The gallbladder normally fills with hepatic bile during a fast, and empties its contents into the duodenumupon stimulation by cholecystokinin (CCK) given eitherexogenously or released endogenously following a meal.At present it is not clear how soon a normal gallbladderbegins to empty and how long it continues to empty following infusion of CCK. Once the CCK infusion isstopped, it is not known how soon the sphincter of Oddiregains its tone, thus facilitating refilling of the gallbladder. The fraction of hepatic bile that enters thegallbladder is controlled primarily by the tone of thesphincter of Oddi. The temporal relationship betweencholecystokinin stimulation and gallbladder emptying

Received Jan. 5, 1983; revision accepted Mar. 28, 1983.For reprints contact: G. T. Krishnamurthy, MD, VA Medical

Center(I ISP),3710SW U.S.VeteransHospitalRoad,Portland,OR97201.

* Current address: Germantown Hospital, Radiology Dept., One

Penn Blvd., Philadelphia, PA 19144.

and refilling is poorly understood primarily because ofunavailability of an appropriate test.

In recent years, the introduction of technetium99m-labeled iminodiacetic acid analogs (Tc-99m IDA)as bile markers has provided investigators with a newmethod to study the biliary physiology thoroughlywithout the use of sedation, intubation tubes, or largequantities of intravenous contrast agents (1 ). The wideruse of IDA analogs has resulted in the establishment ofmany new functional parameters (2,3). It has beensuggested that the gallbladder be emptied routinely orwhen the patient has fasted longer than 24 hr, to facilitate refilling (4,5). In either case it is important to knowhow soon after an infusion of CCK, the gallbladder begins to fill again. If it does not begin to fill early enough,a normal gallbladder might suggest cystic duct obstruction.

The present study was undertaken to explore furtherthe variables of normal biliary physiology with respect

666 THE JOURNAL OF NUCLEAR MEDICINE

Filling, PostcholecystokininEmptying,and Refilling of Normal Gallbladder:

Effects of Two Different Doses of CCK on Refilling: Concise Communication

M. ga G. T. Krishnamurthy, V. A. Bobba, and K. Langrell

NuclearMedicineService, VAMedicalCenter,andOregonHealthSciences University,Portland,Oregon

A studyof 18 normalsubjectswas undertakento evaluate the rapidityof gallbladderfillingwithTc-99m IDAduringfast, and the degree of emptyingand mddenceof refillingafter intravenousinfusionof either 20 or 40 ng/kg of octapeptideof cholecystoklnln(CCK-8). Duringfast, the frequencyof onsetof gallbladderfillingwith Tc-99mIDAat 20, 30, 40, and42 mmwas68%, 84%, 95%, and100%,respectIvely.FollowingCCK-8infusion,the gallbladdermeanejectionperiodof II±4 (s.d.)mmandejectionfractionof 40% ±23weresimilarin subjectsgiveneither a 20 ng/kg ora 40 ng/kg dose.Thefrequencyof onsetof refillingat 20, 30, 40,and50 mmafter CCK-8 was 33% , 63% , 71% , and79% , respectivelyforthe cornbinedgroups.At 50 mm after CCK-8, all subjectsgiven20 ng/kg refilled,whereasonly63% of the 40-ng/kg groupdidso.There was nocorrelationbetweenthe degree ofemptying(ejectionfraction)andonsetof refilling.We concludethatthe frequencyof postCCK-8 onsetof gallbladderrefilling,which reflectssphinctertonerecovery,is widely variable,dependinguponboththe doseandthe durationfromthe time of infusionof CCK-8 and shouldbe taken into considerationif a preemptyingprocedureis adoptedduring hepatobiliaryimagingwith Tc-99rn IDAagents.

J Nuci Med 24: 666-671, 1983

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CLINICAL SCIENCESDIAGNOSTIC NUCLEAR MEDICINE

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Volume 24, Number 8 667

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MESGARZADEH. KRISHNAMURTHY. BOBBA. AND LANGRELL

to (a) how soon the normal gallbladder begins to fill withTc-99m IDA in the fasting state; (b) how soon and howlong it empties following infusion of two different dosesof octapeptide of cholecystokinin (CCK-8); (c) howmuch it does empty; (d) how soon the sphincter of Oddiregains its tone to promote refilling of the gallbladderfollowing cessation of CCK-8 infusion; (e) whether thereis any correlation between the degree of emptying andthe rapidity of refilling; and (f) whether pre-emptyinghastens or delays gallbladder refilling.

