In this report, we present the application of hepatobiliary scintigraphy using Tc-99m mebrofenin in the diagnosis of bronchobiliary fistula caused by a liver hydatid cyst, which penetrated the diaphragm. Hepatobiliary scintigraphy noticeably depicted the leakage of the tracer from the biliary system of the liver to the bronchial tree. Hepatobiliary scintigraphy stands as a robust modality in the accurate diagnosis and treatment planning of bronchobiliary fistulas. © 2015, P.Ziti and Co. All rights reserved

Assadi, M.

Javadi, H.

Kiani, M.

Raeisi, A.

Seyyedmajidi, M.

English

Golestan University of Medical Sciences Repository

                                                                                                                                        Case Report Hepatobiliary scintigraphy with SPET in the diagnosis of bronchobiliary fistula due to a hydatid cyst Mohammadreza  Seyyedma­jidi1 MD, Mojtaba  Kiani1 MD, Hamid  Javadi1 MD,  Alireza  Raeisi2 MD, Majid  Assadi2 MD 1. G ole sta n Re sea rch Ce nte r of Ga stroe nte rolog y a nd He pa tolog y (GRCGH), G ole sta n U nive rsity of Med ica lSc ie nce s, G orga n, I ra n2. The Pe rsia n G ulf N uc lea r Med ic ine Re sea rch Ce nte r, B usheh r U nive rsity of Med ica lSc ie nce s, B usheh r, I ra n Ke yword s: Hepatobiliary scintigraphy - Bronchobiliary fistula - Diagnosis - Modality Correspondence  address:  Majid Assadi MD The Persian Gulf Nuclear Medicine Research Center, Bushehr University of Medical Sciences, Bushehr, Iran Tel: 0098-771-2580169 Fax: 0098-771-2541828 assadipoya@yahoo.com Rece ived: 17 February 2015 Accept ed revis ed: 20 March 2015 Abstract In this report, we present the application of hepatobiliary scintigraphy using Tc-99m mebrofenin in the diagnosis of bronchobiliary fistula caused by a liver hydatid cyst, which penetrated the diaphragm. He-patobiliary scintigraphy noticeably depicted the leakage of the tracer from the biliary system of the liver to the bronchial tree. Hepatobiliary scintigraphy stands as a robust modality in the accurate diagnosis and treatment planning of bronchobiliary fistulas. Hell J Nucl Med 2015; 18(2): 160­162 Epub ahead of print: 19 July 2015 Published online: 5 August 2015 Introduction Bronchobiliary fistula (BBF) is very rare and usually refers to the right bronchi [1]. Bronchobiliary fistula is defined as the abnormal communication between the biliary tract and the bronchial tree [2]. The first case was reported by Peacock in 1850 [3]. The presence of bilioptysis or bile in sputum is its main clinical manifestation, crucial for proper diagnosis [4]. Unlike congenital BBF, which has a prevalence of <1×106, acquired BBF commonly develops as a result of local pressure and/or infection, such as from a hydatid cyst, an amebic abscess of the liver, trauma, obstruction of the biliary tract, or neoplasm [5]. The disease can have diﬀerent pulmonary complications, such as recurrent chemical or bacterial pneumonitis, mediastinitis, bronchiolitis, or bronchiectasis. Timely, accurate diagnosis and treatment are critical to the patients’ out-come [3]. The prognosis for patients with malignancy is poor but patients with infec-tious etiologies after appropriate therapy have good prognosis [3]. Although bilioptysis is characteristic of BBF, imaging techniques are needed to confirm the diagnosis, to de-lineate the site of interconnection, to diagnose the underlying disease and for treat-ment, planning and follow-up [6]. Herein, we describe a rare case of bile extravasation secondary to a hydatid cyst of the liver, associated with BBF and diagnosed by hepatobiliary scintigraphy. The func-tional nature of hepatobiliary scintigraphy enabled the diagnosis of both the cause and the extent of BBF. Case  report A 62 years old housekeeper woman presented with persistent cough and copious ex-pectoration of greenish material containing biliary secretions (bilioptysis). An endo-scopic examination revealed bilious material in the bronchi (Figure 1), and computed tomography (CT) showed a large cystic mass with multiple small cysts inside (daughter cysts) at the base of the dome of the liver (Figure 2). Dynamic and static hepatobiliary scintigraphy by 185MBq technetium-99m N-(3-bromo-2,4,6-trimethylacetanilide) imin-odiacetic acid (99mTc-mebrofenin) and single photon emission tomography (SPET) de-picted tracer accumulation in the right lung (Figure 3), while acquisition showed better delineation of the lesion (Figure 4). There was no indication of another cyst elsewhere in the body. The patient often communicated with unattended dogs. The BBF, which 160 Hellenic Journal of Nuclear Medicine • May ­ August 2015 www.nuclmed.gr                                                                                                                                                                                                                                                                                                  Case Report VC VC­Carina LMB­A B Figure 1. Bronchoscopy demonstrated severe bile secretion and edematous mucosa in both main bronchi. Figure 2. A and B: Computed tomography scan of the fistula from the right lobe of the liver entering into the right lung. communicated with the right bronchial tree was confirmed and corrected by surgical intervention. Over the following two years, the patient was readmitted three times and given conservative treatment. Discussion In the