A new diagnostic approach to biliary atresia with emphasis on the ultrasonographic triangular cord sign: comparison of ultrasonography, hepatobiliary scintigraphy, and liver needle biopsy in the evaluation of infantile cholestasis.

1
A new diagnostic approach to biliary atresia with
emphasis on the ultrasonographic triangular cord
sign comparison of ultrasonography,
hepatobiliary scintigraphy, and liver needle
biopsy in the evaluation of infantile
cholestasis.
2
BACKGROUND/PURPOSE (1)

• the utility of ultrasonography (US),
  Tc-99m-DISIDA hepatobiliary scintigraphy (HS),
  and liver needle biopsy (NBx) in differentiating
  biliary atresia (BA) from intrahepatic
  cholestasis in 73 consecutive infants who had
  cholestasis.

3
BACKGROUND/PURPOSE (2)

• Infantile cholestatic jaundice
• Kasai procedure
• USscreening, focus on shape or contractility of
  gallbladder
• AIM reassess the relative accuracy and the role
  of US, HS, NBx in D/D cholestasis

4
METHODS (1)

• US 7.0-MHz transducer, focusing on the fibrous
  tissue at the porta hepatis.
• Triangular cord (TC) visualization of a
  triangular or tubular shaped echogenic density
  just cranial to the portal vein bifurcation on a
  transverse or longitudinal scan.

5
METHODS(2)

• Time Mar. 1992 Oct. 1996
• 73 infants, age12120 d/o with conjugated
  hyperbilirubinemia or clay- colored stool,
  average T/D 109/6.3
• US TC ?BA no TC?NH or other cause
• HS no excretion of tracer in 24 hrs?BA
• excretion of tracer in 24 hrs?NH or other

6
RESULTS (1)

• 17 / 20 BA infant denoted TC on US,
• 43 no TC infants either NH or other causes of
  cholestasis
• diagnostic accuracy 95
• Sensitivity 85
• Specificity 100

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RESULTS (2)

• 24 / 25 BA infants no gut excretion on HS
• 16 / 46 infants who had either NH or other causes
  of cholestasis had gut excretion
• diagnostic accuracy 56
• Sensitivity 96
• Specificity 35

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RESULTS (3)

• HS gut excretion of tracer ?excluded BA,
• no gut excretion of tracer ?need further
  investigations as liver needle biopsy.
• 44 NBx 19 BA infants
• 24 infants who had either NH or other causes
  of cholestasis.

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RESULTS (4)

• 18 / 20 correctly interpreted as having BA, 23 /
  24 were correctly diagnosed either NH or other
  causes of cholestasis
• diagnostic accuracy 93
• Sensitivity 90
• Specificity 96

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RESULT (5)
Sensitivity () Specificity () Accuracy ()
US 85 100 95
HS 96 35 56
NBx 90 96 93
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CONCLUSIONS (1)

• TC sign on US in the diagnosis of BA seemed to
  be a simple, time-saving, highly reliable, and
  non-invasive tool in the diagnosis of BA from
  other causes of cholestasis.
• When the TC is not visualized, HS is the next
  step. Excretion of tracer into the small bowel
  actually rules out BA.

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CONCLUSIONS(2)

• Liver needle biopsy is reserved only for the
  infants with no excretion of tracer.
• new diagnostic strategy in the evaluation of
  infantile cholestasis emphasis on US TC sign as
  first priority of investigations. When the TC is
  visualized, prompt exploratory laparotomy is
  mandatory without further investigations.

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Use of (99m)Tc-DISIDA biliary scanning with
morphine provocation for the detection of
elevated sphincter of Oddi basal
pressure.Source Gut. 46(6)838-41, 2000 Jun.
14
BACKGROUND (1)

• Endoscopic biliary manometry is useful in the
  assessment of patients with types II and III
  sphincter of Oddi dysfunction, but it is time
  consuming and invasive.

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BACKGROUND (2)

• Recurrent biliary-type pain post-cholecystectomy
  in the absence of pancreaticobiliary
  abnormalities is often attributed to sphincter of
  Oddi dysfunction (SOD).
• Endoscopic biliary manometry (EBM) remain the
  investigation of choice and predict response to
  endoscopic sphincterotomy

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BACKGROUND (3)

• Disadvantage of EBM
• 1.time consuming
• 2.not widely available
• 3.may be associated with complication such as
  pancreatitis

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BACKGROUND (4)

• Clinical differentiation of SOD ? 3 types on the
  basis of transaminase and ERCP abnormalities
• Type 1 generally good response to endoscopic
  sphincterotomy and not necessarily require EBM
  confirmation

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BACKGROUND (5)

• Type 2 and 3 poor correlation with the result
  of EBM and less predictable to endoscopic
  sphincterotomy
• Due to the limitation of EBM?try other less
  invasive approach
• Tc-99m-DISIDA?less sensitive in detecting
  elevated sphincter of Oddi basal pressure (SOBP)

