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Hepatobiliary Imaging

PROCEDURE: HEPATOBILIARY IMAGING
SECTION: GASTROINTESTINAL 4.2
ORIGINAL DATE: 4-27-00
DATE REVISED: 3-30-17
REVIEWED: ANNUAL

Indications

  • Diagnosis of acute cholecystitis 
  • Evaluation of extrahepatic biliary tract obstruction
  • Evaluation of the post-surgical biliary tract
  • Evaluation of gallbladder ejection fraction
  • Detection of bile leaks 
  • Diagnosis of biliary atresia and other congenital anomalies of the biliary tract.

Contraindications: 

  • Oral narcotics should be stopped 4 hrs prior to exam. (See list below-including but not limited to these oral narcotics). Notify Radiologist if this is not possible. Please notify Radiologist if any of the following medications have been given. Note amount of drug given and time of administration. 
  • Approximate duration of affect:
IV PO
Fentanyl Patch 3-5 days ---
Fentanyl P.C.A. 6 hrs ---
Hydrocodone --- 3.5 hrs
Oxycodone --- 3-4 hrs
Oxycotin (Oxycodone CR-control release) --- 10-12 hrs
Lortab (hydrocodone) --- 3.5 hrs
Vicodin (hydrocodone) --- 3.5 hrs
Percocet (oxycodone) --- 3-4 hrs
Percodan (oxycodone) --- 3-4 hrs
Dilaudid (hydromorphone) 4-5 hrs 3.6 hrs
Methadone .03-24 hrs 2-10 hrs
Morphine

*CCK is contraindicated in patients hypersensitive to sincalide and in patients with intestinal irritation or obstruction.
*Regarding patients with multiple exams (i.e. CT w/contrast -oral/IV), HIDA should be done first, due to NPO status and concern with possible contrast caused attenuation.

Patient Preparation

  • Patient should have fasted between 4 and 24 hours. (If a patient has had only water or nothing for 24 hours or greater then we will pre-treat the patient with CCK otherwise we can go ahead and start our procedure as usual).
  • Document date and time of last meal eaten by patient, along with what type and amount. 
  • Document abdominal symptoms patient may be experiencing before and during exam. Use Wong-Baker Pain Rating Scale scale to document discomfort level (Gladiator/Patient Educ./Select Pain Management (left menu)/Scroll to Pain Scale). 
  • Set intermittent IV 
  • Obtain patient’s weight

RRx & Dose

  • Radiopharmaceutical: 99mTc-Lidofenin (Choletec) 
  • Dose: Adult 4 mCi 
  • Dose: Pediatric 0.05 mCi/kg (Dosing Range 0.5-3.7 mCi)
  • CCK dose to pre-treat patient: 0.02 mcg/kg infuse over 5 minute slow IV push. 
  • CCK dose EF study, after 60 min Gall Bladder Visualization images: 0.02 mcg/kg infuse over 44 minutes

Administration Technique

  • Standard intravenous injection through IV for choletec 
  • CCK: use pump device to IV infuse Cholecystokinin (CCK) over 44 minutes. Imaging will begin 1 min before CCK infusion. (45 min total acquisition)
  • ENSURE PLUS: To be used when KINEVAC (CCK) unavailable. Patient drinks 8oz (11.4gm fat) bottle contents. Start 2nd imaging sequence to run for 60 minutes: 60 sec/frame, 128x128.

STATIC ACQUISITION PARAMETERS

Time interval between tracer injection & imaging: None

Collimator: HRES

Patient position: Supine

Energy: 140 keV

Matrix: 128 x 128

Time /View

  • 80 sec Flow: 5 sec/fr 
  • 1 HR dynamic: 60 sec/fr
  • 45 min CCK dynamic: 60 sec/fr
  • *Look for GB activity 
  • If activity in ducts, bowel & GB study may be stopped (non EF study). 
  • For GB EF study proceed to the EF acquisition. Infinia systems choose: ‘Protocols/User folder/Gastrointestinal/HIDA with EF’ Protocol will queue: 60sec/frame, 128 matrix, word mode, and 2700 sec total. 
  • If GB is full prior to 60 min check with Rad if you can go right into EF acquisition. 
  • If GB is not visualized but ducts & bowel are wait 30 min, then take a static ANT, check with image with Rad. If GB still not seen Rad will direct how to proceed.

