GASTROINTESTINAL IMAGING Sodee

GASTROINTESTINALGASTROINTESTINALIMAGINGIMAGING

Sodee & Early: Chapter 20Aunt Minnie

Principles & Practice: Chapter 13

Liver-Spleen Imaging, PlanarLiver-Spleen Imaging, Planar

Indications – Functional Liver DiseaseIndications – Functional Liver DiseaseHepatomegaly, Splenomegaly, Accessory Hepatomegaly, Splenomegaly, Accessory

Spleen, Situs Inversus, Tumors and Spleen, Situs Inversus, Tumors and Metastasis, Jaundice, Cirrhosis, Hepatitis, Metastasis, Jaundice, Cirrhosis, Hepatitis, Abscess, Trauma, Blood Disorders, InfectionsAbscess, Trauma, Blood Disorders, Infections

Contraindications – NoneContraindications – None

Patient PreparationPatient PreparationRecent Contrast Studies May Affect ImagesRecent Contrast Studies May Affect Images

Liver-Spleen Planar Cont’dLiver-Spleen Planar Cont’d

Imaging ProceduresImaging Procedures5-10 mCi (Christian), 2-6 mCi (Early), 2-7 mCi 5-10 mCi (Christian), 2-6 mCi (Early), 2-7 mCi

(Shackett) Tc99m-Sulfur Colloid(Shackett) Tc99m-Sulfur Colloid

Patient is SupinePatient is Supine

Flow: 60 secondsFlow: 60 seconds

Statics: Anterior, Anterior with Marker, RAO, Statics: Anterior, Anterior with Marker, RAO, RLAT, RPO, Posterior, LLAT, LPO and LAORLAT, RPO, Posterior, LLAT, LPO and LAO


Data TreatmentData TreatmentProcess and Label all ViewsProcess and Label all Views

May Draw ROIs on Liver, Spleen and VertebraeMay Draw ROIs on Liver, Spleen and VertebraeCompareCompare

Spleen to LiverSpleen to Liver

Vertebrae to LiverVertebrae to Liver

Vertebrae to SpleenVertebrae to Spleen

Note: Vertebrae ROI Taken From Center Just Below Organs


ResultsResultsNormalNormal

Liver and Spleen Equal Heterogeneous DistributionLiver and Spleen Equal Heterogeneous Distribution

Uptake: Liver 85%, Spleen 10%, Bone Marrow 5%Uptake: Liver 85%, Spleen 10%, Bone Marrow 5%

AbnormalAbnormalNon-Symmetrical, Hot and Cold Spots, Size and Non-Symmetrical, Hot and Cold Spots, Size and

ShapeShape


33 year old woman was found to have an epigastric mass on routine physical exam six months after the birth of her first child. The woman denied any symptoms.

Mildly increased colloid uptake is seen in a large lesion involving the left lobe of the liver. This corresponds to a well circumscribed 7 cm mass at this location on the CT.

Liver-Spleen Imaging, SPECTLiver-Spleen Imaging, SPECT

Continues After Planar ImagingContinues After Planar Imaging

Imaging ProceduresImaging ProceduresRequires 8-12 mCi Tc99m-Sulfur ColloidRequires 8-12 mCi Tc99m-Sulfur Colloid

Either Contoured or Non-CircularEither Contoured or Non-Circular

Process Images In Accordance With Process Images In Accordance With ProtocolsProtocols

Liver-Spleen SPECT Cont’dLiver-Spleen SPECT Cont’d


Liver and Spleen Equal Heterogeneous DistributionLiver and Spleen Equal Heterogeneous Distribution

AbnormalAbnormalNon-Symmetrical, Hot and Cold Spots, Size and Non-Symmetrical, Hot and Cold Spots, Size and

ShapeShape

HemangiomaHemangioma

Common Benign Tumor of LiverCommon Benign Tumor of LiverCT or Ultrasound Usually LocateCT or Ultrasound Usually Locate

Radionuclide Technique 100% Accurate in DiagnosisRadionuclide Technique 100% Accurate in Diagnosis

