- Email: [email protected]
Hepatobiliary scintigraphy: Nonvisualization of activity in the area of the gallbladder associated with intestinal activity
Hepatobiliary Scintigraphy: Nonvisualization of Activity in the Area of the Gallbladder Associated With Intestinal Activity Myron L. Lecklitner and Gerald Growcock
22-year-old, Mexican-American man presented to the emergency service with a two-day history of intermittent, right-upperquadrant (RUQ) pain and nausea, which began shortly after eating bacon and eggs. His past medical history was unremarkable. On physical examination, RUQ tenderness with a positive Murphy's sign was demonstrated. His laboratory data included: WBC 10,600 (normal 4-11,000/mm3), total bilirubin 1.8 (normal 0.2-1.2 mg/dL), SGOT 25 (normal 5-40 IU/ L), SGPT 20 (normal 5-40 IU/L), and serum amylase 11 (normal 2-20 IU/L). Interpretation of his ultrasonic examination was precluded because of interference by bowel gas. Hepatobiliary scintigraphy was requested upon admission. The patient had been fasting for at least two to three hours prior to the scintigraphic study (Fig 1). Shortly after the imaging studies, he was taken to the operating room. The omentum directly inferior to the gallbladder was cyanotic and swollen. The appendix, gallbladder, common bile duct, and small and large bowel appeared normal. A 6 x 6-cm portion of torsed omentum was removed and sent to surgical pathology: hemorrhagic and acutely inflamed omentum consistent with early infarct. The patient had several possible causes for gallbladder nonvisualization by scintigraphy: premature termination of the study, physiologic distension, nonbiliary inflammatory focus, and a remote possibility of asymptomatic chronic cholecystitis.
COMMON
A
From the Department of Radiology, University of South Alabama, Mobile, Ala., and the Division of Nuclear Medicine, Department of Radiology, University of Texas Health Science Center at San Antonio, Tex. Address reprint requests to Myron L. Lecklitner, MD, Associate Professor, Department of Radiology, University of South Alabama, 2451 Fillingim St., Mobile, AL 36617. 9 1984 by Grune & Stratton, Inc. 0001-2998/84/1404~9009505.00/0
Seminars in Nuclear Medicine, Vo114, No 4 (October), 1984
1) 2) 3) 4) 5) 6) 7) 8) 9)
Acute cholecystitis with cholelithiasis ~-3 Acute acalculous cholecystitis4 5 Chronic cholecystitis2-3 Cholecystectomy6-8 Premature termination of study T M Inadequate fasting 12 13 Cystic-duct obstruction by tumor 14-16 Acute biliary pancreatitis 17-24 Severe, diffuse hepatocellular disease 15'25'26 UNCOMMON
1) 2) 3) 4) 5) 6)
Hyperalimentation 27 Prolonged fasting 28 Physiologic distension 1~ Appendicitis 29 Hepatic abscess9'3~ Interpreted as duodenal activity 2'8 RARE
1) Ectopic gallbladder 31 2) Gallbladder displacement 32 3) Congenital absence 33 4) Overlying colonic activity 5) Acute nonbiliary pancreatitis ~7-24 6) Pancreatic cancer 6 7) Visceral heterotaxy (Ivemark's syndrome) 34 8) Dubin-Johnson syndrome 35 9) Hemobilia-induced acute cholecystitis 36
Fig 1. S~Tc-PIPIDA, 8.1 mCi. Anterior views at 30 minutes (A) and 150 minutes (B). Sequential views w e r e obtained from 15 minutes after injection to 150 minutes after injection. The activity is excreted promptly from the liver into the small bowel, but at no time was the gallbladder visualized.
