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

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1 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 performed with either Tc-99m disofenin or Tc-99m mebrofenin. Both of these agents are iminodiacetic acid derivatives that are cleared rapidly from the blood by the hepatocytes and excreted in the bile in high concentrations. In normal fasting subjects, peak liver uptake occurs about 10 minutes after injection, with visualization of the hepatic duct and gallbladder after minutes. In normal subjects, about 9% of the disofenin and 1% of the mebrofenin are excreted in the urine in the first 2 hours. Increased serum levels of bilirubin increase renal excretion and may lead to visualization of the kidneys in some patients. Indications Hepatobiliary scintigraphy with Tc-99m iminodiacetic acid (IDA) compounds is useful in evaluation the patency of the common bile duct and the cystic duct. This test is very sensitive and specific for acute cholecystitis. Because IDA compounds are extracted by hepatocytes and excreted unconjugated into the bile, hepatocyte function and biliary drainage can be evaluated. This test may also be helpful in evaluating patients with jaundice or abdominal pain and after hepatic/biliary operations. This in not a test for cholelithiasis (gallstones), because many patients with cholelithiasis have normal hepatobiliary function. Examination Time Approximately 2 ½ to 3 hours. (Delayed images may be needed.) Patient Preparation If evaluation of the gallbladder is desired, the patient should have fasted for a minimum of 4 hours prior to administration of the radiopharmaceutical. A false-positive study (non-visualization of the gallbladder) may result if the patient has eaten recently. If the patient has received morphine/opiates within 4 hours before the HIDA study, the study must be delayed 4 hours from the dosing as morphine/opiates may result in delayed visualization of the bowel due to constriction of the sphincter of Oddi. If evaluation of the gallbladder is not desired, no patient preparation is necessary. Patient must be off all opiate drugs for 4 hours, this includes Dilaudid. (Be sure to specifically ask the nurse if patient is on Dilaudid, as most do not know it is an opiate!) If necessary, the effects of morphine may be reversed with the IV administration of 0.8 mg naloxone hydrochloride (naloxone is a competitive opiate antagonist). If the patient has fasted for less than 4 hours: a) Delay the study until the patient has fasted for at least 4 hours. If Patient has been NPO for more than 18 hours, the patient may need to be pre-treated with CCK to empty gallbladder prior to the exam. CCK may be administered over 30min using an infusion rate of 0.02 mcg/kg per hour of sincalide over 30minutes. Start exam routine exam 30min post completion of CCK.

2 Equipment & Energy Windows Gamma camera: Large field of view. Collimator: LEHR, VXGP Energy window: 20% window centered at 140 kev. Radiopharmaceutical, Dose & Technique of Administration Radiopharmaceutical: Tc-99m Choletec or Tc-99m Hepatolite Dose: 5-7 mci Tc-99m Choletec Technique of administration: Standard intravenous injection. Patient Position & Imaging Field Patient position: Supine with upper abdomen and entire liver in the field of view. Acquisition Protocol Standard Exam. Acquire dynamic LAO images at 128 x 128, 60 sec/frame for 60 frames. Obtain ANT, LAO and R LATERAL static images at 60 minutes if needed to establish validation of GB fill. Once the gallbladder is full, order the sincalide. At 60 minutes post injection, start the CCK infusion imaging with the camera head in the LAO position visualizing the gallbladder in center of field. CCK will be administered over 30min using an infusion rate of 0.02 mcg/kg per hour of sincalide over 30minutes. If CCK is unavailable, heavy whipping cream, half and half or Ensure plus may be used in its place. If using whipping cream, half and half or Ensure Plus, imaging will be acquired as follows: o Initial imaging for 1 minute/frame for 60 frames o Give patient whipping cream, half and half or Ensure plus o Scan an additional 60 minutes at 1 minute/frame NORMAL VALUE EF: >35 % If the gallbladder has not been visualized by 60 minutes. The Technologist will continue the exam for additional 60 minutes. At 120 minutes a five minute LAO projection of the Liver and Gallbladder bed is taken to evaluate for visualization of the Gallbladder. Have radiologist or attending physician approve recommend any further imaging required. Optional Maneuver: a. Morphine may be given to hasten visualization of the gallbladder if the cystic duct is not obstructed. Upon verification with the attending Radiologist, give 2mg Morphine Sulfate I.V., once only. Image immediately after, at 60sec/fr for 60min. Contraindications to the use of morphine include respiratory depression in non-ventilated patients (absolute), morphine allergy (absolute) and acute pancreatitis (relative). Have radiologist or attending physician approve the order for the morphine per HIDA protocol and administer per facility protocol. b. 1-3 mci of Choletec may be reinjected I.V. if no activity remains in the liver at the time Morphine is to be given. Verify with the radiologist if booster dose is needed. Hepatobiliary 2

