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HIGH GRADE COMMON BILE DUCT OBSTRUCTION
Authored By: Keith Fischer and Peter Phan.
Patient: 51 year old male
History: The patient is a 51-year-old male with right upper quadrant pain.
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Fig. 1
Heptobiliary scan, angiographic phase

Fig. 2
Heptobiliary Scan with a 4 hour delayed image.

Fig. 3
Ultrasound of the gallbladder prior to the heptobilliary scan was equivocal.

Fig. 4
Images from a subsequent endoscopic retrograde cholangiopancreatography
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Findings: 3.2 mCi Tc-99m mebrofenin i.v. Pretreatment with 2.3 microgram of Kinevac  i.v. was given.

There is normal hepatic uptake of the tracer, but without excretion into the biliary tree or bowel throughout the 4 hours of imaging.  Notice the prompt clearance of the tracer from the blood pool (cardiac activity) during the first 5 to 10 minutes of imaging indicating preserved function of the liver. 
DDx: High grade common bile duct obstruction
Diagnosis: High grade common bile duct obstruction
General Discussion: Initial evaluation by ultrasound was equivocal, demonstrating sludge and cholelithiasis, but without wall thickening.   Subsequent evaluation by a hepatobiliary scan shows classic findings of a high grade common bile duct obstruction.   This was reported to the clinicians and the patient underwent an ERCP that evening.   Clinically, the patient was doing well, but developed elevated hepatic and pancreatic enzymes, which quickly resolved after the ERCP.  At ERCP, a stone was not seen, but suspected to have just passed.   Frank puss was noted during the sphincterotomy and a stent was placed for concern of an inflammatory stricture developing.  


Absence of bowel excretion during a hepatobiliary study may be due to severe hepatitis or high grade common bile duct obstruction.   In the case of hepatitis, delay hepatic uptake and clearance of the tracer from the blood pool is generally seen.    The lack of any detectable excretion into the biliary tree is also suggestive of a high grade obstruction.  Whereas with partial CBD obstruction, tracer excretion into biliary ducts is generally seen.
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Case Number: 105863Owner(s): Keith Fischer and Peter PhanLast Updated: 02-07-2013
Anatomy: Gastrointestinal (GI)   Pathology: Infection
Modality: Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: hsnmACR: 70000.28600

Case has been viewed 41 times.
Certified by Keith Fischer on 02-02-2009

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