Sphincter of Oddi spasm (SOS) is a rare disorder whose diagnosis is a great clinical challenge.

Size: px
Start display at page:

Download "Sphincter of Oddi spasm (SOS) is a rare disorder whose diagnosis is a great clinical challenge."

Transcription

1 IJNM, 19(3): 75-80, 2004 Diagnosis of Sphincter of Oddi Spasm with Quantitative Cholescintigraphy Gerbail T. Krishnamurthy and Shakuntala Krishnamurthy Department of Nuclear Medicine Tuality Community Hospital, Hillsboro, Oregon, USA Sphincter of Oddi spasm (SOS) is a rare disorder whose diagnosis is a great clinical challenge. Biliary manometry is considered the gold standard, but it is invasive, expensive, and not available in most hospitals. Main objective of this project is to describe a non-invasive, quantitative, and less expensive test for diagnosis of SOS. Methods Seventeen patients with clinical suspicion of SOS were chosen retrospectively from list of 1179 patients who had undergone quantitative Tc-99m HIDA cholescintigraphy with cholecystokinin for various types of hepatobiliary diseases. All opioids were discontinued for hours, and studies obtained 6-8 hours after fasting with 3-5mCi of Tc-99m mebrofenin. Hepatic phase images were obtained at one frame/ minute for 60 minutes, gallbladder phase images at one frame/minute for 30 minutes. Cholecystokinin (CCK-8) was infused intravenously for three minutes in nine patients and for 10 minutes in the remaining eight patients. CCK-8 induced paradoxical filling of the gallbladder (>30%) was considered as indicative of SOS. Following cholescintigraphic diagnosis, 15 patients were treated with anti-spasmodics and two underwent sphincterotomy. Data were compared with 10 control subjects. Results Bile formation was normal in all of 17 patients with SOS, but relatively less (28%) amount entered the gallbladder (vs small intestine) when compared to control subjects (61%). Gallbladder emptied normally (EF=54%) in most patients, but refilled paradoxically with CCK-8 immediately after the ejection period in all patients with SOS, but in none of the control subjects. Smooth muscle relaxants relieved pain in most patients, and two required sphincterotomy. Conclusion Cholescintigraphy with cholecystokinin is a simple, non-invasive, quantitative, and relatively less expensive diagnostic test and may either supplement or provide an alternative to biliary manometry in the diagnosis of SOS. Diagnosis of sphincter of Oddi spasm with quantitative cholescintigraphy Sphincter of Oddi spasm and cystic duct spasm (chronic acalculous cholecystitis) are two of the disorders included under the broad category of biliary dyskinesia (1). Diagnosis Correspondence to: Gerbail T. Krishnamurthy, M.D., FACP Nuclear Medicine Department, Tuality Community Hospital, 335 SE 8 th Avenue, Hillsboro, OR, Telephone (503) , Fax (503) , GTKrishna@aol.com of cystic duct spasm (CDS) is readily made with quantitative cholescintigraphy using cholecystokinin (2). Sphincter of Oddi spasm (SOS), on the other hand, is relatively a rare disorder and its diagnosis is difficult. Due to delay in diagnosis, SOS patients suffer from abdominal pain for years and undergo many other diagnostic studies, often invasive. Biliary manometry is considered by some as the definitive test for SOS diagnosis, but manometric studies are invasive, expensive, require high skill; and are performed only in few of the academic centers, and usually not available in most nonacademic hospitals (3). We have recently introduced a new non-invasive cholescintigraphic technique for SOS, and 75

2 Gerbail T. Krishnamurthy et al preliminary results have been reported (4). In this communication, we would like to provide data in a larger number of patients than before, and describe the technique to great detail, ready to be adopted in most nuclear medicine departments around the world. Materials and methods Total of 17 patients (16 women and one man) with clinical suspicion of SOS were chosen from a list of 1179 patients who had undergone Technetium-99m HIDA cholescintigraphy for evaluation of varieties of hepatobiliary diseases. In this subgroup of 17 patients, post-prandial abdominal pain was of a chronic nature lasting for longer than 3 to 6 months. Ultrasound and liver function tests were also obtained. Cholescintigraphy: All drugs known to effect the sphincter of Oddi function (e.g.opioids) were discontinued for at least 24 to 48 hours prior to the study. After 6-8 hours of fasting, each patient was given 3 to 5 mci of Tc-99m mebrofenin intravenously and imaged with a large field of view gamma camera fitted with low energy, high-resolution, parallel-hole collimator. Patients were studied in supine position with the gamma camera positioned anterior over the abdomen, covering the liver, stomach, and small and large intestine. Hepatic phase images were obtained at one frame per two seconds for 60 seconds followed by one frame per minute for 59 minutes (total of 60 minutes) and Figure 1: Cholecystokinin induced gallbladder emptying. Note normal emptying (EF=96%) in a control subject (A) and poor emptying (EF=18%) in a patient with cystic duct spasm (B), and there is no paradoxical filling at the end of the ejection period. A patient with sphincter of Oddi spasm (SOS) shows normal emptying (EF=56%), but there is paradoxical filling, exceeding the basal volume prior to CCK infusion, at the end of the ejection period (C). Note small amount of duodeno-gastric bile reflux (S) in SOS. GB=gallbladder, S=stomach. 76

3 Indian Journal of Nuclear Medicine, Vol. 19, No. 3, September 2004 Pseudo paradoxical GB filling with CCK-8 Figure 2: Pseudo-paradoxical filling curve. Gallbladder (GB) empties normally (EF=75%), but the curve shows upslope due to intestinal (INT) superimposition on to gallbladder region of interest in the later frames. recorded over 128 x 128 x16 computer matrix. Gallbladder (GB) phase images were obtained separately at one frame per minute for 30 minutes (61 to 90 minutes after the radiotracer injection) and recorded on the same size matrix as described elsewhere (5). During the gallbladder phase, 10ng/kg of cholecystokinin-8 (CCK-8) was infused intravenously over three minutes (3.3ng/kg/minute) in the first nine patients, and at 3ng/kg/minute for 10 minutes in the next eight patients (6,7). Gallbladder EF of 35% or greater and ER of 3.5%/minute or greater were considered as normal with three minute infusion, and a value of 50% or greater for EF and 3.5% or greater for ER were considered as normal with 10 minute CCK-8 infusion (7,8). Data analysis: First 60 second data is used for analysis of liver perfusion. For the entire 60-minute hepatic phase data, regions of interest were drawn over the heart, right upper lobe, right lower lobe, left lobe and spleen (background). Counts were decay corrected and subjected to deconvolutional analysis to derive hepatic extraction fraction (HEF). Excretion halftime (T1/2), and basal hepatic bile flow into gallbladder (versus GI tract) were obtained using a custom-designed hepatobiliary software (KHBQuant) as described (5). For basal differential bile flow into gallbladder versus GI tract, one region of interest was drawn over the gallbladder and another over abdomen, excluding liver, bile ducts and urinary bladder as described (5). In the gallbladder phase data, ROI s were drawn over the gallbladder, common bile duct, common hepatic duct, including right and left hepatic ducts, duodenum, and liver (as background). The semiautomatic software (KHBQuant) calculated GB ejection fraction (EF), ejection period (EP), and ejection rate (ER as EF%/minute). From the gallbladder curve, paradoxical filling after the end of ejection period was noted (Figure 1). Gallbladder refilling of greater than 30% of basal counts (counts prior to CCK-8 infusion) with CCK-8 was considered as indicative of SOS (4). 77