IndicatorsIndicatorsDetection and Localization of Hepatic Hemangiomas, Detection and Localization of Hepatic Hemangiomas,

Vascularized Tumors, Cysts, Lesions and Areas Vascularized Tumors, Cysts, Lesions and Areas Marked for BiopsyMarked for Biopsy

ContraindicationsContraindicationsPatients Undergoing Contrast StudiesPatients Undergoing Contrast Studies

Patients Receiving Blood ProductsPatients Receiving Blood Products

Hemangioma ContinuedHemangioma Continued

Patient PreparationPatient PreparationNothing SpecialNothing Special

Imaging ProceduresImaging Procedures20-30 mCi Tc99m-Tagged RBCs20-30 mCi Tc99m-Tagged RBCs

In-Vitro, In-Vivo or Modified In-VivoIn-Vitro, In-Vivo or Modified In-Vivo

Flow: 1 to 2 minutesFlow: 1 to 2 minutesStatics: Anterior, Anterior with Marker, RAO, Statics: Anterior, Anterior with Marker, RAO,

Right Lateral, Posterior (Others Possibly)Right Lateral, Posterior (Others Possibly)SPECT: Image at 1 to 2 hours After InjectionSPECT: Image at 1 to 2 hours After Injection

Note: If Hemangioma is Posterior, Use Posterior Images for Flow



Heart, Great Vessels and Spleen ProminentHeart, Great Vessels and Spleen Prominent

Heterogeneous Uptake in Liver on Flow, Statics and Heterogeneous Uptake in Liver on Flow, Statics and SPECTSPECT

AbnormalAbnormalPhotopenic on Flow, Focal Areas of Uptake on Photopenic on Flow, Focal Areas of Uptake on

Statics and SPECTStatics and SPECT

(Note: Hepatomas will appear Photopenic on Statics (Note: Hepatomas will appear Photopenic on Statics and SPECT)and SPECT)


66-year old man with elevated liver function tests and right upper quadrant pain who had a sonogram on 3-17-95 at an outside hospital. The sonogram showed a hyperechoic lesion in the posterior segment of the hepatic lobe, measuring approximately 3 cm. The current examination was performed to confirm that this lesion represents a benign cavernous hemangioma.

HepatobiliaryHepatobiliary

IndicationsIndicationsAcute or Chronic CholecystitisAcute or Chronic Cholecystitis

Cholestasis (Lack of Bile Flow)Cholestasis (Lack of Bile Flow)

Differentiate Acute Hepatitis vs. Acute Biliary Differentiate Acute Hepatitis vs. Acute Biliary ObstructionObstruction

Choledochal Cysts (Common Bile Duct)Choledochal Cysts (Common Bile Duct)

Biliary AtresiaBiliary Atresia

ContraindicationsContraindicationsPatient Has Eaten Within 4 HoursPatient Has Eaten Within 4 Hours

No Morphine Sulfate if Patient is AllergicNo Morphine Sulfate if Patient is Allergic

Note: A Severely Jaundiced Patient May Delay Filling Gallbladder

Hepatobiliary ContinuedHepatobiliary ContinuedPatient PreparationPatient Preparation

NPO 2 Hrs (Early), 2-14 Hrs (Shackett), Usually 4-6 HrsNPO 2 Hrs (Early), 2-14 Hrs (Shackett), Usually 4-6 HrsIf Patient NPO 24 Hrs or Longer, May Pre-treat With If Patient NPO 24 Hrs or Longer, May Pre-treat With

SincalideSincalide

Imaging ProceduresImaging Procedures5-10 mCi Tc99m-IDA, Disofenin or Mebrofenin 5-10 mCi Tc99m-IDA, Disofenin or Mebrofenin

(Choletec)(Choletec)Patient is Supine Patient is Supine (Liver in LUQ of P-Scope)(Liver in LUQ of P-Scope)Anterior Statics or Dynamic for at Least 30 minutesAnterior Statics or Dynamic for at Least 30 minutes

