The role of (99m)technetium-labelled hepato imino diacetic acid (HIDA) scan in the management of biliary pain

Functional, Diagnostic and Therapeutic Aspects of Gastrointestinal Hormones

Gastrointestinal (GI) hormones are essential to many physiologic functions in our body. They have many GI and extra-GI functions. Some of the functions of these hormones, which have GI and extra-GI sources, are still unknown. Specific GI hormones can affect the brain to control food intake, while others can proliferate normal and neoplastic tissue when their receptors are expressed in certain neoplasms. GI hormones also have many diagnostic and therapeutic roles. Physiologic and pathophysiologic aspects as well as the diagnostic and therapeutic values of GI hormones are elaborated in this review.

Ultrasound Image Based Human Gallbladder 3D Modelling along with Volume and Stress Level Assessment

Purpose

Three-dimensional (3D) gallbladder (GB) geometrical models are essential to GB motor function evaluation and GB wall biomechanical property identification by employing finite element analysis (FEA) in GB disease diagnosis with ultrasound systems. Methods for establishing such 3D geometrical models based on static two-dimensional (2D) ultrasound images scanned along the long-axis/sagittal and short-axis/transverse cross-sections in routine GB disease diagnosis at the beginning of emptying phase have not been documented in the literature so far.

Methods

Based on two custom MATLAB codes composed, two images were segmented manually to secure two sets of the scattered points for the long- and short-axis GB cross-section edges; and the points were best fitted with a piecewise cubic spline function, and the short-axis cross-section edges were lofted along the long-axis to yield a 3D geometrical model, then GB volume of the model was figured out. The model was read into SolidWorks for real surface generation and involved in ABAQUS for FEA.

Results

3D geometrical models of seven typical GB samples were established. Their GB volumes are with 15.5% and − 4.4% mean errors in comparison with those estimated with the ellipsoid model and sum-of-cylinders method but can be correlated to the latter very well. The maximum first principal in-plane stress in the 3D models is higher than in the ellipsoid model by a factor of 1.76.

Conclusions

A numerical method was put forward here to create 3D GB geometrical models and can be applied to GB disease diagnosis and GB shape analysis with principal component method potentially in the future.

Systematic review with meta-analysis: cholecystectomy for biliary dyskinesia-what can the gallbladder ejection fraction tell us?

BACKGROUND

Gallbladder dyskinesia (gallbladder spasm, biliary dyskinesia or chronic acalculous cholecystitis) is a poorly defined entity which presents as biliary-type pain without any identifiable organic pathology. Abnormal gallbladder ejection fraction (GBEF) is used by some to select those likely to benefit from cholecystectomy. The validity of this approach has been questioned.

AIM

To systematically review the literature and summarise the evidence surrounding the practice of cholecystectomy based on GBEF for gallbladder dyskinesia.

METHODS

We conducted a systematic search of PubMed/MEDLINE and SCOPUS from 1980 to 2016 to identify the relevant literature.

RESULTS

Twenty-nine studies including 2891 patients were included in the final analysis. In comparing cholecystectomy with medical management, patients with a normal GBEF did not benefit from cholecystectomy; whereas those with low GBEF had a higher chance (RR, relative risk = 2.37) of symptomatic improvement following surgery. When those classified as "low" and "normal" GBEF were compared in terms of outcome following cholecystectomy, the rate of improvement following surgery was similar in the two groups (RR 1.09) which suggests a placebo effect of surgery.

CONCLUSIONS

While a low GBEF may provide some guidance in identifying those with gallbladder dyskinesia who may benefit from cholecystectomy, the available data are inconsistent and based on studies of poor quality which are often subject to bias and the impact of confounding factors. For these reasons, we conclude that the role of scintigraphy and cholecystectomy in the definition and management of this disorder remain unclear pending definitive study.

Role of 99mTc-HIDA Scan for Assessment of Gallbladder Dyskinesia and Comparison of Gallbladder Dyskinesia with Various Parameters in Laparoscopic Cholecystectomy Patients

OBJECTIVES

Pathogenesis of gallstone includes bile stasis due to defect in the gallbladder muscle contraction. Our aim of the study is to find out the role of 99mTc-HIDA scan in assessment of gallbladder dyskinesia in cholelithiasis patients before laparoscopic cholecystectomy and compare the gallbladder dyskinesia with various parameters like symptoms of patients, diabetic status of patients, gallstones size and number, and cholecystitis features in histopathology report after surgery.

