CHOLECYSTOKININ CHOLESCINTIGRAPHY: Clinical Indications and Proper Methodology

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Cholescystokin (CCK) has proved to be an important adjunct to cholescintigraphy, aiding in the diagnosis of various hepatobiliary diseases. This article discusses some of the common indications for the use of CCK in clinical practice and puts special emphasis on the importance of proper methodology for CCK infusion. A partial list of the most common indications for CCK follows and serves as an outline for the first part of this discussion:

  • 1

    Before cholescintigraphy

    • To empty the gallbladder in patients fasting more than 24 hours

    • Used as an alternative to delayed imaging so study can be completed in 60 minutes

  • 2

    During cholescintigraphy

  • 3

    After conventional 60-minute cholescintigraphy

    • To exclude acute acalculous cholecystitis

    • To differentiate common duct obstruction from normal hypertonic sphincter of Oddi

    • To confirm or exclude chronic calculous cholecystitis

    • To confirm the diagnosis of chronic acalculous cholecystitis

Section snippets

PHYSIOLOGY OF CHOLESCYSTOKININ

Cholecystokinin is a 33–amino acid polypeptide endogenously secreted by the duodenal mucosa in response to a fatty meal. The C-terminal octapeptide is the physiologically active portion of the hormone. CCK has numerous gastrointestinal physiologic effects as shown in the following list:

  • Contracts and empties gallbladder

  • Relaxes sphincter of Oddi

  • Increases intestinal motility

  • Contracts pyloric sphincter

  • Inhibits gastric emptying

  • Relaxes gastroesophageal sphincter tone

  • Stimulates hepatic bile

SINCALIDE

In the United States, sincalide is the only commercially available form of CCK approved by the Food and Drug Administration. Sincalide is the physiologically active C-terminal octapeptide of CCK. Its use in radiology dates back to the days of oral cholecystography when it was given to evaluate gallbladder contraction. In the 1970s many investigators sought to determine if poor gallbladder contraction in response to fatty meal or CCK could be used to diagnose chronic acalculous cholecystitis.

Prolonged Fasting Before Cholescintigraphy

If a patient has not eaten for an extended period of time, the gallbladder becomes filled with thick viscous bile. During fasting there is no stimulus to gallbladder contraction; however, the gallbladder's function of concentrating bile continues. This jellylike material may prevent radiotracer (Tc 9m disofenin or mebrofenin) entry during cholescintigraphy and result in a false-positive study (gallbladder nonvisualization in a patient who does not have acute cholecystitis). It has long been

METHODOLOGY FOR CHOLECYSTOKININ INFUSION

It has long been known that a bolus infusion of sincalide can produce spasm of the neck of the gallbladder, resulting in poor contraction.50 The Food and Drug Administration–approved package insert recommends a 30- to 60-second infusion of 0.02 to 0.04 μg/kg sincalide. Many investigators sought to avoid this problem by giving a 1- to 3-minute infusion. For unclear reasons, they defined an abnormal GBEF as less than 35%. This methodology was never validated, however, and normal values were never

PROTOCOL FOR CHOLESCYSTOKIN

  • Routine hepatobiliary iminodiacetic acid (HIDA) study with Tc 99m mebrofenin × 60 minutes.

    • 1

      Nothing by mouth for 3 to 4 hours before HIDA study.

    • 2

      Pre-HIDA CCK infusion if patient has been fasting greater than 24 hours.

    • 3

      Infuse CCK similar to that described next.

    • 4

      Wait at least 30 minutes before radiopharmaceutical injection to allow time for gallbladder to relax.

    • 5

      Large-field-of-view γ camera.

    • 6

      Computer setup: 60 1-minute frames.

    • 7

      Patient setup: Patient supine with camera anteriorly.

    • 8

      Inject Tc

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    Address reprint requests to Harvey A. Ziessman, MD, Division of Nuclear Medicine, Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC 20007. e-mail:[email protected]

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