common condition. After gallbladder disease has beenexcluded as a cause, sphincter ofOddi (SO) dysfunctionmust be considered in the differential diagnosis (1—2).This disorder has been proposed to occur secondary toSO stenosis (due to stone passage or post-inflammatoryfibrosis) or spasm (with sphincteric spasm due to aparadoxical response to cholecystokinin (CCK)) (1—5).SO dysfunction is a difficult and, as of yet, uncertaindiagnosis. Methods used to date for diagnosis haveincluded SO•manometry (1—5),fatty meal-augmentedultrasonography (6-8), and hepatobiliary scintigraphy(8-11). To date,thesemodalitieshavebeenappliedalmost exclusively in patients following cholecystectomy (the post-cholecystectomy syndrome). If SO dysfunction truly exists, it should be possible to diagnose

this disorder prior to cholecystectomy. An imagingmethod of screening patients for SO dysfunction priorto a potentially unnecessary cholecystectomy would beof value. Such a method is also needed to test thephysiologic significance of aberrations in SO manometry. As preliminary work toward this goal, we investigated sincalide-augmented, quantitative hepatobiliaryscintigraphy (QHBS) in “normals.―Our goals were: (1)to determine if common bile duct (CBD) dynamicscould be adequately evaluated before and after stimulation ofgallbladder emptying with sincalide, and if so,(2) to establish normal parameters with this test forfuture investigations of suspected SO dysfunction. Ourthird goal ofthis preliminary investigation was to definethe relationship, if any exists, between the quantitativeparameter at QHBS and SO manometry. From a sci

entific viewpoint, it would be of value to study this

relationship in both normals and abnormals. SO manometry is, however, invasive, and not without signifi

Sphincterof Oddi (SO) dysfunctionpresentswith vagueabdominal pain and/or abnormal liver function tests, andis presumablydue to SO stenosis or spasm. Clinical,laboratory, and imaging methods of diagnosis have beenlessthanideal.Initially,we determinednormalquantitativehepatobiliary scintigraphy (QHBS) parameters both preand post-sincalideadministration.Thirty-one “normals―wereanalyzed,andpost-sincalidecommonbileduct(CBD)dynamicscould be satisfactorilydeterminedin 29 (94%)subjects.Normalvaluesat sincalide-augmentedQHBS arereported.Next, 10 patientssuspectedof havingSO dysfunction were studied prospectively using SO manometryand QHBS. The two tests were in agreement in sevencases(4:normalCBDdynamics,3: abnormal).Inonecaseof advancedSO stenosis,QHBS was abnormal,but SOmanometrycouldnot be performed.In the two remainingcases,SO manometryandQHBS gavediscordantresults.Of greatest importance,no significantcorrelationexistedbetween the quantitative parameters of these two tests.Sincalide-augmentedQHBS is possibleand may, in thefuture, be of value in the diagnosis of SO dysfunction and/orpartialCBDobstruction.

J NucI Med 1990; 31:1462—1468

hronic right upper quadrant (RUQ) pain in theface of a normal diagnostic evaluation is a relatively

ReColvedOct.30,1989;revisionacceptedMar.14,1990.Forrepñntscontact:WalterE. Drane,MD,Div.of NuclearMedacane,

JHMHC,BoxJ-374,Gainesville,FL32610.Disclaimer: The opinions expressed herein reflect those of the authors

and shouldnot be regardedas officialor reflectingthe opinionsof theDep&tmentof theNavyor theDepartmentof Defense.

1462 The Journalof Nudear Medicine•Vol. 31 •No. 9 •September1990

Sincalide-.Augmented QuantitativeHepatobiliary Scintigraphy (QHBS): Definitionof Normal Parameters and Preliminary

Relationship Between QHBS and Sphincter of

Oddi(SO)Manometryin PatientsSuspectedofHaving SO DysfunctionWalter E. Drane and David A. Johnson

Division ofNuclear Medicine, Department ofRadiology, Shands Hospital and the University ofFlorida School ofMedicine, Gainesville,Florida;and Division ofGastroenterology, Naval Hospital Bethesda, and the UniformedServices University ofthe Health Sciences, Bethesda, Maryland

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MeanUpperlimit

mean±2s.d.Timeto Peak (mm)(mm)

Post/Pre-sincalide peak CBD ratio: mean = 0.47; range= 0—1.2; mean + 2 s.d. = 1.23.

