GASTROINTESTINAL (GI) BLEEDING: SCINTIGRAPHIC DETECTION AND LOCALIZATION

Case presentation:
• An elderly male patient with recurrent gastrointestinal bleeding as evident by continuous malena stool. Had blood transfusion on account of anaemia. • Was referred for Tc-99m Red blood cell scan for localization of the source of GI bleeding.

Development of oesophagus

Development of stomach & duodenum

Development of the mid & hind gut

Large intestine is different from small intestine by:
• • • • Omental appendices Teniae coli Haustra Greater caliber

Anatomy of the GIT (arterial supply)

Anatomy of the GIT (venous drainage)

Introduction to the GIT bleeds
• Definition: • Bleeding from the GI tract may present in 5 ways.
– Hematemesis – Melena – Hematochezia – Occult GI bleeding – Symptoms of blood loss

Introduction to the GIT bleeds contd.
• Definition contd: • Upper GI bleeding
– Source in the upper GIT (above the lig. of Treitz)

• Lower GI bleeding
– Source in the small intestine or colon (below the lig. of Treitz)

• Obscure GI bleeding
– Recurrent acute or chronic bleeding for which no known source is identified

• Incidence:
– Upper GI bleeds: 100/100,000 person/year hospital admission (UK & US) – Lower GI bleeds: 100/500,000 persons/yr (UK & US)

• Mechanism: • Disruption of the GI mucosa secondary to:
– inflammation, infection, trauma, or cancer

• Vascular abnormalities, eg
– vascular ectasias or varices due to portal hypertension

Causes of GI bleeds:
• Upper GI bleeding
– Ulcers (31–59%) – Varices (7–20%) – Mallory–Weiss tears (4–8%) – Gastroduodenal erosions (2–7%) – Erosive esophagitis (1–13%) – Cancer (2–7%) – Vascular ectasias (0–6%) – No source identified (8–14%)

Causes of GI bleeds:
• Lower GI bleeding
– Diverticulosis (33–50%) – Vascular ectasias (8–20%) – Tumors (19%) – Colitis (18%) – Hemorrhoids or anal fissures (5%) – Meckel’s diverticulum Pseudomelena
• Ingestion of iron, bismuth, licorice, beets, blueberries, charcoal, or red-tinted foods (e.g., red gelatin)

Imaging in GI bleeds:
• 99mTc-Sc/99mTc-RBC Scintigraphy: • Useful in lower GI bleeds • First demonstrated in 1977 by Alavi et al using 99mTc- Sulphur colloid (99mTc- SC) • In 1979, Winzelberg et al used 99mTc- labeled red blood cell (99mTc-RBC) • Other tracers in GI bleeds: 99mTc-labeled heat treated RBC, 111In-labeled RBC

99mTc-Sc
Dose Dosimetry 10mCi

Vs 99mTc-RBC
20mCi 0.4 rad (WB) 2.0 rad (heart) 2.2 spleen

0.2 rad (WB) 3.4 rad (liver) 2.1 Spleen

Minimal bleeding detectable
Labeling Imaging duration Advantages

0.1ml/min
Commercial kit 20 – 30 min (repeat once) Short imaging time High target to background ratio Difficulty detecting hepatic & splenic flexure bleeding

0.05 – 0.4 ml/min
Commercial kit 60 – 90 mins (repeat as needed up to 24 hrs) Repeat imaging up to 24 hrs False positive due to free Pertechnetate

Disadvantages

99mTc-Sc

scintigraphy

• Mechanism of localization of GI bleeds: • IV injection • Rapidly extracted from the serum (1/2 life = 3mins) by RES • Cleared from the vascular system by 15mins • 99mTc-Sc extravasates at the bleeding site into the bowel lumen • High target to background ratio results from continuous extravasation

99mTc-Sc

scintigraphy contd

99mTc-Sc

scintigraphy contd.

Time–activity curves demonstrate rapid clearance of background and increasing activity at the bleeding site

Imaging protocol for 99mTc-Sc
• Patient preparation: none specific • Dose: 10mCi (370MBq)/ IV • Instrumentation:
– Camera: large field of view – Collimator: LEHR, parallel hole – Computer set up: 1 sec/frame ant.flow images for 60 sec, followed by 1 -2 mins for 30 mins & static images (oblique, lat & post) 500 – 750k counts images

Imaging protocol for 99mTc-Sc contd.
• Patient position:
– Supine; entire abdomen & pelvis in the field of view

• Imaging procedure:
– No bleeding detected, 1000k count ant &oblique images of the upper abdomen. Negative = ant view of lower abdomen – Negative scan, recurrent bleeding, repeat above procedure

Imaging protocol for 99mTc-Sc contd
• Image interpretation:
– may be detected on flow/ static images – will move in an intestinal tract (antegrade/retrograde) – False positive: ectopic spleen, renal transplant, bone marrow)

Tc-99m Sc study: descending colon bleed.

