Upload
patrick89
View
237
Download
4
Tags:
Embed Size (px)
Citation preview
GASTROINTESTINALGASTROINTESTINALIMAGINGIMAGING
Sodee & Early: Chapter 20Aunt Minnie
Principles & Practice: Chapter 13
Liver-Spleen Imaging, PlanarLiver-Spleen Imaging, Planar
Indications – Functional Liver DiseaseIndications – Functional Liver DiseaseHepatomegaly, Splenomegaly, Accessory Hepatomegaly, Splenomegaly, Accessory
Spleen, Situs Inversus, Tumors and Spleen, Situs Inversus, Tumors and Metastasis, Jaundice, Cirrhosis, Hepatitis, Metastasis, Jaundice, Cirrhosis, Hepatitis, Abscess, Trauma, Blood Disorders, InfectionsAbscess, Trauma, Blood Disorders, Infections
Contraindications – NoneContraindications – None
Patient PreparationPatient PreparationRecent Contrast Studies May Affect ImagesRecent Contrast Studies May Affect Images
Liver-Spleen Planar Cont’dLiver-Spleen Planar Cont’d
Imaging ProceduresImaging Procedures5-10 mCi (Christian), 2-6 mCi (Early), 2-7 mCi 5-10 mCi (Christian), 2-6 mCi (Early), 2-7 mCi
(Shackett) Tc99m-Sulfur Colloid(Shackett) Tc99m-Sulfur Colloid
Patient is SupinePatient is Supine
Flow: 60 secondsFlow: 60 seconds
Statics: Anterior, Anterior with Marker, RAO, Statics: Anterior, Anterior with Marker, RAO, RLAT, RPO, Posterior, LLAT, LPO and LAORLAT, RPO, Posterior, LLAT, LPO and LAO
Liver-Spleen Planar Cont’dLiver-Spleen Planar Cont’d
Data TreatmentData TreatmentProcess and Label all ViewsProcess and Label all Views
May Draw ROIs on Liver, Spleen and VertebraeMay Draw ROIs on Liver, Spleen and VertebraeCompareCompare
Spleen to LiverSpleen to Liver
Vertebrae to LiverVertebrae to Liver
Vertebrae to SpleenVertebrae to Spleen
Note: Vertebrae ROI Taken From Center Just Below Organs
Liver-Spleen Planar Cont’dLiver-Spleen Planar Cont’d
ResultsResultsNormalNormal
Liver and Spleen Equal Heterogeneous DistributionLiver and Spleen Equal Heterogeneous Distribution
Uptake: Liver 85%, Spleen 10%, Bone Marrow 5%Uptake: Liver 85%, Spleen 10%, Bone Marrow 5%
AbnormalAbnormalNon-Symmetrical, Hot and Cold Spots, Size and Non-Symmetrical, Hot and Cold Spots, Size and
ShapeShape
Liver-Spleen Planar Cont’dLiver-Spleen Planar Cont’d
Liver-Spleen Planar Cont’dLiver-Spleen Planar Cont’d
33 year old woman was found to have an epigastric mass on routine physical exam six months after the birth of her first child. The woman denied any symptoms.
Mildly increased colloid uptake is seen in a large lesion involving the left lobe of the liver. This corresponds to a well circumscribed 7 cm mass at this location on the CT.
