Role of biliary scintiscan in predicting the need for cholangiography.

BACKGROUND: Currently used predictors for bile duct calculi in patients undergoing cholecystectomy have low specificity resulting in unnecessary cholangiograms being performed. The role of biliary scintiscan in predicting the presence of bile duct calculi was assessed. METHODS: Seventy-five patients with symptomatic gallstone disease were studied prospectively regard- ing the value of a history of jaundice or acute pancreatitis, raised serum bilirubin and serum alkaline phosphatase levels, and visualization of stones or presence of dilated bile ducts on ultrasonography (standard criteria) in detecting bile duct calculi. Results of biliary scintiscan were evaluated against a combination of standard criteria. The 'gold standard' for evaluation was endoscopic or peroperative cholangiography. RESULTS: Biliary scintiscan had a higher sensitivity and specificity (93 and 94 per cent) than a combination of the above standard and modified predictors for biliary calculi (89 and 71 per cent). A combination of ultrasonography and selective use of scintiscan, in the absence of bile duct dilatation only, had higher values (96 and 98 per cent). CONCLUSION: A combination of ultrasonography and biliary scintiscan can accurately predict bile duct calculi and could be used as a guide for selective cholangiography.

Bone scintigraphy in tuberculous spondylodiscitis.

Tuberculous affection of the spine can present in different ways. Plain radiographs may fail to show any abnormality. Bone scintigraphy can be a very useful tool in the diagnosis and management of patients with tuberculous spondylodiscitis. This is a retrospective study of 40 patients in whom bone scan was performed using 99mTc-MDP (technetium methylene diphosphonate) before starting anti-tuberculous therapy or any surgical intervention. Four different types of uptake were noted. The uptake was abnormal in 38 out of 40 patients, giving a sensitivity of 95%. Multicentricity was picked up in 25% of cases. No skull lesion was noticed in any of these patients. Rib lesions were found in six patients (ten ribs affected). The rib lesion was always a typical band pattern. This paper outlines the advantages as well as limitations of bone scan in tuberculous affection of the spine.

Ascitic fluid filtration and intravenous infusion versus total-volume paracentesis with infusion of plasma expander in cirrhosis with tense or intractable ascites.

BACKGROUND: Patients with cirrhotic ascites have low serum albumin levels, and paracentesis of ascitic fluid could compromise them further. AIM: We compared the therapeutic efficacy of ascitic fluid filtration and concentrate infusion (AFI) versus total-volume paracentesis (TVP) with colloid infusion in control of tense or intractable cirrhotic ascites. METHODS: Ten patients underwent AFI; their ascitic fluid was filtered repeatedly through hollow-fiber hemodialyzer, and the concentrate reinfused intravenously. In ten patients TVP was done with simultaneous intravenous colloid infusion. Follow-up was done weekly and the study terminated if the patient needed diuretics or developed complications. RESULTS: Pre-study parameters were similar in the two groups. In the AFI and TVP groups, the duration of procedure was median 12 hours and 5.5 hours; fluid removed by paracentesis was 10.2 L and 8.0 L, respectively; and fluid infused intravenously was 0.5 L [with mean (SD) protein content 5.7 (1.3) g/dl] and 1.1 L, respectively. Glomerular filtration rates were lower than normal in the two groups but did not change significantly with the procedure; body weight remained significantly lower up to week 3 and week 2, respectively. The study was terminated at median week 3 (range 1-8) and week 2 (1-4), respectively. Fever was an accompaniment of AFI and one patient developed peritonitis. CONCLUSION: Patients undergoing AFI remained diuretic-free longer; the procedure is cost-effective but needs to be further evaluated to minimize the side-effects.

Bone imaging in sports medicine.

Increased participation in sports by the general public leads to increase in sports induced injuries including stress fractures, shin splints, arthritis and host of musculotendenous maladies. We have studied twenty patients referred from sports clinic for bone scanning to evaluate clinically difficult problems. It showed stress fracture in twelve patients, bilateral shin splint in five patients and normal bone scan in three patients. Present study highlights the utility of bone imaging for the diagnosis of various sports injuries in sports medicine.