MATERIAL AND METHOD

This is a prospective observational study conducted at our hospital for three years. Totally 40 patients with gallstone were subjected to 99mTc-HIDA scan, to assess the ejection fraction of gallbladder. For all these patients detailed clinical history, presence of comorbid illness like diabetics, and symptomatology were elicited. For all patients, ultrasonogram of abdomen was done to assess number and size of stones. All parameters were tabulated and correlated.

RESULT

While comparing 99mTc-HIDA scan findings with symptoms of patients, 21.2% were asymptomatic and 78.8% symptomatic patients who had ejection fraction less than 80%. All patients in EF >80% group were symptomatic only. It is not statistically significant. On comparing 99mTc-HIDA scan findings with diabetic status of the patients, 42.4% of diabetic and 57.6 % of nondiabetic patients had ejection fraction less than 80%. It is not statistically significant (0.681). While comparing 99mTc-HIDA scan findings with size of the gallstone in ultrasound, 63.6% patients with size less than 1cm and 36.4% with size more than 1cm had ejection fraction < 80%. It is statistically significant (0.048). On comparing 99mTc-HIDA scan findings with number of stones in ultrasound, 18.2% single gallstone patients and 81.8% multiple gallstone patients had EF less than 80% which is statistically significant (0.001). While comparing the 99mTc-HIDA scan findings with histopathology report after laparoscopic cholecystectomy, 21.2% non-cholecystitis patients and 78.8% cholecystitis patients had EF less than 80%, which is statistically (0.017) significant.

CONCLUSION

99mTc-HIDA scan can be an accurate method to diagnose the gallbladder dyskinesia. Gallbladder dyskinesia in 99mTc-HIDA scan can be used to predict large size stones and multiple stones before surgery. The sensitivity can be improved by 99mTc-HIDA scan in diagnosing cholecystitis patients.

Cholecystectomy for Biliary Hyperkinesia

Patients with classic biliary colic symptoms and documented gallbladder ejection fractions on the higher end of the spectrum on hepatobiliary iminoacetic acid scans with cholecystokinin stimulation are presently understudied and the benefits of cholecystectomy are unclear. To determine whether patients with biliary-type pain and biliary hyperkinesia (defined as a gallbladder ejection fractions of 80% or greater) benefit from laparoscopic cholecystectomy, a retrospective chart review encompassing five community hospitals was performed. Patients 16 years and older with diagnosed biliary hyperkinesia who underwent laparoscopic cholecystectomy between January 1, 2010 and May 31, 2015 were included. Pathology reports were reviewed for histologic changes indicating cholecystitis. Resolution of biliary colic symptoms was reviewed one to three weeks after surgery in their postoperative follow-up documentation. Within our study cohort, we found 97 patients who underwent laparoscopic cholecystectomy for biliary hyperkinesia. Within this population, 84.5 per cent of patients undergoing laparoscopic cholecystectomy for biliary hyper-kinesia had positive findings for gallbladder disease on final pathology. Of the 77 patients with data available from their first postoperative visit, 70 (90.9%) reported improvement or resolution of symptoms. Our findings suggest that symptomatic biliary hyperkinesia may be treated successfully with surgery.

Dumbbell Gallbladder Cholecystitis on Tc-99m Diisopropyliminodiacetic acid Hepatobiliary Imaging

We present a case of a 79-year-old immunocompromised female admitted for abdominal pain and sepsis, who had an abdominal computed tomography (CT) showing distal gallbladder fundus wall thickening, pericholecystic edema, and a right posteroinferior hepatic abscess. Subsequent hepatobiliary scintigraphy with Tc-99m diisopropyliminodiacetic acid showed gallbladder filling of the proximal gallbladder fundus, yet no radiotracer filling of the distal gallbladder fundus. Further correlation with the initial CT showed a partial gallbladder stricture and a resultant altered morphology resembling a dumbbell-shaped gallbladder. Percutaneous cholangiogram also confirmed this dumbbell morphology. Nonfilling of radiotracer into the distal end of the dumbbell gallbladder correlating with CT findings of focal gallbladder inflammation indicated that there was a focal inflammation suggesting a distal dumbbell gallbladder cholecystitis. This case demonstrates a unique finding of focal inflammatory pathology involving an anatomic variant - the dumbbell-shaped gallbladder, and the challenges this anatomic variant presents in hepatobiliary scintigraphy image interpretation.

