Biliary Scintigraphy in the Evaluation of Jaundiced Patients: A Review, Study notes of Nuclear medicine

Download Biliary Scintigraphy in the Evaluation of Jaundiced Patients: A Review and more Study notes Nuclear medicine in PDF only on Docsity! he differentiation ofjaundice due to the hepatocel lular disease (medical jaundice) from extrahepatic bili ary obstruction (surgical jaundice) is important in plan fling the appropriate diagnostic and therapeutic procedures. Currently, there are a number of radiologic tech niques available in the investigation of a jaundiced patient. These include: ultrasonography (US), corn puted tomography (CT), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangio-pancreatography (ERCP) ( 1). Some of these (PTC and ERCP) are invasive and/or expensive. Fur thermore, they delineate anatomic lesions but do not provide a functional evaluation. On the other hand, radionuclide hepatobiliary scanning is a noninvasive study and provides the only means of functional evaluation along with imaging. In selecting a single screening test which can differ entiate medical from surgical causes of jaundice, one has to take into account ease of performance, cost effectiveness, complications associated with the proce dure, and degree of accuracy. With the introduction of newer radiopharrnaceuticals such as p-butyl acetanilid iminodiacetic acid (BIDA) labeled with technetium 99m (99mTc) interest in hepatobiliary scintiscanning has increased (2—4). There has not been uniform agreement concerning Received July 19, 1985; revision accepted Mar. 6, 1986. For reprints contact: M.D. Ram, MD, PhD, Chief, Surgical Service, V. A. Medical Center, Lexington, KY 405 11. the diagnostic value of scintiscanning in jaundiced pa tients (5—7).Klingensmith et al. stated that US and hepatobiliary scintigraphy have a complementary role in the evaluation ofbiliary obstruction (8). Their group also suggested that intrahepatic cholestasis can be di agnosed by hepatobiliary scintigraphy (9). This study reviews our experience with the use of radionuclide hepatobiliary imaging as a screening procedure in jaundiced patients. MATERIALS AND METHODS During the period March 1, 1979, through April 30, 1983, we studied 96 patients who were clinically jaun diced. All patients were from our institution and in cluded 79 males and 17 females. The age range was 1 mo to 92 yr (mean 52 yr). The levels of serum bilirubin ranged from 2.1—38.8 mg/dl (normal 0. 1—1.1 mg/dl). Excluded from this review were patients who carried a diagnosis of either acute or chronic cholecystitis alone and also patients who have had previous biliary enteric bypass. These have been previously reviewed by one of us (2—4,10). In addition to scintiscanning, all patients underwent clinical, chemical, radiologic, and endoscopic evalua tions as required. The final diagnosis in each patient was based on the results of all studies noted above and additionally in most patients based on operative find ings or needle biopsy of the liver (details in results). 1407Volume27 •Number9 •September1986 Technetium-99m BIDA Biliary Scintigraphy in the Evaluation of the Jaundiced Patient Anthony W. Lee, Madhira D. Ram, Wei-Jen Shih, and Karen Murphy Surgical and Nuclear Medicine Services, V. A. Medical Center and the Department of Surgery, University ofKentucky Medical Center, Lexington, Kentucky Biliary scintigraphy using @“Tcp-butyl acetanilidiminodiacetic acid (BIDA) was performed as partof the diagnosticevaluationon 96 patientswith jaundice(serumbilirubin>2 mg/dl)to assessits valuein this groupof patients.Theresultsof scintigraphyrevealed(a)no obstruction to the flow of the scintigraphic agent into the duodenum in 54 patients, (b) delayed appearance of the agent (normal upper limit 60 mm) in the duodenum indicating partial obstruction in 22 patients, and (c) complete obstruction of the duct demonstrated by absenceof agentin the duodenumin 20 patients.Thefindingswerecorrelatedwith the final diagnosisandthe overallresultsshowaccuracyof 92.7%,sensitivityof 97.3%,and specificityof 89.8%.Biliaryscintigraphywas thus foundto be usefulin differentiating nonobstructive,partiallyobstructive,andcompletelyobstructivecausesof jaundice. J Nucl Med 27:1407—1412,1986 I 24kii. Informed consent was obtained from all subjects. Technetium-99m BIDA was used as scanning agent and was prepared from a commercial kit and 5mCi of [99mTc]BIDA was injected intravenously. Using a gamma camera,t images were obtained at 2, 5, 10, 15, 30, 45, and 60 mm after the injection and then at 15- mm intervals for up to 90 to 120 mm. Further scans were obtained at 4 to 6 hr as needed and up to 24 hr if indicated. Each image accumulated 300—500kcounts. The details of this technique were previously described (2,11). RESULTS In a normal scintigram, the liver is visualized at 5 to 10 mm after injection of the agent, the gallbladder at ,@â€1̃ 5—20 mm and complete images ofthe liver, galiblad der, common bile duct, and proximal small bowel are obtained between 25 and 30 mm. The criteria used to define extrahepatic biliary obstruction are based on whether the gallbladder and the common bile duct were visualized or not and whether there is radionuclide activity in bowel or not and also the time of appearance of this activity. The results of scintigraphy in this group were classi fled into three categories as follows: (a) nonobstructive group (no obstruction to the flow of the scintigraphic agent into the duodenum), 54 patients; (b) partially obstructive (partial obstruction on the basis of delayed appearance of the agent: 60 mm or more in the bowel), 22 patients (Fig. 1); and (c) completely obstructive (absence of the scanning agent in the small bowel even after 24 hr), 20 patients (Fig. 2). In eight patients who were categorized as partial obstruction, in addition to delayed radioactive tracer excretion in bowel, there was a scintigraphic pattern of intrahepatic bile pooling along the area and/or segmen tal defect in common bile duct (Fig. 3). This character istic pattern has been previously documented (12). There are two scintigraphic patterns of complete obstruction of the common bile duct. One is that of a fairly rapid hepatic uptake of the tracer by the liver but no visualization ofthe hepatic ducts, the common duct, gallbladder, or the bowel even up to 24 hr after injection (13,14) (Fig. 2). The other pattern is a hyperacute complete common bile duct obstruction, scintigraphic features ofwhich include rapid uptake and visualization of the hepatic ducts, common bile duct, and the gall bladder, but no appearance of activity in the bowel through the 24-hr study period ( 15) (Fig. 4). Only one patient in the study showed this pattern. The results of scintigraphy were correlated with the final diagnosis (Tables 1, 2, and 3). The following defi nitions were used: (a) true negative—no obstruction or delay of agent into the duodenum in the scan and no obstruction demonstrated, (b) true positive—obstruc tion or delay of agent into the duodenum by scan and obstruction confirmed, (c) false positive—obstruction or delay of agent into the duodenum by scan but no obstruction present, and (d) false negative—no obstruc tion or delay of agent into the duodenum by scan but obstruction present. Based on the above, the sensitivity of the scan was 97.3%, the specificity was 89.8%, and the overall accuracy was 92.7%. DISCUSSION Our results suggest that scintigraphy is useful in the initial evaluation of the jaundiced patient. The differ entiation of obstructive from nonobstructive jaundice has been a subject of several conflicting reports (17— 20). The area of greatest difficulty centers