Indian Journal of Nuclear Medicine

: 2011  |  Volume : 26  |  Issue : 5  |  Page : 20--23



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. Gastroenterology.Indian J Nucl Med 2011;26:20-23

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. Gastroenterology. Indian J Nucl Med [serial online] 2011 [cited 2022 May 19 ];26:20-23
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Comparative performance of capsulated vs non-capsulated 14 C-urea breath test for the detection of Helicobacter pylori infection

C M Pathak, B Kaur, DK Bhasin, BR Mittal 2 , S Sharma 2 , KL Khanduja

Departments of Biophysics, 1 Gastroenterology, 2 Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Introduction: Conventionally, 14 C-urea breath test ( 14 C-UBT) is employed as a 'gold standard' technique for the detection of active Helicobacter pylori (H. pylori) infection, to follow up the patients after its eradication and for epidemiological evaluations. Due to high accuracy of this test and other benefits it is recommended as the best option for "test-and-treat" strategy in primary health care centers. So far no appropriate study has been done to compare the performance of 14 C-UBT using capsulated versus non-capsulated protocol. In this study, we employed a novel technique of performing capsulated 14 C-UBT with simultaneous monitoring the dynamic movement of capsule and compared the results with non-capsulated protocol. Materials and Methods: Fifty eight H. pylori infected patients (39 M, 19 F, mean age 41.05±10.56 yrs) presented with upper gastrointestinal symptoms were included this study. Upper GI endoscopy was done in majority of cases and biopsies obtained from multiple sites for histopathological examination and rapid urease test. Non-capsulated 14 C-UBT with 37 kBq 14 C-urea was performed in routine manner and next day the study was repeated by encapsulating 14 C-urea along with 5.55 MBq of Tc99m-diethylene triamine penta-acetic acid to follow its dynamic movement in gastrointestinal tract for 30 min using dual head gamma camera. Breath samples were collected in glass vials, containing 0.5 mmol benzethonium hydroxide in scintillation fluid, before and at 10, 15 and 20 min after oral administration of 14 C-urea. The level of exhaled 14 CO 2 in breath samples was measured by Liquid Scintillation Counter and results expressed as 14 CO 2 exhaled per mmol breath CO 2 (% administered dose). Value above 0.006% was considered as positive for infection. Results: Overall accuracy of 14 C-UBT for the detection of H. pylori infection was found to be 98.66 vs 90.66% at 10 min, 96.0 vs 89.33% at 15 min and 93.33 vs 86.66% at 20 min using non-capsulated and capsulated UBT protocols respectively. While considering any one, two and all the three values together, accuracy was found to be 100 vs 93.33%, 96.0 vs 93.33% and 92.0 vs 84% for non-capsulated and capsulated UBT protocols respectively. Dynamic image acquisition of capsule in 3 cases clearly showed that capsule containing 14 C-urea moved out of the stomach without its resolution in less than 10 min after its ingestion. Discussion: This is the first study which provides direct scintigraphy based evidence showing that the misdiagnosis of H. pylori infection may occur in case of capsulated 14 C-UBT due to either rapid transit of 14 C-urea containing capsule from the stomach or its incomplete/non-resolution in stomach during the phase of breath collection. Higher accuracy of non-capsulated 14 C-UBT at all time points shows its superiority over the non-capsulated protocol since ingested 14 C-urea immediately comes in contact globally in stomach; whereas it doesn't happen in case of capsulated protocol till the capsule resolutes completely or partially before the phase of breath collection. Conclusion: Application of non-capsulated 14 C-UBT appears to be a superior option than the conventional capsule based protocol for the detection of H. pylori infection.