Visualize Gallbladder and Bowel: RAO and RT LateralVisualize Gallbladder and Bowel: RAO and RT Lateral

If Not Visualized by 45 minutesIf Not Visualized by 45 minutesPatient Can Lay on Right Side or Walk AroundPatient Can Lay on Right Side or Walk Around

Can Use Pharmacological Agent (morphine, CCK)Can Use Pharmacological Agent (morphine, CCK)Small Bowel Must Be Visualized for CCKSmall Bowel Must Be Visualized for CCK

Delays Taken From 2 to 6 HoursDelays Taken From 2 to 6 Hours

Hepatobiliary ContinuedHepatobiliary Continued


Visualization of Liver QuicklyVisualization of Liver Quickly

Visualization of Hepatic, Common Bile Duct and Visualization of Hepatic, Common Bile Duct and Gallbladder From 5 minutes to 1 HourGallbladder From 5 minutes to 1 Hour

Small Bowel Visualized and Moving 10-60 minutesSmall Bowel Visualized and Moving 10-60 minutes

AbnormalAbnormalGallbladder Not Visualized by 60 minutesGallbladder Not Visualized by 60 minutes

Small Bowel Not Visualized With Gallbladder Small Bowel Not Visualized With Gallbladder Showing by 60 minutesShowing by 60 minutes


Sincalide (0.02 ug/kg) was administered intravenously 30 minutes prior to radiopharmaceutical injection to promote initial emptying of the gallbladder. Static images obtained over the first hour post injection demonstrated good hepatic uptake with prompt excretion into the common bile duct and small bowel. There was no visualization of the gallbladder at 1 hour.


Subsequently, 3 mg of morphine i.v. was administered. Additional imaging for 30 minutes again demonstrated nonvisualization of the gallbladder. These findings are most consistent with acute cholecystitis.

Gallbladder Ejection FractionGallbladder Ejection Fraction

Continuation of Hepatobiliary ImagingContinuation of Hepatobiliary Imaging

Imaging ProceduresImaging Procedures.02 mcg/kg of Sincalide (Synthetic CCK) IV.02 mcg/kg of Sincalide (Synthetic CCK) IV

Fatty MealFatty Meal

Patient is Supine, Camera is AnteriorPatient is Supine, Camera is Anterior

Dynamic or Static Images for 30 minutesDynamic or Static Images for 30 minutes

GB Ejection Fraction Cont’dGB Ejection Fraction Cont’d

The patient is a 41-year-old woman with a history of right upper quadrant pain and a gallbladder polyp. Extraction of HIDA from the blood is good. The gallbladder fills after the initial CCK injection.


The gallbladder ejection fraction is calculated to be 70%.

The mean gallbladder ejection fraction reported in the referenced material is a mean at 45 minutes of 77.2% +/- 4.9%.


Data TreatmentData TreatmentDraw ROIs Around GB Pre and Post-CCK with Draw ROIs Around GB Pre and Post-CCK with

BackgroundBackground


Around 35% (>50% for Men, >20% for Women)Around 35% (>50% for Men, >20% for Women)

AbnormalAbnormalLess than Normal EFLess than Normal EF

%GBEF = Pre-CCK cts – Lowest Post-CCK cts x 100

Pre-CCK cts


Example (page 238, Math Review)Example (page 238, Math Review)Net Counts Pre-CCK = 63,800Net Counts Pre-CCK = 63,800

Net Counts Post-CCK = 37,200Net Counts Post-CCK = 37,200

63,800 counts – 37,200 counts x 100

63,800 counts

GBEF = 42%


Calculate the GBEFCalculate the GBEF

Net Maximum Counts = 235,000Net Maximum Counts = 235,000

Net Minimum Counts = 174,000Net Minimum Counts = 174,000


Calculate the GBEFCalculate the GBEF

Net Maximum Counts = 235,000Net Maximum Counts = 235,000

Net Minimum Counts = 174,000Net Minimum Counts = 174,000

GBEF = 26 %GBEF = 26 %

Gastrointestinal BleedingGastrointestinal Bleeding

Two Major TechniquesTwo Major TechniquesTc99m Sulfur ColloidTc99m Sulfur ColloidTc99m Labeled Red Blood CellsTc99m Labeled Red Blood Cells

