Bile leak detection after trauma by radionuclide scintigraphy

Sir,

Bile leak is one of the serious complications resulting from hepatobiliary trauma and is associated with significant morbidity and mortality.[1] Hepatobiliary scintigraphy is being used since late 1970s for the diagnosis of biliary leakage as it is a highly-sensitive and specific functional imaging modality for identification of bile leak.[2345]

A 7-year-old girl was admitted to our hospital with alleged history of blunt trauma in the abdomen 3 days back, following a fall and run over by a rickshaw. Ultrasonography and computed tomography abdomen revealed liver laceration with fluid in the peritoneum. She was managed conservatively and discharged on request after a week. Four days later, she was again admitted with complaints of pain in the abdomen and distension. A repeat ultrasonography did not reveal any biliary tract anomaly. Posttraumatic acute pancreatitis with subacute intestinal obstruction paralytic ileus was suspected and ascetic fluid diagnostic aspiration was done which revealed biliary ascitis. She was subjected to hepatobiliary scintigraphy to confirm the presence of bile leak and to locate its site.

Tc99 m mebrofenin hepatobiliary scintigraphy showed homogenous hepatic parenchymal uptake on initial dynamic images [Figure 1]. The intra hepatic biliary radicals were not dilated. An area of extrahepatic accumulation of tracer was seen originating from the tip of left lobe of liver, in the left subphrenic space at 10 min, which built up with time. The gall bladder was not visualized. Collection of the tracer was also noted in the gall bladder fossa. The tracer was seen to collect in the entire peritoneal cavity within 40 min [Figure 2]. The patient was managed conservatively. The drain fluid became bile free within a week.

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Figure 1 Hepatobiliary scintigraphy dynamic images after an intravenous injection of 185 MBq Tc99 m-Mebrofenin. Initial images showed homogenous hepatic parenchymal uptake. The intra hepatic biliary radicals were not dilated. An area of extrahepatic accumulation of tracer was seen originating from the tip of left lobe of liver, in the left subphrenic space at 10 min, which built up with time

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Figure 2 Delayed imaging at 2 h showed slowly rising activity in the ascitic fluid

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This image reemphasizes the utility of hepatobiliary scintigraphy as physiologic, rapid, noninvasive, safe, simple procedure for the detection of presence, site and extent of the bile leak occurring due to various etiologies. Due to the low level of radiation exposure involved, it can be repeated; and hence is useful in evaluating the response to medical or surgical treatment.[6]