Liver-Spleen Imaging, SPECTLiver-Spleen Imaging, SPECT
Continues After Planar ImagingContinues After Planar Imaging
Imaging ProceduresImaging ProceduresRequires 8-12 mCi Tc99m-Sulfur ColloidRequires 8-12 mCi Tc99m-Sulfur Colloid
Either Contoured or Non-CircularEither Contoured or Non-Circular
Process Images In Accordance With Process Images In Accordance With ProtocolsProtocols
Liver-Spleen SPECT Cont’dLiver-Spleen SPECT Cont’d
ResultsResultsNormalNormal
Liver and Spleen Equal Heterogeneous DistributionLiver and Spleen Equal Heterogeneous Distribution
AbnormalAbnormalNon-Symmetrical, Hot and Cold Spots, Size and Non-Symmetrical, Hot and Cold Spots, Size and
ShapeShape
HemangiomaHemangioma
Common Benign Tumor of LiverCommon Benign Tumor of LiverCT or Ultrasound Usually LocateCT or Ultrasound Usually Locate
Radionuclide Technique 100% Accurate in DiagnosisRadionuclide Technique 100% Accurate in Diagnosis
IndicatorsIndicatorsDetection and Localization of Hepatic Hemangiomas, Detection and Localization of Hepatic Hemangiomas,
Vascularized Tumors, Cysts, Lesions and Areas Vascularized Tumors, Cysts, Lesions and Areas Marked for BiopsyMarked for Biopsy
ContraindicationsContraindicationsPatients Undergoing Contrast StudiesPatients Undergoing Contrast Studies
Patients Receiving Blood ProductsPatients Receiving Blood Products
Hemangioma ContinuedHemangioma Continued
Patient PreparationPatient PreparationNothing SpecialNothing Special
Imaging ProceduresImaging Procedures20-30 mCi Tc99m-Tagged RBCs20-30 mCi Tc99m-Tagged RBCs
In-Vitro, In-Vivo or Modified In-VivoIn-Vitro, In-Vivo or Modified In-Vivo
Flow: 1 to 2 minutesFlow: 1 to 2 minutesStatics: Anterior, Anterior with Marker, RAO, Statics: Anterior, Anterior with Marker, RAO,
Right Lateral, Posterior (Others Possibly)Right Lateral, Posterior (Others Possibly)SPECT: Image at 1 to 2 hours After InjectionSPECT: Image at 1 to 2 hours After Injection
Note: If Hemangioma is Posterior, Use Posterior Images for Flow
Hemangioma ContinuedHemangioma Continued
ResultsResultsNormalNormal
Heart, Great Vessels and Spleen ProminentHeart, Great Vessels and Spleen Prominent
Heterogeneous Uptake in Liver on Flow, Statics and Heterogeneous Uptake in Liver on Flow, Statics and SPECTSPECT
AbnormalAbnormalPhotopenic on Flow, Focal Areas of Uptake on Photopenic on Flow, Focal Areas of Uptake on
Statics and SPECTStatics and SPECT
(Note: Hepatomas will appear Photopenic on Statics (Note: Hepatomas will appear Photopenic on Statics and SPECT)and SPECT)
Hemangioma ContinuedHemangioma Continued
66-year old man with elevated liver function tests and right upper quadrant pain who had a sonogram on 3-17-95 at an outside hospital. The sonogram showed a hyperechoic lesion in the posterior segment of the hepatic lobe, measuring approximately 3 cm. The current examination was performed to confirm that this lesion represents a benign cavernous hemangioma.
HepatobiliaryHepatobiliary
IndicationsIndicationsAcute or Chronic CholecystitisAcute or Chronic Cholecystitis
Cholestasis (Lack of Bile Flow)Cholestasis (Lack of Bile Flow)
Differentiate Acute Hepatitis vs. Acute Biliary Differentiate Acute Hepatitis vs. Acute Biliary ObstructionObstruction
Choledochal Cysts (Common Bile Duct)Choledochal Cysts (Common Bile Duct)
Biliary AtresiaBiliary Atresia
ContraindicationsContraindicationsPatient Has Eaten Within 4 HoursPatient Has Eaten Within 4 Hours
No Morphine Sulfate if Patient is AllergicNo Morphine Sulfate if Patient is Allergic
Note: A Severely Jaundiced Patient May Delay Filling Gallbladder
Hepatobiliary ContinuedHepatobiliary ContinuedPatient PreparationPatient Preparation
NPO 2 Hrs (Early), 2-14 Hrs (Shackett), Usually 4-6 HrsNPO 2 Hrs (Early), 2-14 Hrs (Shackett), Usually 4-6 HrsIf Patient NPO 24 Hrs or Longer, May Pre-treat With If Patient NPO 24 Hrs or Longer, May Pre-treat With