Gallbladderejectionfraction:mean = 41% and range= 7-80%

. Excludes the seven patients with no post-CCK peak (n = 22).

These parameters were calculated for both pre-sincalide andpost-sincalide time periods. Also, the post/pre-sincalide peakCBDratio wascalculated.Ifno peakin CBDactivityoccurredaftersincalideinjection,this ratio wasgiventhe valueof zero.Gallbladder ejection fractions in response to sincalide alsowere calculated. All resultant data were analyzed by correlativeand linear regression analysis.

A prospectivestudyof sincalide-augmentedQHBSand SOmanometry was performed in ten patients with chronic RUQpain, suspectedof SO dysfunction(primarilybased on theirotherwise uneventful diagnostic evaluations). There were ninefemales and one male (mean age: 42 yr, range 25—59yr). Fourof these patients had previous cholecystectomies. Informedconsent was obtained in each patient. QHBS parametersgreater than 2 standard deviations (s.d.s) above the derivednormals were considered abnormal. SO manometry was performed within 3 days of QHBS. Standard SO manometrictechnique was used, as described in the appendix.

Correlative and linear regression analysis was performedbetween the quantitative parameters of QHBS and SO manometry. If SO manometry was abnormal, the typical courseof action was endoscopic sphincterotomy. However, for thepurposesof this preliminary investigation,the results of SOmanometry were not taken as proofofdisease. Instead, clinicalcourse over the next 12 mo, especially in those patients withattempted therapy by sphincterotomy, was used as the mainindicator of the significance of the findings at QHBS and SOmanometry.

RESULTSOf the 31 normal subjects, 29 (94%) had adequate

scintigraphic visualization ofthe CBD for proper quantitation. The other ROIs were easily produced on allscans. Table 1 shows the mean values and upper limitsof normal (arbitrarily defined as mean ±2s.d.s) of thequantitative results in the “normal―population. A typ

cant complications, and as such, this goal was designedto compare these two techniques in patients clinicallysuspected as having SO dysfunction.

MATERIALSANDMETHODSSincalide-augmented QHBS was performed in 31 subjects,

all of whom were screened for evidence of biliary disease. Allsubjectswere asymptomaticin regard to biliary disease,andscreening laboratory tests and ultrasonography were normal.There were 20 males and 11 females (mean age: 43 yr, range:25—64yr). Ten additional asymptomatic patients (status-postcholecystectomy) were also studied. Informed consent wasobtained from each subject.

Following the bolus injection of 6—8mCi of @mTc@di@isopropyl-iminodiacetic acid (DISIDA), anterior sequentialimages of the upper abdomen were performed using either astandard (23 patients) or a large field-of-view (8 patients)gamma camera, equipped with a low energy, all-purposecollimator. Continuous computer acquisition was used at arate ofone frame/mm for 90 mm. At 60 mm after radiotraceradministration,each subjectwas administered 1.5 zgof sincalide (the eight amino acid, active portion ofCCK) as a slowi.v. push injection over 1—2mm (this injection was given tothe post-cholecystectomy patients as well.) The importance ofremaining motionless during the examination was stressedwith each patient.

Regions of interest (ROIs) were placed about the followingsites: gallbladder, common bile duct (CBD), liver (using asquareROI overan area of the right lobe,avoidingthe majorbile ducts), and the entire hepatobiliary region (liver andCBD). (see Figure 1). Two patients were excluded due tofailure to adequately identify the CBD. Careful attention waspaid to avoid overlapof duodenum with the CBD ROI, andplacement was checked by visual inspection of the dynamicstudyin “movie-mode―with ROIsin placeto excludeoverlapor significant patient motion. Time-activity curves were gencrated for each ofthese ROIs. Time-to-peak activity and halftime of wash-out were calculated for each time-activity curve.