345
LECKLITNER AND GROWCOCK
346
REFERENCES 1. Weissmann HS, Frank MS, Bernstein LH, et al: Rapid and accurate diagnosis of acute cholescintigraphy with 99mTc-HIDA cholescintigraphy. Am J Roentgenol 132:523528, 1979 2. Freitas JE: Cholescintigraphy in acute and chronic cholecystitis. Semin Nucl Med 12:18-26, 1982 3. Rosen PR, Rusing TW, Nusynowitz ML, et al: 99mTcPIPIDA cholescintigraphy in the diagnosis of gallbladder disease. Am J Med Sci 284:23-31, 1982 4. Weissmann HS, Berkowitz D, Fox M, et al: Technetium-99m-iminodiacetic acid cholescintigraphic evaluation of acalculous cholecystitis. J Nucl Med 22:P7, 1981 (Abstr) 5. Mauro MA, McCartney WH, Melmed JR: Hepatobiliary scanning with 99mTc-PIP1DA in acute cholecystitis. Radiology 142:193-197, 1982 6. Kasner JR, Meyers E, Heber D: Unusual Tc-99mPIPIDA images. Clin Nucl Med 6:554 555, 1981 7. Stadalnik RC, Rosenquist J, Trudeau WL, et al: The value of radionuclide scintigraphy in patients with nonvisualizedgallbladders by oral cholecystography. Clin Nucl Med 6:519-522, 1981 8. Weissmann HS, Sugarman LA, Freeman LM: The clinical role of technetium-99m iminodiacetic acid cholescintigraphy. In Freeman LM, Weissmann HS (eds): Nuclear Medicine Annual 1981. New York, Raven Press, 1981, pp 35-89 9. Weissmann HS, Badia J, Sugarman LA, et al: Spectrum of 99m-Tc-lDA cholescintigraphic patterns in acute cholecystitis. Radiology 138:167-175, 1981 10. Zeman RK, Segal HB, Caride VJ: Tc-99m-H1DA cholescintigraphy: The distended photon-deficient gallbladder. J Nucl Med 22:39 41, 1981 11. Weissmann HS, Sugarman LA, Badia JD, et al: Improving the specificity and accuracy of T C 99m cholescintigraphy with delayed views. J Nucl Med 21:P17, 1980 (Abstr) 12. Baker R J, Marion MA: Biliary scanning with 99Tc m P.G.--The effect of food in normal subjects. J Nucl Med 18:793-795, 1977 13. Klingensmith WC lII, Spitzer VM, Fritzberg AR, et al: The normal fasting and postprandial diisopropyl-IDA Tc 99m hepatobiliary study. Radiology 141:771-776, 1981 14. Lecklitner ML, Rosen PR, Nusynowitz ML: Cholescintigraphy: Gallbladder nonvisualization secondary to neoplasm. J Nucl Med 22:699 670, 1981 15. Bennett R J, Stadalnik RC, McGahan JP: Perihepatic abscess detection on cholescintigraphy. Clin Nucl Med 6:393-394, 1981 16. Weissmann HS, Gold M, Goldstein RD, et al: Choledochal cyst complicated by acute cholecystitis and bypass obstruction: diagnostic role of Tc-99m-HIDA cholescintigraphy. Clin Nucl Med 6:395-398, 1981 17. Fonseca C, Greenburg D, Rosenthall L, et al: 99mTcIDA imaging in the differential diagnosis of acute cholecystitis and acute pancreatitis. Radiology 130:525-527, 1979 18. Taavitsainen M, J~irvinen H, Tallroth K: Cholescintigraphy in the diagnosis of acute cholecystitis. Ann Clin Res 10:227-234, 1978 19. Zeman RK, Burrell M1, Cahow CE, et al: Diagnostic
utility of cholescintigraphy and ultrasound in acute cholecystitis. Am J Surg 141:446-451, 1981 20. Edlund G, Kempi V, van der Linden W: Transient nonvisualization of the gallbladder by Tc-99m HIDA cholescintigraphy in acute pancreatitis: concise communication. J Nucl Med 23:117-120, 1982 21. Frank MS, Weissmann HS, Chun KJ, et al: Visualization of the biliary tract with 99mTc-H1DA in acute pancreatitis. Gastroenterology 78:1167, 1980 22. All A, Turner DA, Fordham E Tc-99m IDA cholescintigraphy in acute pancreatitis: Concise communication. J Nucl Med 23:867-869, 1982 23. Serafini AN, AI-Sheikh W, Barkin JS, et al: Biliary scintigraphy in