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BACKGROUND (6)

• Modification with morphine augmentation
• Morphine
• 1.functional obstruction of common bile duct
• 2.spasm of the sphincter of Oddi
• ?hypothesis morphine administration may
  accentuate functional abnormalities in pt with
  SOD

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AIM

• To investigate the role of (99m)Tc-DISIDA
  scanning, with and without morphine provocation,
  as a non-invasive investigation in these patients
  compared with EBM

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METHODS (1)

• Total 34 pt type II (n 21) or III (n 13)
  sphincter of Oddi dysfunction were studied.
• Biliary scintigraphy with 100 MBq of
  (99m)Tc-DISIDA was carried out with and without
  morphine provocation (0.04 mg/kg intravenously)
  and time/activity curves were compared with the
  results of subsequent EBM.

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METHODS (2)

• The criteria for type 2 SOD
• (a) unexplained biliary-type pain persisting for
  gt 6 months post cholecystectomy
• (b)either one or two of the following objective
  findings suggesting partial common bile duct
  obstruction
• CBD dilationgt12 mm in ERCP
• delayed emptying of contrast medium in ERCP
• abnormal liver function(? gt 2)

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METHODS (3)

• Type 3 SOD
• those with typical pain but without any of
  the objective signs listed

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RESULTS (1)

• 18 (9 type II, 9 type III) of the 34 (53)
  patients had SOBP gt upper limit of normal (40 mm
  Hg).
• In the standard DISIDA scan without morphine, no
  significant differences were observed in time to
  maximal activity (Tmax) or percentage excretion
  at 45 or 60 minutes between those with normal and
  those with abnormal EBM.

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RESULTS (2)

• With morphine provocation
• median percentage excretion at 60 minutes was
  4.9 in those with abnormal manometry and 28.2
  in the normal manometry group (p 0.002).

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RESULTS (3)

• Using a cut off value of 15 excretion at 60
  minutes, the sensitivity for detecting elevated
  SOBP by the morphine augmented DISIDA scan was
  83 and specificity was 81.

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RESULTS (4)

• 14 of the 18 patients with abnormal manometry
  complained of biliary-type pain after morphine
  infusion compared with only two of 16 patients in
  the normal manometry group (p 0.001).

28
DISCUSSION (1)

• If SOBP?, then good response to sphincterotomy
• In EMB
• SOBP?in (a) gt90 type 1
• (b)1086 type 2
• (c)055 type 3

29
DISCUSSION (2)

• Effect of Morphine in normal individuals
• 1.cause spasm of sphincter
• 2. ?CBD pressure
• 3. ?phasic pressure wave, basal sphincter
  pressure, phasic wave amplitude
• ?In abnormal SOBP pt,this effect was greatly
  enhanced

30
DISCUSSION (3)

• Morphine injection was found to induce pain in
  pt with elevated SOBP.
• EBM is the gold standard in the Dx of SOD
• ?may not necessarily be true

31
CONCLUSIONS

• (99m)Tc-DISIDA with morphine provocation
  useful non-invasive investigation for types II
  and III SOD to detect those with elevated SOBP
  who may respond to endoscopic sphincterotomy.

32
Hepatobiliary scintigraphy is superior to
abdominal ultrasonography in suspected acute
cholecystitis. Surgery. 127(6)609-13, 2000 Jun.
33
BACKGROUND

• Hepatobiliary scintigraphy is a very accurate
  test in the diagnosis of acute cholecystitis.
• However, ultrasonography is extensively used for
  the diagnosis of this disease.
• In this study, we directly compare the diagnostic
  accuracy of these techniques for acute
  cholecystitis.

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Materials and Methods

• The diagnostic accuracy of scintigraphy and
  ultrasonography was evaluated in 107 consecutive
  patients with suspected acute cholecystitis who
  underwent both imaging modalities within one day.
  
• The incremental diagnostic value of each modality
  was determined.

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RESULTS (1)

• The diagnostic value of scintigraphy for the
  entire cohort was significantly superior to
  ultrasonography the addition of the information
  derived from the latter did not further improve
  the diagnostic value of scintigraphy (global,
  chi(2) 58.2).

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RESULTS (2)

• The sensitivity, specificity, positive and
  negative predictive values, and accuracy for the
  diagnosis of acute cholecystitis in the entire
  cohort were superior for scintigraphy compared
  with ultrasonography.
• The accuracy was 92 for scintigraphy and 77 for
  ultrasonography. Similarly, if only surgically
  treated patients were considered, the accuracy of
  scintigraphy was 91 versus 61 for
  ultrasonography.

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CONCLUSIONS

• Hepatobiliary scintigraphy has superior
  diagnostic accuracy for acute cholecystitis
  compared with ultrasonography. The addition of
  ultrasonography does not further improve the
  diagnostic accuracy of scintigraphy alone.