4 Gerbail T. Krishnamurthy et al Figure 3: Reproducibility of gallbladder paradoxical filling in a patient with sphincter of Oddi spasm. Note that the gallbladder refills to >30% of its original volume when CCK is infused twice. Gallbladder (GB) size is small at 15 minutes, but becomes larger at 30 minutes. Data interpretation: From the hepatic phase data, liver blood flow pattern, HEF and T1/2 excretion were assessed as measure of hepatocyte function. From the GB phase data, GBEF, EP and ER were used as measures of GB function. Cine display of both hepatic and gallbladder phase images were scrutinized carefully to check for any superimposition of bowel radioactivity on to the gallbladder region of interest (4). A false-positive up-going GB curve due to superimposition of small or large intestinal (hepatic flexure) radioactivity on to the gallbladder ROI was considered a technical artifact, and not as SOS (Figure 2). Refilling to more than 30% of the gallbladder counts prior to beginning of CCK-8 infusion was considered as indicative of SOS. Therapy: Following cholescintigraphic diagnosis, patients were treated medically with either calcium-channel blockers or other smooth muscle relaxants. Sphincterotomy was performed in those with failed medical therapy. Results Liver function tests were normal in all of 12 patients in whom the serum test was obtained. Ultrasound study showed normal gallbladder in 13, gallstones in two, polyp in one, and the remaining one patient did not undergo ultrasound study. Fatty liver was found in three of the patients. Abdominal aorta, kidneys, and spleen appear first followed visualization of the liver (5). Perfusion study, as expected, showed major portion of the hepatic blood flow arriving late through the portal venous system. There was no difference in hepatic blood flow pattern between control and SOS patients. Mean (+SD) HEF value of 98% (+7) and T1/2 excretion of 25(+18) minutes in SOS patients were not significantly different (P>0.05) when compared to mean HEF of 100% (+0) and T1/2 of 29 (+11) minutes in 10 control subjects. Basal mean hepatic bile flow into gallbladder of 28%(+24%) in SOS patients was slightly lower than a mean of 61%(+36%) in 10 control subjects (4). Gallbladder mean EF, EP, and ER in SOS patients was 60.9(+29)%, 11(+1.9) minutes, and 6(+3.3)%/ minute, respectively. Cholecystokinin-induced paradoxical filling of the gallbladder of greater than 30% of basal volume was found in all 17 patients with SOS. The gallbladder curve showed maximum decrease in size at the end of the ejection period, but refilled rapidly to reach maximum size after paradoxical filling. Total gallbladder counts at the end of paradoxical filling are usually 2 to 3 times greater than the counts prior to CCK-8 infusion (Figure.1). One patient showed 30% paradoxical filling twice when CCK-8 was infused two times, with an interval of 30-minute between doses (Figure 3). Discussion Biliary dyskinesia is a common clinical entity, but the incidence of SOS is relatively rare. We came across these 17 patients after studying 1179 patients with various types of hepatobiliary diseases, resulting in a ratio of 1:69 in patients with suspected abdominal pain of biliary origin. Sphincter of Oddi is about 1 to 1.5cm in length, contracts 7 to 8 times per minute, and maintains a basal intraluminal pressure of about 15 mmhg. Most contraction waves (54%) start at the proximal part of the sphincter and move antegrade towards the duodenum, some start distally and travel retrograde towards the liver (18%), and the rest (28%)occur simultaneously at both proximal and distal parts. During contraction, wave amplitude rises as high as 113 mmhg (9,10). Sphincter of Oddi muscle contains both contraction and relaxation receptors for cholecystokinin. Contraction receptors in the sphincter maintain a much higher threshold than the contraction receptors in the body and fundus of the gallbladder. Therefore, when a normal physiologic amount of cholecystokinin is released after a meal, only the gallbladder contracts, but not the sphincter. Hormone immediately 78

5 Indian Journal of Nuclear Medicine, Vol. 19, No. 3, September 2004 abolishes the basal contraction waves within the sphincter promoting its relaxation with drop in intraluminal pressure. Net effect of a physiologic amount of cholecystokinin release on a normal sphincter of Oddi is one of relaxation. Table 1: Comparison of functional parameters in control subjects and patients with sphincter of Oddi spasm (SOS) Parameter Control S O S P value Total number Mean age (yrs.) NS Women 8 16 Men 2 1 Gallbladder basal bile entry (%) NS HEF-RUL (%) NS T1/2-RUL (min) NS GBEF (%) NS EP (min) NS ER (%EF/min) NS Paradoxical GB filling (>30%) 0 17 In patients with SOS, a larger number of basal contractions pass retrograde than antegrade. Cholecystokinin administration exaggerates these retrograde contractions and shuts off the sphincter orifice. Bile emptied from the gallbladder, therefore, refluxes into intrahepatic and extrahepatic bile ducts (4). Following discontinuation of cholecystokinin infusion, as the serum level of the hormone falls (CCK serum half life 2.5 minutes), higher threshold receptors in the body and fundus of the gallbladder begin to relax first, but lower threshold receptors in the sphincter stay contracted for a much longer period, diverting hepatic bile into the gallbladder. Cholecystokinin not only stimulates contraction of the gallbladder, but also increases bile secretion and flow from the liver by stimulating intrahepatic cholangiocytes lining the bile ducts (11). Both bile refluxed from the gallbladder and newly secreted by the liver are forced out off the liver to enter the gallbladder paradoxically in the presence of a tightly closed sphincter (Figure 1). Cholecystokinin induced paradoxical filling does not occur in normal subjects or patients with chronic acalculous cholecystitis (cystic duct spasm) or chronic calculous cholecystitis (Figure 1). A normal gallbladder contracts and empties during the entire period of CCK-8 infusion, and also for an additional 10 to 12 minutes after the termination of hormone infusion. Paradoxical filling begins to occur at the end of the ejection period. Therefore it is critical that the gallbladder data collection be continued for an additional minutes after discontinuation of CCK-8 infusion. Paradoxical filling phenomenon may not be evident as clearly if the gallbladder data collection is terminated abruptly coinciding with cessation of CCK-8 infusion. Liver function remains normal in SOS as indicated by normal values of HEF and T1/2 excretion. HEF measures the integrity of the basolateral border of the hepatocyte and T1/2 normal bile passage through canaliculi, and segmental and lobar bile ducts (12,13). Periodic rise in intraductal pressure post-prandially does not seem to affect the function of the hepatocytes in type lll biliary dyskinesia. Hogan and Geenen recommend that only type lll pattern be considered as true SOS, but not type l and ll (14). Our results indicate normal liver function and normal duct morphology in type lll SOS, and satisfy the strict criteria as recommended by Hogan and Geenen (4). The new criteria is also endorsed by the American motility society (15) Normally under the basal state about 61% of hepatic enters the gallbladder (Table1). Basal bile entry into gallbladder of only 28% (Table1) in SOS suggests that the sphincter tone is probably lax, basal contractions are weak, allowing more hepatic bile to enter the bowel than gallbladder. Contractions become much stronger with administration of CCK-8, shutting off (spasm) the sphincter orifice, and diverting bile flow into the gallbladder, paradoxically (Figure 1). Our results show that in patients with SOS gallbladder empties normally with a mean ejection fraction of 61%+29% and an ejection rate of 6+3%/ minute, indicating no significant impedance to bile exit through the cystic duct. Major pathology appears to reside within the sphincter of Oddi. Since the gallbladder serves as a reservoir by accepting hepatic bile when the sphincter goes into spasm with cholecystokinin, cholecystectomy would be detrimental in patients with SOS due to loss of this reservoir function. Post-cholecystectomy syndrome, therefore, is probably an iatrogenic disease exaggerated by cholecystectomy for SOS. Paradoxical filling seen with CCK is specific SOS and cannot be reproduced to the same degree by administering opioids, which have a strong constrictive effect on the sphincter. On a rare occasion when paradoxical filling is seen with morphine, the amount does not exceed more than 10 to 20% of the basal gallbladder volume (4). We recommend discontinuation of all opioids hour prior to scheduling a HIDA study, and use 30% paradoxical filling as the lower cut off limit for diagnosis of SOS. False-positive results may occur in patients with superimposition of bowel radioactivity on to the gallbladder ROI (Figure 2). This can be avoided by carefully reviewing the cine display of the original data. Hepatic flexure or transverse colon superimposition is the most common cause 79

