SCINTIGRAPHY OF THE LIVER AND SPLEEN HEPATOBILIARY...
Transcript of SCINTIGRAPHY OF THE LIVER AND SPLEEN HEPATOBILIARY...
SCINTIGRAPHY OF THE LIVER AND SPLEENHEPATOBILIARY SCINTIGRAPHY
George N. Sfakianakis MDProfessor of Radiology and Pediatrics
Director Division of Nuclear Medicine , University of Miami, Florida
October 2009
GI TRACT AND LIVER/SPLEEN SCINTIGRAPHY
LIVER AND SPLEEN SCAN (Anatomy and Function)(99mTc -Sulfur-Colloid) Reticulo-Endothelial Cell Phagocytosis
HEPATOBILIARY SCINTIGRAPHY (Biliary Disorders)(99mTc-Imino-Di-Acetic-Acid Derivatives) Hepatocyte Uptake and Bile Excretion (no conjugation)
LIVER AND SPLEEN SCAN99mTc -Sulfur-Colloid
Reticulo - Endothelial Cell PhagocytosisSPECT studies
Indications
It is mostly replaced by US/CT/MR, but still some studies are performed inCongenital AnomaliesPolysplenia, Asplenia, Accessory SpleenLiver Storage Disease and other anomalies
Tumors and Focal Infections
Hemangioma Studies
Diffuse Hepatocellular Disease
Trauma of the liver and Spleen
LIVER VARIATIONS
LIVER SPLEEN SCAN NORMALPLANAR IMAGES
SPECT TOMOGRAPHIC IMAGES
TRANSAXIAL
SAGITTAL
CORONAL
6yo boy suspected of functional asplenia
SEVERE CIRRHOSIS
45 yo male with alcoholic cirrhosis
CIRRHOSIS with REGENERATING NODULE
48yo female with history of cirrhosis and multiple low attenuation lesions by CT. R/o hepatoma
CHRONIC ACTIVE HEPATITIS
SEVERE HEPATITIS ASCITESbilirubin = 25
SEVERE HEPATITIS IN A CHILDLung Uptake
Caudate lobe
S/p portocaval shunt
CHEMO INFUSION PUMP INJECTIONTO IDENTIFY APPROPRIATENESS OF POSITION
ACCESSORY SPLEEN
ACCESSORY SPLEEN
Planar imaging
S/P splenectomy for hemolytic anemia
ACCESSORY SPLEEN
Hemolysis sp splenectomy
TRANSAXIAL
SAGITTAL
CORONAL
SPECT
After 0.5 mCi SC IV, Probe guided resection of a 4cm Accessory Spleen
FUNCTIONAL ASPLENIA AND HYPOSPLENIA
Anemia AIDS
SPLENIC INFARCTS
BONE MARROW DISTRBUTION PATTERNS
HEMANGIOMAS
PRINCIPLE
Visualization of the High Blood Pool of the HemangiomaThe Blood flow is usually decreased = 60 min delayed imaging
METHOD
99mTc-LABELED BLOOD POOL STUDY (like the bleeding study)FLOW1hr STATICS SPECT
A patient has a potential hemangioma by MRI
HEMANGIOMA: BLOOD POOL STUDY
TcSC TcSC
Tc-SC not helpful
BLOOD POOL BLOOD POOL
A patient has a potential hemangioma by MRI
HEMANGIOMA: BLOOD POOL STUDY
BLOOD POOL
BLOOD POOL STUDY: NEGATIVE FOR HEMANGIOMA
HEPATOMA
GALLIUM STUDY
Flow
BLOOD POOL STUDY
BLOOD POOL STUDY: No Increased Blood PoolFinal Diagnosis: METASTASIS
SOL in the right lobe by CT and LSS
A patient has a potential hemangioma by MRI
