A crying liver: a scan pattern mimicking spontaneous perforation of the biliary ducts

Somaye Barashki; Hadis Mohammadzadeh Kosari; Emran Askari; Zahra Bakhshi Golestani; Mehran Hiradfar; Ramin Sadeghi

doi:10.5603/NMR.a2022.0028

Clinical vignette

Nuclear Medicine Review 2022, 25, 2: 131–133

DOI: 10.5603/NMR.a2022.0028

ISSN 1506–9680, e-ISSN 1644–4345

A crying liver: a scan pattern mimicking spontaneous perforation of the biliary ducts

Somaye Barashki1

Hadis Mohammadzadeh Kosari1Emran Askari1Zahra Bakhshi Golestani1Mehran Hiradfar2Ramin Sadeghi1

1Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

2Department of Pediatric Surgery, Mashhad University of Medical Sciences, Mashhad, Iran

[Received 27 IV 2021; Accepted 27 IV 2022]

Correspondence to: Ramin Sadeghi, Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran,phone: +985138012794, e-mail: sadeghir@mums.ac.ir; raminsadeghi1355@yahoo.com

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A 2-month-old infant was referred for hepatobiliary scintigraphy due to ascites of unknown cause. The top differential diagnosis was spontaneous perforation of the biliary ducts. Delayed images up to 4 hours were against this diagnosis showing normal distribution of the radiotracer throughout the bowel. However, on delayed images, the scan showed mild tracer retention in the ascites confirmed by SPECT/CT images. Surprisingly, the exploratory abdominal surgery revealed an intact hepatobiliary system, pointing toward other possible etiologies. Second-review surgery was performed due to uncontrolled progressive ascites showing congestive hepatopathy and biliary leak from the hepatic surface suggestive of the “crying liver”.

KEY words: hepatobiliary scintigraphy; crying liver; biliary leak

Nucl Med Rev 2022; 25, 2: 131–133

Hepatobiliary scintigraphy (HBS) is a well-known diagnostic method for the evaluation of bile duct disease and biliary leak. Several studies have reported that HBS has played an important role in diagnosing spontaneous biliary leak, especially when associated with single photon emission computed tomography/computed tomography (SPECT/CT) [1–6].

A 2-month-old female pediatric patient presenting with abdominal distension since 5 days ago and suspicion of spontaneous perforation of the common bile duct was referred to the nuclear medicine department for hepatobiliary scintigraphy (HBS). Laboratory examination showed elevated total and direct bilirubin levels (4.1 and 2.1 mg/dL, respectively) and high alkaline phosphatase (556 IU/L). Abdominal ultrasonography showed ascites with a normal appearance of liver parenchyma, gallbladder, biliary ducts, and portal vein. Ascites fluid analysis was inconclusive for biliary ascites showing borderline elevation of the total bilirubin (1.5 mg/dL) [7]. Hepatobiliary scintigraphy (HBS) was performed after an intravenous injection of 37 MBq of 99mTc-mebrofenin. Dynamic imaging showed normal hepatic uptake and normal intra- and extra-hepatic ducts (Fig. 1A). Delayed static images 2 and 4 hours after injection demonstrated no abnormal radiotracer activity outside the biliary system and intestinal tract (Fig. 1B, C). To increase the sensitivity for detection of bile leakage, 24-hour delayed imaging was also performed showing an accumulation of the tracer throughout the peritoneum (Fig. 1D) [8, 9].

Figure 1. (A) Dynamic imaging from the abdominal region in anterior view showed normal hepatic uptake and biliary ducts with normal excretion of the radiotracer into the intestine; (B) Static image 2 hours after injection; (C) Static image 4 hours after injection;(D) Static image 24 hours after injection in anterior view showing accumulation of the tracer throughout the peritoneum

Single photon emission computed tomography/computed tomography (SPECT/CT) images from the abdominal region confirmed the presence of activity in the ascites fluid (Fig. 2). The presence of radiotracer activity in the ascites fluid on the delayed images raised the possibility of biliary tract perforation. During the exploratory abdominal surgery, the hepatobiliary system was intact but there was a large omental cyst as well as intestinal malrotation with a large amount of yellowish free fluid in the peritoneal cavity. Surgical correction was done by resecting the omental cyst with correction of the intestinal malrotation. Owing to progressive abdominal distention, further, work-up was carried out showing increased ascites in the abdominal cavity. The patient underwent second-look surgery. No culprit pathology was found in the exploratory surgery except for superficial bile leak from the hepatic surface and the appearance of liver congestion suggestive of the “crying liver” [10, 11]. The final diagnosis was in favor of Budd-Chiari syndrome. The patient died 12 days after the second explorative laparotomy.

Figure 2. Computed tomography (CT) scan (top row); SPECT images (middle row) and single photon emission computed tomography/computed tomography SPECT/CT images (bottom row) in axial, sagittal, and coronal views confirmed the presence of activity in the peritoneal cavity

The most probable reason for radiotracer appearance in the ascites fluid on the delayed HBS images was due to oozing of the radiotracer from the liver surface. The present case highlights the usefulness of HBS to narrow the differential diagnosis of ascites of unknown cause in pediatric patients. Delayed imaging is useful in doubtful and challenging cases.

Conflict of interest

The authors declare no conflict of interest.

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