EuropeanJournalof
Nuclear Medicine
Case report
Use of pertechnetate 99mTcfor abdominal scanning in Iocalising an ileal duplication cyst: case report and review of the literature P a s c a l L e c o u f f e ~, C l a i r e S p y c k e r e l l e 2, H e r v e V e n e l 1, S a b i n e M e u r i o t 1, a n d X a v i e r M a r c h a n d i s e 1 1 Service Associ~ de Medecine Nucleaire, H6pital Huriez, Centre Hospitalier Universitaire, 2 avenue Oscar Lambret, F-59037 Lille Cedex, France 2 Service de P6diatrie A, H6pital Saint Antoine, Centre Hospitalier F6ron Vrau, F-59000 Lille, France Received 8 July and in revised form 24 August 1991
Abstract. A 1 0 - y e a r - o l d b o y p r e s e n t e d w i t h p e r i u m b i l i c a l p o s t p r a n d i a l p a i n a n d s o m e melena. P h y s i c a l e x a m i n a tion was n o r m a l . A l l i n v e s t i g a t i o n s were n e g a t i v e except a p e r t e c h n e t a t e 99mTc a b d o m i n a l scan which s h o w e d a very large a n d h o r n - s h a p e d focus o f high a c t i v i t y in the right flank. A n ileal d u p l i c a t i o n was resected. It was lined b y a n t r a l gastric m u c o s a w i t h a large ulcer. T h e p a t i e n t was t r e a t e d successfully. T h e a b d o m i n a l p e r t e c h n e t a t e scan is discussed. Key words: Ileal d u p l i c a t i o n - P e r t e c h n e t a t e
99mTc
Eur J Nuel Med (1992) 19:65-67
Introduction P e r t e c h n e t a t e 99mTc a b d o m i n a l s c i n t i g r a p h y is w i d e l y used in d e t e c t i n g e c t o p i c g a s t r i c m u c o s a ( C o n w a y 1980; S f a k i a n a k i s a n d C o n w a y 1981; S f a k i a n a k i s a n d H a a s e 1982; L a u r i n et al. 1990) w i t h a sensitivity o f 8 5 % a n d a specificity o f 9 5 % ( S f a k i a n a k i s a n d C o n w a y 1981; S f a k i a n a k i s a n d H a a s e 1982). U s u a l l y , e c t o p i c gastric m u c o s a is l o c a t e d in a M e c k e l ' s d i v e r t i c u l u m . N e v e r t h e less, it c a n be f o u n d in o t h e r a b n o r m a l i t i e s such as Barrett's o e s o p h a g u s (Sailer a n d J a n e w a y 1978) o r d u p l i c a tions o f t h e a l i m e n t a r y tract. N o n - s p e c i f i c a c c u m u l a t i o n in o t h e r lesions c a n also be d i a g n o s t i c in p a e d i a t r i c p a tients w i t h g a s t r o i n t e s t i n a l b l e e d i n g ( H o a n d K o n i e c z n y 1975; G o r d o n 1980). H e r e we r e p o r t the case o f a n unu s u a l p o s i t i v e p e r t e c h n e t a t e 99'~Tc scan w h i c h suggested the p r o p e r d i a g n o s i s a n d led to successful surgery.
