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INTERESTING IMAGE
Year : 2016  |  Volume : 31  |  Issue : 1  |  Page : 72-73  

Splenic infarction as a pitfall on labeled red blood cell imaging


1 Department of Nuclear Medicine, Trakya University Medical Faculty, 22030 Edirne, Turkey
2 Department of Radiology, Trakya University Medical Faculty, 22030 Edirne, Turkey

Date of Web Publication21-Dec-2015

Correspondence Address:
Gul Ege Aktas
Department of Nuclear Medicine, Trakya University Medical Faculty, 22030 Edirne
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.172370

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   Abstract 

Patient with a history of overt gastrointestinal bleeding, diabetes mellitus, hypertension, polycythemia vera, and choledocojejunostomy was hospitalized because of hematemesis and melena. An area of Technetium-99m labeled red blood cells accumulation at the splenic flexure similar to an overt bleeding area, was observed on gastrointestinal bleeding scintigraphy (GIBS). In case of underlying malignancy, abdominal computed tomography was performed and demonstrated the infarction area placed laterally in spleen, appearing as a cold region on sctintigraphic image, separating the inferomedial and upper part of splenic uptake. Splenic variants and pathologies can complicate interpretation of GIBS.

Keywords: Gastrointestinal bleeding scintigraphy, labeled red blood cells, splenic infarction


How to cite this article:
Aktas GE, Demir SS, Genchellac H, Sarikaya A. Splenic infarction as a pitfall on labeled red blood cell imaging. Indian J Nucl Med 2016;31:72-3

How to cite this URL:
Aktas GE, Demir SS, Genchellac H, Sarikaya A. Splenic infarction as a pitfall on labeled red blood cell imaging. Indian J Nucl Med [serial online] 2016 [cited 2019 Nov 17];31:72-3. Available from: http://www.ijnm.in/text.asp?2016/31/1/72/172370

A 76-year-old woman with a history of diabetes mellitus, hypertension, polycythemia vera (PV), and previous choledocojejunostomy was hospitalized because of hematemesis and melena. The endoscopic evaluation revealed giant ulceration on the region of choledocojejunostomy anastomosis. Epinephrine infusion was performed to the determined artery on the site of anastomosis. Because of recurrent hematemesis, computed tomography (CT) angiography was performed, but a focus of active bleeding could not be determined. The operation was considered and in case of underlying malignancy CT of the abdomen was performed at same day with gastrointestinal bleeding scintigraphy (GIBS) to determine the site of bleeding. An area of Technetium-99m labeled red blood cells (99mTc-RBCs) accumulation at the splenic flexure, inferomedial site of spleen, similar to a bleeding area was observed [Figure 1]a-d at the early anterior (a), posterior (b) and late anterior (c), posterior (d) scintigraphic images. But the activity accumulation was not moving antegrade or retrograde along the gastrointestinal tract. Ýn correlation with CT images, the accumulation nearby splenic flexure determined as inferomedial part of the enlarged spleen. And the cold region on the sctintigraphic image was corresponding to infarction area [Figure 2]a and b.
Figure 1: An area of Technetium-99m labeled red blood cells accumulation at the splenic flexure, inferomedial site of spleen, similar to a bleeding area was observed (a-d) at the early anterior (a) posterior (b) and late anterior (c) posterior (d) scintigraphic images

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Figure 2: (a and b) Coronal and axial contrast-enhanced computed tomography scan shows an enlarged spleen with splenic infarction, classically described as, peripheral wedge-shaped and low in density region in the middle portion of the spleen

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GIBS is a noninvasive study that is performed with 99mTc-RBCs to determine whether the bleeding is active, to localize the bleeding site and to approximate the bleeding volume. The diagnostic criteria for scintigraphic gastrointestinal bleeding are the appearance of activity outside the expected anatomic blood pool structures, a change in the intensity of activity on consecutive images and movement of activity in a pattern consistent with bowel. [1] But higher bleeding rates are associated with the early appearance of blood in the area and activity can be as intense as or greater than the liver. [2]

