Would a HIDA (Hepatobiliary Iminodiacetic Acid) scan be appropriate for evaluating a patient with adenomyomatosis of the gallbladder, right upper quadrant pain, and steatotic liver disease?

HIDA Scan for Adenomyomatosis with RUQ Pain and Liver Disease

A HIDA scan is appropriate for evaluating a patient with adenomyomatosis of the gallbladder and right upper quadrant pain when ultrasound findings are inconclusive or when gallbladder dysfunction is suspected despite normal laboratory tests. 1

Diagnostic Approach for RUQ Pain with Adenomyomatosis

First-Line Imaging

• Ultrasonography should be the initial imaging modality for evaluating right upper quadrant pain, offering 96% sensitivity for gallstones while also identifying gallbladder wall thickening and evaluating liver parenchyma 1
• Laboratory workup should include:
  • Liver function tests
  • Complete blood count
  • Pancreatic enzymes
  • Calcium and triglycerides 1

When to Consider HIDA Scan

• HIDA scan is indicated when:
  1. Laboratory tests are normal but gallbladder dysfunction is still suspected 1
  2. Symptoms persist despite normal ultrasound findings
  3. There is a need to assess gallbladder function in the setting of adenomyomatosis

Role of HIDA in Adenomyomatosis

HIDA scanning provides functional assessment of the gallbladder, which is particularly valuable in adenomyomatosis cases where structural changes may affect gallbladder function without causing obstruction. The scan can help determine if the adenomyomatosis is contributing to the patient's symptoms by assessing:

• Gallbladder filling
• Bile excretion
• Ejection fraction (EF) after cholecystokinin (CCK) stimulation

Important Considerations

Symptom Reproduction

• Research suggests that symptom reproduction during CCK administration in a HIDA scan may be more predictive of positive surgical outcomes than ejection fraction alone 2
• When patients experience recreation of their typical pain during CCK administration, this correlates better with chronic cholecystitis findings and symptom resolution after cholecystectomy 2

Limitations and Caveats

• HIDA scan results must be interpreted in clinical context
• A normal ejection fraction does not rule out biliary etiology of symptoms 2
• In patients with hepatocellular disease (like your patient with steatotic liver disease), HIDA scans may show poor uptake or secretion, potentially affecting interpretation 3
• The diagnostic value of HIDA in acalculous right upper quadrant pain can be limited, as symptoms may represent various processes including inflammation, dysmotility, or irritable bowel syndrome 4

Advanced Imaging Alternatives

• If biliary obstruction is suspected, MRCP may be more appropriate than HIDA 1
• CT abdomen/pelvis with contrast should be considered if complications or non-biliary pathology are suspected 1
• For patients over 40, CT or EUS should be considered to rule out underlying malignancy 1

In conclusion, for a patient with adenomyomatosis, RUQ pain, and steatotic liver disease, a HIDA scan is an appropriate next step if ultrasound and laboratory tests don't fully explain the symptoms, particularly to assess gallbladder function and determine if the adenomyomatosis is symptomatic.