The evaluation of a gastric bile probe

The purpose of this study was to validate a new technique for measuring duodenogastric bile reflux in the human subject. A custom built cadmium telluride gamma detector (Radiation Monitoring Devices, Mass), small enough to be passed into the oesophagus and stomach, was developed and tested for sensitivity to 99Tcm and 75Se radioisotopes. When immersed in radiolabelled water, the detector was capable of measuring gamma radiation in quantities as low as 0.1 microCi (0.0037 MBq) per ml. Two patients (A and B) with endoscopically proven bile reflux, and three normal volunteers (C, D and E) underwent oesophageal manometry to map the position of the lower oesophageal sphincter (LOS). The gamma probe was passed via the nose, to a position in the gastric fundus, 5 cm below the LOS. Each subject was placed supine under a gamma camera (Siemens LFOV 37 ZLC head), centred on the epigastrium. A 4 mCi (148 MBq) dose of radiolabelled 99Tcm-HIDA was administered intravenously, and simultaneous internal/external scanning was performed for between 45 and 90 min. Internal gamma probe data was transferred by a screened cable to a Memolog 600 portable recorder, using a 5 s counting interval, and from the gamma camera to a Nodecrest Micas III computer, using a 15 s counting interval. Gamma camera counts from a region of interest over the fundus of the stomach were then correlated with counts from the internal probe using a linear regression analysis program on the Nodecrest. The internal gamma probe functioned well at body temperature in the acidic gastric environment. Radiolabelled bile refluxed into the stomach during HIDA scanning in three out of the five subjects (one patient and two normal volunteers). There was a strong correlation between internal and external gamma counts (A, r = +0.79; C, r = +0.53; E, r = +0.54; P greater than 0.01). In the other two cases, there was no bile reflux, but still a significant correlation between internal and external gamma counts (B, r = +0.89; D, r = +0.75; P greater than 0.01). The mean correlation coefficient for the series of five cases was +0.70. We conclude firstly that the newly developed internal gamma detector is capable of measuring the reflux of radiolabelled bile into the human stomach and, secondly, that bile reflux may occur in normal subjects as well as those with upper gastrointestinal pathology.

Standing views to differentiate gallbladder or bile leak from duodenal activity on cholescintigrams

Confusing a gallbladder or bile leak with duodenal activity is a common source of error in the interpretation of cholescintigrams. Techniques such as supplementary oblique views, delayed views, the "water test," dynamic display and combined cholescintigraphy and ultrasound have been used with varying degrees of success. As illustrated in two cases, supplementary standing views provide a simple alternative method to differentiate gallbladder from small bowel activity.

Quantitative imaging in the gastrointestinal tract

Various problems are encountered in measuring gastric emptying, especially relating counts to the volume of meal remaining in the stomach. We have developed a method which has been validated against aspiration of the stomach. In gastric ulcer patients, however, the stomach is large and overlaps the bowel. Results of gastric emptying studies in patients who have had surgery for peptic ulceration show that impaired gastric emptying is related to the extent of vagotomy and pyloric surgery. We have examined the pattern of biliary excretion of iminodiacetic acid derivatives and related enterogastric reflux to the amount of bile in the stomach as determined by aspiration. However the reproducibility is only 75% probably due to day to day variation in its occurrence. The incidence of reflux in control subjects and in those with peptic ulcer is discussed, as is its relationship to the extent of vagotomy and the length of Roux-en-Y loops. Finally the diagnosis of biliary atresia using a similar radiopharmaceutical is described. It has been suggested that a high liver to heart ratio excludes the diagnosis of atresia, but we have failed to confirm this finding.

Reflux sign in cholescintigraphy after administration of a gallbladder contracting agent

This study reviewed 12 patients with the reflux sign in cholescintigraphy to assess its diagnostic usefulness in evaluating biliary passage. The reflux sign was determined by appearance or increase of the radioactivity in peripheral intrahepatic bile ducts after intramuscular injection of 10 micrograms of ceruletide diethylamine (caerulein). Of the 12 patients, there were common bile duct (CBD) stone in four, chronic pancreatitis in two, biliary dyskinesia in two, papillary adenoma of the CBD, dilated CBD, papillitis, and juxtapapillary duodenal diverticulum in one each. Cholangiographically, dilated caliber of the CBD more than or equal to 12 mm was found in five and equivocal caliber of 8 to 11 mm was in the remaining seven. Apparent stenosis of the CBD was found in four with dilated CBD. There were two patients who had CBD stone with equivocal caliber of the CBD. The reflux sign seems to be a sensitive finding indicating the presence of biliary dysfunction, and would be helpful for the detection of incomplete obstruction of the CBD or CBD stone, especially in a patient with equivocal caliber of the CBD.