around the fact that at very high levels of serum bilirubin, lack of images may be due to hepatocellular disease (poor hepatic uptake) or extrahepatic biliary obstruction (poor excretion) ( 16,21 ). In the former situation the tracer remains in the blood pool for a long time and FIGURE 1 Partial obstruction of common bile duct: Fairly rapid radiotracer hepatic uptake and no visualizationof bile ducts, gallbladder,and bowel in 5-, 10-, 15-, 30-, and 60-mm images; colonicactivityseenin 24-hr images but substantial radiotracer remaining in liver at 24 hr, indicatingsevere partialobstruction 1408 Lee, Ram, Shih et al The Journal of Nuclear Medicine FinalclinicaldiagnosisNo. of patientsAverage S. bilirubin (mg/dl)Confirmation ofdiagnosisCholedocholithiasis96.7Operation andcholangiogramPancreatitis33.1Laboratory (amylase)andul trasonographyCommon bileduct stricture212.2Operation andcholangiogramPseudocyst—panc eas16.4Ultrasonography andbarium studiesCarcinoma—gallbladderI19.5Operation andbiopsyLeiomyosarcoma—stomach displacing commonI5.6Operation andbiopsyductDrug inducedcholestasi&28.1LiverbiopsySepsis•12.2History, exploratorycell otomyGas gangreneabdominalwai112.4Physical findings,culturesAlcoholic hepatiti&120.59UverbiopsyTotal22. False positive. Finalclinical diagnosisNo. of patientsAverage S. bilirubin (mg/dl)Confirmation of diagnosisCarcinoma of pancreas81 5.5Operation and biopsyBiliary atresia(extrahe 79.4Uver biopsyandpatic)operationCommon bileduct stric16.7Operation ureCommon bile duct ste12.4OperationnosisIntra-abdominal mass13.8Operationobstructing commonbile ductHemOrrhagiC pancreati115.3Operatio tisPrimary biliarycirrhosis'113.0LiverbiopsyTotal20. False positive. TABLE2 Partially Obstructive Group only one false negative (2.7%). The patient had a mildly elevated bilirubin with choledocholithiasis and may very well not have had enough extrahepatic obstruction to cause a delay in appearance of the agent into the duodenum. Our false positives consist of six patients (5.76%). These patients had serum bilirubin in the range of 8.0—20.6 mg/dl. The dilution of tracer by retained bile may have caused the delay in imaging of the agent into the duodenum ( 17). By performing a BIDA scan as the initial procedure in the workup ofjaundiced patients, only 10% of the “nonobstructive―group (medical jaundice) of patients TABLE3 CompletelyObstructiveGroup would be subjected to further diagnostic workup, whereas 90% would be treated medically after the scan results. In the “obstructive―group (surgical jaundice), all but one patient would have had further appropriate diagnostic studies before their operation. Scintigraphy, therefore, is clearly of benefit as an initial screening procedure. It has the advantages of being noninvasive and it can provide a functional evaluation of the hepa tobiliary system in patients with elevated serum biliru bin. It also has the advantages over ultrasonography in these patients because dilated loops of bowel do not interfere with the imaging. As with other noninvasive studies it is not completely infallible. A precise anatomic diagnosis is not feasible with scintigraphy. In equivocal cases, clinical features and appropriate use of other studies, both invasive and noninvasive, become important. We feel that with a level ofaccuracy over 90%, biliary scintigraphy warrants serious consideration as a screen ing test because it offers a safe, simple procedure free from complications, for primary evaluation of jaundiced patients. In conclusion, biliary scintigraphy is useful as an initial screening tool in differentiating jaundiced pa tients into nonobstructive, partially obstructive and completely obstructive groups. FOOTNOTES . CIS-Us, Inc., Lake Success, NY. t Siemens or General Electric. REFERENCES 1. Toombs BD, Sandier CM: Medical versus surgical jaundice: When and