acute pancreatitis. Radiology 144:591-595, 1982 24. Glazer G, Murphy F, Clayden GS, et al: Radionuclide biliary scanning in acute pancreatitis. Br J Surg 68:766-770, 1980 25. Rao BK, Weir GJ Jr, Lieberman LM: Dissociation of reticuloi~ndothelial cell and hepatocyte functions in alcoholic liver disease: A clinical study with a new Tc-99m-labeled hepatobiliary agent. Cfin Nucl Med 6:289-294, 1981 26. Ohi R, Klingensmith WC Ill, Lilly JR: Diagnosis of hepatobiliary disease in infants and children with Tc-99mdiethyl-IDA imaging. Clin Nucl Med 6:297-302, 1981 27. Shuman WP, Gibbs P, Rudd TG, et al: PIPIDA scintigraphy for cholecystitis: False positives in alcoholism and total parenteral nutrition. Am J Roentgenol 138:1 5, 1982 28. Larsen M J, Klingensmith WC Ill, Kuni CC: Radionuclide hepatobiliary imaging: Nonvisualization of the gallbladder secondary to prolonged fasting. J Nucl Med 23:1003 1005, 1982 29. Smathers RL, Harman PK, Wanebo H J, et al: Hepatobiliary scan with delayed gallbladder visualization in a case of acute appendicitis. Clin Nucl Med 7:222 224, 1982 30. Ram MD, Hagihara PF, Kim EL, et al: Evaluation of biliary disease by scintigraphy (Panel discussion). Am J Surg 141:77 83, 1981 31. Chuang VP: The aberrant gallbladder: Angiographic and radioisotopic considerations. Am J Roentgenol 127:417421, 1976 32. Owshalimpur D, Karimeddini MK: Gallbladder displacement in a cirrhotic patient simulating ectopia. Clin Nucl Med 7:284-286, 1982 33. Henderson RW, Teller N, Halls JM: Gastrobiliary fistula: Pre- and post-operative assessment with 99mTCPIPIDA. AJR 137:163 165, 1981 34. Pastakia B, Lieberman LM, Moodie D, et al: 99~nTechnetium pyridoxylidene glutamate imaging in visceral heterotaxy (lvemark's syndrome). Gastroenterology 77:1105-1108, 1979 35. Bar-Melt S, Baron J, Seligson U, et al: 99mTc-H1DA cholescintigraphy in Dubin-Johnson and Rotor syndromes. Radiology 142:743-746, 1982 36. Lewis J, Varma V, Tice H, et al: Hepatobiliary scanning in hemobilia-induced acute cholecystitis. Gastrointest Radiol 7:169-171, 1982
22-year-old, Mexican-American man presented to the emergency service with a two-day history of intermittent, right-upperquadrant (RUQ) pain and nausea, which began shortly after eating bacon and eggs. His past medical history was unremarkable. On physical examination, RUQ tenderness with a positive Murphy's sign was demonstrated. His laboratory data included: WBC 10,600 (normal 4-11,000/mm3), total bilirubin 1.8 (normal 0.2-1.2 mg/dL), SGOT 25 (normal 5-40 IU/ L), SGPT 20 (normal 5-40 IU/L), and serum amylase 11 (normal 2-20 IU/L). Interpretation of his ultrasonic examination was precluded because of interference by bowel gas. Hepatobiliary scintigraphy was requested upon admission. The patient had been fasting for at least two to three hours prior to the scintigraphic study (Fig 1). Shortly after the imaging studies, he was taken to the operating room. The omentum directly inferior to the gallbladder was cyanotic and swollen. The appendix, gallbladder, common bile duct, and small and large bowel appeared normal. A 6 x 6-cm portion of torsed omentum was removed and sent to surgical pathology: hemorrhagic and acutely inflamed omentum consistent with early infarct. The patient had several possible causes for gallbladder nonvisualization by scintigraphy: premature termination of the study, physiologic distension, nonbiliary inflammatory focus, and a remote possibility of asymptomatic chronic cholecystitis.