99mTc-RBC

Scintigraphy

• Methods of Radiolabeling RBC: • In vivo method (labeling efficiency = 75–80%):
– Add 4.5 mls of water for injection into the stannous pyrophosphate – Inject IV 0.03ml/kg (2.25/75kg) – Wait 15 – 20 mins – Inject IV 555 – 740 MBq (15 – 20 mCi) of Napertechnetate

Methods of Radiolabeling RBC contd:
• Modified in vivo (labeling efficiency = 85 – 90%)
– Inject stannous pyrophosphate – Wait 15 – 20 mins – Withdraw 5 – 8 mls of blood into a shielded syringe + 99mTc – Gently mix syringe content for 10 mins @ RT – Re-inject

Methods of Radiolabeling RBC contd:
• In vitro (labeling eff. 98%)
– Add 4 mls heparinized blood to reagent vial (Sn2+, Na citrate, dextrose + NaCl) – Incubate @ RT – Add 2 mls 4.4% EDTA & Centrifuge – Withdraw 1.25 mls of packed RC – Add to vial of 99mTc & incubate @ RT for 10mins

Methods of Radiolabeling RBC contd:
• In vitro commercial kit (labeling eff. > 97%) • Add 1 – 3mls of anticoagulated blood to reagent vial • Add Na hypochlorite • Add citric acid, Na citrate & dextrose • Add 370 – 3700MBq • Mix & allow to react for 20 mins • Then inject IV

Causes of poor 99mTc-RBC labeling
Drug Stannous ion Heparin Mechanism/comment Too little/too much Formation of 99mTc labeled heparin complex Oxidizes stannous ion Oxidation of stannous ion Labeling efficiency Production of antibodies to RC

Methyldopa Doxorubicin Quinidine

Iodinated contrast

Stannous reducing capacity, Alteration of 99mTc binding sites Competition for RBC binding sites

Dosimetry for GI bleeding: 99mTc-Sc & 99mTc-RBC
99mTc-RBC

(rads /20mCi)

99mTc-Sc

(rads /10mCi)

Heart wall Bladder wall Spleen Blood Liver Red marrow Ovaries Testes

2.0 0.48 2.2 0.08 0.58 0.30 0.32 0.22 3.40 0.27 0.06 0.01 2.10

Whole body

0.3

0.19

Imaging protocol for 99mTc-RBC
• Patient preparation: none specific • Dose: 20mCi (740MBq)/ IV • Instrumentation:
– Camera: large field of view – Collimator: LEHR, parallel hole – Computer set up: 1 sec/frame ant.flow images for 60 sec, then 1 min frame for 60 -90 mins – 2- 4 hrs delayed @ 1 min/frame for 20 – 30 mins – Static images: 2-3 sec flow images & 1000k counts images

Imaging protocol for contd.
• Patient position:

99mTc-RBC

– Supine; entire abdomen & pelvis in the field of view

• Imaging procedure:
– Views: ant, oblique, lat & post. – Negative findings/recurrent bleeding, repeat 30 min acquisition

Creteria for diagnosis of bleeding site
• Focal activity in the bowel lumen • Activity increases with time • Activity movement conforms to intestinal anatomy • Movement may be antegrade or retrograde

Pitfalls in interpretation of 99mTc RBC scintigraphy
Common Free Pertechnetate in stomach, small & large GI Pelvic kidney Ectopic kidney Ureter Bladder Uterine blush penis Uncommon Accessory spleen Hepatic hemangioma Varices; esophageal & gastric Caput medusae Gallbladder varices Pseudoanurysm Arterial grafts Miscellaneous : Rare Abdominal varices Abdominal aortic aneurysm Gastroduodenal artery aneurysm

Cutaneous hemangioma Duodenal telangiectasia

Gallbladder Factitious GI bleeding

Initial flow images

1st set dynamic images

2nd set of dynamic images

Last set of dynamic images

1 hour images

2 hour images

4 hour images

other modalities of detecting GI bleeds:
• Angiography
– Useful in upper GI bleeds – Limited use in lower GI bleeds – Its success depends on:
• Rate of bleeds @ 0.5mls/min • Types (arterial Vs venous) • Time of exam (active bleeding)

• Endoscopy • Upper GI barium radiography
– Accuracy ~80% in identifying an upper GI lesion – Does not confirm source of bleeding – Acceptable alternative to endoscopy in resolved or chronic low-grade bleeding

• CT and MR enterography are newer imaging techniques currently being investigated

Angiography Vs scintigraphy
Angiography Scintigraphy

•Invasive
•Upper GI bleeds •Demonstrate bleeding only when contrast is injected •Repeated study not practical Can detect bleeding rate @0.5mls/min

Non invasive
Lower GI bleeds Can demonstrate bleeding hours after tracer injection Can be repeated Rate @ 0.05 – 0.1mls/min

Treatment approach:
• Hemodynamic resuscitation and stabilization • Procedural intervention
– Endoscopic hemostatic therapy – Colonoscopic removal of bleeding polyp or mass – Surgical resection if necessary

• Targeted medical therapy, e.g in:
– Infection – Peptic ulcer dx.

Thank you

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