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Peacock JG, Hayes HA, Connor TD. Use of a Fatty Meal Cholecystagogue Protocol in Hepatobiliary Scintigraphy for Chronic Functional Gallbladder Disease. J Nucl Med Technol 2024; 52:15-20. [PMID: 38443112 PMCID: PMC10924151 DOI: 10.2967/jnmt.123.266789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/09/2023] [Indexed: 03/07/2024] Open
Abstract
Chronic functional gallbladder disorder, characterized by biliary pain in the absence of structural pathology, poses a diagnostic challenge necessitating reliable cholecystagogues for accurate evaluation. However, recurrent shortages of synthetic cholecystokinin analogs have prompted the exploration of alternative agents. This paper describes the efficacy of Ensure Plus as a viable fatty meal substitute for hepatobiliary scintigraphy in assessing chronic functional gallbladder disorder. Through comparative studies, Ensure Plus demonstrates comparable diagnostic accuracy to cholecystokinin in similar patient populations. Furthermore, Ensure Plus demonstrates significant symptom improvement after cholecystectomy in patients with anomalous gallbladder ejection fractions. This paper offers a detailed protocol for the seamless integration of Ensure Plus into hepatobiliary scintigraphy, providing clinicians with a valuable tool to navigate cholecystokinin shortages while maintaining diagnostic precision in cases of chronic functional gallbladder disorder. The use of Ensure Plus not only addresses practical supply challenges but also underscores its potential as a cost-effective and clinically sound alternative in biliary diagnostics.
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Affiliation(s)
- Justin G Peacock
- Department of Radiology and the Radiological Sciences, Uniformed Services University, Bethesda, Maryland;
- Department of Military Medical Operations, Armed Forces Radiobiology Research Institute, Bethesda, Maryland; and
| | - Horace A Hayes
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
| | - Tylor D Connor
- Department of Radiology, Brooke Army Medical Center, San Antonio, Texas
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Qian L, Jiao Z, Zhong M. Effect of Meal Timings and Meal Content on the AUC 0-12h of Mycophenolic Acid: A Simulation Study. Clin Pharmacol Drug Dev 2022; 11:1331-1340. [PMID: 36045559 DOI: 10.1002/cpdd.1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/20/2022] [Indexed: 01/27/2023]
Abstract
Meal timings and content related to gallbladder emptying in the enterohepatic circulation are important for explaining the high variability in mycophenolic acid exposure. The limited sampling strategy (LSS) was established to estimate the area under the plasma concentration-time curve from time 0 to 12 hours (AUC0-12h ) of mycophenolic acid in therapeutic drug monitoring. The aim of this study is to investigate the effect of meal timings and content on the AUC0-12h of mycophenolic acid and to assess the influence of meals on LSS. A mycophenolic acid pharmacokinetic model with a mechanism-based enterohepatic circulation process was employed to perform simulations under various assumed meal scenarios. The simulations were compared to evaluate the effect of meal timings and meal content on mycophenolic acid AUC0-12h . Monte Carlo simulations were performed using the meal parameter with the greatest impact on mycophenolic acid AUC0-12h as a variable. The corresponding LSS equations were established, and the predictive performance was assessed. Both the meal timings and meal content affected the mycophenolic acid AUC0-12h , and the postdose fasting period had the greatest impact. The predictive performance of the LSS is sensitive to the postdose fasting period. Therefore, meal timings may improve the estimation of mycophenolic acid AUC0-12h and the efficacy of therapeutic drug monitoring.
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Affiliation(s)
- Lixuan Qian
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Zheng Jiao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Mingkang Zhong
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
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Ding F, Guo R, Cui ZY, Hu H, Zhao G. Clinical application and research progress of extracellular slow wave recording in the gastrointestinal tract. World J Gastrointest Surg 2022; 14:544-555. [PMID: 35979419 PMCID: PMC9258241 DOI: 10.4240/wjgs.v14.i6.544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/21/2022] [Accepted: 05/17/2022] [Indexed: 02/06/2023] Open
Abstract
The physiological function of the gastrointestinal (GI) tract is based on the slow wave generated and transmitted by the interstitial cells of Cajal. Extracellular myoelectric recording techniques are often used to record the characteristics and propagation of slow wave and analyze the models of slow wave transmission under physiological and pathological conditions to further explore the mechanism of GI dysfunction. This article reviews the application and research progress of electromyography, bioelectromagnetic technology, and high-resolution mapping in animal and clinical experiments, summarizes the clinical application of GI electrical stimulation therapy, and reviews the electrophysiological research in the biliary system.
