Use of a Fatty Meal Cholecystagogue Protocol in Hepatobiliary Scintigraphy for Chronic Functional Gallbladder Disease.

Chronic functional gallbladder disorder, characterized by biliary pain in the absence of structural pathology, poses a diagnostic challenge necessitating reliable cholecystagogues for accurate evaluation. However, recurrent shortages of synthetic cholecystokinin analogs have prompted the exploration of alternative agents. This paper describes the efficacy of Ensure Plus as a viable fatty meal substitute for hepatobiliary scintigraphy in assessing chronic functional gallbladder disorder. Through comparative studies, Ensure Plus demonstrates comparable diagnostic accuracy to cholecystokinin in similar patient populations. Furthermore, Ensure Plus demonstrates significant symptom improvement after cholecystectomy in patients with anomalous gallbladder ejection fractions. This paper offers a detailed protocol for the seamless integration of Ensure Plus into hepatobiliary scintigraphy, providing clinicians with a valuable tool to navigate cholecystokinin shortages while maintaining diagnostic precision in cases of chronic functional gallbladder disorder. The use of Ensure Plus not only addresses practical supply challenges but also underscores its potential as a cost-effective and clinically sound alternative in biliary diagnostics.

Clinical utility of stimulated cholescintigraphy using a standardized Ensure-Plus fatty meal protocol in patients with suspected functional gallbladder disorder: a retrospective study of seven-years clinical experience.

BACKGROUND: The clinical utility of fatty meal stimulated cholescintigraphy particularly using a standardized formulation in patients with suspected functional gallbladder disorder has not been extensively studied. We present our seven-year clinical experience using an Ensure plus protocol. METHODS: A retrospective study was performed on patients undergoing stimulated cholescintigraphy using Ensure Plus for evaluation of suspected functional gallbladder disorder. A gallbladder ejection fraction (GBEF) of <33% was considered abnormal. RESULTS: Of the 173 patients evaluated, 57 (33%) had an abnormal GBEF, 112 (65%) had a normal GBEF and 4 (2%) had no gallbladder visualization. Of the 57 patients with an abnormal GBEF, symptom improvement occurred in 30/31 (97%) who underwent cholecystectomy and in 17/26 (65%) who were managed conservatively (p = 0.003). Of the 112 patients with a normal GBEF, symptom improvement occurred in 8/10 (80%) who underwent cholecystectomy and 74/102 (73%) who were managed conservatively (p = 1.000). In the subgroup of 102 patients with a normal GBEF managed conservatively, those without symptomatic improvement had lower GBEFs compared to those with symptomatic improvement (median GBEF 46% versus 57%, p = 0.019). CONCLUSION: Our retrospective results support a clinical role for stimulated cholescintigraphy using Ensure Plus in the evaluation of patients with suspected functional gallbladder disorder. While an abnormal GBEF predicts good surgical outcome, our results suggest that using an absolute GBEF cut off value of <33% may not apply to all patients and hence GBEF results should only be used as an adjunct in the surgical decision-making process.

Improving Hepatobiliary Imaging as a Physiologic Test with Superior Clinical Outcomes.

This study aims at prospectively evaluating the difference in the effect of cholecystokinin (CCK) and half-and-half milk (HHM) administered in the same patient on gallbladder contractility and correlation with clinical outcomes. Upon gallbladder visualization during standard hepatobiliary imaging, 0.02 µg/kg of CCK was injected over 3 min, and additional 30 min of dynamic imaging was obtained. Patients with gallbladder ejection fraction (GBEF) <35% after CCK were administered 8 oz of HHM followed by 30 min of imaging. The GBEF was recalculated. The number of patients whom GBEF changed from below 35% (abnormal) after CCK to above 35% (normal) after HHM was recorded. Follow-up of the clinical outcome at 6 months was performed. Fifty patients with abnormal GBEF were prospectively included. The average GBEF after CCK was 14.7% ± 8.5% and after HHM was 30.7% ± 20.8%. The average increase in GBEF with HHM was 16.0% ± 22.2%. The GBEF changed from abnormal to normal in 17 patients (34%). The remaining 33 patients remained abnormal. Clinical outcomes at 6 months were available in 47 patients. Cholecystectomy was performed in 60% of patients with abnormal GBEF with CCK and HHM with resolution or improvement of pain. Two of 16 patients (12%) with abnormal GBEF after CCK but normal after HHM had cholecystectomies with pain improvement, while 8 out of these patients (50%) were diagnosed and treated with other disorders and improved. Hepatobiliary imaging with HHM stimulation is a superior physiologic test which can lower the number of unnecessary cholecystectomies and misdiagnoses as functional cholecystitis.

