Case Reports

CLINICAL SCIENCES



CASE REPORTS









Retained Gastric Antrum Syndrome Diagnosed by

[99@ Tc] Pertech netate Sd ntiphotog ra phy in



Man: Hormonal and Radiolsotopic

Study of Two Cases

G. Sciarretta, P. Malaguti, E. Turba, A. Finj, A. Verri, B. Garagnani, and C. Cacciari



Ospedale Maggiore Monoblocco, Bologna, Italy



Retained-antrum syndrome is a rare condition, occurring in Biliroth II

gastrectomised patients, in which an ulcer recurs associated with high levels

of circulating gastrin. Some gastrin tests are useful to differentiate a re

tamed antrum from a gastrinoma, but a firm diagnosis is sometimes very

difficult. We have studied two cases of retained-antrum syndrome both by

gastrin pertechnetate

tests and by [‘9―'Tc] scintiphotography. By this method

a prominent area of activity was observed on the anatomic site of the duo

denal stump bottom. It appeared after 20 or 30 mm and lasted for the 2 hr

of observation. After surgical resection, no area of activity was observed

at the scintiphotographic followup. No false positive was observed out of

the more than 30 subjects studied. Scintiphotography by pertechnetate

seems able to demonstrate the presence and the size of retained gastric

antrum in B II gastrectomised patients with recurrent ulcer.

1

J Nuel Med 19: 377—380, 978



The Zollinger-Ellison syndrome (gastrinoma) is gastrinemia in subjects suffering from gastrinoma; on

an important cause of ulcer recurrence in gastrec the other hand, the gastrinemia decreases in normal

tomised subjects. Retained-gastric-antrum syndrome subjects and in those with retained antrum (5,6).

is another rare condition, difficult to diagnose, in Bombesin, a tetradecapeptide isolated by Anastasi

which high levels of circulating gastrin are found. et al. (7), is able to stimulate the release of gastrin

Here an area of mucosa from the gastric antrum is from the “G― antral cells (8) so that, in gastrec

retained in the duodenal stump after the Biliroth II tomised subjects, a gastrinemic increase after bom

gastrectomy. Being no longer inhibited by gastric besin indicates the persistence of antral mucosa. The

acidity, its gastrin cells release much more gastrin administration of a protein meal releases antral gas

than is normally responsible for hyperclorhydria and trin (9) , but in a gastrectomised subject, the meal

recurrent stoma! ulcers. must be administered by means of a probe or a fibre

The differential diagnosis between retained antrum gastroduodenoscope for it to reach the antral mucosa

and gastrinoma has been based until now on certain retained in the duodenum. It has recently been shown

gastrin tests consisting of the serum gastrin assay that the administration of a protein meal in the duo

in response to certain pharmacologic stimuli such as

secretin, calcium and, recently, bombesin. In fact the

Received July 21, 1977; revision accepted Oct. 18, 1977.

i.v. infusion both of secretin (1 ,2) and calcium (3,4)

For reprints contact: 0. Sciarretta, Via Oslavia, 5-40 133

causes a further significant increase in basal hyper Bologna, Italy.



Volume 19, Number 4 377

SCIARRETTA, MALAGUTI, TURBA, FINI, VERRI, GARAGNANI, AND CACCIARI





denum releases duodenal gastrin (10) ; thus, in the

presence of retained antrum, the gastrinemic increase

should be greater than that found in healthy gas

trectomised subjects.

The recent introduction of mucosal gastrin radio

immunoassay, made on endoscopic biopsies (11),

should help in the diagnosis of retained antrum, but

endoscopic biopsies from the bottom of the duodenal

stump are not easily performed.

We therefore employed dynamic scintiphotography

a

with 99mTcO4—, radionuclide method that is nor

mally used in the search for ectopic gastric mucosa FIG. 1. Case 1: (A) Obviousarea of activityis presenton

in Meckel's diverticulum (12,13) and Barrett's left side of picture, due to retained antrum. (B) Normal scintigram

after surgery.

esophagus (14) , but has been successfully employed

in experiments on dogs with retained antrum (15).

