The Correlation between Acholic Stool and the Result of Tc(99m) DISIDA Hepatobiliary Scintigraphy and Biochemical Test in Neonatal Cholestasis / 대한소아소화기영양학회지

PURPOSE: The most common causes of neonatal cholestasis are neonatal hepatitis (NH) and extrahepatic biliary atresia (EHBA). Since neonatal cholestasis presents with variable expression of same pathologic process and has similar clinical, biochemical, and histologic features between EHBA and idiopathic neonatal hepatitis (NH), differential diagnosis is often difficult. We reviewed the differences of clinical characteristics and laboratory data to find out any correlation between the results of Tc(99m) DISIDA scan and presence of acholic stool. METHODS: Between June 1993 and January 2001, total 29 infants younger than 4 month-old underwent Tc(99m) DISIDA scan. Their biochemical tests and clinical course were reviewed retrospectively. RESULTS: Patients who had negative intestinal activity on Tc(99m) DISIDA scan showed acholic stool and revealed higher serum direct bilirubin and urine bilirubin level. 18.2% of patients with acholic stool showed intestinal activity on Tc(99m) DISIDA scan and 81.8% of them did not. All the patients without acholic stool showed positive intestinal activity on Tc(99m) DISIDA scan. The result of Tc(99m) DISIDA scan and the presence of acholic stool showed high negative correlation (r :-0.858). Patients with acholic stool and negative intestinal activity on Tc(99m) DISIDA scan showed higher serum total bilirubin level. Patients without acholic stool and positive intestinal activity on Tc(99m) DISIDA scan showed higher serum level of ALT. CONCLUSION: Patients with acholic stool and negative intestinal activity showed high correlation, but 18.2% of patients with acholic stool showed positive intestinal activity. So operative cholangiogram or transcutaneous liver biopsy should be performed for confirmation.

Diagnostic Utility of Tc-99m DISIDA Hepatobiliary Scintigraphy in the Diagnosis of Biliary Atresia / 대한소아소화기영양학회지

PURPOSE: Biliary atresia, one of the major causes of neonatal cholestais, is an idiopathic, serious disorder, affecting the newborn that results in complete obstruction of biliary tract. Successful reestablishment of bile flow is dependent on early surgical intervention, early diagnosis is imperative. The authors evaluate the utility of Tc-99m-labeled diisoprpyliminodiacetic acid (DISIDA) hepatobiliary scintigraphy in the diagnosis of biliary atresia. METHODS: From January, 1995 to August, 1999, total 60 patients with neonatal cholestasis underwent Tc-99m DISIDA hepatobiliary scintigraphy at Asan Medical Center. RESULTS: The undelying causes of neonatal cholestasis were biliary atresia in 14, neonatal hepatitis in 33, intrahepatic bile duct paucity in 9, and total parenteral nutrition induced cholestasis in 4. All patient with biliary atresia were interpreted correctely in DISIDA hepatobiliary scintigraphy, showing 100% sensitivity. Of the 46 patients with neonatal hepatitis and other causes, 37 patients had intestinal radioactivity showing 80% specificity. CONCLUSION: Visualization of DISIDA in the intestinal tract indicates patency of the biliary ducts and excludes the diagnosis of biliary atresia. But the absence of intestinal excretion on the DISIDA hepatobiliary scintigraphy dose not necessarily indicate biliary atresia.

A Case of Alagille's Syndrome / 대한핵의학회잡지

This is a case report of a 5-month-old male who was brought in to hospital for evaluation of jaundice from birth. The baby had a history of ileal atresia operated 2 days after birth. At the age of one month, Tc-99m DISIDA hepatobiliary scintigraphy was performed at other hospital and reported to show good hepatic uptake of the tracer but no uptake in the billiary tree, gall bladder, or intestine for 24 hours post injection. He was judged to have biliary atresia. However, subsequent exploratory laparotomy revealed that the hepatobiliary tree appeared intact and that there was a gall bladder. Additionally, the patient had central aorto-pulmonary shunt for the right ventricular septal defect with pulmonary stenosis of a peripheral type at the age of 4 months. The second hepatobiliary scintigraphy was performed on admission at the age of 5 months, showing a gall bladder but no intestinal uptake up to 24 hours. Retrospectively, the histological specimen of the liver obtained at the exploratory laparotomy was re-evaluated, and by the histological findings coupled with clinical data, arteriohepatic dysplasia (Alagille's syndrome) was diagnosed. In this report, we emphasize the diagnostic limitation of hepatobiliary scintigraphy and the importance of overall clinical and histologic evaluation in a case of Alagille's syndrome. (Korean J Nucl Med 2000;34:154-158)