Magnetic resonance thoracic ductography assessment of serial changes in the thoracic duct after the intake of a fatty meal.

The thoracic duct, a terminal lymph vessel, is thought to dilate after the intake of a fatty meal. However, this physiological change has not been well explored in vivo. Therefore, the present study aimed to assess serial changes in the thoracic duct after the intake of a fatty meal using magnetic resonance thoracic ductography (MRTD). Eight healthy volunteers were subjected to one MRTD scan before a fatty meal and eight serial MRTD scans every hour thereafter. The cross-sectional areas of the thoracic duct were estimated using MRTD measurements of the diameters of the thoracic duct at the upper edge of the aortic arch, the tracheal bifurcation, the mid-point between the tracheal bifurcation and the left part of the diaphragm and the left part of the diaphragm. The change-rates in these areas were calculated before and after the fatty meal intake, and the maximal change-rate and timing of its achievement were determined for each subject. The summed change-rates in the four portions of the thoracic duct ranged from -40.1 to 81.3%, with maximal change-rates for each subject ranging from 22.8 to 81.3% (mean, 50.4%). Although individual variations were observed, most subjects (88.9%) exhibited a maximal change-rate at 4-6 h after meal intake, with subsequent decreases at 7-8 h. In conclusion, MRTD revealed a tendency toward thoracic duct enlargement at 4-6 h after the intake of a fatty meal, followed by contraction.

Increase in serum alkaline phosphatase due to fatty meal in undergraduate students of Khyber Medical University, Khyber Pakhtunkhwa.

OBJECTIVE: To evaluate the effect of fatty meal on intestinal alkaline phosphatase. METHODS: The cross-sectional study was conducted at Khyber Medical University, Peshawar, Pakistan from March to April 2014 and comprised young healthy individuals 18-25 years of age. Whole blood samples were collected from the subjects in ethylenediaminetetraacetic acid anti-coagulated and plane serum tubes. For blood group analysis, blood group anti sera were used, while for serum alkaline phosphatase, a chemistry analyser was used. Alkaline phosphatase levels in the blood before and after breakfast were compared. RESULTS: Of the 177 subjects, there were 139(78.5%) men and 38(21.4%) women. Mean fasting alkaline phosphatise level was 144.22+/-75.57, while mean random value was 174.15+/-96.70 (p=0.001). CONCLUSIONS: Serum alkaline phosphatise must be analysed in fasting state early in the morning.

Standardization of "In-House fatty meal" methodology for cholescintigraphy.

AIM: This study was aimed at standardizing the "In-House fatty meal" methodology in cholescintigraphy and to determine gall bladder ejection fraction (GBEF) with this standardized meal. MATERIALS AND METHODS: This is a prospective case-control study where 61 patients having right upper quadrant pain and postprandial bloating and 59 healthy volunteers were included. They underwent (99m)Tc-mebrofenin fatty meal cholescintigraphy following a standard protocol. Dynamic acquisitions over 120 min were done, with a fatty meal being given between 45- and 60-min. Gallbladder emptying kinetics was studied by assessing the time activity curves and calculation of GBEFs were made at 30-min, 45-min, and at 60-min and assessed. RESULTS: The GBEF at 30-min was 74.42% ± 8.26% (mean ± standard deviation), at 45-min was 82.61% ± 6.5%, and at 60-min was 89.37% ± 4.48% in the volunteer group. The lower limit of GBEF in volunteers at 30-min was 58%, 45-min was 69%, and at 60-min was 81%. Receiver operating characteristic (ROC) analysis showed that 30-min GBEF provided the best separation between healthy and diseased subjects with an area under curve of 0.952 (95% confidence interval = 0.914-0.989). The lower limit of GBEF at 30-min was 58%. CONCLUSIONS: An in-House standard fatty meal could be a reproducible alternative to cholecystokinin as it is well-tolerated. Based on ROC curve analysis, we propose that 30-min GBEF provides good separation between healthy and diseased people with this in-House fatty meal. Hence, dynamic acquisitions beyond 30-min postingestion of the fatty meal may not be warranted.