COMMON
A
From the Department of Radiology, University of South Alabama, Mobile, Ala., and the Division of Nuclear Medicine, Department of Radiology, University of Texas Health Science Center at San Antonio, Tex. Address reprint requests to Myron L. Lecklitner, MD, Associate Professor, Department of Radiology, University of South Alabama, 2451 Fillingim St., Mobile, AL 36617. 9 1984 by Grune & Stratton, Inc. 0001-2998/84/1404~9009505.00/0
Seminars in Nuclear Medicine, Vo114, No 4 (October), 1984
1) 2) 3) 4) 5) 6) 7) 8) 9)
Acute cholecystitis with cholelithiasis ~-3 Acute acalculous cholecystitis4 5 Chronic cholecystitis2-3 Cholecystectomy6-8 Premature termination of study T M Inadequate fasting 12 13 Cystic-duct obstruction by tumor 14-16 Acute biliary pancreatitis 17-24 Severe, diffuse hepatocellular disease 15'25'26 UNCOMMON
1) 2) 3) 4) 5) 6)
Hyperalimentation 27 Prolonged fasting 28 Physiologic distension 1~ Appendicitis 29 Hepatic abscess9'3~ Interpreted as duodenal activity 2'8 RARE
1) Ectopic gallbladder 31 2) Gallbladder displacement 32 3) Congenital absence 33 4) Overlying colonic activity 5) Acute nonbiliary pancreatitis ~7-24 6) Pancreatic cancer 6 7) Visceral heterotaxy (Ivemark's syndrome) 34 8) Dubin-Johnson syndrome 35 9) Hemobilia-induced acute cholecystitis 36
Fig 1. S~Tc-PIPIDA, 8.1 mCi. Anterior views at 30 minutes (A) and 150 minutes (B). Sequential views w e r e obtained from 15 minutes after injection to 150 minutes after injection. The activity is excreted promptly from the liver into the small bowel, but at no time was the gallbladder visualized.
345
LECKLITNER AND GROWCOCK
346
REFERENCES 1. Weissmann HS, Frank MS, Bernstein LH, et al: Rapid and accurate diagnosis of acute cholescintigraphy with 99mTc-HIDA cholescintigraphy. Am J Roentgenol 132:523528, 1979 2. Freitas JE: Cholescintigraphy in acute and chronic cholecystitis. Semin Nucl Med 12:18-26, 1982 3. Rosen PR, Rusing TW, Nusynowitz ML, et al: 99mTcPIPIDA cholescintigraphy in the diagnosis of gallbladder disease. Am J Med Sci 284:23-31, 1982 4. Weissmann HS, Berkowitz D, Fox M, et al: Technetium-99m-iminodiacetic acid cholescintigraphic evaluation of acalculous cholecystitis. J Nucl Med 22:P7, 1981 (Abstr) 5. Mauro MA, McCartney WH, Melmed JR: Hepatobiliary scanning with 99mTc-PIP1DA in acute cholecystitis. Radiology 142:193-197, 1982 6. Kasner JR, Meyers E, Heber D: Unusual Tc-99mPIPIDA images. Clin Nucl Med 6:554 555, 1981 7. Stadalnik RC, Rosenquist J, Trudeau WL, et al: The value of radionuclide scintigraphy in patients with nonvisualizedgallbladders by oral cholecystography. Clin Nucl Med 6:519-522, 1981 8. Weissmann HS, Sugarman LA, Freeman LM: The clinical role of technetium-99m iminodiacetic acid cholescintigraphy. In Freeman LM, Weissmann HS (eds): Nuclear Medicine Annual 1981. New York, Raven Press, 1981, pp 35-89 9. Weissmann HS, Badia J, Sugarman LA, et al: Spectrum of 99m-Tc-lDA cholescintigraphic patterns in acute cholecystitis. Radiology 138:167-175, 1981 10. Zeman RK, Segal HB, Caride VJ: Tc-99m-H1DA cholescintigraphy: The distended photon-deficient gallbladder. J Nucl Med 22:39 41, 1981 11. Weissmann HS, Sugarman LA, Badia JD, et al: Improving the specificity and accuracy of T C 99m cholescintigraphy with delayed views. J Nucl Med 21:P17, 1980 (Abstr) 12. Baker R J, Marion MA: Biliary scanning with 99Tc m P.G.