6 Gerbail T. Krishnamurthy et al of false-positive SOS, followed by an occasional jejunal or ileal loop superimposition. In patients with either 3-minute or 10-minute CCK-8 infusion, intraluminal bile radioactivity at the end of gallbladder phase study stays within jejunum and ileum. Normally the colon is not seen. In patients with irritable bowel syndrome, on the other hand, ascending colon activity is often seen superimposed on to GB ROI (our unpublished observation-2004). Longer duration of CCK-8 infusion, such as 30 or 60 minutes, may promote longer bile transit with superimposition of bowel activity on to GB ROI. In these patients, gallbladder paradoxical curve is attributed to technical artifact and should not be interpreted as SOS (Figure 2). Since SOS is a rare clinical entity, it is important to maintain a high technical standard while conduction the study. Overdiagnosis should be avoided. When in doubt, a second dose of the hormone can be given to confirm paradoxical filling. Paradoxical gallbladder filling with cholecystokinin was reproducible in one of our patient with SOS when two doses of the hormone were infused sequentially on the same occasion (Figure 3). We have not studied SOS with fatty meal stimulation. Post-prandial serum CCK levels are maintained for a much longer duration with fatty meal than after intravenous infusion (5). Gallbladder phase data collection may have to be extended for two to three hours after a fatty meal to be able to document paradoxical filling in patients with SOS. Carefully conducted research studies are needed to characterize gallbladder filling, emptying, and refilling with fatty meal before applying the technique for routine use. Since manometric studies are shown to be non-reproducible in SOS, clinical out-come studies are needed to establish validity of newer diagnostic procedures for SOS (16). Our studies involve patients with an intact gallbladder and thus differ from those studies conducted in patients after cholecystectomy (17). The natures of paradoxical filling and gallbladder size variation are much easier to identify in patients with an intact gallbladder (Figure 1). In conclusion, quantitative cholescintigraphy with cholecystokinin is a simple, non-invasive, and less expensive diagnostic test and may serve as an alternative to biliary manometry, especially at those centers where manometry is not available. Acknowledgement: We thank Mr. Bob Crummett, Tuality Community Hospital, Hillsboro, OR for creating Figures 1, 2, and 3 for the manuscript. References 1. Krishnamurthy GT, Krishnamurthy S. Biliary dyskinesia: role of sphincter of Oddi, gallbladder, and cholecystokinin. J Nucl Med 1997;38: Krishnamurthy GT, Krishnamurthy S. Diagnostic reliability of gallbladder ejection fraction. Indian J Nucl Med 2002; 17: Toouli J, Roberts-Thompson IC, Dent J, Lee J. Manometric disorders in patients with suspected sphincter of Oddi dysfunction. Gastroenterology 1985;88: Krishnamurthy GT, Krishnamurthy S, Watson RD. characterization of basal hepatic bile flow and the effects of intravenous cholecystokinin on the liver, sphincter, and gallbladder in patients with sphincter of Oddi spasm. Eur J Nucl Med Mol Imaging 2004;31: Krishnamurthy GT, Krishnamurthy S. Nuclear Hepatology. T textbook of hepatobiliary diseases. New York, Berlin, Hiedelberg, Springer Krishnamurthy GT, Brown PH. Comparison of fatty meal and intravenous cholecystokinin for gallbladder ejection fraction. J Nucl Med 2002;43: Krishnamurthy GT, Krishnamurthy S, Cerulli-Switzer J, Chapman N. Comparison of gallbladder ejection fraction obtained with regular CCK-8 and pharmacy-compounded CCK-8. J Nucl Med 2003;44: Krishnamurthy GT, Bobba VR, Kingston E. Radionuclide ejection fraction: a technique for quantitative analysis of motor function of the human gallbladder. Gastroenterology 1981;80: Geenen JE, Hogan WJ, Dodds WJ, Steward ET, Arndorfer RC. Intraluminal pressure recording from the human sphincter of Oddi. Gastroenterology 1984;87: Meshkinpour H, Mollot M, Eckerling GB, Brookman L. Bile duct dyskinesia. Clinical and manometric study. Gastroenterology 1984;87: Mutt V. Cholecystokinin: isolation, structure, and function. In: GlassGBJ (ed), Gastrointestinal hormones. Raven Press, New York, 1980, Brown PH, Juni JE, Lieberman DA, Krishnamurthy GT. Hepatocyte versus biliary disease: a distinction by deconvolutional analysis of technetium-99m IDA time-activity curves. J Nucl Med 1988;29: Juni JE, Reichle R, Measurement of hepatocellular function with deconvolutional analysis: application in the differential diagnosis of acute jaundice. Radiology 1990;177: Hogan WJ, Geenen JE. Biliary dyskinesia. Endoscopy 1988;20: Hogan WJ, Sherman S, Pasricha P, Carr-Locke D. American Motility Society. Position Paper. Sphincter of Oddi Manometry. Gastrointestinal Endoscopy 1997;45: Thune A, Scicchitano J, Roberts-Thompson IC, Toouli J. Reproducibility of endoscopic sphincter of Oddi manometry. Dig. Dis. Sci 1991;36: Sostre S, Kalloo AN, Spiegler et al. A noninvasive test for sphincter of Oddi dysfunction in postcholecystectomy patients: the scintigraphic score. J Nucl Med 1992; 33:

Austin Radiological Association Nuclear Medicine Procedure SPHINCTER OF ODDI STUDY (Tc-99m-Mebrofenin)

Austin Radiological Association Nuclear Medicine Procedure SPHINCTER OF ODDI STUDY (Tc-99m-Mebrofenin) Austin Radiological Association Nuclear Medicine Procedure SPHINCTER OF ODDI STUDY (Tc-99m-Mebrofenin) Overview Indications The successively demonstrates hepatic perfusion, hepatocyte clearance, hepatic

More information

SPHINCTER OF ODDI DYSFUNCTION (SOD)

SPHINCTER OF ODDI DYSFUNCTION (SOD) SPHINCTER OF ODDI DYSFUNCTION (SOD) Sphincter of Oddi dysfunction refers to structural or functional disorders involving the biliary sphincter that may result in impedance of bile and pancreatic juice

More information

Hepatocellular Dysfunction

Hepatocellular Dysfunction www.nuclearmd.com A Normal HIDA Scan Dynamic or Static images of the abdomen are acquired after the IV administration 6-8 mci of Tc99m disofenin or mebrofenin, for one hour. Patients have to be NPO for

More information

TRA Medical Imaging BILIARY SCAN Protocols

TRA Medical Imaging BILIARY SCAN Protocols TRA Medical Imaging BILIARY SCAN Protocols Reviewed by: Last reviewed: Contact: (866) 761-4200 and choose option 1. Purpose: Pt Prep: Radiopharm and Dose: Equipment Set-Up: Time Required: Other Materials