Gallbladder function and fasting enterogastric bile reflux

The relationship between gallbladder function and duodenogastric reflux of bile has been investigated in the fasting phase by 99Tcm-EHIDA biliary scintigraphy in 370 patients with abdominal pain. This isotope is cleared from the blood-pool by hepatocellular function and is excreted into the biliary tract. Obstruction of the common bile duct was found in 79 patients, leaving 291 who were evaluable for duodenogastric bile reflux. Gallblader function was present in 169 and absent in 122 patients. Duodenogastric reflux of bile was observed in 82 patients, 10 of whom had had previous gastric surgery. Only 298 of 169 (17%) patients with a functioning gallbladder showed evidence of enterogastric bile reflux compared to 43 of 122 (35%) with absent gallbladder function (p less than 0.005 by Chi Square). These results suggest that continuous bile flow into the duodenum in the absence of a functioning gallbladder facilitates duodenogastric reflux.

Comparison between Henley jejunal interposition and Roux-en-Y anastomosis as concerns enterogastric biliary reflux levels

The amount of enterogastric biliary reflux was assessed in patients who previously underwent Henley operation (n = 8) or Roux-en-Y biliary diversion (n = 7) using the radiopharmaceutical 99mTechnetium-DISIDA. Two other groups were investigated: a control group consisting of patients with unoperated duodenal ulcer (n = 10) and a group of patients who underwent Billroth II gastrectomy (n = 7). The length of the interposed segment of jejunum ranged from 20 to 30 cm (median of 22.5 cm) in the Henley patients, and from 30 to 60 cm (median of 40 cm) in the Roux-en-Y group. In Henley patients, the percentage of administered 99mTechnetium-DISIDA that was recovered from the stomach (median of 0.92%) was lower (p less than 0.01) than that obtained for Billroth II patients (median of 32.28%) and did not differ (p greater than 0.10) from that of the Roux-en-Y (median of 0.36%) and duodenal ulcer groups (median of 2.53%). These results indicate that Henley operation is as effective as Roux-en-Y diversion in promoting the reduction of the amount of enterogastric biliary reflux that follows Billroth II distal gastrectomy.

[Structure of functional scintigraphic images during the development of gallbladder bile reflux into the intrahepatic ducts]

The authors proposed a method of cholescintigraphy with functional imaging reflecting RP distribution within the entire area in the field of vision of a gamma-chamber detector taking account of the type of motor activity of the gall bladder. This method was based on plotting an activity-time curve along the outer contour of a gall bladder image, the determination of moments of change in gall bladder motor activity on this curve, and the calculation of corresponding gradients of RP accumulation and clearance functions represented on an image where the color of each element was determined by a sign of the gradient and its intensity--by its absolute value. The use of this method in 92 patients made it possible to reveal conditions with possible B-bile reflux into the intrahepatic ducts, and to raise its diagnostic accuracy by 7% as compared to a routine analysis of activity-time curves by decreasing the number of false-negative results.

Disorders of gallbladder function related to duodenogastric reflux in technetium-99m DISIDA hepatobiliary scintigraphy

Controversy exists over the relation between gallbladder dysfunction and the propensity for duodenogastric reflux. To evaluate this, Tc-99m DISIDA hepatobiliary imaging studies in 120 patients were reviewed, excluding patients who had had cholecystectomy or subtotal gastrectomy before scintigraphy. Serial images were obtained at 5, 10, 15, 30, 45, and 60 minutes and up to 24 hours, if indicated, after intravenous injection of 5-10 mCi of Tc-99m DISIDA. Normally, the liver, bile ducts, gallbladder, common bile duct, and bowel are visualized sequentially. Reversal of the normal sequence of gallbladder (GB) and bowel visualization indicates GB dysfunction; nonvisualization of the GB reflects cystic duct obstruction or absent GB function. Duodenogastric reflux is identified by radiotracer localized in the area just below or immediately adjacent to the tip of the left hepatic lobe. The intragastric location of the tracer may be verified by oral administration of 300 uCi of Tc-99m sulfur colloid. Twenty-nine patients had duodenogastric reflux between 10 and 60 minutes after injection. Of the 29 patients, 22 had a nonvisualized gallbladder, four had reversal of appearance of GB and bowel activity, and three had a normal study. GB dysfunction or nonfunction is more frequently demonstrated when duodenogastric reflux is present than with normal gallbladder function (P less than 0.001). In conclusion, gallbladder malfunction is closely associated with duodenogastric reflux, an abnormality that may be diagnosed noninvasively by Tc-99m DISIDA hepatobiliary scintigraphy.

