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Society of Nuclear Medicine Procedure Guideline for

Gastrointestinal Bleeding and Meckel’s Diverticulum
Scintigraphy
version 1.0, approved February 7, 1999

Authors: Patrick V. Ford, MD (St. Luke’s Episcopal Hospital, Houston, TX); Stephen P. Bartold, MD (Texas Tech Univer-
sity, Odessa, TX); Darlene M. Fink-Bennett, MD (William Beaumont Hospital, Royal Oak, MI); Paul R. Jolles, MD (Med-
ical College of Virginia, Richmond, VA); Robert J. Lull, MD (San Francisco General Hospital, San Francisco, CA); Alan H.
Maurer, MD (Temple University Hospital, Philadelphia, PA); James E. Seabold, MD (University of Iowa Hospitals and
Clinics, Iowa City, IA).

I. Purpose over intermittent sampling since most GI bleeds are
intermittent and therefore frequently missed.
The purpose of this guideline is to assist nuclear
The clinical findings for active gastrointestinal
medicine practitioners in recommending, perform-
hemorrhage are often unreliable and misleading.
ing, interpreting, and reporting the results of gas-
There is frequently a marked temporal lag between
trointestinal bleeding and Meckel’s diverticulum
the onset of bleeding and the clinical findings. While
scintigraphy.
it may be clinically apparent that the patient has bled
from the presence of melena or hematochezia, the
II. Background Information and Definitions blood may pool in the colon for hours before being
evacuated. A drop in the hematocrit and elevated
Gastrointestinal bleeding scintigraphy is per-
serum blood urea nitrogen (BUN) also lack the tem-
formed in patients suspected of active gastroin-
poral resolution needed to indicate active bleeding.
testinal bleeding using Tc-99m labeled red blood
Orthostatic hypotension and tachycardia occur
cells (RBCs). Sites of active bleeding are identified
more acutely but are insensitive and non-specific.
by the accumulation and movement of labeled Red
In cases where there is only occult bleeding detected
Blood Cells within the bowel lumen. Since activity
by guaiac positive stools, gastrointestinal bleeding
within the lumen of the bowel can move antegrade
scintigraphy is unlikely to be useful. Gastrointestinal
and retrograde, frequent images (1 image every
bleeding scintigraphy can detect bleeding rates as low
10–60 sec) will increase the accuracy of localizing
the bleeding site. Tc-99m sulfur colloid (SC) is as 0.1 to 0.35 ml per min. The guaiac test detects bleeds
rarely used today because of the short residence at rates well below the level necessary to be seen on
time within the blood. Tc-99m SC is cleared from gastrointestinal bleeding scintigraphy.
the blood by the reticuloendothelial system with a
half-time as short as 2 to 3 min while radiolabeled Meckel’s Diverticulum Scintigraphy
RBCs last for hours. A Meckel’s diverticulum is a vestigial remnant of
Gastrointestinal bleeding (GI) is either upper, the omphalomesenteric duct located on the ileum
originating above the ligament of Treitz, or lower, about 50 to 80 cm from the ileocecal valve. About
distal to the ligament of Treitz. Frequent causes of half of Meckel’s diverticuli have gastric mucosa.
upper GI bleeding include esophageal varices, gas- Bleeding may result from ileal mucosal ulceration
tric and duodenal ulcers, gastritis, esophagitis, Mal- from acid secretion. Tc-99m pertechnetate avidly ac-
lory-Weiss tear or neoplasm. Causes of lower GI cumulates in gastric mucosa and is the study of
hemorrhage include angiodysplasia, diverticula, choice for identifying ectopic gastric mucosa in a
neoplasms and inflammation, and, in children, Meckel’s diverticulum.
Meckel’s diverticulum. Endoscopy and angiogra-
phy provide accurate localization of bleeding sites III. Common Indications
and potentially therapeutic control. Scintigraphy
with labeled RBCs is complementary to endoscopy Gastrointestinal Bleeding Scintigraphy
and angiography because it permits continuous The goals of gastrointestinal bleeding scintigraphy
monitoring over hours. This is a major advantage are to locate the bleeding site and to determine who
46 • GI BLEEDING/MECKEL’ S DIVERTICULUM SCINTIGRAPHY

