Apparently, the nuclear medicine community in Pakistan is quite enthusiastic about discussing clinical cases as evidenced by the ongoing discussion. Why don't we start a Case of the Week, which I can put on the PJNM site and share with the group.
Here is one case for you lot to discuss.
Background: A 35-year-old man clinically suffering from iron deficiency anaemia, with normal gastroscopy and colonoscopy, was referred to the nuclear medicine department for a Meckel’ scintigram to investigate the possibility of Meckel’s diverticulum as a source the patient’s blood loss. Following an intravenous injection sequential images of the abdominal and the pelvis were obtained for 30 minutes at 5-min intervals (see below).
Your comments and opinions on the scan are most welcome.
Here is one case for you lot to discuss.
Background: A 35-year-old man clinically suffering from iron deficiency anaemia, with normal gastroscopy and colonoscopy, was referred to the nuclear medicine department for a Meckel’ scintigram to investigate the possibility of Meckel’s diverticulum as a source the patient’s blood loss. Following an intravenous injection sequential images of the abdominal and the pelvis were obtained for 30 minutes at 5-min intervals (see below).
Your comments and opinions on the scan are most welcome.
QAISAR SIRAJ
Dear Dr. Qaisar siraj this is really a good idea....
ReplyDelete1. It should have a specicifica day in the week for posting and then a exactly a week later an answer should be released...
All the member should send thier cases to the PJNM web site manager for minor additions and omitions...
Now coming to your very interesting case...
AS this 35 years old man was reffered to you for a Meckles scan so you must have done this scan with 99mTcO4 to look for hetrotropic gastric mucosa.
Clinically Meckle (with gastric mucosa ) becomes symptomatic quite early in age typically around 2-4 years.
In such patient one should talk to the reffering physician that we want do a labelled RBCs study in stead.
This study looks like a Labelled RBCs scan as we dont see the stomach. secondly vessels are seen till 30 minutes.
Now the further whole description of the study depeds on the Tracer given..
If its still TcO4 then I doubt its quality (if total gastrectomy has been excluded). If Its RBCs labelled study then There is a midline foucus of activity expanding with time but not moving along the gut it appears localized like collection of tracer into some cystic are..
More clinical input is needed like previous surgical history/ ultrasound of pelvis??
a good case to read thanks for posting it..
Aakif
I am glad you like the idea. You can submit cases to me at EditorPJNM@Gmail.com with the relevant clinical details and why do you think it is important. I shall post one case each on the web site of the journal and to your Yahoo group. We can comment on the case until Friday and the cycle shall repeat.
ReplyDeleteAs for your comments on the image, I assure you the tracer is Tc-99m pertechnetate and not a labelled RBC scan. There is nothing wrong with the imaging or the pharmaceutical. This is purely a clinical observation exercise. Keep at it and you might get there. QAISAR SIRAJ
In fact the sensitivity of Meckle scan in Adults is 60-65% in adults. Most the time the finding of ectopic mucosa in adults are case reprts further compromising its utility in statistics...
ReplyDeleteComing to the case....
If Its TcO4 then.....The Meckle can be found anywhere in the abdomin but this focus in hypogastrium is too big to be Meckles.
This can be...
1. Ectopic pelvic Kidney?
2.gastrogenic cyst (its usually higher but still??)
I am thinking......Or just a negative scan for Meckls diverticulum...AAKIF
As clarified by Dr Siraj tracer is Tco4 so study is for Meckel's but we are not seeing any tracer in stomach could be due to wrong positioning of the patient and stomach or part of stomach is out of filed of view
ReplyDeleteor
we have to know whether the patient has had recent in vivo RBC labeling in which circulating RBCs were treated with stannous ion by IV cold pyrophosphate kit. If so, the Meckel's scan may be compromised, because intravenous pertechnetate will label RBCs rather than concentrate in ectopie gastric mucosa. This may occur for days after the administration of stannous pyrophosphate.
So we need input on these aspects
if both options negative we can think of something else .....as we are thinking
Shazia Fatima
This discourse is proving to be an educating experience indeed. Shazia has picked up on and elaborated upon a very important point that adds to our collective knowledge. Well done, I must say.
ReplyDeleteWe all learn from each other all the time and none of us, no matter how experienced, is a "Finished Product".
To take the matter further and address the queries: 1) The positioning is perfect and 2) I can confirm that the patient did not have had a prior in-vivo RBC scan or was pre-tinned with stannous. Qaisar Siraj
it is indeed a nice case to discuss. my humble opinion
ReplyDeleteapperantly it looks like as the scan is negative for any actopic gastric mucosa in the abdomen. there may be some other causes of false negative scan
1. Almost half of all Meckel's diverticula do not contain gastric mucosa. Also, there may not be sufficient gastric mucosa to differentiate from normal background tissues
2. if a diverticulum Meckel's diverticulum which causes complications such as intussusception and obstruction may result in compromise of the vascular supply and thus not allow the tracer to reach the gastric mucosa. in that case we may need to have informatioin about any signs of intestinal obstruction or intussusception?
3. Brisk bleeding may result in dilution of the radioactivity in the small bowel. This leads to insufficient focal uptake and a negative reading.