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Affiliation(s)
- Fan Ding
- Center of Gallbladder Disease, East Hospital of Tongji University, Shanghai 200120, China
- Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200331, China
| | - Run Guo
- Department of Ultrasonography, East Hospital of Tongji University, Shanghai 200120, China
| | - Zheng-Yu Cui
- Department of Internal Medicine of Traditional Chinese Medicine, East Hospital of Tongji University, Shanghai 200120, China
| | - Hai Hu
- Center of Gallbladder Disease, East Hospital of Tongji University, Shanghai 200120, China
- Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200331, China
| | - Gang Zhao
- Center of Gallbladder Disease, East Hospital of Tongji University, Shanghai 200120, China
- Institute of Gallstone Disease, Tongji University School of Medicine, Shanghai 200331, China
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Li AY, Yue H, Kavnoudias H, Cherk MH, Nadebaum DP, Barton H, Beech P, Yap KSK, Smith M, Paul E, Barber TW. Clinical utility of stimulated cholescintigraphy using a standardized Ensure-Plus fatty meal protocol in patients with suspected functional gallbladder disorder: a retrospective study of seven-years clinical experience. ANZ J Surg 2021; 92:774-780. [PMID: 34850524 DOI: 10.1111/ans.17388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The clinical utility of fatty meal stimulated cholescintigraphy particularly using a standardized formulation in patients with suspected functional gallbladder disorder has not been extensively studied. We present our seven-year clinical experience using an Ensure plus protocol. METHODS A retrospective study was performed on patients undergoing stimulated cholescintigraphy using Ensure Plus for evaluation of suspected functional gallbladder disorder. A gallbladder ejection fraction (GBEF) of <33% was considered abnormal. RESULTS Of the 173 patients evaluated, 57 (33%) had an abnormal GBEF, 112 (65%) had a normal GBEF and 4 (2%) had no gallbladder visualization. Of the 57 patients with an abnormal GBEF, symptom improvement occurred in 30/31 (97%) who underwent cholecystectomy and in 17/26 (65%) who were managed conservatively (p = 0.003). Of the 112 patients with a normal GBEF, symptom improvement occurred in 8/10 (80%) who underwent cholecystectomy and 74/102 (73%) who were managed conservatively (p = 1.000). In the subgroup of 102 patients with a normal GBEF managed conservatively, those without symptomatic improvement had lower GBEFs compared to those with symptomatic improvement (median GBEF 46% versus 57%, p = 0.019). CONCLUSION Our retrospective results support a clinical role for stimulated cholescintigraphy using Ensure Plus in the evaluation of patients with suspected functional gallbladder disorder. While an abnormal GBEF predicts good surgical outcome, our results suggest that using an absolute GBEF cut off value of <33% may not apply to all patients and hence GBEF results should only be used as an adjunct in the surgical decision-making process.
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Affiliation(s)
- Acrane Y Li
- Department of Nuclear Medicine and PET, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Helen Yue
- Department of Nuclear Medicine and PET, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Helen Kavnoudias
- Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Martin H Cherk
- Department of Nuclear Medicine and PET, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Alfred Hospital Campus, Melbourne, Victoria, Australia
| | - David P Nadebaum
- Department of Nuclear Medicine and PET, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Howard Barton
- Department of Nuclear Medicine and PET, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Paul Beech
- Department of Nuclear Medicine and PET, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Radiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Kenneth S K Yap
- Department of Nuclear Medicine and PET, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Alfred Hospital Campus, Melbourne, Victoria, Australia
| | - Marty Smith
- Department of Hepatopancreaticobiliary Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Eldho Paul
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thomas W Barber
- Department of Nuclear Medicine and PET, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Alfred Hospital Campus, Melbourne, Victoria, Australia
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Gayed IW, Dawood L, Xu Z, Rizk G, Dupont A, Atta M, Robinson EK. Improving Hepatobiliary Imaging as a Physiologic Test with Superior Clinical Outcomes. World J Nucl Med 2020; 19:353-358. [PMID: 33623504 PMCID: PMC7875040 DOI: 10.4103/wjnm.wjnm_21_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/06/2020] [Accepted: 05/01/2020] [Indexed: 11/24/2022] Open
Abstract
This study aims at prospectively evaluating the difference in the effect of cholecystokinin (CCK) and half-and-half milk (HHM) administered in the same patient on gallbladder contractility and correlation with clinical outcomes. Upon gallbladder visualization during standard hepatobiliary imaging, 0.02 μg/kg of CCK was injected over 3 min, and additional 30 min of dynamic imaging was obtained. Patients with gallbladder ejection fraction (GBEF) <35% after CCK were administered 8 oz of HHM followed by 30 min of imaging. The GBEF was recalculated. The number of patients whom GBEF changed from below 35% (abnormal) after CCK to above 35% (normal) after HHM was recorded. Follow-up of the clinical outcome at 6 months was performed. Fifty patients with abnormal GBEF were prospectively included. The average GBEF after CCK was 14.7% ± 8.5% and after HHM was 30.7% ± 20.8%. The average increase in GBEF with HHM was 16.0% ± 22.2%. The GBEF changed from abnormal to normal in 17 patients (34%). The remaining 33 patients remained abnormal. Clinical outcomes at 6 months were available in 47 patients. Cholecystectomy was performed in 60% of patients with abnormal GBEF with CCK and HHM with resolution or improvement of pain. Two of 16 patients (12%) with abnormal GBEF after CCK but normal after HHM had cholecystectomies with pain improvement, while 8 out of these patients (50%) were diagnosed and treated with other disorders and improved. Hepatobiliary imaging with HHM stimulation is a superior physiologic test which can lower the number of unnecessary cholecystectomies and misdiagnoses as functional cholecystitis.
