the 8 snowmass 2017: pet/ct & nuclear medicine in clinical ...chronic cholecystitis &...
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The 8 th | Snowmass 2017:
PET/CT & Nuclear Medicine in Clinical Practice
Tuesday, February 21, 2017Westin Snowmass Resort • Snowmass Village, Colorado
Educational Symposia
TABLE OF CONTENTSTUESDAY, FEBRUARY 21, 2017
Renal Scintigraphy (Andrew T. Trout, M.D.) .................................................................................................................... 45
State of the Art Hepatobiliary Nuclear Imaging (Pradeep G. Bhambhvani, M.D.) ................................................................ 57
Communicating Risks of Radiation Exposure (Kevin J. Donohoe, M.D.) ............................................................................ 69
Standardized Solid Meal Gastric Emptying Study and Alternatives (Pradeep G. Bhambhvani, M.D.) .................................. 77
Neuroendocrine Imaging (Arif Sheikh, M.D.) ................................................................................................................... 89
SAVE THE DATES - 2018 Winter Symposia
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Page 1
STATE OF ART NUCLEAR HEPATOBILIARY
IMAGING (HIDA SCAN)
PRADEEP BHAMBHVANI, MD
Associate Professor
Molecular Imaging & Therapeutics,
Department of Radiology
The University of Alabama at Birmingham
February 21, 2017
Page 2
Disclosures
Honorarium from Educational Symposia
Page 3
Outline
Introduction
Indications
Procedure
CCK and other interventions
Clinical scenarios and interpretation
Cholecystitis (acute & chronic)
Biliary obstruction
Bile leak
Biliary atresia
Conclusion
References
Page 4
Introduction
Hepatobiliary scintigraphy (HIDA) is a diagnostic
functional imaging test that evaluates hepatocellular
function and the biliary system by tracing the production
of bile from the liver, and its passage through the biliary
system into the small bowel
HIDA from hepatic IDA (iminodiacetic acid)
Page 5
Indications
Right-upper-quadrant pain variants
Acute cholecystitis
Chronic cholecystitis & functional biliary pain syndrome
Biliary obstruction
Neonatal jaundice (biliary atresia/neonatal hepatitis)
Sphincter of oddi dysfunction, choledochal cysts etc.
Post operative biliary tract
Bile leak
Biliary stent patency
Page 6
Radiopharmaceuticals
99mTc-disofenin (DISIDA, 2,6-diisopropylacetanilido
iminodiacetic acid) or
99mTc-mebrofenin (CHOLETEC, bromo-2, 4,6-
trimethylacetanilido iminodiacetic acid)
Dose:
Adults: 111-185 MBq (3-5 mCi) (higher doses in
jaundice)
Infants & children: 1.8-2.59 MBq/kg (0.05-0.07 mCi/
kg), minimum 18.5 MBq (0.5 mCi)
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Page 7
Preparation
Fasting: Minimum 2 hours (preferably 6 hours)
If fasting >24 hours pre-treat with CCK (to empty GB)
Fatty meal prior evening (≥10g of fat, to empty GB)
Hold narcotics for 12-24 hours (4 half lives). Naloxone
reversal an option
Hold drugs affecting GB contractility: atropine, nifedipine,
indomethacin, octreotide, theophylline, histamine blockers,
progesterone, isoproterenol, benzodiazepines, ETOH,
nicotine
Gallbladder ejection fraction (GBEF) best done as an
outpatient exam
Page 8
Procedure
Radiopharmaceutical injected IV while patient lies
supine on imaging table.
NM camera placed anterior to the patient detects
gamma rays emitted to form images. Include drains &
catheters in field of view.
Cine images are acquired initially for up to 60 minutes.
Delayed images & interventions may be done to
improve diagnostic certainty.
Page 9
Normal HIDA Scan
Page 10
Normal HIDA Scan (Alternative view)
RIGHT LATERAL
Page 11 Anterior View
1 2 3 4
5 6 7 8
9 10 11 12
13 14 15
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Page 12 Anterior View
In anterior view the activity in the duodenum often
interferes with activity in the gallbladder region!
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Page 13
Anterior View
Slide Courtesy of Dr. Mark Tulchinsky Page 14
40o
Left Anterior Oblique view separates GB from duodenal
activity – makes good anatomical sense!
Slide Courtesy of Dr. Mark Tulchinsky
Page 15
Anterior View
LAO view separates GB from duodenal
activity – makes good functional
imaging sense!
