HIDA images before and after a 60-minute sincalide infusion, with gallbladder time–activity curves for a normal ejection fraction and a reduced ejection fraction below the 38% lower limit.
Figure. Simulated images and gallbladder time–activity curves during a 60-min sincalide infusion (0.02 µg/kg): the gallbladder empties well in the normal case, but the ejection fraction stays below the lower limit of normal (38%) in the reduced case. Protocol and threshold after the SNM hepatobiliary guideline 4.0 (Tulchinsky 2010).

When to image

  • Suspected acute cholecystitis with equivocal ultrasound.
  • Suspected bile leak after cholecystectomy or trauma.
  • Neonatal cholestasis — biliary atresia vs neonatal hepatitis.
  • Assessing biliary-enteric drainage/function.

How to read it

  • Gallbladder not seen at 60 min is abnormal but not diagnostic; still not seen at 3–4 h, or 30 min after morphine → acute cholecystitis.
  • Tracer outside the biliary tree → bile leak.
  • Absent bowel excretion in a neonate (after priming) → possible biliary atresia.

Protocol

  • Fast at least 2 h, preferably 6 h; if fasting >24 h, pretreat with sincalide; delay ~4 half-lives after opioids; morphine augmentation (0.04 mg/kg) if non-filling at 60 min.
  • Dynamic imaging to 60 min with delayed views as needed.
  • Phenobarbitone priming for neonatal atresia studies.

Pitfalls

  • Prolonged fasting or TPN causes gallbladder non-filling (false positive) — use morphine/CCK.
  • High bilirubin reduces hepatic extraction and image quality.
  • Chronic cholecystitis may show delayed filling.
Evidence & guidelines
  • Meta-analysis (Kiewiet et al., Radiology 2012;264:708–720): cholescintigraphy sensitivity 96%, specificity 90% for acute cholecystitis — higher sensitivity than ultrasound (81%).
  • SNM practice guideline for hepatobiliary scintigraphy 4.0 (Tulchinsky et al., J Nucl Med Technol 2010;38:210–218) covers augmentation and neonatal protocols.
In depth
  • Mebrofenin has about 98% hepatic extraction, a hepatic excretion half-time of about 17 min and about 1% renal excretion, compared with 88%, 19 min and about 9% for disofenin, so it is preferred in hyperbilirubinaemia and hepatic dysfunction.
  • Adults receive 111–185 MBq (3–5 mCi) of ⁹⁹ᵐTc-mebrofenin or disofenin, with higher activity in hyperbilirubinaemia; children receive 1.8 MBq/kg (0.05 mCi/kg), minimum 18.5 MBq (0.5 mCi), and jaundiced neonates at least 37 MBq (1 mCi) with mebrofenin.
  • Adults fast for at least 2 h and preferably 6 h; opioids are withheld for about four half-lives of the drug; if fasting exceeds 24 h or on TPN, give sincalide 0.02 µg/kg over 30–60 min, finishing 15–30 min before tracer injection.
  • Dynamic anterior (or LAO) imaging at 1 frame/min for 60 min with a LEAP or high-resolution collimator and a 140 keV photopeak window, with an optional initial flow phase and right-lateral or oblique views as needed to clarify anatomy.
  • Normally the liver is seen immediately with rapid blood-pool clearance, followed by the bile ducts, gallbladder and small bowel, all within 60 min; delayed biliary-to-bowel transit beyond 60 min occurs as a normal variant in up to 20%.
  • Gallbladder filling excludes acute cholecystitis with high certainty; persistent non-visualisation at 3–4 h, or 30 min after morphine, is the hallmark of acute (calculous or acalculous) cholecystitis.
  • Morphine augmentation (gallbladder not seen at 30–60 min, with tracer in the ducts and small bowel): morphine 0.04 mg/kg or 2 mg IV over 2–3 min, then image for a further 30–60 min; contraindicated with morphine allergy, respiratory depression in non-ventilated patients or raised intracranial pressure in children, and relatively in acute pancreatitis.
  • Gallbladder ejection fraction (35–40° LAO, sincalide 0.02 µg/kg over 60 min): abnormal GBEF <38%, seen in calculous and acalculous disease.
  • In biliary atresia there is no tracer in the bowel even on 24-h images, but this is not specific (hepatocellular disease can mimic it); phenobarbitone 5 mg/kg/day for at least 3–5 days, or ursodeoxycholic acid 20 mg/kg/day for 2–3 days, improves specificity, and bowel activity excludes atresia.
  • False-positive gallbladder non-filling: insufficient fasting, prolonged fasting/TPN, severe hepatocellular disease, high-grade CBD obstruction, rapid biliary-to-bowel transit, prior cholecystectomy.

Sources: SNMMI hepatobiliary 4.0 · Krishnamurthy data cited in PMC6194760 · SNMMI hepatobiliary 4.0 (Ziessman 2010 normal values)

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