TABLE 1NormalQHBS Parameters

SpontaneousLiverCBD

Post-SincalideCBD

Half-timeof Wash-outSpontaneous

LiverCBD

Post-SincalideCBD

122419394•1029

3344631024

FIGURE 1Illustration of placement of ROls: hepatobiliary, hepatic, gallbladder, and common bile duct.

1463QuantitativeHepatobiliaryScintigraphy•Draneet al

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,KcsfLTv\v%@\@L@AJ4

FIGURE 2Common bile duct (CBD) curve (A)showspromptpeakactivityoccurringat 17 mm, spontaneoushalf-timeofwashoutof37 mm,andprompt“spike―inactivitythroughtheCBDinresponseto sincalide administration (arrowmarkstimeof sincalideinjection).Thepost/pre-sincalide peak CBD ratio is0.74 (normal).CurveB is the gallbladder time-activity curve, showingmarked gallbladder emptying in responsetosincalide(85%emptying).(Xaxis in all graphs is shown in seconds,y-axis indicatesactivity)

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ical CBD time-activity curve is shown in Figure 2. Aclear “spike―in activity is seen in the CBD in responseto sincalide. The CBD time-activity curves of sevenpatients showed no “spike―in activity following sincalide. Since the gallbladder clearly contracted in thesecases and CBD activity continued to decline during thisperiod, this pattern was considered a normal variant(see Figure 3). The post/pre-sincalide peak CBD ratiowas under 1.0 in 28 of 29 normals, obviously meaningthat the spontaneous CBD activity almost alwayspeaked at a higher level than the CBD activity afterstimulation of gallbladder contraction. Of interest inthe data presented in Table 1 is the fact that gallbladderejection fraction was relatively variable (mean: 41%;range: 7%—85%).However, there was no significantcorrelation between gallbladder ejection fraction andany of the CBD quantitative parameters, and as such,the rate ofCBD emptying after sincalide administrationwas not affected by degree ofgallbladder contraction.

No significant differences were found between quantitative parameters in the post-cholecystectomy patientsversus the normal individuals with gallbladders. No“spike―occurred in CBD activity after sincalide injection in the post-cholecystectomy group, and no changein the rate of CBD wash-out was seen after sincalideadministration. Time to peak liver activity was 12 ±4mm (mean ±2 s.d.) and 30 ±14 mm for the CBD.Half-time of spontaneous liver washout was 27 ±16mm, and the half-time of spontaneous CBD washoutwas 28 ±23 mm.

In our evaluation of patients with suspected SO dys

FIGURE 3Gallbladder time-activity curve (A)showing only 20% emptying after sincalideadministration.CBDcurve(B)showsabruptincreasein rateof emptying after sincalide.No post-sincalide“spike―inCBDactivityoccurred.(arrowmarkstimeofsincalideinjection).Sinceno “spike―occurred,the post/pre-smncalidepeak CBD ratio is 0 (normal).

function, QHBS and SO manometry were normal infour patients. An etiology for these patients' symptomswas not elucidated. One patient had normal QHBS andabnormal manometry and had continued symptomsafter sphincterotomy. One patient had abnormal QHBSand normal manometry and did not undergo therapy(symptoms were present at a 12-mo follow-up). Three

patients were positive on both tests. One of these patients had an ampullary carcinoma as the cause of hersymptoms (see Figure 4). The other two patients hadreliefofsymptoms following sphincterotomy. The final

patient had positive QHBS, but unsuccessful manometry, and sphincterotomy caused relief of symptoms.