More information

Liver Scan Biliary with Ejection Fraction Measurement

Liver Scan Biliary with Ejection Fraction Measurement APPROVED BY: Director of Radiology Page 1 of 5 Liver Scan Biliary with Ejection Fraction Primary Indications: In patients with chronic abdominal pain, hepatobiliary imaging with gallbladder ejection fraction

More information

Scintigraphy versus manometry in patients with suspected biliary sphincter of Oddi dysfunction

Scintigraphy versus manometry in patients with suspected biliary sphincter of Oddi dysfunction 35 BILIARY DISEASE Scintigraphy versus manometry in patients with suspected biliary sphincter of Oddi dysfunction A G Craig, D Peter, GTPSaccone, P Ziesing, A Wycherley, J Toouli... See end of article

More information

Manometry based randomised trial of endoscopic sphincterotomy for sphincter of Oddi dysfunction

Manometry based randomised trial of endoscopic sphincterotomy for sphincter of Oddi dysfunction 98 GI Surgical Unit, Flinders Medical Centre, Adelaide, Australia J Toouli I C Roberts-Thomson G T P Saccone P Jeans MCox P Anderson C Worthley N Shanks A Craig Department of Gastroenterology, Royal North

More information

Mft ] ~;;I~ [I) I~ t?l3 ilr!f S; [,j ~ M

Mft ] ~;;I~ [I) I~ t?l3 ilr!f S; [,j ~ M Mft ] ~;;I~ [I) I~ t?l3 ilr!f S; [,j ~ M Hepatobiliary Imaging Update Maggie Chester and Jerry Glowniak Veterans Affairs Medical Center and Oregon Health Sciences University, Portland, Oregon This is the

More information

Medford Radiology Group. Guideline: NM.HEPATOBILIARY Effective Date: 09/16/2016 Last Revision Date: 09/16/2016 HEPATOBILIARY SCAN.

Medford Radiology Group. Guideline: NM.HEPATOBILIARY Effective Date: 09/16/2016 Last Revision Date: 09/16/2016 HEPATOBILIARY SCAN. HEPATOBILIARY STUDY Medford Radiology Group Guideline: NM.HEPATOBILIARY Effective Date: 09/16/2016 Last Revision Date: 09/16/2016 SUBJECT: HEPATOBILIARY SCAN Overview Biliary tract scintigraphy can be

More information

Division of Nuclear Medicine Procedure / Protocol University Hospital and The American Center

Division of Nuclear Medicine Procedure / Protocol University Hospital and The American Center HEPATOBILIARY IMAGING CPT CODE: 78223 UPDATED: JULY 2017 Indications: Diagnosis of acute cholecystitis (both calculus and acalculous disease) Determination of patency of common bile duct when ultrasound

More information

CLINICAL PRESENTATION AND RADIOLOGY QUIZ QUESTION

CLINICAL PRESENTATION AND RADIOLOGY QUIZ QUESTION Donald L. Renfrew, MD Radiology Associates of the Fox Valley, 333 N. Commercial Street, Suite 100, Neenah, WI 54956 8/27/2011 Radiology Quiz of the Week # 35 Page 1 CLINICAL PRESENTATION AND RADIOLOGY

More information

Hepatobiliary Scintigraphy:

Hepatobiliary Scintigraphy: Cholecystokinin-Augmented Hepatobiliary Scintigraphy: Dissecting the Art from Science Mark Tulchinsky, MD, FACNP Professor of Radiology and Medicine Penn State University College of Medicine Hershey, Pennsylvania

More information

Prior Authorization Review Panel MCO Policy Submission

Prior Authorization Review Panel MCO Policy Submission Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.

More information

Nasogastric tube. Stomach. Pylorus. Duodenum 1. Duodenum 2. Duodenum 3. Duodenum 4

Nasogastric tube. Stomach. Pylorus. Duodenum 1. Duodenum 2. Duodenum 3. Duodenum 4 Esophagus Barium Swallow Stomach and Duodenum 4 year old Upper GI Nasogastric tube Stomach and Duodenum 4 year old Upper GI Nasogastric tube Stomach Pylorus Duodenum 1 Duodenum 2 Duodenum 3 Duodenum 4

More information

Scintigraphy (Nuclear Medicine Imaging) in Patients with Perplexing Abdominal Complaints

Scintigraphy (Nuclear Medicine Imaging) in Patients with Perplexing Abdominal Complaints Scintigraphy (Nuclear Medicine Imaging) in Patients with Perplexing Abdominal Complaints Mark Tulchinsky, MD, FACNM, CCD Professor of Radiology and Medicine Penn State University College of Medicine Hershey,

More information

Figure 2: Post-cholecystectomy biliary-like pain

Figure 2: Post-cholecystectomy biliary-like pain Figure 2: Post-cholecystectomy biliary-like pain 1 patient with recurrent episodes of pain (not daily), in the epigastrium/right upper quadrant, lasting >30 mins, building to a steady level, interrupting

More information

Pancreas & Biliary System. Dr. Vohra & Dr. Jamila

Pancreas & Biliary System. Dr. Vohra & Dr. Jamila Pancreas & Biliary System Dr. Vohra & Dr. Jamila 1 Objectives At the end of the lecture, the student should be able to describe the: Location, surface anatomy, parts, relations & peritoneal reflection

More information

Small-Bowel and colon Transit. Mahsa Sh.Nezami October 2016

Small-Bowel and colon Transit. Mahsa Sh.Nezami October 2016 Small-Bowel and colon Transit Mahsa Sh.Nezami October 2016 Dyspeptic symptoms related to dysmotility originating from the small bowel or colon usually include : Abdominal pain Diarrhea Constipation However,

More information

Contrast Material and Gallbladder Kinetics: Implications for Same Day Sonography After Intravenous Pyelography or CT Scanning

Contrast Material and Gallbladder Kinetics: Implications for Same Day Sonography After Intravenous Pyelography or CT Scanning Contrast Material and Gallbladder Kinetics: Implications for Same Day Sonography After Intravenous Pyelography or CT Scanning Omar Khan, MD, PhD, Rene Naipaul, RDMS, Rajendra Singh Rampaul, MB, BS, Vinesh

More information

MCAT Biology Problem Drill 20: The Digestive System

MCAT Biology Problem Drill 20: The Digestive System MCAT Biology Problem Drill 20: The Digestive System Question No. 1 of 10 Question 1. During the oral phase of swallowing,. Question #01 A. Initially, the food bolus is moved to the back of the tongue and

More information

Abnormal responses to morphine-neostigmine in patients with undefined biliary type pain

Abnormal responses to morphine-neostigmine in patients with undefined biliary type pain Abnormal responses to morphine-neostigmine in patients with undefined biliary type pain I C ROBERTS-THOMSON AND J TOOULI Gut, 1985, 26, 1367-1372 From the Clinical Research Unit, The Walter and Eliza Hall

More information

Gerbail T. Krishnamurthy Shakuntala Krishnamurthy. Nuclear Hepatology. A Textbook of Hepatobiliary Diseases. Second Edition

Gerbail T. Krishnamurthy Shakuntala Krishnamurthy. Nuclear Hepatology. A Textbook of Hepatobiliary Diseases. Second Edition Nuclear Hepatology Gerbail T. Krishnamurthy Shakuntala Krishnamurthy Nuclear Hepatology A Textbook of Hepatobiliary Diseases Second Edition Gerbail T. Krishnamurthy Tuality Community Hospital Hillsboro,

More information

Usefulness of Fatty-meal Stimulated Gallbladder Contractility by Ultrasonography in the Diagnosis of Acute Cholecystitis

Usefulness of Fatty-meal Stimulated Gallbladder Contractility by Ultrasonography in the Diagnosis of Acute Cholecystitis O R I G I N A L A R T I C L E Usefulness of Fatty-meal Stimulated Gallbladder Contractility by Ultrasonography in the Diagnosis of Acute Cholecystitis Yuan-Ming Tsai 1,2 2, Chiao-Hsiung Chuang *, Hsiu-Chi

More information

Gastrointestinal tract

Gastrointestinal tract Gastrointestinal tract Colloidal liver-spleen imaging Presented by: Jehad Felemban Introduction: To obtain better anatomic display of liver and spleen architecture, we use (CT Ultrasound). (Radionuclide

More information

Nuclear medicine in gastrointestinal system. Assoc. prof. V. Marković, MD, PhD Assoc. prof. A. Punda, MD, PhD A. Barić, MD, nucl. med. spec.