requires aggressive treatment versus those who can b. Change in resting pulse rate from supine to
be medically managed. It is usually in those patients erect position
that require urgent care that the bleeding site is iden- c. Frequency and volume of bleeding
tified. In some patients, the bleeding site is identified d. Current hemoglobin and hematocrit
with sufficient confidence for specific surgical inter- e. Recent hemoglobins and hematocrits
vention (e.g. right hemicolectomy in the case of a f. Number of recent transfusions
bleeding site in the ascending colon). If bleeding is 4. Suspected location of bleeding
detected, the site is usually localized well enough to a. Results of nasogastric aspirate and/or up-
direct the next diagnostic test (e.g. endoscopy or ar- per gastrointestinal endoscopy
teriography). Gastrointestinal scintigraphy should b. Results of sigmoidoscopy or colonoscopy
be done as soon as possible after the patient presents C. Precautions
for medical care, since active bleeding is more likely 1. Patients suspected of acute gastrointestinal
at early times and is needed for correct localization. bleeding should have a blood pressure and
pulse measured upon their arrival in the nu-
clear medicine department to confirm that
Meckel’s Diverticulum Scintigraphy they are not hypotensive. The vital signs
The indication for a Meckel’s scintiscan is to localize should be monitored periodically while the
ectopic gastric mucosa in a Meckel’s diverticulum as patient is being imaged. The patient should
the source of unexplained gastrointestinal bleeding. have a large bore IV catheter in place so that
Bleeding Meckel’s diverticula usually occur in hypotension can be rapidly treated with re-
young children. The Meckel’s scintiscan should be placement fluids or blood.
used when the patient is not actively bleeding. Even 2. The removal of blood for radiolabeling and
in young children, active bleeding is best studied by reinjection poses the risk of misadministra-
radiolabeled RBC scintigraphy. tion to the wrong patient. The handling and
administration of blood products must be
subject to special safeguards and procedures,
IV. Procedures
the goals of which are to eliminate any possi-
Gastrointestinal Bleeding Scintigraphy bility of administration to the wrong patient
A. Patient Preparation or contamination of workers. See “Special
See Precautions (IV.C.) below Considerations for Labeled Blood Products”
B. Information Pertinent to Performing the in the Society of Nuclear Medicine Procedure
Procedure Guideline for Use of Radiopharmaceuticals.
1. History of past bleeding episodes D. Radiopharmaceuticals
a. Number of transfusions in the past The in-vitro method for labeling red blood cells
b. Results of prior studies to localize the is preferred due to its higher labeling efficiency.
bleeding site The in-vivo/in-vitro method can be used. The in-
c. Prior therapeutic interventions vivo method is not recommended. See the Society
d. History of factors that affect RBC radiola- of Nuclear Medicine Procedure Guideline for Use of
beling efficiency (e.g. thalassemia, chemo- Radiopharmaceuticals.
therapy) E. Image Acquisition
2. Current blood pressure and pulse Continuous acquisition of images at a frame rate
3. Clinical signs of active bleeding of one image every 10–60 sec is important in or-
a. Presence of orthostatic hypotension der to accurately localize the bleeding site.

