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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3679_Библиотеки_им_академика_М_И_Перельмана
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signals acute cholecystitis. This imaging fi nding raises the likelihood of more
complicated or advanced gallbladder disease (Lamont et al. 1996 ). There may be
an associated incomplete common bile duct stricture or a common bile duct stone
in chronic calculous cholecystitis; radioactivity in the small intestine excludes
complete or high-grade common bile duct obstruction (Meesala et al. 2006 ;
Panjrath et al. 2004 ).
As for the MPI report, it should document the absence of gallbladder visualization when there is confi dence in this fi nding (e.g., the gallbladder fossa is included
in the fi eld-of-view). Two sample reports follow:
The gallbladder is not visualized, consistent with history of cholecystectomy.
The gallbladder is not visualized; this is an unexpected, abnormal fi nding. Recent ultraso-
nography demonstrated gallstones. Differential diagnosis includes acute or chronic calcu-
lous cholecystitis. The fi nding and differential diagnosis were discussed personally with the
referring physician at the time of interpretation.
ab
See Video 20.3a
See Video 20.3b
Fig. 20.3 “Beating gallbladder.” Note how the gallbladder appears to be fl uttering throughout
both acquisitions ( a , b ); this is a clue to right hemidiaphragmatic breathing motion which could
lead to motion artifact on processed SPECT MPI. The gallbladder should be stationary; however,
the small intestinal activity should change with normal peristalsis as seen here ( a , b ).
( a ) Rest raw projection images (Video 20.3a, frame 1),
99m
Tc sestamibi. ( b ) Stress raw projection
images (Video 20.3b, frame 1),
99m
Tc sestamibi
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ab
c
e
d
See Video 20.4a
See Video 20.4c
See Video 20.4b
Fig. 20.4 Elongated, elevated gallbladder. Note the unusual shape and position of the gallbladder
( a – c ). The CT images defi ne its anatomic position and morphology ( d , e ).
( a ) Rest raw projection images (Video 20.4a, frame 1),
99m
Tc sestamibi. ( b ) Stress raw projection
images (Video 20.4b, frame 1),
99m
Tc sestamibi. ( c ) Stress raw projection image (Video 20.4c,
frame 18),
99m
Tc sestamibi, gallbladder ( green outline ). ( d ) Coronal CT through more anterior liver
and gallbladder, septate gallbladder abuts right hemidiaphragm ( yellow box ). ( e ) Coronal CT
through more posterior liver and gallbladder, posteriormost tail of gallbladder ( yellow box ) abuts
right hemidiaphragm
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Fig. 20.5 “Sunrise/sunset” processing/reconstruction artifact. The gallbladder is “hot” and “high”
(most of it lies above the line defi ning the lower aspect of the heart) ( a , b ). The anterior wall is
“hot” and the inferior wall is “cold” on non-AC images ( c – e ), but the opposite is apparent on the
AC images ( c – e ), giving rise to an unusual “sunrise/sunset” pattern. The AC algorithm overcor-
rects the inferior wall and undercorrects the anterior wall. Although the gallbladder is distant from
the heart, its intensity leads to this unusual artifact.
( a ) Rest raw projection images,
99m
Tc tetrofosmin, white line defi nes lower aspect of heart.
( b ) Stress raw projection images,
99m
Tc tetrofosmin, white line defi nes lower aspect of heart.
( c ) Stress/rest processed SPECT images (SA) (without and with AC). ( d ) Stress/rest processed
SPECT images (VLA) (without and with AC). ( e ) Polar maps without and with AC (from top to
bottom : stress, rest, stress AC, rest AC)
a
c
d
b
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e
Fig. 20.5 (continued)
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a b
c d
See Video 20.6a See Video 20.6b
See Video 20.6c
See Video 20.6d
Fig. 20.6 Differential gallbladder visualization, 1-day rest/stress protocol. There is incomplete
fi lling of the gallbladder at rest ( a , b ), but it appears complete at stress ( b , d ) in a 1-day protocol.
This may represent chronic cholecystitis vs. incomplete fasting before the rest imaging. This
patient had undergone right lung transplant. Did you observe the asymmetry in the lungs? Did you
recognize these images from Fig.
10.7 ?
( a ) Rest raw projection images (Video 20.6a, frame 1),
99m
Tc sestamibi. ( b ) Rest raw projection
image (Video 20.6b, frame 17),
99m
Tc sestamibi, gallbladder ( green oval ). ( c ) Stress raw projection
images (Video 20.6c, frame 1),
99m
Tc sestamibi. ( d ) Stress raw projection image (Video 20.6d
frame 26),
99m
Tc sestamibi, gallbladder ( green oval )
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ab
cd
See Video 20.7a
See Video 20.7b
See Video 20.7c
See Video 20.7d
Fig. 20.7 Differential gallbladder visualization, 2-day rest/stress protocol. For rest imaging on
the fi rst day of a 2-day rest/stress protocol, the patient was not fasting; therefore, there is minimal
visualization of the gallbladder ( a , b ). For the stress test on the second day, the patient was fasting
and there is the expected degree of gallbladder visualization ( c , d ). The hospitalized patient under-
went the rest component the afternoon before (“a late add-on”) and the stress early the following
day to facilitate management.
