hepatobiliary scintigraphy - stanford...
TRANSCRIPT
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Hepatobiliary Scintigraphy
Erik Mittra, MD, PhD Stanford University
Division of Nuclear Medicine
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Outline n What are the studies? n For each study:
n Tracer(s) n Physiology n Protocol n Cases
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
What are the studies? n HIDA scan n Hemangioma scan n Liver-spleen scan
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
What are the studies? n HIDA scan
n Acute cholecystitis n Acute acalculous cholecysititis n Chronic cholecystitis n Biliary duct obstruction n Sphincter of Oddi dysfunction n Biliary atresia n Postoperative biliary tract (i.e., biliary leak) n Evaluation of liver lesions
n Hemangioma scan
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
HIDA Scan
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
HIDA scan n What is the isotope? n What is the energy of the isotope? n What is the half-life? n What is the tracer?
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
HIDA - Radioisotopes
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Hepatobiliary Physiology
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
HIDA - Protocols n Acute cholecystitis n Acute acalculous cholecysititis n Chronic cholecystitis n Biliary duct obstruction n Biliary atresia n Postoperative biliary tract (i.e., biliary leak) n Evaluation of liver lesions
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
HIDA – Key principles
n Should be NPO > 4 hrs but < 24 hrs n CCK causes gallbladder constriction n Morphine (and other narcotics) cause Sphincter of
Oddi constriction n Bilirubin should be < 27
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
HIDA – Normal times
n Blood pool clearance: 5-10 min n Gallbladder filling: 10-30 min (max 1 hr) n Common bile duct filling: 20 min n Common bile duct T1/2: 60 min n Transit to small bowel: 60 min n Transit to large bowel: 3 hrs
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Acute cholecystitis protocol
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Acute cholecystitis protocol Basic outline
CCK?
Administer Choletec
Morphine? Readminister Choletec?
Stop post Morphine
Stop if no Morphine
Hrs -0.5 0 1 2 3
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Acute acalculous cholecystitis protocol
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Acute acalculous cholecystitis protocol
Basic outline
CCK?
Administer Choletec
Morphine? Readminister Choletec?
Stop post Morphine
Stop if no Morphine
Hrs -0.5 0 1 2 3
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Acute acalculous cholecystitis protocol
CCK?
Administer Choletec
CCK? Tc-99m or In-111 WBC?
Administer tagged-WBCs
Re-image if Tc-99m WBC given
Hrs -0.5 0 1 2 3-4 6
Exclusion of false-negative outline
Re-image if In-111 WBC given
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Chronic cholecystitis protocol
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Chronic cholecystitis protocol Basic outline
Pre- treatment?
Administer Choletec
CCK? Morphine??? Readminister Choletec?
Stop post CCK or Morphine
Hrs -0.5 0 1 2
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Biliary obstruction protocol
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Biliary obstruction protocol Basic outline
Administer Choletec
Stop or continue dynamic imaging? CCK or alter pt. position?
Delayed static imaging
Delayed static imaging
Hrs -0.5 0 1 2 24
No CCK!
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Sphincter of Oddi dysfunction protocol
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Sphincter of Oddi dysfunction protocol
Basic outline
Administer Choletec
Stop dynamic imaging
Perform TAC analysis
Hrs -0.5 0 1 2
CCK
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Biliary atresia protocol
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Biliary atresia protocol Basic outline
Administer Choletec
Stop dynamic imaging Delayed static imaging
Hrs - 5 d 0 1 24
Phenobarbital 5mg/kg x 5 days
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Biliary leak protocol
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Biliary leak protocol Basic outline
Administer Choletec
Stop dynamic imaging Delayed static imaging
Hrs -0.5 0 1 2-24
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Evaluation of liver lesions
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Hemangioma scan n What is the isotope? n What is the energy of the isotope? n What is the half-life? n What is the tracer?
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Hemangioma scan – Key issues n No preparation n Sensitivity directly related to size n SPECT/CT?
n Size n Location
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Hemangioma scan protocol
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Hemangioma scan protocol Basic outline
Administer Tc99m-RBCs
Start flow study (1 s/f x 60 sec)
Delayed static planar image, followed by SPECT(CT)
Min 0 1 60-120
Static planar image
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Hemangioma scan protocol
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MIPS Stanford University Molecular Imaging Program at Stanford
School of Medicine Department of Radiology
Cases