Images taken: ANTERIOR Upper abdomen to include liver

Screen caps to make: Images: flow & 1 hr composites GB Emptying data with graph

Send to FUJI: Screencaps

HIDA with EF:
DATA Processing:

  • Highlight pt name, make sure all datasets are there. 
  • Flow and GBEF (if study was ended early may need to modify end time for reframe. For the five minute composites will need to adjust times to be a multiple of 300 (and initial 80).
  • Click “all Applications” tab, drop down “User Applications”. Select and click “GL GBEF” container to start processing.
  • Follow processing prompts.
  • Modify ROI’s as necessary to include Gallbladder and exclude gut and ducts.
  • Adjust intensity on all 3 sections of screen image. 
  • Prior to screen capture annotate image orientation.
  • If acceptable create Screen capture by clicking on Printer icon and click ‘Save’ button.
  • Database study 1024 color (system template)
  • Destination: Database Study 1024 color
  • Color mode: inverse
  • Click ‘file’ and ‘quit’ to exit.
  • EF of less than 40% is abnormal.

Using ENSURE PLUS in place of KINEVAC:

Alternative procedure, supplement-stimulated cholescintigraphy:

  • HIDA with Ensure Plus (Abbott Laboratores): Literature states at least 10 gm of fat are necessary to cause gallbladder contraction. The low range of normal for GBEF with Ensure Plus protocol is 33%.

Taken from JNM:Vol44,No8;pp1263-1266. Cholecystokinin Cholescintigraphy: Methodolgy and Normal Values Using a Lactose-Free Fatty-Meal Food Supplement, Ziessman, et al.
(Call Nutrition Therapy for Ensure Plus if stat need)
Process as “HIDA with EF”, but will need to use full 60 min for EF calculations.

HIDA without EF:

  • DATA Processing:
  • Highlight pt name, make sure Flow and 1HR dyn is present.
  • Click “Favorite Applications” tab, Select GB_REFRAME container.
  • Adjust intensity on both 5-second frames (top ½ of screen) and 5-minute frames (bottom ½ of screen) using the COLOR MAP tab and the sliding scale.
  • Annotate as needed, create SCREEN CAPTURE by clicking the printer icon and click “Save” button. 
    • Database Study 1024 color (system template)
    • Destination: Database Study 1024 color
    • Color mode: inverse
  • Click “File” and “Quit” to complete.

MORPHINE AUGMENTATION:

  1. If the gallbladder has not visualized by approximately 90 minutes, morphine may be given to hasten visualization of the gallbladder. Morphine causes contraction of ampulla and speeds up gallbladder visualization. You only need to take images out to 1‑1/2 hours to see whether gallbladder visualizes. Morphine eliminates the need to take delayed films out to 4 hours or until only minimal liver and bile duct activity remains. 
    • If after 60 minutes the activity remaining in the liver is not sufficient to visualize the gallbladder, then 1 - 2 mCi of Tc-Choletec may be administered. Imaging should begin 15 minutes post injection.
  2. A physician must write an order for morphine sulfate prior to its administration. Follow GLMC Imaging Department policy ‘Imag-0800’, which is attached to paper policy in control area
    • For OUTPT, use prescription pad found in Hot Lab drawer under computer.
  3. Inject 0.04 mg/kg of morphine diluted in 10 mL of saline intravenously over 3 minutes (This is given when bile ducts and bowel activity is seen but the gall bladder does not visualize). Maximum dose is 3 mg. 
  4. Acquire additional ANT and R LAT images every 15 minutes through approximately 2 hours from injection of the radiopharmaceutical.
  5. Reversing the effects of morphine: If the patient has recently received morphine and if the Images suggest common bile duct obstruction, naloxone may be given intravenously to reverse the effects of morphine and relax the sphincter of Oddi. 
  6. When Morphine sulfate is given the following steps MUST be completed:
    • a) Have the crash cart and O2 readily available.
    • b) Take baseline blood pressure and respiratory rate prior to morphine administration.
    • c) Check patient chart and ask patient if they have ever had any adverse reactions to morphine.
    • d) Inject Morphine slowly over 2‑3 minutes.
    • e) Monitor patient's respirations and blood pressure.
  7. A change in the patient's vitals may suggest narcotic overdose. Narcan should be administered to counter the effects. Give 0.4 mg IV. (Can give 0.4 ‑ 2 mg) Children 0.01 mg/kg IV. Wait 2‑3 minutes, if no effect repeat dose up to a total of 10 mg for adults.