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Affiliation(s)
- Isis W. Gayed
- Department of Diagnostic and Interventional Imaging, Nuclear Medicine Section, Houston, Texas, USA
| | - Lydia Dawood
- Department of Diagnostic and Interventional Imaging, Nuclear Medicine Section, Houston, Texas, USA
| | - Zhang Xu
- Department of Internal Medicine, UTHealth McGovern Medical School, University of Texas, Houston, Texas, USA
| | - Grace Rizk
- Department of Diagnostic and Interventional Imaging, Nuclear Medicine Section, Houston, Texas, USA
| | - Andrew Dupont
- Department of Gastroenterology, UTHealth McGovern Medical School, University of Texas, Houston, Texas, USA
| | - Monica Atta
- Department of Diagnostic and Interventional Imaging, Nuclear Medicine Section, Houston, Texas, USA
| | - Emily K. Robinson
- Department of Surgery, UTHealth McGovern Medical School, University of Texas, Houston, Texas, USA
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Eiken A, Fuglsang S, Eiken M, Svane MS, Kuhre RE, Wewer Albrechtsen NJ, Hansen SH, Trammell SAJ, Svenningsen JS, Rehfeld JF, Bojsen-Møller KN, Jørgensen NB, Holst JJ, Madsbad S, Madsen JL, Dirksen C. Bilio-enteric flow and plasma concentrations of bile acids after gastric bypass and sleeve gastrectomy. Int J Obes (Lond) 2020; 44:1872-1883. [PMID: 32317753 DOI: 10.1038/s41366-020-0578-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 03/04/2020] [Accepted: 03/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Bile acids in plasma are elevated after bariatric surgery and may contribute to metabolic improvements, but underlying changes in bile flow are poorly understood. We assessed bilio-enteric flow of bile and plasma bile concentrations in individuals with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery compared with matched non-surgical controls (CON). SUBJECTS/METHODS Fifteen RYGB, 10 SG and 15 CON underwent 99Tc-mebrofenin cholescintigraphy combined with intake of a high-fat 111In-DTPA-labelled meal and frequent blood sampling. A 75Se-HCAT test was used to assess bile acid retention. RESULTS After RYGB, gallbladder filling was decreased (p = 0.045 versus CON), basal flow of bile into the small intestine increased (p = 0.005), bile acid retention augmented (p = 0.021) and basal bile acid plasma concentrations elevated (p = 0.009). During the meal, foods passed unimpeded through the gastric pouch resulting in almost instant postprandial mixing of bile and foods, but the postprandial rise in plasma bile acids was brief and associated with decreased overall release of fibroblast growth factor-19 (FGF-19) compared with CON (p = 0.033). After SG, bile flow and retention were largely unaltered (p > 0.05 versus CON), but gastric emptying was accelerated (p < 0.001) causing earlier mixture of bile and foods also in this group. Neither basal nor postprandial bile acid concentrations differed between SG and CON. CONCLUSIONS Bilio-enteric bile flow is markedly altered after RYGB resulting in changes in plasma concentrations of bile acids and FGF-19, whereas bile flow and plasma concentrations are largely unaltered after SG.
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Affiliation(s)
- Aleksander Eiken
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Stefan Fuglsang
- Department of Clinical Physiology and Nuclear Medicine, Centre for Functional Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark
| | - Markus Eiken
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Maria S Svane
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Rune E Kuhre
- NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai J Wewer Albrechtsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,NNF Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department. of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Svend H Hansen
- Department. of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | - Samuel A J Trammell
- NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens S Svenningsen
- NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens F Rehfeld
- Department. of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark
| | | | - Nils B Jørgensen
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Jens J Holst
- NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark
| | - Jan L Madsen
- Department of Clinical Physiology and Nuclear Medicine, Centre for Functional Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark
| | - Carsten Dirksen
- Department of Endocrinology, Hvidovre Hospital, Hvidovre, Denmark.
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Ziessman HA. Sincalide: A Review of Clinical Utility, Proper Infusion Methodology, and Alternative Cholecystogogues. J Nucl Med Technol 2019; 47:210-212. [PMID: 31019045 DOI: 10.2967/jnmt.119.226019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 02/25/2019] [Indexed: 11/16/2022] Open
Abstract
Sincalide (Kinevac) is widely used in conjunction with cholescintigraphy for a variety of clinical indications. Over the years, numerous publications have verified the optimal infusion methodology. Published data and consensus recommendations emphasize that sincalide, 0.02 μg/kg, should be infused over 60 min. Production problems sometimes limit the availability of sincalide. In that case, non-Food and Drug Administration pharmacy-compounded sincalide may serve as an alternative. Fatty meals have also been used. Various illnesses and drugs may inhibit gallbladder contraction. Thus, these drugs should be withheld for 48 h before the study. Sincalide cholescintigraphy is most commonly used to diagnose or exclude chronic acalculous gallbladder disease. The study should preferably be performed as an outpatient procedure.
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Affiliation(s)
- Harvey A Ziessman
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland
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