False positive results because of increased Tc-99m-RBCs activity due to other causes in literature are; penile blood pool mistaken for rectal bleeding, variable uterine activity during the ovulatory cycle, uterine leiomyoma, renal activity especially from an unexpected location such as a pelvic or ectopic kidney, horseshoe kidney, or a renal transplant and pooling of urine activity. [3],[4],[5],[6],[7]

Vascular causes of abnormal RBC distribution on GIBS can include aneurysms of the abdominal aorta, gastroduodenal artery, iliac artery, and other arterial vessels. Vascular grafts and arterial leaks can also mimick gastrointestinal bleeding. In addition, aortoduodenal fistula rupture, hemangiomas in the liver or small bowel, and abdominal varices are other causes of false positive GIBS. [1],[7],[8]

Splenic variants and pathology can also cause fixed activity in the form of accessory spleens and splenosis. [9] Retroperitoneal bleeding can show focal uptake that grows in intensity but is not expected to move in a luminal pattern. [10] We represented a case with splenic infarction causing abnormal RBC distribution. The area of activity accumulation was seen on the early imaging in accordance with the patient's history of overt gastrointestinal bleeding. But it was neither moving like gastrointestinal bleeding, nor growing in intensity like retroperitoneal bleeding. Splenic infarction is associated with benign conditions such as hypercoagulable states, sickle hemoglobinopathies, and malign hematological disorders, also diabetes mellitus. Splenic infarction may be rare but the first evidence of thrombosis in PV. [11] The patient in this case represented with PV, diabetes mellitus, hypertension, choledocojejunostomy, and overt gastrointestinal bleeding. An area of Tc-99m-RBCs accumulation at the splenic flexure was determined as inferomedial part of the enlarged spleen in correlation with CT images. And the cold region on the sctintigraphic image was corresponding to infarction area on CT.

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Dam HQ, Brandon DC, Grantham VV, Hilson AJ, Howarth DM, Maurer AH, et al. The SNMMI procedure standard/EANM practice guideline for gastrointestinal bleeding scintigraphy 2.0. J Nucl Med Technol 2014;42:308-17.  Back to cited text no. 1
    
2.
Smith R, Copely DJ, Bolen FH. 99mTc RBC scintigraphy: Correlation of gastrointestinal bleeding rates with scintigraphic findings. AJR Am J Roentgenol 1987;148:869-74.  Back to cited text no. 2
    
3.
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4.
Karacalioglu O, Ilgan S, Arslan N, Ozguven M. Uterine doughnut in early proliferating phase: Potential pitfall in gastrointestinal bleeding studies. Ann Nucl Med 2003;17:685-7.  Back to cited text no. 4
    
5.
Gafton AR, Caride VJ. Fibroid uterus confounding the correct localization of active gastrointestinal bleeding during Tc-99m RBC scan. Clin Nucl Med 2006;31:508-10.  Back to cited text no. 5
    
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Infante JR, González FM, Vallejo JA, Torres M, Pacheco C, Latre JM. False-positive results of a gastrointestinal bleeding study caused by an ectopic kidney. Clin Nucl Med 2000;25:645-6.  Back to cited text no. 6
    
7.
Mariani G, Pauwels EK, AlSharif A, Marchi S, Boni G, Barreca M, et al. Radionuclide evaluation of the lower gastrointestinal tract. J Nucl Med 2008;49:776-87.  Back to cited text no. 7
    
8.
Ziessman HA. Gastrointestinal system. In: Biersack HJ, Freeman LM, editors. Clinical Nuclear Medicine. Berlin: Springer-Verlag Berlin, Heideberg, New York; 2007. p. 213-38.  Back to cited text no. 8
    
9.
Mavi A, Degirmenci B, Bekis R, Durak H. Intra-abdominal splenosis mimicking massive gastrointestinal bleeding. Clin Nucl Med 2003;28:226-7.  Back to cited text no. 9
    
10.
Ring DH, Silverman ED. Scintigraphic detection of an occult bleed into a retroperitoneal mass using Tc-99m labeled red blood cells. Clin Nucl Med 1997;22:765-7.  Back to cited text no. 10
    
11.
Nores M, Phillips EH, Morgenstern L, Hiatt JR. The clinical spectrum of splenic infarction. Am Surg 1998;64:182-8.  Back to cited text no. 11
    


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