SincalideSincalide
Imaging ProceduresImaging Procedures5-10 mCi Tc99m-IDA, Disofenin or Mebrofenin 5-10 mCi Tc99m-IDA, Disofenin or Mebrofenin
(Choletec)(Choletec)Patient is Supine Patient is Supine (Liver in LUQ of P-Scope)(Liver in LUQ of P-Scope)Anterior Statics or Dynamic for at Least 30 minutesAnterior Statics or Dynamic for at Least 30 minutes
Visualize Gallbladder and Bowel: RAO and RT LateralVisualize Gallbladder and Bowel: RAO and RT Lateral
If Not Visualized by 45 minutesIf Not Visualized by 45 minutesPatient Can Lay on Right Side or Walk AroundPatient Can Lay on Right Side or Walk Around
Can Use Pharmacological Agent (morphine, CCK)Can Use Pharmacological Agent (morphine, CCK)Small Bowel Must Be Visualized for CCKSmall Bowel Must Be Visualized for CCK
Delays Taken From 2 to 6 HoursDelays Taken From 2 to 6 Hours
Hepatobiliary ContinuedHepatobiliary Continued
ResultsResultsNormalNormal
Visualization of Liver QuicklyVisualization of Liver Quickly
Visualization of Hepatic, Common Bile Duct and Visualization of Hepatic, Common Bile Duct and Gallbladder From 5 minutes to 1 HourGallbladder From 5 minutes to 1 Hour
Small Bowel Visualized and Moving 10-60 minutesSmall Bowel Visualized and Moving 10-60 minutes
AbnormalAbnormalGallbladder Not Visualized by 60 minutesGallbladder Not Visualized by 60 minutes
Small Bowel Not Visualized With Gallbladder Small Bowel Not Visualized With Gallbladder Showing by 60 minutesShowing by 60 minutes
Hepatobiliary ContinuedHepatobiliary Continued
Sincalide (0.02 ug/kg) was administered intravenously 30 minutes prior to radiopharmaceutical injection to promote initial emptying of the gallbladder. Static images obtained over the first hour post injection demonstrated good hepatic uptake with prompt excretion into the common bile duct and small bowel. There was no visualization of the gallbladder at 1 hour.
Hepatobiliary ContinuedHepatobiliary Continued
Subsequently, 3 mg of morphine i.v. was administered. Additional imaging for 30 minutes again demonstrated nonvisualization of the gallbladder. These findings are most consistent with acute cholecystitis.
Gallbladder Ejection FractionGallbladder Ejection Fraction
Continuation of Hepatobiliary ImagingContinuation of Hepatobiliary Imaging
Imaging ProceduresImaging Procedures.02 mcg/kg of Sincalide (Synthetic CCK) IV.02 mcg/kg of Sincalide (Synthetic CCK) IV
Fatty MealFatty Meal
Patient is Supine, Camera is AnteriorPatient is Supine, Camera is Anterior
Dynamic or Static Images for 30 minutesDynamic or Static Images for 30 minutes
GB Ejection Fraction Cont’dGB Ejection Fraction Cont’d
The patient is a 41-year-old woman with a history of right upper quadrant pain and a gallbladder polyp. Extraction of HIDA from the blood is good. The gallbladder fills after the initial CCK injection.
GB Ejection Fraction Cont’dGB Ejection Fraction Cont’d
The gallbladder ejection fraction is calculated to be 70%.
The mean gallbladder ejection fraction reported in the referenced material is a mean at 45 minutes of 77.2% +/- 4.9%.
GB Ejection Fraction Cont’dGB Ejection Fraction Cont’d
Data TreatmentData TreatmentDraw ROIs Around GB Pre and Post-CCK with Draw ROIs Around GB Pre and Post-CCK with
BackgroundBackground
ResultsResultsNormalNormal
Around 35% (>50% for Men, >20% for Women)Around 35% (>50% for Men, >20% for Women)
AbnormalAbnormalLess than Normal EFLess than Normal EF
%GBEF = Pre-CCK cts – Lowest Post-CCK cts x 100
Pre-CCK cts
GB Ejection Fraction Cont’dGB Ejection Fraction Cont’d
Example (page 238, Math Review)Example (page 238, Math Review)Net Counts Pre-CCK = 63,800Net Counts Pre-CCK = 63,800
