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A new diagnostic approach to biliary atresia with emphasis on the ultrasonographic triangular cord sign: comparison of ultrasonography, hepatobiliary scintigraphy, and liver needle biopsy in the evaluation of infantile cholestasis.


?the utility of ultrasonography (US), Tc-99m-DISIDA hepatobiliaryscintigraphy (HS), and liver needle biopsy (NBx) in differentiating biliaryatresia(BA) from intrahepatic cholestasis in 73 consecutive infants who had cholestasis.


?Infantile cholestatic jaundice

?Kasai procedure

?US:screening, focus on shape or contractility of gallbladder

?AIM: reassess the relative accuracy and the role of US, HS, NBx in D/D cholestasis


?US: 7.0-MHz transducer, focusing on the fibrous tissue at the porta hepatis.

?Triangular cord (TC): visualization of a triangular or tubular shaped echogenic density just cranial to the portal vein bifurcation on a transverse or longitudinal scan.


?Time: Mar. 1992 ~Oct. 1996

?73 infants, age:12~120 d/o with conjugated hyperbilirubinemia or clay-colored stool, average T/D: 109/6.3

?US: TC →BA ; no TC→NH or other cause?HS: no excretion of tracer in 24 hrs→BA ;

excretion of tracer in 24 hrs→NH or other


?17 / 20 BA infant : denoted TC on US,

?43 no TC infants: either NH or other causes of cholestasis

?diagnosticaccuracy: 95%

?Sensitivity: 85%

?Specificity: 100%


?24 / 25 BA infants : no gut excretion on HS

?16 / 46 infants who had either NH or other causes of cholestasis had gut excretion

?diagnosticaccuracy: 56%

?Sensitivity: 96%

?Specificity: 35 %


?HS: gut excretion of tracer →excluded BA, ?no gut excretion of tracer →need further investigations as liver needle biopsy.?44 NBx: 19 BA infants

24 infants who had either NH or other causes of cholestasis.


?18 / 20 correctly interpreted as having BA, 23 / 24 were correctly diagnosed either NH or other causes of cholestasis

?diagnosticaccuracy: 93%

?Sensitivity: 90%

?Specificity: 96%


Sensitivity (%)



NBx859690Specificity (%)Accuracy (%)1003596955693


?TC sign on US in the diagnosis of BA: seemed to be a simple, time-saving, highly reliable, and non-invasive tool in the diagnosis of BA from other causes of cholestasis.

?When the TC is not visualized, HS is the next step. Excretion of tracer into the small bowel actually rules out BA.


?Liver needle biopsy is reserved only for the infants with no excretion of tracer.

?newdiagnosticstrategy in the evaluation of infantile cholestasis : emphasis on US TC sign as first priority of investigations. When the TC is visualized, prompt exploratory laparotomy is mandatory without further investigations.

Use of (99m)Tc-DISIDAbiliary scanning with morphine provocation for the detection of elevated sphincter of Oddi basal pressure.Source: Gut. 46(6):838-41, 2000 Jun.


?Endoscopic biliary manometry is useful in the assessment of patients with types II and III sphincter of Oddi dysfunction, but it is time consuming and invasive.


?Recurrent biliary-type pain post-cholecystectomy in the absence of pancreaticobiliary abnormalities is often attributed to sphincter of Oddi dysfunction (SOD).

?Endoscopic biliary manometry (EBM): remain the investigation of choice and predict response to endoscopic sphincterotomy


?Disadvantage of EBM:

1.time consuming

2.not widely available

3.may be associated with complication such as pancreatitis


?Clinical differentiation of SOD → 3 types on the basis of transaminase and ERCP abnormalities ?Type 1: generally good response to endoscopic sphincterotomy and not necessarily require EBM confirmation


?Type 2 and 3: poor correlation with the result of EBM and less predictable to endoscopic sphincterotomy

?Due to the limitation of EBM→try other less invasive approach

?Tc-99m-DISIDA→less sensitive in detecting elevated sphincter of Oddi basal pressure (SOBP)


?Modification: with morphine augmentation?Morphine:

1.functional obstruction of common bile duct

2.spasm of the sphincter of Oddi

→hypothesis: morphine administration may accentuate functional abnormalities in p’t with SOD


?To investigate the role of (99m)Tc-DISIDAscanning, with and without morphine provocation, as a non-invasive investigation in these patients compared with EBM


?Total 34 p’t: type II (n = 21) or III (n = 13) sphincter of Oddi dysfunction were studied.