how the radiologist can help. Tex Med77:52—58, 1981 Volume 27 •Number 9 •September 1986 1411 2. Ram MD, Hagihara PF, Kim EE, et al: Evaluation of biliary disease by scintigraphy. Am J Surg 141:77—83, 1981 3. Ram MD, Mattingly SS, Kim EE, et al: Biliary scm tiscanning in acute cholecystitis. World J Surg 6: 110— 114,1982 4. Ram MD: The value of scintigraphy in the diagnosis of biliary disease. Ann R Coil Surg Eng 63:333—336, 1981 5. Matzen P, Malchow-Moller A, Brun B, et al: Ultra sonography, computed tomography, and cholescintig raphy in suspected obstructive jaundice—A prospec tive comparative study. Gastroenterology 84:1492— 1497,1983 6. O'Connor KW, Snodgrass PJ, Swonder JE, et al: A blinded prospective study comparing four current noninvasive approaches in the differential diagnosis of medical versus surgical jaundice. Gastroenierology 84:1498—1504,1983 7. Zeman RK, Burrell MI, Gold JA, et al: The intrahe patic and extrahepatic bile ducts in surgical jaundice: Radiological evaluation and therapeutic implications. CRC Cr11Rev DiagImaging21:1—36,1984 8. Klingensmith M, Johnson MC, Kuni CC, et al: Com plementary role of Tc-99m diethyl IDA and US in large and small duct biliary tract obstruction. Radio!- ogy138:177—184,1981 9. Kuni CC, Klingensmith WC, Fritzberg AR: Evalua tion of intrahepatic cholestasis with radionuclide hep atobiliary imaging. Gastrointest Radio! 9:163—166, 1984 10. Tidmore H, Ram MD: Hepato-biliary scintiscanning in the evaluation of biliary enteric anastomoses. Am Surg5l:158—l61,1985 11. Williams W, Krishnamurthy GT, Brar HS, et al: Scm tigraphic variations of normal biliary physiology. J NuclMed25:160—165,1984 12. Krishnamurthy GT, Lieberman OJ, Brar HD: Detec tion, localization and quantitation of degree of com mon bile duct obstruction by scintigraphy. JNuc!Med 26:726—735,1985 13. Blue PW: Biliary scanning interpretation using Tc 99m DISIDA. Clin Nucl Med 10:742—745,1985 14. Klingensmith WC, Whitney WP, Spitzer VM, et al: Effect of complete biliary tract obstruction on serial hepatobiliary imaging in an experimental model: Con cisc communication. J NuclMed 22:866—868,1981 15. Blue PW: Hyperacute complete common bile duct obstruction demonstrated with Tc-99m IDA chole scintigraphy. Nuc! Med Commun 6:275—279,1985 16. Floyd JL, Collins TL: Discordance of sonography and cholescintigraphy in acute biliary obstruction. Radio!- ogy140:501—502,1983 17. Taavisainen M, Korhola 0, Riihimaki E, et al: Tech netium-99m-diethyl-IDA cholescintigraphy in the dif ferential diagnosis ofjaundice. Scand J Gastroentero! 14:567—575,1979 18. Rosenthall L, Shaffer EA, Lisbona R, et al: Diagnosis ofhepatobiliary disease by 99mTc-HIDA cholescintig raphy. Radiology 126:467—474,1978 19. Scott BB, Evans JA, Unsworth J: The initial investi gation of jaundice in a district general hospital: A study of ultrasonography and hepatobiliary scintigra phy.BrJRadiol53:557—562,1980 20. Nadel M, Srenson TI, Jerichau I, et al: Hepatobiliary scintigraphy with 99mTc-labelled diethyl acetanilide iminodiacetic acid in the differential diagnosis ofjaun dice.Dan Med Buil27:278—280,1980 21. Majd M, Reba RC, Altman RP: Hepatobiliary scintig raphy with 99mTc-PIPIDA in the evaluation of neo nataljaundice.Pediatrics67:140—145,1981 22. Kuni CC, Klingensmith WC: Atlas of Radionuclide Hepatobi!iary Imaging, Boston, GK Hall Medical Publishers, 1983 23. Nicholson RW, Herman KL, Shields RA, et al: The plasma protein binding of HIDA. Eur J Nuc! Med 5:311—312,980 24. Wiston BW, Subramanian G, Van Heertuan RL, et al: An evaluation of Tc-99m labelled hepatobiliary agents.JNuclMed 18:455—561,1977 25. Subramanian G, McAfee JG, Henderson RW, et al: The influence of structural changes on biodistribution of Tc-99m labelled N-substituted IDA derivatives. J Nuc!Med 18:624,1977 1412 Lee,Ram,Shihet al TheJournalof NuclearMedicine