Bile Leak From Gallbladder Perforation Mimicking Bowel Activity and a False-Negative Result in a Morphine-Augmented Cholescintigraphy

Wei-Jen Shih, Sylvia Magoun, B.J. Mills and Calixto Pulmano

Department of Veterans Affairs Medical Center and University ofKentucky Medical Center, Lexington, Kentucky

same day, computerized tomography (CT) and ultrasound (US) Cholescintigraphyof a patientwithbileleakdemonstratedof the abdomen were performed; the CT showed a thickened intra-abdominal activity that mimicked normal bowel activity. edematous gallbladder wall and was suggestive of pericholecystic Because the gallbladder was not visualized, morphine was fluid collection (Fig. 2). The US showed a thickened gallbladder injected intravenously. Gallbladder activity after morphine in wall and a single acoustic shadow in the gallbladder suggestive of jectionwasmisleadinginthefindingofchroniccholecystitis.a calculus(Fig.3). Laboratoryfindingsat the time of admission Concurrentabdominalsonographyandcomputerizedtomog included alkaline phosphatase 1299 (n = 38—126 U/liter), AST raphyrevealeda thickenedgallbladderwallwitha gallstone 60 (n = 5—42U/liter), ALT 35 (n = 7—60U/liter) and amylase and pericholecystic fluid collection. Exploratory laparotomy 84 (n = 30—110 U/liter). confirmed acute and chronic cholecystitis, cholelithiasis, cho On the secondhospitalday, the patient underwentan explor ledocholithiasis, and a pericholecystic abscess. The false atory laparotomy. Operative findings included multiple gallblad negative conclusion for acute cholecystitis in the patient's der stones, perforated gallbladder, pericholecystic abscess, morphine-augmentedcholescintigraphyresultedfromanac adhesion of the small bowel to the liver and gallbladder, numer celeration of bile leakage due to pre-existing gallbladder per ous (50) common bile duct stones, and extensive bowel adhesion. foration. Enterolysis ofadhesions, cholecystectomy and common-bile-duct exploration were performed. Morphological diagnoses ofthe gall J NucI Med 1993;33:131—133 bladder confirmed acute and chronic cholecystitis and choleli thiasis.

DISCUSSION CASE REPORT Two linear areas of faint activity in the abdomen sug A 70-yr-old male with a 3-day history of nausea, vomiting and gested bowel activity in our patient's cholescintigraphy. abdominal pain was admitted with an impression of a small During the imaging procedure, because no gallbladder bowel obstruction secondary to acute cholecystitis and question activity was visualized, although some abdominal activity able common bile duct obstruction. Two months previously, the patient had undergone total gastrotomy and Roux-En-Y esopha was apparent, morphine sulfate was administered intra gojejunostomy because massive hemorrhage of multiple gastric venously to aid in the diagnosis of acute versus chronic ulcerations that extended to the gastroesophageal junction. His cholecystitis. Any indication of gallbladder activity on the past medical history included a laryngectomy for squamous cell 60 mm image was quite faint and difficult to detect. The carcinoma and an above-the-knee amputation of the left leg 13 right and left areas of abdominal activity (as indicated by and 48 yr ago, respectively. Physical exam on admission revealed solid arrows on the 45-mm image) could represent activity a midlinescar on the abdomen,and left-lower-quadranttender in the bowel or not in the bowel. In either case, the ness with mildly distended abdomen. Intravenous antibiotics persistent configuration throughout the imaging may be were instituted on the day of admission. explained by intraperitoneal bowel adhesions, later found The first hospital day the patient underwent hepatobiliary in exploratory laparotomy, which were consequent to the scintigraphy. Scintigraphy showed a prominent porta hepatis and previous total gastrectomy. dilated common bile duct, with no obvious visualization of the gallbladder until after a 2-mg morphine intravenous injection. Stones found in the common bile duct during surgery Mild and diffuse increase in uptake in the right abdomen was can cause nearly complete obstruction ofthe common bile more prominent after morphine administration (Fig. I). The duct. The small amount ofdrained bile in the bowel might not be enough to be visible on scintigraphic imaging. Once morphine is given intravenously, it causes contraction of ReceivedJun. 3, 1992;revisionaccepted Aug.12, 1992. For reprints or correspondencecontact: Wei-Jen Shih, MD, Nuclear Medi the sphincter of Oddi resulting in increased intraluminal cine Service,VeteransAffairs Medical Center, Lexington, KY 40511. bile duct pressure and would then serve to hinder appear

False-NegativeResult in a Morphine-Augmented Cholescintigraphy •Shih et al 131 FIGURE1. Technetium-99m-choletec hepatobiliaryimages up to 60 mm (ob tamed on the first hospital day) show a prominentportahepatis,dilatedcommon bileduct, faint radioactivityin right and left ‘p abdomen(arrow)andnogallbladderactiv 15m 45 ity.Two milligramsof morphinesulfate is injected intravenously at 60 mm; activity of thegallbladderareais visualizedand two areas of band-likeactivity in the ab domenaregraduallymoreapparent(open arrows)up to 30 mmafter morphineinjec 10Pm 2OPm 3Opm tion. 60

