LEARN NUCLEAR MEDICINE
Gastrointestinal · Case 02
Read the history, inspect the study, then reveal the teaching.
IMAGE PLACEHOLDER · Diagnostic study
Original study · Companion image placeholders
Clinical history
A 1 month-old male presents with jaundice, acholic stool and hepatomegaly with dark urine. Total bilirubin 8mg/dl and direct bilirubin 5mg/dl with elevated GGT, ALP,AST and ALT. Ultrasound was equivocal for biliary atresia.
Read the images before opening the teaching panel below.
Biliary atresia
Imaging Findings
Homogenous distribution within the liver with no excretion into the gastrointestinal tract.
Differential Diagnosis
Neonatal hepatitis
Cholestasis
Essential Facts
Biliary Atrasia is extrahepatic and intrahepatic biliary duct obstruction secondary to inflammation and sclerosis.
Biliary excretion into the bowel excludes biliary atresia and confirms neonatal hepatitis.
Cholescintigraphy accuracy: sensitivity=100%; specificity = 75-80%
SPECT and SPECT/CT scans can improve specificity
Excretion into the bowel excludes biliary atresia.
False-positives occur in patients with severe parenchymal liver disease.
Scan Information
Preparation:
To increase test specificity: phenobarbital 5mg/kg per day for 5 days, this is done to activate liver excretion enzymes and increase bile flow
Dose: Tc-99m IDA is 200 micro Ci/kg
Normal Findings
Homogenous uptake within the liver
Clearance of cardiac blood pool
Clearance from the liver
Excretion into the bowel and gallbladder
Abnormal Findings
Delayed blood pool clearance
No biliary excretion or clearance
Persistent hepatic uptake
References
“Nuclear Medicine: The Requisites.” Nuclear Medicine: the Requisites, by Harvey A. Ziessman et al., Elsevier Saunders, 2014, pp. 147–148.
Zhou, Luyao, et al “Ultrasound for the Diagnosis of Biliary Atresia: A Meta-Analysis : American Journal of Roentgenology : Vol. 206, No. 5 (AJR).” American Journal of Roentgenology, 2016, www.ajronline.org/doi/10.2214/AJR.15.15336.
“Case 35.” Nuclear Medicine Case Review Series, by Harvey A. Ziessman, Elsevier, 2011, pp. 244.