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 Table of Contents     
CASE REPORT
Year : 2017  |  Volume : 32  |  Issue : 3  |  Page : 233-234  

Gallbladder visualization on Tc-99m-labeled red cell scintigraphy: A rare finding with an emphasis on role of single-photon emission computed tomography/computed tomography


1 Department of Nuclear Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
2 Department of Radiodiagnosis, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication13-Jun-2017

Correspondence Address:
Sanjay Gambhir
Department of Nuclear Medicine, SGPGIMS, Raebareli Road, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_40_17

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   Abstract 

Tc-99m labeled red blood cell (RBC) scintigraphy is one of the most sensitive tests to diagnose occult gastrointestinal (GI) bleed. Visualization of gallbladder is a rare finding in this study. Most of the previously reported cases with similar false-positive finding were associated chronic renal failure, anemia, and received multiple blood transfusions. Thus, while interpreting GI bleed scan, a thorough clinical history is of utmost importance to avoid any false-positive findings. Here, we report a case of gallbladder visualization in 99mTc-RBC scintigraphy confirmed by single-photon emission computed tomography/computed tomography in a patient with chronic renal failure and anemia with failed renal transplant within 3 months.

Keywords: Chronic renal failure, gallbladder, gastrointestinal bleeding scintigraphy, single-photon emission computed tomography/computed tomography, Tc-99m red blood cell scintigraphy


How to cite this article:
Kumar N, Singh RK, Dutta D, Ravina M, Kheruka SC, Gambhir S. Gallbladder visualization on Tc-99m-labeled red cell scintigraphy: A rare finding with an emphasis on role of single-photon emission computed tomography/computed tomography. Indian J Nucl Med 2017;32:233-4

How to cite this URL:
Kumar N, Singh RK, Dutta D, Ravina M, Kheruka SC, Gambhir S. Gallbladder visualization on Tc-99m-labeled red cell scintigraphy: A rare finding with an emphasis on role of single-photon emission computed tomography/computed tomography. Indian J Nucl Med [serial online] 2017 [cited 2017 Jun 24];32:233-4. Available from: http://www.ijnm.in/text.asp?2017/32/3/233/207890




   Introduction Top


Gastrointestinal bleeding scintigraphy (GIBS) is performed on patients with suspected gastrointestinal (GI) bleeding to determine whether the bleeding is active and to localize the bleeding site. GIBS enables continuous monitoring of the GI tract up to 24 h.[1] The power of this study is to perform continuous imaging which increases the possibility of detection of intermittent bleeding over modalities which are limited to only a single-time point or periodic sampling.[2],[3],[4]99m Tc-labeled red blood cell (RBC) and 99m Tc sulfur colloid scans are two commonly used nuclear medicine procedures to detect active bleeding. More prolonged or delayed imaging is possible with 99m Tc-labeled RBC, but a thorough knowledge of possible pitfalls is required to avoid misinterpretation of the bleeding location because of a higher likelihood of radiotracer movement through the bowel away from the bleeding site.


   Case Report Top


A 16-year-old boy, known case of chronic glomerulonephritis underwent renal transplantation in October 2010, followed by graft failure within 3 months. The patient was kept on continuous ambulatory peritoneal dialysis and intermittent hemodialysis. Subsequently, he developed severe anemia (hemoglobin-5.0 mg/dl) and received multiple units of blood transfusion. The anemia deteriorated (hemoglobin-4.0 mg/dl) and abdominal CT angiography to locate the site of bleeding, was normal.99m Tc-labeled RBC scan was performed by modified in vitro method to locate the site of any occult GI bleed.

