The Role of Nuclear Medicine in the Detection of Acute Gastrointestinal Bleeding

https://doi.org/10.1053/j.semnuclmed.2005.11.001Get rights and content

The clinical consequences of lower gastrointestinal bleeding range from trivial to life-threatening. Nuclear medicine imaging techniques allow identification of those patients who are actively bleeding. The demonstration of active bleeding not only provides important prognostic information but also allows for a coordinated imaging approach using angiography and aids localization of the bleeding site. 99mTc-labeled erythrocytes and 99mTc sulfur colloid are 2 commonly used techniques to detect active bleeding. Each has its respective advantages and disadvantages, but the medical literature indicates that both tests are useful. More prolonged or delayed imaging is possible using 99mTc-labeled erythrocytes but care is required to prevent misinterpretation of the bleeding location because of a higher likelihood of radiotracer movement through the bowel away from the bleeding site. These forms of scintigraphy may be helpful in risk-stratifying patients and planning radiological and surgical interventions. Careful selection of patients to include those who have a high likelihood of active bleeding greatly increases the clinical utility of these tests. In addition, 99mTc pertechnetate imaging may be diagnostic of ectopic gastric mucosa in a Meckel’s diverticulum as a potential source of bleeding. Patients also should be carefully selected for this test, based on age and exclusion of other causes of bleeding.

Section snippets

99mTc-Labeled Autologous Erythrocyte Scintigraphy

Because of the ready availability of good quality commercial kits, enabling rapid and reliable erythrocyte labeling and the ability to image in dynamic early-phase followed by extended equilibrium-phase, this technique is currently the most popular method. Variations in the technique exist, including in vivo, modified in vitro, and in vitro imaging protocols (Table 1). These imaging protocols have previously been well described.11, 12, 13, 14 This test is commonly indicated when, in the

99mTc-Labeled Sulfur Colloid Scintigraphy

This technique was first described in animal experiments in 197721 A recommended imaging protocol is shown in Table 2. The principle of radiolabeled sulfur colloid imaging relates to the use of this radiotracer as an early phase vascular imaging agent that is rapidly cleared from the vascular space by extraction to liver, spleen and bone marrow. Consequently, extravasation from a vascular source, such as that which occurs during active gastrointestinal bleeding, will potentially yield a high

Other Techniques

99mTc-labeled albumin was the earliest intravascular agent used to detect gastrointestinal bleeding.20 This technique showed promising results but was soon surpassed by techniques using more reliable labeling techniques.2499mTc-labeled heat-damaged erythrocytes also have been used as an intravascular technique where a high target-to-background ratio is achieved by clearance of damaged erythrocytes by the spleen and extravasation of labeled-heat-damaged erythrocytes at a site of active

Meckel’s Diverticulum

Bleeding from a Meckel’s diverticulum can potentially occur at any age but is more likely to occur in infancy or early childhood. A Meckel’s diverticulum is an embryological remnant caused by incomplete closure of the omphalomesenteric duct, most commonly located in the distal ileum. It is not known what proportion of these diverticulae contain ectopic mucosa, but estimates range from 10% to 60%.29, 30, 31 The most common type of ectopic tissue in Meckel’s diverticulae is gastric mucosa, and

Image Interpretation Pitfalls

Interpretation of 99mTc sulfur colloid imaging in the upper abdomen may be problematic in certain clinical settings because of reticuloendothelial cell uptake of this radiotracer within liver and spleen. Also, potential false-positive interpretation of focal abnormal uptake has been reported as the result of an accessory spleen.48 Unexpected bleeding from a ruptured spleen also has been reported using 99mTc labeled erythrocyte scintigraphy,49 as well as a photopenic region seen in the spleen on

Patient Risk Stratification

A retrospective study of 565 hospitalizations (488 patients) for AGH in a large tertiary referral hospital during a 7-year period showed that in 89% of cases bleeding stopped spontaneously,87 which is an indicator as to the vagaries of AGH and the difficulties involved in establishing protocols for the management of patients. A large proportion of patients admitted to hospital with AGH will be discharged from hospital without a satisfactory diagnosis for the cause of bleeding.88 Consequently,

Recommended Roles of Imaging Modalities

The role of nuclear medicine scintigraphy in the detection of lower gastrointestinal hemorrhage fits into a neat theoretically algorithm. This algorithm places the scintigraphy study as one of the first imaging investigations to be performed with the aim of determining a sufficient rate of bleeding to facilitate successful angiography and possible angiographic intervention.16 However, gastrointestinal bleeding is a law unto itself with respect to timing, severity, and clinical context.

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