Nuclear medicine in gastrointestinal system. Assoc. prof. V. Marković, MD, PhD Assoc. prof. A. Punda, MD, PhD A. Barić, MD, nucl. med. spec. Nuclear medicine in gastrointestinal system Assoc. prof. V. Marković, MD, PhD Assoc. prof. A. Punda, MD, PhD A. Barić, MD, nucl. med. spec. Hepatobiliary imaging Hepatobiliary imaging is nuclear medicine

More information

Localization of Gastrointestinal Bleeding by Cinematic 99m Tc Labeled Red Blood Cell Scan

Localization of Gastrointestinal Bleeding by Cinematic 99m Tc Labeled Red Blood Cell Scan Localization of Gastrointestinal Bleeding by Cinematic 99m Tc Labeled Red Blood Cell Scan Chia-Shang Wu 1, Chang-Chung Lin 1, Nan-Jing Peng 1, 1 Department of Nuclear Medicine, Kaohsiung Veterans General

More information

Lab Monitor Images Dissection of the Abdominal Vasculature + Lower Digestive System

Lab Monitor Images Dissection of the Abdominal Vasculature + Lower Digestive System Lab Monitor Images Dissection of the Abdominal Vasculature + Lower Digestive System Stomach & Duodenum Frontal (AP) View Nasogastric tube 2 1 3 4 Stomach Pylorus Duodenum 1 Duodenum 2 Duodenum 3 Duodenum

More information

SUMMARY OF PRODUCT CHARACTERISTICS. for. BRIDATEC, kit for radiopharmaceutical preparation

SUMMARY OF PRODUCT CHARACTERISTICS. for. BRIDATEC, kit for radiopharmaceutical preparation February 9, 2010 SUMMARY OF PRODUCT CHARACTERISTICS for BRIDATEC, kit for radiopharmaceutical preparation 1. NAME OF THE MEDICINAL PRODUCT BRIDATEC 2. QUALITATIVE AND QUANTITATIVE COMPOSITION N-(3-bromo-2,4,6-trimethylphenylcarbamoyl

More information

A Guide to Gastrointestinal Motility Disorders

A Guide to Gastrointestinal Motility Disorders A Guide to Gastrointestinal Motility Disorders Albert J. Bredenoord André Smout Jan Tack A Guide to Gastrointestinal Motility Disorders Albert J. Bredenoord Gastroenterology and Hepatology Academic Medical

More information

4/9/2018 OBJECTIVES PANCREAOTO BILIARY ULTRASOUND: BEYOND CHOLECYSTITIS

4/9/2018 OBJECTIVES PANCREAOTO BILIARY ULTRASOUND: BEYOND CHOLECYSTITIS PANCREAOTO BILIARY ULTRASOUND: BEYOND CHOLECYSTITIS Jean Yves Sewah Kaiser Permanente West Los Angeles 1 OBJECTIVES Discuss the role of ultrasound in the evaluation of the gallbladder, biliary tree and

More information

Case Report (1) Sphincter of Oddi Dysfunction. Case Report (3) Case Report (2) Case Report (4) Case Report (5)

Case Report (1) Sphincter of Oddi Dysfunction. Case Report (3) Case Report (2) Case Report (4) Case Report (5) Dr David Westaby Imperial NHS Trust Imperial College Medical School London Case Report (1)! TD 33yr old male! Feb May 2010: Recurrent episodes of abdominal pain! June 2010 Episode severe abdominal pain

More information

What Are Gallstones? GALLSTONES. Gallstones are pieces of hard, solid matter that form over time in. the gallbladder of some people.

What Are Gallstones? GALLSTONES. Gallstones are pieces of hard, solid matter that form over time in. the gallbladder of some people. What Are Gallstones? Gallstones are pieces of hard, solid matter that form over time in the gallbladder of some people. The gallbladder sits under the liver and stores bile (a key digestive juice ). Gallstones

More information

Radiology of hepatobiliary diseases

Radiology of hepatobiliary diseases GI cycle - Lecture 14 436 Teams Radiology of hepatobiliary diseases Objectives 1. To Interpret plan x-ray radiograph of abdomen with common pathologies. 2. To know the common pathologies presentation.

More information

DRUG ELIMINATION II BILIARY EXCRETION MAMMARY, SALIVARY AND PULMONARY EXCRETION

DRUG ELIMINATION II BILIARY EXCRETION MAMMARY, SALIVARY AND PULMONARY EXCRETION DRUG ELIMINATION II BILIARY EXCRETION MAMMARY, SALIVARY AND PULMONARY EXCRETION ROUTE OF DRUG ADMINISTRATION AND EXTRAHEPATIC DRUG METABOLISM The decline in plasma concentration after drug administration

More information

Biliary tree dilation - and now what?

Biliary tree dilation - and now what? Biliary tree dilation - and now what? Poster No.: C-1767 Congress: ECR 2012 Type: Educational Exhibit Authors: I. Ferreira, A. B. Ramos, S. Magalhães, M. Certo; Porto/PT Keywords: Pathology, Diagnostic

More information

In The Name of God. Advanced Concept of Nursing- II UNIT- V Advance Nursing Management of GIT diseases. Cholecystitis.

In The Name of God. Advanced Concept of Nursing- II UNIT- V Advance Nursing Management of GIT diseases. Cholecystitis. In The Name of God (A PROJECT OF NEW LIFE HEALTH CARE SOCIETY, KARACHI) Advanced Concept of Nursing- II UNIT- V Advance Nursing Management of GIT diseases. Cholecystitis. Shahzad Bashir RN, BScN, DCHN,MScN

More information

What can you expect after your ERCP?

What can you expect after your ERCP? ERCP Explained and respond to bed rest, pain relief and fasting to rest the gut with the patient needing to stay in hospital for only a few days. Some patients develop severe pancreatitis and may require

More information

Utilization of Cholecystokinin Cholescintigraphy in Clinical Practice

Utilization of Cholecystokinin Cholescintigraphy in Clinical Practice COLLECTIVE REVIEWS Utilization of Cholecystokinin Cholescintigraphy in Clinical Practice Bryan K Richmond, MD, MBA, FACS, John DiBaise, MD, Harvey Ziessman, MD Cholecystokinin-cholescintigraphy (CCK-HIDA)

More information

Preview from Notesale.co.uk Page 1 of 34

Preview from Notesale.co.uk Page 1 of 34 Abdominal viscera and digestive tract Digestive tract Abdominal viscera comprise majority of the alimentary system o Terminal oesophagus, stomach, pancreas, spleen, liver, gallbladder, kidneys, suprarenal

More information

Section Coordinator: Jerome W. Breslin, PhD, Assistant Professor of Physiology, MEB 7208, ,

Section Coordinator: Jerome W. Breslin, PhD, Assistant Professor of Physiology, MEB 7208, , IDP Biological Systems Gastrointestinal System Section Coordinator: Jerome W. Breslin, PhD, Assistant Professor of Physiology, MEB 7208, 504-568-2669, jbresl@lsuhsc.edu Overall Learning Objectives 1. Characterize

More information

Chapter 26 The Digestive System

Chapter 26 The Digestive System Chapter 26 The Digestive System Digestive System Gastroenterology is the study of the stomach and intestine. Digestion Catabolism Absorption Anabolism The actions of the digestive system are controlled

More information

SOD (Sphincter of Oddi Dysfunction)

SOD (Sphincter of Oddi Dysfunction) SOD (Sphincter of Oddi Dysfunction) SOD refers to the mechanical malfunctioning of the Sphincter of Oddi, which is the valve muscle that regulates the flow of bile and pancreatic juice into the duodenum.