Acute Calculous Cholecystitis Missed on Computed Tomography and Ultrasound but Diagnosed with Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography

We present a case of a 69-year-old patient who underwent ascending aortic aneurysm repair with aortic valve replacement. On postsurgical day 12, he developed leukocytosis and low-grade fevers. The chest computed tomography (CT) showed a periaortic hematoma which represents a postsurgical change from aortic aneurysm repair, and a small pericardial effusion. The abdominal ultrasound showed cholelithiasis without any sign of cholecystitis. Finally, a fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT examination was ordered to find the cause of fever of unknown origin, and it showed increased FDG uptake in the gallbladder wall, with no uptake in the lumen. FDG-PET/CT can diagnose acute cholecystitis in patients with nonspecific clinical symptoms and laboratory results.

HIDA Scan with Ejection Fraction is over Utilized in the Management of Biliary Dyskinesia

Patients with upper abdominal pain, nausea, and vomiting are often evaluated with ultrasound to diagnose symptomatic cholelithiasis or cholecystitis. With a normal ultrasound, a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. The purpose of this study was to evaluate whether the HIDA scan with EF was appropriately utilized in considering cholecystectomy. Over 18 months, we performed 1533 HIDA scans with EF. After exclusion, 1501 were analyzable, 438 of whom underwent laparoscopic cholecystectomy. Patients were divided into two groups: those with typical and atypical symptoms of biliary colic. Our primary endpoint was symptom resolution of those who underwent laparoscopic cholecystectomy. Symptom resolution was assessed by chart review of postop visits or readmissions. In patients with typical symptoms, resolution occurred in 66 per cent of patients with positive HIDA and 77 per cent with negative HIDA ( P = 0.292). In patients with atypical symptoms, resolution occurred in 64 per cent of patients with positive HIDA and 43 per cent with negative HIDA ( P = 0.013). A HIDA scan with EF was not useful in patients with typical symptoms of biliary colic and negative ultrasounds, and should not be used to make a decision for cholecystectomy. However, this test can be helpful in patients with atypical symptoms, as it does predict symptom improvement in this group.

Management of gallbladder dyskinesia: patient outcomes following positive ⁹⁹mtechnetium (Tc)-labelled hepatic iminodiacetic acid (HIDA) scintigraphy with cholecystokinin (CCK) provocation and laparoscopic cholecystectomy

AIMS

To evaluate clinical outcomes in patients with typical biliary pain, normal ultrasonic findings, and a positive (99m)technetium (Tc)-labelled hepatic iminodiacetic acid analogue (HIDA) scintigraphy with cholecystokinin (CCK) provocation indicating gallbladder dyskinesia, as per Rome III criteria, undergoing laparoscopic cholecystectomy (LC).

METHODS AND MATERIALS

Consecutive patients undergoing LC for gallbladder dyskinesia were identified retrospectively. They were followed up by telephone interview and review of the electronic case records to assess symptom resolution.

RESULTS

One hundred consecutive patients (median age 44; 80% female) with abnormal gallbladder ejection fraction (GB-EF <35%) were followed up for a median of 12 months (range 2-80 months). Following LC, 84% reported symptomatic improvement and 52% had no residual pain. Twelve percent had persisting preoperative-type pain of either unchanged or worsening severity. Neither pathological features of chronic cholecystitis (87% of 92 incidences when histology available) nor reproduction of pain on CCK injection were significantly predictive of symptom outcome or pain relief post-LC.

CONCLUSION

In one of the largest outcome series of gallbladder dyskinesia patients in the UK with a positive provocation HIDA scintigraphy examination and LC, the present study shows that the test is a useful functional diagnostic tool in the management of patients with typical biliary pain and normal ultrasound, with favourable outcomes following surgery.