Radiation Dosimetry in Adults
Radiopharmaceutical Administered Organ Receiving the Largest Effective Dose*
Activity Radiation Dose*
MBq mGy mSv
(mCi) (rad) (rem)
Tc-99m labeled RBCs 750 – 1100 i.v. 0.023 0.0085
heart
(20 – 30) (0.085) (0.031)

*per MBq (mCi)
(ICRP 53 page 210 )
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL JUNE 2002 • 47

1. Equipment These images are optional. Typically de-
Camera: Large field-of-view layed images are done from 2–6 hr and/or
Collimator: A low energy, all-purpose, paral- at 18–24 hr after the injection of the radio-
lel hole collimator is preferred. pharmaceutical. Delayed images are useful
When the study must be per- in showing subsequent bleeding and cate-
formed at the bedside, a di- gorizing the severity, but may result in in-
verging collimator is useful to correct localization when identifying a
see the maximum abdominal bleeding site. Initiating a new dynamic
area. study may give useful localizing informa-
Photopeak: Typically 20% window at 140 tion if the patient is actively bleeding at the
keV. time of imaging. This may be done while
Computer: 128 x 128 matrix, single or 2-byte initiating a new study by radiolabeling a
mode. (One byte has been called new RBC kit.
byte-mode and 2-bytes, word- d. Additional Views
mode.) Due to overlying bladder activity, activity
2. Patient position: Supine in the rectum can be difficult to appreci-
3. Imaging field: Abdomen and pelvis ate. Lateral views may be needed to see
4. Acquisition Protocol rectal bleeding. Anterior oblique and pos-
a. Abdominal Flow Study terior views are frequently helpful in de-
Anterior abdominal flow images (1–5 ciding if activity is located anteriorly ver-
secs/frame x 1 min) are recommended. sus posteriorly.
b. Dynamic Abdominal Imaging e. Region of interest counts over extravasated
i. Dynamic anterior abdominal images blood in the bowel may be used to estimate
are acquired at a frame rate of 10–60 blood loss when normalized to counts ob-
sec per frame over a 60 to 90 min pe- tained from a blood sample drawn simul-
riod. Acquiring these images in multi- taneously from the patient and corrected
ple sets of 10–15 min each may facili- for attenuation. The precision and accuracy
tate review of these images by the of such estimates should be determined by
physician as the images are being each institution making such estimates.
acquired. f. In cases where extravasated blood is seen
ii. If computer acquisition is not possible: but does not move sufficiently to deter-
Sequential static images 1 million mine the location or where the movement
counts per image at least every 5 min is unusual, the following may be useful: re-
for 60–90 min. Localization might be view of prior barium studies; oral Tc-99m
aided by obtaining images at a shorter SC to outline the upper GI and small bowel
interval, every 2–3 min. anatomy; or Tc-99m SC enema to outline
c. Delayed Imaging the colon.
For Tc-99m RBCs, if no bleeding site is F. Interventions
identified on the initial 60–90 min dynamic Pharmacologic (pharmacologic intervention is
images, delayed images may be acquired. controversial and is not widely used).

Radiation Dosimetry in Children
(5 year old)
Radiopharmaceutical Administered Organ Receiving the Largest Effective Dose*
Activity Radiation Dose*
MBq mGy mSv
(mCi) (rad) (rem)
Tc-99m labeled RBCs 10 – 15 i.v. 0.062 0.025
heart
(0.3 – 0.4) (0.23) (0.093)