Slide Courtesy of Dr. Mark Tulchinsky
Page 16
Post CCK
2 min/frame
40o LAO Projection
1 2 3 4
5 6 7 8
9 10 11 12
13 14 15
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Interventions
Suspected acute cholecystitis: GB not seen in the first
hour
IV Morphine Sulfate (preferred): 0.04 mg/kg or fixed
2 mg dose over 2-3 min or
Delayed images at 3-4 hours
Assessment of GBEF
Fatty Meal: Inconsistent
CCK (Gold standard)
Page 18
Normal GBEF
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Page 19
GBEF Formula
GBEF(%) =(NetGBcountsmax− NetGBcountsmin)
NetGBcountsmax×100
Page 20
Cholecystokinin (CCK, Sincalide, Kinevac®)
33 amino acid polypeptide made in the proximal small
bowel. Active component is the C-terminal octapeptide
Can be safely used with gallstones
Boluses cause abdominal pain and nausea (50%)
Sincalide: Synthetic analog of the terminal octapeptide
Dose: 0.02 µg/kg IV infusion in 30-50 ml NS
Pretreatment (over 30-60 min) if:
Prolonged fasting (>24h)
Hyperalimentation
GBEF (over 60 min)
Page 21
CCK Protocols, SNM practice guidelines for hepatobiliary
scintigraphy. J Nucl Med Tech 2010;38:210–218
a. 0.04, 3, 43±26%, 15-88%, 12.
b. 0.02, 3, 35±17%, 17-59%, 6.
c. 0.02, 3, 56±27, 0-100%, 23.
d. 0.01, 3, 46±20, 12-74%, 20.
e. 0.01, 10, 76±16, 37-96%, 13.
f. 0.02, 15, 76±22, 32-98%, 15.
g. 0.02, 15, 57±29, -2-98, 60.
h. 0.01, 30, 64±20, 26-95%, 14.
i. 0.02, 30, 70±22, 17-97%, 23
j. 0.02, 30, 71±25, 8-99%, 60.
k. 0.015, 45, 75±12, >40% (95% confidence limits), 40.
l. 0.01, 60, 68±16, 15-88%, 20.
m. 0.02, 60, 84±16, 38-100%, 60.
Format: sincalide dose (μg/kg),
time of infusion (min), GBEF
(mean±SD), GBEF range, and
number of normals studied
Page 22
Bhambhvani P et al. Variability in cholescintigraphy protocols in hospitals
across the state of Alabama. J Nucl Med 2010; 51 (Supplement 2):597.
Hours NPO 2-4 hrs 4 or more hrs
18 45
Screening for
Opiate Use
No Yes
13 50
CCK Pretreatment if
NPO > 24hrs
No Yes
58 5
GBEF Determination
Method
CCK Fatty Meal Variable
57 5 1
CCK Dose 0.01-.02 µcg/kg > than 0.02 µcg/kg
53 4
Duration of CCK
infusion (5 sites
used a Fatty Meal)
<3 min 3- 5 min >5 but <30
min
30 min
12 3 24 18
Normal GBEF (≥) 30% 35% 40% 50%
6 47 7 3
Evaluation if GB not
seen at 1 hr
2 hr delay 3-4 hr
delay
Morphine
use
Variable
16 35 6 6
Page 23
J Nucl Med 2010; 51:277–281
Page 24
J Nucl Med 2010; 51:277–281
60 volunteers (32-F, 28-M); Ages 20-62
4 Institutions, 15 subjects each
All got CCK 0.02 µg/kg over 15, 30 and 60 min
Coefficient of variation: 52%, 35% & 19% for the 15, 30
& 60 min infusion (p<0.0007)
Normal GBEF (lower end of normal) :
15 & 30 min: ≥15% & ≥13%
60 min: ≥38% (least variation & highest EF’s)
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J Nucl Med Technol. 2010 Dec;38(4):210-8.
Page 26
Clinical Gastroenterology and Hepatology 2011;9:376–384
Page 27
Unavailability of Sincalide: Options
Generic Sincalide (QC concerns)
Fatty meals (Normal GBEF)
Whole milk, 300 mL (≥ 51%)
Ensure Plus®, 237 mL (≥ 33%)
Lipomul: Soybean oil emulsion 30 mL (≥ 20%)
Ziessman H, Petry NA. J Nucl Med. 2013 Aug;54(8):17N.
