sincalide and Biliary-Tract-Diseases

Since the early 1980s interventions have been used in conjunction with (99m)Tc-iminodiacetic acid (IDA) radiopharmaceuticals in many different clinical situations, eg, to prepare the patient for the study, to reduce the time of a study, to improve its diagnostic accuracy, and to make diagnoses not otherwise possible. Interventions all have underlying physiological rationales. Some of these interventions are as simple as having the patient fast before the study or eat a meal with high fat content. However, most are pharmacologic interventions, eg, morphine sulfate, cholecystokinin, and phenobarbital. Although these are probably the most common interventions used today, numerous other interventions have been used during the years and likely will be in the future. Interventions have aided in the diagnosis of acute cholecystitis, chronic cholecystitis, biliary obstruction, and sphincter of Oddi dysfunction. This review will discuss in detail the interventions commonly is use today and in somewhat less detail many that have been successfully used on an investigational basis and may have some larger role in the future.

Topics: Biliary Tract Diseases; Cholecystitis; Cholecystitis, Acute; Cholecystokinin; Chronic Disease; Gallbladder Emptying; Humans; Morphine; Radionuclide Imaging; Radiopharmaceuticals; Sincalide; Technetium Tc 99m Diethyl-iminodiacetic Acid

Chronic acalculous gallbladder and chronic acalculous biliary disease are considered functional hepatobiliary diseases. Cholescintigraphy provides physiologic imaging of biliary drainage, making it ideally suited for their noninvasive diagnosis. For chronic acalculous gallbladder disease, calculation of a gallbladder ejection fraction during sincalide cholescintigraphy can confirm the clinical diagnosis and has become a common routine procedure in many nuclear medicine clinics. Published data generally confirm a high overall accuracy for predicting relief of symptoms with cholecystectomy. However, data also exist suggesting it is not useful. The discrepant results probably are caused by the various different methodologies that have been used for sincalide infusion. Proper methodology of sincalide infusion is critical for providing accurate reproducible results, minimizing false positive studies, and preventing adverse side effects. The most common causes for the postcholecystectomy pain syndrome are partial biliary obstruction secondary to stones or tumor and sphincter of Oddi dysfunction. The latter is a partial biliary obstruction at the level of the sphincter. This has long been considered a functional hepatobiliary disease because of the lack of anatomical abnormalities. Sphincterotomy is the present treatment; however, diagnosis requires invasive procedures, such as endoscopic retrograde cholangiopancreatography and sphincter of Oddi manometry, which has a high complication rate and is not widely available. The unique ability of cholescintigraphy to image biliary drainage allows noninvasive diagnosis. Different methodologies have been reported, many with good overall accuracy. Various pharmacologic interventions and quantitative methodologies have been used in conjunction with cholescintigraphy to enhance its diagnostic capability. Further investigations are needed determine the optimal methodology; however, cholescintigraphic methods have already a clinical role in the diagnosis of sphincter of Oddi dysfunction and will be used increasingly in the future.

Topics: Biliary Tract; Biliary Tract Diseases; Chronic Disease; Gallbladder; Gallbladder Diseases; Humans; Radionuclide Imaging; Sincalide; Sphincter of Oddi Dysfunction

Cholecystokinin is a useful diagnostic adjunct to cholescintigraphy. Clinical indications include contracting the gallbladder before cholescintigraphy in patients fasting greater than 24 hours, during cholescintigraphy to diagnose sphincter of Oddi dysfunction, and after cholescintigraphy to exclude acute acalculous cholecystitis, differentiate common duct obstruction from normal variation, and to confirm the diagnosis of chronic acalculous cholecystitis. Proper methodology is mandatory for a diagnostically useful test. Data presented shows that a 3-minute infusion of 0.01 or 0.02 microg/kg is nonphysiologic and often results in ineffective contraction similar to that seen with a bolus infusion. Normal gallbladder ejection (GBEF) values cannot be established using a 3-minute infusion because of the wide variability in response. Instead, infusions of 30 or 60 minutes are required. Normal GBEF values have been established for these methods and are 30% and 40%, respectively.

Topics: Biliary Tract; Biliary Tract Diseases; Cholecystokinin; Humans; Radionuclide Imaging; Sincalide

Significant advances in the understanding of biliary tract physiology have occurred during the past 20 years. Through careful studies in animals, the fluid mechanics and normal regulatory mechanisms involved in sphincter of Oddi function have been partially elucidated. Many of the basic concepts have been validated in human studies by newly developed testing methods. Endoscopic retrograde cholangiopancreatography is crucial in demonstrating both normal anatomy and mechanical or structural abnormalities of the duct system. Fat-meal--or CCK-stimulated ultrasonography and quantitative hepatobiliary scintigraphy offer reliable and noninvasive screening methods to evaluate patients with suspected sphincter of Oddi dysfunction. Biliary manometry is key in defining normal and abnormal motility patterns of the sphincter of Oddi region. The existence of the problem is being solidly established, but the optimal therapy is still somewhat unclear. The use of endoscopic balloon dilatation is not encouraging; drug therapy holds promise, but must be subjected to careful clinical trials. Sphincter surgery is fading from use and is being replaced by endoscopic sphincterotomy. Unfortunately the long-term results of sphincterotomy and the overall safety of the procedure are not known. Biliary motility problems do exist, but both diagnostic studies and therapeutic maneuvers require judgement and skill in their application. Use of potentially harmful treatments must be employed only after careful and thorough testing.