Net Counts Post-CCK = 37,200Net Counts Post-CCK = 37,200
63,800 counts – 37,200 counts x 100
63,800 counts
GBEF = 42%
GB Ejection Fraction Cont’dGB Ejection Fraction Cont’d
Calculate the GBEFCalculate the GBEF
Net Maximum Counts = 235,000Net Maximum Counts = 235,000
Net Minimum Counts = 174,000Net Minimum Counts = 174,000
GB Ejection Fraction Cont’dGB Ejection Fraction Cont’d
Calculate the GBEFCalculate the GBEF
Net Maximum Counts = 235,000Net Maximum Counts = 235,000
Net Minimum Counts = 174,000Net Minimum Counts = 174,000
GBEF = 26 %GBEF = 26 %
Gastrointestinal BleedingGastrointestinal Bleeding
Two Major TechniquesTwo Major TechniquesTc99m Sulfur ColloidTc99m Sulfur ColloidTc99m Labeled Red Blood CellsTc99m Labeled Red Blood Cells
IndicationsIndicationsDetection and Localization of Bleeding SitesDetection and Localization of Bleeding Sites
Must be Actively Bleeding to ImageMust be Actively Bleeding to ImageCaused by Aspirin, Ulcers, Perforation, Cancer, DiverticulaCaused by Aspirin, Ulcers, Perforation, Cancer, Diverticula
ContraindicationsContraindicationsPatients Undergoing Contrast StudiesPatients Undergoing Contrast Studies
Patient PreparationPatient PreparationNothing SpecialNothing Special
GI Bleed – Tc99m Sulfur ColloidGI Bleed – Tc99m Sulfur Colloid
Imaging ProceduresImaging Procedures7-10 mCi (Christian), 10-15 mCi (Early), 10-20 mCi 7-10 mCi (Christian), 10-15 mCi (Early), 10-20 mCi
(Shackett) Tc99m-Sulfur Colloid(Shackett) Tc99m-Sulfur ColloidPositioning Very Important, Clears QuicklyPositioning Very Important, Clears Quickly
Supine, Anterior View of Lower AbdomenSupine, Anterior View of Lower Abdomen
Flow: 2 to 3 minutesFlow: 2 to 3 minutes
Dynamic: Up to 30 minutesDynamic: Up to 30 minutes
Statics: Oblique, Lateral and Posterior Images May Help Statics: Oblique, Lateral and Posterior Images May Help Define Location of BleedDefine Location of Bleed
Bleeding Best Demonstrated in First 12-15 minutesBleeding Best Demonstrated in First 12-15 minutes
GI Bleed – Tc99m Tagged RBCsGI Bleed – Tc99m Tagged RBCs
Imaging ProceduresImaging Procedures10-20 mCi Tc99m Tagged RBCs10-20 mCi Tc99m Tagged RBCs
In-Vitro, In-Vivo, Modified In-VivoIn-Vitro, In-Vivo, Modified In-Vivo
Supine, Anterior View of Lower AbdomenSupine, Anterior View of Lower AbdomenFlow: 2 to 3 minutesFlow: 2 to 3 minutesDynamic: Up to 30 minutesDynamic: Up to 30 minutesStatics: Oblique, Lateral and Posterior Images May Help Statics: Oblique, Lateral and Posterior Images May Help
Define Location of BleedDefine Location of BleedDelayed Images PossibleDelayed Images Possible
2, 4 and 6 hour Delays2, 4 and 6 hour DelaysEspecially for Patients with MelenaEspecially for Patients with Melena
Gastrointestinal Bleeding Cont’dGastrointestinal Bleeding Cont’d
ResultsResultsNormalNormal
Tc99m-Sulfur ColloidTc99m-Sulfur ColloidLiver, Spleen and Bone Marrow Well VisualizedLiver, Spleen and Bone Marrow Well VisualizedNo Areas of Focal Uptake in Abdominal AreaNo Areas of Focal Uptake in Abdominal Area
Tc99m-Tagged RBCsTc99m-Tagged RBCsHeart and Great Vessels ProminentHeart and Great Vessels ProminentNo Areas of Focal Uptake in Abdominal AreaNo Areas of Focal Uptake in Abdominal Area
AbnormalAbnormalFocal Areas of Uptake in Any of the ImagesFocal Areas of Uptake in Any of the ImagesTagged RBCs Show Colonic Bleeding WellTagged RBCs Show Colonic Bleeding Well
Gastrointestinal Bleeding Cont’dGastrointestinal Bleeding Cont’d
Part way through the examination, a bleeding focus is seen in the mid upper abdomen. Based on these images, this was felt to represent a proximal small bowel source, as the activity appears more diffuse than would be expected for a transverse colon source.
History of blood per rectum. Multiple negative GI bleeding studies in the past.
