- RUQ pain - cholecystitis - biliary obstruction - gallbladder function (GBEF) - biliary leakage - biliary atresia vs. neonatal hepatitis

- Mebrofenin (BRIDA) - Disofenion (DISIDA)

- NPO min 4H but eaten within last 24H - no opiates within 6H

- reflux of bile - delayed biliary to bowel transit (bowel not at >60 min)

- didn't fast long enough - fasted more than 24H - TPN

Hepatobiliary Imaging Flashcards by Cecilia Nguyen

purpose

trace formation and flow of bile from liver to small intestine

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indications

RUQ pain
cholecystitis
biliary obstruction
gallbladder function (GBEF)
biliary leakage
biliary atresia vs. neonatal hepatitis

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what causes gallbladder to contract?

fat as it stimulates the release of CCK

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what does bilirubin indicate?

decrease in liver function
and/or
indication for CBD blockage

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RPs

Mebrofenin (BRIDA)
Disofenion (DISIDA)

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trade name for BRIDA

Choletec

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trade name for DISIDA

Hepatolite

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which RP is least affected by hyperbilirubinemia?

BRIDA/Mebrofenin

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prep

NPO min 4H but eaten within last 24H
no opiates within 6H

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if a patient is TPN, what needs to be done?

pre-treat with CCK

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dose of RP

111-370 MBq (typically, 185 MBq)

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why do we give a higher dose to those with higher levels of bili?

bili competes with the RP for uptake

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dose of CCK

0.02 ug/kg administered over 60 mins

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common names for CCK

sincalide (kinevac)

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when do you inject the RP when using CCK?

30 mins post CCK infusion

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FOV

liver in top FOV

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normal results

liver, biliary ducts, GB and bowel seen by 60 min and GBEF >50%

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normal variant

reflux of bile
delayed biliary to bowel transit (bowel not at >60 min)

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false positives

didn’t fast long enough
fasted more than 24H
TPN

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what does morphine do?

contracts the sphincter of oddi = forces bile back into the GB

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what can hepatic insufficiency cause?

it can lead to delayed GB filling due to poor uptake of RP

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what does TPN do?

it can cause non-visualization of GB due to no stimulation of contraction

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when can you calculate GBEF?

when you see GB, duct and small bowel

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what does CCK do?

contracts the GB and relaxes the Sphincter of Oddi

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what is an alternative to CCK?

fatty meal ensure

what is done if small bowel is seen but no GB?

administer morphine

dose of morphine

0.04 mg/kg over 1-3 mins

delayed images when...

when no gb at 60 mins when no bowel at 60 mins

morphine when...

when no gb at 60 mins

cck when...

when no bowel at 60 mins

normal GBEF

=>38%

formula for GBEF

[(decayed NET pre-CCK - NET post-CCK)/decayed NET pre-CCK] * 100

acute cholecystitis

- no GB after morphine - delayed imaging up to 4H and still no GB

chronic cholecystitis

- GB after morphine or... delayed GB visualization between 1H-4H

partial CBD (common bile duct)

- GB but no bowel after 60 mins

high grade CBD obstruction

no GB, biliary ducts or bowel but has prominent liver activity

view good for GB separation

LAO GB sep from duodenum

rim sign

increased hepatic uptake or uptake beside GB fossa due to inflammation of liver

cystic duct sign

dilation proximal to obstruction that can be misinterpreted as GB

liver scan sign

no biliary tree but good visualization of liver

prep for biliary atresia

- pretreat with phenobarbital 5mg/kg/day for 5 days prior to scan

abnormal biliary atresia

no biliary clearance into bowel by 24H

positives for biliary leaks

progressive increasing pool of RP in area of GB fossa or hepatic hilum

liver parenchyma visualization by ______

5-10 mins

bile ducts and GB visualization by ______

10-20 mins

small intestines visualization by ______

30-60 mins

Which of the following would not be a cause of acute acalculous cholecystitis? A. Inflammatory debris B. Cholelithiasis C. Local edema D. Inspissated bile

b key is no stones!

A dilated cystic duct proximal to a site of obstruction can be misinterpreted as the following: A. False-positive for acute cholecystitis B. Inflammation in the gallbladder fossa C. Radiotracer activity in the bowel D. Gallbladder filling

RP dose if bili 2-10 mg/dL

278 MBq

RP dose if bili 10 mg/dL

370 MBq

preferred RP for neonates

BRIDA

during blood flow imaging, what organ(s) are seen during the arterial flow phase?

spleen and kidneys

during blood flow imaging, what organ(s) are seen during the venous flow phase?

liver

what does increased blood flow to the gallbladder fossa indicate?

severe acute cholecystitis

by 60 mins, ductal activity should decreased by ...

>50% of peak activity

adverse reactions to CCK

nausea, vomiting, abdominal pain, urge to defecate

adverse reactions to morphine

resp depression, dizzy, sedation, nausea, vomiting, sweaty, constipation, tolerance, dependence

why do you not admin CCK if no bowels are seen?

because it can indicate obstruction

nm appearance of acute cholecystitis vs. acute acalculous cholecystitis

no visualization of GB but with acute acalculous = no gallstones in anatomic imaging modalities and sometimes slight slight GB filling?

false positives for acute cholecystitis

- chronic cholecystitis - partial cystic duct obstruction (rmr cystic duct to common bile duct to duodenum) - viscous bile - poor liver function

false negs for acute cholecystitis

- cystic duct sign/nubbin = dilation of cystic duct - acute acalculous cholecystitis

how can you differentiate between chronic ACALCULOUS cholecystitis and calculous cholecystitis?

GBEF being normal = acalculous

symptoms of biliary duct obstruction

abdominal pain, jaundice, elevated ALP and bilirubin, fever IF infection is present

which pathology describes a congenital dilation of the bile ducts?

choledochal cyst

how does choledochal cysts present in kids?

biliary obstruction, pancreatitis or cholangitis

appearance of non obstructed choledochal cysts

GB filling slower with prolonged retention and then slow clearance

appearance of obstructed choledochal cysts

no filling due to high back pressure

Hepatobiliary Imaging Flashcards

(68 cards)