Hepatobiliary scintigraphy

A report skeleton for 99mTc-mebrofenin or disofenin cholescintigraphy, with or without morphine augmentation and sincalide gallbladder ejection fraction. It follows the report contents and interpretation criteria of the SNM hepatobiliary guideline 4.0.

Based on: SNM practice guideline for hepatobiliary scintigraphy 4.0 (Tulchinsky 2010); interdisciplinary consensus on cholecystokinin-cholescintigraphy (DiBaise 2011) with the 60-min sincalide GBEF reference values (Ziessman 2010)

HEPATOBILIARY SCINTIGRAPHY

CLINICAL INDICATION:
  [Suspected acute cholecystitis / chronic acalculous gallbladder disease (GBEF) / bile leak / common bile duct obstruction / neonatal jaundice (biliary atresia) / sphincter of Oddi dysfunction / other]
  Ultrasound: [ ]; bilirubin [ ]
  Last oral intake: [date, time] (fasting [ ] h); parenteral nutrition: [yes / no]
  Medication: [opioids (last dose [ ]) / other interfering drugs / none]

TECHNIQUE:
  Radiopharmaceutical: [99mTc-mebrofenin / 99mTc-disofenin] [ ] MBq IV
  Acquisition: dynamic anterior [1 frame/min] for [60] min; additional views: [right lateral / LAO / decubitus]; delayed images at [ ] h
  Pretreatment: [none / sincalide [ ] µg/kg over [ ] min, [ ] min before tracer / phenobarbital or ursodeoxycholic acid (infant)]
  Morphine: [not given / morphine sulfate [0.04 mg/kg / 2 mg] IV at [ ] min, imaging continued [30–60] min; second tracer dose [ ] MBq: yes / no]
  Sincalide for GBEF: [not performed / 0.02 µg/kg infused over 60 min]
  Adverse reactions: [none / [ ]]

COMPARISON:
  [Prior study / ultrasound / MRCP / none]

FINDINGS:
  Liver: [prompt, homogeneous uptake with rapid blood-pool clearance / delayed uptake / persistent cardiac blood pool]
  Intrahepatic ducts and common bile duct: [visualised at [ ] min / dilated / not visualised]
  Gallbladder: [visualised at [ ] min / visualised only after morphine at [ ] min / visualised on [ ] h delayed image / not visualised by [ ] h or 30 min after morphine]
  Rim sign (pericholecystic hepatic band of increased activity): [absent / present]
  Small bowel: [activity at [ ] min / not seen by [ ] min]
  Unusual activity: [none / extraluminal collection at [site] (bile leak) / tracer in drain / enterogastric reflux]
  GBEF: [ ]% at 60 min (reference ≥38% for the 60-min 0.02 µg/kg infusion)

IMPRESSION:
  1. [Patent cystic duct: acute cholecystitis excluded / gallbladder not visualised by [ ] h or 30 min after morphine: consistent with acute cholecystitis / rim sign: severe (phlegmonous or gangrenous) acute cholecystitis]
  2. [Normal biliary-to-bowel transit / delayed transit beyond 60 min: partial common bile duct obstruction possible / no biliary excretion: high-grade obstruction]
  3. [Bile leak present at [site] / no leak]
  4. [GBEF [ ]%: normal / reduced (below 38%)]

Before you sign

• The hallmark of acute cholecystitis is persistent gallbladder non-visualisation after 3–4 h of passive imaging or 30 min after morphine. Give morphine only when there is tracer in the common duct and small bowel.
• Report a rim sign when present. It marks severe late-stage acute cholecystitis and has been associated with phlegmonous or gangrenous cholecystitis, which is a surgical emergency.
• False-positive non-visualisation: fasting under 2–4 h or over 24 h, parenteral nutrition, severe intercurrent illness, severe hepatocellular disease, high-grade CBD obstruction, rapid transit and previous cholecystectomy. Record fasting time and opioid use.
• GBEF reference values depend on the method. With the 0.02 µg/kg infusion over 60 min the normal lower limit is 38%. Shorter infusions give low values in healthy people, and results from different methods cannot be compared.
• Many drugs reduce GBEF, including opioids, atropine, calcium-channel blockers, octreotide, progesterone, indometacin, theophylline, benzodiazepines and histamine H₂-receptor antagonists. Check for them before calling a low GBEF.
• A bile leak is tracer outside the liver, gallbladder, ducts, bowel and urine. Include drains in the field of view and add 2–4 h delayed and decubitus images.
• Gastrointestinal symptoms during a short sincalide infusion are not specific for gallbladder disease and should not appear in the report.

Sources

1. Tulchinsky M, Ciak BW, Delbeke D, et al. SNM practice guideline for hepatobiliary scintigraphy 4.0. J Nucl Med Technol. 2010;38:210–8.
2. Ziessman HA, Tulchinsky M, Lavely WC, et al. Sincalide-stimulated cholescintigraphy: a multicenter investigation to determine optimal infusion methodology and gallbladder ejection fraction normal values. J Nucl Med. 2010;51:277–81.
3. DiBaise JK, Richmond BK, Ziessman HA, et al. Cholecystokinin-cholescintigraphy in adults: consensus recommendations of an interdisciplinary panel. Clin Gastroenterol Hepatol. 2011;9:376–84.