Effect of Gastro-jejunostomy technique on gastric empying in patients undergoing Whipples surgery - Scintigraphic evaluation with liquids and solid meal

Anand Kumar, Tabassum Aijaz, Kumaresan K, Sanjeev M Patil 1 , Pradeep 1

KK Nuclear Scans and 1 Asian Institute of Gastroenterology, Hyderabad, Andhra Pradesh, India

Aim: To evaluate liquid and solid gastric emptying in patients who have undergone Whipples Pancreaticoduodenectomy and to compare the findings between supracolic and infracolic anastamosis of stomach and jejunum. Materials and Methods: A total of 88 patients (Age Mean 55 yrs. Range 14 to 70; Males 60, Females 30) underwent the procedure on the 7 th and 8 th postoperative day. Tc99m-Sulfur Colloid labelled batter was used to prepare idlis for solid meal.Tc99m DTPA was added to drinking water for the liquid study. The studies were performed on separate days in either sequence after over night fasting. Erect anterior and posterior isotime (1 min Each) images were obtained for every 15 mins upto 1 hr for liquid study and at every 1 hr upto 4 hrs for the solid study. The scans were categorized as normal and delayed based on exponential T1/2 value for the liquid study and percentage emptying at different timings (1 hr, 2 hrs, 4 hrs) for solid study. Results: Liquid emptying was delayed only in 31 patients (35%). In 29 out of these 31 patients, solid emptying was also delayed. However another 19 patients had discordant finding of delayed solid emptying when liquid was normal. Rapid emptying which is not considered abnormal in this study group was noted in 16% patients and is predominantly seen with infracolic anastamosis. The association of delayed emptying with the technique of anastamosis was found to be:


Conclusion: Our study shows that (i) gastric emptying of liquid and solid are affected to variable extent in patients undergoing Whipples surgery (ii) delayed emptying of liquid is a matter of concern than delayed solid emptying and (iii) infracolic anastamosis of stomach and jejunum is associated with better emptying and better outcome.


Role of Tc99m mebrofenin SPECT-CT in hepatobiliary scintigraphy in suspected cases of bile leak

S Arun, Santhosh Sampath, Kuruva Manohar, Raghav Kashyap, A Bhattacharya, B Singh, BR Mittal

Department of Nuclear Medicine and PET, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Introduction: Bile leak is one of the well recognised indications for hepatobiliary scintigraphy (HIDA). Though planar scintigraphy provides useful information, it might be difficult to localise and demonstrate the extent of biliary collection. SPECT-CT provides a unique advantage of providing anatomical localisation of the tracer activity. Although assumed to provide additional information, there has been no systematic study to document the added role of SPECT-CT in the assessment of bile leak. Objective: To establish the added value of SPECT-CT over planar HIDA in suspected cases of bile leak. Materials and Methods: Retrospective analysis of the data of all patients who underwent HIDA study with suspicion of bile leak from April 2008 to August 2011 was done. All patients had undergone an initial 45 min dynamic study, after i.v. injection of Tc99m Mebrofenin followed by multiple static images as required till 24 hrs. The dynamic and static as well as SPECT-CT images were reviewed by two nuclear medicine physicians independently. Results: A total of 183 HIDA studies were done in which 100 studies were positive for bile leak. Positive studies included cases with suspicion of bile leak following cholecystectomy (68), abdominal surgery (7), surgery for hydatid/amoebic cyst (10) and blunt trauma abdomen (15). In 44 studies SPECT-CT was done, which included 3 cases with no bile leak. The major indications for performing SPECT-CT were: (i) to distinguish whether a collection is inside liver, (intraparenchymal / subcapsular) or outside liver (subdiaphragmatic, perihepatic or in gall bladder fossa) (n=24) (ii) characterisation of intraparenchymal leak (n=6) (iii) characterisation of large abdominal collections (2 cases) (iv) characterisation of suspected contamination (4 cases) (v) suspected collection (3cases) (vi) miscellaneous (2 cases). In 31 patients with bile leak, SPECT-CT was useful in defining the exact location of collection (intracapsular vs extracapsular vs intraparenchymal leak (n=17), defining the extent of intraparenchymal collections (n=6), and defining the extent of large abdominal collections and contamination sites in two and four patients respectively. Defining the extent and exact localisation of collection can have therapeutic implications like accurate site of placement of drain for drainage. SPECT-CT was useful in cases with bile leak in 5/7 (71%) cases when performed within 2 hrs, 18/24 (75%) cases when done within 2-6 hrs, and in 8/10 (80%) cases when SPECT-CT was done after 6 hrs of start of respectively. In 34 of the 44 studies (77%), SPECT-CT was found to provide additional useful information over planar imaging. In 31 of the 100 cases (31%) where HIDA study was positive for bile leak, and the 3 cases negative for bile leak in which SPECT-CT was done, it had provided additional useful information over planar imaging. Conclusion: In 31% of all bile leak positive HIDA studies SPECT-CT had provided additional useful information over planar imaging. When done, SPECT-CT provided additional useful information over planar imaging in 77% cases. SPECT-CT is most useful in localising and defining the extent of biliary collections. It had decreased ambiguity in reporting, increased the confidence and accuracy of reporting and made it more objective.