Page 28
Acute Cholecystitis
Most common indication for HIDA
US is the initial test of choice (sufficient in 80% patients)
HIDA is more accurate
Sensitivity 95-98%, specificity 90% (HIDA) versus
70% & 86% (US)
Detects the pathophysiologic event (GB/CD obstruction)
seen as persistent non-visualization of the GB
Page 29
Acute Cholecystitis
Calculous (90-95%)
Acalculous (5-10%)
Elderly
Critically ill (burns, sepsis, immunosuppressed, DM)
Postpartum
Vasculopathy
Page 30
Acute Cholecystitis: GB Non-visualization
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Acute Cholecystitis: GB Non-visualization
Page 32
Pitfalls
False Positives
Chronic cholecystitis
Prolonged or no fasting
Poor liver function
Congenital/surgical absence of GB
False Negatives
GB mimics (bowel, diverticulum, cystic duct & rim signs)
Intermittent GB obstruction
Acalulous cholecystitis (sensitivity 70-80%)
Cystic duct is less often obstructed
CCK challenge & WBC scan
Page 33
Cystic Duct Sign
Page 34
Rim Sign
Page 35
Recurrent biliary colic with gallstones seen on US &
relieved with cholecystectomy
If symptoms atypical, HIDA with CCK GBEF very useful.
Abnormal suggests CCC. Refer for cholecystectomy
Normal consider other etiologies
Chronic Calculous Cholecystitis (CCC)
Page 36
Chronic Cholecystitis: HIDA findings
1) Delayed GB filling (after 1 hour) with normal biliary to bowel transit
2) Delayed/disparate GB filling relative to small bowel in the 1st hour
3) Delayed biliary to bowel transit with normal GB filling
4) Unusually slow GB filling
5) Irregular or eccentric GB filling
6) Faint or very small contracted GB
7) Band or septa across GB
8) Photopenic defects in GB
9) GB non-visualization
10) Poor response to sincalide (Low GB ejection fraction)
11) Combinations of the above
12) Normal hepatobiliary scan with prompt GB and small bowel activity
Chamarthy M, Freeman LM. Hepatobiliary Scan Findings in Chronic Cholecystitis
Clin Nucl Med 2010;35: 244–251
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Chronic Cholecystitis: Low GBEF
Page 38
GB non-visualization in an outpatient without acute symptoms:
Chronic Cholecystitis
Page 39
Chronic Acalculous Cholecystitis (CAC)
5-10% of chronic cholecystitis
CT/US not useful as no gallstones. HIDA has a role
Synonyms
Gallbladder/biliary dyskinesia
Functional gallbladder disorder
Chronic acalculous gallbladder disease
Acalculous gallbladder dysfunction
Gallbladder spasm
Page 40
Chronic Acalculous Cholecystitis
Recurrent biliary colic
No gallstones
Low GBEF
Symptoms improve with cholecystectomy
Pathology reveals chronic inflammation
Page 41
Chronic Acalculous Cholecystitis
CCK 0.02 mcg/kg over 45 min (EF measured at 60 min)
103 patients, 21 with GBEF <40%
11 randomized to cholecystectomy
10 became asymptomatic
1 improved
No surgery group (10) remained symptomatic, 2 had
cholecystectomy with symptom resolution
12/13 GB had chronic inflammation on histopathology
Yap L et al. Acalculous biliary pain: cholecystectomy alleviates symptoms in
patients with abnormal cholescintigraphy. Gastroenterology 1991;101:786–793.