Evaluation of the Gallbladder Ejection Fraction by Tc-99m DISIDA Scintigraphy after Gastric Operations

BACKGROUND : Truncal vagotomy produces a reduction in bile flow, an increased gallbladder volume, a delay in gallbladdr emptying, decrease in resting pressure, and decreased contraction following stimulation with cholecystokinin. Retrospective studies have suggested that vagotomy can be responsible for a 4 to 6 fold increase in the 4% to 5% control rate of cholelithiasis noted in the Framingham study. The measurement of the gallbladder ejection fraction by using Tc-99m DISIDA scintigraphy is suitable for the study of the motor functions of the gallbaldder. A gallbladder ejection fraction of less than 35% is highly predictive of the presence of gallbladder disease and is a good indicator of a favorable outcome following a cholecystectomy. METHODS : Between January 1995 and December 1996, 24 patients (truncal vagotomy + pyloroplasty, 5; truncal vagotomy partial + gastrectomy + Billroth I, 4; truncal vagotomy + partial gastrectomy + Billroth II, 12; total gastrectomy, 3) and 18 healthy volunteers were investigated prospectively by Tc-99m DISIDA scintigraphy for the measurement of the gallbladder ejection fraction. RESULTS : In normal subjects, the mean value of the gallbladder ejection fraction was 70.8%, and in patients after a gastric operations, it was 66.0% (p>0.05). Three (25.0%) of the 12 patients with a truncal vagotomy, partial gastrectomy, and Billroth II gastrojejunostomy had gallbladder ejection fractions of less than 35% (p<0.05). CONCLUSIONS : There was no difference in the gallbladder ejection fractions between the control group and the patients after gastric operations, including a truncal vagotomy. However there was a significant difference between the patients with a truncal vagotomy, partial gastrectomy, and Billroth II anastomosis and those receiving other gastric operations.

Clinical Significance of Seogmental Parenchymal Excretion Delay on Tc-99m DISIDA Hepatobiliary Scan / 대한핵의학회잡지

PURPOSE: Segmental parenchymal excretion delay on Tc-99m DISIDA scan is caused by intrahepatic bile duct obstruction. However, the diagmostic value for intrahepatic bile duct obstruction is unknown. We conducted this study to assess the positive predictive value of segmental excretiom delay for the diagnosis of intrahepatic bile duct obstruction, and additional benefit over other noninvasive radiologic studies. MATERIALS AND METHODS: The study population consisted of 43 patients (48 scans) Who showed segmental parenchymal excretion delay on Tc-99m DISIDA scan. The results of abdominal CT or ultrasonography, which was done within 1 month of Tc-99m DISIDA scan, were compared with scintigraphic findings. RESULTS: The etiology of segmental parenchymal excretion delay was determined by ERC or PTC in 31 scans, and follow-up studies in 13 scans. No causes were identified in 4 scans. The positive predictive value of segmental parenchymal excretion delay for intrahepatic bile duct obstruction was 92% (44/48). On the other hand, 13% (5/38) of CT and 28% (5/18) of ultrasonography were normal. In 18% (7/38) of CT and 17% (3/18) of ultrasonography, only intraheipatic bile duct dilatation was noted without any diagnostic findings of intrahepatic bile duct obstruction. CONCLUSION: Segmental parenchymal excretion delay on Tc-99rn DISIDA scan had a high positive predictive value for the diagnosis of intrahepatic bile duct obstruction. Tc-99m DISIDA scan may be useful for the diagnosis of intrahepatic bile duct obstruction, especially in patients with nondiagnostic CT or ultrasonography. The diagnostic usefulness need to be confirmed by further prospective studies. KW: Tc-99m DISIDA, Segmental parenchymal excretion delay, Intrahepatic bile duct obstruction.

