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Per-Rectal Portal Scintigraphy Is Complementary to Ultrasonography and Endoscopy in the Assessment of Portal Hypertension in Children with Chronic Cholestasis

¹ Department of Pediatrics, Medical School of the University of Naples "Federico II," Naples, Italy
² European Laboratory for the Investigation of Food-Induced Diseases, Naples, Italy
³ Section of Radiology, Department of Biomorphologic and Functional Sciences, Medical School of the University of Naples "Federico II," Naples, Italy
⁴ Section of Gastroenterology, Department of Clinical and Experimental Medicine, Medical School of the University of Naples "Federico II," Naples, Italy

We evaluated the clinical usefulness of ^99mTc-pertechnetate per-rectal portal scintigraphy (PPS) in the assessment of portal circulation in children with chronic cholestasis. Methods: PPS percentage shunt index (%SI) (the amount of radionuclide that shunts the liver and reaches the systemic blood after injection in the rectum) was measured in 22 children (mean age, 7.2 ± 4.9 y) and compared with established clinical, laboratory, and endoscopic and imaging parameters of portal hypertension (PH). Fourteen children had surgically treated biliary atresia, and 8 had chronic intrahepatic cholestasis. Six clinically well children served as control subjects. Results: The %SI was 14.3 ± 3.1 and 34.7 ± 18.8 in controls and in patients, respectively (P < 0.01). A cutoff of 19% correctly allocated 100% of controls and 86% of patients. Mean %SI values were significantly higher in patients with biliary atresia, a high risk of pretransplantation death, esophageal varices (EV) at endoscopy, and an abnormal value for the ratio of lesser omentum thickness to abdominal aorta diameter (LO/Ao) at ultrasonography. Correlations between %SI values and several ultrasonographic continuous variables were statistically significant only for LO/Ao ratios (r = 0.51; P = 0.005) and spleen longitudinal diameters (r = 0.53; P = 0.01). The presence of EV could correctly be predicted only when values of %SI were greater than 30% (100% specificity; 56% sensitivity). Endoscopic and PPS findings agreed for a diagnosis of PH with EV in 3 of 7 patients with normal or borderline ultrasonographic LO/Ao ratios. PPS patterns and %SI values became normal in 3 children who underwent liver transplantation. Conclusion: In children with chronic cholestasis, PPS may be an advantageous, minimally invasive tool complementary to ultrasonography and endoscopy for better assessment and follow-up of PH before and after liver transplantation.

Key Words: biliary atresia • esophageal varices • portal hypertension • per-rectal portal scintigraphy

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