uhrad.com - Nuclear and SPECT Teaching Files
Case Nine -Bile Leak
DISIDA Scan (Image 1 and Image 2)
CT Scan (Images 1, 2 and 3)
Click on Images for Enlarged View
Clinical History: Patient is s/p open cholecystectomy, presented to the emergency room on post op day 10 with abdominal pain, vomiting.
Findings:
- DISIDA scan: Image 1 shows abnormal collection of radiopharmaceutical around liver, in region of Morrison’s pouch and tracking along right paracolic gutter into pelvis. Image 2 is a delayed image obtained at 60 minutes post injection and further demonstrates abnormal location of radiopharmaceutical.
- CT scan of abdomen and pelvis done following administration of oral and IV contrast. Image 1 shows clips in gallbladder fossa c/w cholecystectomy and perihepatic fluid collection. Image 2 shows fluid in Morrison’s pouch. Image 3 shows free fluid in pelvis, corresponding with the abnormal distribution of radiopharmaceutical seen on DISIDA scan.
Diagnosis: Bile leak.
Discussion: Hepatobiliary scan is the most appropriate non-invasive imaging technique for evaluation of bile leaks. The reported sensitivity of DISIDA scan is 87% and specificity 100%, when minimal flow of 2-3 ml of labeled bile is present; and when the study is continued either till a leak is demonstrated or the radiopharmaceutical is completely cleared from the liver. Typically, the radiopharmaceutical is seen in an extrahepatic and extraluminal location and the activity gets more intense with time. It has been suggested that standing views may be helpful in addition to anterior oblique views to differentiate intraluminal/gastric activity from a true leak. Having the patient ingest water to help wash out intraluminal tracer may be another helpful technique for differentiating intraluminal activity from a leak.
References:
- Creutzig H, et al. Follow up of liver transplanted patients with radionuclides.
In Lutz M, ed: Imaging Methods in Hepatology, Lancaster, 1989, MIT.
- Rosenberg D, Brugge WR, Alavi A. Bile Leak Following an Elective Laparascopic
Cholecystectomy: The Role of Hepatobiliary Imaging in the Diagnosis and Management
of Bile Leaks. Journal of Nuclear Medicine, Vol. 32, No. 9, pp. 1777-1781.
- Lette J., et al. Standing Views to Differentiate Gallbladder or Bile leak From Duodenal
Activity on Cholescintigrams. Clinical Nuclear Medicine, Vol. 15, April 1990, pp. 231-236.
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Submitted by:
Puneet Singha, M.D.
Peter Faulhaber, M.D.
