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** European Association for Nuclear Medicine (EANM) | ** European Association for Nuclear Medicine (EANM) | ||
* [[Technetium-99m|Technetium-99m pertechnetate scanning]] helps in the detection of a symptomatic [[bleeding]] Meckel’s diverticulum. | * [[Technetium-99m|Technetium-99m pertechnetate scanning]] helps in the detection of a symptomatic [[bleeding]] Meckel’s diverticulum. | ||
* It is preferred as the investigation of choice for the diagnosis of Meckel's diverticula in children due to the following features:<ref name="urlFundamentals of Pediatric Surgery - Google Books">{{cite web |url=https://books.google.com/books?id=-AAD9WiIZLAC&pg=PA773&lpg=PA773&dq=Mattei,+P.+(2011).+Fundamentals+of+Pediatric+Surgery.+New+York,+NY:+Springer+Science%2BBusiness+Media,+LLC.&source=bl&ots=VWeSV7HsOo&sig=p2LET6NVySpB-ANSdF3G1YmAzw8&hl=en&sa=X&ved=0ahUKEwip4uPoya3YAhUG_IMKHUn8ABIQ6AEIQTAD#v=onepage&q=Mattei%2C%20P.%20(2011).%20Fundamentals%20of%20Pediatric%20Surgery.%20New%20York%2C%20NY%3A%20Springer%20Science%2BBusiness%20Media%2C%20LLC.&f=false |title=Fundamentals of Pediatric Surgery - Google Books |format= |work= |accessdate=}}</ref> | * It is preferred as the investigation of choice for the diagnosis of Meckel's diverticula in children due to the following features:<ref name="urlFundamentals of Pediatric Surgery - Google Books">{{cite web |url=https://books.google.com/books?id=-AAD9WiIZLAC&pg=PA773&lpg=PA773&dq=Mattei,+P.+(2011).+Fundamentals+of+Pediatric+Surgery.+New+York,+NY:+Springer+Science%2BBusiness+Media,+LLC.&source=bl&ots=VWeSV7HsOo&sig=p2LET6NVySpB-ANSdF3G1YmAzw8&hl=en&sa=X&ved=0ahUKEwip4uPoya3YAhUG_IMKHUn8ABIQ6AEIQTAD#v=onepage&q=Mattei%2C%20P.%20(2011).%20Fundamentals%20of%20Pediatric%20Surgery.%20New%20York%2C%20NY%3A%20Springer%20Science%2BBusiness%20Media%2C%20LLC.&f=false |title=Fundamentals of Pediatric Surgery - Google Books |format= |work= |accessdate=}}</ref><ref name="pmid28972258">{{cite journal |vauthors=Mhiri A, Slim I, Ben Slimène F |title=Hemorrhagic Meckel's diverticulum. Interest of the digestive pertechnetate scintigraphy |journal=Tunis Med |volume=94 |issue=10 |pages=629–631 |year=2016 |pmid=28972258 |doi= |url=}}</ref><ref name="pmid28685802">{{cite journal |vauthors=Mhiri A, Slim I, Ben Slimène F |title=Hemorrhagic Meckel's diverticulum. Interest of the digestive pertechnetate scintigraphy |journal=Tunis Med |volume=94 |issue=8-9 |pages=629–631 |year=2016 |pmid=28685802 |doi= |url=}}</ref> | ||
** High accuracy | ** High accuracy | ||
** [[Non-invasive (medical)|Noninvasive]] nature | ** [[Non-invasive (medical)|Noninvasive]] nature | ||
| Line 19: | Line 19: | ||
** Approximately 50% of symptomatic Meckel's diverticula have [[Ectopia|ectopic]] [[Stomach|gastric]] or [[Pancreas|pancreatic cells]] contained within them<ref name="pmid10706156">{{cite journal |vauthors=Martin JP, Connor PD, Charles K |title=Meckel's diverticulum |journal=Am Fam Physician |volume=61 |issue=4 |pages=1037–42, 1044 |year=2000 |pmid=10706156 |doi= |url=}}</ref> | ** Approximately 50% of symptomatic Meckel's diverticula have [[Ectopia|ectopic]] [[Stomach|gastric]] or [[Pancreas|pancreatic cells]] contained within them<ref name="pmid10706156">{{cite journal |vauthors=Martin JP, Connor PD, Charles K |title=Meckel's diverticulum |journal=Am Fam Physician |volume=61 |issue=4 |pages=1037–42, 1044 |year=2000 |pmid=10706156 |doi= |url=}}</ref> | ||
* [[Technetium-99m|Technetium-99m pertechnetate scanning]] is not preferred in adults as [[Type I and type II errors|false negative]] rates are high with [[Specificity (tests)|specificity]] of 9% and [[Sensitivity (tests)|sensitivity]] of 62%. | * [[Technetium-99m|Technetium-99m pertechnetate scanning]] is not preferred in adults as [[Type I and type II errors|false negative]] rates are high with [[Specificity (tests)|specificity]] of 9% and [[Sensitivity (tests)|sensitivity]] of 62%. | ||