SPHINCTER OF ODDI DISFUNCTION

  1. Dose: 5 mCi 99mTc disofenin, 15 minutes post CCK infusion
  2. Patient Prep: NPO at least 4 hours prior to exam (Obtain patient weight)
  3. Procedure: Place patient supine under camera 
  4. Infuse CCK at 0.02 ug/Kg over 3 minutes (diluted to 15cc with NaCl) Reconstitute the CCK with 5 ml of Sterile h20 to make the solution 1mcg/ml.
  5. 15 min post infusion of CCK inject Disofenin 
  6. Time of Imaging:
    • a) Flow: Immediate anterior dynamic images for 60 minutes 
    • b) Use 1 frame/minute, word mode, 128 matrix
    • c) Sum images at 3,6,9,15,30,45,60 min for static delays
  7. Processing: 
    • a) 2 ROI's distal CBD and peripheral in right lobe of Liver CBD as distal as possible but avoid bowel. 
    • b) Measure: 
      • time to peak activity in CBD 
      • time to peak activity in Liver
      • activity in CBD at 15 minutes
      • activity in Liver at 15 minutes
      • activity in CBD at 60 minutes
      • activity in Liver at 60 minutes
    • c) Measure % CBD emptying:
      • 100 X (peak CBD counts ‑ CBD counts at 60 min) peak CBD counts
      • Normal is > 50%
    • d) Use computer program to draw ROI's and generate curves for CBD and Liver from dynamic data

Diagnosis of Biliary Atresia, Neonatal Hepatitis, and other Congenital Anomalies of the Biliary Tract

Preparation:

  • Breast-feeding infants- NPO 2-hrs prior to exam for both pre/port phenobarbital.
  • Formula feeding infants- 3 to 4 hrs NPO. (per Dr. Hanratty 5/04)

PEDIATRIC PATIENTS: For patients < 6 months old, ask if they have been pretreated with phenobarbital, and if not why. When differential between biliary atresia and neonatal hepatitis, give 5 mg/kg/d Phenobarbital in 2 divided doses/day (per Dr. Manske) over 2 consecutive days prior to exam (per Dr. Hanratty 5/04).


Phenobarbital induces hepatic microsomal enzymes leading to increased bilirubin conjugation and excretion in patients with a patent extra hepatic biliary system, by priming the liver for better excretion of RRx and therefore earlier identification of a patent biliary tree.

    1. Supine imaging of the Ant abdomen. Patient may be sedated if unable to lay still for 3-5 minute images. Zoom as needed to visualize liver similar to general hepatic scanning.
    2. Acquire 5-minute images consecutively for 1 hour. 
    3. Delayed imaging at both 4 and 24 hours of the anterior abdomen. 
    4. Visualization of the tracer in the intestinal tract with or without visualization of the gallbladder indicates patency of the biliary system and excludes biliary atresia.

BILE LEAKS: ANT and POST dynamic images. 60 seconds per frame. 128 x 128 matrix, 3600 seconds.

Patient preparation: Patients do not need to stop narcotics for study per Dr. Manske 12/07.

  1. ANT images with the patient standing: May be used to help differentiate the gallbladder and bile leaks from the duodenum.
  2. Other hepatobiliary parameters may be quantitated.
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