We are reporting two clinical cases of retained Case 1. A 50-year-old man, gastrectomised by

gastric-antrum syndrome studied both by gastrin B II 6 mo previously for bleeding duodenal ulcer,

tests and pertechnetate scintiphotography. was operated on again, 1 mo later, for a large bleed

ing anastomotic ulcer. On this occasion it was not

METHODS

possible to carry out the hormonal study because of

Hormonal study. We performed four gastrin tests the serious condition of the patient. He was admitted

on our subjects, as follows. to our gastroenterology ward for melena with severe

1 . Secretin test. After drawing two blood samples anaemia. Roentgenographs and endoscopic examina

at a 15-mm interval for basal serum gastrin assay, tions brought to light a new anastomotic ulcer. The

75 CU. of G.I.H. secretin were given intravenously. basal gastrinemia, assayed a number of times on

Blood samples for gastrin RIA were taken at 2.5, 5, different days, reached the maximum level of 160

10, 20, and 30 mm after injection. pg/ml (our normal range for gastrectomised sub

2. Calcium test. After drawing the two blood sam jects is 60 ± 12 pg/rn!) ; the secretin and calcium

ples for basal gastrinemia, Ca2+ was given i.v. for tests were negative for gastrinoma, the gastrinemia

3 hr at a rate of 5 mg/kg-hr. Blood samples for gas decreasing by about 20 pg/mi. The bombesin and

tnnemia were taken at 30-mm intervals for 4 hr. the protein meal induced a gastrinemic increase of

3. Protein meal test. In B II gastrectomised sub about 40 pg/mi,. leading to suspicion of the presence

jects the oral administration of a liquid protein meal of antral mucosa.

(oxo-test) is useless; for this reason we infused 15 g The Tc-99m scintiphotography showed an intense

of meat extract, diluted in 50 ml of water, through area of activity in the anatomic site of the duodenal

the bioptic channel of the fibregastroduodenoscope stump from the 20th mm on (Fig. 1A). The patient

into the afferent loop. After drawing the two blood was operated on to remove the anastomotic ulcer

samples for basal gastrinemia, the serum gastrin con and the bottom of the duodenal stump, where a

centration was measured at 10, 20, 30, and 40 mm pouch of antral mucosa was found, confirmed by his

after the protein meal infusion. tologic examination. After the operation the basal

4. Bombesin test. The serum gastrin concentration gastrinernia dropped to 75 pg/rn! and the scintipho

was measured at 10, 20, 30, 40, and 60 mm from tographic check after 15 days proved normal (Fig.

the beginning of the i.v. infusion of bombesin at the 1B). The patient is now well, 8 mo after the op

rate of 10 ng/kg-min for 30 mm. eration.

Serum gastrin RIA was carried out by a C.E.A. Case 2. A 49-year-old man was gastrectornised

Sorin kit. for duodenal ulcer 9 mo previously. Three months

Radionudide study. A dynamic scintiphotographic after the operation epigastric pain and pyrosis be

study of the antral mucosa was performed using the gan; he was admitted to a surgical ward for melena

pertechnetate procedure of Jaros et al. (16). Per and severe anaemia. The emergency endoscopic cx

technetate was injected intravenously at the rate of amination showed a large anastomotic ulcer covered

0.10 mCi/kg; a gamma camera was used to take by a clot. After blood transfusions and medical ther

Polaroid pictures every 10 mm for a 2-hr period. apy, the bleeding stopped and gastrin tests to exclude

The radiation dose per mCi of pertechnetate was gastrinoma could be carried out. Basal gastrinemia

0.1 rad in the thyroid, 0.32 in the stomach, and 0.1 reached a maximum level of 120 pg/rn!; after secre

in the other regions of the body. tin and calcium tests a rapid gastrinemic decrease of



378 THE JOURNAL OF NUCLEAR MEDICINE

CLINICAL SCIENCES

CASE REPORTS





about 50 pg/mI was observed. Bombesin and the

--

protein meal induced a slight gastrinemic increase

of about 20 pg/ml.

The endoscopic examination was repeated and a

biopsy of the duodenal stump could be carried out:

histologic examination indicated a mucosa of antral

type.

Scintiphotography by pertechnetate (Fig. 2A) re

vealed, from the 30th mm on, the presence of an

intense area of activity to the right of the gastric

stump. The patient was operated on to remove the

anastomotic ulcer and the antral mucosa retained FIG. 2. Case2: (A)Weakerarea of activity,yet quitevisible,

due to retained antrum. (B) Negative scintiphotography after sur

at the duodenal bottom; histologic examination of gery.

the resected specimen confirmed the diagnosis. Basal

gastrinemia dropjed to 55 pg/rn!; the scintiphoto

graphic check proved normal (Fig. 2B). Now, 7 mo besin test, causing a slight gastrinemic increase, sug

after the operation, the patient is well. gested the persistence of a part of the antral mucosa.