Offprint requests to: X. Marchandise
Case report A 10-year-old boy was referred to Saint Antoine Hospital in Lille (France) because of abdominal pain. He was born in India and adopted by a French family. He had been living on the Ivory Coast for 5 years. Two months before admission he had a fever with enanthema. Two days later he began to have periumbilical postprandial pains which became daily. He was at first referred to Abidjan Hospital. On admission, physical examination was normal. All investigations (abdominal ultrasonography, upper gastrointestinal series, barium enema, oesophagogastric endoscopy, stool culture) did not show any abnormality. Antiparasitic trial treatment was without any effect. He was discharged, and psychosomatic disorders were suspected. When his parents came back to Europe, he was still suffering, and the constrictive pains were more acute and localized around the umbilicus and in the right iliac fossa. They always began 30-45 min after meals and lasted for i or 2 h. They were not alleviated by food intake. Vomiting or diarrhoea usually occurred just after the pains. Sometimes he passed melena stools. On admission physical examination was again normal except for weight loss. Biological parameters were within normal values. A gastrointestinal parasitosis was excluded by normal parasitical examinations and serodiagnosis. Stool cultures and bacterial serodiagnosis results were also negative. Oesophagogastric endoscopy and abdominal ultrasonography were normal. Cerebral and abdominal CT scan did not demonstrate any abnormality. Other less frequent diagnoses were eliminated: lead poisoning, porphyrism, phaeochromocytoma. To exclude Meckel's diverticulum, a technetium scan was carried Out. Dynamic gammacamera imaging was obtained over 20 min after intravenous injection of pertechnetate Tc 99m (1.85 MBq/kg).'No abnormal vascular activity was observed. Then a marked increase in activity was observed in the right flank. This focus of high activity was very large and horn-shaped with a small photopenic image (Fig. 1). The increase of activity during acquisition was exactly similar to that of the gastric area (Fig. 2). The diagnosis was heterotopic gastric mucosa, and because of the extension of the hyperactivity, a small bowel duplication was suggested. Two days later an exploratory laparotomy was performed, and a 20-cm ileal duplication was found 50 cm from the caecum. The duplication was tubular and communicated with the ileum. It formed a blind loop which was lined by antral gastric mucosa. There was a very large and haemorragic ulcer at the end of the blind loop. The duplication was easily
© Springer-Verlag 1992
66
dkl
Fig. 1. Sequential 5-min images obtained after injection of pertechnetate 99mTcshowing gastric uptake and abnormal uptake in right flank counts/s 36-
10 20 min Fig. 2. Time-activity curves in gastric area and in lesion
resected with 13 cm of ileum. The patient was treated successfully and became asymptomatic.
Discussion Ileum is the most common location for duplications of the alimentary tract (Bower et al. 1978). Duplications may be cystic or tubular, non-communicating or more rarely communicating. The triad of intestinal obstruction, a palpable mass and gastrointestinal hemorrhage is highly suggestive of this diagnosis (Scully et al. 1980). Our patient had some symptoms of intermittent intestinal obstruction and later blood loss.
This case report is noteworthy because of several points. First, this patient was 10 years old, whereas in 85%-90% of patients symptoms appear in the first 2 years of life (Scully et al. 1980). Moreover, two-thirds of the patients are diagnosed prior to 1 year of age. However, a significant number of patients may not become symptomatic until adult life (Bower et al. 1978). The diagnosis of intestinal duplication was only suggested by technetium scan, while other investigations did not give any information. Diagnosis of duplication may be made by barium study when the communication is wide enough to permit entry of barium into the duplicated segment (Ohba et al. 1981 ; Gilchrist et al. 1990). In this case, the pertechnetate scan was unusual. The hyperactivity was too large to be related to a Meckel's diverticulum. Urinary non-specific accumulation of pertechnetate was easily eliminated. Other non-specific accumulations were only briefly considered (Sfakianakis and Conway 1981; Sfakianakis and Haase 1982): there was no argument for intussusception or for obstructed loops of bowel, and there was no vascular activity as would be observed in arteriovenous malformation (Heyman and McCarthy 1990). An inflammatory lesion could not be absolutely eliminated, and intestinal cancer could also give false-positive results (Mehall et al. 1991), but ectopic gastric mucosa in intestinal abnormality such as duplication was suggested because of strictly similar time-activity curves in the lesion and in the gastric area. An interesting use of the pertechnetate scan in intestinal duplications has been reported in cystic (Schwesinger et al. 1975; Wilson et al. 1977; Winter 1977; Scully et al. 1980) as well as in tubular (Ohba et al. 1981) duplications. Multiple duplications have been discovered by pertechnetate scan (Gilchrist et al. 1990). A photopenic cystic duplication has been observed during a technetium scan (Vazquez et al. 1989). Of course, a pertechnetate scan is positive when duplications contain ectopic gastric mucosa. The frequency of gastric mucosa in duplications is variable among authors, 20%-50% (Bower etal. 1978; Scully etal. 1980; Ohba etal. 1981). In our patient, the whole duplication was lined by gastric mucosa, which gave a highly positive pertechnetate scan. Moreover, ileal duplication which contains gastric mucosa is frequently associated with peptic ulceration and haemorrhage (Bower et al. 1978; Scully et al. 1980). In this case, there was a large ulcer with blood loss. The small photopenic image observed on scan could be related to luminal clot. These complications were responsible for the clinical symptoms. It should be stressed once more that the pertechnetate scan is a non-invasive procedure which may be easily performed, especially in young patients with unusual abdominal symptoms or gastrointestinal bleeding prior to radiographic contrast studies (Ho and Konieczny 1975).