Gastrointestinal Bleeding Cont’dGastrointestinal Bleeding Cont’d
53 year old with dizziness and maroon stools, who presents with hematocrit of 15 requiring transfusion. NG tube aspirate is reportedly negative.
Meckel’s DiverticulumMeckel’s Diverticulum
Usually Performed to Find the Cause of Usually Performed to Find the Cause of GI Bleeding in ChildrenGI Bleeding in Children
IndicationsIndicationsAbdominal Pain (esp. Children), Positive Stool Abdominal Pain (esp. Children), Positive Stool
Guaiac Test, GI Bleed, Diverticulitis, Guaiac Test, GI Bleed, Diverticulitis, Obstruction, Intussusception, VolvulusObstruction, Intussusception, Volvulus
ContraindicationsContraindicationsBarium Contrast StudiesBarium Contrast Studies
Meckel’s Diverticulum Cont’dMeckel’s Diverticulum Cont’d
Patient PreparationPatient PreparationNPO 4-12 Hours, Infants Miss One FeedingNPO 4-12 Hours, Infants Miss One FeedingDiscontinue Thyroid Blocking Agents (KCODiscontinue Thyroid Blocking Agents (KCO44))Patient to Void BladderPatient to Void BladderNo Radiographic Barium Studies Within 48 HrsNo Radiographic Barium Studies Within 48 Hrs
Imaging ProceduresImaging Procedures15-20 mCi TcO15-20 mCi TcO44
- - (200 uCi/kg in Pediatric Patients)(200 uCi/kg in Pediatric Patients)Patient is SupinePatient is SupineFlow: 60 secondsFlow: 60 secondsDynamic: 15 – 30 minutesDynamic: 15 – 30 minutesStatics: Posterior, Laterals, Obliques if Area VisualizedStatics: Posterior, Laterals, Obliques if Area Visualized
Meckel’s Diverticulum Cont’dMeckel’s Diverticulum Cont’d
ResultsResultsNormalNormal
Uptake in Stomach, Renal Activity – 10-20 minutesUptake in Stomach, Renal Activity – 10-20 minutesBladder Uptake Increases with TimeBladder Uptake Increases with TimeAbnormalAbnormalFocal Increased Activity – Usually RLQFocal Increased Activity – Usually RLQ
Near Ileocecal ValveNear Ileocecal ValveAppears Before 60 minutesAppears Before 60 minutes
Appears at Same Time as Stomach ActivityAppears at Same Time as Stomach ActivityCompare Intensity with StomachCompare Intensity with StomachDoes Not DiminishDoes Not Diminish
Meckel’s Diverticulum Cont’dMeckel’s Diverticulum Cont’d
The patient is a 2 1/2 year old boy with several months of nausea/vomiting and melana. A previous upper GI series demonstrated esophogeal reflux, but was otherwise normal.
A discrete focus of increased uptake is seen in the right lower quadrant, with approximately the same intensity as the stomach. On dynamic images (not shown here) this focus accumulated the tracer at the same rate as did the gastric mucosa.
Meckel’s Diverticulum Cont’dMeckel’s Diverticulum Cont’d
2 1/2 year old male with a one day history of bloody stools. An air contrast enema was performed immediately prior to this scintogram that demonstrated no evidence of intussusception.
Meckel’s Diverticulum Cont’dMeckel’s Diverticulum Cont’dThis patient is an 18 month old female who presented to an outside hospital witha history of a large maroon bowel movement. She was noted to have a hemoglobin of 4.0.
Sequential abdominal images demonstrate an abnormal focus of increased activity in the right upper quadrant. This activity does not move and is not related to the collecting system of the kidney.
