Intraoperative Scintigraphic Localization ofa Gastrointestinal by klutzfu43

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									                                                                                                              CLINICAL     SCIENCES
                                                                                                                       CASE REPORTS


38. BRONSTEIN BR, STEELE GD, JR, ENSMINGER W, et al:                               GD,         JL,
                                                                      40. BRAUNSTEIN VAITUKAITIS CARBONEPP, et al:
    The use and limitationsof serialplasmacarcinoembryonic                Ectopicproductionof human chorionicgonadotrophinby
    antigen (CEA) levelsas a monitorofchanging metastatic liver           neoplasms. Ann mt Med 78:39-45, 1973
    tumor volume in patients receiving chemotherapy. Cancer           41. Wu S-Y, GREEN WL: Triiodothyronine (T3)-binding im
               1980
    46:266—272,                                                         munoglobulins in a euthyroid woman: effects on measurement
39. KLEEGG, Go VLW: Serum tumor markers. Mayo Clin                        of T3 (RIA) and on T3 turnover. J C/in Endocrinol Metab
    Proc57:129—132,
                  1982                                                              1976
                                                                          42:642—652,




                  ScintigraphicLocalization a Gastrointestinal
     Intraoperative                        of                BleedingSite
                               J           K        S.      A             a
                     Christopher . Palestro, odendera DuLeep, lanH.Rlchman, ndCarlJ. Collica

                                              Norwalk Hospital, Norwalk, Connecticut

                  We presenta case reportof lntraoperatlve    scintigraphiclocalizationof an active
                gastrointestinal bleeding site in a 65-yr-old female who had repeatedly negative
                endoscopy and angiography.

                                          1
                J Nuci Med 25: 1209—1211, 984

  Gastrointestinal bleeding, even when clinically massive,gen         doscopieswere performed, extending from the ligament of Treitz
                                                procedures, to the ileocecalvalve,but no bleedingsite was found. The patient
erallyoccursintermittently(1); inorderforinvasive
such as endoscopy and angiography to be successful, the patient       was stable for approximately 48 hr following surgery but then
must be actively bleeding at the time of the study. Recently,         began passing tarry stools; her hemoglobin dropped from 10 to 8
scintigraphy ofgastrointestinal bleeding with Tc-99m sulfur colloid   g. The tagged-RBC study was repeated and was virtuallyidentical
or Tc-99m-tagged red cells has proven to be an accurate and ef        to the initial study, again demonstrating active intermittent
fectivemethodfor the detectionand localizationofupper and lower       bleeding in the left upper quadrant, presumably in mid jejunum.
gastrointestinal bleeding (2,3). We present a case report of in       Repeat arteriogramsand upperendoscopyto the ligamentof Treitz
traoperative scintigraphic location of an active GI bleeding site.    were negative.
                                                                         At a second operation, an attempt was made scintigraphically
                                                                      to locate the bleeding site more precisely with an uncollimated
                         CASE REPORT

  A 65-yr-old female, with a 3-wk history of melena and a he
moglobin of 4.5 g, received seven units of packed red blood cells
and one unit of fresh-frozenplasma;however,her hemoglobinand
hematocrit continued to drop slowly and her stools remained
heme-positive. A barium enema and upper GI series were unre
markable. Endoscopy demonstrated a duodenal ulcer but no dis
crete bleeding site. A tagged-red-cell study was performed (4) but
no evidence of active bleeding was noted on the first day of the
study. On the following day the study was repeated, and a focus
of radioactivity was observed in the left upper quadrant of the
abdomen (Fig. 1). Sequential imaging over the next 4 hr showed
       o                  i
movement f the radionuclidentothe rightlowerquadrant(Fig.
2), indicating that the bleeding originated in the small bowel and
not in the colon. Celiac, superior mesenteric, and inferior mesen
teric arteriography werefoundnormal.An exploratorylaparotomy
was not revealing. Multiple enterotomies and intraoperative en
                                                                      FIG. 1. AnterIorimageof abdomenshowingabnormalradlonuclide
                                                                      accumulation in left upper quadrant. Noteanteriorlydisplaced left
  ReceivedMar. 16, 1984;revisionacceptedJune 1, 1984.                 kkkiey(arrow)medial to bleeding site. LPOimage confirmed location
   For reprintscontact: ChristopherJ. Palestro, MD, Section of Nu.                w                bylage phOtOn-defiCient
                                                                      ofleftkidney, hichwasdisplaced                  region
clear Medicine, Norwalk Hospital, Norwalk, CT 06856.                  confirmed on angiography to be cyst.