hepatobiliary scintigraphy: Lighting the right (Hepatobiliary) track

Borde CR, PS Sundaram

Department of Nuclear Medicine and PET/CT, Amrita institute of Medical Sciences and research, Cochin

Introduction: Bile leaks are a cause of great morbidity in afflicted patients. Most of the biliary leaks are iatrogenic in origin. With increase in number of complicated laparoscopic maneuvers and increase in availability of liver transplant the incidence of biliary leaks is expected to increase. Endoscopic Retro-Cholangio Pancreaticography (ERCP) is a combined diagnostic as well as therapeutic procedure in such cases but comes with its own set of side effects. Hepatobiliary scintigraphy on the other hand is highly sensitive, non invasive test for demonstrating biliary leak. Aims and Objectives: This retrospective study was aimed at identifying the impact of hepatobiliary scintigraphy in management of patients with suspected bile leaks. We attempted to prognosticate these patients by qualitative as well as semi quantitative analysis of hepatobiliary scans. Materials and Methods: Hepatobilary scintigraphy scans done for 23 patients, referred to our center with suspicion of bile leak were retrospectively analyzed (year 2009- 2010). The patient's records were accessed for ERCP data, physician's notes and other clinical follow up. All patients underwent hepatobiliary scintigraphy with Tc99m- Membrofenin. Initial dynamic images were acquired for minimum of 30 mins followed by anterior and posterior static images every 30 to 40 mins till minimum of 4 hours and maximum of 24 hrs. SPECT/CT scan was also performed in all patients just after completion of dynamic images. Ultimate clinical outcome of the patient at 6 months of duration post hepatobiliary scintigraphy was taken as end point for the study. Results: Out of 23 patients 12 patients did not show any scintigraphic evidence of biliary leak. One patient from this group underwent ERCP due to persistent symptoms. ERCP in this patient was -ve for leak and patient was managed conservatively. Rest of the 11 patients did not require any further intervention and they all recovered well without any complications. This gives 100% ve predictive value to hepatobiliary scintigraphy in ruling out biliary leak. In remaining 11 patients 3 patients showed minimal leak, 3 patients had mild to moderate biliary leak and 5 patients showed significant leak. All the 3 patients who showed minimal leak did not require any endoscopic intervention and they were safely weaned off drain without further recurrence. All patients who had significant leak underwent ERCP with therapeutic intent. ERCP confirmed presence of leak and localized the site of leak to be corresponding to suspicious site as noted on scintigraphy. 4/5 (80%) of these patients had persistence/ recurrence of biliary leak post ERCP. 3 patients who had moderate biliary leak on scintigraphy underwent ERCP. ERCP confirmed the presence and site of leak in these patients. Conclusion: Many previous case reports and studies have shown hepatobiliary scintigraphy to be highly sensitive for diagnosis of biliary leak. In our study we did SPECT/CT as a routine part of the scintigraphy. We found SPECT/CT to be of help in delineating the track of bile leak and increased confidence in localizing the site of leak. We found that absence of biliary leak on scintigraphy in spite of strong clinical suspicion did not show any recurrence / persistence of biliary leak on follow up. This study shows that assessment of grade of leak on scintigraphy has a prognostic value for predicting response and triaging the patients for management. Based on above results we propose that hepatobiliary scintigraphy should routinely be used for triage of patients suspected to have biliary leak and SPECT/CT (if required) for further confidence in localizing the site of biliary leak.