Page 42
Enterogastric Reflux
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High Grade Biliary Obstruction (Persistent Liver Scan)
Page 44
Partial Obstruction & Sphincter of Oddi Dysfunction
Good hepatic uptake, prompt secretion into the biliary
ducts, and gallbladder filling; however, clearance from
the biliary ducts is delayed
Biliary to bowel transit does not exclude partial
obstruction. Poor clearance from biliary ducts is
characteristic
CCK infusion can help differentiate from functional
delays (prompt transit after CCK)
Page 45
Bile Leak: Post MVA Liver Laceration
Page 46
Bile Leak-Post Cholecystectomy: SPECT-CT
Page 47
Biliary Atresia
Progressive, idiopathic, fibro-obliterative disease of the
extrahepatic biliary tree. Presents as neonatal jaundice
Early diagnosis is critical to prevent irreversible liver failure
HIDA: Persistent hepatogram and no biliary-to-bowel
transit over 24 hours
Preparation to prime liver enzymes:
Phenobarbital: 5mg/kg/d for 3-5d or
Ursodeoxycholic Acid: 20 mg/kg/d for 2-3d prior
Treatment:
Palliative hepatoportoenterostomy (Kasai procedure)
Often, ultimately, liver transplantation
Page 48
Biliary Atresia (Absent Bowel Activity)
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Neonatal Hepatitis (+ Bowel Activity). No Biliary Atresia
Page 50
Conclusions
HIDA is a valuable time tested imaging modality of the
hepatobiliary tract
Its main advantage over other modalities is that it permits
physiologic imaging of liver function and biliary patency
Morphine augmented HIDA allows for rapid diagnosis of acute
cholecystitis
CCK (0.02 µg/kg infusion over 60 min) has the least variability
& may be considered the GBEF method of choice
Page 51
References
Ziessman HA. Hepatobiliary Scintigraphy in 2014. J Nucl Med 2014; 55:1–9
Ziessman HA. Nuclear Medicine Hepatobiliary Imaging. Clinical
Gastroenterology and Hepatology 2010;8:111–116
Tulchinsky M et al. SNM practice guidelines for hepatobiliary scintigraphy. J
Nucl Med Tech 2010;38:210–218
Ziessman HA. Sincalide Cholescintigraphy-32 Years Later: Evidence-Based
Data on Its Clinical Utility and Infusion Methodology. Semin Nucl Med 42:79-83
Ziessman HA et al. Cholecystokinin Cholescintigraphy: Methodology and
Normal Values Using a Lactose-Free Fatty-Meal Food Supplement. J Nucl Med. 2003; 44: 1263-1266.
Covington MF et al. Classification Schema of Symptomatic Enterogastric Reflux
Utilizing Sincalide Augmentation on Hepatobiliary Scintigraphy. J Nucl Med
Technol 2014; 42:198–202
Tulchinsky M et al. Hepatobiliary Scintigraphy in Acute Cholecystitis. Semin
Nucl Med 42:84-100
Chamarthy M, Freeman LM. Hepatobiliary Scan Findings in Chronic
Cholecystitis. Clin Nucl Med 2010;35: 244–251
Page 52
Thank You
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Disclosures/Disclaimers
I have no conflicts of interest.
Three Things to Learn
• Communication includes listening.
• You must be trustworthy.
• Don’t expect to win many people to your side,
no matter how good your evidence.
Why Think About Radiation Risk?
71
What do people fear?
• Unknown
• Can’t see
• Can’t smell
• Can’t taste
• Can’t touch
Risk Communication
Who you will communicate with
Medical colleagues
Patients
Research subjects
Hostile groups
Intentional exposures
Unintentional exposure
Fear vs. Risk
Rank hazard mortality
Rank fear of hazard
Correlation between fear and risk is ~ .2
How to Communicate Risk
Know your audience
Educational level
Study subject?
What are their concerns?
Health
Property
Financial
Your Audience – Who is More Fearful?
Listen to your audience before you speak
What is their concern?
Health effects?
Economic concerns?
Family?
Assess understanding as you go along.
Summarize
Ask them what they think about what you have
told them
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Assess Level of Education and Understanding
• Listening helps
• Know what vocabulary to use
• Chest X-ray or .?
• Background
• Have they already made up their mind?
• Where do they get their information?
• What is worrying them?
Speaking to Specific Groups
• Anti-nuclear
• Regulators
• General Public
• Medical Professionals
• Disaster drills
• Consumers of radiological services
Educating Medical Professionals
• •
•
•
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•
•
•
• •
•
Intentional vs Unintentional Exposures
• Intentional
• Medical
• Radiation worker
• Unintentional
• Accidents
• Terrorist attacks
• Power Plants
Besides Speaking
• Written communication
• Web-based
• Blogs
• Social media
• Wiki articles
• Newspapers
• Editorials
• Letters
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What if you Don’t Know?
• Say:
• “I don’t know”
• Do not lose credibility with your
audience. You need to remain a
trusted source.
Ultimate Goal
• In speaking to patients –
• You are an advocate for the patient
• We are adding risk to their lives, we are
damaging their tissues
• What is the risk of NOT doing the scan?
• In speaking to Physicians –
• You are an advocate for the patient AND
physician
• In speaking to regulators –
• You are an advocate for the patient
• Is something not working well?