* Indications of Meckel's scan:<ref name="pmid12540005">{{cite journal |vauthors=Lin S, Suhocki PV, Ludwig KA, Shetzline MA |title=Gastrointestinal bleeding in adult patients with Meckel's diverticulum: the role of technetium 99m pertechnetate scan |journal=South. Med. J. |volume=95 |issue=11 |pages=1338–41 |year=2002 |pmid=12540005 |doi= |url=}}</ref><ref name="pmid23417523">{{cite journal |vauthors=Sinha CK, Pallewatte A, Easty M, De Coppi P, Pierro A, Misra D, Biassoni L |title=Meckel's scan in children: a review of 183 cases referred to two paediatric surgery specialist centres over 18 years |journal=Pediatr. Surg. Int. |volume=29 |issue=5 |pages=511–7 |year=2013 |pmid=23417523 |doi=10.1007/s00383-013-3270-3 |url=}}</ref><ref name="pmid29103471">{{cite journal |vauthors=Irvine I, Doherty A, Hayes R |title=Bleeding meckel's diverticulum: A study of the accuracy of pertechnetate scintigraphy as a diagnostic tool |journal=Eur J Radiol |volume=96 |issue= |pages=27–30 |year=2017 |pmid=29103471 |doi=10.1016/j.ejrad.2017.09.008 |url=}}</ref> | |||
** Patients with intermittent or less severe GI [[Bleeding|bleed]] | |||
** High suspicion of Meckel’s diverticulum | |||
** Failure to identify source of [[Bleeding|bleed]] | |||
* [[Type I and type II errors|False-positives]] are seen in the following conditions: | * [[Type I and type II errors|False-positives]] are seen in the following conditions: | ||
** [[Intussusception]] | ** [[Intussusception]] | ||
| Line 26: | Line 30: | ||
** [[Carcinoid Tumor|Carcinoid]] of the [[Vermiform appendix|appendix]] | ** [[Carcinoid Tumor|Carcinoid]] of the [[Vermiform appendix|appendix]] | ||
** [[Carcinoma]] of the [[cecum]] | ** [[Carcinoma]] of the [[cecum]] | ||
* On [[Intravenous therapy|intravenous]] administration, the [[Technetium-99m|Technetium-99m | * On [[Intravenous therapy|intravenous]] administration, the [[Technetium-99m|Technetium-99m pertechnetate radioisotope]] is taken up by the [[gastric mucosa]].<ref name="pmid15241619">{{cite journal |vauthors=Rerksuppaphol S, Hutson JM, Oliver MR |title=Ranitidine-enhanced 99mtechnetium pertechnetate imaging in children improves the sensitivity of identifying heterotopic gastric mucosa in Meckel's diverticulum |journal=Pediatr. Surg. Int. |volume=20 |issue=5 |pages=323–5 |year=2004 |pmid=15241619 |doi=10.1007/s00383-004-1189-4 |url=}}</ref> | ||
* In order to obtain a positive result, | * In order to obtain a positive result, at least 1.8 cm2 of [[Ectopia|ectopic]] [[gastric mucosa]] in Meckel's diverticulum is required. | ||
* A Meckel's diverticulum containing [[gastric mucosa]] manifests as a small rounded area of increased activity in the right lower quadrant. | * A Meckel's diverticulum containing [[gastric mucosa]] manifests as a small rounded area of increased activity in the right lower quadrant. | ||
* Normal activity simultaneously appears in the [[stomach]]. | * Normal activity simultaneously appears in the [[stomach]]. | ||
| Line 38: | Line 42: | ||
*** Blocks intraluminal release of [[isotope]] | *** Blocks intraluminal release of [[isotope]] | ||
*** Minimizes [[Type I and type II errors|false negative]] results | *** Minimizes [[Type I and type II errors|false negative]] results | ||
* | * Agents promoting retention of [[Technetium-99|99m technetium pertechnetate]]:<ref name="pmid729309">{{cite journal |vauthors=Petrokubi RJ, Baum S, Rohrer GV |title=Cimetidine administration resulting in improved pertechnetate imaging of Meckel's diverticulum |journal=Clin Nucl Med |volume=3 |issue=10 |pages=385–8 |year=1978 |pmid=729309 |doi= |url=}}</ref> | ||
