Hepatobiliary (HIDA) Scan Report

Exam: Hepatobiliary (HIDA) Scan [with morphine augmentation / with sincalide stimulation / with fatty meal / with SPECT/CT] (Include applicable modifiers only; omit bracketed options if none apply.)

Date/Time: [Study date and time]

Ordering Provider: [Ordering provider name]

Clinical Information

[Clinical indication] (Map to clinical intent: evaluate for acute cholecystitis, biliary dyskinesia/GBEF calculation, suspected bile leak, or biliary patency. If not provided, state exactly: "Indication: Not provided.")

[Pertinent surgical history, key labs, and relevant prior imaging summary] (Include only elements that are provided; omit this line entirely if none available.)

Comparison

[Prior relevant studies with date and modality] (Single line; if none, state: "None available.")

Technique

[Radiopharmaceutical name] [Activity] [Units] IV. NPO for [Hours] hours. Last opioid exposure: [Timing and agent / Unknown].

[Protocol-specific details] (Include only the applicable protocol below.)

• Acute cholecystitis protocol: Morphine [Dose] mg IV administered at [Time post-injection]. (If not given, state reason: [Contraindication / Unavailable / Patient declined].)
• GBEF protocol: [Sincalide / Fatty meal] stimulation. If sincalide: [Dose] mcg/kg infused over [REQUIRED: infusion duration] minutes. If fatty meal: [Meal description] at [Timing]. GBEF calculated from time-activity curve.
• Bile leak protocol: Delayed images obtained at [Times]. Positional maneuvers: [Performed / Not performed].

[SPECT/CT or other acquisition parameters] (Include only if affecting interpretation.)

Findings

• Hepatic uptake: [Prompt / Delayed]; clearance: [Normal / Delayed]. (Note if delayed uptake limits interpretation.)
• Biliary ducts: [Visualization pattern] at [Time] minutes; bowel activity at [Time] minutes.
• Gallbladder: [Visualized at [Time] minutes / Nonvisualization through [Time] minutes]. [Outcome of augmentation or delayed imaging, if performed].
• Bile leak evaluation: [No tracer activity outside expected biliary tract / Abnormal tracer accumulation at [Location] with [Behavior over time]]. (Include only for bile leak indication or if abnormal.)
• GBEF: [Value]% following [Stimulant] over [Infusion duration]. Reference threshold: [Value]% for this protocol. [Limitations to validity, if any]. (Include only for GBEF studies.)
• [Study limitations] (Include only if applicable: hepatocellular dysfunction, recent opioid exposure, motion, overlapping bowel activity.)

Impression

1. [Primary conclusion addressing clinical question] (Use indication-specific language: For acute cholecystitis: cite gallbladder visualization status and timepoint. For biliary patency: state CBD patency with time to bowel. For bile leak: state presence/absence and location. For GBEF: state value, stimulant method, and interpretation vs. reference threshold.)
2. [Secondary conclusion] (Include only if supported by Findings; no new information.)
3. [Recommendation] (Include only if actionable: further imaging if limited, clinical correlation if discordant.)

[Critical finding communication: Recipient and date/time] (Include only if urgent communication occurred.)