Presentation
Intermittent colicky pain in the right hypochondrium associated with nausea and vomiting for three days. Pain aggravated with fatty and spicy meals.
Patient Data
No gallstones or abnormal gallbladder wall thickening /pericholecystic fluid is seen. Mildly dilated partially visualised proximal CBD measuring 6 mm.
No gall bladder abnormality is seen. Normal calibre and course of the intra and extra-hepatic biliary radicles, down to the insertion of the CBD in the duodenum. No pancreatic mass or pancreatic duct dilatation is seen. No detectable stone or mass in the vicinity of the ampulla. Normal kidneys with bilateral extrarenal pelvis (anatomical variant).
Radiopharmaceutical: 194 MBqs of Tc-99m-BrIDA (mebrofenin trimethylbromo-iminodiacetic acid). Technique: Two sets of 60 minutes dynamic images were acquired. The second set was acquired after the meal.
Findings:
There is good hepatic parenchymal uptake indicating good hepatic function. Subsequent images showed visualisation of common bile duct at 14 minutes, gallbladder at 26 minutes and gut activity at 20 minutes of the study (normal). Post meal study showed good contraction of the gallbladder with good clearance of the radiotracer from the gallbladder with an estimated gallbladder ejection fraction of 92% (normal > 30). The ejection rate of gallbladder is measured as 2% per minute.
Case Discussion
Ultrasound was negative for cholelithiasis or cholecystitis; however, it showed mildly dilated proximal CBD without any stone.
Laboratory investigations showed elevated LFTs {Alkaline phosphatase=165 U/L (40-150), AST=86 U/L (5-34), ALT= 185 U/L (5-55), total bilirubin=22.5 umol/L (3.4-20.5) and direct bilirubin=15.7 umol/L (≤8.6)}.
No biliary obstruction or dilatation was noted on MRCP. Cholescintigraphy was done which showed normal gallbladder contraction excluding the possibility of gallbladder dysfunction.
The patient was managed conservatively and the LFTs returned to normal levels.
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