Is it worth even having a Hida Scan with CCK?

[RobynLee]

Hi everyone,
Can anyone comment on the article I have copied below?  It basically states that the Hida Scan w/cck is worthless in that it was not predictive of whether or not a patient would benefit from having their gallbladder removed - regardless of how low thier ejection fraction was, or how much in the way of symptoms it provoked.  

It is a pretty large study done by a reputable medical center, so I'm on the fence about whether or not to have this test.  I currently have elevated pancreatic enzymes (6+ weeks), abdominal pain, difficulty eating and severe rib and shoulder pain on the right.  MRI and MRCP only picked up an 8mm cyst in the gb.   Not sure what to do and really thought the Hida with cck would be valuable information.  No I wonder.

Thanks for your thoughts!
RobynLee


Laparoscopic cholecystectomy for acalculous gallbladder disease  

ROB A. FULLER, MD, JOSEPH A. KUHN, MD, TAMMY L. FISHER, RN, THOMAS W. NEWSOME, MD, BRUCE A. SMITH, MD, AND RONALD C. JONES, MD
From the Department of Surgery, Baylor University Medical Center, Dallas, Texas.
Dr. Fuller is now a surgical oncology fellow at the City of Hope National Medical Center, Duarte, California.

This work was supported in part by a grant from the Seeger Foundation.

Corresponding author: Rob A. Fuller, MD, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, California 91010.





Use of laparoscopic cholecystectomy (LC) to treat patients with symptoms due to gallstone disease is well established. However, use of LC for patients with acalculous gallbladder disease remains controversial. In this study, we examined the use of hepatobiliary iminodiacetic acid (HIDA) scans with cholecystokinin (CCK) infusion to identify patients with acalculous gallbladder disease who would benefit from LC. From December 1991 to February 1997, 4480 patients underwent cholecystectomy at Baylor University Medical Center, including 72 patients who underwent LC for acalculous disease following preoperative HIDA scan. We retrospectively analyzed their preoperative symptoms and workup. Follow-up was obtained by telephone questionnaire in 59 of 72 patients (82%). Overall, 48 of 59 patients (82%) reported an excellent outcome following LC. We found no significant difference in outcome in patients who underwent HIDA scan with CCK infusion, regardless of gallbladder ejection fraction or exacerbation of symptoms caused by the infusion. Preoperative symptom complex was also not predictive of postoperative outcome. LC is an effective treatment for patients with acalculous gallbladder disease. A preoperative HIDA scan with CCK infusion does not accurately predict treatment success or failure. Patients with a normal ejection fraction and absence of symptoms from a HIDA scan can still have excellent relief of symptoms after LC.


  
DISCUSSION

LC is an effective treatment for biliary tract disease related to gallstones, with resolution of symptoms obtained in approximately 95% of patients (2). The reported resolution of symptoms following cholecystectomy for acalculous gallbladder disease is likewise high, ranging from 82% to 100% (4-14). Even with these excellent results, some authors suggest performing cholecystectomy for acalculous disease only when HIDA scans with CCK infusion demonstrate an abnormally low ejection fraction (30% to 50%) and/or recurrence of symptoms with CCK infusion (5-7, 9, 11, 12). Others have evaluated the usefulness of HIDA scans with CCK and found that they were not accurate predictors of patient outcome (4, 10). All agree that the diagnosis is difficult to make and requires a thorough search for other etiologies of the patient's complaints prior to proceeding with cholecystectomy.

In our study, 72 patients who had acalculous gallbladder disease, underwent HIDA scans with CCK infusion, and were subsequently treated with LC were evaluated, with complete follow-up in 59 patients. The overall response to LC is in agreement with several prior studies; 82% had either markedly improved symptoms or complete relief of symptoms.

Differences in this study compared with others are the wide range of ejection fractions measured prior to LC (0% to 97%) and the inability of the HIDA scan with CCK infusion to accurately differentiate which patients would experience excellent outcomes from their surgery vs those who would derive little or no benefit from LC. Patients with normal gallbladder ejection fractions (>30%) had the same outcome as those with abnormal gallbladder ejection fractions (<30%). The surgeons in this report have traditionally used a conservative ejection fraction
cutoff of 30% to help determine patients who have poorly functioning gallbladders and who would potentially benefit from LC. However, an abnormal ejection fraction <35% or <40% also did not help predict which patients would benefit from LC.

In addition, exacerbation of symptoms during injection of CCK did not accurately predict resolution of symptoms after LC. This result was not affected by the method of CCK infusion. In several studies, pain with CCK infusion has been used prior to proceeding to LC (4, 5, 7, 10). However, several authors have also noted that reproducible symptoms after CCK injection are not a reliable predictor of excellent outcome following LC (4, 10). In the present study, 7 patients had a fast bolus injection of CCK instead of a slow continuous infusion of CCK. Return of symptoms after this bolus injection was not significantly different at predicting improved outcome when compared with the slower CCK infusion.