Salivary (Parotid)Salivary (Parotid)
Nuclear SialographyNuclear SialographySize, Location, FunctionSize, Location, Function
Some IndicatorsSome IndicatorsWarthin’s TumorWarthin’s Tumor
XerostomiaXerostomiaSjorgren’s SyndromeSjorgren’s Syndrome
Following Radiation to Head and NeckFollowing Radiation to Head and Neck
Palpable MassPalpable Mass
Salivary (Parotid) Cont’dSalivary (Parotid) Cont’d
Patient PreparationPatient PreparationNo Special Preparation RequiredNo Special Preparation Required
Imaging ProcedureImaging Procedure8-12 mCi TcO8-12 mCi TcO44
- - (Christian 1-5 mCi) IV(Christian 1-5 mCi) IV
Flow: 1 minuteFlow: 1 minute
Dynamic: 30 to 60 minutesDynamic: 30 to 60 minutes
Statics: Anterior, Anterior Marker, LateralsStatics: Anterior, Anterior Marker, LateralsHead Tilted Back, Chin on DetectorHead Tilted Back, Chin on Detector
Stimulation: Lemon Juice or GumStimulation: Lemon Juice or GumRepeat StaticsRepeat Statics
Salivary (Parotid) Cont’dSalivary (Parotid) Cont’d
ResultsResultsNormalNormal
Symmetrical UptakeSymmetrical Uptake
Uptake in Thyroid, Sublingual glands, Nasal CavityUptake in Thyroid, Sublingual glands, Nasal Cavity
Reduced Uptake after StimulationReduced Uptake after Stimulation
AbnormalAbnormalWarthin’s Tumor – Increased Uptake, RetainedWarthin’s Tumor – Increased Uptake, Retained
Sjorgren’s Syndrome – Decreased, Patchy UptakeSjorgren’s Syndrome – Decreased, Patchy Uptake
No Reduction after StimulationNo Reduction after StimulationBlockage, Stenosis, SialolithiasisBlockage, Stenosis, Sialolithiasis
Abscesses and Cysts - PhotopenicAbscesses and Cysts - Photopenic
Esophageal Motility/TransitEsophageal Motility/Transit
For Detection of Motor AbnormalitiesFor Detection of Motor AbnormalitiesBarium used for ObstructionsBarium used for Obstructions
IndicationsIndicationsDysphagiaDysphagia
Strictures, Obstruction, Retention, Hiatal HerniaStrictures, Obstruction, Retention, Hiatal Hernia
Achalasia – Delay in PeristalsisAchalasia – Delay in Peristalsis
Scleroderma – Thickened/Hardened EpitheliumScleroderma – Thickened/Hardened Epithelium
Esophageal Motility/Transit Cont’dEsophageal Motility/Transit Cont’d
Patient PreparationPatient PreparationNPO 2 Hrs (Christian), 8 Hrs (Shackett), past Midnight NPO 2 Hrs (Christian), 8 Hrs (Shackett), past Midnight
(Early)(Early)
Imaging ProceduresImaging Procedures150 – 300 uCi Tc99m Sulfur Colloid in Water150 – 300 uCi Tc99m Sulfur Colloid in WaterPatient Supine – Entire Esophagus in ViewPatient Supine – Entire Esophagus in ViewFlow: 1 minuteFlow: 1 minuteDynamic: Next 9 minutesDynamic: Next 9 minutesBolus Swallow (Have Patient Practice)Bolus Swallow (Have Patient Practice)
Requires 15 ml to Cause PeristalsisRequires 15 ml to Cause PeristalsisDry Swallow Every 15 SecondsDry Swallow Every 15 Seconds
Esophageal Motility/Transit Cont’dEsophageal Motility/Transit Cont’d
Data TreatmentData TreatmentROIs Around Bolus DoseROIs Around Bolus Dose
ROI Around Entire EsophagusROI Around Entire EsophagusCan Differentiate Between Upper, Middle, LowerCan Differentiate Between Upper, Middle, Lower
Calculate % Esophageal ActivityCalculate % Esophageal Activity
% = A – B x 100
A
A – Total Activity of Bolus
B – Activity of Bolus During Any One Image
Esophageal Motility/Transit Cont’dEsophageal Motility/Transit Cont’d
ResultsResultsNormalNormal
Activity Passes Within 5 to 10 Seconds of 1Activity Passes Within 5 to 10 Seconds of 1stst SwallowSwallow
Smooth Progression of ActivitySmooth Progression of Activity
AbnormalAbnormalScleroderma – Most of Bolus Enters StomachScleroderma – Most of Bolus Enters Stomach
