Gastrointestinal · Case 01

Acute cholecystitis

Imaging Findings

Homogenous distribution in the liver with normal excretion into the bowel. Due to non-visualization of the gallbladder at 60 minutes, morphine was administered. 30 minutes of additional imaging failed to show visualization of the gallbladder.

Essential Facts

The lack of the visualization of the gallblader at 60 minutes is abnormal.  If the patient is acute ill the diagnosis is likely acute cholecystitis and if the patient is not acutely ill the diagnosis is likely chronic cholecystitis.  Typically if the gallbladder is not seen at 60 minutes delayed imaging up to 3 or 4 hours is performed or give morphine then obtain additional 30 minutes of images.
90% due to cystic duct obstruction by impacted calculus.
10% due to acalculus cholecystitis.
Administering IV cholecystokinin approximately 30 mins before the radiotracer may help to prevent false-positive findings.


False-positive causes:

prolonged fasting (> 24hrs)
recent feeding (< 4hrs)
hyperalimentation
concurrent severe illness
chronic cholecystitis
hepatic dysfunction

Scan Information

Hepatobiliary scintigraphy is often reserved for indeterminate findings in other imaging studies.
Accuracy: sensitivity=98%; specificity = 100%

HIDA-Cholecystitis
5-10 mCi IDA analog IV injection then dynamic image for  60 mins, if gallbladder does not fill you have two options:


Administer morphine, then obtain additional imaging at 30 minutes
delayed imaging at 4 hours
IDA not conjugated

References

Ziessman HA, Rehm PK. Nuclear Medicine. St. Louis, MO: Elsevier Mosby; 2011
Uliel L, Mellnick VM, Menias CO, Holz AL, Mcconathy J. Nuclear Medicine in the Acute Clinical Setting: Indications, Imaging Findings, and Potential Pitfalls. RadioGraphics. 2013;33(2):375-396. doi:10.1148/rg.332125098.