Gerbail T. Krishnamurthy’s research while affiliated with Tuality Healthcare and other places

To explore the extension of cholecystokinin-cholescintigraphy in the evaluation of abdominal pain. A total of 1554 patients with abdominal pain underwent Tc-mebrofinin cholescintigraphy. Gallbladder ejection fraction was obtained with cholecystokinin (sincalide) and abdominal pain was graded. Fourteen different types of hepatobiliary and gastrointestinal motility disorders were identified. Biliary dyskinesia was found in 453 patients, septate gallbladder in 33, and duodeno-gastric bile reflux in 46 patients. Sincalide-induced intestinal hyperperistalsis alone was found in 65 and in combination with other diseases in 64 patients. Abdominal pain was mild to moderate in intensity, and occurred in 50-60% of patients with abnormal gallbladder function. Severe abdominal pain was usually associated with intestinal hyperperistalsis. Tc-mebrofinin cholescintigraphy enables the identification of motility disorders of the gastrointestinal and hepatobiliary tract, and post-sincalide abdominal pain in most cases can be assigned to functional abnormality of the gallbladder or/and intestine.

This study was undertaken to develop comprehensive new hepatobiliary software to quantify segmental and lobar liver function and to obtain FDA approval. Hepatobiliary software written on JAVA platform and loaded on to a PC accepts 99mTc-HIDA dicom image data transferred from a gamma camera. Liver boundary was determined by threshold-based auto edge detection and liver height at right midclavicular (RMCL) line. Geometric mean area of the physiologic right lobe, physiologic left lobe and total liver area were measured. Segmental liver function was determined using the 5th minute frame as the default (100%). In 24 control participants, mean (+/-SD) liver height at RMCL was 14.7+/-0.12 cm. Geometric mean area of the physiologic right lobe was 116+/-3 cm2, left lobe 96+/-4 cm2, and total liver area 212+/-3 cm. Right upper lobe (segments 7 and 8) contributed 31+/-0.7%, right lower lobe (segments 5 and 6) 34+/-0.6%, left medial (segments 4A and 4B) 24+/-1%, left lateral (segments 2 and 3) 10+/-2%, and caudate lobe (segment 1) 1+/-0.02% of total liver function. In 23 patients, contrast three-dimensional computerized tomographic volume of the right lobe was 1194+/-419 ml, left lobe 434+/-221 ml, and total liver volume 1628+/-490 ml. Right lobe area was 120+/-30 cm2, left lobe (plus caudate) 88+/-29 cm2 with total liver area of 208+/-51 cm. Right upper lobe (segments 7 and 8) contributed 33+/-10%, right lower lobe (segments 5 and 6) 34+/-7%, left medial (segments 4A and 4B) 23+/-6%, left lateral (segments 2 and 3) 9+/-3%, and caudate lobe (segment 1) 1+/-0.4% of total liver function. There was good correlation of RMCL height, and area of right lobe and total liver with computerized tomographic liver volume. Correlation of percentage volume with percentage function was excellent. New FDA approved software provides quantitative assessment of segmental, lobar, and total liver size and function from a planar 99mTc-HIDA cholescintigraphy and may enable universal standardization in nuclear hepatology. Quantification may aid surgeons in the determination of the amount of tissue resection during liver surgery.

To develop a software tool for quantification of liver and gallbladder function, and to assess the repeatability and reproducibility of measurements made with it. The software tool developed with the JAVA programming language uses the JAVA2 Standard Edition framework. After manual selection of the regions of interest on a 99mTc hepatic iminodiacetic acid study, the program calculates differential hepatic bile flow, basal duodeno-gastric bile reflux (B-DGBR), hepatic extraction fraction (HEF) of both the lobes with deconvolutional analysis and excretion half-time with nonlinear least squares fit. Gallbladder ejection fraction, ejection period (EP), ejection rate (ER), and postcholecystokinin (CCK) DGBR are calculated after stimulation with CCK-8. To assess intra-observer repeatability and intra-observer reproducibility, measurements from 10 normal participants were analyzed twice by three nuclear medicine technologists at the primary center. To assess inter-site reproducibility, measurements from a superset of 24 normal participants were also assessed once by three observers at the primary center and single observer at three other sites. For the 24 control participants, mean+/-SD of hepatic bile flow into gallbladder was 63.87+/-28.7%, HEF of the right lobe 100+/-0%, left lobe 99.43+2.63%, excretion half-time of the right lobe 21.50+6.98 min, left lobe 28.3+/-11.3 min. Basal DGBR was 1.2+/-1.0%. Gallbladder ejection fraction was 80+/-11%, EP 15.0+/-3.0 min, ER 5.8+/-1.6%/min, and DGBR-CCK 1.3+/-2.3%. Left and right lobe HEF was virtually identical across readers. All measures showed high repeatability except for gallbladder bile flow, basal DGBR, and EP, which exhibited marginal repeatability. Ejection fraction exhibited high reproducibility. There was high concordance among the three primary center observers except for basal DGBR, EP, and ER. Concordance between the primary site and one of the other sites was high, one was fair, and one was poor. New United States Food and Drug Administration-approved personal computer-based Krishnamurthy Hepato-Biliary Software for quantification of the liver and gallbladder function shows promise for consistently repeatable and reproducible results both within and between institutions, and may help to promote universal standardization of data acquisition and analysis in nuclear hepatology.