Hybrid SPECT-CT with Tc99m-Mebrofenin for detection and localization of postoperative and post-traumatic bile leak

Kalpa Jyoti Das, Punit Sharma, Harmandeep Singh, Rakesh Kumar, Chandrashekhar Bal, Arun Malhotra

All India Institute of Medical Sciences, New Delhi, India

Purpose: To evaluate the role of single photon emission tomography-computed tomography (SPECT-CT) with Tc 99m -N-(3-bromo-2,4,6-trimethylacetanilide) iminodiacetic acid (Mebrofenin) for detection and localisation of post-operative and post-traumatic bile leak and compare the same with planar hepatobiliary scintigraphy (HBS). Materials and Methods: Data of 32 consecutive patients (Age-35.7±15.3 years; Female-53.2%) who underwent Tc99m-Mebrofenin planar HBS and SPECT-CT for suspected bile leak was prospectively collected and retrospectively analyzed. Twenty six patients were post-operative and six had history of abdominal trauma. Planar HBS and SPECT-CT images were evaluated by two experienced nuclear medicine physicians. Sensitivity, specificity, and predictive values, were calculated for planar HBS and SPECT-CT. Final diagnosis was established based on a combination of re-operative findings, follow up imaging and clinical follow up (1-4 week).For evaluation of observer confidence a third observer used a scoring scale of 1 to 5, with 1 being definite bile leak and 5 being no leak. Receiver operating characteristic (ROC) curves were drawn and the areas under the curves (AUC) were compared. Results: The sensitivity, specificity and accuracy of SPECT-CT were 88.8%, 100%, and 96.8% while that of planar HBS were 77.7%, 60.8% and 65.6% respectively. Planar HBS showed very low diagnostic accuracy compared to SPECT-CT (65.6% vs. 96.8%; P=0.021). It was false positive in 9 patients. SPECT-CT also correctly localised the site of bile leak in 8 of 9 patients. On ROC analysis the observer confidence for SPECT-CT was significantly better than that for planar scintigraphy (P=0.045). Conclusion: Tc99m-Mebrofenin hybrid SPECT-CT is highly sensitive and specific for detection and localisation of post-operative and post-traumatic bile leak. It is more accurate than planar HBS and should be routinely done in such patients


Utility of delayed imaging and SPECT/CT in Tc99m- labelled red blood cell scintigraphy

Reema Goel, Raghava Kashyap, Kuruva Manohar, Anish Bhattacharya, B Singh, BR Mittal

Department of Nuclear Medicine, PGIMER, Chandigarh, India

Introduction: Tc99 m labelled red blood cell scintigraphy plays an important role in demonstration and localisation of site of active bleeding. Prolonged or delayed imaging using Tc99m -labelled erythrocytes is possible but definite incremental role of delayed imaging up to 24 hrs in not known conclusively. Also role of hybrid SPECT/CT imaging in detection of bleeding is not well described. Objective: To evaluate the utility of delayed imaging (after 6 hours of radiotracer injection) and SPECT/CT in Tc99m labelled red blood cell scintigraphy. Materials and Methods: Ninety three consecutive gastrointestinal bleeding studies performed during the past 2 years (August 2009 to February 2011) in our department were reviewed retrospectively. All patients showing evidence of bleed during the initial dynamic study or up to 6 hours and those with signs of active bleed beyond 6 hours (up to 24 hours) were analysed separately. Results: In a total of 93 scans performed, there was evidence of bleed in 43 patients (34 males;9 females) on scintigraphy of which 29 (67.4%) patients showed signs of active bleed within 6 hours of start of the study whereas 14 (32.5%) showed positivity later. 21 patients (48.8%) had the site of bleeding localised to the small bowel, 14 (32.5%) in the large bowel, 5 (11.1%) in the stomach and 3 (7%) at the ileocaecal junction. Of 16 patients who presented with history of melena and a positive scan, 9 patients (56.25%) showed evidence of bleeding within 6 hours and the remaining 7 patients (43.75%) showed evidence of bleed thereafter. Of the 27 patients who presented with history of fresh bleeding per rectum, 19 patients (70.37%) showed evidence of bleed within 6 hours of study whereas the remaining 8 patients (29.63%) showed positivity thereafter. SPECT-CT Hybrid imaging performed in 12/43 (27.9%) patients having discrepancy regarding the site of bleeding, accurately localised the site of bleeding to the stomach in 3 patients, proximal jejunum in 1 patient, proximal ileum in 2 patients, distal ileum in 3 patients, transverse colon in 2 patients and ileocaecum in 1 patient. Conclusion: Delayed imaging detected bleed in total 32% of the patients. There was no significant difference in yield rates of delayed imaging in patients with fresh bleed or with melena. Hybrid SPECT/CT imaging helped in accurate localisation of the site of bleed in about 28% patients.


