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Technetium-99M BIDA Biliary Scintigraphy in the Evaluation of the Jaundiced Patient

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Technetium-99M BIDA Biliary Scintigraphy in the Evaluation of the Jaundiced Patient 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 thusfoundto be usefulin differentiating nonobstructive,partiallyobstructive,andcompletelyobstructivecausesof jaundice. J Nucl Med 27:1407—1412,1986 he differentiation ofjaundice due to the hepatocel the diagnostic value of scintiscanning in jaundiced pa lular disease (medical jaundice) from extrahepatic bili tients (5—7).Klingensmith et al. stated that US and ary obstruction (surgical jaundice) is important in plan hepatobiliary scintigraphy have a complementary role fling the appropriate diagnostic and therapeutic in the evaluation ofbiliary obstruction (8). Their group procedures. also suggested that intrahepatic cholestasis can be di Currently, there are a number of radiologic tech agnosed by hepatobiliary scintigraphy (9). This study niques available in the investigation of a jaundiced reviews our experience with the use of radionuclide patient. These include: ultrasonography (US), corn hepatobiliary imaging as a screening procedure in puted tomography (CT), percutaneous transhepatic jaundiced patients. cholangiography (PTC), and endoscopic retrograde cholangio-pancreatography (ERCP) ( 1). Some of these (PTC and ERCP) are invasive and/or expensive. Fur MATERIALS AND METHODS thermore, they delineate anatomic lesions but do not provide a functional evaluation. On the other hand, During the period March 1, 1979, through April 30, radionuclide hepatobiliary scanning is a noninvasive 1983, we studied 96 patients who were clinically jaun study and provides the only means of functional diced. All patients were from our institution and in evaluation along with imaging. cluded 79 males and 17 females. The age range was 1 In selecting a single screening test which can differ mo to 92 yr (mean 52 yr). entiate medical from surgical causes of jaundice, one The levels of serum bilirubin ranged from 2.1—38.8 has to take into account ease of performance, cost mg/dl (normal 0. 1—1.1 mg/dl). Excluded from this effectiveness, complications associated with the proce review were patients who carried a diagnosis of either dure, and degree of accuracy. With the introduction of acute or chronic cholecystitis alone and also patients newer radiopharrnaceuticals such as p-butyl acetanilid who have had previous biliary enteric bypass. These iminodiacetic acid (BIDA) labeled with technetium have been previously reviewed by one of us (2—4,10). 99m (99mTc) interest in hepatobiliary scintiscanning In addition to scintiscanning, all patients underwent has increased (2—4). clinical, chemical, radiologic, and endoscopic evalua There has not been uniform agreement concerning tions as required. The final diagnosis in each patient Received July 19, 1985; revision accepted Mar. 6, 1986. was based on the results of all studies noted above and For reprints contact: M.D. Ram, MD, PhD, Chief, Surgical additionally in most patients based on operative find Service, V. A. Medical Center, Lexington, KY 405 11. ings or needle biopsy of the liver (details in results). Volume27 •Number9 •September1986 1407 Informed consent was obtained from all subjects. There are two scintigraphic patterns of complete Technetium-99m BIDA was used as scanning agent obstruction of the common bile duct. One is that of a and was prepared from a commercial kit and 5mCi of fairly rapid hepatic uptake of the tracer by the liver but [99mTc]BIDA was injected intravenously. Using a no visualization ofthe hepatic ducts, the common duct, gamma camera,t images were obtained at 2, 5, 10, 15, gallbladder, or the bowel even up to 24 hr after injection 30, 45, and 60 mm after the injection and then at 15- (13,14) (Fig. 2). The other pattern is a hyperacute mm intervals for up to 90 to 120 mm. Further scans complete common bile duct obstruction, scintigraphic were obtained at 4 to 6 hr as needed and up to 24 hr if features ofwhich include rapid uptake and visualization indicated. Each image accumulated 300—500kcounts. of the hepatic ducts, common bile duct, and the gall The details of this technique were previously described bladder, but no appearance of activity in the bowel (2,11). 