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IMAGE INTERPRETATION · HEPATOBILIARY AND GI

Acute Cholecystitis on HIDA Scan with Morphine

Tc-99m HIDA scan post-morphine augmentation (2-minute frames, 0–70 min) — absent gallbladder filling despite biliary excretion, consistent with acute cholecystitis
Tc-99m HIDA scan post-morphine augmentation (2-minute frames, 0–70 min) — absent gallbladder filling despite biliary excretion, consistent with acute cholecystitis

Provided clinical image

Question

A Tc-99m HIDA (hepatobiliary iminodiacetic acid) scan is performed in a patient with right upper quadrant pain and fever. The scan shows prompt hepatic uptake and biliary excretion with normal common bile duct and small bowel visualization, but NO gallbladder activity even on 4-hour delayed images. Morphine augmentation confirms persistent absent gallbladder filling. This pattern is MOST consistent with:

  1. AAcute cholecystitis — cystic duct obstruction prevents HIDA from entering the gallbladder
  2. BNormal HIDA scan
  3. CChronic cholecystitis
  4. DCommon bile duct obstruction
Show the answer and explanation

A. Acute cholecystitis — cystic duct obstruction prevents HIDA from entering the gallbladder

On a Tc-99m HIDA scan, acute cholecystitis is diagnosed by ABSENT gallbladder visualization despite good hepatic extraction and biliary excretion, due to obstruction of the cystic duct (typically by an impacted gallstone). Normally, the gallbladder fills within 30–60 minutes. Absent gallbladder activity on images up to 4 hours (with morphine augmentation), combined with normal CBD and bowel visualization, confirms cystic duct obstruction = acute cholecystitis. Sensitivity is ~96%, specificity ~90%. Morphine augmentation (increases sphincter of Oddi tone, promoting gallbladder filling if the cystic duct is patent) is used to confirm absence. False positives include prolonged fasting (>24 hrs), TPN, hepatitis.

More hepatobiliary and gi images

Tc-99m HIDA with CCK infusion (LAO15, 4 min/frame) — gallbladder fills but GBEF = 22% at 59 min, consistent with biliary dyskinesiaLow Gallbladder Ejection Fraction on CCK HIDA Tc-99m HIDA scan (5–50 min and 4 hr) showing hepatic uptake with absent biliary excretion into bowel — pattern of biliary atresiaBiliary Atresia on Neonatal HIDA Scan Tc-99m RBC scan (ANT 60 min, sequential frames) — focal activity appearing in the right lower quadrant and migrating along the colon, indicating active GI hemorrhageActive Lower GI Bleed on Tagged RBC Scan Tc-99m mebrofenin hepatobiliary scan: 12 sequential frames over the first hourNormal Hepatobiliary Scan Sequence (Mebrofenin) Tc-99m mebrofenin hepatobiliary scan: 12 sequential frames over the first hourPatient Preparation for a HIDA Scan Dynamic abdominal scan: sequential frames at 3 min/frame from 30 to 60 minutes post-injectionMeckel’s Diverticulum Scan with Tc-99m Pertechnetate
← Meckel’s Diverticulum Scan with Tc-99m PertechnetateLow Gallbladder Ejection Fraction on CCK HIDA →

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