Hepatic perfusion index in portal hypertension of cirrhotic and non-cirrhotic aetiologies.

The hepatic perfusion index (HPI), the ratio of hepatic arterial to total liver blood flow, was determined by radionuclide angiography in 28 subjects with normal livers and 62 patients with portal hypertension of various aetiologies. The latter group comprised 50 patients with cirrhosis (14 Child class A, 20 Child class B, 16 Child class C) and 12 patients with non-cirrhotic portal hypertension (7 non-cirrhotic portal fibrosis, 5 extrahepatic portal venous obstruction). The mean (+/- S.D.) HPI was significantly higher among the patients with cirrhosis (Child class A, 53.9 +/- 18.1; Child class B, 65.6 +/- 29.4; Child class C, 78.6 +/- 33.5) and non-cirrhotic portal hypertension (54.9 +/- 17.7) compared with the subjects with normal livers (35.6 +/- 10.5). The patients with non-cirrhotic portal hypertension had a mean value similar to that of the cirrhotic patients in Child class A. A higher HPI was associated with worsening liver status. We conclude, therefore, that the HPI will be high in portal hypertension irrespective of aetiology and a rise in the HPI may indicate a deterioration in the condition of the liver.

Scintigraphic detection of bile leak and follow-up in a post-cholecystectomy patient with recognition of tail sign.

Early detection of site and extent of biliary tract disruption can significantly reduce mortality and morbidity in a postoperative biliary leak. We report a case in whom extent and location of post surgical biliary leak was detected with the help of 99mTc BULIDA cholescintigraphy and showed a good correlation with "T" tube cholangiography. Cholescintigraphy was also useful in assessing the follow up of this patient. We conclude that 99mTc BULIDA cholescintigraphy is a non-invasive, safe, simple and sensitive procedure in the detection of the site, extent of the leak and in follow up of the postoperative biliary leak.

Detection of medullary carcinoma of thyroid, with liver metastasis, using 99mTc DMSA(V) scintigraphy.

A sixty year old female referred for thyroid and liver scintigraphy had a clinical history of progressive swelling in the neck with hepatomegaly. A large cold area was detected in the right thyroid lobe using 99mTc pertechnetate and in the right lobe of liver using 99mTc phytate. Subsequent whole body scan with 99mTC DMSA(V) showed avid tracer uptake in right lobe of thyroid and liver. Aspiration cytology of thyroid and liver showed medullary carcinoma of thyroid with its metastasis in liver. Histopathology following thyroidectomy confirmed the diagnosis. Thus 99mTc pentavalent DMSA contributes specificity to diagnose medullary carcinoma of thyroid and metastatic lesions.

SPECT with HMPAO compared to PET with FDG in Huntington disease.

OBJECTIVE: It is the aim of this study to compare the performance of 99mTc-d,l-hexamethylpropyleneamine oxime (HMPAO) SPECT with that of [18F]fluorodeoxyglucose (FDG) PET in detecting striatal dysfunction as it occurs in Huntington disease (HD). MATERIALS AND METHODS: For the determination of regional cerebral glucose consumption, the PET camera PC-4096 was used; the cerebral uptake of HMPAO was measured using the three-head SPECT camera TRIAD. Eight patients with manifest HD, seven subjects at risk for HD, and nine normal individuals were included in the study. In both modalities data evaluation was performed using caudate-to-whole-slice (C/S) ratios. The patients' data were compared to 95% confidence intervals determined in the nine controls. RESULTS: The PET and SPECT C/S values correlated significantly (n = 24; r = 0.87; p < 0.0001). The C/S values were significantly reduced in PET in all eight and in SPECT in seven of the eight HD patients studied. Five of the seven at-risk subjects had normal C/S values in PET and SPECT, one showed reduced C/S values in both diagnostic methods, and the remaining at-risk individual showed a reduced C/S value in PET only. Thus, concordant results between PET and SPECT were obtained in seven of eight patients and six of seven at-risk subjects studied, corresponding to an 87% accuracy of SPECT in the detection of striatal dysfunction as compared to the "gold standard" PET. CONCLUSION: With use of a multidetector camera, HMPAO-SPECT comes near the performance of FDG-PET in the diagnosis of striatal dysfunction as it occurs in HD.

