Hepato Test out

100% of pts have bowel showing at.....

90 min

Morphine dose

0.04 mg/kg slowly over 2-3 mins

Gallbladder

stores and concentrates bile

7-10 cm long

holds approx 30 ml of bile

Bile Pathway

common hepatic duct -> cystic duct -> GB -> cystic duct -> common bile duct -> sphincter of Oddi -> duodenum

Liver

Hepatocytes produce and secrete approx 1 Liter of bile per day

Hepato clinical indications

-eval function of hepato system

-bile leak

-obstruction

-congenital abnormalities (biliary atresia)

-acute/chronic cholecystitis

-Calculate GBEF

-Eval enterogastric reflux

-Eval cold spots seen on liver

GBEF

normal is greater than 30-35%

(max counts-bkg)-(min counts-bkg)/(max counts-bkg)

Patient Prep for HIDA Scan

-Fasting for 4-12 hours

-Fasts greater than 24 hours or on TPN should be avoided because there could be bile build up leading to false positive

-no opiates 4-12 hours before exam (constricts sphincter of oddi)

-correlate with other studies , hx, and meals

HIDA Dose

3-10 mCi of Tc-BrIda (mebrofenin/Choletec)

Routine HIDA imaging

do a flow for 2 min

do dynamic imaging for 60 min

can do statics of RLAT, RAO, LAO to differentiate between GB or bowel

Biliary activity should be seen at

15 min

> 90% of pts show GB at.....

30 min

approx 80% of pts have small bowel showing at....

60 min

liver activity should exceed________by 5 min post injection

cardiac pool

Cardiac pool clears by....

10 min

Sincalides max effect on GB seen by

15 min

T 1/2 Sincalide

2.5 min

Show GB by _________ min, if shown then.....

60 min

GBEF using CCK is done

If GB is not visualized by _____________ min then....

60 min

morphine is given or delay images at 2-4 hours done

Biliary obstruction

-Pt has normal hepatic function for initial 24 hours

-Function becomes compromised by 24-96 hours and its usually mild to moderate

-After 96 hours enough hepatocyte function is lost to mimic hepatitis

Bile leak

most often seen after a cholecystectomy near GB fossa, looking for activity leaking into peritoneal space

How biliary obstruction can look

1. It can have good liver uptake with GB and CBD seen but no bowel

2. It can have good liver uptake with no other structures seen due to increased intrahepatic ductal pressure

3. there can be a dilated duct

Liver Transplant

to assess liver ischemia, rejection, intrahepatic cholestasis, and diffuse infection after transplant

done like routine HIDA

looking for absence of blood flow and appears as decreased liver uptake with corresponding increased blood pool activity

Enterogastric Reflux

detect bile reflux into the stomach, can cause alkaline gastritis

Enterogastric reflux imaging

-Can be done like GB study

-OR using a dual isotope version with 100-250 uCi In-111 DTPA in a 250 cc fatty meal and Tc99m Disida injected via IV with statics taken every 15 minutes for 1 minute each, and an ROI drawn over stomach, liver, GB, and bile ducts

Enterogastric reflux formula

EGRI= [(St-So)/(Hb0-Hbt)]

EGRI should be....

-less than 15% at 15 and 30 minutes, if post surgery less than 25%

-abnormal is closer to 80%

Hepatic Extraction Efficiency formula

HEF= Initial Hepatic Uptake/ Peak vascular Uptake

Normal hepatic extraction efficiency

92% with max uptake at 5 minutes

Hepatic extraction efficiency T 1/2 clearance

Less than 37 min with bowel seen at 30-40 min

What is pediatric hepato imaging for?

To differentiate biliary atresia from other liver disorders

What/ how do you pretreat peds for biliary atresia imaging?

Give phenobarbital 5ug/kg/day for 5 days

this helps increase liver enzyme production

What is phenobarbital used for? 

Differentiating biliary atresia from other neonatal jaundice  

Biliary atresia imaging

-Give 0.05 uCi Tc 99m Disida via IV

-Do flow images for 5 minutes

-do statics Ant & RLAT up to 1 hour and every 3-4 hours until 24 hours or bowel is visualized

Cholecystokinin

it is endogenously produced and released by the duodenum when you eat, it is stimulated by increasing concentration of fatty acids

What does CCK stimulate?

-stomach, causes constriction of pyloric sphincter

- pancreas, stimulates pancreatic juices

-small intestine, increases motility

-GB, causes it to constrict

Dose of CCK

0.02 ug/kg over 60 mins

can be given over 3-5 min or slowly infused over 30 minutes (can cause bile duct spasms if given fast)

What does CCK need to be made with?

Sterile water so its stable, if made with saline it is only 80% chemically stable

Bile plug

child has sludge resulting from dehydration, cystic fibrosis, hematological disorder, or TPN nutrition

-HEF is normal but decreased clearance/abnormal appearance

Biliary dyskinesia

-when CCK causes sphincter of Oddi to contract instead of releasing

If someone has biliary dyskinesia what will show after giving CCK

-After CCK images will show delayed biliary bowel transit and a dilated CBD but normal GBEF

Biliary dyskinesia procedure

Pt fasts for 3-4 hrs and then given CCK over min of 3 minutes, wait 15 minutes, give 5 mCi Tc99m Disida via IV, do flow for 60 min

% CBD emptying

100x (Peak CBD-CBD 60 min)/ peak CBD

Chronic Cholecystitis

long term condition usually caused by cholelithiasis

No GB at 60 min but do see it within 30 min post morphine or on 3-4 hr delays

acute choleycystitis

caused by common bile duct obstruction (95% from a stone blocking the cystic duct)

No GB seen at 60 min or after morphine or after 3-4 hours

How does morphine affect the GBEF?

makes sphincter of oddi spasm decreasing GBEF

How does atropine affect the GBEF?

inhibits GB emptying

How does calcium channel blockers affect the GBEF?

interferes with the smooth muscle in GB wall

How does diabetes affect the GBEF?

neuropathy associated with disease reduces GB contractility

How does a vagotomy affect the GBEF?

reduces GB contractility and increases GB volume

How does cholinergic meds affect the GBEF?

-they act on sympathetic nervous system

-enhance GB emptying

Biliary disease symptoms

RUQ pain

Nausea/Vomiting

Leukocytosis

Biliary atresia

-congenital destruction of bile ducts due to inflammatory process (may be due to an intrauterine viral infection)

-Pt presents with persistently elevated bilirubin levels

When can biliary atresia be cured?

If caught within 60 days, if caught late it will cause irreversible damage and baby will only live 2-3 months

How is biliary atresia diagnosed?

absence of bowel at 24 hrs

NM images look like with biliary atresia?

-pt will have normal HEF(unless older than 3 months then it will be decreased)

-images show no excretion from liver and biliary tree and bowel not seen

-Heart to liver ratios at 5 min stay high

hepatitis/ choleostasis

Get decreased HEF but see bowel within 24 hours

Rotors syndrome

Inherited disease which affects anion exchange resulting in decreased uptake of liver

Low HEF but still see bowel by 24 hours

Dublin Johnson syndrome

inherited disease that affects hepatocytes ability to clear bilirubin

rapid liver uptake with high HEF

slow to leave liver, long T1/2

still enters bowels by 24 hrs

Choledochal cyst

dilated cystic ducts

rare congenital abnormality mostly seen in female children

Pts are ususally jaundiced

sphincter of oddi, junction of CBD, and pancreatic ducts are malformed

Pancreatic juice refluxes into CBD causing inflammation, fibrosis, scarring, and dilation