3*BOTH THE LIVER AND SPLEEN ARE MOBILE AND SOFT. THEREFORE THEIR APPEARANCES AND POSITION ARE HIGHLY DEPENDENT ON THE SURROUNDING ORGANS AND THE POSITION OF THE DIAPHRAGM*

4*THE SHAPE OF THE LIVER WILL BE AFFECTED BY THE SURROUNDING STRUCTURES, AND SCAN INTERPRETATION WILL BE DEPENDENT ON CLINICAL EXAMINATION OF THE PATIENT*

5*THE LIVER/SPLEEN SCAN IS HIGHLY SUSCEPTIBLE TO ABSORPTION ARTIFACTS FROM OVERLYING TISSUE AND OTHER OBJECTS. AN ATTEMPT SHOULD ALWAYS BE MADE TO IDENTIFY 'LESIONS' IN MORE THAN ONE VIEW*

6*ROUTINE ELEVATION OF THE BREAST DURING ANTERIOR IMAGING IS AN ADVISABLE PRECAUTION. HOWEVER, GOLD RINGS ON THE PATIENT'S FINGER MAY CAUSE FURTHER ARTIFACTS*

7*ALTHOUGH EXCEPTIONS OCCUR, METASTASES TO THE LIVER FROM BREAST AND LUNG CANCER ARE SMALL, WHILE THOSE FROM GASTROINTESTINAL CARCINOMA ARE LARGE AND CLEAR-CUT*

8*IT IS IMPORTANT TO REMEMBER THAT THE FINDING OF A FOCAL LESION ON THE LIVER/SPLEEN SCAN IS NON-SPECIFIC. SIMPLE CYSTS APPEAR IDENTICAL TO METASTASES, AND IT COULD BE CLEARLY AFFECT PATIENT MANAGEMENT PROFOUNDLY IF METASTASES ARE ASSUMED*

9*IT MAY BE IMPOSSIBLE TO DIFFERENTIATE A RENAL MASS FROM AN INTRAHEPATIC MASS. WHEN A RIM OF FUNCTIONING TISSUE IS PRESENT, THIS WILL CONFIRM THE INTRAHEPATIC POSITION OF THE LESION. ULTRASOUND MUST BE USED TO DISTINGUISH A SOLID LESION FROM A CYST*

10*THE ABDOMEN MUST ALWAYS BE PALPATED FOR ADEQUATE LIVER SCAN REPORTING, WITH MARKERS BEING PLACED ON UPPER ABDOMINAL MASS*

11*OCCASIONALLY, DIFFUSE METASTATIC DEPOSITS FROM CARCINOMA OF THE BAREST WILL SHOW ONLY AS SLIGHT INHOMOGENEITIES ON THE SCAN, AND VERY RARELY THE ONLY SCAN EVIDENCE WILL BE HEPATOMEGALY WITH HOMOGENEOUS TRACER DISTRIBUTION*

12*ALTHOUGH ULTRASOUND AND CT DEMONSTRATE MASS LESIONS IN THE LIVER EXTREMELY WELL, THE RADIONUCLIDE LIVER/SPLEEN SCAN MAY BE THE BEST AND SIMPLEST METHOD TO FOLLOW THE PROGRESS OR RESOLUTION OF METASTASES. TO BE EFFECTIVE, HOWEVER, IT IS VITAL THAT THE MAGNIFICATION AND INTENSITY OF THE IMAGE, AND THE POSITION OF THE PATIENT, STAY CONSTANT*

13*REVIEW LIVER SCANS IN COMPARISON WITH PREVIOUS STUDIES TO AVOID ERRORS OF INTERPRETATION*

14*METASTATIC DEPOSITS IN THE SPLEEN ARE RARE. THE SPLENIC NOTCH AND POSITION OF THE SPLEEN AND ITS RELATION TO THE LEFT LOBE MAY SIMULATE METASTASES. IT IS ALWAYS ADVISABLE TO CONFIRM METASTASES WITH A DENATURED RED CELL SPLENIC SCAN*

15*THE PRESENCE OF SPACE-OCCUPYING LESIONS IN THE SPLEEN SHOULD ALWAYS RAISE THE POSSIBILITY OF LYMPHOMA RATHER THAN METASTATIC CARCINOMA*

16*INCREASED ACTIVITY IN THE SPLEEN AND BONE MARROW IS SEEN BECAUSE AS PROGRESSIVE IMPAIRMENT OF LIVER FUNCTION OCCURS THE HIGH EXTRACTION EFFICIENCY OF THE LIVER FOR COLLOID DIMINISHES, MORE COLLOID BECOMING AVAILABLE FOR UPTAKE BY THE REST OF THE RES*
*THE SPLEEN LIES POSTERIORLY AND SHOULD NOT NORMALLY APPEAR 'HOTTER' THAN THE LIVER ON THE ANTERIOR VIEW*

17*WHEN THE UPTAKE IS VERY POOR, IT MAY NOT BE POSSIBLE TO VISUALIZE THE LIVER SUFFICIENTLY WELL TO EXCLUDE A HEPATOMA*
*A SECOND ANTERIOR VIEW FOR A LONGER TIME AND WITH THE INTENSITY TURNED UP TO SATURATE THE SPLEEN AND THE BONE MARROW MAY HELP TO VISUALIZE THE LIVER*