Comparison of direct radionuclide cystography with micturating cystourethrography for the diagnosis of vesicoureteric reflux, and its correlation with cystoscopic appearances of the ureteric orifices.

Forty-eight patients with strong clinical suspicion of vesicoureteric reflux (VUR) as the cause for their renal disease; were subjected to direct radionuclide cystography and roentgenographic micturating cystourethrography for its detection. Forty-four of them underwent cystoscopy under local anaesthesia to document the position and appearance of the ureteric orifices. Of the 92 kidney-ureter 'units' available for study, 20 had reflux positive on micturating cystourethrography and 22 had direct radionuclide cystography positivity. Two of the three units picked up on direct radionuclide cystography but missed on micturating cystourethrography were severe refluxes up to the renal pelvis. On the other hand, one unit missed on direct radionuclide cystography but picked up on micturating cystourethrography was a lower ureteric reflux. The sensitivity and specificity of direct radionuclide cystography to detect VUR as compared to micturating cystourethrography is 95% and 95.8% respectively. The localization and appearance of ureteric orifices which were classified as per Lyon's classification greatly enhanced the predictive value of determining past or present VUR. Patients with golf-hole orifices placed laterally had 100% incidence of reflux. Thus, combining direct radionuclide cystography with cystoscopy may enhance the predictive value for diagnosis of VUR even higher than a micturating cystourethrography study.

Pulmonary metastases on bone scan in a patient with osteogenic sarcoma.

This paper describes a young man who was treated with amputation for osteogenic sarcoma of the lower end of the right tibia. Pre-operative whole body bone scan with 99 mTc did not reveal abnormal tracer concentration in the lungs. A similar follow-up bone scan six months post-operatively demonstrated an area of abnormal tracer concentration in the lower lobe of each lung.

Radionuclide assessment of peritoneovenous shunt patency.

Denver shunt patency can be easily assessed by sequential scintigraphy with a Gamma camera after an intraperitoneal injection of 99mTc sulphur colloid. If the shunt is patent, the tracer will be seen throughout the shunt upto it's opening into the right atrium. The following case report illustrates the application and usefulness of this procedure.

Cholescintigraphic detection of biliary leaks.

We report four cases in whom post-traumatic or post-surgical biliary leak was detected using dynamic 99mtechnetium-iminodiacetic acid (IDA) cholescintigraphy. This technique is a non-invasive, safe, simple and sensitive method of documenting the presence, location and extent of biliary leaks. Further, it can be repeated and hence, is useful in evaluating the response to treatment. Surgery is indicated when a moderate extravasation of labeled bile suggests that the leak is the chief pathway of bile drainage, with relatively little bile entering the intestine.

Scintigraphic right-to-left liver lobe ratio and liver-to-spleen ratio in cirrhosis and non cirrhotic liver diseases.

Various criteria are used together for the scintigraphic diagnosis of cirrhosis as no single criterion may be reliable. However, low right-to-left hepatic lobe uptake ratio has been reported to be sensitive and specific for alcoholic cirrhosis. A low liver-to-spleen uptake ratio has also been reported in various hepatocellular disorders. We tested these ratios in patients with cirrhosis and non cirrhotic causes of portal hypertension. The right-to-left lobe uptake ratio was significantly lower (1.59 +/- 1.23 vs 2.36 +/- 0.63 in normals; p = 0.037) in only Child's C alcoholic cirrhosis, but the sensitivity of this ratio was low (40%) even in this subgroup of cirrhosis (mean +/- SD 1.72 +/- 1.08) as against 1 of 10 patients with non cirrhotic portal hypertension (3.57 +/- 1.33; p = 0.0005). We conclude that the right-to-left hepatic lobe uptake ratio is not a discriminatory scintigraphic sign in liver disease. A low liver-to-spleen uptake ratio can distinguish cirrhosis from non cirrhotic causes of portal hypertension.