Is there any study undertaken after pharmacologic interventions with Pentagastrin, cimetidine, or glucagon? these interventions may reduce the false negative rate and initial negative scans may become positive after the administration of one or more of these agents.
in summary, we have three choices
1. repeat scan without any pharamacological intervention (there are reported cases in which repeat scan turned out to be positive)
2. repeat scan with pharamacological intervention (there are evidences in the literature that after pharamacological interventions detection rate enhances)
3. if again negative and clinical suspicion is high and Hb < 10, exploratory laparotomy may be an option which can be discussed in the joint meeting with internist, and surgeon on board
ALEEM
Dear Aleem: Thank you very much for your valuable comments, which when added to Shazia'a comments and others that may follow would give us enough ammunition for a review article on the subject.
ReplyDeleteNow to answer your technical questions. No, there was no pharmacological intervention with cimetidine, pentagastrin or glucagon nor was the patient bleeding.
More comments please. What I would ask you all is what would you do when given a scan like this or how would you report it. Later, I will tell you exactly what I did do next and why I did it. Now that's a clue.
Dear all: We have some valuable comments by the younger nuclear medicine specialists. How about some input from the peers and teachers. You can Email me your opinion privately and in summarising I shall preserve your anonymity. But please do participate. There is no wrong answer so far. Later today or tomorrow I shall show you a positive scan depending on the number of comments I receive. More later..Qaisar Siraj
Dear Dr. Qaiser Siraj and friends!!
ReplyDeleteWhenever a commonly performed test is presented to the community as a "case of the week", the viewers and especially trainees find opportunity of learning from it. Most of the time we are biased in our opinion making by assuming:
1. this is not a straight forward case must be trick/catch associated with it.
2. We normally do not report it normal if it look absolute normal. what so ever clue we get we try to make something out of it.
3. We raise questions by challenging its clinical scenarios and try to be vigilant about Quality assurance Issues.
If such a case is presented in routine reporting session then the report would be quite different. Just comments on our over enthusiastic commitments while comenting, secondly I tried to trigger a debate but no body has time to react on things. It will take some time before the whole community is sensitized about these academic activities.
AAKIF
You have beautifully summarised the nature of the responses Aakif.
ReplyDeleteI am making note of these and would publish these when I summarise.
You are absolutely right when you say that if one gets this scan to report under normal circumstances, he would and should report it as normal. In that everyone is right; however, you have come closest to the point than anyone else. You shall later on find how and why. I shall be sending some more relevant scans later. This is a great educational exercise. Qaisar Siraj
Dear friends
ReplyDeleteThere is no absolute right or wrong answer to a quiz, Every mind has its own imaging reading and thought processing process. Its not important who is right and who is wrong Its important how you go for a case.
Am I right Dr. Qaiser Siraj??
So dear younger colleagues don't be shy to participate as you may be more right than all the others even the member posting a case.
Dear senior colleagues don't ignore us , Please give us some time so we may learn from your experiences. Regards to all the seniors and juniors..
Aakif U. Khan
On summarizing what we have so far discussed:
ReplyDeleteStudy was technically perfect
no pharmacological intervention was done
The D/D of this image so far suggested have been a negative scan for heterotrophic gastric mucosa, intussusception, obstruction, Brisk bleeding, gastrogenic cyst,
Ectopic pelvic Kidney? For me this was a negative meckels scan but after reading this article i was having optical illusions of areas which may become more obvious after hybrid CT SPECT.
Is it my feeling or background is actually high??? I am more interested in cause of anemia ...any more workup for this patient anemia? Shazia Fatima
Many thanks indeed Shazia for adding your comments, which are quite pertinent and valuable.
ReplyDeleteSince there are no more comments forthcoming, I would like to point out that the lesson to be learnt from this case is that a deviation from normality is as important as detection of an abnormality.
I shall post my findings later in the day in about 3 hours time and summarize the case in light of the collective comments.
Congratulations to all who participated and for their valuable input. Qaisar Siraj
This discourse is proving to be an educating experience indeed. Shazia has picked up on and elaborated upon a very important point that adds to our collective knowledge. Well done, I must say.
We all learn from each other all the time and none of us, no matter how experienced, is a "Finished Product".
To take the matter further and address the queries:
1) The positioning is perfect and 2) I can confirm that the patient did not have had a prior in-vivo RBC scan or was pre-tinned with stannous. Qaisar Siraj
does a case of the week need to have something "positive"? I wonder what the reaction would be if this were just a routine case that came up with the others on an average day. Sabih
ReplyDeleteDear all
ReplyDeleteI would like to thank all the participants including Aakif, Aleem, Shazia and Sabih and others, for participating in this academic exercise and for their invaluable time, their comments and their opinions.
The idea behind this exercise was to stimulate and to provoke discussion which might (and did) benefit us all.
There was no right or wrong answer. Everyone's comments were correct and pertinent. No one said, and I agree, that the scan was positive for a Meckel's diverticulum. I never suggested that in my original submission. The point that I wanted to make was that an abnormal finding is as important as an observation on deviation from the expected normal distribution.
When I was given this scan to check by my Technologist to report, I knew it to be a negative scan for Meckel's. What bothered me was the absence of normal gastric activity. I am glad that this was mentioned in the chain of discussion.
See the images at the end of this discussion and the findings. The report is under publication and copyrighted.
QAISAR SIRAJ
THE ANSWER
I was intrigued by the non-visualisation of the stomach in the field-of-view and the first thing I wanted to check was uptake in the thyroid and you can see what I found serendipitously.
I suspect that you injected DTPA.
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