Radiation Doses and Dose Limits Dose Examples
Source Dose – mSv (mrad)
Torso CT (w/wo) 40 (4,000)
PET/CT 8 – 25 (800 – 2,500)
Myocardial perfusion (R/S) 7 (700)
Chest CT 7 – 1.5 (700 – 150)
Natural background (per
year)
3.5 (350)
Chest x-ray 0.1 (10)
Dental X-rays 0.005 (0.5)
Flying 0.003 (0.3) /hr
Radiologyinfo.org
Physical
Radionuclide Half-Life Activity Use
Cesium-137 30 yrs 1.5x106 Ci Food Irradiator
Cobalt-60 5 yrs 15,000 Ci Cancer Therapy
Plutonium-239 24,000 yrs 600 Ci Nuclear Weapon
Iridium-192 74 days 100 Ci Industrial Radiography
Hydrogen-3 12 yrs 12 Ci Exit Signs
Strontium-90 29 yrs 0.1 Ci Eye Therapy Device
Iodine-131 Therapy 8 days 0.015 Ci Nuclear Medicine
Technetium-99m 6 hrs 0.025 Ci Diagnostic Imaging
Americium-241 432 yrs 0.000005 Ci Smoke Detectors
Radon-222 4 days 1 pCi/l Environmental Level
Examples of Radioactive Materials Communication in Radiation Disaster
• The “worried well” are going to require a large
amount of resources.
• Emphasize medical care over radiation
exposure concerns.
• Communication of reliable and accurate
information is very important and very
unlikely.
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Decontamination
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Max Mussel
Tammy Tech
References
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RADIONUCLIDE GASTRIC EMPTYING STUDY
Standard Solid-Meal & Alternatives
PRADEEP BHAMBHVANI, MD
Associate Professor
Molecular Imaging & Therapeutics,
Department of Radiology
The University of Alabama at Birmingham
February 21, 2017
Page 2
Disclosures
Honorarium from Educational Symposia
Page 3
Outline
Introduction
Consensus Guideline and Standardized Meal
Patient Preparation
Interpretation
Rapid Emptying
Alternative Meal
Shortened Protocol
Liquid Emptying
Conclusions
Page 4
Radionuclide Gastric Emptying
GOLD STANDARD
Page 5
Radionuclide Gastric Emptying
Most comprehensive & physiologic studies of gastric
motor function
Widely available
Simple, noninvasive & quantitative
Uses a physiologic meal (solids with or without
liquids)
Can determine therapy effectiveness
Page 6
Scintigraphy Alternatives
Not routinely done as more studies needed
13C Octanoic acid breath testing
Wireless motility capsule
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Page 7
Normal Stomach Physiology
Antrum: - Phasic contractions, grind solid
food particles
Controls Solid Emptying
Fundus: - Tonic reservoir which
undergoes receptive relaxation
- Constant pressure gradient
Controls Liquid Emptying
Page 8
Liquid Emptying: Exponential Solid Emptying: Linear
Lag Phase
Gastric Emptying: Time Activity Curves
Page 9
Introduction
Gastroparesis is a syndrome of objectively delayed
gastric emptying in the absence of mechanical
obstruction and with symptoms of nausea, vomiting, early
satiety, bloating and/or upper abdominal pain
The radionuclide study cannot differentiate functional
delay from anatomic obstruction (e.g. tumor or ulcer).
EGD or CT or barium study can aid with that
More symptoms with delays in solid emptying versus
liquid emptying
Page 10
Etiology of Gastroparesis
Idiopathic (50%)
Diabetes Mellitus
Post-surgical (vagus injury): Bilroth II, heart & lung
transplants, fundoplication
Medications
Viral
Dysautonomia
CNS: MS, Brainstem CVA/tumor, PD, SCI
Infiltrative disorders: Scleroderma, Amyloid etc.
Page 11
Factors Affecting Gastric Emptying
Meal related (fat, protein, acid, osmolality, volume,
weight, caloric density, particle size)
Patient position (standing, sitting, supine)
Incomplete meal or emesis
Stress, Exercise
Medications
Tobacco smoking
Hyperglycemia
Menstrual cycle
Page 12
Effect of increasing liquid calorie content on liquid (a) and solid (b) emptying
Collins PJ et al., Gut, 1983, Dec;24(12):1117-25.