** [[Aluminium hydroxide|Aluminum hydroxide]] | |||
* | ** [[Ranitidine]], Cimetidine | ||
[[File:Mgiff.gif|500px|center|thumb|Radionuclide scan or Technetium-99m scan in patients with Meckel's diverticulum <br> Source: Wikimedia commons <ref name="urlFile:Meckels Diverticulum by Technetium-99m Pertechnetate Scan.jpg - Wikimedia Commons">{{cite web |url=https://commons.wikimedia.org/wiki/File:Meckel%27s_Diverticulum_by_Technetium-99m_Pertechnetate_Scan.jpg |title=File:Meckel's Diverticulum by Technetium-99m Pertechnetate Scan.jpg - Wikimedia Commons |format= |work= |accessdate=}}</ref>]] | |||
==== Angiography ==== | ==== Angiography ==== | ||
* [[Angiogram|Angiography]] may assist in determining the location and severity of [[bleeding]] in case of a bleeding Meckel's diverticulum. | * [[Angiogram|Angiography]] may assist in determining the location and severity of [[bleeding]] in case of a bleeding Meckel's diverticulum. | ||
* In patients presenting with acute [[Gastrointestinal bleeding|GI bleeding]], [[Superior mesenteric artery|superior mesenteric]] [[Angiogram|angiography]] is effective if [[blood]] loss exceeds 0.5 mL/min(brisk [[bleeding]]). | * In patients presenting with acute [[Gastrointestinal bleeding|GI bleeding]], [[Superior mesenteric artery|superior mesenteric]] [[Angiogram|angiography]] is effective if [[blood]] loss exceeds 0.5 mL/min(brisk [[bleeding]]).<ref name="urlFundamentals of Pediatric Surgery - Google Books">{{cite web |url=https://books.google.com/books?id=-AAD9WiIZLAC&pg=PA773&lpg=PA773&dq=Mattei,+P.+(2011).+Fundamentals+of+Pediatric+Surgery.+New+York,+NY:+Springer+Science%2BBusiness+Media,+LLC.&source=bl&ots=VWeSV7HsOo&sig=p2LET6NVySpB-ANSdF3G1YmAzw8&hl=en&sa=X&ved=0ahUKEwip4uPoya3YAhUG_IMKHUn8ABIQ6AEIQTAD#v=onepage&q=Mattei%2C%20P.%20(2011).%20Fundamentals%20of%20Pediatric%20Surgery.%20New%20York%2C%20NY%3A%20Springer%20Science%2BBusiness%20Media%2C%20LLC.&f=false |title=Fundamentals of Pediatric Surgery - Google Books |format= |work= |accessdate=}}</ref> | ||
* Conventional contrast mesenteric arteriography has the following indications:<ref name="pmid2352792">{{cite journal |vauthors=Routh WD, Lawdahl RB, Lund E, Garcia JH, Keller FS |title=Meckel's diverticula: angiographic diagnosis in patients with non-acute hemorrhage and negative scintigraphy |journal=Pediatr Radiol |volume=20 |issue=3 |pages=152–6 |year=1990 |pmid=2352792 |doi= |url=}}</ref><ref name="pmid23192375">{{cite journal |vauthors=García-Blázquez V, Vicente-Bártulos A, Olavarria-Delgado A, Plana MN, van der Winden D, Zamora J |title=Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis |journal=Eur Radiol |volume=23 |issue=5 |pages=1181–90 |year=2013 |pmid=23192375 |doi=10.1007/s00330-012-2721-x |url=}}</ref> | |||
** If a source of [[gastrointestinal bleeding]] is brisk and may require [[Blood transfusion|transfusion]] | |||
** If the source has not been identified using other [[imaging]] modalities | |||
** In patients with ongoing [[Bleeding|hemorrhage]], active [[Contrast medium|contrast]] [[extravasation]] may be visible | |||
** Detection of an anomalous branch of the [[superior mesenteric artery]] that feeds the [[diverticulum]]. This anomalous branch usually has the following features: | |||
*** Non branching | |||
*** Long | |||
*** Terminates in irregular, small branches after