Click on Images for Enlarged View

Findings: Hepatobiliary scintigraphy was performed following the intravenous administration of 5 mCi of technetium-99m DISIDA. The early images demonstrate good hepatic accumulation. By ten minutes there is excretion into the biliary ductal system and accumulation at the inferior aspect of the liver adjacent to the portahepatis. Further delayed images demonstrate progressive accumulation of activity in the subhepatic region. This also extends laterally from the inferolateral aspect of the right hepatic lobe.

No further antero grade progression of activity into the small bowel is noted.

Diagnosis: Anastomotic biliary leak.

Discussion: Hepatobiliary scintigraphy is by far the most sensitive examination for the detection of bile leak. It has the advantage over cross-sectional modalities of demonstrating physiology as well as anatomy. CT and U/S might demonstrate a subhepatic fluid collection, but they would not be able to differentiate between ascites, post-operative fluid retention, abscess, hematoma, or bile leak. Only a direct aspiration of fluid to confirm the presence of bile is more sensitive.

Technetium-99m labeled DISIDA is excreted by hepatocytes without biliary conjugation. This radiopharmaceutical is used extensively in the diagnosis of biliary tract disorders, especially acute cholecystitis where lack of visualization of the gallbladder is a highly sensitive sign of acute cystic duct obstruction. This patient had undergone cholecystectomy as part of the liver transplant procedure.

A bile leak is suggested by persistent and progressive accumulation of radiopharmaceutical in a subhepatic location that does not conform to bowel morphology. No change in location over several images helps to confirm diagnosis. In some cases the diagnosis is uncertain due to inability to differentiate between radiopharmaceutical within bowel and activity which is not. A glass of water may help to move intraluminal activity along to allow a definitive diagnosis (i.e. activity which does not move following water ingestion water is extraluminal).

References:

1. George EA, Salimi Z, and Goodgold HM: Value of hepatobiliary imaging
   in the detection of bile leaks and/or obstruction following liver transplantation.
   J Nucl Med 1995;36:218(P).

2. Mohsin J, Reich H, and Alavi A: The role of cholescintigraphy for the
   evaluation of bile leaks. J Nucl Med 1994;35:13(P).

3. Rosenberg DJ, Brugge WR, and Alavi A: Bile leak following elective
   laparoscopic cholecystectomy: the role of hepatobiliary imaging in the
   diagnosis and management of bile leaks. J Nucl Med 1991;32:1777-1781.