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  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Case report
 ::  Discussion
 ::  Acknowledgment
 ::  References
 ::  Article Tables

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CASE REPORT
Year : 1995  |  Volume : 41  |  Issue : 1  |  Page : 15-7

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


Department of Nuclear Medicine & Surgery, Seth GS Medical College, Parel, Mumbai.,

Correspondence Address:
S V Shikare
Department of Nuclear Medicine & Surgery, Seth GS Medical College, Parel, Mumbai.

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PMID: 0010740695

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 :: Abstract 

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.


Keywords: Bile, Biliary Tract, radionuclide imaging,Case Report, Cholangiography, Cholecystectomy, Human, Male, Middle Age, Postoperative Complications, radionuclide imaging,Technetium Compounds, diagnostic use,


How to cite this article:
Shikare S V, Supe A N, Tilve G H. Scintigraphic detection of bile leak and follow-up in a post-cholecystectomy patient with recognition of tail sign. J Postgrad Med 1995;41:15

How to cite this URL:
Shikare S V, Supe A N, Tilve G H. Scintigraphic detection of bile leak and follow-up in a post-cholecystectomy patient with recognition of tail sign. J Postgrad Med [serial online] 1995 [cited 2014 Sep 30];41:15. Available from: http://www.jpgmonline.com/text.asp?1995/41/1/15/475





  ::   Introduction Top


It may be difficult to document the presence and extent of suspected post surgical bile leakage. The methods currently in use are non-physiologic in that visualisation of the biliary system requires retrograde flow of contrast through biliary channels. Cholescintigraphy with 99m Tc IDA has proved to be one of the most sensitive means of detecting bile leakage and its location[1],[2],[3],[4]. We have performed cholescintigraphy in a patient suspected of having biliary leak. In the present case, post-surgical leak and its location was demonstrated. Cholescintigraphy was also useful in determining the function of the biliary system in the follow-up period.


  ::   Case report Top


A 59 years old male with chronic calculus cholecystitis underwent cholecystectomy with common bile duct exploration and T tube drainage. Intra-operatively, the gall bladder had severe adhesions and cholecystectomy was described as technically difficult. The patient developed a drain-site bile leak in-spite of a well draining T tube.

99m Tc BULIDA Cholescintigraphy of this patient demonstrated [Figure:1] (a) Area of increased tracer concentration lateral to common bile duct (cystic duct region) with evidence of triangular accumulation of radio-tracer at the inferior edge of the right lobe of the liver, and from there into the colostomy bag kept over right lumbar region (b) Minimal tracer excretion through common bile duct into the intestine (c) Tracer excretion through the T tube.

Most of the tracer was excreted through the bile leak with minimal excretion through the common bile duct into intestine and from T tube. T tube cholangiogram showed the same finding [Figure:2].

The patient was treated conservatively and the bile leak disappeared over a period of fifteen days. Hence, no surgical intervention was required. Repeat cholescintigraphy showed normal patency of common bile duct with normal tracer excretion into the intestine. No bile leak or tracer excretion through T Tube was seen.


  ::   Discussion Top


Documenting the presence and extent of a bile leak can be a difficult diagnostic problem, especially in a postcholecystectomy patient. Cholangiography, cholescintigraphy utilising 99m Tc IDA derivatives and ultrasonography are complementary diagnostic modalities for diagnosing intra-hepatic and extra-hepatic biliary pathology[5]. Ultrasound demonstrates the anatomy of the liver and biliary tree, whereas cholescintigraphy demonstrates hepatocyte function and biliary drainage, cholangiogram delineates the biliary anatomy. It is unphysiological and has high risk of introducing infection because of introduction of tubes and contrast media.

The bile leak detected on cholescintigraphy shows abnormal radio-tracer pathways away from anatomical tract. Weissman et al have demonstrated the usefulness of cholescintigraphy in detecting bile leak in 6 postcholecystectomy patients[6]. Reports say that cholescintigraphy is unable to localise a bile leak accurately. In our case we could detect the site of bile leak which was confirmed with cholangiography.

In our patient, the initial cholescintigram demonstrated three flows as leak, normal bilioenteric flow and T tube tract flow. What was more important was the approximate quantification of the flow which may be of great value in deciding further management.

The cholescintigraphy showed clearly, the abnormal accumulation of activity tracking down the right lobe resembling a tail attached to the inferior portion of the right hepatic lobe (tail sign).

Cholescintigraphy has an added advantage that it is a non-invasive, safe, simple and sensitive procedure. It can also be repeated in postoperative phase for follow-up as was done in our case.

In summary, cholescintigraphy is a non-invasive, easily accessible modality for detecting the presence, extent and approximate location of bile leak in a physiological manner which can be successfully repeated for follow up.


  ::   Acknowledgment Top


We thank the Dean, Seth GS Medical College and King Edward Memorial Hospital for allowing us to publish this case report.

 
 :: References Top

1. Devan AJ, Berne TV. Liver and bile duct injury. In Blumgart LH Ed. Surgery of the Liver and Biliary tract, 1sted Edinburgh: Churchill Livingstone; 1988, pp 1049-1050.  Back to cited text no. 1    
2.Ure JR, Brodmerkel GJ. Traumatic rupture of the gall bladder Preoperative diagnosis by ERCP. Gastrointestinal Endoscopy 1979; 27:74-75.  Back to cited text no. 2    
3.Safrany L, Van Husen N, Kautz G. Endoscopic retrograde cholangiography in surgical emergencies Ann Surg 1978; 187:20-23.  Back to cited text no. 3    
4.Weissmann HS, Chun KJ, Frank M, Keenigsberg M, Milestein DM, Freeman LM. Demonstration of traumatic bile leakage with Cholescintigraphy and ultrasonography. Am J Rad 1979; 131:843-847.  Back to cited text no. 4    
5.Rienzo RJ, Tyler G, Morel DE. Sonographic and scintigraphic detection of a bile leak in a postcholecystectomy patient Clin Nu Med 1983; 10:480-482.  Back to cited text no. 5    
6.Weissman HS, Gleidman MD, Wilk PJ. Evaluation of postoperative patient with 99mTc 0A cholescintigraphy. Semin Nucl Med 1982; 12:27.   Back to cited text no. 6    


    Tables

[Table - 1]

This article has been cited by
1 Laparoscopic cholecystectomy: Postoperative Imaging
Thurley PD, Dhingsa R
AMERICAN JOURNAL OF ROENTGENOLOGY. 2008; 191(3): 794-801
[Pubmed]



 

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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
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