67
References Bower RJ, Sieber WK, Kiesewetter WB (1978) Alimentary tract duplications in children. Ann Surg 188 : 669-674 Conway JJ (1980) Radionuclide diagnosis of Meckel's diverticulum. Gastrointest Radiol 5 : 209-213 Gilchrist AM, Sloan JM, Logan CJ, Mills JO (1990) Case report: gastrointestinal bleeding due to multiple ileal duplications diagnosed by scintigraphy and barium studies. Clin Radiol 41 : 134136 Gordon I (1980) Gastro-intestinal haemorrhage unrelated to gastric mucosa diagnosed on 99Tom pertechnetate scans. Br J Radiol 53 : 322-324 Heyman S, McCarthy K (1990) Arteriovenous malformation of the small bowel demonstrated during the flow phase of a Meckel's scan. Clin Nucl Med 15 : 119-121 Ho JE, Konieczny KM (1975) The sodium pertechnetate Tc 99m scan: an aid in the evaluation of gastrointestinal bleeding. Pediatrics 56 : 34-40 Laurin NR, Powe JE, Driedger AA (1990) Meckel's diverticulum in a 41-year-old patient: detection with pertechnetate scintigraphy. Clin Nucl Med 15:195-196 Mehall CJ, Klein RM, Muz J, Davis LP (1991) Intestinal neoplasm mimicking a Meckel's diverticulum on scintigraphic imaging. Clin Nucl Med 16:233-236 Ohba S, Fukuda A, Kohno S, Takeuchi S (1981) Ileal duplication and multiple intraluminal diverticula: scintigraphy and barium meal. Am J Roentgenol 136 :992-994
Sailer JF, Janeway CM (1978) Pertechnetate demonstration of a Barrett's esophagus involving the length of the esophagus. J Nucl Med 19 : 1366-1367 Schwesinger WH, Croom RD, Habibian MR (1975) Diagnosis of an enteric duplication with pertechnetate 99mTc scanning. Ann Surg 181:428-430 Scully RE, Galdabini JJ, McNeely BU (1980) Case records of the Massachusetts General Hospital. N Engl J Med 302:958-962 Sfakianakis GN, Conway JJ (1981) Detection of ectopic gastric mucosa in Meckel's diverticulum and in other aberrations by scintigraphy: II. Indications and methods - a 10-year experience. J Nucl Med 22:732-738 Sfakianakis GN, Haase GM (1982) Abdominal scintigraphy for ectopic gastric mucosa: a retrospective analysis of 143 studies. Am J Roentgenol 138 : 7-12 Vazquez R, Oates E, Sarno RC, Statz E (1989) Incidental discovery of a large duplication cyst during Meckel's scintigraphy. Clin Nucl Med 14:537-537 Wilson JP, Wenzel WW, Campbell JB (1977) Technetium scans in the detection of gastrointestinal hemorrhage. Preoperative diagnosis of enteric duplication in an infant. JAMA 237 : 265266 Winter PF (1977) Sodium pertechnetate Tc 99m scanning of the abdomen: diagnosis of an ileal duplication cyst. JAMA 237:1352-1353
Nuclear Medicine
Case report