We therefore suggest that scintiphotographic study

DISCUSSION with pertechnetate is able to demonstrate the pres

Dynamic scintiphotography with pertechnetate has ence and the size of retained gastric antrum in man.

provided a precise diagnosis of retained-antrum syn From Figs. 1 and 2 we can infer that even a very

drome, with consequent successful surgical therapy. small antral area should be seen by this method,

Ectopic images create problems of interpretation: because the intensity of activity in the antral mucosa

the presence of an area of activity situated in the right is much higher than in the background. Moreover,

upper quadrant of a subject gastrectomised by B II this radiotracer technique is easily performed and

may suggest, apart from retained antrum, an accu entails low radioactivity risk for the patient.

mulation at the duodenal bottom of the pertechne In conclusion, we emphasize the value of pertech

tate coming from the gastric stump—or perhaps netate scintiphotography in the diagnosis of retained

secreted by the duodenum, as occurs in rats (17). gastric antrum in B II gastrectomised patients with

More than 30 B II gastrectomised subjects were stud recurrent ulcer. Gastrin tests should be regarded as

ied in this way, many of whom had recurrent ulcer, extremely useful in excluding the coexistence of gas

but no false positive has yet been found. Further trinoma and, in the case of normal scintiphotography,

more, in the two cases described, ectopic activity was should suggest the possible presence of gastrinoma.

very intense and persisted throughout the course of

the examination, reaching its maximum intensity REFERENCES

towards the 60th mm. We believe that continuous

observation with gamma camera and the taking of JI, E,

1. ISENBERO WALSH JH, PASSARO et al: Unusual

effect of secretin on serum gastrin, serum calcium and gas

photos every 10 mm allow any false images from tric acid secretion in a patient with suspected Zollinger

accumulation or enteric secretion to be excluded. 1

Ellison syndrome. Gastroenterol 62: 626—63 , 1972

Another problem is the ascertainment of the cellu 2. KORMAN MG, S0vENY C, HANSKY J : Paradoxical ef

lar site of pertechnetate secretion in the stomach. fect of secretin on serum immunoreactive gastrin in the

Recent autoradiographic studies in animals (18) Zollinger-Ellison syndrome. Digestion 8: 407—416, 1973

WL, MCGUIGAN

3. TRUDEAU JE: Effects of calcium on

have shown that Tc-99m is concentrated predomi serum gastrin levels in the Zollinger-Ellison syndrome.

nantly by the mucus-secreting cells of the stomach, NEnglJMed28l: 862—866, 1969

and less by the parieta! and chief cells; for this reason J M

4. ISENBERGI, WALSHJH, GROSSMAN I: Zolilnger

the antral mucosa, lacking parietal cells, is able to Ellison syndrome. Gasiroenterol 65 : 140—165,1973

concentrate the Tc-99m and can be seen by this 5. KORMANMG, Scorr DF, HANSKYJ : Hypergastrinemia

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8. BASSO GIRl S, IMPROTA0, et al: External pancreatic

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I

3rd ANNUAL WESTERN REGIONAL MEETING

THE SOCIETY OF NUCLEAR MEDICINE



October 13-15, 1978 Vancouver Hotel Vancouver, B.C., Canada



ANNOUNCEMENT AND FIRST CALL FOR ABSTRACTS FOR SCIENTIFIC PROGRAM

The Scientific Program Committee welcomes the submission of abstracts of original con

tributions in nuclear medicine from members and nonmembers of the Society of Nuclear

Medicine for the 3rd Annual Western Regional Meeting. Physicians, scientists, and tech

nologists—membersand nonmembers—are invited to participate. The program will be

structured to permit the presentation of papers from all areas of interest in the specialty of

nuclear medicine.Abstractssubmitted by technologists areencouragedand will be presented

at the scientific program. Abstracts for the scientific program will be printed in the program

booklet and will be available to all registrants at the meeting.



Guidelines for Submitting Abstracts

The abstracts will be printed from camera-readycopy provided by the authors. Therefore,

only abstracts preparedon the official abstractsform will beconsidered.Theseabstractforms

will be available from the Western Regional Chapters SNM office (listed below). Abstract

forms will only be sent to the Pacific Northwest,Southern California, Northern California, and

Hawaii Chapters in a regular mailing. All other requests will be sent on an individual basis.

All participants will be required to register and pay the appropriate fee.

Pleasesend the original abstract form, supporting data, and six copies to:

Jean Lynch, Administrative Coordinator

3rd Western Regional Meeting

P.O. Box 40279

San Francisco, CA 94140

Deadline for abstract submission: Postmark midnight, July 7, 1978.

THE 3RD ANNUAL WESTERN REGIONAL MEETING WILL HAVE COMMERCIAL EX

HIBITS AND ALL INTERESTEDCOMPANIES ARE INVITED. Pleasecontact the Western

Regional SNM office (addressabove). Phone: (415) 647-1668or 647-0722.









380 THE JOURNAL OF NUCLEAR MEDICINE