Table 2 shows the quantitative data for the individualpatients. No statistically significant correlation wasfound between SO manometric parameters and thoseof QHBS. Figure 5 shows an abnormal CBD timeactivity curve from a patient with an intact gallbladderand both QHBS and manometry compatible with SOdysfunction. This curve shows abnormal delays in both

spontaneous CBD peak activity and post-sincalide CBDpeak, as well as elevation ofthe post/pre-sincalide peakCBD ratio.

DISCUSSION

This investigation has shown that QHBS can analyzethe dynamics ofCBD emptying in response to sincalide.Krishnamurthy et al. (12) previously studied biliarykinetics using a similar approach in normals and patients with cholelithiasis, using somewhat different tech

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1464 The Journalof NuclearMedicine•Vol. 31 •No. 9 •September1990

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FIGURE4Sixty-minute (A) and 120-mm (B) images from hepatoblliaryscan showingnormal biliary-bowel transft, butmarkedprominenceof theCBD.Thegallbladder has been previously removed.PeakCBD activity occurred at47 mm,with a half-timeof wash-out of82mm(bothvaluesabnormal).SOmanometryshoweda normalbasalpressure,but markedincreasein frequencyof contractions. Ampullary carcinomawasthecauseofthispattern.A B

nical and quantitative parameters. They emphasizedthe analysis of gallbladder ejection parameters and notthe indices of CBD dynamics. In our current study,quantitation of CBD dynamics was possible in 94% ofvolunteers, in spite of the fact that 74% of the studieswere performed on an older standard field of viewgamma camera. We have found that identification ofthe CBD is easier when studies are performed on amodern, large field-of-view gamma camera, with greaterspatial resolution. Most patients exhibited a clear-cut“spike―in CBD activity in response to sincalide, withboth a rapid rise and fall in activity.

Several interesting findings occurred during definition of these normal parameters. We would have predicted that gallbladder ejection fraction or rate of contraction would have a major effect on CBD dynamics

FIGURE 5CBD time-activitycurve showing spontaneouspeak activityat46mm(abnormal)withnormalspontaneousCBDwashout(half time of 10 mm).Post-sincalidetime to peak is abnormal(13mm)and the post/pre-sincalidepeakCBDratio is 1.71, anelevated value (arrow marks time of sincalide injection). Basalsphincter pressurewas 35 mm of Hg, and symptoms wererelieved following sphincterotomy. (Each division on the x-axisis@ 6 mm.)

after sincalide. This, however, was not the case, and nosignificant correlation was found. This finding simplyshows that emptying ofthe CBD is not simply a passiveresponse to gallbladder contracture and SO relaxation.Other factors, such as peristaltic activity of the bowelmay play a role in CBD dynamics as well. Simply stated,CBD dynamics are a complex process.

In our “normal―population, thirteen individuals hadgallbladder ejection fractions below 35%, which manyinvestigators have considered abnormal (13—14). Allthese patients were asymptomatic, and as shown byDavis Ct al. (15) and Mesgarzadeh et al. (16), lowgallbladder ejection fractions can occur in “normals―in response to a single dose of sincalide. Interestingly,the dynamics ofthe CBD activity in response to sincalide could be analyzed in all these patients with lowgallbladder ejection fractions, and their quantitativeparameters were not significantly different than thoseindividuals with gallbladder ejection fractions above35% (see Figure 6). This finding suggests that sincalideaugmented CBD dynamics can be studied in patientswith decreased gallbladder ejection fractions, even inthe face of potential chronic cholecystitis. However,until further work substantiates this opinion, we recommend that post-sincalide CBD dynamics be viewedwith caution in patients with diminished gallbladderejection fraction (<35%).

The CBD dynamics in patients (status: post-cholecystectomy) were no different from the “normal―mdividuals. No “spike―occurred after sincalide, since therewas no gallbladder to contract. Also, no alteration inCBD wash-out occurred. A paradoxical response tosincalide, as proposed in SO spasm, would presumablydelay CBD wash-out, but no such effect was seen inthese asymptomatic post-cholecystectomy patients.