traversing the [[mesentery]] | |||
** [[CT angiography|High-resolution CT angiography]] is preferred in patients when [[bleeding]] is less brisk (as little as 0.3 mL/minute). | |||
** [[CT angiography]] may help detect active signs of [[bleeding]] diverticulum, that may be undetectable with other modalities such as | |||
*** Tagged red blood cell scan | |||
*** [[Colonoscopy]] | |||
*** Conventional [[Angiogram|arteriography]] | |||
** Disadvantage: | |||
*** Patient is subject to [[ionizing radiation]] | |||
*** [[Invasive (medical)|Invasive]] | |||
==== Single-photon emission computed tomography (SPECT)/CT fusion imaging ==== | |||
*The role of [[Single photon emission computed tomography|Single-photon emission computed tomography]] ([[Single photon emission computed tomography|SPECT]])/[[Computed tomography|CT]] fusion imaging as a [[Diagnosis|diagnostic]] modality is currently under exploration.<ref name="pmid19784878">{{cite journal |vauthors=Dillman JR, Wong KK, Brown RK, Frey KA, Strouse PJ |title=Utility of SPECT/CT with Meckel's scintigraphy |journal=Ann Nucl Med |volume=23 |issue=9 |pages=813–5 |year=2009 |pmid=19784878 |doi=10.1007/s12149-009-0301-1 |url=}}</ref> | |||
==References== | ==References== | ||
Latest revision as of 19:12, 11 January 2018
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Meckel's diverticulum Microchapters |
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Meckel's diverticulum other imaging findings On the Web |
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American Roentgen Ray Society Images of Meckel's diverticulum other imaging findings |
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Risk calculators and risk factors for Meckel's diverticulum other imaging findings |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Overview
A technetium-99m (99mTc) pertechnetate scan is the investigation of choice for the diagnosis of Meckel's diverticulum. This scan detects gastric mucosa; since approximately 50% of symptomatic Meckel's diverticula have ectopic gastric (stomach) cells contained within them. A Meckel's diverticulum containing gastric mucosa manifests as a small rounded area of increased activity in the right lower quadrant, while normal activity simultaneously appears in the stomach.
Other Imaging Findings
Technetium-99m pertechnetate radioisotope scanning
- September 2014: Guidelines for the Scintigraphy for Meckel’s diverticulum were laid down by:[1]
- Society of Nuclear Medicine and Molecular Imaging (SNMMI)
- European Association for Nuclear Medicine (EANM)
- Technetium-99m pertechnetate scanning helps in the detection of a symptomatic bleeding Meckel’s diverticulum.
- It is preferred as the investigation of choice for the diagnosis of Meckel's diverticula in children due to the following features:[2][3][4]
- High accuracy
- Noninvasive nature
- 95% specificity
- 85% sensitivity
- Approximately 50% of symptomatic Meckel's diverticula have ectopic gastric or pancreatic cells contained within them[5]
- Technetium-99m pertechnetate scanning is not preferred in adults as false negative rates are high with specificity of 9% and sensitivity of 62%.
- Indications of Meckel's scan:[6][7][8]
- False-positives are seen in the following conditions:
- Intussusception
- Volvulus
- Obstruction of the small intestine
- Acute appendicitis
- Carcinoid of the appendix
- Carcinoma of the cecum
- On intravenous administration, the Technetium-99m pertechnetate radioisotope is taken up by the gastric mucosa.[9]
- In order to obtain a positive result, at least 1.8 cm2 of ectopic gastric mucosa in Meckel's diverticulum is required.