HEMANGIOMA: BLOOD POOL STUDY
A patient has a potential hemangioma by MRI
HEMANGIOMA with Central Necrosis
A patient has a potential splenic hemangioma by MRI
HEMANGIOMA of the SPLEEN with Central Necrosis
HEPATOBILIARY SCINTIGRAPHY99mTc-Imino-Di-Acetic-Acid Derivatives
Hepatocyte Uptake and Bile Excretion (no conjugation)
Indications
Congenital AnomaliesBiliary Atresia vs Neonatal HepatitisBiliary Tree Anomalies
Acute Cholecystitis (Chronic Cholecystitis)
Obstruction of the Biliary Tree
Complications of Liver Transplants
Rejection/Hepatitis vs Obstruction
Bile Leaks
RADIOPHARMACEUTICALS for HEPATOBILIARY STUDIES
NORMAL HEPATOBILIARY STUDYThe Gall Bladder is visualized before the Bowel
41yo female with right abdominal pain and fever. Final Dx Pyelonephritis
NORMAL HEPATOBILIARY STUDYGB after Bowel (can be Chronic Cholecystitis)
RUQ pain; r/o acute cholecystitis
CONGENITAL ANOMALIES
1 BILIARY ATRESIA vs NEONATAL HEPATITISClinical Presentation:Direct Hyperbilirubinemia in the NeonateBegins as a prolongation of the neonatal jaundice and persists and deterioratesNo other test is diagnosticBilliary Atresia needs surgical decompression
2 OTHER ANOMALIES OF THE BILIARY TRACTCholedochal CystAbnormal Communications of the ductsCaroli’s Disease etc
HEPATOBILIARY STUDY IN NEWBORNProtocol
Preparation with oral Phenobarbital 10mg/Kg day for 1week
Injection 1mCi 99mTc-Hepatobiliary agent iv in the morning
Imaging Dynamic Planar 1hr and then every 4hr until bowel (or gall bladder) activity is definitely visible (=Hepatitis)if not visible by late afternoon inject another 0.5mCi HBL agent
Imaging (anterior and lateral) static next day
If bowel activity not present 90% Biliary Atresia, 10% Inspissated Bile Syndrome
NEONATAL JAUNDICE
NEONATAL HEPATITIS
Only the liver
NORMAL STUDYBILIARY ATRESIA
NEONATAL JAUNDICE
VERY SEVERE NEONATAL HEPATITIS
CHOLEDOCHAL CYST
A case of neonatal jaundice is evaluated
CHOLECOCHAL CYST
CHOLEDOCHAL CYST
CHOLEDOCHAL CYST
A case of neonatal jaundice is evaluated
HEPATOBILIARY STUDY IN NEWBORNNeonatal Hepatitis
NB with direct hyperbilirubinemia and NV of bowel on an outside study; we suggested repeat after 5 day phenobarbital preparation (10mg/kg)
HEPATOBILIARY STUDY IN NEWBORNNeonatal Hepatitis
New born with direct hyperbilirubinemia
HEPATOBILIARY STUDY IN NEWBORNNeonatal Hepatitis
No bowel or GB activity
The study became diagnostic at 24hr post injection
HEPATOBILIARY STUDY IN NEWBORNNeonatal Hepatitis
NB with persistent direct hyperbilirubinemia.