SO dysfunction is a difficult clinical diagnosis. SOspasm represents a clinical syndrome, without definitivepathologic findings. Ultrasonography (both with orwithout fatty meal challenge)(6—8),QHBS (8—11),andSO manometry (1-5) have all been used for possiblediagnosis. However, appropriate strategies for diagnos

1465Quantitative Hepatobiliary Scintigraphy •Drane et al

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TABLE 2QHBS and SO Manometric Findings in Patients Suspected of Having Biliary Dyskinesia

Positive findings are listed in boldface.. Patient was found to have ampullary carcinoma.

n.a.= manometrywastechnicallyunobtainable.t No pre-sincalide peak occurred prior to sincalide injection.

Patient No.

Quantitative Parameters1 2 3 4 5678910Hepaticpeak1 0 10 5 10 9 12732120HepaticT½26 40 41 28 34 3140103844SpontaneousCBDpeak25

35 46 55 142735135947SpontaneousCBDT½56 58 10 25 2428465829582Post-sincalideCBDpeak2 5 13 3 70————Post-sincalideCBD T½1 5 10 3 1 833————Hepatobiliary

peak1 0 17 60 15 37602662820GBejectionfraction56% 28% 62% 72% 60%24%————Post/Pre-sincalide

peakCBDratio0.83 0 1.71 0.33 0.7300—0.73BasalSOpressure22 78 35 20 20 282010n.a.25Frequency

of contractions4.5 5 4 5 584—n.a.10%retrograde contractions(All patients had less than 50% retrogradecontractions)Paradoxical

Sincalideresponse(No patienthada paradoxicalresponsetosincalide)SphincterotomyNoYes Yes No NoYesNoNoYesRelief

of symptomsNo No Yes No No YesNoNoYes

tic evaluation of potential SO dysfunction have notbeen adequately established.

Non-quantitative HBS has been used for the diagnosis of SO stenosis in the “post-cholecystectomy syndrome― (9—10).These non-quantitative methods analyzed the “prominence―of the CBD as well as a qualitative evaluation of its rate of emptying. Sensitivities of80%—90%were reported for the detection ofSO stenosisby non-quantitative methods alone, but the patientsreported by Zeman et al. (9) all had CBD dilatationand probably represented an advanced phase of thespectrum of disease.

Quantitative methods at hepatobiliary scintigraphyhave been previously applied to this difficult populationas well. Using clinical presentation, instead of SO manometry or blinded results of therapy, for categorization, Shaffer et a!. (1 1) studied post-cholecystectomypatients versus normal “controls―.They reported thedetection of eight of nine patients using QHBS, butcould not differentiate SO dysfunction from cholestasis.Darweesh et al. (8) studied QHBS in a similar group of

FIGURE 6Gallbladder time-activity curve (A)shows only 12% emptyingafter sincalide.Inspiteof thislimitedgallbladdercontraction, a clear “spike―in CBD activity (curve B) is seen. The post/presincaJidepeak CBD ratio is 0.83 (normal). (Arrow marks time of sincalideinjection)

patients (32 post-cholecystectomy “controls―,28 patients with suspected partial CBD obstruction). Theseauthors used endoscopic retrograde cholangio-pancreatography (ECRP) and SO manometry as the “goldstandard―for disease. They reported a 67% sensitivityand 85% specificity for partial CBD obstruction withQHBS, with hepatic washout at 45 mm as the bestindicator ofdysfunction. The authors also studied fattymeal sonography (FMS) in this population. They foundQHBS and FMS to be complementary, with FMS haying a higher specificity.

If a fatty meal (basically a more prolonged CCKresponse) is needed to detect these abnormalities atultrasonography, a similar physiologic response should

be of benefit at QHBS. We chose sincalide challengeover fatty meal because of its more predictable time ofonset of effect, allowing a shorter imaging duration.Sincalide-augmented QHBS should theoretically bemore sensitive for partial CBD obstruction ofany etiology than standard QHBS. Sincalide-augmented QHBShas not been previously applied to a population of

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1466 The Journal of Nuclear Medicine •Vol. 31 •No. 9 •September 1990

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by Geenen et al. (19), 208 of 289 patients with possibleSO dysfunction were excluded from further biliary evaluation after ECRP showed no evidence of biliary abnormality and biochemical parameters were normal.