ance of radioactivity in the bowel. Delay in appearance of tient's gallbladder visualization and histopathological con bowel activity for more than 3.5 hr has been documented firmation of acute cholecystitis may constitute a false (1). The fact that our scintigraphicfindings demonstrated negative. Presumably his cystic duct was patent. Increased more prominent activity in one of these two linear areas, intraluminal pressure of the bile duct alone, secondary to concurrently with radioactivity of the gallbladder area, sphincter ofOddi contraction in response to the morphine confirmed a bile leak from the perforated gallbladder. and the pressure of stones impacted in the common bile These findings reflected acceleration of bile leakage from duct, allowed bile flow through the cystic duct and leakage the pre-existing gallbladder perforation. from pre-existing gallbladder perforation. Radioactivity in the gallbladder area after morphine Gallbladder perforation is an unusual condition, with a administration may represent radioactivity in the galiblad mortality rate of approximately 5% (8), that is usually der, radioactivity in the pericholecystic region (perichole secondary to acute cholecystitis (9). Cholescintigraphic cystic activity), or both. In a relatively low-pressure con patterns of gallbladder perforation include free-spill pen dition, the gallbladder would accumulate radiotracer in cholecystic activity and chronic cholecystoentenc fistula the bile before the bile leaked out; therefore, radioactivity (10). US findingsofthe gallbladderinclude pericholecystic in the gallbladder region presumably represented both fluid (10) or pneumobilia with gallstones, and CT findings pericholecystic activity and intracholecystic activity. include pericholecystic fluid collection (8,11 ). Cholescin Whether morphine contributes to the perforation of the tigraphic detection of gallbladder perforation is reported gallbladder is debatable (2). In our case, morphine might to be 50% (10); US detection, 18% (10). Although chole have aggravated bile leakage (evidenced by more activity scintigraphy appears superior to US, both imagings are in the regions of the intraperitoneal cavity). Without CT relatively insensitive in the detection of gallbladder perfo and/or US detection of pericholecystic fluid collection, ration (10). Cholescintigraphy combined with 67Ga-citrate leakage to the pericholecystic region might be missed. imaging (8), CT, and US (8,1 1) has been described; the Though morphine-augmented cholescintigraphy can re combined radiologic imaging methods complement one duce imaging time from 4—24hr to 60—90mm and serves another, leading to highly accurate preoperative diagnosis as an alternative to delayed imaging in the differentiation ofgallbladder perforation (8,11). Our case concurred with of acute cholecystitis from chronic cholecystitis (3), false previous reports in that fluid collection was demonstrated positive results have been reported, especially in severely by CT and US, and cholelithiasis and thickened gallblad ill patients (4—6).False-negative results have also been der wall were shown by US. In turn, these changes helped reported (7). The explanation suggested for a false-positive clarify the findings on cholescintigraphy. was the dislodging of a cystic duct stone from increased pressure, allowing bile flow to the gallbladder. Our pa

} FIGURE3. Sonog FIGURE2. CT of raphy of the abdo the abdomen (per men (performed the formed the first hos first hospitalday) \ pital day) shows a shows a thickened thickened edema gallbladderwalland tous gallbladderwall a single acoustic with pencholecystlc shadow in the gall fluidcollection. bladder. Is.

132 The Journal of Nuclear Medicine •Vol. 34 •No. 1 •January1993 In summary, our case illustrated a false-negative result scintigraphy in acute cholecystitis: use ofintravenous morphine. Radio/ogy l984;lS1:203—207. in morphine-augmented cholescintigraphy. Combined di 4. Kim EE, Pjura G, Lowry P, Nguyen M, Pollack M. Morphine-augmented agnostic imagings—cholescintigraphy, CT, and US—of cholescintigraphyin the diagnosisof acute cholecystitis.AiR 1986;l47: the abdomen complement one another, enabling accurate 1177—1179. 5. Keslar PJ, Turbiner EH. Hepatobiliary imaging and the use of intravenous preoperative diagnosis. morphine. C/in Nuc/Med 1987;12:592—596. 6. Fig LM, WahI RL, Stewart RE, Shapiro B. Morphine-augmented hepa tobiliary in the severely ill: caution is in order. Radio/ogy 1990:175: ACKNOWLEDGMENT 467—473. 7. Mack JM, Slavin JD, Spencer RP. Two false-negative results using mor Wethank Ms.LillianOwensand Mrs.AleeneMillerfor their phinesulfatein hepatobiiary imaging.CilnNuciMed 1989;l4:87—88. secretarial help. 8. Yeo E, Chen DCP, Siegel ME. Hepatobiliary imagings in gallbladder perforation: a case report and review ofthe literature. C/in Nuc/Med 1989; 14:77—81. REFERENCES 9. WayLW,PellegriniCA.Surgeryofthegailb/adderandbileducts.Phila delphia:WBSaunders:1987:265—273. 1. Jochl Ri, Koch KL, Nahr Wald DL Opioid drugs cause bile duct obstruc 10. SwayneLC,FilipponeA.Gallbladderperforation:correlationofcholescin tion during hepatobiliary scans. JAm Surg l984;l47:134—138. tigraphicand sonographicfindingswiththe Niemeierclassification.J Nuc/ 2. Moreno AJ, Ortenzo CA, Rodriguez AA, Kyle FM, Turnbull GL Gall Med 1990;31:1915—1920. bladder perforation seen on hepatobiliaryimaging followingmorphine 11. Mihas AA, Lewis 0, Athar M, Shueke M. Gallbladder perforation: preop sulfate injection. C/in Nuc/Med l989;l4:651—653. erative diagnosis by combined imaging techniques. Gastro Radio/ 1991; 3, ChoyD,ShiEC,McLeanRG,HoschlR,MurrayIPC,HamJM.Chole 17:24—26.

False-NegativeResult in a Morphine-Augmented Cholescintigraphy •Shih et al 133