The significance of gastric bile reflux seen at endoscopy

We evaluated the significance of bile seen in the stomach at the time of endoscopy. Twenty-three percent of 110 consecutive patients undergoing elective panendoscopy were found to have bile in their stomachs. Gastric biopsies were obtained from these patients. To assess the significance of bile reflux, the patients underwent a quantitative gastric bile analysis on two separate days. On day 1, gastric juice was aspirated by nasogastric suction, and bile acid concentrations were measured. On day 2, bile reflux into the stomach was quantitated by scintiscan measurement of gastric nucleotide after intravenous administration of 99mTc-DISIDA. Approximately half the patients with bile reflux showed histologic evidence of mucosal injury. However, fewer than half with histologic injury had significant bile reflux when measured by quantitative methods. There was no correlation among the gastric bile acid concentration, degree of histologic injury, or severity of endoscopic changes. We conclude that finding bile reflux at endoscopy is probably of no clinical significance.

Scintigraphic evaluation of enterogastric reflux using 75Se-HCAT: methodology and first clinical observations

The aim of this study was to assess the possibility of detecting enterogastric reflux (EGR) by 75Se-HCAT cholescintigraphy. The lowest detectable activity in the gastric area at different concentrations of the radiotracer in the gallbladder was preliminary measured both in a plastic phantom and in an in vivo model. Ten patients were studied after a single oral administration of 1480 KBq 75Se-HCAT. Gamma camera imaging was carried out for five consecutive days during both fasting and after meal ingestion. In our in vivo model an EGR corresponding to 1% of gallbladder content on day one and 8% on day five was detected. In three out of five patients in whom bile was present in the stomach at endoscopy, 75Se-HCAT cholescintigraphy demonstrated an EGR, while in three out of five patients in whom endoscopy was negative, 75Se-HCAT cholescintigraphy detected EGR either during fasting or after meal ingestion. As EGR is not constant, 75Se-HCAT may be a useful tracer of bile to detect EGR over a prolonged period of time and in different physiological conditions.

Scintigraphic evaluation of duodenogastric reflux. Problems, pitfalls, and technical review

Bile reflux has been implicated in the pathogenesis of gastritis, gastric ulcer, and esophagitis. Radionuclide techniques provide the only non-invasive method to detect duodenogastric reflux. To analyze the problems that occur with attempts at quantitation, 55 patients were prospectively evaluated (45 patients with reflux esophagitis or Barrett's esophagus and ten patients with clinical symptoms of bile reflux, four of whom had Bilroth II surgery) with Tc-99m DISIDA, using a fasting technique with gallbladder stimulation by sincalide. Visual duodenogastric reflux occurred in 16 of 55 patients. Overlap of small bowel with the stomach is the major problem for accurate quantitation and occurred in 20 of 55 patients (36%). Overlap of left lobe of the liver occurred in 40 of 55 patients (73%), but its contribution to gastric activity was slight and could be easily subtracted. Reflux was intermittent in six of the 16 positive studies (38%), and continuous computer acquisition is needed to detect its maximum value. Primarily because of the problem of small bowel overlap, scintigraphic evaluation of duodenogastric reflux is only, at best, semi-quantitative. A review of the technical variables used in this examination, as well as potential problems that can occur, is provided.

Evaluation of gastrointestinal function with isotopic tracers

Nuclear medicine is the application of tracer methodology mainly to clinical diagnosis. We use chemical compounds labelled with radioisotopes as tracers. The examinations provide us with the information on regional function of tissues and organs. In this review we describe the nuclear medicine procedures for the diagnosis of gastrointestinal diseases based on our experiences. The emphasis is put on the evaluation of the functional aspect of the gastrointestinal tract. The procedures to be described include diagnosis of Meckel's diverticulum by gastric mucosal scintigraphy, measurement of esophageal, gastric and intestinal transit, detection of portocaval shunt and measurement of lactose absorption and detection of bacterial deconjugation of bile salts by means of breath analysis technique.

Hepatobiliary imaging after Whipple's operation

Hepatobiliary imaging after Whipple's operation provides information regarding the flow of bile. In the case presented there was jejunogastric bile reflux. This demonstrated the incompetence of the side to side jejunojejunostomy, which was surgically recommended to avoid bile reflux to the stomach. Jejunogastric bile reflux explains the patient's complaint of dyspepsia and occasional bilious vomiting in this case.