Obviously, a large number of patients with chronicabdominal pain remain an enigma. A controlled, double-blinded trial of placebo versus sphincterotomy ordrug therapy for the treatment ofpotential SO dysfunction, using therapeutic relief of symptoms as the “goldstandard― for the presence of disease and with careful

prospective analysis ofthe roles of sincalide-augmentedQHBS, FMS and SO manometry is still needed.

Sincalide-augmented QHBS has potential use in theevaluation of other etiologies of partial CBD obstruction. The study of CBD kinetics after gallbladder contracture will potentially improve the ability of QHBSto separate partial CBD obstruction from cholestasis.Much greater clinical experience with sincalide-augmented QHBS is needed.

APPENDIXSO manometrywasperformedby the followingtechnique:

Manometrics were performed using a 1.7-mm outer diameter,0.8 mm inner diameter triple lumen catheter connected to alow-compliancepneumohydrauliccapillary pump, perfusedat 0.25 ml/min. Baseline duodenal pressures were recordedusing a standard ECRP catheter (1.7 mm outer diameter, 1.0mm inner diameter). The manometric catheter was passedinto the papilla of Vater until the distal tip was localized.Position of the catheter was documented radiographicallywithout injection of contrast material. The catheter was thenwithdrawn across the SO using the marked rings on thecatheter for reference. All measurements were averaged froma 2-mm recording period and expressed relative to intraduodenal pressure which was defined as zero. The followingparameters were measured: Basal SO pressure (normal: <35mm of Hg), peak amplitude of phasic contractions (normal:<350 mm of Hg), frequencyof contractions(normal: @6permm), and direction of propagationof contractions (normal:<50% retrograde).The entireprocedurewasrepeatedin everypatient following the injection of sincalide (0.02 @zg/kgi.v.).

REFERENCES

1. Meskinpour H, Mollot M, Eckerling GB, Bookman L. Bileduct dyskinesia:clinical and manometric study. Gasiroenterology 1984; 87:759—762.

2. Toouli J, Roberts-Thomson IC, Dent J, Lee J. Manometricdisorders in patients with suspected sphincter of Oddi dysfunction. Gastroenterology 1985; 88:1243—1250.

3. Bar-Meir S, Geenen JE, Hogan WJ, Dodds WJ, Stewart ET,Arndorfer RC. Biliary and pancreatic duct pressure measuredby ERCP manometry in patients with suspected papillarystenosis.DigDisSd 1979;24:209—213.

4. Bolen G, Javitt NB. Biliary dyskinesia: mechanisms andmanagement. Hosp Pract 1982; 17:115—130.

5. Geenen JE, Hogan Wi. The value of sphincter of Oddimanometry in the postcholecystectomy syndrome and idiopathic recurrent pancreatitis. Endoscopy Review 1987; 40—46.

patients suspected of SO dysfunction prior to cholecystectomy. Our current work clearly shows that this technique is possible and potentially adds very valuablephysiologic data concerning CBD function.

A number of studies of SO dysfunction have alreadyused SO manometry as the “goldstandard―for diagnosis(1—5). This is a premature award to this technique.SO manometry has a number oflimitations. It is technicaily difficult to perform and interpret, it has a significant incidence of post-procedural pancreatitis, and itrequires a very cooperative patient (5). Artifacts occurfrom patient movement, respiration, retching, and duodenal activity. Overall success rate is only about 70%—80%. A well-controlled, blinded study of SO manometry, FMS, and QHBS has never been performed, usingrelief of symptoms by sphincterotomy or drug therapy(calcium channel blockers) as the proof of disease.Abnormalities of the esophagus have been overdiagnosed in the past at manometry (1 7-18). A similarproblem is clearly possible with SO dysfunction and SOmanometry. Care must be maintained to prevent an

unquestioned acceptance of SO manometry.Obviously, our reported patient population is small