IndicationsIndicationsDetection and Localization of Bleeding SitesDetection and Localization of Bleeding Sites

Must be Actively Bleeding to ImageMust be Actively Bleeding to ImageCaused by Aspirin, Ulcers, Perforation, Cancer, DiverticulaCaused by Aspirin, Ulcers, Perforation, Cancer, Diverticula

ContraindicationsContraindicationsPatients Undergoing Contrast StudiesPatients Undergoing Contrast Studies


GI Bleed – Tc99m Sulfur ColloidGI Bleed – Tc99m Sulfur Colloid

Imaging ProceduresImaging Procedures7-10 mCi (Christian), 10-15 mCi (Early), 10-20 mCi 7-10 mCi (Christian), 10-15 mCi (Early), 10-20 mCi

(Shackett) Tc99m-Sulfur Colloid(Shackett) Tc99m-Sulfur ColloidPositioning Very Important, Clears QuicklyPositioning Very Important, Clears Quickly

Supine, Anterior View of Lower AbdomenSupine, Anterior View of Lower Abdomen

Flow: 2 to 3 minutesFlow: 2 to 3 minutes

Dynamic: Up to 30 minutesDynamic: Up to 30 minutes

Statics: Oblique, Lateral and Posterior Images May Help Statics: Oblique, Lateral and Posterior Images May Help Define Location of BleedDefine Location of Bleed

Bleeding Best Demonstrated in First 12-15 minutesBleeding Best Demonstrated in First 12-15 minutes

GI Bleed – Tc99m Tagged RBCsGI Bleed – Tc99m Tagged RBCs

Imaging ProceduresImaging Procedures10-20 mCi Tc99m Tagged RBCs10-20 mCi Tc99m Tagged RBCs

In-Vitro, In-Vivo, Modified In-VivoIn-Vitro, In-Vivo, Modified In-Vivo

Supine, Anterior View of Lower AbdomenSupine, Anterior View of Lower AbdomenFlow: 2 to 3 minutesFlow: 2 to 3 minutesDynamic: Up to 30 minutesDynamic: Up to 30 minutesStatics: Oblique, Lateral and Posterior Images May Help Statics: Oblique, Lateral and Posterior Images May Help

Define Location of BleedDefine Location of BleedDelayed Images PossibleDelayed Images Possible

2, 4 and 6 hour Delays2, 4 and 6 hour DelaysEspecially for Patients with MelenaEspecially for Patients with Melena

Gastrointestinal Bleeding Cont’dGastrointestinal Bleeding Cont’d


Tc99m-Sulfur ColloidTc99m-Sulfur ColloidLiver, Spleen and Bone Marrow Well VisualizedLiver, Spleen and Bone Marrow Well VisualizedNo Areas of Focal Uptake in Abdominal AreaNo Areas of Focal Uptake in Abdominal Area

Tc99m-Tagged RBCsTc99m-Tagged RBCsHeart and Great Vessels ProminentHeart and Great Vessels ProminentNo Areas of Focal Uptake in Abdominal AreaNo Areas of Focal Uptake in Abdominal Area

AbnormalAbnormalFocal Areas of Uptake in Any of the ImagesFocal Areas of Uptake in Any of the ImagesTagged RBCs Show Colonic Bleeding WellTagged RBCs Show Colonic Bleeding Well


Part way through the examination, a bleeding focus is seen in the mid upper abdomen. Based on these images, this was felt to represent a proximal small bowel source, as the activity appears more diffuse than would be expected for a transverse colon source.

History of blood per rectum. Multiple negative GI bleeding studies in the past.


53 year old with dizziness and maroon stools, who presents with hematocrit of 15 requiring transfusion. NG tube aspirate is reportedly negative.