14 C Urea Breath Test as a diagnostic tool in Helicobacter pylori infection studies

Swaroop K, HM Somashekarappa, Jayachandran 1 , N Sivaprasad 1 , Khamar Jaha Banu 2

Centre for Application of Radioisotopes and Radiation Technology, Mangalore University, Mangalagangotri, 1 Board of Radiation and Isotope Technology, BRIT, Vashi Complex, Sector 20, Vashi, Navi Mumbai, 2 S Hegde Medical Academy, NITTE University, Deralakatte, Mangalore, India

Introduction: Helicobacter pylori are a Gram-negative, spiral shaped urease producing bacterium that lives in the stomach and duodenum. There is now irrefutable evidence that, this bacterium is responsible for the pathological processes leading to chronic active gastritis and severe gastro duodenal disease, including peptic ulcer, gastric cancer and gastric MALT (Mucosa Associated Lymphoid Tissue) lymphoma. H pylori are common and infect half of the world's population and all those infected will develop gastritis. Since its introduction to the scientific community by Marshall and Warren in 1982, H pylori have been the focus of clinical research and debate. Age, ethnicity, gender, geography and socio-economic status are all factors that influence the incidence and prevalence of H pylori infection. About 70% of all surgical consultation deals with symptoms of acid peptic diseases which includes gastritis, duodenitis, gastric ulcers, duodenal ulcers and gastric cancers. Though H pylori are not the cause in all, but it is responsible for majority of these conditions. Eradication of these bacteria causes complete cure of these conditions. Objective: By the application of radiation much progress has been made worldwide in the field of medicine. This article presents the application of 14 C Urea Breath Test (UBT) for the diagnosis of the H pylori bacteria which present in the stomach and duodenum. Generally, testing for H pylori infection have been carried out using conventional histological techniques on gastric and duodenal biopsies obtained during endoscopy. Endoscopy carries a small percentage of risk like cardiac complications and risk of aspiration. In addition, 14 C UBT has an advantage of assessing the total presence of H pylori throughout the stomach, where as the endoscopy based test are limited to focal assessments (at the site of biopsy) with the consequent risk of false-negative test due to sampling errors. Materials and Methods: H pylori bacterium is a urease producing enzyme and urea will react with urease to produce 14 CO 2 and ammonia. 1-3 Depending on this fact, 14 C labeled urea capsule has been developed by the Board of Radiation and Isotope Technology (BRIT, Mumbai). The biological half life of 14 C is 10 to 12 days. The capsule containing 1 mg of 14 C urea adsorbed on 350 mg of NPS, which is having the radioactivity 1 μCi (37 KBq) with radiochemical purity of 99%. It emits the low energy β-rays (49 KeV­mean, 156 KeVmax­) and no other radiations have been found. 14 C UBT is a qualitative and non invasive method for the diagnosis of H pylori. 14 C urea capsule is administered to the patient; urea is split to form 14 CO­ 2 and NH 3 if gastric urease from H pylori is present, ten minutes later the breath sample is collected in trapping solution. The collected breath samples are counted for radioactivity due to the presence of 14 C by Liquid Scintillation Counter (LSC). Results and Conclusion: The 14 C UBT method developed by BRIT, Mumbai is discussed in detail. Results obtained employing this method as a part of epidemiological studies conducted in coastal Karnataka region are analyzed, discussed and reported in this paper. Results are reported as disintegration per minute (DPM). Out of 40 samples collected and analyzed so far nearly 30% found to be H pylori positive. However, in case of subjects with symptoms it is found to be almost 42%, but with asymptomatic subjects it is found to be about 20%. Detailed results and discussion will be presented in the paper.