(n = 10). We feel, however, that this preliminary information is very important. We initially hypothesizedthat a relationship between gallbladder ejection fraction, post-sincalide CBD dynamics, and SO pressureswould exist. However, no significant correlation wasfound between any ofthese parameters, simply emphasizing the fact that biliary dynamics are a complexfunction. The results of this preliminary study are notintended to support the use of QHBS for the diagnosisof SO dysfunction. Instead, we hope to emphasize thatlittle is truly known about this syndrome, that SOmanometry and QHBS results are complex and nosimple relationship exists between the physiologic parameters that each measures, and that much greaterclinical investigation is needed. In this small population,we have found that QHBS can identify atypical biliarydynamics in cases where SO manometry is either normal or cannot be performed, and also, that QHBS maybe normal in the face of abnormal SO manometry.Both methods, as well as FMS, have a potential role inthe evaluation of SO dysfunction.

A prospective, double-blind study of sphincterotomyversus “sham―procedure in patients with suspected SOdysfunction was recently reported by Geenen et al. (19).This study showed that SO manometry could be usedto select patients who will improve with sphincterotomy. Patients with elevated sphincter pressures werealmost uniformly improved after sphincterotomy, andimprovement persisted for 4 yr after treatment. Thoughextremely encouraging, these results have yet to bereplicated. Because of the complexity of SO manometry, its fairly high failure rate, and its invasive nature, anoninvasive substitute would be of value. In the study

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6. Simeone iF, Mueller PR, Ferrucci iT Jr., et al. Sonographyof the bile ducts after a fatty meal: an aid in the detection ofobstruction. Radiology 1982; 143:211—215.

7. Simeone iF, Butch Ri, Mueller PR, et al. The bile ducts aftera fatty meal: further sonographic observations. Radiology1985;154:763—769.

8. Darweesh RMA, Dodds WJ, Hogan, WJ, et al. Efficacy ofquantitative hepatobiliary scintigraphy and fatty meal sonography for evaluating patients with suspected partial commonbile duct obstruction. Gasiroenierology 1988; 94:779—786.

9. Zeman RK, Burrell MI, Dobbins J, Jaffe M, Chouke PL.Postcholecystectomy syndrome: Evaluation using biliary scmtigraphy and endoscopic retrograde cholangiopancreatography.Radiology1985;156:787—792.

10. Lee RL, Gregg JA, Koroshetz AM, Hill TC, Clouse ME.SphincterofOddistenosis:diagnosisusinghepatobiliaryscmtigraphy and endoscopic manometry. Radiology 1985;156:793—796.

I I. Shaffer EA, Hershfield NB, Logan K, Kloiber R. Cholescintigraphic detection of functional obstuction of the sphincterofOddi. Gastroenierology1986;90:728—733.

12. Krishnamurthy GT, Bobba yR. McConnell D, Turner F,MesgarzadehM, Kingston E. Quantitative biliary dynamics:Introduction of a new noninvasive scintigraphy technique. JNuclMed 1983;24:217—223.

13. Fink-Bennett DF, DeRidder P, Kolozsi W, Gordon R, RappJ. Cholecystokinin cholescintigraphy findings in the cysticductsyndrome.J NuclMed 1985;26:1123—1128.

14. Doherty PW, Schlegel P, King MA, Zawacki JK. Abnormalgallbladderemptying in response to cholecystokinin (op-cck)in patients with acalculus gallbladder disease [Abstract]. JNuclMed 1983;24:P8.

15. Davis GB, Berk RN, Scheible FW, Witztum KF, Gilmore IT,Strong RM. Cholecystokinin cholecystography, sonography,and scintigraphy: detection ofchronic acalculus cholecystitis.AiR 1982; 139:515—523.