[Nuclear medicine demonstration of esophageal bile reflux]

Biliary and pancreatic juice has been implicated as a cause of regional inflammation or carcinoma after gastric surgery. We studied 38 patients after gastrectomy using a modification of cholescintigraphy (185 mBq 99m-Tc-DESIDA i.v.). As soon as the tracer had reached the duodenum, a dynamic study (30 min, 120 frames) was started. Thereafter a static image of the epigastrium and thorax in the anterior view with more than 1000 cts/cm2 was recorded. This procedure was repeated after a meal. Of 29 patients without complaints only 4 had a reflux into the jejunal loop. By contrast in 7 of 9 patients with suggestive symptoms this examination demonstrated bile reflux which reached the oesophagus in 6 cases. A stenosis of the distal oesophagus prevented oesophageal reflux in one patient. 2 patients with oesophageal reflux had a history of oesophageal stenosis and oesophagitis confirmed by endoscopy. The remaining 2 patients without demonstrable reflux had neither oesophagitis nor radiologically verified reflux. Cholescintigraphy as modified by us may detect clinical relevant bile reflux into the oesophagus. This is important for surgeons selecting patients with potential benefit from a reoperation. Since most patients with complaints after gastrectomy have had demonstrable bile reflux, reflux-reducing surgical techniques should be used in all.

99mTc-HIDA dynamic scintigraphy for the diagnosis of gastroesophageal reflux of bile

In 5 patients with partial gastric resection and esophagitis, in whom esophageal pH metry was unable to demonstrate significant gastroesophageal reflux (GER), we administered i.v. 5 mCi (185 MBq) of 99mTc-HIDA, the patient lying under a computer-assisted LFOV gamma camera. When gallbladder image was evident, caerulein was administered i.v. at a physiologic dose in order to induce gallbladder contraction, and in the subsequent 45 min the patient was asked to perform a standard series of manoeuvres that increase the intraabdominal pressure (Valsalva, etc.) and favour GER. Scintigraphic images and time/activity curves obtained from areas of interest corresponding to gastric remnant and distal esophagus showed that at least one of these manoeuvres in each case was followed by the appearance of the radiocompound in the distal esophagus, indicating a 99mTc-HIDA-tagged bile GER. Consequently, we believe that HIDA-GER dynamic scintigraphy may be more useful than esophageal pH metry in demonstrating the biliary origin of an esophagitis.

Anatomy of the choledochopancreatic duct junction in primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a rare disease for which the etiology is unknown. Because abnormalities of the choledochopancreatic duct junction (CDPDJ) have been implicated in the pathogenesis of other rare biliary problems such as choledochal cysts and biliary atresia, we reviewed the cholangiographic anatomy of the CDPDJ in our patients with PSC. From 1955 through July 1983, 46 patients with PSC were seen at the University of California at Los Angeles Medical Center. In 20 of these 46 patients anatomy of the CDPDJ could be evaluated by review of endoscopic retrograde cholangiopancreatography (11 patients) or by reflux into the pancreatic duct during transhepatic, operative, or postoperative tube cholangiography (nine patients). Roentgenograms were evaluated for the length of common channel of the biliary and pancreatic ducts and the degree of reflux into and anatomic abnormalities of the pancreatic duct. All bile ducts were abnormal, and pancreatic duct reflux occurred in 14 of 42 patients (33%) who underwent transhepatic or tube cholangiography. An abnormally long (greater than 15 mm) common channel was present in two of 20 patients (10%), pancreatic duct reflux of more than 100 mm occurred in six of 14 patients (43%), and pancreatic duct abnormalities were seen in nine of 18 patients (50%). These data suggest that in patients with PSC abnormal pancreatic duct reflux and anatomy are common but variations in the anatomy of the CDPDJ are rare. However, altered function of the CDPDJ may contribute to excessive reflux into and anatomic changes of the pancreatic ducts and the moderate incidence of pancreatitis observed in patients with PSC.

Duodenogastric bile reflux in patients with gastric ulcer

The duodenogastric bile reflux rate in 33 patients with gastric ulcer is compared with the rates in 33 non-ulcer patients. Duodenogastric bile reflux was measured by a non-invasive isotope method using 99mTc-diethyliminodiacetic acid. Reflux occurred significantly oftener in the ulcer patients (27 of 33) than in the non-ulcer patients (14 of 33) (p less than 0.01) but did not differ significantly in quantity between these two groups. The results suggest that the magnitude of bile reflux cannot be used to distinguish between ulcer patients and non-ulcer patients.

Duodenogastroesophageal reflux. Demonstration with Tc-99m DISIDA imaging

Duodenogastroesophageal reflux is demonstrated using cholescintigraphy in a patient with severe esophagitis.