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 RESULTS final diagnosis (Tables 1, 2, and 3). The following defi In a normal scintigram, the liver is visualized at 5 to nitions were used: (a) true negative—no obstruction or 10 mm after injection of the agent, the gallbladder at delay of agent into the duodenum in the scan and no ,@‘1 5—20 mm and complete images ofthe liver, galiblad obstruction demonstrated, (b) true positive—obstruc der, common bile duct, and proximal small bowel are tion or delay of agent into the duodenum by scan and obtained between 25 and 30 mm. The criteria used to obstruction confirmed, (c) false positive—obstruction define extrahepatic biliary obstruction are based on or delay of agent into the duodenum by scan but no whether the gallbladder and the common bile duct were obstruction present, and (d) false negative—no obstruc visualized or not and whether there is radionuclide tion or delay of agent into the duodenum by scan but activity in bowel or not and also the time of appearance obstruction present. of this activity. Based on the above, the sensitivity of the scan was The results of scintigraphy in this group were classi 97.3%, the specificity was 89.8%, and the overall fled into three categories as follows: (a) nonobstructive accuracy was 92.7%. group (no obstruction to the flow of the scintigraphic agent into the duodenum), 54 patients; (b) partially DISCUSSION obstructive (partial obstruction on the basis of delayed appearance of the agent: 60 mm or more in the bowel), Our results suggest that scintigraphy is useful in the 22 patients (Fig. 1); and (c) completely obstructive initial evaluation of the jaundiced patient. The differ (absence of the scanning agent in the small bowel even entiation of obstructive from nonobstructive jaundice after 24 hr), 20 patients (Fig. 2). has been a subject of several conflicting reports (17— In eight patients who were categorized as partial 20). The area of greatest difficulty centers around the obstruction, in addition to delayed radioactive tracer fact that at very high levels of serum bilirubin, lack of excretion in bowel, there was a scintigraphic pattern of images may be due to hepatocellular disease (poor intrahepatic bile pooling along the area and/or segmen hepatic uptake) or extrahepatic biliary obstruction tal defect in common bile duct (Fig. 3). This character (poor excretion) ( 16,21). In the former situation the istic pattern has been previously documented (12). 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-hrimages but substantial radiotracer remaining I in liver at 24 hr, indicatingsevere partialobstruction ii. 24k 1408 Lee, Ram, Shih et al The Journal of Nuclear Medicine 15m 30m 2h FIGURE 2 Complete obstruction due to biliary atresia in 2-mo-old girl: Radiotracer israpidlytakenbyliverbut bileducts, gallbladder,and bowel are persist ently not visualized, even in 20-hr 20h image the biliary tract will not be imaged. However, in patients tion has scintigraphic features that include rapid hepatic with very high levels of bilirubin, these results may be uptake and visualization of the hepatic ducts, the com equivocal because of dilution of the tracer ( 17). mon bile duct, and the gallbladder, but no appearance The scintigraphic patterns associated with biliary of activity in the bowel through and up to the 24-hr obstruction and jaundice are briefly outlined below. study period ( 15) (Fig. 4). This pattern is very rare 1. In complete obstruction ofthe common bile duct, because such a patient is usually studied immediately there is a fairly rapid hepatic uptake of the tracer, but following the onset of the common duct obstruction no visualization ofthe hepatic ducts, the common duct, while the gallbladder is still continuing to reabsorb gallbladder, or the bowel 24 hr after injection (13) water. There is an initial imaging of the biliary system (Fig. 1). while there is net bile flow until the bile is maximally 2. Hyperacute complete common bile duct obstruc concentrated. Eventually when the pressure in the sys ‘mom-@i@m‘@30m-@.@,@45@60m120m FIGURE 3 Partial obstruction associated wfth
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