HIDA Scans:

SWCSNM 2011
HIDA Scans:
Hepatobiliary Scintigraphy
Mike Middleton, MD, FACNM
Professor of Radiology
Division of Nuclear Radiology & Advanced
Molecular Imaging
Scott & White Clinic/TAMUHSC

OUTLINE
• Functional/Morphologic Hepatic Imaging
Dependent on the Radiopharmaceutical Utilized
(TABLE 1)
• Biliary Scans and agents
• Brief History
• Scheduling
• Physiology/Preparation
• Techniques
• Interpretation
• Interventions

NM Scheduling Program

NM Scheduling Program

Common Hepatic
Studies on a typical
day utilizing the Scott
& White NM
Scheduling Program

Hepatobiliary Scintigraphy

Scheduling a HIDA
scan with CCK

General
• Biliary iv agents are rapidly excreted by
hepatocytes and delivered to bile
unconjugated
• The liver, biliary system, bowel, and
sometimes portions of the stomach are
normally visualized

Objectives
• Detect cystic duct obstruction (ie. As in
acute cholecystitis)
• Detect CBD obstruction
• Detect biliary leaks
• Detect GB dysfunction
• Detect or assess post-op GI tract
complications
• Assess neonatal jaundice

Technique/Preparation
• Pharmaceuticals
• 5mCi Tc-99m Disofenin
• 5mCi Tc-99m Mebrofenin
• Patient Preparation
• Fasting >4hrs but 24hrs, administer CCK to contract GB
(0.02ug/kg Sincalide, slowly iv)

Technique
• LFOV Camera, ant views
• Dynamic 1 minute (summed 5 min images)
• Extra views may help distinguish GB from bowel
prn, ie LAO, Rt lat.
• (Note to Techs: if in doubt do a R lat for your doc
!!!!)
• Shielding with lead may be helpful if trying to
bring out a faintly visualized GB or gut
• Exam tailored to question being asked

Technique
• After imaging 1 hr, images checked
• Interventions made until examination
considered complete
• Sometimes delayed or ultra-delayed views
are required

Technique
• Interventions
• Water po to wash out duodenal activity to distinguish it
from GB
• MSO4 to increase sphincter of Oddi to accelerate GB
visualization (.02ug/kg slow iv)
• Milk, fatty snack, or CCK (sincalide) to increase
contraction of GB and increase bowel visualization
• Peds: Repeat c/ Phenobarbitol to induce liver enzyme
activity for several days in a neonate if nonvisualization
of Bowel by 24 hrs

SAMPLE FLOW
SCHEME:
HIDA Scans

• A normal scan
Interpretation
• GB and bowell seen within 1 hr
• Normal response to sincalide with a GBEF >
35%

Interpretation
• Nonvisualization of GB at 4hrs
• Activity normally enters the GB passively from
the ductal system. In acute cholecystitis, there
is usually cystic duct obstruction preventing
bile from entering the GB (90-95% of pts)
• DDX: acute cholecystitis, s/p cholecystectomy,
prolonged fast or recent fatty meal, chronic
chlocecystitis (rare)

First Hour

4
hours

Interpretation
• “Rim” or “Stripe” Sign
• Nonvisualization of the GB with increased
activity at the liver margin near the GB fossa
• Seen in pts with sever acute cholecystittus and
has a 20-40% incidence of grangrenous
cholecystitus

Interpretation
• Delayed visualization of the GB
• After 1 hr by “convention”, sometimes
considered if >30 minutes after bowel has been
confirmed, (even if within the 1 hr)
• Most commonly seen with chronic cholecystitis

Interpretation
• Delayed visualization of Gut with GB
visualization
• “NON specific”
• DDX: chronic cholecystitis, post-opiate
administration, partial CBD obstruction, other
inflammatory bowel processes (including
pancreatitis, etc)

Interpretation
• Leak
• Most often seen post-op (ie lap
cholecystectomy) or penetrating trauma
• Usually seen as intense activity nor conforming
to normal anatomical structures…..multiple
views help (ie right pericolic gutter activity)

Interpretation
• Hepatic uptake only (nonvisualization of
the ducts, GB, and gut)
• Acute CBD obstruction vs cholestatic
hepatitis….however the clinical presentations
of these generally differ
• Hepatic uptake may be a clue to interpretation,
being more diminished in hepatitis.
• NOTE: In complete CBD obstruction – it is
rare to see GB activity because of backpressure
in the biliary system

Interpretation
• Bowel distortions
• Pacreatitis or masses may compress the
duodenum and cause non-vis. of the 3 rd portion
• Prior bowel surgery
• Cut-off CBD sign
• Stone impacted in the CBD?

Interpretation
• Stomach visualized – enterogastric reflux
but sometimes normal?

Interpretation
• Parenchymal defects
• Any lesion which displaces hepatocytes may
cause a liver defect on early images (ie mets,
abscess, cyst, tumor)
• Hepatomas and adenomas occasionally show
delayed uptake of HIDA compared with
surrounding liver

Interpretation
• SPECIAL PROCEDURES
• GB Ejection Fraction (GBEF) Commonly Performed (
more common now than emergent HIDA scans)
• When chronic acalculous cholecystitis or a biliary dyskinetic
syndrome is suspected for chronic RUQ pain (not really an
indication for an emergency study)
• GBEF of >35% considered normal at 20 minutes post
CCK (sincalide) administration
•

Pediatric Applications of HIDA
Scans

Pediatrics
• In the neonatal setting, the HIDA scan be helpful
in distinguishing Neonatal Hepatitis from Biliary
Atresia
• Imaging should be performed up to 4 and 24 hours
if needed
• Visualization of bowel excludes biliary atresia
• Suggest -Repeat with Phenobarbitol if no bowel
• Visualization of bowel by 4-24 hrs more typical of
neonatal hepatitis

Pediatrics
BILIARY ATRESIA: NO bowel by 24 hours

CASE STUDY
What’s the diagnosis?

The End
Thank You For Your Attention