Meckel’s DiverticulumMeckel’s Diverticulum

Usually Performed to Find the Cause of Usually Performed to Find the Cause of GI Bleeding in ChildrenGI Bleeding in Children

IndicationsIndicationsAbdominal Pain (esp. Children), Positive Stool Abdominal Pain (esp. Children), Positive Stool

Guaiac Test, GI Bleed, Diverticulitis, Guaiac Test, GI Bleed, Diverticulitis, Obstruction, Intussusception, VolvulusObstruction, Intussusception, Volvulus

ContraindicationsContraindicationsBarium Contrast StudiesBarium Contrast Studies

Meckel’s Diverticulum Cont’dMeckel’s Diverticulum Cont’d

Patient PreparationPatient PreparationNPO 4-12 Hours, Infants Miss One FeedingNPO 4-12 Hours, Infants Miss One FeedingDiscontinue Thyroid Blocking Agents (KCODiscontinue Thyroid Blocking Agents (KCO44))Patient to Void BladderPatient to Void BladderNo Radiographic Barium Studies Within 48 HrsNo Radiographic Barium Studies Within 48 Hrs

Imaging ProceduresImaging Procedures15-20 mCi TcO15-20 mCi TcO44

- - (200 uCi/kg in Pediatric Patients)(200 uCi/kg in Pediatric Patients)Patient is SupinePatient is SupineFlow: 60 secondsFlow: 60 secondsDynamic: 15 – 30 minutesDynamic: 15 – 30 minutesStatics: Posterior, Laterals, Obliques if Area VisualizedStatics: Posterior, Laterals, Obliques if Area Visualized



Uptake in Stomach, Renal Activity – 10-20 minutesUptake in Stomach, Renal Activity – 10-20 minutesBladder Uptake Increases with TimeBladder Uptake Increases with TimeAbnormalAbnormalFocal Increased Activity – Usually RLQFocal Increased Activity – Usually RLQ

Near Ileocecal ValveNear Ileocecal ValveAppears Before 60 minutesAppears Before 60 minutes

Appears at Same Time as Stomach ActivityAppears at Same Time as Stomach ActivityCompare Intensity with StomachCompare Intensity with StomachDoes Not DiminishDoes Not Diminish


The patient is a 2 1/2 year old boy with several months of nausea/vomiting and melana. A previous upper GI series demonstrated esophogeal reflux, but was otherwise normal.

A discrete focus of increased uptake is seen in the right lower quadrant, with approximately the same intensity as the stomach. On dynamic images (not shown here) this focus accumulated the tracer at the same rate as did the gastric mucosa.


2 1/2 year old male with a one day history of bloody stools. An air contrast enema was performed immediately prior to this scintogram that demonstrated no evidence of intussusception.

Meckel’s Diverticulum Cont’dMeckel’s Diverticulum Cont’dThis patient is an 18 month old female who presented to an outside hospital witha history of a large maroon bowel movement. She was noted to have a hemoglobin of 4.0.

Sequential abdominal images demonstrate an abnormal focus of increased activity in the right upper quadrant. This activity does not move and is not related to the collecting system of the kidney.

Salivary (Parotid)Salivary (Parotid)

Nuclear SialographyNuclear SialographySize, Location, FunctionSize, Location, Function

Some IndicatorsSome IndicatorsWarthin’s TumorWarthin’s Tumor

XerostomiaXerostomiaSjorgren’s SyndromeSjorgren’s Syndrome

Following Radiation to Head and NeckFollowing Radiation to Head and Neck

Palpable MassPalpable Mass

Salivary (Parotid) Cont’dSalivary (Parotid) Cont’d

Patient PreparationPatient PreparationNo Special Preparation RequiredNo Special Preparation Required

Imaging ProcedureImaging Procedure8-12 mCi TcO8-12 mCi TcO44

- - (Christian 1-5 mCi) IV(Christian 1-5 mCi) IV

Flow: 1 minuteFlow: 1 minute

Dynamic: 30 to 60 minutesDynamic: 30 to 60 minutes

Statics: Anterior, Anterior Marker, LateralsStatics: Anterior, Anterior Marker, LateralsHead Tilted Back, Chin on DetectorHead Tilted Back, Chin on Detector

