1. 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.

2. BACKGROUND/PURPOSE (1) the utility of ultrasonography (US), Tc- 99m-DISIDA hepatobiliary scintigraphy (HS), and liver needle biopsy (NBx) in differentiating biliary atresia (BA) from intrahepatic cholestasis in 73 consecutive infants who had cholestasis.

3. BACKGROUND/PURPOSE (2) 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

4. METHODS (1) 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.

5. METHODS(2) 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

6. RESULTS (1) 17 / 20 BA infant : denoted TC on US, 43 no TC infants: either NH or other causes of cholestasis diagnostic accuracy: 95% Sensitivity: 85% Specificity: 100%

7. RESULTS (2) 24 / 25 BA infants : no gut excretion on HS 16 / 46 infants who had either NH or other causes of cholestasis had gut excretion diagnostic accuracy: 56% Sensitivity: 96% Specificity: 35 %

8. RESULTS (3) 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.

9. RESULTS (4) 18 / 20 correctly interpreted as having BA, 23 / 24 were correctly diagnosed either NH or other causes of cholestasis diagnostic accuracy: 93% Sensitivity: 90% Specificity: 96%

10. RESULT (5) Sensitivity (%) Specificity (%) Accuracy (%) US8510095 HS963556 NBx909693

11. CONCLUSIONS (1) 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.

12. CONCLUSIONS(2) Liver needle biopsy is reserved only for the infants with no excretion of tracer. new diagnostic strategy 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.

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

14. BACKGROUND (1) 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.

15. BACKGROUND (2) 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

16. BACKGROUND (3) Disadvantage of EBM: 1.time consuming 2.not widely available 3.may be associated with complication such as pancreatitis

17. BACKGROUND (4) 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

18. BACKGROUND (5) 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)

19. BACKGROUND (6) 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

20. AIM To investigate the role of (99m)Tc-DISIDA scanning, with and without morphine provocation, as a non-invasive investigation in these patients compared with EBM

21. METHODS (1) 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-DISIDA was carried out with and without morphine provocation (0.04 mg/kg intravenously) and time/activity curves were compared with the results of subsequent EBM.

22. METHODS (2) 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×)

23. METHODS (3) Type 3 SOD: those with typical pain but without any of the objective signs listed

24. RESULTS (1) 18 (9 type II, 9 type III) of the 34 (53%) patients had SOBP > upper limit of normal (40 mm Hg). In the standard DISIDA scan 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.

25. RESULTS (2) 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).

26. RESULTS (3) Using a cut off value of 15% excretion at 60 minutes, the sensitivity for detecting elevated SOBP by the morphine augmented DISIDA scan was 83% and specificity was 81%.

27. RESULTS (4) 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).

28. DISCUSSION (1) 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

29. DISCUSSION (2) 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

30. DISCUSSION (3) 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

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

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

33. BACKGROUND Hepatobiliary scintigraphy is 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.

34. Materials and Methods The diagnostic accuracy of scintigraphy and 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.

35. RESULTS (1) The diagnostic value of scintigraphy for 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).

36. RESULTS (2) The sensitivity, specificity, positive and negative predictive values, and accuracy for the diagnosis of acute cholecystitis in the entire cohort were superior for scintigraphy compared with ultrasonography. The accuracy was 92% for scintigraphy and 77% for ultrasonography. Similarly, if only surgically treated patients were considered, the accuracy of scintigraphy was 91% versus 61% for ultrasonography.

37. CONCLUSIONS Hepatobiliary scintigraphy has superior diagnostic accuracy for acute cholecystitis compared with ultrasonography. The addition of ultrasonography does not further improve the diagnostic accuracy of scintigraphy alone.