Hepatobiliary scintigraphy uses radiolabeled tracers like Tc-99m mebrofenin to evaluate liver function and bile flow. It is indicated for conditions like neonatal jaundice, bile leaks, and gallbladder disease. The tracer is taken up by hepatocytes and secreted into bile for imaging. Imaging involves static and dynamic acquisition over hours. Interpretation looks for normal tracer flow and any delays, leaks, or other abnormalities that could indicate underlying bile disorders.

1. MEMBROFENIN
SCINTIGRAPHY IN BILE
DISORDERS
Presenter: Dr. Ravishwar Narayan

2. INTRODUCTION

3.  Hepatobiliary scintigraphy evaluates
hepatocellular function and the biliary
system by tracing the production and flow
of bile from the formative phase in the
liver, and its passage through the biliary
system into the small intestine.

4. INDICATIONS

5.  Neonatal hyperbilirubinemia (biliary
atresia vs. neonatal hepatitis)
 Enterogastric (duodenogastric) reflux
assessment
 Assessment of biliary enteric bypass for
bile leakage (e.g., Kasai procedure)
 Esophageal bile reflux after gastrectomy
 Acute cholecystitis
 Chronic cholecystitis

6. RADIOPHARMACY

7.  Radionuclide
99mTct1/2: 6 hours
Energies: 140 keV
 Radiopharmaceutical
◦ IDA (Imino Diacetic Acid)
◦ DISIDA (2,6-diisopropylacetanilido-
iminodiacetic acid)
◦ BRIDA (2,4,6-trimethyl,5-bromoacetanilido-
iminodiacetic acid/ mebrofenin)

8. Biokinetic features of Tc-99m mebrofenin and Tc-99m disofenin

9. Albumin delivers the radiotracer to the space of Disse. Tc-99m HIDA is taken up by the
hepatocyte and secreted into bile canaliculi in free form where it mixes with the hepatic bile
and serves as an ideal in vivo tracer for imaging of the entire hepatobiliary tree

10.  NPO for 4–6 hours (2 hours for infants)
 no opiates for 4 to 8 hours prior to exam
 Explain the procedure
PATIENT PREPARATION

11. EQUIPMENT & COMPUTER SETUP

12.  Camera: Large field of view
 Collimator: LEAP/ LEHR
 Computer Set-up
◦ Static Images: 500,000–1 million counts
◦ Flow Studies: 2 sec/frame for 60 seconds, then
immediate blood pool image
◦ Dynamic Studies: 60 sec/frame for 60–90
minutes
◦ Delayed images may be needed till 24 hrs

13.  Positioning:
◦ patient supine
◦ camera anterior
◦ liver in upper left quadrant of field of view

14. PHARMACOLOGIC INTERVENTIONS

15.  Cholecystokinin:
◦ If patient is NPO for many hours, GB becomes
inactive, may be full of bile or sludge and so
may not visualize. CCK is used to contract
gallbladder so that visualization of bowel may
occur after refilling
◦ 0.02 µg/ kg body wt. slow IV
◦ Contraindication: recent positive ultrasound
examination for gallstones.

16.  Morphine Sulphate :
◦ When acute cholecystitis is suspected and the
gallbladder is not seen by 30–60 min, 0.04
mg/kg morphine sulfate may be administered
slow I.V.
◦ If the cystic duct is patent, flow of bile into the
gallbladder will be facilitated by morphine-
induced temporary spasm of the sphincter of
Oddi
◦ Imaging is continued for another 30–60 min
after morphine administration.

17. ◦ Imaging after morphine injection distinguishes
between acute [no visualization] and chronic
[eventual visualization] cholecystitis.
◦ Contraindications:
 increased intracranial pressure in children
 respiratory depression in non-ventilated patients
 allergic to morphine
 history of pancreatitis

18.  Phenobarbital
◦ 5 mg/ kg/day in two equally divided doses, for
5–7 days prior to cholescintigraphy.
◦ Phenobarbital stimulates bile production and
increases the secretion of the radiotracer into
bile, enabling better delineation of bile ducts
and duodenum in infants with neonatal
hepatitis, but not in those with congenital
biliary atresia

19. INTERPRETATION

20.  Normal Results
◦ Visualization of liver 5–15 seconds after
injection
◦ hepatic and common bile duct and gallbladder
5–60 minutes.
◦ Intestinal activity within 10–60 minutes
◦ Gallbladder filling implies a patent cystic duct
and excludes acute cholecystitis with a high
degree of certainty

21. Normal cholescintigraphy.

22.  Bile leak
◦ present when tracer is found in a location other
than the liver, gallbladder, bile ducts, bowel, or
urine
◦ Causes:
 Post procedural: M.C.
◦ cholecystectomy, liver transplant
 Trauma to right upper quadrant area