*per MBq (mCi)
(ICRP 53 page 210 )
48 • GI BLEEDING/MECKEL’S DIVERTICULUM SCINTIGRAPHY

Glucagon has been suggested as an adjunct to ated with early appearance of blood in the bowel
GI bleeding studies. Glucagon decreases intesti- and intense activity equal to or greater than the
nal peristalsis and increases vasodilatation. liver.
Glucagon is not widely used. I. Reporting
Heparin also has been suggested as an ad- Aside from patient demographics, the report
junct to GI bleeding studies in selected patients should include the following information:
with recurrent significant bleeding from a site 1. Indication for the study
that has not been localized using standard diag- 2. Procedure
nostic tests. Standard procedure is to administer a. Radiopharmaceutical
IV 6,000 units heparin as a loading dose, fol- i. Dose
lowed by 1,000 units IV heparin per hr. The pa- ii. Radiolabeling method for RBCs (e.g.,
tient’s baseline coagulation status should be in-vivo)
evaluated before giving heparin. Heparin provo- iii. Method of administration (i.v.)
cation is not widely used. Surgical coverage b. Acquisition
should be immediately available as a precaution- i. Duration of acquisition (e.g., 1 hr)
ary measure. Close monitoring of the patient ii. Frame rate (e.g., 10 sec/frame)
is necessary and protamine sulfate should be iii. Projections acquired (e.g., anterior, lat-
immediately available to reverse the effects of erals)
heparin. c. Display (e.g., static vs. cine)
G. Processing d. Findings
Other than optional subtraction/contrast en- i. Onset
hancement or blood loss estimation, there is no ii. Location
routine processing. If the software is available, iii. Characteristics
motion correction may be used to minimize the (a) Size and Shape (e.g., focal, diffuse)
effects of patient movement. (b) Pattern of movement (e.g. moves
Subtraction Cine vs. stationary, serpentine small
The first frame or normalized summed set of bowel pattern vs. colonic, ante-
data can be subtracted from the latter images to grade or retrograde)
improve contrast. When using this technique, (c) Severity (e.g., waxing or waning
the patient must remain still during the exam or intensity, qualitative intensity
have appropriate motion correction software. compared to the liver, qualitative
H. Interpretation Criteria volume—large/small)
Accurate interpretation of GI bleeding scintigra- e. Study limitations, confounding factors
phy requires knowledge of the normal and ab- f. Interpretation (e.g., positive, negative, in-
normal variations in the abdominal vascular determinate) and state location of bleeding
space. site
Labeled red blood cells rapidly reach equilib- J. Quality Control
rium within the vascular space of the liver, Quality control for the gamma camera, computer
spleen and great vessels. It is normal for some ra- system and image display are as described by the
dioactivity to be excreted in the urine and the Society of Nuclear Medicine Procedure Guideline for
urinary tract to be seen even when in vitro label- General Imaging.
ing is used. K. Sources of Error
Extravasated radiolabeled RBCs within the 1. Delay in implementing the procedure since
lumen of the bowel are identified as an area of bleeding may have stopped.
activity that increases in intensity with time, 2. Failure to use a computer to display dynamic
and/or as a focus of activity that moves in a pat- images as a movie. Subtle areas of bleeding
tern corresponding to the lumen of the large or may go undetected or the location of the
small bowel. Small bowel bleeding usually can bleeding may be inaccurately identified if im-
be distinguished from large bowel bleeding by ages are not reviewed as a movie. Use of win-
its rapid serpiginous movement. dowing levels and different color schemes on
GI bleeding scintigraphy may be used to esti- a computer display also facilitates the detec-
mate the severity of the bleeding. Factors associ- tion of subtle abnormalities.
ated with a low bleeding rate are visualization of 3. It is important to continue to acquire images
blood after one hour and activity less intense after abnormal activity is detected. Accurate
than the liver. Higher bleeding rates are associ- localization of the bleeding site is dependent
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL J UNE 2002 • 49