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Medications and Gastric Emptying
ACCELERATE
Metoclopramide
Erythromycin
Domperidone
Cisapride
DELAY
Narcotics (Morphine, Percocet, Vicodin)
Alpha-2-adrenergic agonists (Clonidine), Atropine
Tricyclic antidepressants, Benzodiazepines & Phenothiazines
Calcium channel blockers, Progesterone, Theophylline
Anticholinergics (Bentyl, Levsin, Donnatal)
Octreotide
Page 14
Study to Establish Normal Values
Page 15
Tougas G et al. Am J Gastroenterol. 2000;95:1456-1462
11 sites in 4 countries (US, Canada, Italy, Netherlands)
123 volunteers (60-F, 63-M); ages 19-73
No GI illness/surgery, no ongoing medical condition &
no medications
All had a 99mTc-labeled low fat egg meal. 20 patients
also had the 99mTc-labeled liver meal
1 min images and gastric retention at 60, 120 and 240
minutes
Page 16
Tougas G et al. Am J Gastroenterol. 2000;95:1456–1462
Percent Retention Median 95th Percentile
1 hour 69 90
2 hour 24 60
4 hour 1.2 10
T-50 (min) 83 132
Lag phase (min) 21 49
Results N=123
Page 17
Tougas G et al. Am J Gastroenterol. 2000;95:1456–1462
Other Results
No significant difference in emptying between meals,
except 3h retention was higher with the liver meal
Gender: There was more gastric retention in women at
1 and 2h but no difference from men at 4h
Age: Greater retention in younger patients
BMI: No relationship with gastric emptying
Page 18
Consensus Recommendations
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SNMMI Guideline
J Nucl Med Technol. 2009 Sep;37(3):196-200
Page 20
Patient Preparation
Minimum 4 hour fasting
Fasting blood sugar less than 200 mg%
Insulin & oral medications OK with standardized meal
Stop Narcotics, Prokinetics, Anticholinergics for 2 days
If nausea or vomiting, Zofran use is safe
Women are ideally studied on days 1-10 of menstrual cycle
Avoid smoking on day of test
Page 21
Standardized Meal: Egg Whites Sandwich (255 kcal)
EGG-BEATERS (118 ml/4 oz. 60 kcal), 0.5-1 mCi 99mTc sulfur
colloid mixed with egg whites, scrambled or omelet
2 toasted white bread slices (120 kcal)
30g strawberry jam (75 kcal)
120 ml water
Meal eaten separately or as sandwich in <10 minutes
At least 50% of the meal should be consumed
Page 22
Imaging
Anterior & posterior 1 minute images after meal & hourly up
to 4 hours
Calculate gastric retention from geometric mean after region
of interest (ROI) drawn around stomach
Geometric mean = √ anterior counts x posterior counts
ROI should avoid small bowel
Higher sensitivity at 4 hours
Page 23
Interpretation
Normal Values for Low Fat Egg-Whites Gastric Emptying Study
Am J Gastroenterol. 2007;102:1–11
Time Point Lower Normal Limit for
Gastric Retention
Upper Normal Limit for
Gastric Retention
0 min A lower value suggests
rapid emptying
A greater value suggests
delayed emptying
1 hour 30% 90%
2 hour 60%
3 hour 30%
4 hour 10%
Page 24
Interpretation
Delayed Emptying
2 hour retention >60% and/or
4 hour retention of ≥10%
Rapid Emptying
1 hour retention <30%
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NORMAL EMPTYING
GASTRIC RETENTION
1 HOUR: 69%
2 HOUR: 25%
3 HOUR: 17%
4 HOUR: 2%
4 HOUR
Page 26
SEVERE DELAYED EMPTYING
GASTRIC RETENTION
1 HOUR: 76%
2 HOUR: 64%
3 HOUR: 47%
4 HOUR: 40%
Page 27
Severity of Gastroparesis
No correlation between severity and symptoms
Severity scale (% gastric retention)
11-15%: Mild
16-35%: Moderate
>35%: Severe
Camilleri M. N Engl J Med 2007;356:820-9.