presented case, it was likely that penetration of the di-aphragm developed through its invasion by the subdi-aphragmatic hydatid cyst.Computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiography, and hepatobiliary scintigraphy are the most frequently used imaging modalities in diagnosing BBF. Percutaneous transhepatic cholangiography (PTC), bron-choscopy, and bronchography may also be used to confirm diagnosis [7].Figure 3. A and B: Hepato-biliary scintigraphy. Dy-namic and static imaging depicted an abnormal col-lection of radioactivity overlying the right lobe of the liver, tracking up over the dome of the liver and communicating with the right bronchial tree, where was accumulated over the next six hours. Serial im-ages showed good hepato-cyte uptake and excretion of the tracer into the gut. A B ➱ Figure 4. Acquisition of the SPET images demonstrated better delineation of the fis-tula.Computed tomography incidentally may show indirect ev-idence of BBF, such as subphrenic fluid collection, discontinu-ity of the diaphragm, bronchiectasis, atelectasis, or pleural eﬀusion [8]. In the present case, CT revealed a large complex cystic mass with air-fluid levels crossing the right diaphragm [6]. Bronchoscopy cannot accurately locate BBF, especially when the BBF tracks through the diaphragm. Percutaneous transhepatic cholangiography is an invasive technique, which should be used only in patients when external percutaneous biliary fistulization has already been diagnosed [9]. Endo-scopic RCP is an excellent technique for detecting BBF and for visualizing the eﬀect of treatment of the involved biliary ducts, but is more invasive and may have significant compli-cations compared with hepatobiliary scintigraphy [6, 10]. www.nuclmed.gr Hellenic Journal of Nuclear Medicine • May ­ August 2015 161                                                                                           n on lusion                    ut ors l r  t t t y v  no on i ts o  int r st                      r                 lin u l                         orl   stro nt rol                          i tr m tol n ol                 u l ommun                 u l                 nt rn                              lin u l                     in  r um tol                  or n  iol                   nn u l              Case Report Hepatobiliary scintigraphy is noninvasive, shows the anatomy and function of the biliary tree, the site of any bile collection and provides information about treatment plan-ning of the BBF [11].Treatment of the BBF can be endoscopic, percutaneous or surgical [11].Hepatobiliary scintigraphy has been used eﬀectively to di-agnose even trivial BBF without posing any risk to the pa-tient and can be performed repeatedly after therapy to assess whether the fistula was closed [6]. Therefore, hepato-biliary scintigraphy seems to be the diagnostic modality of choice for BBF.I c c , our case showed that hepatobiliary scintig-raphy with 99mTc-mebrofenin diagnosed a hydatid cyst caus-ing BBF and suggesting treatment planning. The a h dec a e ha he ha e c fl c f e e .Bibliography 1.	 Savitch I, Esser JD, Krige LP et al. The use of technetium-99m-di-iso propyl-iminodiacetic acid imaging in the demonstration of a biliary-bronchial fistula. S Af Med J 1984; 65: 779-80. 2.	 Berk F, Corapcioglu F, Demir H et al. Bronchobiliary fistula detected with hepatobiliary scintigraphy. C N c Med 2006; 31: 237-9. 3.	 Liao GQ, Wang H, Zhu GY et al. Management of acquired bronchobil-iary fistula: A systematic literature review of 68 cases published in 30 years. W d J Ga e e 2011; 17: 3842-9. 4.	 Corapcioglu F, Sarper N, Demir H et al. A child with undiﬀerentiated sarcoma of the liver complicated with bronchobiliary fistula and detected by hepatobiliary scintigraphy. Ped a He a O c 2004; 21: 427-33. 5.	 Santra A, Kumar R, Maharjan S et al. Traumatic bronchobiliary fistula diagnosed by 99mTc-mebrofenin hepatobiliary scintigraphy. N c Med C 2009; 30: 652-3. 6.	 Velchik MG, Roth GM, Wegener W, Alavi A. Bronchobiliary fistula de-tected by cholescintigraphy. J N c Med 1991; 32: 136-8. 7.	 Uramoto H, Kawano O, Sugimoto M et al. Congenital bronchobiliary fistula in a 65-year-old woman. I e Med 2008; 47: 1367-70. 8.	 Bird R, Fagen K, Taysom D, Silverman ED. A case of bronchobiliary fistula in the setting of adult polycystic kidney and liver disease, with a review of the literature. C N c Med 2005; 30: 326-8. 9.	 Liao GQ, Wang H, Hu QH, Tai S. A successful treatment of traumatic bronchobiliary fistula by endoscopic retrograde biliary drainage. Ch J T a a 2012; 15: 59-61. 10.	 Karabulut N, Cakmak V, Kiter G. Confident diagnosis of bronchobiliary fistula using contrast-enhanced magnetic resonance cholangio-graphy. K ea J Rad 2010; 11: 493-6. 11.	 Annovazzi A, Viceconte G, Romano L et al. Detection of a suspected bronchobiliary fistula by hepatobiliary scintigraphy. A N c Med 2008; 22: 641-3. Cornelis Dusart, Copperplate. Applying hot cups to relieve pain.162 Hellenic Journal of Nuclear Medicine • May ­ August 2015	 www.nuclmed.gr 

Hepatobiliary scintigraphy with SPET in the diagnosis of bronchobiliary fistula due to a hydatid cyst

http://eprints.goums.ac.ir/4735/1/Hepatobiliary_scintigraphy_with_SPET.pdf

Hepatobiliary scintigraphy with SPET in the diagnosis of bronchobiliary fistula due to a hydatid cyst

Abstract

Similar works

Full text

Available Versions

Golestan University of Medical Sciences Repository