upon identification of the focus of initial and 150 mg/dose for adults. Glucagon relaxes
blood collection, and upon the movement of the smooth muscles of the gastrointestinal tract,
the blood away from the bleeding focus. decreasing peristalsis. The dose for glucagon is
4. The entire abdomen must be examined be- 50 micrograms/kg i.v. 10 min after the Tc-99m
fore concluding that no bleeding was de- pertechnetate.
tected. A lateral, posterior and/or sub-pubic It is not recommended that an H2 blocker and
view is best to help in identifying activity in pentagastrin be combined since H2 blockers an-
the rectum that would otherwise not be de- tagonize pentagastrin.
tected due to overlying bladder activity or Pharmacologic pre-treatment is not consid-
soft tissue attenuation. ered necessary for performing a high-quality
5. Inexperienced readers may mistake mesen- Meckel’s scan.
teric varices or penile blood pool for areas of Determine whether the patient has had recent
bleeding. A full urinary bladder may ob- in-vivo RBC labeling where all circulating RBC
scure sigmoid or rectal bleeding. Radioac- were treated with stannous ion via i.v. adminis-
tive urine in the renal pelvis of a trans- tration of a “cold” pyrophosphate kit. If so, the
planted kidney, in either the right or left Meckel’s scan may be compromised, since i.v.
lower quadrant of the abdomen, may look Tc-99m pertechnetate will label RBC rather than
like colonic activity. concentrate in ectopic gastric mucosa. This may
6. Gastric mucosal and renal activity is seen occur for days after the administration of stan-
when free Tc-99m pertechnetate is present. nous pyrophosphate. This is not a problem with
This potential source of error can be avoided in-vitro labeling.
by using in vitro RBC labeling method and Patients may also be placed in a left lateral de-
performing QC for free pertechnetate, and cubitus position to decrease small bowel activity
by recognizing that intraluminal blood arising from the stomach. Nasogastric tube suc-
moves in a distinct pattern. Images of the tion has also been used for this purpose.
thyroid and salivary glands can confirm the B. Information Pertinent to Performing the
presence of free Tc-99m pertechnetate as a Procedure
source of artifact. 1. History of past bleeding episodes
2. Results of prior studies to localize the bleed-
ing site
Meckel’s Diverticulum Scintigraphy
3. Has in-vivo RBC labeling been done?
A. Patient Preparation 4. Clinical signs of active bleeding
Pretreatment with pentagastrin, Histamine H2 C. Precautions
blockers or glucagon is reported to enhance the None
sensitivity of the Meckel’s scan. Pentagastrin is a D. Radiopharmaceuticals (see Tables)
potent stimulator of gastric secretions and in- E. Image Acquisition
creases gastric mucosa uptake of pertechnetate. 1. Equipment
It also stimulates secretion of pertechnetate and Camera: Large field-of-view
GI motility, potentially reducing ectopic site ac- Collimator: A low energy, all-purpose, paral-
tivity. Pentagastrin is administered subcuta- lel hole collimator is preferred.
neously, 6 micrograms/kg 15 to 20 min prior to Photopeak: Typically 20% window at 140
injecting the Tc-99m pertechnetate. Histamine keV.
H2 blockers (cimetidine, ranitidine) block secre- Computer: 128 x 128 matrix, single or 2-byte
tion from the cells and increase gastric mucosa mode.
uptake. Oral cimetidine should be administered, 2. Patient position: Supine (optional: left lateral
300 mg QID x 2 days in adults, 20 mg/kg/day x decubitus)
2 days in children, or 10–20 mg/kg/day in 3. Imaging field: Abdomen and pelvis
neonates prior to starting. Intravenous cimeti- 4. Acquisition Protocol
dine should be administered at a rate of 300 mg a. Optional acquisition of anterior abdominal
in 100 ml of D5W over 20 min with imaging start- flow images (1–5 sec/frame x 1 min).
ing 1 hr later. Ranitidine may be substituted for b. Anterior abdominal images at a frame rate
cimetidine. Ranitidine dosage is 1 mg/kg i.v. for of one image every 30–60 sec for at least 30
infants, children and adults, up to a maximum of min (some favor 60 min).
50 mg, infused over 20 min and imaging starting c. Additional static images, anterior oblique
one hr later, or 2 mg/kg/dose p.o. for children projections, laterals and posterior projec-
50 • GI BLEEDING/MECKEL’S DIVERTICULUM SCINTIGRAPHY

Radiation Dosimetry in Adults
Radiopharmaceutical Administered Organ Receiving the Effective Dose*
Activity Largest Radiation Dose*
MBq mGy mSv
(mCi) (rad) (rem)
Tc-99m pertechnetate 300 – 450 i.v. 0.062 0.013
ULI#
(8 – 12) (0.23) (0.048)