Since the day-to-day tone of the sphincter ofOddi maybe variable depending upon the duration of fast, amongother factors, the present study was designed to study allthree functions (filling during fast, post CCK-8 emptying, and refilling with Tc-99m IDA) after an overnightfast.

MATERIAL AND METHODS

Eighteen normal adult volunteers (8 male, 10 female)ranging in age from 22 to 53 yr (mean 33 yr) were chosen. Their good health was confirmed by medical history,physical examination, and liver function tests (totalbilirubin, alkaline phosphatase, albumin, total protein,glutamic transaminase, and lactic dehydrogenase). Ultrasound study indicated normal liver and gallbladder.The subject's informed consent was obtained for theinstitutional subcommittee for human studies. Subjectswere divided into A and B groups according to the doseof CCK-8 used to stimulate gallbladder emptying: sixsubjects in Group A received 20 ng/kg and 12 subjectsin Group B received 40 ng/kg (Table 1).

Datacollection.This wasconductedin two phases.The first phase (for gallbladder filling) lasted for 60 mm.The second phase (gallbladder emptying and refilling)lasted for another 60 mm (Tables 1,2).

First phase. After an overnight fast (minimum 8 hr)each subject received 1.5 mCi i.v.of commercial Tc-99mparabutyl-IDA (PBIDA) or 5 mCi of Tc-99m dimethyl-1DA (HIDA). The difference in dosage wasplanned because the liver's excretion half-time is longerfor PBIDA than for HIDA (107 mm compared with 42).The intent was to have at least 500 zCi in the liver whenthe second phase started, at 60 mm after Tc-99m IDAinjection. Using a parallel-hole collimator, analog imageswere made every 2 mm for an hour, while a computerstored images at one frame/mm in a 64 X 64 matrix.

Secondphase.After the first-phasecollection,a 5-mmpinhole collimator was substituted and focussed over thegallbladder in a way that best separated the gallbladderfrom the bile ducts and intestine. Two-minute imagesand one-minute digital data were obtained as before, foranother hour. A saline placebo was infused i.v. at 5 mmafter the second phase began. At 10 mm, CCK-8 wasinfused over 3 mm with a Harvard infusion pump, either20 ng/kg (Group A) or 40 ng/kg (Group B).

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- CLINICAL SCIENCES

DIAGNOSTICNUCLEAR MEDICINE

DATA ANALYSIS

First phase. Two equal regions of interest were chosen—oneover the gallbladder and the other over the liverfor background—and a net time-activity curve,(decay-corrected) was generated for the gallbladder(Fig. 1). Analog images were inspected carefully and theearliest time of the appearance of the gallbladder wasrecorded. The gallbladder filling fraction (FF), at thetime of its appearance, was calculated by the followingequation:

GB FillingFraction(%)

1-mm GB cts

decreasing specific activity of the hepatic bile, a refillingvalue equal to or greater than half of the filling fractionwas considered to indicate gallbladder refilling. TableI shows the filling fraction and the refilling index. Refilling fraction = FF X RI.

RESULTS

The time of gallbladder appearance during fast was20 ±2 mm (mean ±s.d.) in Group A, 21 ±10 mm inGroup B (p <0.05) and 21 ±8 mm for the combinedgroups. At 20, 30, and 40 mm after injection of Tc-99mIDA, 68%, 84%, and 95% respectively of the galibladders

were visualized. By 42 mm, all gallbladders were visualized (Table 1). Mean filling fraction was 11%±8% inGroup A and 3.7% ±2.5% in Group B, the differencesreflecting mainly the effects of dose: 5 mCi for the former and 1.5 mCi for the latter.

The mean ejection period was 10 ±4 mm in Group Aand 11 :E5 mm in Group B (p >0.05) and 11 ±4 mm forthe combined group. The mean ejection fractions were35% ±17% in Group A, 43% ±26% in Group B (p>0.05) and 40% ±23% in the combined group. Therewas no significant difference between the two groups inthe gallbladder appearance time, ejection period, andejection fraction (p >0.05). In Group A subjects (dose20 ng/kg), the frequency of refill at 20, 30, 40, and 50mm post CCK-8 was 50, 83, 83, and 100% respectively.The corresponding values in Group B subjects (40ng/kg) were 25, 50, 62, and 63%, respectively. When thetwo groups are combined, these frequencies become 33%,63%, 7 1%,and 79%. There was no correlation betweenthe degree of emptying (ejection fraction) and the 30-mm refilling fraction (Fig. 3).