Use of pertechnetate 99mTcfor abdominal scanning in Iocalising an ileal duplication cyst: case report and review of the literature P a s c a l L e c o u f f e ~, C l a i r e S p y c k e r e l l e 2, H e r v e V e n e l 1, S a b i n e M e u r i o t 1, a n d X a v i e r M a r c h a n d i s e 1 1 Service Associ~ de Medecine Nucleaire, H6pital Huriez, Centre Hospitalier Universitaire, 2 avenue Oscar Lambret, F-59037 Lille Cedex, France 2 Service de P6diatrie A, H6pital Saint Antoine, Centre Hospitalier F6ron Vrau, F-59000 Lille, France Received 8 July and in revised form 24 August 1991
Abstract. A 1 0 - y e a r - o l d b o y p r e s e n t e d w i t h p e r i u m b i l i c a l p o s t p r a n d i a l p a i n a n d s o m e melena. P h y s i c a l e x a m i n a tion was n o r m a l . A l l i n v e s t i g a t i o n s were n e g a t i v e except a p e r t e c h n e t a t e 99mTc a b d o m i n a l scan which s h o w e d a very large a n d h o r n - s h a p e d focus o f high a c t i v i t y in the right flank. A n ileal d u p l i c a t i o n was resected. It was lined b y a n t r a l gastric m u c o s a w i t h a large ulcer. T h e p a t i e n t was t r e a t e d successfully. T h e a b d o m i n a l p e r t e c h n e t a t e scan is discussed. Key words: Ileal d u p l i c a t i o n - P e r t e c h n e t a t e
99mTc
Eur J Nuel Med (1992) 19:65-67
Introduction P e r t e c h n e t a t e 99mTc a b d o m i n a l s c i n t i g r a p h y is w i d e l y used in d e t e c t i n g e c t o p i c g a s t r i c m u c o s a ( C o n w a y 1980; S f a k i a n a k i s a n d C o n w a y 1981; S f a k i a n a k i s a n d H a a s e 1982; L a u r i n et al. 1990) w i t h a sensitivity o f 8 5 % a n d a specificity o f 9 5 % ( S f a k i a n a k i s a n d C o n w a y 1981; S f a k i a n a k i s a n d H a a s e 1982). U s u a l l y , e c t o p i c gastric m u c o s a is l o c a t e d in a M e c k e l ' s d i v e r t i c u l u m . N e v e r t h e less, it c a n be f o u n d in o t h e r a b n o r m a l i t i e s such as Barrett's o e s o p h a g u s (Sailer a n d J a n e w a y 1978) o r d u p l i c a tions o f t h e a l i m e n t a r y tract. N o n - s p e c i f i c a c c u m u l a t i o n in o t h e r lesions c a n also be d i a g n o s t i c in p a e d i a t r i c p a tients w i t h g a s t r o i n t e s t i n a l b l e e d i n g ( H o a n d K o n i e c z n y 1975; G o r d o n 1980). H e r e we r e p o r t the case o f a n unu s u a l p o s i t i v e p e r t e c h n e t a t e 99'~Tc scan w h i c h suggested the p r o p e r d i a g n o s i s a n d led to successful surgery.