*per MBq (mCi)
# Upper Large Intestine
(ICRP 53 page 199, no blocking agent)

tion views are recommended at the end of though classically it is seen in the right lower
the dynamic acquisition. Stopping the dy- quadrant. The activity that is most often con-
namic acquisition to obtain these images fused for a Meckel’s diverticulum is activity in
when abnormal activity is first seen can be the kidneys, ureter or bladder. Activity in the
helpful to distinguish activity in a Meckel’s urinary tract usually first appears after activity is
diverticulum from activity in the kidney, seen in the normal gastric mucosa. Small
ureter or bladder. Post-void images can Meckel’s diverticulum may seem to appear at a
also be helpful to detect activity in a later time than the stomach.
Meckel’s diverticulum observed by the uri- Pertechnetate that is secreted by the gastric
nary bladder. mucosa will gradually accumulate in the small
F. Interventions bowel. This activity can be distinguished from a
See Patient Preparation (IV.A) above. Meckel’s diverticulum by its delayed appearance
A urinary catheter to drain the bladder of ac- and by its appearance as an area of mildly, ill-de-
tivity can be helpful if the Meckel’s diverticulum fined increased activity.
is adjacent to the bladder. Viewing the dynamic image as a cine on a
Alternatively, decubitus or upright views can computer display that also permits adjustment
sometimes cause the Meckel’s diverticulum to of image contrast is helpful.
fall away from the bladder. I. Reporting
G. Processing Aside from patient demographics, the report
None should include the following information:
H. Interpretation Criteria 1. Indication for the study
Activity in the ectopic gastric mucosa should ap- 2. Procedure
pear at the same time as the activity in the nor- a. Radiopharmaceutical
mal gastric mucosa. A Meckel’s diverticulum i. Dose
may appear anywhere within the abdomen, al- ii. Method of administration (i.v.)

Radiation Dosimetry in Children
(5 year old)
Radiopharmaceutical Administered Organ Receiving the Largest Effective Dose*
Activity Radiation Dose*
MBq mGy mSv
(mCi) (rad) (rem)
Tc-99m pertechnetate 4.0 – 6.0 i.v. 0.21 0.040
ULI#
(0.11 – 0.16) (0.78) (0.15)

*per MBq (mCi)
#Upper Large Intestine
(ICRP 53 page 199, no blocking agent )
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL JUNE 2002 • 51

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VIII. Disclaimer
Siddiqui AR, Schauwecker DS, Wellman HN, et al.
Comparison of technetium-99m sulfur colloid and The Society of Nuclear Medicine has written and
in-vitro labeled technetium-99m RBCs in the detec- approved guidelines to promote the cost-effective
tion of gastrointestinal bleeding. Clin Nucl Med use of high quality nuclear medicine procedures.
1985;10:546–549. These generic recommendations cannot be applied
Smith R, Copely DJ, Bolen FH. 99m Tc RBC scintigra- to all patients in all practice settings. The guidelines
phy: correlation of gastrointestinal bleeding rates should not be deemed inclusive of all proper proce-
with scintigraphic findings. Am J Roentgenology dures or exclusive of other procedures reasonably
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Meckel’s Diverticulum Studies
tients seen in a more general practice setting. The
Datz FL, Christian PE, Hutson W, et al. Physiological appropriateness of a procedure will depend in
and Pharmacological Intervention in part on the prevalence of disease in the patient
Radionuclide Imaging of the Tubular Gastro- population. In addition, the resources available to
intestinal Tract. Sem Nucl Med 1 9 9 1 ; 2 1 ( 2 ) : care for patients may vary greatly from one med-
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glucagon, secretin and perchlorate on the gastric Advances in medicine occur at a rapid rate. The
handling of 99m-Tc-pertechnetate in mice. Radiol- date of a guideline should always be considered in
ogy 1976;120:629–631. determining its current applicability.