Acute cholecystitis, biliary obstruction, and biliary leakage

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Abstract

The use of cholescintigraphy to diagnose acute cholecystitis, biliary obstruction, and biliary leakage dates back to the late 1970s. Today, despite the many advances in imaging instrumentation, radiopharmaceuticals, and methodology over these years, cholescintigraphy still plays an important role in confirming or excluding these diagnoses in acutely ill patients. Acute calculous and acalculous cholecystitis, gallbladder perforation, biliary obstruction, and biliary leakage often present as acute abdominal pain, and must be differentiated from other surgical and nonsurgical etiologies with similar symptoms and presentation. Understanding the pathophysiology of acute hepatobiliary diseases is vital for deciding on the most advantageous imaging work-up and for interpretation of the studies. To optimize the value of cholescintigraphy, up-to-date methology, proper use of appropriate pharmacologic interventions, and recognition of characteristic image findings are critical.

Section snippets

Acute cholecystitis

ACUTE ABDOMINAL pain is a common emergency room complaint and not uncommon in ill, hospitalized patients. Its etiology must be differentiated from various other acute abdominal conditions (eg, acute appendicitis, perforated/penetrating duodenal or gastric ulcer, acute pancreatitis, small bowel obstruction, lower lobe pneumonia, ureteral calculus). The pathophysiology of biliary colic and acute cholecystitis begins with cystic duct obstruction. Obstruction to venous and lymphatic outflow

Optimal methodology

Attention to technique and methodology maximizes the accuracy of cholescintigraphy. The radiopharmaceutical dose can be increased in patients with hepatic insufficiency.40 Although the larger dose will increase the count rate, it will not improve the target-to-background ratio. At times, there is diagnostic uncertainty caused by the overlap of anatomy and biliary flow of the gallbladder, biliary ducts, and small bowel in the anterior view. Right lateral and left anterior oblique views are often

Biliary obstruction

Common causes for biliary obstruction include malignancy, choledocholithiasis, and inflammatory stricture. Much less common causes are sclerosing cholangitis, choledochal cyst, hemobilia, duodenal diverticulum, echinococcus, and ascariasis. Stone formation is related to the secretion of lithogenic bile. Approximately 90% of calculi form in the gallbladder and pass into the biliary duct via the cyst duct. A minority of calculi form de novo outside the gallbladder in the intrahepatic or

Bile leaks

Bile leaks after post-cholecystectomy are common. Small quantities of leakage after cholecystectomy do not usually lead to serious medical complications. Gilsdorf et al. performed cholescintigraphy routinely 2 to 4, hours after open cholecystectomy.134 Bile leaks were detected in 44% of patients. Most leaks were not clinically significant. The cause of bile leakage after cholecystectomy is often caused by surgical transection of small biliary radicles entering directly into the gallbladder bed

References (163)

  • F.C. Laing et al.

    Ultrasonic evaluation of patients with acute right upper quadrant pain

    Radiology

    (1981)
  • E.A. Eikman et al.

    A test for patency of the cystic duct in acute cholecysitis

    Ann of Int Med

    (1975)
  • L. Rosenthall et al.

    Diagnosis of hepatobiliary disease by 99m Tc-HIDA cholescintigraphy

    Radiology

    (1975)
  • R.C. Stadalnik et al.

    The validity of 99mTc-pyridoxylidene glutamate cholescintigraphy as a diagnostic test for cholecystitis

    Clin Nucl Med

    (1978)
  • H.S. Weissmann et al.

    Rapid and accurate diagnosis of acute cholecysitis with 99m Tc-IDA cholescinigraphy

    AJR Am J Roentgenol

    (1979)
  • C.A. Suarez et al.

    The role of HIDA/PIPIDA scanning in diagnosing cystic duct obstruction

    Ann Surg

    (1980)
  • R.E. Szlabick et al.

    Hepatobiliary scanning in the diagnosis of acute cholecysitis

    Arch Surg

    (1980)
  • J.E. Freitas et al.

    Rapid evaluation of acute abdominal pain by hepatobiliary scanning

    JAMA

    (1980)
  • H.S. Weissmann et al.

    Spectrum of 99mTc-IDA cholescintigraphic patterns in acute cholecystitis

    Radiology

    (1981)
  • J.E. Freitas et al.

    Suspected acute cholecystitis. Comparison of hepatobiliary scintigraphy versus ultrasonography

    Clin Nucl Med

    (1982)
  • M.A. Mauro et al.

    Hepatobiliary scanning with 99mTcPIPIDA in acute cholecystitis

    Radiology

    (1982)
  • B.I. Samuels et al.

