The diagnostic value of hepatobiliary scintigraphy for choledochal cysts in the era of magnetic resonance imaging with cholangiopancreatography and contrast-enhanced hepatobiliary phase: a case report and review

Objective: Choledochal cysts (CCs) represent cystic dilatations of the intra- or extrahepatic biliary tract. The diagnosis of CCs may not always be straightforward particularly for the intrahepatic subtype. Whereas the gold standard for diagnosing CCs is endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) is commonly used as primary diagnostic tool for delineation of biliary pathologies including CCs. Methods: We report a case of cystic hepatic lesion near the confluence of bilateral intrahepatic ducts. MRCP shows direct anatomical communication between the lesion and the biliary tract, raising suspicion of a CC. Endoscopic ultrasound shows no communication between the lesion and biliary system. 99mTc-hepatic iminodiacetic acid scintigraphy (hepatobiliary scintigraphy) was subsequently performed, showing no tracer uptake in the concerned cystic hepatic lesion despite visualisation of gallbladder and transit of tracer into the intestine. Overall scintigraphic findings speak against a CC. Conclusion: The case showed conflicting anatomical findings of a CC on MRCP and endoscopic ultrasound. Hepatobiliary scintigraphy and hepatobiliary contrast MRI may both functionally demonstrate communication of a hepatic lesion with the biliary tract. But hepatobiliary scintigraphy offers the advantage of much higher hepatic extraction and hence higher resistance to competition from plasma bilirubin compared with hepatobiliary contrast MRI. The better pharmacokinetics of HIDA confer superior lesion contrast that may offset inferior image spatial resolution, in particular for large lesions and patients with hyperbilirubinaemia. Hepatobiliary scintigraphy should be considered a suitable functional diagnostic modality for CCs even in the era of magnetic resonance imaging with cholangiopancreatography and contrast-enhanced hepatobiliary phase.

Erudition after neonatal gastric transposition for esophageal atresia at 10 years of follow-up

Background: Gastric transposition (GT) is a well-established procedure of esophageal re­placement (ER) for children with esophageal atresia. ER in the neonatal period is sparsely reported. We report characteristics of children who have undergone neonatal GT and have completed ten years of follow-up. Methods: The cross-sectional study was conducted which included all children who under­went neonatal GT at the institute and have completed a follow-up of at least 10-years. An­thropometry, oral contrast study, Hepatobiliary Scintigraphy, Gastroesophageal reflux study, Gastric emptying test, spirometry, and blood investigations were done for all the children. Results: Four children (three male and one female) were included in the study. The mean age at ER was 5.3 ±2.2 days with a mean birth-weight of 2.43 ±0.13 kg. Two children had prima­ry GT, while the other two had GT following a leak in primary anastomosis. During the mean follow-up of 180.25 ±43.5 months, none of the children required esophageal dilatation or other surgical intervention or procedures. All children were below 3rd centile for weight-for-age while all except one were below 50th centile for height-for-age. There was no stricture on oral contrast study, however, one child had grade III reflux on GER scan. Persistent duode­nogastric reflux on HIDA scan was seen in one child. Three children had restrictive parame­ters on spirometry. Symptomatically, all reported poor weight gain, one had left vocal cord palsy with hoarseness, and one had chest-wall protuberance. Conclusions: Neonatal gastric transposition is a feasible alternative to delayed esophageal replacement for neonates with esophageal atresia with limited complications.

Increased Hepatic Microvascular Density, Oxygenation, and VEGF in the Hypertrophic Lobe following Portal Vein Embolization in Rabbits

<b><i>Introduction:</i></b> The microvascular events following portal vein embolization (PVE) are poorly understood despite the pivotal role of the microcirculation in liver regeneration and tumor progression. We aimed to assess the changes in hepatic microvascular perfusion and neo-angiogenesis after experimental PVE. <b><i>Methods:</i></b> PVE of the cranial liver lobes was performed in 12 New Zealand White rabbits divided into 2 groups of permanent (P-PVE) and reversible PVE (R-PVE), respectively. Hepatobiliary scintigraphy and CT were used to evaluate hepatic function and volume. Hepatic microcirculation was assessed using a handheld vital microscope (Cytocam) to measure microvascular density (total vessel density; TVD) before PVE, right after PVE, and 20 min after PVE, as well as at 14 days (D14 post-PVE) and 35 days (D35 post-PVE). Additionally, on D35, microvascular PO₂ and liver parenchymal VEGF were assessed. <b><i>Results:</i></b> Eleven rabbits were included after PVE (R-PVE, <i>n</i> = 5; P-PVE, <i>n</i> = 6). TVD in the nonembo­lized (hypertrophic) lobes was higher than in the embolized (atrophic) lobes of the P-PVE group at D35 post-PVE (36.7 ± 7.2 vs. 23.4 ± 4.9 mm/mm²; <i>p</i> &#x3c; 0.05). In the R-PVE group, TVD in the nonembolized lobes was not increased at D35. Function and volume were increased in the nonembolized lobes of the P-PVE group compared to the embolized lobes, but not in the R-PVE group. Likewise, the mmicrovascular PO₂ and VEGF staining rate were higher in the nonembolized lobes of the P-PVE group at D35 post-PVE. <b><i>Discussion/Conclusion:</i></b> Successful volumetric and functional hypertrophy of the nonembolized lobe was accompanied by microvascular alterations featuring increased neo-angiogenesis, microvascular density, and microvascular oxygen pressure following P-PVE.

Pediatric Gallbladder Dysmotility: Not as Rare as Previously Considered a Case Report and Review of Literature

Introduction: Chronic abdominal pain in children is mostly functional, but in association with alarm symptoms such as recurrent vomiting, it is necessary to determine proper tests for the diagnosis of probable underlying organic problems. Case Presentation: Four patients with chronic refractory abdominal pain and nonspecific gastrointestinal symptoms presented to our tertiary pediatric center. After thorough medical and psychological investigations and hepatobiliary scintigraphy, and calculating gallbladder ejection fraction, laparoscopic cholecystectomy was performed. One year after the surgery, they were relatively symptom-free and returned to their routine life. Conclusions: Biliary tract abnormalities should be considered as a probable cause of chronic abdominal pain in children. Hepatobiliary scintigraphy can provide promising results to help to identify the underlying causes of chronic abdominal pain in association with nonspecific gastrointestinal manifestations.