From the Guidelines
Non-visualization of the gallbladder on a HIDA scan is a strong indicator of gallbladder dysfunction or disease, and surgical consultation for possible cholecystectomy is recommended. This finding suggests either cystic duct obstruction (often from gallstones), severe chronic cholecystitis, or acute cholecystitis 1. If symptoms like right upper quadrant pain, nausea, or vomiting are present, managing them with a low-fat diet, adequate hydration, and pain control with medications like acetaminophen or NSAIDs as tolerated is crucial 1. It is also important to avoid fatty foods, alcohol, and large meals which can trigger symptoms.
In acute cases with fever or severe pain, seeking immediate medical attention is necessary as this could indicate infection requiring antibiotics (such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours) 1. The non-visualization occurs because the radiotracer cannot enter the gallbladder due to blockage or poor gallbladder function, making this test valuable for diagnosing gallbladder conditions even when ultrasound results are normal.
Some key points to consider include:
- The usefulness of US is limited in critically ill patients where gallbladder abnormalities are common in the absence of acute cholecystitis 1.
- If complicated cholecystitis is suspected, US remains the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain 1.
- CT with IV contrast is preferable and usually appropriate when CT is obtained for subsequent imaging, especially if complications of acute cholecystitis or acute cholangitis are suspected 1.
- In non-pregnant adults with suspected acute cholecystitis, if both US and CT are equivocal/nondiagnostic and clinical suspicion persists, obtaining either an abdominal MRI/MRCP or HIDA scan as subsequent imaging to diagnose acute cholecystitis may be suggested 1.
From the Research
Non-Visualization of Gallbladder on HIDA Scan
- The non-visualization of the gallbladder on a HIDA scan can be due to various reasons, including acute cholecystitis, chronic cholecystitis, or technical issues with the scan 2, 3, 4.
- A study published in 1985 found that in patients with suspected acute cholecystitis, the HIDA scan was diagnostic in 19 out of 23 patients, but non-visualization of the biliary tree occurred in 4 patients due to abnormal liver function tests 2.
- Another study published in 2001 found that the sensitivity of HIDA scan in diagnosing acute cholecystitis was 86%, which was higher than that of ultrasonography (48%) 3.
- A study published in 2016 found that HIDA scan had a sensitivity and specificity of 87% and 79%, respectively, in diagnosing acute cholecystitis, which was superior to ultrasonography (26% sensitivity and 80% specificity) 4.
- In cases where the gallbladder is not visualized on a HIDA scan, but the bowel is not visualized either, additional imaging with CCK or delayed imaging may not be necessary if the clearance of liver parenchymal activity is prompt 5.
- A study published in 1979 found that non-visualization of the gallbladder by cholecystosonography had a positive predictive value of 88% for diseased gallbladders with obliteration of the lumen, and recommended oral cholecystography for further evaluation in such cases 6.
Possible Causes of Non-Visualization
- Acute cholecystitis
- Chronic cholecystitis
- Abnormal liver function tests
- Technical issues with the scan
- Obliteration of the gallbladder lumen
Diagnostic Approach
- HIDA scan is a sensitive and specific test for diagnosing acute cholecystitis 3, 4.
- Ultrasonography can be used to confirm the presence of gallbladder stones, but is not as sensitive as HIDA scan in diagnosing acute cholecystitis 3.
- Additional imaging with CCK or delayed imaging may be necessary in cases where the gallbladder is not visualized on a HIDA scan, but the bowel is not visualized either, and the clearance of liver parenchymal activity is not prompt 5.