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INTERESTING IMAGE
Year : 2021  |  Volume : 36  |  Issue : 3  |  Page : 351-353  

Simultaneous detection of biliary injury and vascular infarct using 99mTc-HIDA scintigraphy in a patient with trauma


Department of Nuclear Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission22-Jan-2021
Date of Decision07-Apr-2021
Date of Acceptance07-May-2021
Date of Web Publication23-Sep-2021

Correspondence Address:
Dr. Anshul Sharma
Department of Nuclear Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.ijnm_8_21

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   Abstract 


A 45-year-old male with a history of trauma was referred to the department of nuclear medicine to identify site of a biliary leak, which could not be identified in ultrasound and exploratory laparotomy. Contrast-enhanced computed tomography (CT) was able to identify lacerations in the right lobe of the liver, but the extent of injury to the biliary pathways and vessels was unclear. 99mTc-HIDA scintigraphy with single-photon emission CT/CT was not only able to identify the site of leak but also the extent of infarcted area.

Keywords: 99mTc-HIDA, biliary leak, single-photon emission computed tomography/computed tomography, vascular infarct


How to cite this article:
Jaiswal H, Sharma A, Singh TP, Sethi RS. Simultaneous detection of biliary injury and vascular infarct using 99mTc-HIDA scintigraphy in a patient with trauma. Indian J Nucl Med 2021;36:351-3

How to cite this URL:
Jaiswal H, Sharma A, Singh TP, Sethi RS. Simultaneous detection of biliary injury and vascular infarct using 99mTc-HIDA scintigraphy in a patient with trauma. Indian J Nucl Med [serial online] 2021 [cited 2021 Dec 8];36:351-3. Available from: https://www.ijnm.in/text.asp?2021/36/3/351/326555




   Case Top


A 45-year-old m ale sustained a fall from height, after which he became unconscious. After regaining consciousness, he complained of severe abdominal pain, which was nonradiating and not relieved by medication. After focused assessment with sonography in trauma assessment, diagnosis of blunt trauma to the abdomen with hemoperitoneum and Grade III liver injury was made. The patient underwent exploratory laparotomy with peritoneal lavage, and a left pelvic drain was placed. Over the course of next few days, leak (with bile) of >500 mL was noted from the drain. Ultrasound was only able to identify some free fluid in the peritoneal cavity. Contrast-enhanced computed tomography (CECT) identified nonenhancing lacerations in the segments V/VIII and doubtful involvement of segment IV of the liver with likely areas of infarct in the right lobe. The patient was referred to the department of nuclear medicine with primary objective of identification of the site of biliary leak. During the dynamic images, reduced extraction with persistent photopenia was noted in the region of the right lobe of the liver [Figure 1]a and [Figure 1]b. On the other hand, preserved radiotracer extraction was noted in the left lobe of the liver [Figure 1]. Biliary leak was seen in the subhepatic region within 15 min, which rapidly transited into the peritoneal cavity. Single-photon emission computed tomography (SPECT)/computed tomography (CT) was acquired to evaluate the tracer in the intestines. It showed a significant radiotracer collection in the hilum [Figure 2]a and [Figure 2]b and the right subhepatic region [Figure 2]c and [Figure 2]d. Radiotracer activity was also seen transiting from the hilar region into the duodenum and distal intestines [Figure 2]e and [Figure 2]f. In addition, a relatively hypodense area with no significant radiotracer activity was noted in the segments V/VIII of the right lobe of the liver (corresponding to the site of vascular infarct as identified in CECT) [Figure 2]g and [Figure 2]h. Furthermore, the preserved radiotracer extraction as seen in the segment IV in SPECT/CT ruled out any significant vascular compromise (CECT had shown doubtful involvement). Furthermore, a laceration was seen extending from the hepatic surface till hilum in the region of segment V [[Figure 2]a (arrow) and [Figure 2]b]. Pooling of the radiotracer was noted in the perihilar extent of this laceration [[Figure 2]b (arrow)], and an injury to right hepatic duct was identified as likely origin of the biliary leak. Due to patent bilio-enteric pathway and reduction in the amount of bile in the drain, clinicians decided on conservative management. The patient was also sent for magnetic resonance cholangiopancreatography (MRCP), which confirmed injury to the right anterior sectoral duct (from segment V/VIII). The patient improved during consecutive days.
Figure 1: Dynamic frames (a) and delayed static (b) 99mTc-HIDA scintigraphy images in a 45-year-old male with history of blunt trauma to the abdomen, showing a relatively photopenic defect in the region of the right lobe (a) and biliary leak in the sub-hepatic region (b)

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Figure 2: Single-photon emission computed tomography (SPECT)/computed tomography (CT) in the same patient showing radiotracer collection in the hilum [a and b] and the right subhepatic region [c and d]. A laceration can also be seen extending from the hepatic surface till hilum in the region of segment V [a and b (arrows)]. Also seen is some drainage from the hilar region into the duodenum and distal intestines [e and f]. The hypodense area in planar images in Figure 1 corresponded to the segments V/VIII (confirmed as site of vascular infarct in CECT) [g and h]

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While 99mTc-HIDA scintigraphy has been routinely used in imaging postoperative biliary leaks[1],[2] and patency of bilio-enteric pathway, it has been underutilized in cases with blunt hepatic trauma. While some studies have pointed to a role in the identification of infarcts in patients with liver failure and venous occlusion,[3],[4] literature on its utility for simultaneous assessment of vascular injury in hepatic trauma patients is scarce. In this case, we were able to identify the site of biliary leak, demonstrate the patency of biliary enteric pathway, confirm vascular infarcts in the segments V/VIII, and rule out similar vascular injury to segment IV. In this way, this single, cheap, and relatively common investigation was able to impact patient management. Demonstration of the capability of this tracer in the assessment of hepatic vascular injury is important in cases with trauma, as additional solid organ injuries (like vascular or renal) may preclude contrast administration or patient may not be stable enough to undergo MRCP. In addition, this case shows the importance of SPECT/CT in the identification of patent bilio-enteric pathway, when a relatively small amount of activity was transiting through the physiological pathway (which could not be confirmed in planar imaging, as it was being obscured by the biliary leak into the peritoneum).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Uliel L, Mellnick VM, Menias CO, Holz AL, McConathy J. Nuclear medicine in the acute clinical setting: Indications, imaging findings, and potential pitfalls. Radiographics 2013;33:375-96.  Back to cited text no. 1
    
2.
Walker AT, Shapiro AW, Brooks DC, Braver JM, Tumeh SS. Bile duct disruption and biloma after laparoscopic cholecystectomy: Imaging evaluation. AJR Am J Roentgenol 1992;158:785-9.  Back to cited text no. 2
    
3.
Brown RK, Memsic LD, Busuttil RW, Pusey E, Ray RA, Kangarloo H, et al. Accurate demonstration of hepatic infarction in liver transplant recipients. J Nucl Med 1986;27:1428-31.  Back to cited text no. 3
    
4.
Donnelly LF, Nishiyama H, Milstein MS. Absent uptake on hepatobiliary scintigraphy in hepatic lobar infarction from portal vein occlusion in cholangiocarcinoma. J Nucl Med 1995;36:474-5.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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