Sunday, October 12, 2008

HIDA Scans: A call for a moratorium



We can all agree that baseball games last far too long. One of the biggest reasons for these protracted snoozefests are all the extraneous time waster crap that occurs. Batter stepping out of the box to adjust their wristbands and gloves. Or pick-off attempts, for example. Now I don't mean the quick move to first when there's an actual basestealer taking a big lead off first. I'm talking about those lazy, lobbed soft tosses to first when the slow, lumbering clean-up hitter is standing 7 inches from the bag. It's like the pitcher is saying, " you know, I'm really not ready to pitch to the batter. I think I'll kill some time by needlessly lobbing one to my first baseman." I can't stand it. It wastes time. It doesn't add anything. Nothing is gained. Ban it.

With health care costs spiralling out of control, it would be prudent to re-evaluate the American way of ordering test after test on patients who come into the hospital. We need to start asking ourselves: What can we eliminate? HIDA scans, in a way, are the general surgical equivalent to the lobbed pick-off throw to first. For the most part, they don't add much to the proceedings. Here's the typical scenario: Patient presents to ER with RUQ pain and nausea. An ultrasound is performed which shows multiple gallstones in the neck of the gallbladder. Some wall thickening of the gallbladder is noted. The patient is admitted to the internist on call (happens more often than you'd think). The internist then reads the official US report in the morning. Invariably, there will be sentence at the end of the report along the lines of this: "Recommend HIDA scan if there is concern for acute cholecystitis". So, the dutiful internist orders the "recommended" HIDA scan and gets a general surgery consult. General Surgeon comes to see patient but patient not in room. Down in nuclear medicine, the clerk says. So general surgeon leaves, comes back in an hour or two. Still no patient. Still in nuclear medicine for delayed images. General surgeon silently swears into his head. Returns at the end of the day. Patient clearly has RUQ tenderness, a positive Murphy's sign. The US shows stones. The HIDA hasn't been read yet. Doesn't matter. He books the patient for lap chole as soon as OR time available, which likely will be the following day. So now, the patient gets an extra couple days and an unnecessary test added on to his/her final bill.


A HIDA scan (hepatobiliary iminodiacetic acid scan) is an imaging procedure that involves injecting a radiotracer into a peripheral vein. The tracer gets picked up by the biliary system of the liver and is excreted via the common bile duct into the gallbladder and duodenum. A HIDA scan that shows non-filling of the gallbladder after a certain amount of time is diagnostic of acute cholecystitis; cystic duct obstruction being the sine qua non of the calculous biliary disease.

Sounds all well and good. But acute cholecystitis is, for the most part, a clinical diagnosis. RUQ pain. Nausea/bloating. Often developing after eating a fatty meal. Positive Murphy's sign on exam. An ultrasound demonstrating gallstones pretty much confirms the diagnosis. You really don't need anything more. A HIDA scan may or may not be positive, but the result is irrelevant. You already have a strong clinical suspicion of cholecystitis; so take out the gallbladder!

There are plenty of scenarios where a HIDA is warranted and useful:
-The demented old lady with gram negative sepsis who is a poor historian and has an unreliable physical exam.
-The ill patient in the ICU who has been on TPN for weeks and has an unexplained leukocytosis.
-Patients with symptoms of biliary dyskinesia (another blog post altogether)
-Evaluating for the possibility of a bile leak after biliary surgery

But straight-forward acute calculous cholecystitis in a reasonably healthy, alert patient should be obvious enough without biliary scintigraphy. Let's save ourselves the $1500 a pop that HIDA scans cost. Ultrasounds are cheap and highly sensitive. Enough is enough. Starting now, let's all try to limit how often we send our patients down to the basement of radiology for time-consuming, expensive, needless, and ultimately useless, testing. We can do it; I have faith.

22 comments:

Frank Drackman said...