Offprint requests to: X. Marchandise
Case report A 10-year-old boy was referred to Saint Antoine Hospital in Lille (France) because of abdominal pain. He was born in India and adopted by a French family. He had been living on the Ivory Coast for 5 years. Two months before admission he had a fever with enanthema. Two days later he began to have periumbilical postprandial pains which became daily. He was at first referred to Abidjan Hospital. On admission, physical examination was normal. All investigations (abdominal ultrasonography, upper gastrointestinal series, barium enema, oesophagogastric endoscopy, stool culture) did not show any abnormality. Antiparasitic trial treatment was without any effect. He was discharged, and psychosomatic disorders were suspected. When his parents came back to Europe, he was still suffering, and the constrictive pains were more acute and localized around the umbilicus and in the right iliac fossa. They always began 30-45 min after meals and lasted for i or 2 h. They were not alleviated by food intake. Vomiting or diarrhoea usually occurred just after the pains. Sometimes he passed melena stools. On admission physical examination was again normal except for weight loss. Biological parameters were within normal values. A gastrointestinal parasitosis was excluded by normal parasitical examinations and serodiagnosis. Stool cultures and bacterial serodiagnosis results were also negative. Oesophagogastric endoscopy and abdominal ultrasonography were normal. Cerebral and abdominal CT scan did not demonstrate any abnormality. Other less frequent diagnoses were eliminated: lead poisoning, porphyrism, phaeochromocytoma. To exclude Meckel's diverticulum, a technetium scan was carried Out. Dynamic gammacamera imaging was obtained over 20 min after intravenous injection of pertechnetate Tc 99m (1.85 MBq/kg).'No abnormal vascular activity was observed. Then a marked increase in activity was observed in the right flank. This focus of high activity was very large and horn-shaped with a small photopenic image (Fig. 1). The increase of activity during acquisition was exactly similar to that of the gastric area (Fig. 2). The diagnosis was heterotopic gastric mucosa, and because of the extension of the hyperactivity, a small bowel duplication was suggested. Two days later an exploratory laparotomy was performed, and a 20-cm ileal duplication was found 50 cm from the caecum. The duplication was tubular and communicated with the ileum. It formed a blind loop which was lined by antral gastric mucosa. There was a very large and haemorragic ulcer at the end of the blind loop. The duplication was easily
© Springer-Verlag 1992
66
dkl
Fig. 1. Sequential 5-min images obtained after injection of pertechnetate 99mTcshowing gastric uptake and abnormal uptake in right flank counts/s 36-
10 20 min Fig. 2. Time-activity curves in gastric area and in lesion
resected with 13 cm of ileum. The patient was treated successfully and became asymptomatic.
Discussion Ileum is the most common location for duplications of the alimentary tract (Bower et al. 1978). Duplications may be cystic or tubular, non-communicating or more rarely communicating. The triad of intestinal obstruction, a palpable mass and gastrointestinal hemorrhage is highly suggestive of this diagnosis (Scully et al. 1980). Our patient had some symptoms of intermittent intestinal obstruction and later blood loss.
This case report is noteworthy because of several points. First, this patient was 10 years old, whereas in 85%-90% of patients symptoms appear in the first 2 years of life (Scully et al. 1980). Moreover, two-thirds of the patients are diagnosed prior to 1 year of age. However, a significant number of patients may not become symptomatic until adult life (Bower et al. 1978). The diagnosis of intestinal duplication was only suggested by technetium scan, while other investigations did not give any information. Diagnosis of duplication may be made by barium study when the communication is wide enough to permit entry of barium into the duplicated segment (Ohba et al. 1981 ; Gilchrist et al. 1990). In this case, the pertechnetate scan was unusual. The hyperactivity was too large to be related to a Meckel's diverticulum. Urinary non-specific accumulation of pertechnetate was easily eliminated. Other non-specific accumulations were only briefly considered (Sfakianakis and Conway 1981; Sfakianakis and Haase 1982): there was no argument for intussusception or for obstructed loops of bowel, and there was no vascular activity as would be observed in arteriovenous malformation (Heyman and McCarthy 1990). An inflammatory lesion could not be absolutely eliminated, and intestinal cancer could also give false-positive results (Mehall et al. 1991), but ectopic gastric mucosa in intestinal abnormality such as duplication was suggested because of strictly similar time-activity curves in the lesion and in the gastric area. An interesting use of the pertechnetate scan in intestinal duplications has been reported in cystic (Schwesinger et al. 1975; Wilson et al. 1977; Winter 1977; Scully et al. 1980) as well as in tubular (Ohba et al. 1981) duplications. Multiple duplications have been discovered by pertechnetate scan (Gilchrist et al. 1990). A photopenic cystic duplication has been observed during a technetium scan (Vazquez et al. 1989). Of course, a pertechnetate scan is positive when duplications contain ectopic gastric mucosa. The frequency of gastric mucosa in duplications is variable among authors, 20%-50% (Bower etal. 1978; Scully etal. 1980; Ohba etal. 1981). In our patient, the whole duplication was lined by gastric mucosa, which gave a highly positive pertechnetate scan. Moreover, ileal duplication which contains gastric mucosa is frequently associated with peptic ulceration and haemorrhage (Bower et al. 1978; Scully et al. 1980). In this case, there was a large ulcer with blood loss. The small photopenic image observed on scan could be related to luminal clot. These complications were responsible for the clinical symptoms. It should be stressed once more that the pertechnetate scan is a non-invasive procedure which may be easily performed, especially in young patients with unusual abdominal symptoms or gastrointestinal bleeding prior to radiographic contrast studies (Ho and Konieczny 1975).