Achalasis – Marked DelayAchalasis – Marked Delay
Diffuse Spasm – First ½ Reduced Transit Rate, Diffuse Spasm – First ½ Reduced Transit Rate, Second ½ Normal RateSecond ½ Normal Rate
Gastroesophageal RefluxGastroesophageal Reflux
GERD ImagingGERD ImagingDetection and QuantitationDetection and QuantitationEvaluate Diaphragmatic HerniaEvaluate Diaphragmatic HerniaChildren with Asthma, Chronic Lung Disease or Children with Asthma, Chronic Lung Disease or
Aspiration PneumoniaAspiration Pneumonia
IndicatorsIndicatorsHeartburnHeartburnRegurgitationRegurgitationChest PainChest Pain
Gastroesophageal Reflux Cont’dGastroesophageal Reflux Cont’d
Patient PreparationPatient PreparationNPO 4 Hrs (Shackett), 8 Hrs (Christian), Past Midnight NPO 4 Hrs (Shackett), 8 Hrs (Christian), Past Midnight
(Early)(Early)
Imaging ProceduresImaging Procedures300 uCi Tc99m Sulfur Colloid in Orange Juice300 uCi Tc99m Sulfur Colloid in Orange Juice
150 ml of OJ and 150 ml of 0.1 N HCL150 ml of OJ and 150 ml of 0.1 N HCL
Supine (Christian and Shackett), Upright and then Supine (Christian and Shackett), Upright and then Supine (Early)Supine (Early)
30 Second Image – Baseline30 Second Image – Baseline30 Second Images with Abdominal Binder30 Second Images with Abdominal Binder
Increase 20 mm/Hg Each Successive Image Until 100 mm/HgIncrease 20 mm/Hg Each Successive Image Until 100 mm/Hg
Gastroesophageal Reflux Cont’dGastroesophageal Reflux Cont’d
Data TreatmentData TreatmentDraw ROIs Around Lower Esophagus, Stomach Draw ROIs Around Lower Esophagus, Stomach
and Lower Left Lung (Background)and Lower Left Lung (Background)
Calculate % Gastroesophagealreflux at Each Calculate % Gastroesophagealreflux at Each PressurePressure
% = A – B x 100
C
A – Esophageal Counts Minus Prebinder Esophageal Counts
B – Background Counts From Lung ROI
C – Gastric Counts From Prebinder Gastric ROI(Decay Correct for Each Image)
Gastroesophageal Reflux Cont’dGastroesophageal Reflux Cont’d
ResultsResultsNormalNormal
All or Most of Activity Remains in StomachAll or Most of Activity Remains in Stomach
Less than 4 % RefluxLess than 4 % Reflux
AbnormalAbnormalMore than 4 % RefluxMore than 4 % Reflux
Evidence of Reflux on ImagesEvidence of Reflux on ImagesPatients with Esophageal Motor Disorders or Hiatal Hernia Patients with Esophageal Motor Disorders or Hiatal Hernia
May Require a Nasogastric TubeMay Require a Nasogastric Tube
Gastric Emptying (Liquid/Solid)Gastric Emptying (Liquid/Solid)
Used to Quantify Gastric EmptyingUsed to Quantify Gastric EmptyingIndicationsIndications
Delayed Gastric EmptyingDelayed Gastric EmptyingMechanical or Anatomical ObstructionMechanical or Anatomical ObstructionGastroparesis (Diabetic and Idiopathic)Gastroparesis (Diabetic and Idiopathic)Nausea, Vomiting and Early SatietyNausea, Vomiting and Early SatietyWeight LossWeight Loss
ContraindicationsContraindicationsAllergy to Foods Used in Solid EmptyingAllergy to Foods Used in Solid Emptying
Gastric Emptying ContinuedGastric Emptying Continued
Patient PreparationPatient PreparationNPO 4-12 Hrs (Shackett), 8 Hrs (Christian), Past NPO 4-12 Hrs (Shackett), 8 Hrs (Christian), Past
Midnight (Early)Midnight (Early)Discontinue Sedatives 12 Hrs (Shackett)Discontinue Sedatives 12 Hrs (Shackett)
Imaging ProceduresImaging ProceduresBaseline Liquid Study Can Be Done FirstBaseline Liquid Study Can Be Done First
500 uCi Tc99m-DTPA in 120 ml Water or Orange Juice500 uCi Tc99m-DTPA in 120 ml Water or Orange Juice