4 hours 8 hours
Dynamic
Bowel
Infant with direct hyperbilirubinemia sp 2weeks treatment with phenobarbital
NEONATAL HEPATITIS
NEONATAL HEPATITIS
Direct hyperbilirubinemia; r/o biliary atresia
NEONATAL JAUNDICE
NEONATAL HEPATITIS
Only the liver
NORMAL STUDYBILIARY ATRESIA
This infant had complicated life with pneumonias and failure to thrive
BRONCHOBILIARY FISTULA
The early images were normal except for GER Delayed images
were interesting
HEPATOBILIARY SCINTIGRAPHY FOR DIAGNOSIS OF ACUTE CHOLECYSTITIS
99mTc –IminoDiAceticAcid Dynamic Imaging
Highly sensitive based on cystic duct obstructionand non-visualization of the gall bladder which characterize acute cholecystitis
Specificity enhanced by CCK or Morphine
Alternative and Complementary to Ultrasonography
INTRAHEPATIC GALL BLADDER
GALLBLADDER OVER DUODENUM
CHRONIC CHOLECYSTITIS HBL+MORPHINE
ACUTE CHOLECYSTITIS: RIM SIGN
HEPATOBILIARY AND Ga SCINTIGRAPHY FOR ACUTE CHOLECYSTITIS
99mTc-IDA1 hour Image
30min post Morphine
67Ga-citrate3 hour Image
NON-VISUALIZATION OF GB
A patient with jaundice and abdominal pain
OBSTRUCTION (PARTIAL) OF CBD
Retention within the duct and partial excretion
BILIARY OBSTRUCTION
PARTIAL COMPLETE
CAROLI’S DISEASE
LIVER TRANSPLANTS
COMPLICATIONS
Ischemic Damage, Rejection, HepatitisObstruction of the Billiary TreeBile Leak, BilomaInfection
LIVER TRANSPLANT NL: BLIND LOOP SIGN
Patient after liver transplant; r/o bile leak
Patients with liver transplants are evaluated
LIVER TRANSPLANT:HEPATOCELLULAR DISEASE
The liver never empties
12yo male sp liver and kidney transplantation; r/o biliary obstruction
LIVER TRANSPLANT:HEPATOCELLULAR DISEASE
Rule out obstruction or bile leak
DIFFUSE HEPATOCELLULAR DISEASE
LIVER Tx REJECTION and HEMATOMA
Liver Tx Rejection +Hematoma (biopsy)
LIVER TRANSPLANT REJECTIONAND BLIND LOOP
Patient with Liver Tx to rule out obstruction
BILE LEAK
LIVER ABSCESS
111In WBC IMAGINGand 99mTc-SULFUR COLLOID L/S SCAN:
INFECTED HEPATIC HEMATOMA
LIVER SCAN 99mTc-SC 111In-WBC
Patient with hepatic hematoma from MVA developed FUO
AMEBIC ABSCESS
SULFUR COLLOID GALLIUM
Patient has recently returned from a trip abroad and developed FUO, and RUQ pain
111In WBC IMAGING SPECT
Which Hepatic Cyst is Infected?
SPLEEN
FALSE NEGATIVE 111In WBC IMAGINGIN OLD INFECTION
111In WBC Study
67Ga Citrate Study
ABDOMINAL-PERISPLENIC ABSCESS
Infant with post-op fever; Sonograms non-diagnostic
Gallium scan diagnostic
Repeat Sonogram diagnostic
GALLIUM SPECT: ABDOMINAL WALL ABSCESS 1
Planar FN
Infant with a nephrostomy tube and FUO
GALLIUM SPECT: ABDOMINAL WALL ABSCESS 2
FALSE POSITIVE GALLIUM IN TUMORS
Patient with Lung cancer and FUO is evaluated for Infection
ABDOMINAL ABSCESS AND LIVER TRAUMA
111In WBC imaging 24 hr post injection
LIVER TUMOR F/U
January July
METASTATIC COLORECTAL CARCINOMA
99mTc-sulfur colloid liver scan 131I-CEA-Antibody Scan
LIVER METASTASIS
LIVER METASTASES SPECT VOLUME
LIVER METASTASES SPECT VOLUME
CT of the Liver
FDG-PET SCAN FOR TUMOR OF UNKNOWN ORIGIN
transaxial cuts
Sagittal cuts
coronal cuts
High intensity focal activity in the Known Hepatic Lesion and also in the Left Pararenal Space both c/w Tumor
Correlation of PET with the CT of the Abdomen
PET CT
Retrospectively, a mass lesion was present in the peri-renal space on a recent CT (Colon Cancer), which has been overlooked as normal bowel
RECURRENT LYMPHOMA
Patient with history of lymphoma; recent CT was “negative”
MELANOMA
Melanoma of the right great toe diagnosed 1mo
PANCERATIC IMAGING
Planar 75Se-Seleno-Methionine PET 11C-Tryptophan