--The effect of food in normal subjects. J Nucl Med 18:793-795, 1977 13. Klingensmith WC lII, Spitzer VM, Fritzberg AR, et al: The normal fasting and postprandial diisopropyl-IDA Tc 99m hepatobiliary study. Radiology 141:771-776, 1981 14. Lecklitner ML, Rosen PR, Nusynowitz ML: Cholescintigraphy: Gallbladder nonvisualization secondary to neoplasm. J Nucl Med 22:699 670, 1981 15. Bennett R J, Stadalnik RC, McGahan JP: Perihepatic abscess detection on cholescintigraphy. Clin Nucl Med 6:393-394, 1981 16. Weissmann HS, Gold M, Goldstein RD, et al: Choledochal cyst complicated by acute cholecystitis and bypass obstruction: diagnostic role of Tc-99m-HIDA cholescintigraphy. Clin Nucl Med 6:395-398, 1981 17. Fonseca C, Greenburg D, Rosenthall L, et al: 99mTcIDA imaging in the differential diagnosis of acute cholecystitis and acute pancreatitis. Radiology 130:525-527, 1979 18. Taavitsainen M, J~irvinen H, Tallroth K: Cholescintigraphy in the diagnosis of acute cholecystitis. Ann Clin Res 10:227-234, 1978 19. Zeman RK, Burrell M1, Cahow CE, et al: Diagnostic
utility of cholescintigraphy and ultrasound in acute cholecystitis. Am J Surg 141:446-451, 1981 20. Edlund G, Kempi V, van der Linden W: Transient nonvisualization of the gallbladder by Tc-99m HIDA cholescintigraphy in acute pancreatitis: concise communication. J Nucl Med 23:117-120, 1982 21. Frank MS, Weissmann HS, Chun KJ, et al: Visualization of the biliary tract with 99mTc-H1DA in acute pancreatitis. Gastroenterology 78:1167, 1980 22. All A, Turner DA, Fordham E Tc-99m IDA cholescintigraphy in acute pancreatitis: Concise communication. J Nucl Med 23:867-869, 1982 23. Serafini AN, AI-Sheikh W, Barkin JS, et al: Biliary scintigraphy in acute pancreatitis. Radiology 144:591-595, 1982 24. Glazer G, Murphy F, Clayden GS, et al: Radionuclide biliary scanning in acute pancreatitis. Br J Surg 68:766-770, 1980 25. Rao BK, Weir GJ Jr, Lieberman LM: Dissociation of reticuloi~ndothelial cell and hepatocyte functions in alcoholic liver disease: A clinical study with a new Tc-99m-labeled hepatobiliary agent. Cfin Nucl Med 6:289-294, 1981 26. Ohi R, Klingensmith WC Ill, Lilly JR: Diagnosis of hepatobiliary disease in infants and children with Tc-99mdiethyl-IDA imaging. Clin Nucl Med 6:297-302, 1981 27. Shuman WP, Gibbs P, Rudd TG, et al: PIPIDA scintigraphy for cholecystitis: False positives in alcoholism and total parenteral nutrition. Am J Roentgenol 138:1 5, 1982 28. Larsen M J, Klingensmith WC Ill, Kuni CC: Radionuclide hepatobiliary imaging: Nonvisualization of the gallbladder secondary to prolonged fasting. J Nucl Med 23:1003 1005, 1982 29. Smathers RL, Harman PK, Wanebo H J, et al: Hepatobiliary scan with delayed gallbladder visualization in a case of acute appendicitis. Clin Nucl Med 7:222 224, 1982 30. Ram MD, Hagihara PF, Kim EL, et al: Evaluation of biliary disease by scintigraphy (Panel discussion). Am J Surg 141:77 83, 1981 31. Chuang VP: The aberrant gallbladder: Angiographic and radioisotopic considerations. Am J Roentgenol 127:417421, 1976 32. Owshalimpur D, Karimeddini MK: Gallbladder displacement in a cirrhotic patient simulating ectopia. Clin Nucl Med 7:284-286, 1982 33. Henderson RW, Teller N, Halls JM: Gastrobiliary fistula: Pre- and post-operative assessment with 99mTCPIPIDA. AJR 137:163 165, 1981 34. Pastakia B, Lieberman LM, Moodie D, et al: 99~nTechnetium pyridoxylidene glutamate imaging in visceral heterotaxy (lvemark's syndrome). Gastroenterology 77:1105-1108, 1979 35. Bar-Melt S, Baron J, Seligson U, et al: 99mTc-H1DA cholescintigraphy in Dubin-Johnson and Rotor syndromes. Radiology 142:743-746, 1982 36. Lewis J, Varma V, Tice H, et al: Hepatobiliary scanning in hemobilia-induced acute cholecystitis. Gastrointest Radiol 7:169-171, 1982