( a ) Day 1: rest raw projection images (Video 20.7a, frame 1),
99m
Tc sestamibi (non-fasting).
( b ) Day 1: rest raw projection image (Video 20.7b, frame 12),
99m
Tc sestamibi (non-fasting), gall-
bladder ( green circle ). ( c ) Day 2: stress raw projection images (Video 20.7c, frame 1),
99m
Tc sesta-
mibi (fasting). ( d ) Day 2: stress raw projection image (Video 20.7d, frame 16),
99m
Tc sestamibi
(fasting), gallbladder ( green oval )
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a b
c d
See Video 20.8a See Video 20.8b
See Video 20.8b
Fig. 20.8 Contracted gallbladder. The gallbladder appears contracted ( a , b ) on MPI and on cor-
relative CT ( c ). This patient had undergone TIPS; note small liver ( a , c ), splenomegaly ( a , d ) and
a “hot” stomach (gastropathy) ( a , d ), characteristic signs of cirrhosis.
( a ) Stress raw projection images (Video 20.8a, frame 1),
99m
Tc sestamibi. ( b ) Stress raw projection
image (Video 20.8b, frame 9),
99m
Tc sestamibi, gallbladder ( yellow oval ). ( c ) Coronal CT through
gallbladder ( yellow oval ). ( d ) Stress raw projection image (Video 20.8b, frame 43),
99m
Tc sesta-
mibi, stomach ( green outline ), spleen ( blue oval )
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ab
c
See Video 20.9a
See Video 20.9b
Fig. 20.9 Non-visualized gallbladder due to chronic calculous cholecystitis. The gallbladder fails
to fi ll ( a , b ). The activity at the lower edge of the fi eld-of-view represents small intestine with peri-
staltic movements; when there is large volume ascites, the small intestine loops fl oat centrally. There
is a large gallstone in a contracted gallbladder on CT ( c ). Note marked “cold” ascites surrounding
the liver ( a – c ), splenomegaly ( a , b ), and a medially displaced, shrunken liver ( a – c ).
( a ) Rest raw projection images (Video 20.9a, frame 1),
99m
Tc sestamibi. ( b ) Stress raw projection
images (Video 20.9b, frame 1),
99m
Tc sestamibi. ( c ) Coronal CT through gallbladder, gallstone
( yellow oval ), ascites ( green boxes )
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a b
c
d
e
See Video 20.10a
See Video 20.10b
See Video 20.10c
Fig. 20.10 “Cold” gallbladder due to chronic calculous cholecystitis. The gallbladder is not simply non-visualized; it actually appears round, distended, and frankly “cold.” It is located in the usual
position at the inferior aspect of the right hepatic lobe ( a ). Note the small gallstone in a distended
gallbladder by CT ( b ). The “whole-fi eld-of-view” fusion images confi rm the relationship between
the “cold” scintigraphic fi nding and the bile-fi lled, stone-containing gallbladder ( c ). Interestingly,
comparison with previous MPI ( d , e ) shows a similar pattern in this chronic condition.
( a ) Stress raw projection images (Video 20.10a, frame 1),
99m
Tc sestamibi. ( b ) Coronal CT at level
of gallbladder and gallstone. ( c ) Coronal SPECT/CT fusion, whole-fi eld-of-view reconstruction,
gallbladder with gallstone ( yellow box ). ( d ) Two years previously: stress raw projection images
(Video 20.10b, frame 1),
99m
Tc sestamibi. ( e ) Two years previously: stress raw projection image
(Video 20.10c, frame 6),
99m
Tc sestamibi, gallbladder fossa ( yellow circle ), common bile duct
( green lines )
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Key Points
• The gallbladder should fi ll with radioactive bile and appear “hot”; it is
often the “hottest” fi nding in the fi eld-of-view.
• When superiorly displaced, the “hot” gallbladder can create a processing
artifact on the reconstructed SPECT MPI.
• The degree of gallbladder visualization can vary between rest and stress
imaging on both 1-day and 2-day protocols and is dependent on the fasting
state of the patient.
• The gallbladder is usually well-distended in the fasting state; a contracted
gallbladder is considered abnormal.
• Non-visualization of the gallbladder, if not surgically absent, or a distended
“cold” gallbladder signifi es underlying gallbladder disease; such fi ndings
warrant clinical correlation and communication with the referring
physician.
• Radioactivity in the small intestine excludes high-grade or complete common bile duct obstruction.
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