Stimulation: Lemon Juice or GumStimulation: Lemon Juice or GumRepeat StaticsRepeat Statics

Salivary (Parotid) Cont’dSalivary (Parotid) Cont’d


Symmetrical UptakeSymmetrical Uptake

Uptake in Thyroid, Sublingual glands, Nasal CavityUptake in Thyroid, Sublingual glands, Nasal Cavity

Reduced Uptake after StimulationReduced Uptake after Stimulation

AbnormalAbnormalWarthin’s Tumor – Increased Uptake, RetainedWarthin’s Tumor – Increased Uptake, Retained

Sjorgren’s Syndrome – Decreased, Patchy UptakeSjorgren’s Syndrome – Decreased, Patchy Uptake

No Reduction after StimulationNo Reduction after StimulationBlockage, Stenosis, SialolithiasisBlockage, Stenosis, Sialolithiasis

Abscesses and Cysts - PhotopenicAbscesses and Cysts - Photopenic

Esophageal Motility/TransitEsophageal Motility/Transit

For Detection of Motor AbnormalitiesFor Detection of Motor AbnormalitiesBarium used for ObstructionsBarium used for Obstructions

IndicationsIndicationsDysphagiaDysphagia

Strictures, Obstruction, Retention, Hiatal HerniaStrictures, Obstruction, Retention, Hiatal Hernia

Achalasia – Delay in PeristalsisAchalasia – Delay in Peristalsis

Scleroderma – Thickened/Hardened EpitheliumScleroderma – Thickened/Hardened Epithelium

Esophageal Motility/Transit Cont’dEsophageal Motility/Transit Cont’d

Patient PreparationPatient PreparationNPO 2 Hrs (Christian), 8 Hrs (Shackett), past Midnight NPO 2 Hrs (Christian), 8 Hrs (Shackett), past Midnight

(Early)(Early)

Imaging ProceduresImaging Procedures150 – 300 uCi Tc99m Sulfur Colloid in Water150 – 300 uCi Tc99m Sulfur Colloid in WaterPatient Supine – Entire Esophagus in ViewPatient Supine – Entire Esophagus in ViewFlow: 1 minuteFlow: 1 minuteDynamic: Next 9 minutesDynamic: Next 9 minutesBolus Swallow (Have Patient Practice)Bolus Swallow (Have Patient Practice)

Requires 15 ml to Cause PeristalsisRequires 15 ml to Cause PeristalsisDry Swallow Every 15 SecondsDry Swallow Every 15 Seconds


Data TreatmentData TreatmentROIs Around Bolus DoseROIs Around Bolus Dose

ROI Around Entire EsophagusROI Around Entire EsophagusCan Differentiate Between Upper, Middle, LowerCan Differentiate Between Upper, Middle, Lower

Calculate % Esophageal ActivityCalculate % Esophageal Activity

% = A – B x 100

A

A – Total Activity of Bolus

B – Activity of Bolus During Any One Image



Activity Passes Within 5 to 10 Seconds of 1Activity Passes Within 5 to 10 Seconds of 1stst SwallowSwallow

Smooth Progression of ActivitySmooth Progression of Activity

AbnormalAbnormalScleroderma – Most of Bolus Enters StomachScleroderma – Most of Bolus Enters Stomach

Achalasis – Marked DelayAchalasis – Marked Delay

Diffuse Spasm – First ½ Reduced Transit Rate, Diffuse Spasm – First ½ Reduced Transit Rate, Second ½ Normal RateSecond ½ Normal Rate

Gastroesophageal RefluxGastroesophageal Reflux

GERD ImagingGERD ImagingDetection and QuantitationDetection and QuantitationEvaluate Diaphragmatic HerniaEvaluate Diaphragmatic HerniaChildren with Asthma, Chronic Lung Disease or Children with Asthma, Chronic Lung Disease or