    A comparison of radionuclide hepatobiliary imaging and real-time ultrasonography for detection of acute cholecystitis

    Radiology

    (1983)
  • P.W. Ralls et al.

    Prospective evaluation of 99mTc-IDA cholescintigraphy and gray-scale ultrasound in the diagnosis of acute cholecystitis

    Radiology

    (1982)
  • N.J. Worthen et al.

    Cholecystitis. Prospective evaluation of sonography and 99mTc-HIDA cholescintigraphy

    AJR Am J Roentgenol

    (1981)
  • W.P. Shuman et al.

    Evaluation of acute right upper quadrant painSonography and 99mTc-PIPIDA cholescintigraphy

    AJR Am J Roentgenol

    (1982)
  • Chatziioannou et al.

    Hepatobiliary scintigraphy is superior to abdominal ultrasonography in suspected acute cholecystitis

    Surgery

    (2000)
  • J.E. Freitas et al.

    Influence of scan and pathologic criteria on the specificity of cholescintigraphyConcise communication

    J Nucl Med

    (1983)
  • W.C. Klingensmith et al.

    The normal fasting and postprandial diisopropyl-IDA Tc-99m hepatobiliary study

    Radiology

    (1981)
  • R.J. Baker et al.

    Biliary scanning with Tc-99, pyridoxylideneglutamate—the effect of food in normal subjectsConcise communication

    J Nucl Med

    (1977)
  • M.J. Larson et al.

    Radionuclide hepatobiliary imagingNon-visualization of the gallbladder secondary to prolonged fasting

    J Nucl Med

    (1982)
  • B.W. Warner et al.

    The value of hepatobiliary scans in fasted patients receiving total parenteral nutrition

    Surgery

    (1987)
  • G. Stone et al.

    Gallbladder emptying stimuli in obese and normal-weight subjects

    Hepatology

    (1992)
  • V. Kalf et al.

    Predictive value of an abnormal hepatobiliary scan in patients with severe intercurrent illness

    Radiology

    (1983)
  • J.J. Roslyn et al.

    Increased risk of gallstones in children receiving total parenteral nutrition

    Pediatrics

    (1983)
  • T. Potter et al.

    Effect of fasting and parenteral alimentation on PIPIDA scintigraphy

    Dig Dis Sci

    (1983)
  • W.P. Shuman et al.

    PIPIDA scintigraphy for cholecysitisFalse positive in alcholism and total parenteral nutrition

    AJR Am J Roentgenol

    (1982)
  • W.E. Drane et al.

    The need for routine delayed radionuclide hepatobiliary imaging in patients with intercurrent disease

    Radiology

    (1984)
  • R.W. Nicholson et al.

    HIDA scanning in gallbladder diseae

    Br J Radiol

    (1980)
  • C. Fonseca et al.

    Differential diagnosis of jaundice by Tc-99m IDA hepatobilary imaging

    Clin Nucl Med

    (1979)
  • C. Fonseca et al.

    Tc-99m IDA imaging in the differential diagnosis of acute cholecystitis and acute pancreatitis

    Radiology

    (1979)
  • M.S. Frank et al.

    Visualization of the biliary tract with Tc-99m HIDA in acute pancreatitis

    Gastroenterology

    (1980)
  • A.N. Serafini et al.

    Biliary scintigraphy in acute pancreatitis

    Radiology

    (1982)
  • H.S. Weissmann et al.

    The clinical role of technetium-99m iminodiacetic acid cholescingraphy

  • P. Pare et al.

    Nonvisualization of the gallbladder by 99mTc-HIDA cholescinitigraphy as evidence of cholecystitis

    CMAJ

    (1978)
  • R.L. Wahl

    The “water-ida”A simple means to separate duodenal from gallbladder activity on cholescintigraphic studies

    Eur J Nucl Med

    (1984)
  • P.B. Shaffer et al.

    Differentiation of the gallbladder from the duodenum on cholescintigrams by dynamic display

    Radiology

    (1982)
  • R.E. Coleman et al.

    The dilated cystic duct signA potential cause of false-negative cholescintigraphy

    Clin Nucl Med

    (1984)
  • C.K. Kim et al.

    Delayed biliary-to-bowel transit in cholescintigraphy after cholecystokinin treatment

    Radiology

    (1990)
  • S. Sostre et al.

    Gallbladder response to a second dose of cholecystokinin during the same imaging study

    Eur J Nucl Med

    (1992)
  • H.A. Ziessman et al.

    Normal values for sincalide cholescintigraphyComparison of two methods

    Radiology

    (2001)
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