More information

The biliary tract transports, stores, and regulates. Functional Gallbladder and Sphincter of Oddi Disorders

The biliary tract transports, stores, and regulates. Functional Gallbladder and Sphincter of Oddi Disorders GASTROENTEROLOGY 2006;130:1498 1509 Functional Gallbladder and Sphincter of Oddi Disorders JOSE BEHAR,* ENRICO CORAZZIARI, MOISES GUELRUD, WALTER HOGAN, STUART SHERMAN, and JAMES TOOULI # *Rhode Island

More information

Sphincter of Oddi dysfunction: SOD after EPISOD, Now what do we do?

Sphincter of Oddi dysfunction: SOD after EPISOD, Now what do we do? Sphincter of Oddi dysfunction: SOD after EPISOD, Now what do we do? Priya A. Jamidar, M.D., FASGE Professor of Medicine, Director of Endoscopy Yale School Y A L E S CH OO L O F MEDIC IN E February in Connecticut

More information

Anatomical and Functional MRI of the Pancreas

Anatomical and Functional MRI of the Pancreas Anatomical and Functional MRI of the Pancreas MA Bali, MD, T Metens, PhD Erasme Hospital Free University of Brussels Belgium mbali@ulb.ac.be Introduction The use of MRI to investigate the pancreas has

More information

Abdominal ultrasound:

Abdominal ultrasound: Abdominal ultrasound: Non-traumatic acute abdomen Wittanee Na-ChiangMai, MD Department of Radiology ChiangMai University 26/04/2017 Contents Technique of examination Normal anatomy Emergency conditions

More information

My Patient Has Abdominal Pain PoCUS of the Biliary Tract and the Urinary Tract

My Patient Has Abdominal Pain PoCUS of the Biliary Tract and the Urinary Tract My Patient Has Abdominal Pain PoCUS of the Biliary Tract and the Urinary Tract Objectives PoCUS for Biliary Disease PoCUS for Renal Colic PoCUS for Urinary Retention Biliary Disease A patient presents

More information

Background. RUQ Ultrasound Normal, Recommend Clinical Correlation. Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children s Hosptial

Background. RUQ Ultrasound Normal, Recommend Clinical Correlation. Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children s Hosptial RUQ Ultrasound Normal, Recommend Clinical Correlation Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children s Hosptial Background Incidence of pediatric gallbladder disease continues to rise U.S. Pediatric

More information

The evaluation of gallbladder (GB) motility by cholescintigraphy is a valuable technique

The evaluation of gallbladder (GB) motility by cholescintigraphy is a valuable technique The role of cholescintigraphy in demonstrating delayed post prandial gallbladder motility in cirrhotic patients Ruirui Hao 1 MD, Huiji Wang 1 MD, Chunlin Li 2 MD, Jigang Yang 2 MD, PhD Medical Healthcare

More information

-12. -Renad Habahbeh. -Dr Mohammad mohtasib

-12. -Renad Habahbeh. -Dr Mohammad mohtasib -12 -Renad Habahbeh - -Dr Mohammad mohtasib The Gallbladder -The gallbladder has a body, a fundus (a rounded end), a neck, Hartmann s pouch before the neck and a cystic duct that meets the common hepatic

More information

Duration of Pain Is Correlated With Elevation in Liver Function Tests in Patients With Symptomatic Choledocholithiasis

Duration of Pain Is Correlated With Elevation in Liver Function Tests in Patients With Symptomatic Choledocholithiasis CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:1077 1082 Duration of Pain Is Correlated With Elevation in Liver Function Tests in Patients With Symptomatic Choledocholithiasis ALA I. SHARARA, NABIL M.

More information

ANATOMY & PHYSIOLOGY ONLINE COURSE - SESSION 13 THE DIGESTIVE SYSTEM

ANATOMY & PHYSIOLOGY ONLINE COURSE - SESSION 13 THE DIGESTIVE SYSTEM ANATOMY & PHYSIOLOGY ONLINE COURSE - SESSION 13 THE DIGESTIVE SYSTEM The digestive system also known as the alimentary canal or gastrointestinal tract consists of a series of hollow organs joined in a

More information

Tools of the Gastroenterologist: Introduction to GI Endoscopy

Tools of the Gastroenterologist: Introduction to GI Endoscopy Tools of the Gastroenterologist: Introduction to GI Endoscopy Objectives Endoscopy Upper endoscopy Colonoscopy Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic ultrasound (EUS) Endoscopic

More information

Chapter 20 The Digestive System Exam Study Questions

Chapter 20 The Digestive System Exam Study Questions Chapter 20 The Digestive System Exam Study Questions 20.1 Overview of GI Processes 1. Describe the functions of digestive system. 2. List and define the four GI Processes: 20.2 Functional Anatomy of the

More information

NOTES: The Digestive System (Ch 14, part 2)

NOTES: The Digestive System (Ch 14, part 2) NOTES: The Digestive System (Ch 14, part 2) PANCREAS Structure of the pancreas: The pancreas produces PANCREATIC JUICE that is then secreted into a pancreatic duct. The PANCREATIC DUCT leads to the The

More information

Change in Bile Duct Pressure Responses After Cholecystectomy: Loss of Gallbladder as a Pressure Reservoir

Change in Bile Duct Pressure Responses After Cholecystectomy: Loss of Gallbladder as a Pressure Reservoir GASTROENTEROLOGY 1984;87;1154-9 Change in Bile Duct Pressure Responses After Cholecystectomy: Loss of Gallbladder as a Pressure Reservoir MASAO TANAKA, SEIYO IKEDA, and FUMIO NAKAYAMA Department of Surgery

More information

PREVALENCE OF SUBCLINICAL HYPOTHYROIDISM IN COMMON BILE DUCT STONE PATIENTS

PREVALENCE OF SUBCLINICAL HYPOTHYROIDISM IN COMMON BILE DUCT STONE PATIENTS 1 Original Article PREVALENCE OF SUBCLINICAL HYPOTHYROIDISM IN COMMON BILE DUCT STONE PATIENTS Ashok Kumar 1, Prem Chand 2, Vandana Singla 3, Vivek Pahuja 4, Associate Professor Surgery, Department of

More information

LAPAROSCOPIC GALLBLADDER SURGERY

LAPAROSCOPIC GALLBLADDER SURGERY LAPAROSCOPIC GALLBLADDER SURGERY Treating Gallbladder Problems with Laparoscopy A Common Problem If you ve had an attack of painful gallbladder symptoms, you re not alone. Gallbladder disease is very common.

