Case 7

Shortly after this exam, LFTs and bilirubin became elevated and Endoscopic Retrograde Cholangiopancreatogrphy (ERCP) was performed. Sludge and stones were cleared from the bile ducts during ERCP and the patient experienced symptomatic relief, as well as a decrease in LFTs and bilirubin. The cause of the HIDA scan appearance as depicted above was high-grade biliary obstruction.

http://www.filmjacket.com/readarticle.php?article_id=17

Case 8

Delayed abdominal hepatobiliary scan (45 min after injection, when radioactivity has almost cleared from hepatocellular compartment) obtained with a 99mTc-iminodiacetic acid analog for a patient with persisting dyspepsia after endoscopic cholecystectomy. Reflux of radioactive bile from duodenum into stomach is obvious (arrows), possibly explaining persistence of symptoms.

http://jnm.snmjournals.org/cgi/content-nw/full/45/6/1004/F2

Case 9

Biliary leak with pooling within the gal bladder fossa and the right paracolic gutter.

Treatment: An ERCP (Endoscopic Retrograde Cholangio Pancreatography) was ordered to further evaluate the leak which showed a leak from the cystic stunt. Stent was placed after a partial sphincterotomy. Following ERCP, the patient's diet was slowly advanced, which she tolerated well. Drains lessened the amount of fluid they were draining out and they were eventually discontinued. The patient was discharged on Day 13, after she was tolerating a diet and doing well with no abdominal pain, fever or other symptoms. She was discharged to home in good condition.

 

Case 9 -statements from the article

Findings:

Sincalide (0.02 ug/kg) was administered intravenously 30 minutes prior to radiopharmaceutical injection to promote initial emptying of the gallbladder. Static images obtained over the first hour post injection demonstrated good hepatic uptake with prompt excretion into the common bile duct and small bowel. There was no visualization of the gallbladder at 1 hour. Subsequently, 3 mg of morphine i.v. was administered. Additional imaging for 30 minutes again demonstrated nonvisualization of the gallbladder. These findings are most consistent with acute cholecystitis.

Discussion:

Sincalide is the synthetic C terminal octapeptide of CCK. Its use in this case was to promote initial gallbladder emptying in this patient with a distended gallbladder who had been on prolonged fasting with parenteral nutrition. Morphine augmentation was performed in this case to contract the sphincter of Oddi and thus promote biliary flow into the cystic duct instead of the common bile duct. Acalculous cholecystitis accounts for approximately 5-15% of all acute cholecystitis cases. It is seen most commonly in severely ill hospitalized patients with trauma, severe burns, sepsis, or recent surgery. The etiology is thought to be related to gallbladder ischemia or cystic duct obstruction by inflammatory edema, inspissated bile, or inflammatory debris

Case 11

This is a great example of a bile leak following surgical removal of the gal bladder. Note the excess accummulation of the IDA agent. Likewise, there is coorelation with the CT with excessive fluid noted above the liver. http://www.uhrad.com/spectarc/nucs009.htm

Case 12

What the arrows are pointing at is known as the rim sign. This is an indication of acute cholecystitis. Further imaging will show no vis of the GB. Ultrasound image is another example of stones in the GB.

Case 13

The activity appears to stop just after the cystic duct as it enters the common bile duct. 1) Should CCK have been given? 2) Should the image at 2 hours be adjusted for a better "veiw point?"

Return to the Table of Content

11/22