18*ALTHOUGH INCREASED TRACER UPTAKE INTO BONE MARROW IN ASSOCIATION WITH IMPAIRED LIVER FUNCTION IS USUALLY ASSOCIATED WITH INCREASED UPTAKE IN THE SPLEEN, THIS IS NOT ALWAYS THE CASE. FOR EXAMPLE, IF THERE IS SPLENIC HYPOFUNCTION (eg COELIAC DISEASE) ASSOCIATED WITH THE LIVER DISEASE, THERE WILL BE INCREASED UPTAKE IN THE MARROW WITHOUT INCREASED UPTAKE IN THE SPLEEN. INCREASED UPTAKE IN THE MARROW ALONE MAY BE DUE EITHER TO MARROW HYPERACTIVITY, eg IN ASSOCIATION WITH ANAEMIA CAUSED BY BLOOD LOSS OR CHRONIC HEMOLYSIS, OR TO PRIMARY MARROW HYPERACTIVITY, AS SEEN IN POLYCYTHEMIA RUBRA VERA*

19*TRACER UPTAKE IS SEEN IN THE HYPERTROPHIED CAUDATE LOBE, SINCE THIS HAS A DIFFERENT VENOUS DRAINAGE WHICH MAY BE SPARED IN THE OBSTRUCTIVE PROCESS*
*A HEPATOMA REPLACING THE RIGHT LOBE OF THE LIVER SHOULD NOT BE MISDIAGNOSED AS BUDD-CHIARI SYNDROME*

20*CAREFULLY OBTAINED SUBTRACTION IMAGES OF COLLOID FROM Ga67 STUDY WILL INCREASE THE SENSITIVITY FOR DETECTION OF MISMATCHED LESIONS WHICH ARE INDICATIVE OF A HEPATOMA*

21*THE ABSOLUTE UPTAKE OF DENATURED RED CELLS AND THE RATE OF UPTAKE INTO THE SPLEEN CAN BOTH BE USED AS QUANTITATIVE MEASURES OF SPLENIC FUNCTION*

22*A RADIONUCLIDE COLLOID LIVER/SPLEEN SCAN IS THE SIMPLEST, MOST RAPID AND ACCURATE INVESTIGATION FOR SUSPECTED LIVER/SPLEEN TRAUMA. THIS STUDY CAN OFTEN BE PERFORMED IMMEDIATELY AFTER THE PATIENT HAS BEEN IN THE ACCIDENT DEPARTMENT*

23*WHEN THE LIVER AND SPLEEN ARE DIFFICULT TO SEPARATE ON THE COLLOID SCAN, A RADIOPHARMACEUTICAL WHICH LOCALIZES IN ONE ORGAN AND NOT THE OTHER CAN BE USED. THIS MAY BE A HEPATOBILIARY AGENT FOR THE LIVER, OR DENATURED RED CELLS FOR THE SPLEEN*

24*IF A BILE LEAK IS SUSPECTED, DELAYING IMAGING FOR UP TO 2 HOURS MAY BE NECESSARY TO DEMONSTRATE THE LEAK ADEQUATELY*

25*THE EARLY PARENCHYMAL PHASES OF THE HEPATOBILIARY SCAN ARE AS SENSITIVE AS COLLOID SCAN FOR DETECTION OF METASTASES, IF PERFORMED CAREFULLY. THE INFORMATION OBTAINED FROM THE PARENCHYMAL PHASE SHOULD ALWAYS BE USED, EVEN WHEN INVESTIGATING THE BILE DUCT DRAINAGE SYSTEM*

26*THE FOCAL DEFECTS FROM LONG-STANDING BILE DUCT OBSTRUCTION MAY SIMULATE MULTIPLE METASTASES*

27*BECAUSE Ga67 IS TAKEN UP INTO NORMAL HEPATIC TISSUE AS WELL AS INFLAMMATORY OR TUMOUR TISSUE, ABNORMALITIES MAY BE OBSCURED ON A Ga67 SCAN ONLY. HOWEVER, WHEN COMPARED WITH THE 99mTc LIVER COLLOID SCAN, THERE WILL BE A MISMATCH BETWEEN THE UPTAKE OF THE TWO ISOTOPES, AND THEREFORE A COLLOID LIVER SCAN IS AN ESSENTIAL PART OF EVERY Ga67 INVESTIGATION WHEN THE LIVER MAY BE ABNORMAL*

28*AS COLLOID NEVER REACHES EQUILIBRIUM IN THE BLOOD (BECAUSE EXTRACTION IS SO RAPID), DYNAMIC STUDIES WITH COLLOID MAY MISLEADING SUGGEST A RELATIVELY AVASCULAR LESION*

29*THE INCLUSION OF THE LIVER IN THE RADIOTHERAPY FIELD MAY CAUSE LIVER DAMAGE. THE KUPFFER CELLS, WHICH TAKE UP COLLOID PARTICLES, MAY BE PERMANENTLY FUNCTIONALLY IMPAIRED. THE CLUE ON THE SCAN TO POSSIBLE RADIATION DAMAGE IS ALMOST ALWAYS THE GEOMETRIC APPEARANCE OF THE DEFECT*