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CASE REPORT
Year : 2012  |  Volume : 27  |  Issue : 4  |  Page : 257-258  

Vicarious visualization of gall bladder on Tc-99m ethylene dicysteine renal dynamic study


Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication23-Jul-2013

Correspondence Address:
Nishikant A Damle
Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.115400

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   Abstract 

Though the hepatobiliary excretion of Technetium-99m ethylene dicysteine (99mTc-EC) is very low and usually does not effect image interpretation on routine posterior imaging, the possibility of visualization of the gall bladder should be kept in mind while reporting the 99mTc-EC scan especially, when anterior imaging is performed as in renal transplant patients.

Keywords: Gall bladder, technetium-99m ethylene dicysteine, vicarious visualization


How to cite this article:
Arora G, Damle NA, Tripathi M, Bal C, Kumar P. Vicarious visualization of gall bladder on Tc-99m ethylene dicysteine renal dynamic study. Indian J Nucl Med 2012;27:257-8

How to cite this URL:
Arora G, Damle NA, Tripathi M, Bal C, Kumar P. Vicarious visualization of gall bladder on Tc-99m ethylene dicysteine renal dynamic study. Indian J Nucl Med [serial online] 2012 [cited 2019 Dec 13];27:257-8. Available from: http://www.ijnm.in/text.asp?2012/27/4/257/115400


   Introduction Top


The application of Technetium-99m ethylene dicysteine (99mTc-EC), as potential renal imaging agent was first proposed in 1990 and was based on the observation that brain perfusion agent ethylene cysteine dimer is rapidly cleared through kidneys after being metabolized to ethylene dicysteine. 99mTc-EC has since evolved to be the scintigraphy agent of choice for assessment of renal function. [1]

Various pre-clinical and clinical studies have established 99mTc-EC as a better tubular agent than 131I-Orthoiodohippurate (OIH) as well as 99mTc-Mercaptoacetyl triglycine (MAG3). It has a high first pass extraction of ~70% and low plasma protein and red blood cell binding (~30% and ~5-6%, respectively). Apart from these merits, the key characteristics 99mTc-EC are low or negligible extra-renal clearance and high kidney-to-background ratio. [1],[2],[3] Herein we report a rare vicarious excretion of 99mTc-EC through hepatobiliary route.


   Case Report Top


A 10-year-old patient with history of dual cadaveric renal transplant presented with abdominal pain of 1 month duration. The ultrasound study showed a collection in the pelvis. The patient underwent renal scintigraphy at our department for evaluation of renal function. 185 MBq of activity was administered. Dynamic images were acquired anteriorly, on a Symbia T6 dual head SPECT/CT system (Siemens) at 2 s/frame for 60 s followed by 15 s/frame for 20 min. Delayed static images were acquired for 100 s at 256 × 256 matrix. An urinoma was detected in the delayed image of the renal dynamic scan pushing the bladder. Uptake in gall bladder (GB) was incidentally observed on delayed images [Figure 1] indicating hepatobiliary excretion of 99mTc-EC. GB activity was confirmed on SPECT/CT images acquired at 15 s/frame, 32 frames in step and shoot mode, 12° angulation and 80 kVp; 52 mAs; 1.5 pitch [Figure 2].
Figure 1: Delayed static image (ant/post) in a renal dynamic scan showing an urinoma in the pelvis pushing the bladder. Also noted is uptake in the right hypochondriac region just below the liver

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Figure 2: Fused SPECT/CT, CT only and SPECT only transaxial images localizing the ethylene dicysteine uptake to the gall bladder

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   Discussion Top


Unexpected visualization of GB with non-hepatobiliary radiopharmaceuticals has been reported in many studies and is not always pathological. Altered bio-distribution of a radiopharmaceutical might be a result of its low radiochemical purity. [4],[5],[6] However, GB visualization in the present study cannot be attributed to the quality of 99mTc-EC because GB activity was not seen in any other patient injected with the same preparation of 99mTc-EC. Liver or GB activity has been frequently reported on delayed scintigraphy images with 99mTc-MAG3. Around 10% of 99mTc-MAG3 is known to be cleared through hepatobiliary system and can affect the interpretation of the study. [7],[8],[9],[10] This is unlike 99mTc-EC that might show some low-level uptake in liver (<6%) in anuric patients but even in such patients no significant GB activity is seen. [1] Prvulovich et al. have shown that even in patients with chronic renal failure the hepatobiliary excretion of 99mTc-EC remains low enabling clear delineation of right kidney from liver. [2] It is, therefore, a very rare case when a significant amount of GB uptake is seen on a 99mTc-EC scan.

 
   References Top

1.Kabasakal L. Technetium-99m ethylene dicysteine: A new renal tubular function agent. Eur J Nucl Med 2000;27:351-7.  Back to cited text no. 1
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2.Prvulovich EM, Bomanji JB, Waddington WA, Rudrasingham P, Verbruggen AM, Ell PJ. Clinical evaluation of technetium-99m-L, L-ethylenedicysteine in patients with chronic renal failure. J Nucl Med 1997;38:809-14.  Back to cited text no. 2
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3.Domingues FC, Fujikawa GY, Decker H, Alonso G, Pereira JC, Duarte PS. Comparison of relative renal function measured with either 99mTc-DTPA or 99mTc-EC dynamic scintigraphies with that measured with 99mTc-DMSA static scintigraphy. Int Braz J Urol 2006;32:405-9.  Back to cited text no. 3
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4.Bhatnagar P, Chakraborti KL, Sachdev P, Sawroop K, Bhatnagar A, Kashyap R. Serendipitous gallbladder uptake in a bone scan. Clin Nucl Med 2005;30:512-3.  Back to cited text no. 4
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5.Niederkohr RD, McDougall IR. Incidental gallbladder visualization on nonhepatobiliary nuclear medicine studies: Case series and review of the literature. Clin Nucl Med 2007;32:915-9.  Back to cited text no. 5
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6.Santos-Oliveira R. Undesirable events with radiopharmaceuticals. Tohoku J Exp Med 2009;217:251-7.  Back to cited text no. 6
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7.Tulchinsky M, Eggli DF. False appearance of urinary stasis on Tc-99m MAG3 renal scan secondary to vicarious tracer concentration in the gallbladder. Clin Nucl Med 1995;20:836-8.  Back to cited text no. 7
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8.Rosen JM. Gallbladder uptake simulating hydronephrosis on Tc-99m MAG3 scintigraphy. Clin Nucl Med 1993;18:713-4.  Back to cited text no. 8
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9.Arroyo AJ, Semaan HB, Minkus KD, Patel YP. Factors affecting the hepatobiliary excretion of 99mTc-MAG3: Its clinical significance in routine renography. J Nucl Med Technol 2003;31:18-20.  Back to cited text no. 9
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10.Itoh K. 99mTc-MAG3: Review of pharmacokinetics, clinical application to renal diseases and quantification of renal function. Ann Nucl Med 2001;15:179-90.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2]



 

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