Since its introduction by Krishnamurthy, the HIDA scan with CCK has been touted as the diagnostic procedure of choice in the group of patients with acalculous gallbladder disease (3). Clearly, the HIDA scan provides physiologic and anatomic information about biliary excretion. In this study if only those patients with abnormal ejection fractions and reproducible symptoms with CCK injection were analyzed, the HIDA scan would seem to be a good predictor for excellent outcomes after LC. However, this study represents one of the largest series of patients with normal HIDA scans who underwent LC. Surprisingly, a normal HIDA scan did not predict a lower success rate for LC.

As technology advances and the indications for LC broaden, there is still no accurate test to predict which patients with presumed acalculous gallbladder disease will benefit from LC (15). When an exhaustive workup in a patient with signs and symptoms consistent with acalculous gallbladder disease is negative, clinical acumen remains the only reliable test to determine those patients who will benefit from LC.

[RobynLee]

Thank you so much for your input.  As it turned out, I had a complete gi rule out (colonoscopy/endodoscopy).  Ulcers, reflux ibd etc. has been ruled out.  My lipase and amylase continued to be elevated with symptoms so the surgeon performed a laparascopic chole 3 days ago.
One  medicical intervention I did not do before removing the gallbladder was ERCP wtih Manometry...which would tell us if the sphincter of oddi pressure was elevated. I was informed that this is a high risk intervention (can cause severe pancreatitis).  Also  I am currently scheduled for an endoscopic ultrasound to further rule out chronic pancreatitis, in a few weeks if I do not feel the surgery has solved my issues.

At this point I am hoping that the enzymes return to normal.

The pathology on my gallbladder did show sludge...along with adhesions to the transverse colon (not seen on imaging).

Do you have any thoughts on my case now, knowing how things progressed?  I do think the surgeon and gastroenterologist were conflicted in there opinion of how to proceed.  I think the gastro was more concerned with sod and the surgeon believes the gallbladder is responsible.

Thanks for your input!  RobynLee

[DrDaveSTL]

Make sure you have a complete workup to include the HIDA, right upper quadrant ultrasound, and CT scan of the abdomen and pelvis. If everything comes out normal, then you may have a cholecytectomy based solely on your symptoms, according to the examination of a surgeon. The "cyst" described above is likely not clinically significant, so I would ignore that. My only other suggestion is that you consult a gastroenterologist, who may have other reasons for your symptoms, such as acid reflux, ulcers, or other things that the above radiologic exams don't characterize well.
I'm a radiologist, so that's the background for the above suggestions.

[RobynLee]

Hi  Nanahuckster....
How funny that you wrote me today of all days.... YES - today was my long awaited Hida-scan.  I made out ok during the test...just 3 minutes of cramping and nausea with the cck.  

Oddly... the pain I felt was on the left and the pain I'd been having on the right seemed to fade out when the cck took effect.  I was left with more left sided rib pain - which I fear could be the pancreas.

My pancreatic enzymes had finally come down - and as of yesterday they are elevated again.  I'm concerned that I either have chonic pancreatitis - or there is a blockage in the duct that is not being picked up.

You are right... the study makes it look as though 80% of folks with gi symptoms will be happier once their gallbladder is out - regardless of HIDA scan score.  BTW I scored a 37%!!!!  Not too great - but not bad enough to say it's the whole problem.

The cyst -- which they are calling a polyp now - is pretty big at 8mm.  None of the docs seem to think it's part of the problem though.  I read at 10mm they say take it out to be sure it's not gb cancer!

Still in a lot of chronic pain... rib soreness nausea.  It's all the time - not just related to food.

Have no idea what to do next.  I have read some do worse after LC - so I want to be careful with hasty decisions...but i sure need a break.

Any thoughts for me?  Thanks
RobynLee

[nanahuckster]

Only an 8mm cyst?  That's like a third of an inch.  And what does this cyst consist of?  Who knows!  It seems that regardless of the results of a HIDA scan, the majority of persons with symptoms consistent with acalculous gallbladder disease who had their gall bladders removed saw their symptoms markedly improve or completely relieved.  You have symptoms and an 8mm cyst.  Skip the HIDA scan and schedule a LC!  I had a HIDA scan and my ejection fraction was 17 and I just felt a bit of gas with the CCK.  My doctor left it up to me to decide to have the GB out.  I haven't done it yet, but I don't have a CYST!!!!!!!!!!!  As soon as my symptoms flare up again, I'll probably schedule the LC.  My mom, my daughter, and my sister have all had a LC and say it's not bad at all.  I guess bad gall bladders run in my family!

Good luck to you!