Cholecystectomy for biliary dyskinesia: how did we get there?

BACKGROUND

The focus of biliary dyskinesia (BD) shifted within the last 30 years, moving from symptoms after cholecystectomy (CCY) to symptoms with morphological normal gallbladder, but low gallbladder ejection fraction.

METHODS

We searched the pubmed database to systematically review studies focusing on the diagnosis and treatment of gallbladder dysfunction.

RESULTS

Impaired gallbladder contraction can be found in about 20% of healthy controls and an even higher number of patients with various other disorders. Surgery for BD increased after introduction of laparoscopic CCY, with BD now accounting for >20% of CCY in adults and up to 60% in pediatric patients. The majority of cases reported were operated in the USA, which differs from surgical series for cholelithiasis. Postoperative outcomes do not differ between groups with abnormal or normal gallbladder function.

CONCLUSION

Functional gallbladder testing should not be seen as an indicator of relevant biliary tract disease or prognostic marker to identify patients who may benefit from operative intervention. Instead biliary dyskinesia should be considered as a part of a spectrum of functional disorders, which are generally managed conservatively. Small proof of concept studies have demonstrated effects of medical therapy on biliary dysfunction and should thus be never tested in appropriately designed trials.

Pain provocation and low gallbladder ejection fraction with CCK cholescintigraphy are not predictive of chronic acalculous gallbladder disease symptom relief after cholecystectomy

INTRODUCTION

Chronic acalculous gallbladder disease (CAGD) falls within the spectrum of diseases associated with gallbladder dysmotility. Cholecystokinin-cholescintigraphy (CCK-CS) has been used to evaluate for CAGD, with a gallbladder ejection fraction (GBEF) of <35 % being indicative of gallbladder dysfunction. The reproduction of biliary colic upon administration of CCK has been cited as indicative of CAGD. Our purpose was to determine whether low GBEF or reproduction of pain during CCK-CS was predictor of surgical outcomes related to resolution of symptoms or as a correlate to gallbladder pathology.

METHODS

A retrospective review of patients was performed to evaluate adults with a diagnosis of CAGD who underwent CCK-CS prior to surgical intervention. CPT and ICD-9 coding queries were used to identify the patient population. Patients with cholelithiasis were excluded.

RESULTS

Sixty-four patients met inclusion criteria. Two patients were lost to follow-up and were excluded. During CCK-CS, 41 patients (66 %) reported symptoms similar to their presenting complaint. Twenty-one patients reported no symptoms with CCK-CS. There was no significant relationship between gallbladder pathology and either GBEF or reproduction of symptoms with CCK-CS (p = 0.14). About 81 % of patients (n = 50) had relief of symptoms following cholecystectomy. Sixty-six percentage of patients (n = 33) with long-term symptom relief after cholecystectomy had reproduction of symptoms with CCK-CS. Nineteen percentage of all patients (n = 12) had long-term symptom recurrence despite surgery. Eight of these patients (66 %) had symptom reproduction with CCK-CS. There was no significant correlation with either the GBEF or symptoms reproduction with CCK-CS as a predictor of postoperative outcome (p = 0.12).

CONCLUSION

Provocation of pain by CCK-CS and low GBEF are unreliable predictors of postoperative relief of symptoms following cholecystectomy for biliary dyskinesia or chronic acalculous gallbladder disease.

Normokinetic biliary dyskinesia: a novel diagnosis

BACKGROUND

Biliary dyskinesia diagnosed with CCK-HIDA scan and ejection fraction less than 35 % has been successfully treated by laparoscopic cholecystectomy. However, a population of patients with symptomatic biliary pain and a normal CCK-HIDA scan never receive a diagnosis, and thus no definitive treatment. Some of these patients report a reproducible pain during their CCK-HIDA scan. It is hypothesized that these patients have a novel diagnosis, normokinetic biliary dyskinesia, and may have resolution of pain when treated with cholecystectomy.