Topics: Biliary Tract; Biliary Tract Diseases; Dietary Fats; Humans; Manometry; Muscular Diseases; Radionuclide Imaging; Sincalide; Sphincter of Oddi; Ultrasonography

Basal and stimulated serum CCK concentrations were not statistically significant differences (p > 0.05) with the control group in patients studied in the whole and in patients subgroups, formed by the diagnosis of biliary pathology and the character of gallbladder emptying. Increased stimulated CCK concentration was found in patients with symptomatic variants. Reduce of serum-cholecystokinin concentration growth (ACCK) after intake of Sorbitol was revealed in subgroup of patients with low-symptom variant. Reduced sensitivity of the gallbladder to CCK was observed in subgroups of patients with gallbladder hypokinetic dyskinesia and one with symptomatic variant of biliary pathology.. The sensitivity of the gallbladder neuromuscular apparatus to CCK is associated with clinical and functional variability of the biliary pathology.

Topics: Adult; Biliary Tract Diseases; Case-Control Studies; Female; Gallbladder; Gallbladder Emptying; Humans; Male; Middle Aged; Sincalide; Ultrasonography

Topics: Biliary Tract Diseases; Dietary Fats; Gallbladder Emptying; Humans; Radionuclide Imaging; Sincalide

Although several approaches to overcome difficult bile duct cannulation and gain free biliary access have been popularized, the use of gastrointestinal peptide hormonal agents such as sincalide, a cholecystokinin agonist, as an alternative method has not been evaluated. I have carried out a prospective, nonrandomized assessment of the use of sincalide for diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Overall, sincalide was used in 23% (32/136) of ERCPs in 26.6% (29/109) patients. Sincalide was successfully used to (a) obtain a cholangiogram after initial failure using only a standard catheter in 12 of 19 patients; (b) precisely locate the papilla and bile duct orifice in five of five patients; (c) locate the bile duct opening to obtain a cholangiogram and free cannulation during needle-knife papillotomy or weeks later in five of seven and three of three patients, respectively; and (d) gain free access (deep cannulation) to the bile duct after a cholangiogram in 5 of 10 patients. The selected use of sincalide appears to enhance the success of diagnostic and therapeutic ERCP; however, perseverance alone may account for some of this success. Controlled, randomized trials comparing sincalide or nothing, sincalide or a sphincterotome, or sincalide or glide or guide wire in patients in whom initial attempts to obtain a cholangiogram are unsuccessful are warranted.

Topics: Biliary Tract Diseases; Cholangiopancreatography, Endoscopic Retrograde; Cholecystokinin; Humans; Prospective Studies; Sincalide

Twelve patients with biliary colic had no evidence of gallstones but underwent cholecystokinin-augmented hepatobiliary scintigraphy that revealed gallbladder ejection fractions of less than 35%. All 12 patients underwent cholecystectomy. Biliary colic was relieved in all patients at a mean postoperative follow-up of 2.5 years. The biliary colic in these patients was probably caused by abnormal gallbladder emptying, itself apparently produced by either cystic duct obstruction or abnormal motility. Biliary abnormality was seen at operation in most patients, and all patients had abnormalities of the gallbladder or cystic duct seen grossly or histologically. These abnormalities included cystic duct stenosis or adhesions, chronic inflammation, and cholesterolosis.

Topics: Adult; Aged; Aniline Compounds; Biliary Tract Diseases; Cholecystectomy; Colic; Female; Follow-Up Studies; Gallbladder; Glycine; Humans; Imino Acids; Male; Middle Aged; Organotechnetium Compounds; Radionuclide Imaging; Sincalide; Technetium Tc 99m Disofenin

Previous studies have suggested that chronic alcohol consumption in man is associated with an increased secretion of pancreatic enzymes. Precise quantitation of the output of protein and trypsin in the interdigestive state has not been possible because of large variations and small volume of pancreatic juice. We utilized a multilumen, marker-perfused duodenal catheter to simultaneously monitor intraluminal pressures and collect mixed duodenal juice at the ligament of Treitz in five groups of patients: normal volunteers (group I), alcoholics without pancreatitis (group II), alcoholics who had recovered from acute pancreatitis (group III), alcoholics with chronic pancreatitis (group IV), and nonalcoholics who had recovered from acute pancreatitis secondary to biliary tract disease (group V). The output of trypsin and protein during 30 min of phase II and 60 min of CCK-OP 40 ng/kg/hr was determined in each group. The output of trypsin during phase II was 1.3 +/- 1.2 and 3.0 +/- 2.5 mg/kg/hr in groups II and III, respectively, compared to 0 +/- 0.1 in group IV (normal = 0.6 +/- 0.5). The outputs in group V were similar to normals. The output of protein during the interdigestive state was 15.7 +/- 13.7 mg/min in group III, compared to 4.5 +/- 3.6 in normals (group I). The duodenal contraction rate was 4.6 +/- 3.0 and 3.3 +/- 2.7 contractions/min in groups III and II, respectively (significantly greater than the normal rate of 2.2 +/- 1.5).(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Alcoholism; Biliary Tract Diseases; Catheterization; Digestion; Duodenum; Fluoroscopy; Gastric Juice; Gastrointestinal Motility; Humans; Hydrogen-Ion Concentration; Pancreas; Pancreatic Juice; Pancreatitis; Pressure; Proteins; Sincalide; Sulfobromophthalein; Trypsin