DISCUSSION

The fraction of hepatic bile entering the gallbladderis controlled primarily by the tone of the sphincter ofOddi and the resulting differences in hydrostatic pressureat various levels of the biliary tract. The resting meanpressures in the Oddi sphincter, common bile duct, andgallbladder are known to be about 15, 12, and 10 cmH20 respectively (7,8). The sphincter tone fluctuates,

thus releasing bile into the duodenum entry or divertingit into the gallbladder.

Of all of the known cholecystogogues, cholecystokininis considered to be the principal hormone that controls

gallbladder contraction and emptying. In man the serumhalf-time of exogenously administered cholecystokininis 2.5 mm (9). The mean ejection period of I I mm for ourcombined group suggests that gallbladder emptying lastsfor about 41/2serum CCK half-time. The mean ejectionperiods did not differ significantly between Groups A &B (10 compared with 1 1). Both groups also had similar

ejection fractions. There was a clear difference, however,

— 1-mm baseline

at its appearance ct at 10 mm@ 100

1-mm GB cts at 59-60 mm

The filling fraction at appearance time essentiallyrepresents the fraction of the total 60-mm gallbladderradioactivity required to visualize it on analog images.The early rise in the gallbladder curve is probably dueto unsubtracted hepatic uptake anterior to the gallbladder. The 10-mm count is considered to represent thisforeground peak activity due to liver uptake (6).

Second phase. Two equal regions of interest werechosen: one over the entire gallbladder and the othersuperior and lateral to the gallbladder, representing liverbackground. The net gallbladder time-activity curve wasobtained after subtraction of the normalized background, and the gallbladder's net count was decay-corrected. The gallbladder ejection fraction was calculatedas(2).

GB Ejection Fraction (%) =

net GB cts before CCK-net GB cts after CCK@

net GB cts before CCK

The period from beginning to end of gallbladderemptying (ejection period) was noted from the curve.The gallbladder refilling fraction (RF, Fig. 2) was calculated for every 10 mm, beginning 20 mm after CCK-8infusion up to the termination of the study, using theequation:

Refilling fraction (%) after CCK-8 at time (t)

GB cts after Cts at the end

CCK-8 at time (t) ofGB ejection period@

GB cts just before OP-CCK infusion

We have chosen to calculate the refilling fraction forevery 10 mm. A refilling index (RI) was obtained bydividing refilling fraction by filling fraction. This normalizes the results and compensates for the differencesin Tc-99m IDA dose between the two groups. Since the

liver continuously excretes HIDA and PBIDA, thus

Volume 24, Number 8 669

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MISGARZADEH. KRISHNAMURTHY. BOBBA, AND LANGRELI.

Normal Gall Bladder Filling, Emptying and RefillingUU

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FIG. 1. CalculatIon of filling, emptying, andrefilling:gallbladderfillingfractionat 20 mmwhenseenonanalogniiagesis17% (left).Gallbladderempties 80% of its contentsafter CCK-8 infusion, with ejection period10 mm (right). Small fluctuating peaks at30, 40, and50 mmare consideredas noiseand true gallbladder refilling starts at 60mm, with refilling indexof 2.0.

@o 10 20 30 40 50 60 0 10 20 30 40 50 60

Time (Minutes)

with regard to the frequency ofpost-CCK refill. GroupA (20 ng/kg) had 50% refilling at 20 mm and 100% at

50 mm. Group B (40 ng/kg) had 25% and 63%. Thissuggests that the larger CCK-8 dose may not promotegreater emptying but it does delay refilling. This mightresult from prolonging the increased tone of the gallbladder, or prolonging the relaxation time of thesphincter of Oddi, or both.

Since all fasting subjects showed gallbladder fillingwithin 42 mm in but only 83% (A) and 63% (B) afterCCK it seems logical to use fasting subjects to facilitate

rapid gallbladder filling. If a CCK-8 dose of 40 ng/kgis used, a period longer than 50 mm should be allowed

before injecting Tc-99m IDA. Baker et al. and Klingensmith et al. showed that in normal subjects fastinghastened gallbladder filling and oral feeding delayed it,probably secondary to the prolonged effects of endoge

Twns(Minuiss)