The liver is a common site for both primary and metastatic malignant lesions. Although the metastatic lesions are the most common, primary malignancies like hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) have become increasingly more common in recent years in the United States [1]. HCC arises from the hepatic parenchymal cells, the hepatocytes, and CC from the cells lining the major bile ducts and gallbladder, the cholangiocytes. In Asian countries like China, Taiwan, and Japan, HCC is one of the three most common causes of death due to malignancy. HCC has a serum marker in the form of α-fetoprotein, and no such marker exists for CC. Gallium-67 citrate, which has been an imaging agent for HCC over the years, still remains popular in places where F-18 fluorodeoxyglucose (F-18 FDG) is not readily available. A filling defect on a radiocolloid liver scan (Fig. 12.1.1) associated with intense Ga-67 uptake (Fig. 12.1.2) and increased serum α-fetoprotein in a patient is more likely to be HCC than any other type of malignancy. F-18 FDG shows avidity for CC, HCC, metastatic lesions, and abscesses. Being a common imaging agent for many different types of liver lesions, F-18 FDG imaging provides no specificity for any one particular type of malignancy.

This second edition of Nuclear Hepatology: A Textbook of Hepatobiliary Diseases has been revised so as to encompass all of the most recent developments in the field. The result is a comprehensive, up-to-date book that will serve as a ready reference and a clinical and procedural guide. The authors, both of whom are nuclear medicine physicians, present nuclear hepatobiliary imaging techniques in the context of the many other possible diagnostic studies, thereby acquainting the reader with the role of these procedures. Throughout, care is taken to maintain a clear clinical focus and to emphasize the importance of integrating information on morphology and quantitative physiology as the basis for diagnosis. Each of the chapters is well illustrated and referenced. This book will prove invaluable not only to nuclear medicine physicians but also to practitioners of radiology, internal medicine, pediatrics, gastroenterology, hepatology, primary care, general surgery, and liver transplantation surgery.

The effects of folds or septa on gallbladder filling and emptying are not known. Gallbladder filling and emptying were measured in seven patients with two chambers (segmental) and compared with 10 subjects with a single chamber (control). Percent bile flow into gallbladder, and percent ejection fraction from the proximal and distal segments, and entire gallbladder were measured with cholecystokinin. Bile entry into gallbladder was similar in both groups. In patients with segmentation, overall emptying was low mostly due to poor emptying of the distal segment. Segmentation of the gallbladder does not affect bile entry, but acting as a one-way valve, a fold or septum lowers emptying significantly, mostly from the distal segment.

Without Abstract

This study was undertaken to test the effect of sequential administration of an opioid and intravenous cholecystokinin (CCK) on gallbladder ejection fraction. Forty-nine patients who had received an opioid underwent quantitative cholescintigraphy with octapeptide of CCK (CCK-8). Gallbladder ejection fraction and CCK-8-induced paradoxical filling were calculated. In the basal state, more of the hepatic bile entered the gallbladder (67%) than the small intestine (33%). After CCK-8 infusion, gallbladder ejection fraction was low in 37 (76%) of 49 patients and normal in 12 (24%). All 5 types of opioids lowered ejection fraction. CCK-induced paradoxical filling of the gallbladder was noted in 7 patients, but only one showed paradoxical filling of greater than 20% and none had a normal gallbladder ejection fraction. The lowering effect of opioids on gallbladder ejection fraction may last as long as 18 h after intake. CCK-8 produced a normal gallbladder ejection fraction in 24% of patients who had received an opioid and thus could exclude both acute and chronic cholecystitis during a single hepatobiliary study.