PPLIED RADIOLOGY

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September

2016

APPLIED HEPATOBILIARY SCINTIGRAPHY IN CHRONIC GALLBLADDER DISEASES

SA-CME

gallbladder disorder in the proper clini-

cal setting.”

It is important to adhere to

this recommendation in order to improve

consistency of our reporting.

Chronic calculous cholecystitis

Presence of gallstones (cholelithiasis)

in the general population is as high as 1

in every 5 people.

They are classified

into asymptomatic and symptomatic.

Establishing asymptomatic cholelithi-

asis is obvious when there are no ab-

dominal complaints. But the seemingly

simple division is complicated in many

patients with abdominal pain because

of inherent challenges in eliciting and

interpreting subjective symptoms. The

combination of typical chronic biliary

symptoms and anatomical demonstra-

tion of cholelithiasis is a reliable evi-

dence of chronic cholecystitis, requiring

no further diagnostic evaluation prior to

cholecystectomy. However, additional

diagnostic testing may be useful in pa-

tients with atypical abdominal symptoms

and cholelithiasis in order to afﬁrm causal

relationship by demonstrating abnor-

mal GBEF. Administration of sincalide

in patients with cholelithiasis could be

viewed by some professionals as unsafe

for the concern of dislodging a stone and

precipitating biliary tract obstruction

and/or pain. The fact remains that there

are studies that used sincalide in patients

with known gallstones and none reported

obstructive complications. Abdominal

pain was reported in 1/67 patients with

gallstones during sincalide infusion.

The

consensus of specialists also found no

evidence for this concern and considered

sincalide testing safe.

The literature ex-

perience shows that majority of patients

(>75%) with gallstones and abdominal

symptoms have normal GBEF.

This

means that their abdominal pain is of

non-GB etiology. On the other hand, ab-

normal GBEF was a strong predictor of

biliary pain recurrences.

Non-gallbladder ﬁndings leading

to cause of abdominal pain

It is important to carefully examine

the images for other potential causal

ﬁndings. The ﬁnding of the malrotation,

as shown in Figure 3, is one such causal

ﬁnding that while very rare is deﬁnitely

most consequential. Another finding

to watch out for is increased peristalsis

that may indicate irritable bowel syn-

drome when activity transits rapidly

into the colon after sincalide adminis-

tration.

This ﬁnding needs to be clini

cally correlated by the referring service.

In many cases one can observe some

duodenogastric reflux of bile, which

when prominent should be suggested as

a potential cause of bilious gastritis.

Practical interpretation algorithm

In patients with chronic abdominal

pain and abnormal GBEF on CCK-HBS,

the pertinent information should be que-

ried for the absence or presence of gall-

stones and/or sludge. If an anatomical

study is normal, the most appropriate

interpretation would be to suggest the di-

agnosis of FGBD. If, on the other hand,

there is presence of stones and/or sludge,

the interpretation should implicate

chronic calculous cholecystitis. While

this represents a simple algorithm, it is

probably too simple to fully capture the

clinical reality. It is well understood that

with time the poor motility of the GB

observed in FGBD may lead to forma-

tion of sludge and later probably results

in GB stones. Yet the above interpreta-

tional algorithm offers a reasonable and

a logical approach. In those with normal

CCK-HIDA, it is important to scrutinize

the study for causal non-GB ﬁndings.

Conclusion

HBS continues to enjoy frequent ap-

plication in clinical gastroenterology,

particularly in the workup of chronic bil-

iary pain. The most appropriate indica-

tion remains suspected FGBD in patients

with biliary-type or atypical chronic ab-

dominal pains and negative ﬁndings on

anatomical imaging. The preponderance

of evidence is in favor of using abnormal

GBEF as a pathophysiological rationale

for identifying abnormal GB function in

these patients and using this ﬁnding for

selecting patients for cholecystectomy.

Adherence to the standard GB stimula-

tion methodology is critical for preventing

false-positive results and calls for admin-

istration of 0.02 micrograms of sincalide

per kilogram of body weight that should

be infused over 60 minutes. However,

more evidence is needed to establish util-

ity of this test in patients with cholelithi-

asis in the era of optimized sincalide

infusion standardization.

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