Nuclear Medicine - Clinical Guidelines -Hepatobiliary Imaging

Front 1

Where is the gall bladder located?

Back 1

Covered by the liver and behind the liver

Front 2

What are the two cell types of the liver?

Back 2

hepatocytes and RES or Kupffer cells

Front 3

How and where is bile produced?
(what is it a product of?)

Back 3

In the liver by the hepatic cells. it is a product of erythrocyte breakdown and hepatocyte metabolism
what is bile used for(3 actions)?

Hint 3

to emulsify fats, stimulate peristalsis and enhance absorption of fatty acids

Front 4

Where is bile stored, where does it go and what stimulates its secretion?

Back 4

Stored in the gall bladder, ends up in the duodenum for digestion and is stimulated by Cholecystokinin (CCK) a hormone in the duodenum that stimulates the GB when fatty foods enter

Front 5

What is clinical indication for a patient to have hepatobiliary imaging?
(what is the primary reason for the study?)

Back 5

Abdominal pain in the upper right quadrant. (lots of time pain is radiating to back) need to rule out cystic duct obstruction (acute cholecystitis)
what do 98% of the cases end up being?

Hint 5

Obstructed cystic ducts

Front 6

________________ is the formation of stones in the biliary tree

Back 6

Cholelithesis is the formation of stones in the biliary tree

Front 7

What are some other indications of abdominal pain?

Back 7

Cancer: ampullary, pancreatic or liver
also pancreatitis, due to infected bile backing up into the pancreatic ducts

Front 8

What are the 3 possible stone locations in the biliary tree?

Back 8

Cystic, common hepatic and common bile duct

Front 9

What is the radiopharmaceutical used for hepatobiliary scans?

Back 9

IDA or Imiondiacetic acids
Two brands used:
1. Tc99m Disofenid - Hepatolite
2. Tc99m Mebrofenin -Choletec

Front 10

How long is the study and when is the maximum liver uptake?

Back 10

1 hour and 10-11 minutes for max uptake

Front 11

How does the Hepatolite or Choletec get to the liver, gb, duodenum?

Back 11

Carried to the liver and extracted from the blood by the hepatocytes and then follow path of bile flow
What is the potential problem with heightened bilirubin levels?

Hint 11

competes with the uptake of IDA agents, pts with elevated bilirubin levels may require higher doses

Front 12

What is the dosage that is used for hepatobiliary scans?

Back 12

2-8 mCi Tc99m IDA agent, average is 6

Front 13

What is the patient prep for the hepatobiliary procedure?
(important)

Back 13

1. 2-4 hr fasting (prevent release of CCK), but no more than 24 hrs
2. no opiated drugs 4 hrs prior

Front 14

What is the problem when patient fasts for more than 24 hrs or is on a feeding tube (hyperalimentation)?

Back 14

no stimulus for the gallbladder to contract, so it stays full
what is the problem if opiods are present?

Hint 14

the sphincter of Oddi relaxes so bile flows freely into sm intestine, instead of gall bladder

Front 15

Imaging procedures for hepatobiliary?

Back 15

LEAP or HIRES collimator
Image immediately following injection
(some facilities do flow study)
Pt supine, detector placed over abdomen, with liver at upper left corner of field of view
Sequential images every 5 min, for 1 hr*
delayed images at 2, 4 and 24 hrs
*how can this be done easier?

Hint 15

instead of hitting the button every 5 min, set up dynamic study

Front 16

What positioning is usually done for hepatobiliary scan?

Back 16

anterior and LAO, sometimes lateral, depending on facility

Front 17

How do you know if the cholecystitis is chronic or acute?

Back 17

If GB shows up after 1-4 hours it is chronic, if it never shows up it is acute

Front 18

Time frame for what anatomy is seen on normal hepatobiliary study?

