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Age: 84

Sex: Male

Indication: Left-sided chest pain, recent cholecystectomy

Radiotracer: Tc99m mebrofenin (an iminodiacetic acid analog)

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Case #1


Findings

  • Linear low level activity is seen around 40 minutes in the two right flank surgical drains. No discrete intraabdominal collections containing radiotracer
  • Prompt liver radiotracer uptake with normal excretion into the biliary tree and bowel in under 60 minutes
  • Normal flow imaging
  • Expected background distribution of radiotracer
  • Small amount of residual activity at the injection site in the left arm


Diagnosis

  • Postoperative bile leak with diversion of leaking bile into two right abdominal biliary drains
  • No large intra-abdominal collection of bile
  • No evidence of obstruction of the common bile duct

Sample Report

Positive for biliary leak, which is drained by the existing surgical drains.

No evidence of intra-abdominal bile collections.

No evidence of common bile duct obstruction.


Discussion

  • The term HIDA comes from the first agent used: (Hepatic) dimethyl IminoDiacetic Acid
  • Hepatobiliary scintigraphy is most commonly used for the physiologic diagnosis of acute calculous cholecystitis, but is also a useful functional tool in the postoperative setting when there is concern for bile leak
  • Surgeries which can be complicated by biliary leak include cholecystectomy, liver transplant, and hepaticojejunostomy
  • Although less common, biliary injury can also occur in the setting of trauma
  • Familiarity with the surgical history and existing surgical drains is important. Likewise, correlation with available anatomic imaging can evaluate for postoperative collections
  • The bile leak protocol is similar to a standard HIDA done for the evaluation of acute cholecystitis, but a few modifications can be made to improve sensitivity:
    • Delayed imaging of the right paracolic gutter, where fluid is likely to accumulate
    • Delayed imaging of the right subdiaphragmatic region including lateral projections, which can identify bile tracking along the liver capsule or even coating the surface of the liver making the liver seem to paradoxically reappear during the study (“reappearing liver sign”)
    • Delayed imaging of drains to evaluate for activity within the collection reservoirs, which can help evaluate for subtle leak. Note that windowing may be necessary to appreciate small amounts of radiotracer activity
    • SPECT/CT to localize any activity if there is question as to the location of the activity (e.g. intraluminal vs peritoneal)
  • Delayed imaging is usually completed at 2-4 hours after injection of radiotracer
  • Treatment of biliary leak depends on the origin of the leak and if there is a coexisting biliary obstruction. Regardless of treatment, follow up HIDA may evaluate for resolution of the leak


Images

Initial postoperative ultrasound in this patient showing a heterogeneous collection in the gallbladder fossa (blue arrows). External biliary drain was then placed by interventional radiology (red arrows). Normal early imaging with normal hepatic uptake (yellow arrows), normal excretion into the common bile duct (green arrows), and normal excretion into bowel (brown arrows). Faint linear activity along the right flank (green arrows) correlating with known surgical drains. After windowing, the radiotracer accumulation within the surgical drains is more apparent (green arrows). Normal activity in the urinary bladder (orange arrows). Infiltration at site of injection in the left arm (purple arrows).

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