Static images at 2 h [Figure 1]a and 24 h [Figure 1]b revealed an abnormal focal tracer uptake in the right hypochondrium (blue arrow). Single-photon emission computed tomography/computed tomography (SPECT/CT) images of the abdomen [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d,[Figure 2]e,[Figure 2]f, acquired at 2 h to locate the site of tracer concentration (red arrow), revealed the tracer uptake at the gall bladder. Imaging was continued till 24 h to look for site of occult blood leak, but no further abnormal suspicious foci were found.
Figure 1: Static images at 2 h (a) and 24 h (b) revealed an abnormal focal tracer uptake in the right hypochondrium (blue arrow)

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Figure 2: SPECT/CT images of the abdomen (coronal images [a: CT, b: SPECT, c: SPECT/CT fusion] and transaxial [d: CT, e: SPECT, f: SPECT/CT fusion]), acquired at 2 h to locate the site of tracer concentration (red arrow), revealed the tracer uptake at the gall bladder. SPECT/CT: Single-photon emission computed tomography/computed tomography

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   Discussion Top


Anemia is a common finding in patients with renal failure.[5] Till now, only a few cases of gallbladder visualization during 99m Tc-labeled RBC scintigraphy for occult GI bleed have been reported in the literature.[6],[7],[8],[9] The common conditions among the previously reported and current study are chronic renal disease and multiple blood transfusions to treat the severe anemia. One of the reasons for the gallbladder visualization is attributed to the bile labeling, probably due to the breakdown of hemoglobin to bilirubin. However, Dewanjee [9] and Rehani andSharma [10] have demonstrated that most of the labeling of hemoglobin occurs on the Beta globin chains, the portion of the hemoglobin that does not contribute to the formation of bilirubin. However, Rehani et al. have reported that 75.8% ± 2.3% of the labeling occurs on the globin chain, and 19 ± 1.5% labeling occurs on the heme part.[10] Labeled heme part enters the biliary system as heme is the biochemical precursor of bilirubin. Another possible explanation proposed by David R Brill that prior multiple blood transfusions to treat renal failure-related anemia lead to the fragility of transfused cells, which abnormally accelerates the breakdown of these RBCs with unusual concentration of labeled bilirubin in the bile.[3] Our patient was treated with multiple blood transfusions and erythropoietin injections, following which the final hemoglobin (8 mg/dl) was maintained.


   Conclusion Top


SPECT/CT is a well-known modality known to provide better anatomical localization of tracer distribution. Even in our case, the confirmation of the anatomic localization was done by SPECT/CT. Hence, we recommend the use of SPECT/CT in case of abnormal tracer accumulation in the right hypochondrial region in the Tc-99m labeled RBC scintigraphy, done to avoid false-positive results as in our case. This is the first case reported from India which reveals gallbladder visualization during Tc-99m labeled RBC scintigraphy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Winzelberg GG, McKusick KA, Strauss HW, Waltman AC, Greenfield AJ. Evaluation of gastrointestinal bleeding by red blood cells labeled in vivo with technetium-99m. J Nucl Med 1979;20:1080-6.  Back to cited text no. 1
    
2.
Maurer AH. Gastrointestinal bleeding and cine-scintigraphy. Semin Nucl Med 1996;26:43-50.  Back to cited text no. 2
    
3.
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. 3
    
4.
Eckstein MR, Athanasoulis CA. Gastrointestinal bleeding. An angiographic perspective. Surg Clin North Am 1984;64:37-51.  Back to cited text no. 4
    
5.
Zadrazil J, Horak P. Pathophysiology of anemia in chronic kidney diseases: A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2015;159:197-202.  Back to cited text no. 5
    
6.
Abello R, Haynie TP, Kim EE. Pitfalls of a 99mTc-RBC bleeding study due to gallbladder and ileal-loop visualization. Gastrointest Radiol 1991;16:32-4.  Back to cited text no. 6
    
7.
Brill DR. Gallbladder visualization during technetium-99m-labeled red cell scintigraphy for gastrointestinal bleeding. J Nucl Med 1985;26:1408-11.  Back to cited text no. 7
    
8.
Howarth D, Davidson P. Neonatal gastric hemorrhage showing gallbladder visualization with Tc-99m red blood cell scintigraphy. Clin Nucl Med 2002;27:524-6.  Back to cited text no. 8
    
9.
Dewanjee MK. Binding of 99m Tc ion to hemoglobin. J Nucl Med 1974;15:703-6.  Back to cited text no. 9
    
10.
Rehani MM, Sharma SK. Site of Tc-99m binding to the red blood cell: Concise communication. J Nucl Med 1980;21:676-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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