Aspiration PneumoniaAspiration Pneumonia

IndicatorsIndicatorsHeartburnHeartburnRegurgitationRegurgitationChest PainChest Pain

Gastroesophageal Reflux Cont’dGastroesophageal Reflux Cont’d

Patient PreparationPatient PreparationNPO 4 Hrs (Shackett), 8 Hrs (Christian), Past Midnight NPO 4 Hrs (Shackett), 8 Hrs (Christian), Past Midnight

(Early)(Early)

Imaging ProceduresImaging Procedures300 uCi Tc99m Sulfur Colloid in Orange Juice300 uCi Tc99m Sulfur Colloid in Orange Juice

150 ml of OJ and 150 ml of 0.1 N HCL150 ml of OJ and 150 ml of 0.1 N HCL

Supine (Christian and Shackett), Upright and then Supine (Christian and Shackett), Upright and then Supine (Early)Supine (Early)

30 Second Image – Baseline30 Second Image – Baseline30 Second Images with Abdominal Binder30 Second Images with Abdominal Binder

Increase 20 mm/Hg Each Successive Image Until 100 mm/HgIncrease 20 mm/Hg Each Successive Image Until 100 mm/Hg


Data TreatmentData TreatmentDraw ROIs Around Lower Esophagus, Stomach Draw ROIs Around Lower Esophagus, Stomach

and Lower Left Lung (Background)and Lower Left Lung (Background)

Calculate % Gastroesophagealreflux at Each Calculate % Gastroesophagealreflux at Each PressurePressure

% = A – B x 100

C

A – Esophageal Counts Minus Prebinder Esophageal Counts

B – Background Counts From Lung ROI

C – Gastric Counts From Prebinder Gastric ROI(Decay Correct for Each Image)



All or Most of Activity Remains in StomachAll or Most of Activity Remains in Stomach

Less than 4 % RefluxLess than 4 % Reflux

AbnormalAbnormalMore than 4 % RefluxMore than 4 % Reflux

Evidence of Reflux on ImagesEvidence of Reflux on ImagesPatients with Esophageal Motor Disorders or Hiatal Hernia Patients with Esophageal Motor Disorders or Hiatal Hernia

May Require a Nasogastric TubeMay Require a Nasogastric Tube

Gastric Emptying (Liquid/Solid)Gastric Emptying (Liquid/Solid)

Used to Quantify Gastric EmptyingUsed to Quantify Gastric EmptyingIndicationsIndications

Delayed Gastric EmptyingDelayed Gastric EmptyingMechanical or Anatomical ObstructionMechanical or Anatomical ObstructionGastroparesis (Diabetic and Idiopathic)Gastroparesis (Diabetic and Idiopathic)Nausea, Vomiting and Early SatietyNausea, Vomiting and Early SatietyWeight LossWeight Loss

ContraindicationsContraindicationsAllergy to Foods Used in Solid EmptyingAllergy to Foods Used in Solid Emptying

Gastric Emptying ContinuedGastric Emptying Continued

Patient PreparationPatient PreparationNPO 4-12 Hrs (Shackett), 8 Hrs (Christian), Past NPO 4-12 Hrs (Shackett), 8 Hrs (Christian), Past

Midnight (Early)Midnight (Early)Discontinue Sedatives 12 Hrs (Shackett)Discontinue Sedatives 12 Hrs (Shackett)

Imaging ProceduresImaging ProceduresBaseline Liquid Study Can Be Done FirstBaseline Liquid Study Can Be Done First

500 uCi Tc99m-DTPA in 120 ml Water or Orange Juice500 uCi Tc99m-DTPA in 120 ml Water or Orange Juice

200 – 500 uCi Tc99m Sulfur Colloid in a Standardized 200 – 500 uCi Tc99m Sulfur Colloid in a Standardized Meal (Begin Imaging Immediately After Meal)Meal (Begin Imaging Immediately After Meal)

Patient Supine, Standing or SittingPatient Supine, Standing or SittingAnterior, LAO and or PosteriorAnterior, LAO and or Posterior