3 Note: Outpatients are not given morphine. Data Processing Per processing protocol Optional Maneuvers Quantitative cholescintigraphy: May be used in the evaluation of sphincter of Oddi dysfunction or cystic duct dysfunction. Carbonated beverage can be administrated for duodenum and proximal small bowel clearance. Occasional isotope concentration at duodenum or proximal small bowel may lie across gallbladder activity. Drinking warm 7-UP/Sprite (4 to 8 oz.) will stimulate gas movement rapidly and disperse the concentrated activity. Anterior images with the patient standing: May be used to help differentiate the gallbladder and bile leaks from the duodenum. Duodeno-gastric reflux evaluation: The hepatobiliary study may be modified to quantitatively evaluate duodeno-gastric reflux. Other hepatobiliary parameters may be quantitated. Principle Radiation Emission Data - Tc-99m Physical half-life = 6.01 hours. Radiation Mean % per disintegration Mean energy (kev) Gamma Dosimetry - Tc-99m-Trimethylbromo-IDA Organ rads/6 mci mgy/222 MBq Large intestine Small intestine Gallbladder wall Ovaries Liver Bladder wall Whole body Testes Red marrow References 1. Weissmann HS, Badia J, Sugarman LA, et al: Spectrum of Tc-99m-IDA cholescintigraphic patterns in acute cholecystitis. Radiology 138: , Klingensmith WC: Scintigraphic diagnosis of acute cholecystitis. In Current Practice of Radiology, JH Thrall, ed, BC Decker, Philadelphia, Klingensmith WC, Johnson ML, Kuni CC, et al: Complementary role of Tc-99m-diethyl-IDA and ultrasound in large and small duct biliary obstruction. Radiology 138: , Rosenthall L, Fonseca C, Arzoumanian A, et al: Tc-99m-IDA hepatobiliary imaging following upper abdominal surgery. Radiology 130: , Bile leaks. In Atlas of Radionuclide Hepatobiliary Imaging, CC Kuni, WC Klingensmith, eds, GK Hall, Boston, 1983, pp Hepatobiliary 3