16. Mesgai-zadehM, Krishnamurthy GT, Bobba VR, LangrellK.Filling, postcholecystokinin emptying, and refilling of normalgalibladdec Effects oftwo different doses ofCCK on refilling[concise communication]. J NuclMed 1983; 24:666—671.

17. Drane WE, Johnston DA, Hagan DP, Cattau EL, Jr. “Nutcracker―esophagus: diagnosis with radionuclide esophagealscintigraphyversus manometry. Radiology 1987; 163:33—37.

18. Ott DJ, RictherJE, Wu WC, Chen YM, Gelfand DW, CastellDO. Radiologic and manometric correlation in “nutcracker―esophagus. AJR 1986; 147:692—695.

19. Geenen JE, Hogan WJ, Dodds WJ, Toouli J, Venu RP. Theefficacyof endoscopic sphincterotomy after cholecystectomyin patients with sphincter-of-oddidysfunction. N Englf Med1989; 320:82—87.

S uspected partial obstructivesphincter-of-Oddi (SO) dysfunction due to stenosis or

dyskinesia is a common diagnosticconsideration in patients with unexplained biliary-like upper abdominal pain. Generally, most of thesepatients have symptoms after a cholecystectomy (postcholecystectomysyndrome). Potentially useful diagnostic tests emphasized during thepast decade include SO manometry,fatty-meal sonography, and quanti

tative hepatobiliary scintigraphy(QHBS).

In this issue, Drane and coworkera describe a study that evaluatesQHBS in 31 patients judged to benormal and in 10 patients with suspected SO dysfunction. In their

ReceivedApr. 27, 1990; revisionacceptedApr. 27, 1990.

Forreprintscontact:W@1ieJ. Dodds,MD,Dept.of Radiology.FroedtertMemOrialLutheranHospital,9200W. WisconsinAve.,Milwaukee,WI53226.

study, most of the controls had anintact gallbladder although the exactpercentage is not given. In several

previous studies that evaluatedquantitative or semiquantitativehepatobiliary scintigraphy in patients with suspected partial common bile duct obstruction, investigation was limited to patients witha cholecystectomy because of theconcern that a normal gallbladdermight act as a reservoir that obscured the findings of distal common bile duct obstruction (1—4).Therefore, the precise utility of thepooled control values given byDrane et al. is not clear. Evidence isnot provided to show that normalvalues for noncholecystectomizedand cholecystectomized subjects arecomparable.

Another innovative approach byDrane et al. is the use of sincalidein an attempt to develop an augmented QHBS stress test that mightunmask abnormalities not shown

by standard methods. Regrettably,however, the authors used a smallbolus dose of sincalide (1.5 @igi.v.)that would provide only a shortlived stimulus. Because of theirshort half-life, bolus doses of CCKor sincalide have a biologic effectfor only several minutes whereas asustained effect of 30 mm or moreis needed for maximal emptying ofthe gallbladder or to maximize theenterohepatic cycling of bile acidsand hepatic bile flow. Thus, the design ofthis study does not allow anyconclusions about the utility of sincalide augmentation for QHBS.One of the rationales for the use ofCCK or CCK-like agents duringQHBS is the notion that an important type of SO dyskinetic is paradoxical contraction of the SO inresponse to CCK. This variant ofSO dyskinesia, however, is uncommon among SO dyskinesia patients.The most common variant of SOdyskinesia is sphincter spasm

1468 The Journal of Nuclear Medicine •Vol. 31 •No. 9 •September 1990

EditorialQuantitativeHepatobiliaryScintigraphy

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1990;31:1462-1468.J Nucl Med.   Walter E. Drane and David A. Johnson  (SO) Manometry in Patients Suspected of Having SO Dysfunction

OddiNormal Parameters and Preliminary Relationship Between QHBS and Sphincter of Sincalide-Augmented Quantitative Hepatobiliary Scintigraphy (QHBS): Definition of

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