?Biliary scintigraphy with 100 MBq of (99m)Tc-DISIDAwas carried out with and without morphine provocation (0.04 mg/kg intravenously) and time/activity curves were compared with the results of subsequent EBM.


?The criteria for type 2 SOD:

(a) unexplained biliary-type pain persisting for > 6 months post cholecystectomy

(b)either one or two of the following objective findings suggesting partial common bile duct obstruction:

CBD dilation>12 mm in ERCP

delayed emptying of contrast medium in ERCP

abnormal liver function(↑ > 2×)


?Type 3 SOD:

those with typical pain but without any of the objective signs listed


?18 (9 type II, 9 type III) of the 34 (53%) patients had SOBP > upper limit of normal (40 mm Hg).

?In the standard DISIDAscan without morphine, no significant differences were observed in time to maximal activity (Tmax) or percentage excretion at 45 or 60 minutes between those with normal and those with abnormal EBM.


?With morphine provocation:

median percentage excretion at 60 minutes was 4.9% in those with abnormal manometry and 28.2% in the normal manometry group (p = 0.002).


?Using a cut off value of 15% excretion at 60 minutes, the sensitivity for detecting elevated SOBP by the morphine augmented DISIDAscan was 83% and specificity was 81%.


?14 of the 18 patients with abnormal manometry complained of biliary-type pain after morphine infusion compared with only two of 16 patients in the normal manometry group (p = 0.001).


?If SOBP↑, then good response to sphincterotomy?In EMB:

SOBP↑in : (a) >90% type 1

(b)10~86% type 2

(c)0~55% type 3


?Effect of Morphine in normal individuals:

1.cause spasm of sphincter

2. ↑CBD pressure

3. ↑phasic pressure wave, basal sphincter pressure, phasic wave amplitude

→In abnormal SOBP p’t,this effect was greatly enhanced


?Morphine injection was found to induce pain in p’t with elevated SOBP.

?“EBM is the gold standard in the Dx of SOD”→may not necessarily be true


?(99m)Tc-DISIDAwith morphine provocation : useful non-invasive investigation for types II and III SOD to detect those with elevated SOBP who may respond to endoscopic sphincterotomy.

Hepatobiliaryscintigraphyis superior to abdominal ultrasonography in suspected acute cholecystitis. Surgery. 127(6):609-13, 2000 Jun.


?Hepatobiliaryscintigraphyis a very accurate test in the diagnosis of acute cholecystitis.

?However, ultrasonography is extensively used for the diagnosis of this disease.

?In this study, we directly compare the diagnostic accuracy of these techniques for acute cholecystitis.

Materials and Methods

?The diagnostic accuracy of scintigraphyand ultrasonography was evaluated in 107 consecutive patients with suspected acute cholecystitis who underwent both imaging modalities within one day. ?The incremental diagnostic value of each modality was determined.


?The diagnostic value of scintigraphyfor the entire cohort was significantly superior to ultrasonography ; the addition of the information derived from the latter did not further improve the diagnostic value of scintigraphy(global, chi(2) = 58.2).


?The sensitivity, specificity, positive and negative predictive values, and accuracy for the diagnosis of acute cholecystitis in the entire cohort were superior for scintigraphycompared with ultrasonography.

?The accuracy was 92% for scintigraphyand 77% for ultrasonography. Similarly, if only surgically treated patients were considered, the accuracy of scintigraphywas 91% versus 61% for ultrasonography.


?Hepatobiliaryscintigraphyhas superior diagnostic accuracy for acute cholecystitis compared with ultrasonography. The addition of ultrasonography does not further improve the diagnostic accuracy of scintigraphyalone.

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