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Perigastric varices detected in a gastrointestinal bleeding study with 99mTc-labeled red blood cells SPECT/CT
Varices perigástricas detectadas en un estudio de hemorragia digestiva mediante SPECT/TC con hematíes marcados con 99mTc
Myoung Hyoun Kim, Soon-Ah Park, Dae-Weung Kim
Corresponding author
Department of Nuclear Medicine, Wonkwang University School of Medicine and Institute of Wonkwang Medical Science, Iksan, Republic of Korea
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(B) MIP and axial slices of <span class="elsevierStyleSup">18</span>F-FDG PET/CT in which, in addition to a hypermetabolic pulmonary nodular lesion (arrow-head), a 30<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>36<span class="elsevierStyleHsp" style=""></span>mm soft tissue density nodular lesion (arrow) located subcutaneous on the left flank with high metabolic activity (SUVmax: 77.45) was observed.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Francisco Javier García-Gómez, Teresa Cambil-Molina, Tomás Martín-Hernández, Gertrudis Sabatel-Hernández, María de la Cinta Calvo-Morón, Juan Castro-Montaño" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "García-Gómez" ] 1 => array:2 [ "nombre" => "Teresa" "apellidos" => "Cambil-Molina" ] 2 => array:2 [ "nombre" => "Tomás" "apellidos" => "Martín-Hernández" ] 3 => array:2 [ "nombre" => "Gertrudis" "apellidos" => "Sabatel-Hernández" ] 4 => array:2 [ "nombre" => "María de la Cinta" "apellidos" => "Calvo-Morón" ] 5 => array:2 [ "nombre" => "Juan" "apellidos" => "Castro-Montaño" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S2253654X18301458" "doi" => "10.1016/j.remn.2018.09.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253654X18301458?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808918300776?idApp=UINPBA00004N" "url" => "/22538089/0000003800000003/v1_201905020850/S2253808918300776/v1_201905020850/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2253808918301113" "issn" => "22538089" "doi" => "10.1016/j.remnie.2018.11.001" "estado" => "S300" "fechaPublicacion" => "2019-05-01" "aid" => "1017" "copyright" => "Sociedad Española de Medicina Nuclear e Imagen Molecular" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Esp Med Nucl Imagen Mol. 2019;38:183-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2 "PDF" => 2 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical note</span>" "titulo" => "<span class="elsevierStyleSup">18</span>F-FDG PET/CT in a patient with atypical presentation of cardiac angiosarcoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "183" "paginaFinal" => "185" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "PET/TC con <span class="elsevierStyleSup">18</span>F-FDG en paciente con presentación atípica de angiosarcoma cardiaco" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 671 "Ancho" => 900 "Tamanyo" => 46930 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET/TC. 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Axial SPECT (A), corresponding CT (B) and fusion (C) images of SPECT/CT demonstrated focal increased activity in the perigastric area (arrows), but not in the stomach.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 66-year-old female with a 6-year history of liver cirrhosis (Child-Turcotte-Pugh class C) complained of drowsiness, intermittent hematochezia and melena. She received endoscopic injection sclerotherapy for gastroesophageal varices two years ago. Her hemoglobin level was 7.5<span class="elsevierStyleHsp" style=""></span>g/dL (reference range, 12.0–15.9<span class="elsevierStyleHsp" style=""></span>g/dL) and gastrointestinal bleeding was suspected. An upper gastrointestinal endoscopy showed gastric and duodenal ulcers without active bleeding. On colonoscopy, large amount of bleeding was showed, but exact bleeding focus was not demonstrated. The patient was referred for a gastrointestinal bleeding scintigraphy with <span class="elsevierStyleSup">99m</span>Tc-labeled red blood cells (<span class="elsevierStyleSup">99m</span>Tc-RBC) to identify and localize the gastrointestinal bleeding.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Serial gastrointestinal bleeding scintigraphy showed <span class="elsevierStyleSup">99m</span>Tc-RBC activity restricted to the perigastric area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, arrows). The activity of perigastric area did not show anterograde nor retrograde migration. There was no other evidence of gastrointestinal bleeding until 24<span class="elsevierStyleHsp" style=""></span>hours after injection. Additional SPECT/CT was performed for differential diagnosis at 1 hour after injection of <span class="elsevierStyleSup">99m</span>Tc-RBC. SPECT/CT demonstrated focal increased activity in the perigastric area, but not in the stomach (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Subsequent contrast-enhanced abdomen CT showed tortuous and enlarged veins in the perigastric area (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). These veins are the left gastric vein, which is responsible for the portosystemic collateral. The liver was atrophied, showed nodular surface, and was accompanied by small amount of ascites.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Esophageal and gastric varices result from portal hypertension and increased collateral venous flow in patients with advanced liver cirrhosis. Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths. Although gastric varices have less frequent bleeding than esophageal varices, once bleeding occurs, they can cause massive bleeding and have higher mortality. Therefore, it is very important to confirm the presence of bleeding in the gastric varices and to identify the bleeding focus.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Gastrointestinal bleeding scintigraphy performed with <span class="elsevierStyleSup">99m</span>Tc-RBC or <span class="elsevierStyleSup">99m</span>Tc-sulfur colloid has been a clinically useful tool since the 1970s. The study is useful to confirm active bleeding and to aid angiographers/surgeons in localization and treatment planning. Recently, SPECT/CT has been applied to further define the location of bleeding, and Dolezal et al. reported that SPECT or SPECT/CT can increase the sensitivity and specificity.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> Although gastrointestinal bleeding scintigraphy with <span class="elsevierStyleSup">99m</span>Tc-RBC is useful for localization of the active bleeding focus, multiple false positive findings have been described including abdominal/gluteal hematomas, aortic aneurysms and hemangiomas.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> Also, mesenteric and ileal varices mimicking an acute gastrointestinal hemorrhage have been reported.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> Therefore, nuclear medicine physicians should be aware of potential false positives in order to improve diagnostic accuracy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">To the best of our knowledge this is the first documented case of <span class="elsevierStyleSup">99m</span>Tc-RBC SPECT/CT findings in a patient with gastric varices. This case highlights the usefulness of SPECT/CT to differentiate false positive cases in a patient with uncertain findings on the gastrointestinal bleeding scans.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-05" "fechaAceptado" => "2018-07-09" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Kim MH, Park S-A, Kim D-W. Varices perigástricas detectadas en un estudio de hemorragia digestiva mediante SPECT/TC con hematíes marcados con <span class="elsevierStyleSup">99m</span>Tc. Rev Esp Med Nucl Imagen Mol. 2019;38:186–187.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1612 "Ancho" => 1500 "Tamanyo" => 178414 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Gastrointestinal bleeding scintigraphy showed <span class="elsevierStyleSup">99m</span>Tc-RBC activity restricted to the perigastric area (arrows). On the serial images, the activity of perigastric area neither show anterograde nor retrograde migration. There was no other evidence of gastrointestinal bleeding until 24<span class="elsevierStyleHsp" style=""></span>h after injection.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1878 "Ancho" => 905 "Tamanyo" => 121742 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SPECT/CT was performed at 1 hour after injection of <span class="elsevierStyleSup">99m</span>Tc-RBC. Axial SPECT (A), corresponding CT (B) and fusion (C) images of SPECT/CT demonstrated focal increased activity in the perigastric area (arrows), but not in the stomach.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 557 "Ancho" => 1255 "Tamanyo" => 109990 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Axial (A) and coronal (B) images of subsequent contrast-enhanced abdomen CT showed tortuous and enlarged veins (arrows) in the perigastric area. These veins are the left gastric vein, which is responsible for the portosystemic collateral. The liver was atrophied with nodular surface, and small amount of ascites was detected.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Single-photon emission computed tomography enhanced Tc-99m-pertechnetate disodium-labelled red blood cell scintigraphy in the localization of small intestine bleeding: a single-centre twelve-year study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Dolezal" 1 => "J. Vizda" 2 => "M. Kopacova" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Digestion" "fecha" => "2011" "volumen" => "84" "paginaInicial" => "207" "paginaFinal" => "211" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pitfalls of gastrointestinal bleeding studies with 99mTc-labeled RBCs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.L. Lecklitner" 1 => "J.J. Hughes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Semin Nucl Med" "fecha" => "1986" "volumen" => "16" "paginaInicial" => "151" "paginaFinal" => "154" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "False positive GI bleed on Tc-99m RBC scintigraphy due to ileal varices" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.N. Chen" 1 => "R.K. Brown" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Radiol Case Rep" "fecha" => "2012" "volumen" => "6" "paginaInicial" => "23" "paginaFinal" => "28" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack404832" "titulo" => "Acknowledgement" "texto" => "<p id="par0030" class="elsevierStylePara elsevierViewall">This study was supported by Wonkwang University in 2018.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22538089/0000003800000003/v1_201905020850/S2253808918300594/v1_201905020850/en/main.assets" "Apartado" => array:4 [ "identificador" => "47121" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Interesting image" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22538089/0000003800000003/v1_201905020850/S2253808918300594/v1_201905020850/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808918300594?idApp=UINPBA00004N" ]
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