Back 18

Immediate - heart, liver, spleen, kidneys and major vessels
5 min - liver clearly seen
10-11 min - optimal hepatocyte phase
10-15 min - hepatic bile ducts & GB
30-60 min - sm intestine
GB and sm intestine must be seen by 60 min for a normal study

Front 19

Purpose of doing Ejection Fraction with CCK on gall bladder?

Back 19

Although you see all the way to the sm intestine showing bile flow, the GB may still not being functioning right or slow. EF shows functionality

Front 20

What is the problem if you inject CCK before the hepatobiliary study if they have fasted more than 24hrs or on feeding tube?

Back 20

you stimulate the GB so you can do the study, but you cannot to the morphine again if necessary or inject CCK to do GBEF afterward

Front 21

List 3 protocol variations for hepatobiliary study

Back 21

sequential imaging for 1 hr, then reframe at 5 min intervals
intermittent imaging after 1 hr
anterior, RAO, Rt lat, post flow study, 30 min flow, with or w/o CCK

Front 22

What is a possible overlap problem in a hepatobiliary study and how do you correct it?

Back 22

bile duct and GB can overlap, making it hard to distinguish, so have to do oblique or lateral view

Front 23

What other imaging modality works with NM in diagnosing acute cholecystitis?

Back 23

Ultrasound, they can see stones

Front 24

Identify all the anatomy

Back 24

Front 25

How do you know you have a complete obstruction when doing a hepatobiliary study?

Back 25

stone in common bile duct, only the liver seen

Front 26

What is morphine augmentation?

Back 26

no visualization of GB at 1 hr, give morphine sulphate, which causes contraction of sphincter of Oddi, will force radiopharaceutical into GB if patent, will rule out acute cholecystitis since acute is associated with cystic dyct obstruction

Front 27

What is the "RIM sign" an indication of?

Back 27

Gangrenous cholecystitis and perforation, (rim around leaking perforated GB)

Front 28

How can a common bile duct obstruction be fixed without surgery and removing GB?

Back 28

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. ...

Front 29

Why do you use a lead blocker over the sm intestine or the gall bladder when doing a hepatobiliary scan?

Back 29

To get better counts on the unblocked anatomy so you can see if you have visualization

Front 30

What is duodenogastric bile reflux?

Back 30

reflux of bile into stomach

Front 31

What is GB ejection done for?

Back 31

To determine functionality of gallbladder.
what is the normal value?

Hint 31

35%

Front 32

Why is it better to administer CCK over 30-60 minutes rather than 3 minutes followed by 2nd dose?

Back 32

shorter dose and 2nd dose cause pt nausea and vomiting and not as realistic as eating a meal
what is the dose?

Hint 32

CCK 0.02 ug/kg

Front 33

What are some variables that can cause inaccuracy in EF graph?

Back 33

patient motion and anatomy overlapping

Front 34

What is the EF for GB?

Back 34

Pre CCK GB counts - post CCK/ pre X 100
A - B/A X 100

Front 35

What is post surgical duct patency?

Back 35

Checking for bile leaks after GB removal?
What would be indicative of a leak?

Hint 35

uptake to the right, viable ducts will go to the left

Front 36

What is a leveen shunt and why do we image a patient with it?

Back 36

shunt to remove excess fluid from perionteal cavity terminating at sup vena cava. image to see blockage

Front 37

What radiopharmaceutical do you use for a leveen shunt?

Back 37

3-5 mCi Tc99m MAA or 2 mCi sulfur colloid

Front 38

What is CCK?

Back 38

hormone produced by duodenum to stimulate GB to contract. name is Cholecystokinin, Sincalide is a synthetic form of CCK, used in pretreatment and EF

Front 39

What is the dosage when doing an ejection fraction for GB?

Back 39

CCK 0.02 ug/kg itraveneously over 3 min and then 2nd dose at .04 if no contraction
what is the better way?

Hint 39

administer cck .02 ug/kg for 30 minutes to better mimic a meal and less harsh on patient