67
References Bower RJ, Sieber WK, Kiesewetter WB (1978) Alimentary tract duplications in children. Ann Surg 188 : 669-674 Conway JJ (1980) Radionuclide diagnosis of Meckel's diverticulum. Gastrointest Radiol 5 : 209-213 Gilchrist AM, Sloan JM, Logan CJ, Mills JO (1990) Case report: gastrointestinal bleeding due to multiple ileal duplications diagnosed by scintigraphy and barium studies. Clin Radiol 41 : 134136 Gordon I (1980) Gastro-intestinal haemorrhage unrelated to gastric mucosa diagnosed on 99Tom pertechnetate scans. Br J Radiol 53 : 322-324 Heyman S, McCarthy K (1990) Arteriovenous malformation of the small bowel demonstrated during the flow phase of a Meckel's scan. Clin Nucl Med 15 : 119-121 Ho JE, Konieczny KM (1975) The sodium pertechnetate Tc 99m scan: an aid in the evaluation of gastrointestinal bleeding. Pediatrics 56 : 34-40 Laurin NR, Powe JE, Driedger AA (1990) Meckel's diverticulum in a 41-year-old patient: detection with pertechnetate scintigraphy. Clin Nucl Med 15:195-196 Mehall CJ, Klein RM, Muz J, Davis LP (1991) Intestinal neoplasm mimicking a Meckel's diverticulum on scintigraphic imaging. Clin Nucl Med 16:233-236 Ohba S, Fukuda A, Kohno S, Takeuchi S (1981) Ileal duplication and multiple intraluminal diverticula: scintigraphy and barium meal. Am J Roentgenol 136 :992-994
Sailer JF, Janeway CM (1978) Pertechnetate demonstration of a Barrett's esophagus involving the length of the esophagus. J Nucl Med 19 : 1366-1367 Schwesinger WH, Croom RD, Habibian MR (1975) Diagnosis of an enteric duplication with pertechnetate 99mTc scanning. Ann Surg 181:428-430 Scully RE, Galdabini JJ, McNeely BU (1980) Case records of the Massachusetts General Hospital. N Engl J Med 302:958-962 Sfakianakis GN, Conway JJ (1981) Detection of ectopic gastric mucosa in Meckel's diverticulum and in other aberrations by scintigraphy: II. Indications and methods - a 10-year experience. J Nucl Med 22:732-738 Sfakianakis GN, Haase GM (1982) Abdominal scintigraphy for ectopic gastric mucosa: a retrospective analysis of 143 studies. Am J Roentgenol 138 : 7-12 Vazquez R, Oates E, Sarno RC, Statz E (1989) Incidental discovery of a large duplication cyst during Meckel's scintigraphy. Clin Nucl Med 14:537-537 Wilson JP, Wenzel WW, Campbell JB (1977) Technetium scans in the detection of gastrointestinal hemorrhage. Preoperative diagnosis of enteric duplication in an infant. JAMA 237 : 265266 Winter PF (1977) Sodium pertechnetate Tc 99m scanning of the abdomen: diagnosis of an ileal duplication cyst. JAMA 237:1352-1353