Orange juice intake during a fatty meal consumption reduces the postprandial low-grade inflammatory response in healthy subjects.

BACKGROUND AND AIMS: Evidence associates polyphenol-rich foods to reduction of low-grade inflammation and mortality for cardiovascular disease, the mechanisms underlying such effects being still unclear. Consumption of a fatty meal by healthy volunteers induces rapid and reversible low-grade inflammation. The aim of the present study was to evaluate the effect of orange juice on cellular modifications induced by a fatty meal. METHODS AND RESULTS: 18 apparently healthy subjects consumed a fatty meal, during which they drunk orange juice, either blond or red, or water, according to a randomized cross-over design. Two hours after the end of the fatty meal, both white blood cell (WBC) and platelet counts significantly increased (12.5 and 5%, respectively), while mean platelet volume decreased and a 25% release of myeloperoxidase (MPO) from polymorphonuclear leukocyte occurred. Both juices significantly prevented WBC increase and MPO degranulation, in respect to control. Triglycerides significantly increased (42%) after the fatty meal, but at a lower extent when red orange juice was consumed with the meal (20%), in respect to blond orange juice or control. This effect was statistically significant in the subgroup of 8 subjects with hypertriglyceridemia. Vascular stiffness (augmentation index), measured by Endo-PAT2000, significantly decreased after the meal only in conjunction with red orange juice. CONCLUSION: In healthy subjects the concomitant intake of orange juice may prevent the low-grade inflammatory reaction induced by a fatty meal, at cellular and possibly at vascular function levels. The relative role of different polyphenols on the observed effects of orange juices remains to be established.

Liver enzymes derangement and the influence of diet in animals given oral albendazole.

BACKGROUND: Albendazole is used as an anthelmintic in the treatment of some parasitic infections. This study determined how the effects of albendazole on liver enzymes are influenced by diet. MATERIALS AND METHOD: Thirty adult male Wistar rats of mean weight 304.12 ± 11.34 g were randomly grouped into five: Group A: Control, was given rat pellets and water only; Group B received 15 mg/kg/d of albendazole while fasting; Group C received 15 mg/kg/d of albendazole with fatty meal; Group D received 15 mg/kg/d of albendazole with normal diet (rat pellets); and, Group E received 30 mg/kg/d of albendazole with normal diet (rat pellets); they were given orally for 3 consecutive days. The animals were sacrificed thereafter and blood samples obtained for quantitative study of the serum activities of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP). RESULTS: Significant elevation in the serum levels of the transaminases especially in animals which were on their normal diet (rat pellets), while ALP was either reduced or increased based on dietary factors. CONCLUSIONS: Oral administration of albendazole before meal or with a fatty diet could help limit severe elevation of liver enzymes associated with its use, while still ensuring optimal efficacy.

Postprandial effect of orlistat on the peaking of lipid level after sequential high fat meals.

