IS Case 312: Chronic cholecystitis

Gunvir Gill, MD

Imaging Sciences URMC 2009
Publication Date: 2009-09-14


Patient is a 55-year-old male status post-bone marrow transplant, cutaneous graft-versus-host disease (GVHD), now with new onset of fevers as well as liver function test abnormalities.


Nonvisualization of gallbladder for one hour following administration of Technetium 99m Choletec, with visualization of the gallbladder following administration of morphine.


Intravenous morphine is frequently utilized to improve the diagnostic accuracy of hepatobiliary scanning. Morphine is known to cause sphincter of Oddi constriction which increases intraductal pressure by as much as 60%, and consequently increases radiotracer flow into the gallbladder.

If, as in the setting of chronic cholecystitis, the cystic duct is patent and there is enough residual radiotracer in the liver, the gallbladder usually fills within 5-10 minutes of morphine administration. Nonvisualization of the gallbladder 30 minutes after morphine administration indicates acute cholecystitis.

The cystic duct sign, which represents partial filling of the cystic duct proximal to the site of obstruction, is sometimes seen in acute cholecystitis. If this sign is seen morphine should not be used since nonphysiologic constriction at sphincter of Oddi can cause filling of the gallbladder leading to acute cholecystitis being misdiagnosed as chronic cholecystitis.


  1. Mettler FA, Guiberteau MJ. Essentials of Nuclear Medicine Imaging. 5th ed., Saunders, 2005.

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