Page 28
Rapid Gastric Emptying
Usually seen
After peptic ulcer surgery (pyloroplasty)
In early type 2 DM
Zollinger-Ellison syndrome
Hyperthyroidism
Symptoms: Diarrhea, abdominal pain, bloating, nausea (early
dumping syndrome), diaphoresis, palpitations, weakness, fainting
(late dumping syndrome)
Symptoms often similar to gastroparesis
Page 29
Rapid Gastric Emptying
Page 30
Alternative Meal (Ensure Plus®)
Use of a High Caloric Liquid Meal (Ensure Plus®) as
an Alternative to a Solid Meal for Gastric Emptying
Scintigraphy
20 healthy volunteers
Egg-whites sandwich (EWS) and Liquid Nutrient Meal
(LNM) GE exams on separate days
Sachdeva et al: Dig Dis Sci July 2013, Volume 58, Issue 7, 2001-6
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EWS versus Ensure Plus®
Egg Whites Sandwich
(EWS)
Liquid Nutrient Meal
(LMN) Ensure Plus®
Calories (kcal) 255 350
Fat % 2 28
Protein % 24 15
Carbohydrate % 72 57
Fiber % 2 0
Sachdeva et al: Dig Dis Sci July 2013, Volume 58, Issue 7, 2001-6
Page 32
Alternative Meal (Ensure Plus®)
Ensure Plus® gastric emptying is overall similar to EWS
Ensure Plus® meal empties without a lag phase and
takes slightly longer to empty from the distal stomach,
likely due to its higher fat content
Reasonable alternative to the EWS meal
Sachdeva et al: Dig Dis Sci July 2013, Volume 58, Issue 7, 2001-6
Page 33
Shortened Protocol
174 patients (123-F, 51-M)
Abnormal Emptying: >65% retention at 2 hours
Normal Emptying: <45% retention at 2 hours
Very accurate
<25% patients needed 4 hour imaging
Bonta V et al: Clin Nucl Med; Vol 36(4), Apr 2011, p 283-285
Page 34
Shortened Protocol
J Nucl Med 2015; 56:873–876
Page 35
4 academic institutions; 431 patients
At 2 hours:
261 (60.6%) had gastric retention <45%, i.e. normal
62 (14.4%) had gastric retention >65%, i.e. delayed emptying; and
108 (25.1%) had intermediate values requiring imaging through 4 hours
Bonta criteria had a sensitivity, specificity, and accuracy of 92.4%, 96.9%,
and 95.8%. False negative results seen in 8 patients (1.9%).
Bonta criteria shortened the study duration in most patients,
resulting in an effective compromise between reduced resource use,
improved patient convenience, and preserved accuracy.
J Nucl Med 2015; 56:873–876
Shortened Protocol
Page 36
Sources of Error
Vomiting after meal or Incomplete meal or prolonged
meal ingestion time
Non-standard meal
Poor labeling
Slow meal passage from the mouth/esophagus into
the stomach
Gastroesophageal reflux
Overlap of small-bowel activity with the stomach ROI
Lack of decay correction etc.
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Page 37
Issues Requiring Clarification
Pediatric GES (no standards yet)
Post-surgical (Bariatric, Billroth-no normal values)
Value of other emptying metrics:
Fundal–antral and antral-pyloric coordination
Gastric accommodation
Regional muscular contraction patterns
Antral motility
Fundal accommodation response
Separate fundal and antral emptying curves
Effect of varying meal composition on emptying etc.
Page 38
Liquid Gastric Emptying
Conventional belief: There is good correlation between
solid & liquid emptying, so the latter is not done routinely
Alternative to solid meal or part of a solid-liquid study
Post-operative states
Solid meal intolerance
Dumping syndrome or
Research study
Page 39
“Solid gastric emptying is more sensitive than liquid emptying
for detection of Gastroparesis liquid emptying is preserved
until the disorder is advanced” Tadataka Yamada, Textbook of
Gastroenterology 4th edition
“Liquid emptying is always normal when solid emptying is
normal” and “A liquid only study should be reserved for those
who cannot tolerate solids” The Requisites: Nuclear Medicine 3rd
Edition. Harvey Ziessman, Janis P O’Malley & James H Thrall
“Liquid GE studies are by themselves of limited clinical value
because liquid emptying usually is not abnormal until
gastroparesis is far advanced” Update on GI Scintigraphy,
Seminars in Nuclear Medicine, 2006, 36, 110-118, Alan H Maurer,
Henry P Parkman
Liquid Gastric Emptying
Page 40
Ziessman HA et al. J Nucl Med 2009 50: 726-731.
101 symptomatic patients (24-M 77-F) had sequential liquid solid GES
7 patients were diabetic
Liquid GES with 111In DTPA and solid GES with EWS
Normal liquid GES: <19 min (mean ± 2SD) or <22 min (mean ± 3 SD)
Page 41
Ziessman HA et al. J Nucl Med 2009 50: 726-731.
A Normal liquid
GES
Delayed
liquid GES
Total
Normal solid
GES
58 27 85
Delayed solid
GES
4 12 16
Total 62 39 101
B Normal liquid
GES
Delayed
liquid GES
Total
Normal solid
GES
61 24 85
Delayed solid
GES
4 12 16
Total 65 36 101
Normal liquid GES
T1/2 <19 min
Normal liquid GES
T1/2 <22 min
Page 42
Ziessman HA et al. J Nucl Med 2009 50: 726-731.