More information

BILE FORMATION, ENTEROHEPATIC CIRCULATION & BILE SALTS

BILE FORMATION, ENTEROHEPATIC CIRCULATION & BILE SALTS 1 BILE FORMATION, ENTEROHEPATIC CIRCULATION & BILE SALTS Color index Important Further explanation 2 Mind map...3 Functions of bile & stages of bile secretion... 4 Characteristics & composition of bile...5

More information

Morphine-Modified Hepatobiliary Scanning Protocol for the Diagnosis of Acute Cholecystitis

Morphine-Modified Hepatobiliary Scanning Protocol for the Diagnosis of Acute Cholecystitis Nuclear Medicine and Molecular Imaging Original Research Solomon et al. Imaging Diagnosis of Acute Cholecystitis Nuclear Medicine and Molecular Imaging Original Research Robert W. Solomon 1,2 Abraham Albert

More information

Biliary Tree Ultrasound - In a nutshell. Pamela Parker Lead Sonographer

Biliary Tree Ultrasound - In a nutshell. Pamela Parker Lead Sonographer Biliary Tree Ultrasound - In a nutshell Pamela Parker Lead Sonographer Aims Review what we know about the biliary system Common pathologies Pitfalls Reporting tips The Nutshell Background Biliary examinations

More information

Duodenum retroperitoneal

Duodenum retroperitoneal Duodenum retroperitoneal C shaped Initial region out of stomach into small intestine RETROperitoneal viscus Superior 1 st part duodenal cap ; moves upwards and backwards to lie on the R crura medial to

More information

The Frequency of Gastroesophageal Reflux Disease in Nutcracker Esophagus and the Effect of Acid-Reduction Therapy on the Motor Abnormality

The Frequency of Gastroesophageal Reflux Disease in Nutcracker Esophagus and the Effect of Acid-Reduction Therapy on the Motor Abnormality Bahrain Medical Bulletin, Vol.22, No.4, December 2000 The Frequency of Gastroesophageal Reflux Disease in Nutcracker Esophagus and the Effect of Acid-Reduction Therapy on the Motor Abnormality Saleh Mohsen

More information

GASTRIC EMPTYING STUDY (SOLID)

GASTRIC EMPTYING STUDY (SOLID) GASTRIC EMPTYING STUDY (SOLID) Aim To evaluate patients with symptoms of altered of gastric emptying and/or motility, and quantitatively measure the rate of gastric emptying. This study provides a physiologic,

More information

Medical Policy. MP Ingestible ph and Pressure Capsule

Medical Policy. MP Ingestible ph and Pressure Capsule Medical Policy BCBSA Ref. Policy: 2.01.81 Last Review: 11/15/2018 Effective Date: 11/15/2018 Section: Medicine Related Policies 2.01.20 Esophageal ph Monitoring 6.01.33 Wireless Capsule Endoscopy as a

More information

Pancreas and Biliary System

Pancreas and Biliary System Pancreas and Biliary System Please view our Editing File before studying this lecture to check for any changes. Color Code Important Doctors Notes Notes/Extra explanation Objectives At the end of the lecture,

More information

Surface Anatomy. Location Shape Weight Role of Five Surfaces Borders Fissures Lobes Peritoneal Lig

Surface Anatomy. Location Shape Weight Role of Five Surfaces Borders Fissures Lobes Peritoneal Lig The Liver Functions Bile production and secretion Detoxification Storage of glycogen Protein synthesis Production of heparin and bile pigments Erythropoiesis (in fetus) Surface Anatomy Location Shape Weight

More information

Jhia Anjela D. Rivera 1 1. BS Biology, Department of Biology, College of Science, Polytechnic University of the Philippines

Jhia Anjela D. Rivera 1 1. BS Biology, Department of Biology, College of Science, Polytechnic University of the Philippines DIGESTIVE SYSTEM Jhia Anjela D. Rivera 1 1 BS Biology, Department of Biology, College of Science, Polytechnic University of the Philippines DIGESTIVE SYSTEM Consists of the digestive tract (gastrointestinal

More information

Navigating the Biliary Tract with CT & MR: An Imaging Approach to Bile Duct Obstruction

Navigating the Biliary Tract with CT & MR: An Imaging Approach to Bile Duct Obstruction Navigating the Biliary Tract with CT & MR: An Imaging Approach to Bile Duct Obstruction Ann S. Fulcher, MD Medical College of Virginia Virginia Commonwealth University Richmond, Virginia Objectives To

More information

COPYRIGHTED MATERIAL. 1 Approach to the patient with gross gastrointestinal bleeding. Grace H. Elta, Mimi Takami

COPYRIGHTED MATERIAL. 1 Approach to the patient with gross gastrointestinal bleeding. Grace H. Elta, Mimi Takami 1 Approach to the patient with gross gastrointestinal bleeding Grace H. Elta, Mimi Takami Gastrointestinal (GI) bleeding is a common clinical problem that requires more than 300 000 hospitalizations annually

More information

USMLE and COMLEX II. CE / CK Review. General Surgery. 1. Northwestern Medical Review

USMLE and COMLEX II. CE / CK Review. General Surgery. 1. Northwestern Medical Review USMLE and COMLEX II CE / CK Review General Surgery 1. Northwestern Medical Review Northwestern Medical Review www.northwesternmedicalreview.com Lansing, Michigan 2014-2015 Acute Abdomen 1. Your patient

More information

Austin Radiological Association Nuclear Medicine Procedure WHITE BLOOD CELL MIGRATION STUDY (In-111-WBCs, Tc-99m-HMPAO-WBCs)

Austin Radiological Association Nuclear Medicine Procedure WHITE BLOOD CELL MIGRATION STUDY (In-111-WBCs, Tc-99m-HMPAO-WBCs) Austin Radiological Association Nuclear Medicine Procedure WHITE BLOOD CELL MIGRATION STUDY (In-111-WBCs, Tc-99m-HMPAO-WBCs) Overview Indications The White Blood Cell Migration Study demonstrates the distribution

More information

Hepatobiliary Scintigraphy in Patients with Bile Leaks

Hepatobiliary Scintigraphy in Patients with Bile Leaks Hepatobiliary Scintigraphy in Patients with Bile Leaks Sandra L. Carichner and Conrad E. Nagle William Beaumont Hospital, Troy, Michigan Hepatobilillry scintigraphy has been recognized as u useful tool

More information

Biliary MRI w Eovist

Biliary MRI w Eovist Biliary MRI w Eovist Is there any added value? Elmar M. Merkle, MD Director of MR Imaging Duke University Medical Center elmar.merkle@duke.edu Declaration of Conflict of Interest or Relationship Research

More information

DIGESTIVE SYSTEM CLASS NOTES. tube along with several

DIGESTIVE SYSTEM CLASS NOTES. tube along with several DIGESTIVE SYSTEM CLASS NOTES Digestion Breakdown of food and the of nutrients in the bloodstream. Metabolism Production of for and cellular activities. The digestive system is composed of the canal which

More information

Case Scenario 1. Discharge Summary

Case Scenario 1. Discharge Summary Case Scenario 1 Discharge Summary A 69-year-old woman was on vacation and noted that she was becoming jaundiced. Two months prior to leaving on that trip, she had had a workup that included an abdominal

More information

Congenital Pediatric Anomalies: A Collection of Abdominal Scintigraphy Findings: An Imaging Atlas

Congenital Pediatric Anomalies: A Collection of Abdominal Scintigraphy Findings: An Imaging Atlas ISPUB.COM The Internet Journal of Nuclear Medicine Volume 5 Number 1 Congenital Pediatric Anomalies: A Collection of Abdominal Scintigraphy Findings: An Imaging Atlas V Vijayakumar, T Nishino Citation

More information

Chapter 20 The Digestive System Exam Study Questions

Chapter 20 The Digestive System Exam Study Questions Chapter 20 The Digestive System Exam Study Questions 20.1 Overview of GI Processes 1. Describe the functions of digestive system. 2. List and define the four GI Processes: 20.2 Functional Anatomy of the