4 6. Howman-Giles R, Uren R, Bernard E, et al: Hepatobiliary scintigraphy in infancy. J Nucl Med 39: , Gerhold JP, Klingensmith WC, Kuni CC, et al: Diagnosis of biliary atresia with radionuclide hepatobiliary imaging. Radiology 146: , Shah AN, Dodson F, Fung J: Role of nuclear medicine in liver transplantation. Sem Nucl Med 25:36-48, Klingensmith WC, Spitzer VM, Fritzberg AR: The normal fasting and postprandial Tc-99m-diisopropyl-IDA hepatobiliary study. Radiology 141: , Larsen MJ, Klingensmith WC, Kuni CC: Radionuclide hepatobiliary imaging: Non-visualization of the gallbladder secondary to prolonged fasting. J Nucl Med 23: , Fink-Bennett D: Augmented cholescintigraphy: Its role in detecting acute and chronic disorders of the hepatobiliary tree. Sem Nucl Med 21: , Silberstein EB, Marcus CS: Uterine response to sincalide. J Nucl Med 35:26N, January, Ziessman HA, Fahey FH, Hixson DJ: Calculation of a gallbladder ejection fraction: Advantage of continuous sincalide infusion over the three-minute infusion method. J Nucl Med 33: , Krishnamurthy S, Krishnamurthy GT: Cholecystokinin and morphine pharmacological intervention during Tc-99m-HIDA cholescintigraphy: A rational approach. Sem Nucl Med 26:16-24, Klingensmith WC, Fritzberg AR, Spitzer VM, et al: Clinical evaluation of Tc-99m-trimethylbromo-IDA and Tc-99m-diisopropyl-IDA for hepatobiliary imaging. Radiology 146: , Chen CC, Holder LE, Maunoury C, et al: Morphine augmentation increases gallbladder visualization in patients pretreated with cholecystokinin. J Nucl Med 38: , Fig LM, Wahl RL, Stewart RE, et al: Morphine-augmented hepatobiliary scintigraphy in the severely ill: Caution is in order. Radiology 175: , Fink-Bennett D, Balon H, Robbins T, et al: Morphine-augmented cholescintigraphy: Its efficacy in detecting acute cholecystitis. J Nucl Med 32: , Kim CK, Tse KKM, Juweid M, et al: Cholescintigraphy in the diagnosis of acute cholecystitis: Morphine augmentation is superior to delayed imaging. J Nucl Med 34: , Krishnamurthy S, Eddy K, Schmidt V, et al: Comparison of three methods for calculating of gallbladder ejection fraction (GBEF). J Nucl Med 39:126P, Donald JJ, Fache JS, Buckley AR, et al: Gallbladder contractility: Variation in normal subjects. Am J Roentgenol 157: , Yap L, Wycherley AG, Morphett AD, et al: Acalculous biliary pain: Cholecystectomy alleviates symptoms in patients with abnormal cholescintigraphy. Gastroenterol 101: , Krishnamurthy S, Krishnamurthy GT: Gallbladder ejection fraction: A decade of progress and future promise. J Nucl Med 32: , Xynos E, Pechlivanides G, Zoras OJ, et al: Reproducibility of gallbladder emptying scintigraphic studies. J Nucl Med 35: , Madacsy L, Velosy B, Lonovics J, et al: Evaluation of results of the prostigmine-morphine test with quantitative hepatobiliary scintigraphy: A new method for the diagnosis of sphincter of Oddi dyskinesia. Eur J Nucl Med 22: , Sostre S, Kalloo AN, Spiegler EJ, et al: A noninvasive test of sphincter of Oddi dysfunction in post cholecystectomy patients: The scintigraphic score. J Nucl Med 33: , Patch GG, Morton KA, Arias JM, et al: Naloxone reverses pattern of obstruction of the distal common bile duct induced by analgesic narcotics in hepatobiliary imaging. J Nucl Med 32: , Ben-Haim S, Seabold JE, Kao SS, et al: Utility of Tc-99m mebrofenin scintigraphy in the assessment of infantile jaundice. Clin Nucl Med 20: , Majd M, Reba RC, Altman RP: Hepatobiliary scintigraphy with Tc-99m-PIPIDA in the evaluation of neonatal jaundice. Pediatrics 67: , Lette J, Morin M, Heyen F, et al: Standing views to differentiate gallbladder or bile leak from duodenal activity on cholescintigrams. Clin Nucl Med 15: , Borsato M, Bonavina L, Zanco P, et al: Proposal of a modified scintigraphic method to evaluate duodenogastroesophageal reflux. J Nucl Med 32: , Doo E, Krishnamurthy GT, Eklem MJ, et al: Quantification of hepatobiliary function as an integral part of imaging with technetium-99m-mebrofenin in health and disease. J Nucl Med 32:48-57, Tc-99m: In MIRD: Radionuclide Data and Decay Schemes, DA Weber, KF Eckerman, AT Dillman, JC Ryman, eds, Society of Nuclear Medicine, New York, 1989, pp Package insert for Choletec. Squibb Diagnostics, New Brunswick, New Jersey, Normal Findings Hepatobiliary 4

5 > Klingensmith WC: Hepatobiliary imaging: Normal appearance and normal variations. In Diagnostic Nuclear Medicine, A Gottschalk, PA Hoffer, HJ Berger, EJ Potchen, eds, Williams and Wilkins, Baltimore, > Klingensmith WC, Spitzer VM, Fritzberg AR: The normal fasting and postprandial Tc-99m-diisopropyl-IDA hepatobiliary study. Radiology 141: , > Kim CK, Palestro CJ, Solomon RW, et al: Delayed biliary-to-bowel transit in cholescintigraphy after cholecystokinin treatment. Radiology 176: , > Sarva RP, Schreiner DP, Van Thiel D, et al: Gallbladder function: Methods for measuring filling and emptying. J Nucl Med 26: , > Madacsy L, Toftdahl DB, Middelfart HV, et al: Comparison of the dynamics of bile emptying by quantitative hepatobiliary scintigraphy before and after cholecystectomy in patients with uncomplicated gallstone disease. Clin Nucl Med 24: , > Shish WJ, Magoun S, Wierzbinski B, et al: Morphine augmented cholescintigraphy enhances duodenogastric reflux. Eur J Nucl Med 21:567, Hepatobiliary 5