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