Volume 25, Number 11                                                                                                             1209
PALESTRO, DULEEP, RICHMAN, AND COLLICA


                                                                     gamma camera. The most intense tracer concentrationwas found
                                                                     in the proximal 50 cm ofsmall bowel, with a discrete focus of ra
                                                                     dioactivity approximately 10 cm distal to the ligament of Treitz
                     4                                                                             r
                                                                     (Fig.3)andonlyminimalactivityemained   neartheileocecalvalve
                                                                     (Fig.4). The first 50cmof smallboweldistalto the ligamentof
                                                                     Treitzwasresected.Examination   revealedextcnsivC bloodclots
                                                                                          h          f           mmindiameter,
                                                                     andthreesubmucosal emorrhagicoci,each“-‘1
                                                                                                                             T
                                                                     fourcm proximalto the mostintensefocusof radioactivity. he
                                                                     microulcerationswere felt by the pathologistto be the cause of the
                                                                     patient's GI bleeding, although their cause could not be ascer
                                                                     tamed. The patient had an uneventful recovery, was discharged
                                                                     approximately 1 wk later, and has remained stable over the past
                                                                     4 mo.
                                        4
                                                                                               DISCUSSION
FIG.2. Anteriorimage of abdomen performed 4 hr after image in                                                          t
                                                                       Thesearchfora bleedingsitein the gastrointestinalract can
Fig. 1. Note small-bowel radloactivfty in right lower quadrant.                                   can
                                                                     be an arduoustask.Angiography identifyareasof gastroin
                                                                     testinal bleeding only when hemorrhage is actively occurring at
Geiger-Mullerprobe,but no discrete focusofsignificantlyelevated      greater than 1 ml per minute (5-7). Tc-99m RBC imaging offers
radioactivity could be discerned. During surgery as much of the      a prolonged opportunity (up to 24 hr) to monitor patients with
small bowel as possible was imaged sequentially with a portable      gastrointestinalbleeding,and bleedingsitesofas little as 5 ml have




FIG. 3. Sequential intraoperative images of small bowel, each 90 sac: arrows indicate most intense focus of radioactivfty. Left, first
25 cm of small bowel; center, 25—75cm; right, 75—150 cm.




                                                                                            FIG.4. Sequential 90-sec intraoperative
                                                                                            images of small bowel. Activity continued
                                                                                            to decrease diètallytop left, 150-250 cm;
                                                                                            top rI@t, 250-350 cm; bottom, 350 cm to
                                                                                            lleocecal valve.


1210                                                                             THE    JOURNAL       OF   NUCLEAR       MEDICINE
                                                                                                                CLINICAL      SCIENCES
                                                                                                                          CASE REPORTS