FIG. 2 Gallbladder in Subject A (Upper) was seen at 20 mm, withfilling fraction 5.1% . Subject received CCK-8,40 ng/kg. Refillingfraction at 50 mm is 1.3% , with refilling index of 0.25 (1.3/5.1),considered“norefill.―GallbladderinSubjectB(lower)wasalsoseenat 20 mm,with filling fraction of 22.8%. SubJectreceivedOP-CCK,20 ng/kg, and ejection fraction was 53%. RefillIng index in thissubject Is 2.31 (53.9/22.8), indicatingdefinite refill.

nous cholecystokinin (10,/I). It appears logical, then,to increase sphincter tone as much as possibleto facilitaterapid gallbladder filling. The factors that decreasesphincter tonus will delay filling. Note, however, thatfasting longer than 24 hr may have an opposite effect,namely, the gallbladder with a patent cystic duct maynot fill with Tc-99m IDA (5). In such cases, preemptying appears logical.

We do not know yet whether a diseased gallbladderresponds to cholecystokinin like a normal one. Only ifthey react alike may one claim that fasting is the bestmethod to facilitate rapid filling. Since the durations ofaction of cholecystokinin on the diseased gallbladder andthe sphincter are not known, we cannot say whetherpre-emptying hinders or helps GB refilling. Until thisquestion has been settled, it may be best to use fastingto fill the gallbladder for routine Tc-99m IDA imagingbut to consider pre-emptying when the duration of thefast is longer than 24 hr. In the latter case, the Tc-99mI DA injection should be given 30—60 mm after the

cholecystokinin, depending on the CCK dose.

10 20 30 40 @O 60 70 80 90%t@son Froct@n

FlO. 3. CorrelatIon between gallbladderejection fraction (X) and30-mm refilling fraction (Y) is negligible (r = 0.07) suggestIngthatmagnitudeof emptying has no effect on degree of refill at 30 mmafter CCK-8.

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ACKNOWLEDG MENT

We thank Mrs. Barbara Wright for assistance in preparation andtyping of the manuscript.

CCK-8 (Kinevac)wassuppliedthroughthecourtesyof ER. Squibb& Sons, Princeton, New Jersey.

This project was supported by the Veterans Administration.

REFERENCES

1. LOBERG MD, COOPER M, HARVEY D, Ctal: Developmentof new radiopharmaceuticals based on N-substitution of iminodiacetic acid. J Nuci Med I7:633—638,1976

2. KRISHNAMURTHYGT,BOBBAyR. KINGSTONE:Radionuclide ejection fraction: a technique for quantitativeanalysis of motor function of the human gallbladder. Gastroenierology80:482-490,1981

3. MESGARZADEHM, KRISHNAMURTHY GT, BOBBAVR,et al: Biliary dynamics in health and patients with cholelithiasis. J Nuci Med 23:P28, 1982 (abst)

4. EIKMAN EA, CAMERON JL, COLMAN M, Ctal: A test forpatency of the cystic duct in acute cholecystitis. Ann InternMed 82:318—322,1975

5. LARSEN MJ, KLINGENSMITH WC Ill, KUNI CC: Radionuclide hepatobiliaryimaging: Non-visualizationof thegallbladder secondary to prolonged fasting. I Nuci Med 23:1003—1005,1982

6. BROWN PH, KRISHNAMURTHY GT, BOBBA yR. et al:Radiation dose calculation for five Tc-99m IDA hepatobiliaryagents.JNuc! Med 23:1025-1030,1982

7. JACOBSONB: Determination of pressure in the common bileductat andafteroperation.Ada C/in(Scand) I13:483-488,I957

8. ANDERSON AC, HAGSTROM W: A comparison of pancreaticandbiliarypressurerecordedsimultaneouslyinman.Can J Surg 5:46 1-470, I962

9. THOMASJC,FENDERHR. RAWUSNI, Ctal: Cholecystokinin metabolism in man and dogs. AnnSurg 182:496-504,I975

10. BAKERRG, MARIONMA: Biliary scanningwith Tc-99mpyridoxylideneglutamate: The effect of food in normalsubjects.J Nuci Med 18:793-795, 1977

II. KLINGENSMITH WC III, SPITZER VM, FRITZBERG AR,et al: The normal fasting and postprandial diisopropyl-IDATc-99m-hepatobiliarystudy. Radiology I41:771-776,I981

Volume 24, Number 8 671

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1983;24:666-671.J Nucl Med.   M. Mesgarzadeh, G. T. Krishnamurthy, V. R. Bobba and K. Langrell  Two Different Doses of CCK on Refilling: Concise CommunicationFilling, Postcholecystokinin Emptying, and Refilling of Normal Gallbladder: Effects of

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