SNM issues guidelines for hepatobiliary scintigraphy
SNM has issued guidelines to assist nuclear medicine practitioners in recommending, performing, interpreting and reporting results of hepatobiliary scintigraphy in adults and children.

SNM said the goal of hepatobiliary scintigraphy (including planar, SPECT or SPECT/CT) is to provide diagnostic and management assistance to physicians who are involved in the care of patients with liver and biliary system ailments.

According to the guidelines, 99mTc-disofenin (DISIDA, 2,6-diisopropylacetanilido iminodiacetic acid) or 99mTc-mebrofenin (BRIDA, bromo-2, 4,6-trimethylacetanilido iminodiacetic acid) is administered intravenously in activities of 111-185 MBq (3-5 mCi) for adults; higher administered activity may be needed in hyperbilirubinemia. The administered activity for infants and children is 1.8-2.59 MBq/kg (0.05-0.07 mCi/kg) with a minimum administered activity of 18.5 MBq (0.5 mCi). Mebrofenin, with a minimum administered activity of 37 MBq (1.0 mCi), is preferred in neonates with hyperbilirubinemia , as up to 24-hour delayed images are often necessary.

A variety of pharmacologic or physiologic interventions may enhance the diagnostic value of the examination such as sincalide pretreatment, morphine sulfate, sincalide stimulation, fatty meal stimulation, phenobarbital and ursodeoxycholic acid.

The indications for hepatobiliary scintigraphy according to the guidelines are:
  • Functional biliary pain syndromes in adults;
  • Functional biliary pain syndromes in pediatric patients; 
  • Acute cholecystitis; 
  • Right upper quadrant pain variants, as defined by the American College of Radiology (ACR) Appropriateness Criteria;
  • Biliary system patency; 
  • Bile leak; 
  • Neonatal hyperbilirubinemia (biliary atresia versus neonatal hepatitis “syndrome”);
  • Assessment of biliary enteric bypass (e.g., Kasai procedure);
  • Assessment of liver transplant;
  • Afferent loop syndrome;
  • Assessment of choledochal cyst;
  • Calculation of gallbladder ejection fraction;
  • Functional assessment of the liver prior to partial hepatectomy;
  • Demonstration of anomalous liver lobulation;
  • Enterogastric (duodenogastric) reflux assessment; 
  • Esophageal bile reflux after gastrectomy; and
  • Sphincter of Oddi dysfunction.

The guideline document was developed and revised collaboratively by the SNM Hepatobiliary Scintigraphy Task Force with input from the ACR and the European Association of Nuclear Medicine (EANM).