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AbdomenDemonstration data

HIDA Hepatobiliary Scintigraphy

Hepatobiliary scintigraphy (HIDA scan) uses a Tc-99m-labelled iminodiacetic acid analogue (mebrofenin or disofenin) that is extracted by hepatocytes and excreted into bile, allowing dynamic evaluation of hepatocyte function, bile flow and gallbladder filling. It is the most specific imaging test for acute cholecystitis (non-visualisation of the gallbladder from cystic-duct obstruction), and with sincalide (CCK) provocation it quantifies gallbladder ejection fraction for suspected chronic acalculous cholecystitis and biliary dyskinesia. It also detects bile leaks and evaluates biliary atresia in neonates.

Indications

  • Suspected acute cholecystitis when ultrasound is equivocal
  • Suspected chronic acalculous cholecystitis / biliary dyskinesia — gallbladder ejection fraction with CCK
  • Detection and localisation of post-operative or post-traumatic bile leak
  • Assessment of biliary-enteric anastomosis patency and biliary obstruction
  • Differentiation of neonatal biliary atresia from neonatal hepatitis (with phenobarbital priming)

Contraindications & Cautions

  • Pregnancy is a relative contraindication; justify and minimise dose
  • Breastfeeding: interruption is generally not required for Tc-99m mebrofenin, though local guidance may advise brief interruption for free pertechnetate
  • Sincalide (CCK) is contraindicated in the presence of gallstones at risk of impaction and in pregnancy
  • Morphine augmentation is contraindicated in suspected complete biliary obstruction, morphine allergy and acute pancreatitis
  • Very high serum bilirubin (>~5-10 mg/dL) reduces hepatic extraction and biliary excretion, degrading study quality (mebrofenin tolerates higher bilirubin than older agents)

Patient Preparation

  • Fast for 4-6 hours to allow gallbladder filling (a full, recently stimulated gallbladder may not fill and mimic obstruction)
  • Avoid a fast longer than ~24 hours or ensure sincalide pre-treatment to empty a stagnant, bile-filled gallbladder
  • Withhold opioids for ~6 hours before the study as they contract the sphincter of Oddi and delay bowel transit
  • For gallbladder ejection fraction, infuse sincalide (0.02 mcg/kg over 60 minutes) to avoid falsely low values from rapid infusion
  • Confirm pregnancy status and recent oral contrast or opioid administration

Technique & Parameters

  • Inject Tc-99m mebrofenin (or disofenin) 185-370 MBq intravenously
  • Acquire dynamic anterior images over the right upper quadrant for ~60 minutes (1 frame/min)
  • If the gallbladder is not seen by 60 minutes, give morphine 0.04 mg/kg IV to contract the sphincter and promote filling, then image a further 30 minutes; alternatively acquire delayed images to 3-4 hours
  • For ejection fraction, infuse sincalide over 30-60 minutes and record pre- and post-stimulation gallbladder counts
  • Add SPECT/CT or delayed lateral/oblique views to localise bile leaks or ectopic accumulation

Systematic Review

  • Confirm prompt hepatic extraction and blood-pool clearance (hepatocyte function)
  • Track biliary excretion into intrahepatic ducts, common duct, gallbladder and bowel and note the timing of each
  • Assess gallbladder visualisation by 60 minutes and after morphine or on delayed images
  • Calculate gallbladder ejection fraction from pre- and post-sincalide counts
  • Search for tracer outside the biliary tree (subhepatic, paracolic, peritoneal) indicating a leak

Key Findings & Significance

  • Non-visualisation of the gallbladder by 60 minutes and after morphine (or by 3-4 h delayed) indicates cystic-duct obstruction / acute cholecystitis
  • Gallbladder ejection fraction below ~35-38% after CCK/sincalide is abnormal and supports chronic acalculous cholecystitis / biliary dyskinesia
  • Pericholecystic hepatic "rim sign" (increased uptake adjacent to the gallbladder fossa) suggests complicated/gangrenous cholecystitis
  • Tracer accumulating outside the ducts and gallbladder confirms a bile leak
  • Absent bowel activity at 24 hours with good hepatic uptake in a neonate suggests biliary atresia

Differential Considerations

  • Gallbladder non-visualisation: acute cholecystitis, chronic cholecystitis, prolonged fasting, recent meal, prior cholecystectomy
  • Delayed bowel transit: biliary obstruction, sphincter of Oddi dysfunction, opioid effect
  • Low ejection fraction: chronic acalculous cholecystitis, biliary dyskinesia, medication effect (opioids, calcium-channel blockers)
  • Extrabiliary activity: bile leak, duodenogastric reflux, free pertechnetate in stomach, urinary/renal excretion
  • Neonatal absent bowel activity: biliary atresia versus severe neonatal hepatitis

Pearls & Pitfalls

  • Non-visualisation is highly specific for acute cholecystitis; delayed visualisation (1-4 h) suggests chronic cholecystitis
  • Both over-fasting (>24 h) and recent eating cause false non-visualisation — control fasting time and consider sincalide pre-treatment
  • Infuse sincalide slowly (over 30-60 min); rapid infusion causes gallbladder spasm and a falsely low ejection fraction
  • The rim sign raises concern for gangrenous cholecystitis and warrants urgent surgical correlation
  • Morphine augmentation shortens the study by promoting gallbladder filling but must be avoided in complete obstruction

Structured Report

  • State tracer, activity, fasting time, and any morphine or sincalide intervention
  • Report hepatic extraction, biliary-to-bowel transit times and gallbladder visualisation timing
  • Give the gallbladder ejection fraction with the reference threshold when performed
  • Describe and localise any bile leak on delayed or SPECT/CT images
  • Provide a clear conclusion addressing acute versus chronic cholecystitis, dyskinesia, leak or obstruction

References

  • Tulchinsky M, et al. SNMMI Practice Guideline for Hepatobiliary Scintigraphy 4.0. J Nucl Med Technol 2010
  • EANM procedure guidelines for hepatobiliary scintigraphy
  • Ziessman HA. Hepatobiliary scintigraphy in 2014. J Nucl Med 2014
  • Tulchinsky M, et al. Radionuclide imaging of the hepatobiliary system. RadioGraphics

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.