BACKGROUND: Postprandial lipemia has been found to be strongly associated with atherosclerosis due to its atherogenic and thrombogenic lipoprotein changes. This phenomenon occurs even in normal subjects especially after high fat meals. Orlistat, an anti- obesity drug, has been shown to address postprandial lipemia after a single high fat meal. OBJECTIVES: To compare the effects of orlistat and placebo on the postprandial lipid levels after sequential high-fat meals in healthy individuals with normal fasting lipid levels. PATIENTS AND METHODS: Thirty-one healthy adult volunteers with normal fasting lipid levels were fed 50% fat meals (3 meals and 2 snacks of pre-weighted butter and bread). The subjects were blindly randomized to receive either placebo or orlistat 120 mg before each main meal. The outcome parameters were total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and very-low-density lipoprotein (VLDL) cholesterol levels measured at fasting (0 h) and every 2 h thereafter, until the sixteenth hour. Additionally, we estimated the lipid levels at the fifth and ninth hour. RESULTS: The non-orlistat group showed a significant postprandial rise in the levels of TG and VLDL, which began 4 h after breakfast (P < 0.05); this rise in levels was sustained until 9 h after breakfast for TG and up to 10 h after breakfast for VLDL. In contrast, only one significant rise in both TG and VLDL levels (at 4 h after breakfast) was noted in the orlistat group. The maximum mean difference from the baseline TG level for the orlistat group was lower than that for the non-orlistat group (0.22 mmol/L vs. 0.756 mmol/L, respectively). Similarly, the maximum mean difference from the baseline VLDL level from baseline in the orlistat group was only 0.099 mmol/L, which was lower than that in the non-orlistat group (0.588 mmol/L). LDL levels rose to a lesser extent in the orlistat group than in the non-orlistat group (0.268 vs. 0.362 mmol/L). The TC levels did not show a postprandial rise; instead, the levels reduced in both groups, with the orlistat group showing a higher reduction than the non-orlistat group (-0.288 vs. -0.188 mmol/L). The orlistat group did not show any significant differences in the HDL measurements. CONCLUSIONS: Administration of orlistat abolished the significantly sustained postprandial rise of TG and VLDL levels in healthy individuals who were fed sequential 50% fat meals.

Advances in endoscopic retrograde cholangiopancreatography cannulation.

Endoscopic retrograde cholangiopancreatography is an important tool in the diagnosis and treatment of pancreatobiliary diseases. A critical step in this procedure is deep cannulation of the bile duct as failure of cannulation generally results in an aborted procedure and failed intervention. Expert endoscopists usually achieve a high rate of successful cannulation while those less experienced typically have a much lower rate and a greater incidence of complications. Prolonged attempts at cannulation can result in significant morbidity to patients, anxiety for endoscopists, unnecessary radiation exposure and inefficient patient care. Here we review the most common endoscopic techniques used to achieve selective biliary cannulation. Pharmacologic aids to cannulation are also discussed briefly in this review.

Reproducibility of gallbladder ejection fraction measured by Fatty meal cholescintigraphy.

PURPOSE: There are conflicting data in the literature regarding the reproducibility of the gallbladder ejection fraction (GBEF) measured by fatty meal cholescintigraphy (CS). We aimed to test the reproducibility of GBEF measured by fatty meal CS. METHODS: Thirty-five subjects (25 healthy volunteers and 10 patients with chronic abdominal pain) underwent fatty meal CS twice in order to measure GBEF1 and GBEF2. The healthy volunteers underwent a repeat scan within 1-13 months from the first scan. The patients underwent a repeat scan within 1-4 years from the first scan and were not found to have chronic acalculous cholecystitis (CAC). Our standard fatty meal was composed of a 60-g Snickers chocolate bar and 200 ml full-fat yogurt. RESULTS: The mean ± SD values for GBEF1 and GBEF2 were 52 ± 17% and 52 ± 16%, respectively. There was a direct linear correlation between the values of GBEF1 and GBEF2 for the subjects, with a correlation coefficient of 0.509 (p = 0.002). Subgroup data analysis of the volunteer group showed that there was significant linear correlation between volunteer values of GBEF1 and GBEF2, with a correlation coefficient of 0.473 (p = 0.017). Subgroup data analysis of the non-CAC patient group showed no significant correlation between patient values of GBEF1 and GBEF2, likely due to limited sample size. CONCLUSIONS: This study showed that fatty meal CS is a reliable test in gallbladder motility evaluation and that GBEF measured by fatty meal CS is reproducible.