Liquid gastroparesis seen in 30% of patients with
normal solid emptying
Gastroparesis diagnosis increased from 16% with only
abnormal solid study to an additional 28-32% with
normal solid but abnormal liquid study
85
Page 43 Page 44
Sachdeva P et al. Dig Dis Sci (2011) 56:1138–1146
Retrospective study; 449 patients (346-F & 103-M)
62 diabetics (15%)
27% (60/228) had delayed liquid & normal solid emptying
Normal
solid GES
Delayed
solid GES
Rapid solid
GES
Total
Normal liquid
GES
168 90 11 269
Delayed liquid
GES (>50%
retention at 1h)
60 117 3 180
Total 228 207 14 449
Page 45
Added Value of Liquid Emptying
Prior publications have found poor correlation between
symptoms and GES
One reason may be that only antral function has been
studied
Therapies specific for fundal dysfunction are needed
Page 46
Conclusions
Solid-meal gastric emptying is standardized!
Ensure Plus® is a viable alternative meal
Shortened protocol maintains accuracy while improving
clinic workflow
Liquid emptying has added diagnostic value
Page 47
References
Abell TL, Camilleri M, Donohoe K, et al. Consensus recommendations for gastric emptying
scintigraphy: a joint report of the American Neurogastroenterology and Motility Society
and the Society of Nuclear Medicine. Am J Gastroenterol. 2008;103:753–763.
Tougas G, Eaker EY, Abell TL, et al. Assessment of gastric emptying using a low fat meal:
establishment of international control values. Am J Gastroenterol. 2000;95:1456–1462.
Ziessman HA. Goetze S, Bonta D, Ravich W. Experience with a new standardized 4-hr
gastric emptying protocol. J Nucl Med. 2007;48:568–572.
Sachdeva P, Malhotra N, Pathikonda M, et al. Gastric emptying of solids and liquids for
evaluation for gastroparesis. Dig Dis Sci. 2011 Apr;56(4):1138-46.
Ziessman HA, et al. The added diagnostic value of liquid gastric emptying compared with
solid Emptying alone. J Nucl Med 2009 50: 726-731.
Bonta D, Lee H, Ziessman H. Shortening the 4 hour gastric emptying protocol. Clin Nucl
Med. 36(4), April 2011, pp 283-285.
Donohoe KJ et al. Procedure Guideline for Adult Solid-Meal Gastric-Emptying Study 3.0. J.
Nucl. Med. Technol. 2009 Sep;37(3):196-200.
Collins PJ, Horowitz M, Cook DJ et al. Gastric emptying in normal subjects-a reproducible
technique using a single scintillation camera and computer system. Gut. 1983 Dec;24(12):
1117-25.
Sachdeva P, Kantor S, Knight LC, et al. Use of a high caloric liquid meal as an alternative
to a solid meal for gastric emptying scintigraphy. Dig Dis Sci. 2013 Jul;58(7):2001-6.
Pelletier-Galarneau M, Sogbein OO, Pham X et al. Multicenter validation of a shortened
gastric-emptying protocol. J Nucl Med. 2015 Jun;56(6):873-6.
Page 48
Thank You
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NeuroendocrineImaging
NeuroendocrineImaginghasbeenoneofthefirstreceptorbasedimagingmodalitiesinNuclearMedicine.ItisnowbecomingincreasinglyimportantastheinvolvementofNuclearMedicineinthisfieldisgrowing.ThetalkwillreviewthebasicindicationsofimagingwithPentetreotideandmIBGimagingwithSPECT,anddiscussoptionsthathavebeenusedclinicallyinPET,includingthenewlyapprovedtracers.
1) ReviewofpathologieswithinNeuroendocrineImaging
2) ReviewofSPECTtracersusedforclinicalimaging
3) ReviewofPETtracersusedforclinicalimaginginNeuroendocrineDiseases
4) ComparisonofPETvs.SPECTtracers
5) ImplicationsofprognosisandtherapywithNuclearMedicine
References:
1) PfannenbergAC,etal.“BenefitofAnatomical-functionalImageFusionintheDiagnosticWork-upofNeuroendocrineNeoplasms”EurJNuclMedMolImaging.2003;30:835–43
2) BuchmannI,etal.“Comparisonof68Ga-DOTATOCPETand111In-DTPAOC(Octreoscan)SPECTinPatientswithNeuroendocrineTumours”EurJNuclMedMolImaging(2007)
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