Buckeye, agree %100 on the HIDA scan thing, but banning the sucker Pickoff Move? Now I know you're from Ohio, so you haven't had a real team since Pete Rose was bettin on the Reds, but you GOTTA have that lame move, it gets the runner to lead off further than he should, THATS when u give them the Trickery Dickery, So-Close-To-A-Balk move that if you looked up "Balk" in the dictionary, you'd see yourself, Move. Agree the games last too long, but thats mostly because of the pitching changes. Anyway, Braves got eliminated in August, so haven't watched as much. Does anyone do Oral Cholecystograms anymore? Rotated at a rural alabama hospital in 86' that did.

anna gregory said...

Nice to see you back - I thought that the nasty experience you told us about a few weeks ago was putting you off carrying on with your blog. Please carry on - your posts are a great help to us clueless medical students.

I don't think we have that scan in the UK.

HudsonMD said...

Buckeye,
It's funny because i deal with the opposite problem. ER calls with patient with RUQ pain... I do the admit and get the US that shows thickened Bag. I consult surgery because of RUQ pain, +Murphy's sign, and abnormal US. The surgeon wants HIDA (day 2). HIDA comes back with EF 20%(day 3). Surgeon still not satisfied and wants to do EGD and check for bile crystals!! (day 4)WTF!! So i book OR and threaten to do it myself. I love our health care system.

HudsonMD said...

Buckeye,
Now you have me all worked up. How about the radiologists these days who are unwilling to make and real decisions on their reads. A recent CT scan of Abdomen had the following impression. (done for abd pain and wt loss):
1. Thickened stomach lining could be just non-distended vs inflammation vs other. Clinical correlation.
2. Scarring of lung bases, suggest CT chest.
3. Adrenal nodule vs volume sparing from stomach. US recommended.
4. Renal cyst. Recommend US.
5. Thickening of sigmoid to suggest diverticulosis can't rule out diverticulitis.
6. Thickened bladder wall possibly due to non-distended gall bladder. Clinical correllation.
7. Hepatic cyst vs other process. Recommend US.
So in summary i need to send my patient for:
US Liver
US Renal and Adrenal Glands
EGD
Cystoscopy
CT Chest
Colonoscopy
WTF

HudsonMD said...

sorry i meant non-distended bladder not gall bladder

doc said...

Hudson needs to find a new surgeon....

Buckeye Surgeon said...

Hudson-
I agree; surgeons are just as culpable. Say General Surgeon X has a full day booked in the OR. You admitted an acute gallbag from the ER and you get the surgical consult. Surgeon X isn't going to be able to get the case done until later in the evening, unless he bumps his scheduled cases. He doesn't want to operate at 9 at night so he puts it on for the following day.

But so it doesn't look like he's blowing off your patient he says he "wants to get a HIDA scan first". That way, it appears that he's simply waiting for the results of a test prior to proceeding with definitive surgery....It's all about appearances unfortunately.

rlbates said...

Good post and nice discussion here.

Rob said...

We only order HIDA scans when the ultrasound is negative but the sx are referable to the GB. Do HIDA with CCK stimulation. May be bogus in that it seems the radiologists are generous with the interpretation of the ejection fraction, but it has been a way to justify a chole for someone with a negative US.

Buckeye Surgeon said...

Rob- I agree; negative US but sx's highly suspicious for gallbladder disease ought to lead to a CCK-HIDA scan. Ejection fraction isn't as reliable as whether or the patient has sx's reproduced by the sinaclide infusion....

Frank Drackman said...

Ever seen the Hidden Ball Trick? Its hard to pull off at the major league level, cause they have a guy whos whole job is to keep track of the ball. Its a thing of beauty, when it works, that look of surprise when the runner gets tagged as he takes his lead, Priceless. The Pitcher has the hardest part, since you can't step on the rubber without the ball, or its a Balk.

Bongi said...

i can't even conceive of an internist being consulted for anything remotely related to the galbladder. as usual buckeye is a surgeon after my own heart. only thing, why swear quietly or in your head?

Anonymous said...

Hudson:
You need to have a face to face with that radiologist and the film. If it is as he/she states...fair enough. Otherwise he/she needs to realize that a radiologist is a doctor's doctor (ie an aid in a clinican's decision making), not a hedge.

HudsonMD said...