200 – 500 uCi Tc99m Sulfur Colloid in a Standardized 200 – 500 uCi Tc99m Sulfur Colloid in a Standardized Meal (Begin Imaging Immediately After Meal)Meal (Begin Imaging Immediately After Meal)
Patient Supine, Standing or SittingPatient Supine, Standing or SittingAnterior, LAO and or PosteriorAnterior, LAO and or Posterior
Static or Dynamic Images for 90 minutes to 2 HoursStatic or Dynamic Images for 90 minutes to 2 Hours
Gastric Emptying ContinuedGastric Emptying Continued
Data TreatmentData TreatmentDraw ROIs Around StomachDraw ROIs Around Stomach
Performed on Each ImagePerformed on Each ImageDivide Gastric Counts by Decay FactorDivide Gastric Counts by Decay FactorPlot Time/Activity CurvePlot Time/Activity CurveObtain t½ Emptying From CurveObtain t½ Emptying From Curve
ResultsResultsNormalNormal
Solid – 50% Emptying with a Mean of 90 MinutesSolid – 50% Emptying with a Mean of 90 MinutesLiquid – 80% in About an HourLiquid – 80% in About an Hour
AbnormalAbnormalLittle or No MovementLittle or No MovementRapid Emptying – “Dumping Syndrome”Rapid Emptying – “Dumping Syndrome”
Gastric Emptying ContinuedGastric Emptying Continued
Gastric Emptying MathematicsGastric Emptying MathematicsFound on Page 243, Mathematics ReviewFound on Page 243, Mathematics Review
Geometric Mean (GM) = Geometric Mean (GM) = √Anterior ROI Counts x Posterior ROI √Anterior ROI Counts x Posterior ROI CountsCounts
% Remaining at time T = % Remaining at time T = GM @ time T GM @ time T x 100 x 100
GM @ time 0 x DF @ time TGM @ time 0 x DF @ time T
% Emptying at time T = % Emptying at time T = GM @ time 0 – GM @ time TGM @ time 0 – GM @ time T x 100 x 100
GM @ time 0GM @ time 0
Note: Recommend Using Processing Software
LeVeen Shunt PatencyLeVeen Shunt Patency
LeVeen ShuntLeVeen ShuntUsed to Relieve Excess Ascites in Peritoneal Used to Relieve Excess Ascites in Peritoneal
CavityCavity
IndicationsIndicationsIncreasing AscitesIncreasing Ascites
Patient PreparationPatient PreparationNothing SpecialNothing Special
LeVeen Shunt Patency Cont’dLeVeen Shunt Patency Cont’d
Imaging ProceduresImaging Procedures1.5-5 mCi Tc99m-MAA (Preferred)1.5-5 mCi Tc99m-MAA (Preferred)3 mCi Tc99m-Sulfur Colloid3 mCi Tc99m-Sulfur ColloidPatient is Supine Patient is Supine Intraperitoneal Injection by PhysicianIntraperitoneal Injection by Physician
Abdominal Palpation or Roll Patient (LeVeen)Abdominal Palpation or Roll Patient (LeVeen)Patient Pumps System Vigorously (Denver Shunt)Patient Pumps System Vigorously (Denver Shunt)
Flow: 60 secondsFlow: 60 secondsStatics: Anterior Abdomen at 15, 30, 45 & 60 minutesStatics: Anterior Abdomen at 15, 30, 45 & 60 minutesWhole Body: OptionalWhole Body: OptionalDelays: 2 to 4 Hours if No Lung (Liver) VisualizationDelays: 2 to 4 Hours if No Lung (Liver) Visualization
LeVeen Shunt Patency Cont’dLeVeen Shunt Patency Cont’d
ResultsResultsNormalNormal
Lungs Seen in 60 minutes (Usually 10-30 minutes)Lungs Seen in 60 minutes (Usually 10-30 minutes)
Liver Seen in 60 minutes (Tc99m-Sulfur Colloid)Liver Seen in 60 minutes (Tc99m-Sulfur Colloid)Can be Difficult to Separate Liver From AscitesCan be Difficult to Separate Liver From Ascites
AbnormalAbnormalNo Lung Seen After 4 Hours – ObstructionNo Lung Seen After 4 Hours – Obstruction
No Liver Seen After 4 Hours – ObstructionNo Liver Seen After 4 Hours – Obstruction
Activity Stops at Pump – Valve Failure or Activity Stops at Pump – Valve Failure or ObstructionObstruction
LeVeen Shunt Patency Cont’dLeVeen Shunt Patency Cont’d
Other StudiesOther Studies
Barrett’s Esophagus ImagingBarrett’s Esophagus Imaging
Retained Antrum ImagingRetained Antrum Imaging