Use of Tc-99m Diisopropyl Iminodiacetic Acid (Tc-99m DISIDA) Scintigraphy for a Noninvasive Estimate of Bile Reflex after Gastric Operations

BACKGROUNDS:Bile reflux gastritis can occur when pylorus ablation is associated with bile stasis in the stomach. It can also occur with a gastrojejunostomy when bile is continuously poured into the gastric remnant after a vagotomy and an antrectomy. The diagnosis of bile reflux gastritis can be made only when the patient has bile gastritis documented on biopsy; the simple observation of a bile-stained mucosa in a gastric remnant is not sufficient to make the diagnosis of bile reflux gastritis. METHODS: Technetium-99m diisopropyl iminodiacetic acid (Tc-99m DISIDA) scintigraphy was used to study bile reflux into the gastric remnant in 31 patients with gastric operations. All patients had gastrofibroscopic biopsies in order to identify the bile reflux gastritis. RESULTS: Tc-99m DISIDA Scintigraphy identified bile reflux in 15 (83.2%) of 18 patients after a subtotal gastrectomy and a Billroth II gastrojejunostomy. Hewever, no bile reflux occured in either the 10 patients with a hemigastrectomy plus Billroth I gastoduodenostomy or the 3 patients with a truncal vagotomy plus pyloroplasty. Also, gastrofibroscopic biopsies identified bile reflux gastritis in only 3 patients (9.7%) with a subtotal gastrectomy plus Billroth II reconstruction. CONCLUSIONS: The patients who underwent a subtotal gastrectomy and Billroth II reconstruction showed higher bile reflux rates than did the patients who underwent a hemigastrectomy plus Billroth I reconstruction and a truncal vagotomy plus pyloroplasty (p<0.05). Also, only 9.7% of the postgastrectomy patients developed bile reflux gastritis.

Comparison of Tc-99m DISIDA Hepatobiliary Scintigraphy and Percutaneous Needle Biopsy in the Diagnosis of Biliary Atresia from Intrahepatic Cholestasis

We retrospectively evaluated the utility of Tc-99m DISIDA hepatobiliary scintigraphy and percutaneous needle biopsy in differentiating biliary atresia from intraheaptic cholestasis in 60 consecutive infants. Twenty three patients proved to have biliary atresia and remaining 37 patients had intraheaptic cholestasis such as neonatal heaptitis (34 patients), TPN induced jaundice (2 patients) and Dubin-Johnson syndrome (1 patient). All sixty patients underwent Tc-99m DISIDA hepatobiliary scintigraphy with phenobarbital pretreatment. Of 23 patients with biliary atresia, 22 were correctly interpreted showing 96% sensitivity while of 37 patients with intraheaptic cholestasis, only 12 had intestinal excretion of radionuclide showing 32% specificity. Forty needle biopsies were carried out in 17 patients with biliary atresia and 23 patients with intraheaptic cholestasis. Of 40 biopses, 37 were correctly interpreted as either having biliary atresia or intrahepatic cholestasis showing overall diagnostic accuracy of 93%. Of 3 misdiagnostic cases, the histologic findings of two patients with biliary atresia (aged 43 days and 54 days at the first needle biopsy) essentially were the same as those of neonatal heaptitis but follow-up biopsies showed the findings consistent with biliary atresia. The histologic findings of the 3rd patient (VLBW premie with history of 8 weeks TPN) showed mild ductal proliferation and portal fibrosis being interpreted suspicious biliary atresia, but jaundice resolved gradually. In short, the patients who have intestinal excretion of radionuclide on Tc-99m DISIDA hepatobiliary scintigraphy, biliary atresia can be ruled out. But the patients who do not have intestinal excretion of radionuclide should have further investigation as needle biopsy because of high degree of accuracy of percutaneous needle biopsies in differentiating biliary atresia from intrahepatic cholestasis. We conclude that judicious use of a combination of Tc-99m DISIDA hepatobiliary scintigraphy and percutaneous needle biopsy gives correct diagnosis in 95% or more of infantile cholestasis.