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 Required: To evaluate the function of the gallbladder, gallbladder ejection fraction, bile leak, or post-surgical changes in biliary excretion. NPO 4 hours No morphine or opioids for at least 4hours before the study. Tc-Mebrofenin (Choletec), 6 mci, IV LFOV Camera with LEHR Collimators 1 ½ Hours for routine Biliary + GB EF CCK (0.02 ug/kg to a max of 2.5 ug) Morphine (if indicated) 1. Biliary with Ejection Fraction 2. Biliary without Ejection Fraction 3. Biliary with Morphine 4. Bile Leak Study 5. Biliary SOD 6. BILIARY S.O.D. WORKSHEET
1. Biliary with Ejection Fraction 1) Inject patient with 6 mci Tc-Mebrofenin. Leave IV in for use with CCK. 2) At 40 min post-injection, do 2 static images (RLAT and LAO 20-25 degrees) to determine if the gallbladder has filled. 3) If GB is not visualized, image every 10 min out to 60 min or until visualized. 4) When GB has filled, proceed to dynamic GB EF study (NOTE: gallstones do not contraindicate CCK) : a) Add CCK (0.02 ug/kg to a max of 2.5 ug) to a 250 ml bag of normal saline. b) Infuse IV at a rate which delivers the entire 250 ml in 30 min. c) Begin dynamic image acquisition at the same time as the infusion (30 frames at 60 sec each) 5) Determine the GB EF on Pegasys through Global Q -> General Nuc Med -> GALLBLADDER EJECTION FRACTION 6) Snapshot all results and send to PACS Processing Note: Please indicate on film if patient experienced symptoms or not, during or following the injection of CCK 2. Biliary without Ejection Fraction 1. Inject patient with ~ 6 mci Tc-Mebrofenin. 2. Immediately begin a dynamic acquisition for 60 minutes, 1 min/frame 3. When dynamic images finish, do a static image of the right lateral. 4. Frame compress images for display to 3 min/frame, and display 20 frames on a 24 format. If at the end of the dynamic images the Choletec has not progressed past the Sphincter of Oddi, give the patient a can of BOOST to drink. Have them sit for a while, and when there is camera time (30-60 min after BOOST), do a 3 min static image to see how far the Choletec has progressed. 3. Biliary with Morphine If gallbladder is not seen by 60 minutes, check with nuc med MD re: morphine intervention. NOTE: Pt must not drive an automobile for several hours after receiving morphine.
o If the pt must drive, morphine will not be used and delayed imaging will be done between 2 and 4 hours post-injection. You will need enough camera time to perform a CCK-EF if the gallbladder shows. o If the pt s schedule or the camera s schedule do not permit imaging in the 2 to 4 hour timeframe, reschedule the pt for a no-charge repeat when the pt can bring a driver. Administer 2 mg morphine sulfate, IV, slowly injected over 2 min. (Dr. Sam, 9-8-11) Acquire spot views every few minutes for another 30 minutes. Always check with nuc MD before terminating exam and releasing patient. 4. Bile Leak Study (no prep required) Inject 6 mci Choletec. Immediately begin a 45 min anterior dynamic acquisition, 1 min/frame. This dynamic acq must continue until tracer is seen in small bowel extend the dynamic if necessary. After dynamic images are complete, have patient lie on their right side for 5 minutes. Finish the exam by acquiring a 2 minute anterior static while the patient remains in this rightdecubitus position. (Dr. Sam, 12/09/2011) 5. Biliary SOD For the identification of Sphincter of Oddi Dysfunction in post-cholecystectomy patients who develop RUQ pain. Acquisition 1. Pre-treat patient with CCK (0.02 ug /kg). Infuse CCK in 3 min. 2. 15 minutes after completion of CCK infusion inject 6 mci Tc-Mebrofenin, and
immediately begin a dynamic acquisition. 3. Acquire data for 60 minutes at 1 min/frame. Processing 1. Extract the following frames to be displayed as static images: 3, 5, 10, 15, 30, 45, and 60. 2. Draw regions of interest over the liver and the common bile duct, to generate time activity curves over each area. Be sure to draw the CBD ROI over the lowest portion of the duct which is not superimposed by bowel activity. 3. From the liver curve determine the time of hepatic peak. 4. From the CBD curve determine the % CBD emptied. [(peak CBD-60 min CBD)/peak CBD] If the CBD is continuously rising, use the 30 minute count as the peak. Send all data to PACS and provide the reading radiologist with the attached score sheet. Scores of 0-4 are normal. Scores of 5-12 indicate Sphincter of Oddi dysfunction. (Scoring sheet on next page.)
6. BILIARY S.O.D. WORKSHEET Reference: Sostre S, Wagner H, et al.; A Noninvasive Test of Sphincter of Oddi Dysfunction in Postcholecystectomy Patients: The Scintigraphic Score; Journal of Nuclear Medicine, June 1992; p. 1216 PATIENT : DATE : Criteria Value Score Peak Time of Liver a. Less then 10 min 0 b. 10 or more min 1 Time of Biliary Visualization a. Less than 15 min 0 b. 15 or more min 1 Prominence of Biliary Tree a. Not prominent 0 b. Prominent major intrahepatic ducts 1 c. Prominent small intrahepatic ducts 2 Bowel Visualization a. Less than 15 min 0 b. 15-30 min 1 c. More than 30 min 2 CBD Emptying a. By more than 50% 0 b. Less than 50% 1 c. No change 2 d. Shows increasing activity 3 CBD-to-Liver Ratio a. CBD@60 < / = Liver@60 0 b. CBD@60 > LIVER@60, but Lower than LIVER@15 1 c. CBD@60 > LIVER@60 and = to LIVER@15 2 d. CBD@60 > both LIVER@60 and LIVER@15 3 TOTAL =======