25.  Biliary atresia
◦ Non visualization of Extra hepatic biliary tree &
failure of tracer to enter the gut
◦ d/d:
 hepatocellular disease

26. Efficacy of cholescintigraphy, ultrasonography, and liver biopsy in the
differential diagnosis of congenital biliary atresia from neonatal
hepatitis

27. Biliary tract evaluation

28.  Bile reflux
◦ Activity reflux from the duodenum into the
stomach.
◦ Spontaneously in ~8%
◦ post op.
 vagotomy,
 hemigastrectomy
 Bilroth II gastrojejunostomy

29. 1 min/frame static images showing entero-gastric reflux at 30th min

30.  Acute cholecystitis
◦ persistent gallbladder non-visualization after
3–4 hr. of passive imaging or 30 min. after
morphine administration
◦ pericholecystic hepatic band of increased
activity (rim sign) has been associated with
severe phlegmonous or gangrenous acute
cholecystitis, a surgical emergency

31. RIM SIGN: pericholecystic hepatic band of increased activity

32. ◦ Morphine-augmented hepatobiliary scintigraphy
has sensitivity, specificity, positive predictive
value, and negative predictive value of 95%,
99%, 97%, and 98%, respectively
(c/f USG Abd: positive predictive value of
>90% in detecting acute cholecystitis)

33.  Chronic cholecystitis
◦ gallbladder visualization within 30 min of
morphine administration or on 3-4 hr delayed
images
◦ gallbladder that is not visualized until after the
time that the bowel is visualized correlates
significantly with chronic cholecystitis.

34.  Gallbladder EF
◦ Normal: ≥ 35%
◦ Abnormal: < 35%
 suggestive of
◦ chronic cholecystitis
◦ cystic duct syndrome
◦ sphincter of Oddi spasm
◦ gallbladder dyskinesia

35.  Gallbladder EF

36. ◦ The finding of reduced gallbladder ejection
fraction in response to Cholecystokinin is a
strong indicator of the need for surgical
intervention
◦ Negative predictive value of a normal
gallbladder ejection fraction is >91%,

37. False positives False negatives
(gallbladder non-visualization (gallbladder visualization in
in the absence of acute the presence of acute
cholecystitis) cholecystitis)
Insufficient fasting bile leak due to gallbladder
perforation
Prolonged fasting bowel loop simulating gallbladder
Previous cholecystectomy Acute acalculous cholecystitis

41. Causes of enterogastric reflux
Spontaneously in ~8%
 post op.
◦ vagotomy,
◦ hemigastrectomy
◦ Bilroth II gastrojejunostomy

42. pathophysiology
 mechanism of reflux is related to the lack of
normally functioning gallbladder.
 In the absence of the usual storage of bile
with release on cholecystokinin (CCK)
stimulation, the patient develops a constant
drip of bile into the duodenum.
 After meals there is a postdigestive phase of
food leaving the stomach, mixing with the
bile pancreatic and duodenal secretions, and
all being swept downstream in the normal
fashion

43.  Two hours after a meal and especially
during extended periods of fast, e.g.,
during sleep, the bile pools in the
duodenum, most going downstream and
some refluxing backward through the
pylorus into the antrum.
 In time, the presence of the biliary
pancreatic duodenal secretions in the
stomach produces such an irritant effect
that significant gastritis and esophagitis
result.

44.  criteria for the diagnosis of reflux
gastritis:
◦ constant burning epigastric pain
◦ worse after meals
◦ unrelieved by antacids and diet
◦ endoscopic demonstration of a gastric bile pool
◦ endoscopic biopsy proof of gastritis and
esophagitis
◦ hypochlorhydria.

45. treatment
 Medical:
◦ Bland diet
◦ Metoclopromide
 Surgical:
◦ Roux-en-Y drainage of the biliary system and
Braun enteroenterostomy (BEE)

46.  Dose Range
◦ Adults:
 3–5 mCi
 higher doses (upto 15 mCi) for patients with
elevated bilirubin levels (causes less hepatic
uptake, more background activity, and greater
renal excretion).
◦ For children:
 0.05–0.07 mCi per kg
 minimum dose = 0.3 mCi

47.  Ensure patient
 Ensure patient has had. Injection and
imaging may be postponed 4 hours if
patient has been injected with this type of
medication.
 Explain the procedure; usually runs ~1
hour but baseline studies can go as long
as 4 hours with up to 24-hour delays
required in some instances.

48. indications

50.  Sequential (or dynamic) images of the
liver, biliary tree, and gut are obtained.
 Computer acquisition and analysis,
including pharmacologic interventions, are
used according to varying indications and
an individual patient’s needs.

51. No bowel excretion or gallbladder visualization is noted
small arrowhead: kidney activity
large arrowhead:bladder

52. Normal neonatal hepatobiliary scan