Caveats Relating To The Use Of Cholecystokinincholescintigraphy

CCK-CS involves the intravenous administration of 99mtechnetium-labeled hepato-iminodiacetic acid, which is taken up by the liver and excreted into the biliary system, where it accumulates in the gallbladder. A GBEF then can be measured reliably after stimulating gallbladder emptying, most commonly with CCK. A low GBEF has been suggested to be indicative of gallbladder dysfunction and supportive of a diagnosis of functional gallbladder disorder; however, its use is not without controversy.37 This is reflected in clinical practice by the not uncommon scenario of patients with suspected functional biliary pain and a reduced GBEF reporting no or incomplete relief of symptoms or recurrence of symptoms following cholecystectomy.

It is important to recognize that the finding of a low GBEF is not specific for functional gallbladder disorder and may occur in asymptomatic, healthy individuals, in patients with various medical conditions including diabetes, celiac disease, or irritable bowel syndrome,37 and as a result of a number of medications such as opioid analgesics, calcium channel blockers, oral contraceptive agents, histamine-2 receptor antagonists, and benzodiazepines.38 It also must be recognized that the gallbladder may not be responsible for a decreased GBEF as, occasionally, outflow obstruction from abnormalities of the cystic duct or sphincter of Oddi may be responsible.39 Therefore, this test should be considered only when there is a high index of suspicion

Cholecystokinin Disease

Fig. 1. Suggested algorithm for the diagnosis and treatment of suspected functional biliary pain in patients with a gallbladder. *using slow CCK infusion for at least 30 minutes. CCK-CS, cholecystokinin cholescintigraphy; GBEF, gallbladder ejection fraction. (Reproduced from DiBaise JK. Evaluation and management of functional biliary pain in patients with an intact gallbladder. Expert Rev Gastroenterol Hepatol 2009;3(3):305-13; with permission.)

Fig. 1. Suggested algorithm for the diagnosis and treatment of suspected functional biliary pain in patients with a gallbladder. *using slow CCK infusion for at least 30 minutes. CCK-CS, cholecystokinin cholescintigraphy; GBEF, gallbladder ejection fraction. (Reproduced from DiBaise JK. Evaluation and management of functional biliary pain in patients with an intact gallbladder. Expert Rev Gastroenterol Hepatol 2009;3(3):305-13; with permission.)

of a gallbladder origin of the symptoms and other diagnoses have been eliminated. Furthermore, when considering whether to perform CCK-CS, it is preferable for it to be performed as an outpatient procedure on a patient who is not having pain at the time given the potential of confounding effects of acute illness in the hospitalized patient who may be receiving multiple medications.37

The clinician should be familiar with how the test is performed and interpreted at his or her institution. At present, there is no consensus on the dose, rate, and duration of CCK infusion used in CCK-CS. Many CCK-CS studies are conducted using a rapid infusion of CCK over 2 to 3 minutes, a methodology that has been shown to yield highly variable results.37 In contrast, the slow infusion of CCK over 30 to 60 minutes results in an overall increase in mean GBEF compared with its rapid infusion and less inter- and intrasubject variability.40-42 Regarding CCK-CS interpretation, there remains no consensus on the definition of an abnormal GBEF, although most clinicians consider a value of less than 35% as abnormal.20,38 A multicenter trial is in progress that is attempting to determine the best methodology and establish normal values in a large healthy population.43

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