METHODS

A retrospective chart review was completed looking for patients with biliary pain in accordance with the ROME III criteria. Additional inclusion criteria were (1) greater than age 18 years, (2) reproducible biliary symptoms during the CCK-HIDA scan, and (3) an ejection fraction greater than 35 %. Treatment modality was laparoscopic cholecystectomy. Descriptive statistics were preformed, and data were reported as mean ± standard deviation and range.

RESULTS

Nineteen patients met the inclusion criteria for this study from August 2008 to July 2011. There were 15 women and 4 men with a mean age of 48.4 ± 13.0 years. The mean ejection fraction was 75.1 ± 19.4 %. The average duration of preoperative symptoms was 6.8 ± 5.9 months and postoperative follow-up was 21.8 ± 10.6 months. Seventeen patients had complete resolution of symptoms, one had partial resolution, and one had no change. There was a complete resolution rate of 89.5 % and an improvement rate of 94.7 %.

CONCLUSIONS

We suggest that patients who present with biliary pain, a normal CCK-HIDA scan with an ejection fraction greater than 35 %, and with reproducible symptoms on infusion of CCK could have a novel diagnosis: normokinetic biliary dyskinesia. Currently, these patients are excluded from the diagnosis of biliary dyskinesia and thus treatment. We hypothesize a potential new diagnosis, suggest cholecystectomy as treatment, and recommend a prospective study design for further evaluation.

The cholecystokin provocation HIDA test: recreation of symptoms is superior to ejection fraction in predicting medium-term outcomes

BACKGROUND

The (99m) technetium labelled hepato imino diacetic acid (HIDA) scan is widely used in the investigation of patients with typical biliary pain but whose trans-abdominal ultrasound scan (US) is normal. Although the standard measure by which the HIDA scan is deemed positive is the presence of an ejection fraction (EF) of <35% following provocation with cholecystokinin (CCK), there still remains debate as to the usefulness of this measure. The aim of this study was to compare the roles of EF and symptom provocation following CCK infusion in relation to the outcome following laparoscopic cholecystectomy (LC). More specifically, we aimed to review the resolution of symptoms for our significant population of patients with normal HIDA scan EFs for whom surgery has traditionally been deemed inappropriate.

PATIENTS AND METHODS

All patients undergoing LC for a presumed diagnosis of biliary dyskinesia were identified from a prospectively maintained database. Data were collected regarding pre-operative symptoms, EF and symptom provocation during the CCK HIDA scan, histological findings, early symptomatic outcome, and medium-term follow-up.

RESULTS

During the period from March 2006 to October 2009, 42 patients with biliary symptoms but a negative US were referred for assessment by a single surgeon. There were 31 women and 11 men with a mean age of 39.0 ± 12.6 years. All underwent a CCK HIDA scan of which 17 were positive with an EF <35% and the remaining 25 were negative. All patients reported recreation of symptoms following administration of CCK. All gallbladders were delivered intact for histological assessment and all but one showed evidence of chronic cholecystitis. At each postoperative visit, approximately 2 weeks following the procedure, all patients reported resolution of symptoms. After a mean of 18.7 ± 12.1 months symptom recurrence had been noted in only one of 42 (2.4%).

CONCLUSIONS

The CCK HIDA scan is a useful study in the investigation of acalcalous cholecystitis; however, we would suggest that recreation of symptoms following CCK provocation is superior to EF for the identification of underlying chronic cholecystitis. Indeed, a normal gallbladder ejection fraction does not necessarily rule out a biliary aetiology of symptoms for this patient population.

Biliary, pancreatic, and hepatic imaging for the general surgeon

Technologic advancements have allowed imaging modalities to become more useful in the diagnosis of hepatobiliary and pancreatic disorders. Computed tomography scanners now use multidetector row technology with contrast-delayed imaging for quicker and more accurate imaging. Magnetic resonance imaging with cholangiopancreatography can more clearly delineate liver lesions and the biliary and pancreatic ducts, and can diagnose pathologic conditions early in their course. Newer technologies, such as single-operator cholangioscopy and endoscopic ultrasonography, have sometimes shown superiority to traditional modalities. This article addresses the literature regarding available imaging techniques in the diagnosis and treatment of common surgical hepatobiliary and pancreatic diseases.