CASE OF THE WEEK: SUMMARY & RESULTS

Dear all

I 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 below.

See the images at the end of this discussion and the findings. The report is under publication and copyrighted. 

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. 

 

Serendipitous Detection of Intrathoracic Stomach I: Tc-99m Pertechnetate Meckel’s Imaging 

QAISAR H. SIRAJ, Department of Nuclear Medicine, Royal Hospital Haslar, Gosport, United Kingdom.

ABSTRACT: A 35-year-old man had a 6-month history of unexplained iron deficiency anaemia (Hb 6.8). Following a normal colonoscopy the patient was referred for Tc-99m pertechnetate scintigraphy in order investigate the possibility of fuctional gastric mucosa in Meckel’s diverticulum, as the source of patient’s blood loss. The sequential images of the abdomen revealed no evidence of any uptake in the abdomen to suggest the presence of functioning gastric mucosa (normal or ectopic). Images of the thorax however showed the uptake of the isotope in the mid-thoracic region, located posterior-superiorly to the liver and posterior to the heart. This was later confirmed on gastroscopy. The unsuspected detection of congenital intra-thoracic stomach on a Meckel’s scan has not been reported previously.

Fig. 1. Anterior projection of the abdomen and pelvis. Sequential images of the abdomen and pelvis were obtained in the anterior projection at 5-min intervals for 30 minutes (clockwise from the top right). The images showed normal activity in the circulatory system, liver, and the spleen, together with progressive accumulation of the tracer in the bladder, but the scan did not reveal the presence of ectopic functional gastric mucosa. However, a close look at the images showed no evidence of the expected gastric activity usually seen in the left upper quadrant of the image field in the sub-diaphragmatic region.

Fig. 2. Anterior projection of the thorax at 40 min postinjection (left) shows uptake in the thyroid with gastric activity in the mid-chest region astride the spine and posterior to the heart. Further imaging at 60 min postinjection (right) shows distal transit of activity into the duodenum. Negative Meckel’s scan with complete intra-thoracic stomach may well explain the cause of the patient’s anaemia.