Static or Dynamic Images for 90 minutes to 2 HoursStatic or Dynamic Images for 90 minutes to 2 Hours


Data TreatmentData TreatmentDraw ROIs Around StomachDraw ROIs Around Stomach

Performed on Each ImagePerformed on Each ImageDivide Gastric Counts by Decay FactorDivide Gastric Counts by Decay FactorPlot Time/Activity CurvePlot Time/Activity CurveObtain t½ Emptying From CurveObtain t½ Emptying From Curve


Solid – 50% Emptying with a Mean of 90 MinutesSolid – 50% Emptying with a Mean of 90 MinutesLiquid – 80% in About an HourLiquid – 80% in About an Hour

AbnormalAbnormalLittle or No MovementLittle or No MovementRapid Emptying – “Dumping Syndrome”Rapid Emptying – “Dumping Syndrome”


Gastric Emptying MathematicsGastric Emptying MathematicsFound on Page 243, Mathematics ReviewFound on Page 243, Mathematics Review

Geometric Mean (GM) = Geometric Mean (GM) = √Anterior ROI Counts x Posterior ROI √Anterior ROI Counts x Posterior ROI CountsCounts

% Remaining at time T = % Remaining at time T = GM @ time T GM @ time T x 100 x 100

GM @ time 0 x DF @ time TGM @ time 0 x DF @ time T

% Emptying at time T = % Emptying at time T = GM @ time 0 – GM @ time TGM @ time 0 – GM @ time T x 100 x 100

GM @ time 0GM @ time 0

Note: Recommend Using Processing Software

LeVeen Shunt PatencyLeVeen Shunt Patency

LeVeen ShuntLeVeen ShuntUsed to Relieve Excess Ascites in Peritoneal Used to Relieve Excess Ascites in Peritoneal

CavityCavity

IndicationsIndicationsIncreasing AscitesIncreasing Ascites


LeVeen Shunt Patency Cont’dLeVeen Shunt Patency Cont’d

Imaging ProceduresImaging Procedures1.5-5 mCi Tc99m-MAA (Preferred)1.5-5 mCi Tc99m-MAA (Preferred)3 mCi Tc99m-Sulfur Colloid3 mCi Tc99m-Sulfur ColloidPatient is Supine Patient is Supine Intraperitoneal Injection by PhysicianIntraperitoneal Injection by Physician

Abdominal Palpation or Roll Patient (LeVeen)Abdominal Palpation or Roll Patient (LeVeen)Patient Pumps System Vigorously (Denver Shunt)Patient Pumps System Vigorously (Denver Shunt)

Flow: 60 secondsFlow: 60 secondsStatics: Anterior Abdomen at 15, 30, 45 & 60 minutesStatics: Anterior Abdomen at 15, 30, 45 & 60 minutesWhole Body: OptionalWhole Body: OptionalDelays: 2 to 4 Hours if No Lung (Liver) VisualizationDelays: 2 to 4 Hours if No Lung (Liver) Visualization



Lungs Seen in 60 minutes (Usually 10-30 minutes)Lungs Seen in 60 minutes (Usually 10-30 minutes)

Liver Seen in 60 minutes (Tc99m-Sulfur Colloid)Liver Seen in 60 minutes (Tc99m-Sulfur Colloid)Can be Difficult to Separate Liver From AscitesCan be Difficult to Separate Liver From Ascites

AbnormalAbnormalNo Lung Seen After 4 Hours – ObstructionNo Lung Seen After 4 Hours – Obstruction

No Liver Seen After 4 Hours – ObstructionNo Liver Seen After 4 Hours – Obstruction

Activity Stops at Pump – Valve Failure or Activity Stops at Pump – Valve Failure or ObstructionObstruction

Other StudiesOther Studies

Barrett’s Esophagus ImagingBarrett’s Esophagus Imaging

Retained Antrum ImagingRetained Antrum Imaging

GASTROINTESTINAL IMAGING Sodee

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