More information

Congenital dilatation of the common bile duct and pancreaticobiliary maljunction clinical implications

Congenital dilatation of the common bile duct and pancreaticobiliary maljunction clinical implications Langenbecks Arch Surg (2009) 394:209 213 DOI 10.1007/s00423-008-0330-6 CURRENT CONCEPT IN CLINICAL SURGERY Congenital dilatation of the common bile duct and pancreaticobiliary maljunction clinical implications

More information

Lab 5 Digestion and Hormones of Digestion. 7/16/2015 MDufilho 1

Lab 5 Digestion and Hormones of Digestion. 7/16/2015 MDufilho 1 Lab 5 Digestion and Hormones of Digestion 1 Figure 23.1 Alimentary canal and related accessory digestive organs. Mouth (oral cavity) Tongue* Parotid gland Sublingual gland Submandibular gland Salivary

More information

OPERATIVE TREATMENT OF ULCER DISEASE

OPERATIVE TREATMENT OF ULCER DISEASE Página 1 de 8 Copyright 2001 Lippincott Williams & Wilkins Greenfield, Lazar J., Mulholland, Michael W., Oldham, Keith T., Zelenock, Gerald B., Lillemoe, Keith D. Surgery: Scientific Principles & Practice,

More information

The gallbladder. Bile secretion:

The gallbladder. Bile secretion: The gallbladder is a thin walled green muscular sac on the inferior surface of the liver. The gallbladder stores bile that is not immediately needed for digestion and concentrates it. When the muscular

More information

Understanding Food and Nutrition

Understanding Food and Nutrition Understanding Food and Nutrition Dr Joan Webster-Gandy Published by Family Doctor Publications Limited in association with the British Medical Association IMPORTANT NOTICE This book is intended not as

More information

Gastroenterology Fellowship Program

Gastroenterology Fellowship Program Gastroenterology Fellowship Program Outpatient Clinical Rotations I. Overview A. Three Year Continuity Clinic Experience All gastroenterology fellows will be required to have a ½ day continuity clinic

More information

The abdominal Esophagus, Stomach and the Duodenum. Prof. Oluwadiya KS

The abdominal Esophagus, Stomach and the Duodenum. Prof. Oluwadiya KS The abdominal Esophagus, Stomach and the Duodenum Prof. Oluwadiya KS www.oluwadiya.com Viscera of the abdomen Abdominal esophagus: Terminal part of the esophagus The stomach Intestines: Small and Large

More information

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Endoscopic Retrograde Cholangiopancreatography (ERCP) Endoscopic Retrograde Cholangiopancreatography (ERCP) Medical Imaging and Treatment of the Bile and Pancreatic Ducts CIE-02718 Understanding ERCP Brochure Update_F.indd 1 7/11/18 9:51 A Minimally Invasive

More information

GASTROINTESTINAL SYSTEM

GASTROINTESTINAL SYSTEM GASTROINTESTINAL SYSTEM Topographic Anatomy of the Abdomen Surface Landmarks Xiphoid process T9/T10 Inferior costal margin L2/L3 Iliac Crest L4 level ASIS L5/S1 level Pubic symphysis level of greater trochanter

More information

What is sphincter of Oddi dysfunction?

What is sphincter of Oddi dysfunction? Leading article Gut, 1989, 30, 753-761 What is sphincter of Oddi dysfunction? Summary Ever since its description approximately 100 years ago, the sphincter of Oddi has been surrounded by controversy. First,

More information

Urinary System VASTACCESS, INC.

Urinary System VASTACCESS, INC. Urinary System www.vastaccess.com 2 Urinary Tract Kidney Ureter Urinary Bladder Urethra Prostate (male) Membranous (male) Spongy (male) 3 Kidney Relations Suprarenal (Adrenal) Glands Liver Duodenum Transverse

More information

The effect of metoclopramide on gastroduodenal

The effect of metoclopramide on gastroduodenal Gut, 1971, 12, 158-163 The effect of metoclopramide on gastroduodenal and gallbladder contractions A. G. JOHNSON From the Department of Surgery, Charing Cross Hospital Medical School, London SUMMARY The

More information

Cholecystokinin-cholescintigraphy (CCK-CS) is commonly REVIEW

Cholecystokinin-cholescintigraphy (CCK-CS) is commonly REVIEW CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:376 384 REVIEW Cholecystokinin-Cholescintigraphy in Adults: Consensus Recommendations of an Interdisciplinary Panel JOHN K. DIBAISE,* BRYAN K. RICHMOND,

More information

Principles of Anatomy and Physiology

Principles of Anatomy and Physiology Principles of Anatomy and Physiology 14 th Edition CHAPTER 24 The Digestive System Introduction The purpose of this chapter is to Identify the anatomical components of the digestive system as well as their

More information

Why would fatty foods aggravate the patient s RUQ pain? What effect does cholecystokinin (CCK) have on gastric emptying?

Why would fatty foods aggravate the patient s RUQ pain? What effect does cholecystokinin (CCK) have on gastric emptying? CASE 28 A 43-year-old woman presents to the emergency department with the acute onset of abdominal pain. Her pain is located to the right upper quadrant (RUQ) and radiates to the right shoulder. She reports

More information

Chapter 1. General introduction and outline

Chapter 1. General introduction and outline Chapter 1 General introduction and outline General introduction The function of the stomach comprises storage of ingested food, production of gastric secretion and mixing food with gastric secretion,

More information

Gallstones and Cholecystectomy Information Sheet

Gallstones and Cholecystectomy Information Sheet Gallstones and Cholecystectomy Information Sheet Gallstones & Cholecystectomy This information sheet desrcibes what they are, the treatment options, and what to expect following a operation. The following

More information

Nuclear Medicine - Hepatobiliary

Nuclear Medicine - Hepatobiliary Scan for mobile link. Nuclear Medicine - Hepatobiliary Hepatobiliary nuclear medicine imaging helps evaluate the parts of the biliary system, including the liver, gallbladder and bile ducts, using small

More information

What location in the gastrointestinal (GI) tract has tight, or impermeable, junctions between the epithelial cells?

What location in the gastrointestinal (GI) tract has tight, or impermeable, junctions between the epithelial cells? CASE 32 A 17-year-old boy presents to his primary care physician with complaints of diarrhea for the last 2 days. The patient states that he just returned to the United States after visiting relatives

More information

The stomach is formed of three parts: -

The stomach is formed of three parts: - The stomach is formed of three parts: - (a) CARDIAC STOMACH: - It receives the oesophagus through Cardiac aperture guarded by a cardiac sphincter which prevents regurgitation of food. (b) FUNDIC PART:

More information

Nuclear medicine studies of the digestiv system. Zámbó Katalin Department of Nuclear Medicine

Nuclear medicine studies of the digestiv system. Zámbó Katalin Department of Nuclear Medicine Nuclear medicine studies of the digestiv system Zámbó Katalin Department of Nuclear Medicine Anatomy of the liver Liver scintigraphy The labelled colloid (200 MBq 99mTc-Fyton) is phagocyted by the Kuppfer-cells

More information

Gallstones Information Leaflet THE DIGESTIVE SYSTEM. Gutscharity.org.uk

Gallstones Information Leaflet THE DIGESTIVE SYSTEM.  Gutscharity.org.uk THE DIGESTIVE SYSTEM http://healthfavo.com/digestive-system-for-kids.html This factsheet is about gallstones Gall is an old-fashioned word for bile, a liquid made in the liver and stored in the gall bladder

More information