Anon
I did bring the read to the radiologist and told her i expected more with the reads(or really less). I also had it re-read by one of the senior radiologists. i just want a confident and assertive impression.

The Happy Hospitalist said...

I wonder if anyone has ever done a study comparing utilization of HIDA scan in those with and those without insurance. Or MRCP in the same population. Any thoughts?

Anonymous said...

HIDA with CCK is a combination useful in ferreting out a diseased gall bladder without stones......

Dawn said...

I had a what I assumed was a gall bladder attack one night. Toughed it out and called my Dr the next day. Had an ultrasound that shows a polyp and sludge. They scheduled a HIDA scan but I have to wait over 2 weeks to get it. Is this what you would consider an unnecessary use of this test?

Anonymous said...

HIDA is a big money maker and is not necessary. Just like CT scans and presumed appendicitis....is it really necessary to get a CT scan in a pt with severe RLQ pain and rebound tenderness???

Matt @ Edit Me F.A.S.T. said...

Great posting. I had a gallbladder full of stones and kept having attacks (very severe pain in my back that woke me up and kept me up for several hours each time). I then had my gallbladder removed three years ago and have had BSD ever since. My mom is now having episodes of pain and nausea... no gallstones, but her pcp is recommending the hida test. Any concerns about this test? I'd hate to see any complications. Thanks.

Anonymous said...

Anatomy alone just does'nt cut it(no pun) physiology is needed for evaluation of function. Millions have gone to their grave with gallstones and never knew they had Stones. US is not enough. Murphys sign (or RUQ gas ball) not enough.
If your going to start whaking organs out, first get a diagnosis.

Anonymous said...

HudsonMD,

Just to pick apart your whining about the radiology report, some of which may be justified...

1. Thickened stomach lining could be just non-distended vs inflammation vs other. Clinical correlation.

Big deal. Ask the patient if they have upper abdominal pain. No pain, forget about this finding.

2. Scarring of lung bases, suggest CT chest.

Scarring, unless nodular, doesn't need to be followed up, especially if it is seen to be stable. Either you misread the report or it was a weak radiologist.

3. Adrenal nodule vs volume sparing from stomach. US recommended.

I don't know what this is about. If one can't tell the adrenal from the stomach on CT, an ultrasound sure isn't going to help.

4. Renal cyst. Recommend US.

Simple renal cysts don't need any further workup. More complex cysts do (higher Bosniak criteria) as they have upwards of a 25% chance of developing into a malignancy. Furthermore, you don't get a followup study right away, you wait 6 months or so. No radiologist recommends a followup scan for a simple renal cyst.

5. Thickening of sigmoid to suggest diverticulosis can't rule out diverticulitis.

Diverticulosis is diverticulosis--thickening isn't involved. If there is some wall thickening in a sigmoid with diverticulosis, it could represent early diverticulitis. Again, there's nothing to be done except maybe ask the patient if they have any LLQ pain. Even if there was pain to suggest early diverticulitis, would you have the medical savvy to handle this issue?


6. Thickened bladder wall possibly due to non-distended gall bladder. Clinical correllation.

A patient either has a thickened gallbladder wall or doesn't, whether it's distended or not. Either a poor report or misremembered.

7. Hepatic cyst vs other process. Recommend US.

Simple hepatic cysts never require further workup, and it's very east to determine if something is a simple cyst. Only if there's a question of it being solid will an ultrasound or MRI be warranted. And guess what, if you don't follow it up and it turns out to be a solid malignancy, it's your ass, not the radiologist's. Don't get the test if you can't handle the responsibility of finding out the results.

Anonymous said...

What would you recommend for a person who has a bilirubin total 2.5. Direct 0.4 and indirect 2.1. Has some nausea but also has a lot of stress and migraines. Both times bilirubin was tested they hadnt ate the night before and morning of the test. Hadn't been feeling well (migraines and nausea) and stress. Dr says possible Gilberts Disease. But if patients concerned can do a MRCP or a Hida scan. What would you recommend? Does the patient really have Gilberts? Could they just be stressed out and since not eating much its elevated? If a test is necessary, which one is advised? By the way, this is a family doctor.