beendetectedbythismethod(8). Unfortunately    thescintigraphic travasation. In fact, much of what we imaged was undoubtedly
studysuffersfrompooranatomicresolutionand an inabilityto clotted blood within the bowel lumen. As scintigraphically dem
locate a bleedingsite precisely,especiallyin the small bowel; onstrated, owever,
                                                                         h                    ofactivitydecreased
                                                                                   theintensity                 dramatically
however, as this case demonstrates, the more anatomically detailed   beyond the first 50 cm of jejunum, so we considered that the
but !csssensitivestudies such as endoscopyand angiography may        bleeding site was probably within the proximal segment. We be
be negative.                                                         lieve that intraoperative scintigraphic search for a gastrointestinal
                        to
   Facedwithan inability locatethebleedingsiteinthispatient, bleeding site may provide a valuable guide to surgical manage
             h                  r
theclinicians adtwoalternatives,esectionoftheentirejejunum ment.
or, resectionof segmentsof the jejunum in multipleoperative
procedures until the bleeding site was removed. Since neither al                                REFERENCES
ternative wasdesirable, weattempted a radiotracer intraoperative
         A
procedure. surveymeterwasusedfirstinan effortto locatethe            I . Sos TA, LEE JG, WIxS0N D, et al: Intermittent bleeding
bleeding site; however, the very sensitive directional response,        from minute to minute in acute massive gastrointestinal hem
relatively low efficiency for the 140-keV photon of technetium,         orrhage: Arteriographic demonstration. Am J Roentgenol
                          the
and the radiationexceeding maximumcountrate capability                  131:1015—1017,1978
                 i                    the          o
ofthe instrument nseveralareasprevented localization fthe            2. ALAVI A: Scintigraphic demonstration of acute gastrointes
most intense focus ofactivity, presumably the bleeding site, with       tinal bleeding. Gastrointest Radiol 5:205-208, 1980
certainty. In addition, radiation from internal blood vesselsand     3. WINZELBERG GG, MCKUSICK KA, STRAUSS HW, et al:
organs contributed to the total count rate and consequently the         Evaluation of gastrointestinal bleeding by red blood cells la
survey meter's maximal response may not have been at the actual         beledin vivowith technetium-99m.J Nucl Med 20:1080-1086,
bleeding site.                                                          1979
  A small collimated scintillation probe would be an improvement     4. MCKUSICK KA, FROELICH JW, CALLAHAN RJ, Ct al:
over the uncollimatcd instrument that we used. Its responses would      Tc-99m red bloodcells for detection ofgastrointestinal bleed
be less directional; perhaps the maximum count rates obtained           ing: Experience with 80 patients. Am J Roentgenol              137:
wouldnotexceedthe maximumcapabilityof the instrument.Its               1981
                                                             1113—1118,
relativelylowefficiencyfor the 140keVphotonof technetium, 5. BESTEB, TEAFORDAK, RADER FH, et al: Angiography in
however, would still be a problem.                                      chronic recurrent gastrointestinal bleeding: A nine year study.
  Chamberssuchas thoseusedin radiationtherapyto measure                                            1979
                                                                        SurgClinNorthAm 59:811—829,
dose rates in the rectum and bladder from therapeutic implants       6. BAR AH, DELAURENTISDA, PARRY CE, et al: Angiogra
                        Ancod-window
sufferfromlowsensitivity.          betaprobe(eyeprobe)                  phy in the management of massive lower gastrointestinal tract
used for intraocular tumor location has reasonable directionality,                                                       1
                                                                        hemorrhage. Surg Gynecol Obstet 150:226—228, 980
                          dueto itsthinnonmetallic indow
butsuffersfromlowefficiency                      w                   7. ATHANASOULISCA, WALTMAN AC, NOVELLINE RA, et
(9). A clear advantage that the imaging device has over noni            al: Angiography: Its contribution to the emergency manage
magingprobesis that the variousstructuresthemselves be can              ment of gastrointestinal hemorrhage. Radiol C/in North Am
identifiedand separatedfromoneanother.                                  14:265—280,  1976
  We are cognizantof the drawbacksof intraoperativescintig           8. SMITH RK, ARTERBURN G: Detection and localization of
raphy,whichincludecontamination(radioactiveand septic)of                gastrointestinal bleeding using Tc-99m-pyrophosphate in vivo
                                                         that
the operativesuiteand the patientas wellas the possibility                                                               1980
                                                                        labelled red blood cells. C/in Nucl Med 5:55—60,
the patientmay not havebledactivelyduringthe operation.In            9. PACKER 5: Ocular tumor localizing radionuclides. In
addition,just movingthe smallbowelaroundunderthe camera                 Handbook Series in Clinical Laboratory Science, vol 1,CRC
may have displaced radioactive blood away from the site of cx                          O
                                                                        Press,Cleveland, hio,1977,pp 72-76




                           American Board of Science in Nuclear Medicine
     June 1, 1985                                                                                              Houston, Texas
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Volume 25, Number 11                                                                                                                 1211

								
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