- A Meckel's diverticulum containing gastric mucosa manifests as a small rounded area of increased activity in the right lower quadrant.
- Normal activity simultaneously appears in the stomach.
- Technetium-99m pertechnetate scanning requires 30 images, taken at 1-minute intervals to demonstrate terminal ileum activity.
- The use of Pentagastrin in Technetium-99m pertechnetate scanning has a synergistic effect:
- Role of Pentagastrin:
- Histamine-2 (H2) receptor blocker
- Enhances radioisotope uptake by the cells:
- Promotes isotope retention
- Blocks intraluminal release of isotope
- Minimizes false negative results
- Agents promoting retention of 99m technetium pertechnetate:[10]
- Aluminum hydroxide
- Ranitidine, Cimetidine
Source: Wikimedia commons [11]
Angiography
- Angiography may assist in determining the location and severity of bleeding in case of a bleeding Meckel's diverticulum.
- In patients presenting with acute GI bleeding, superior mesenteric angiography is effective if blood loss exceeds 0.5 mL/min(brisk bleeding).[2]
- Conventional contrast mesenteric arteriography has the following indications:[12][13]
- If a source of gastrointestinal bleeding is brisk and may require transfusion
- If the source has not been identified using other imaging modalities
- In patients with ongoing hemorrhage, active contrast extravasation may be visible
- Detection of an anomalous branch of the superior mesenteric artery that feeds the diverticulum. This anomalous branch usually has the following features:
- Non branching
- Long
- Terminates in irregular, small branches after traversing the mesentery
- High-resolution CT angiography is preferred in patients when bleeding is less brisk (as little as 0.3 mL/minute).
- CT angiography may help detect active signs of bleeding diverticulum, that may be undetectable with other modalities such as
- Tagged red blood cell scan
- Colonoscopy
- Conventional arteriography
- Disadvantage:
- Patient is subject to ionizing radiation
- Invasive
Single-photon emission computed tomography (SPECT)/CT fusion imaging
- The role of Single-photon emission computed tomography (SPECT)/CT fusion imaging as a diagnostic modality is currently under exploration.[14]
References
- ↑ Spottswood SE, Pfluger T, Bartold SP, Brandon D, Burchell N, Delbeke D, Fink-Bennett DM, Hodges PK, Jolles PR, Lassmann M, Maurer AH, Seabold JE, Stabin MG, Treves ST, Vlajkovic M (2014). "SNMMI and EANM practice guideline for meckel diverticulum scintigraphy 2.0". J Nucl Med Technol. 42 (3): 163–9. doi:10.2967/jnmt.113.136242. PMID 24948825.
- ↑ 2.0 2.1 "Fundamentals of Pediatric Surgery - Google Books".
- ↑ Mhiri A, Slim I, Ben Slimène F (2016). "Hemorrhagic Meckel's diverticulum. Interest of the digestive pertechnetate scintigraphy". Tunis Med. 94 (10): 629–631. PMID 28972258.
- ↑ Mhiri A, Slim I, Ben Slimène F (2016). "Hemorrhagic Meckel's diverticulum. Interest of the digestive pertechnetate scintigraphy". Tunis Med. 94 (8–9): 629–631. PMID 28685802.
- ↑ Martin JP, Connor PD, Charles K (2000). "Meckel's diverticulum". Am Fam Physician. 61 (4): 1037–42, 1044. PMID 10706156.
- ↑ Lin S, Suhocki PV, Ludwig KA, Shetzline MA (2002). "Gastrointestinal bleeding in adult patients with Meckel's diverticulum: the role of technetium 99m pertechnetate scan". South. Med. J. 95 (11): 1338–41. PMID 12540005.
- ↑ Sinha CK, Pallewatte A, Easty M, De Coppi P, Pierro A, Misra D, Biassoni L (2013). "Meckel's scan in children: a review of 183 cases referred to two paediatric surgery specialist centres over 18 years". Pediatr. Surg. Int. 29 (5): 511–7. doi:10.1007/s00383-013-3270-3. PMID 23417523.
- ↑ Irvine I, Doherty A, Hayes R (2017). "Bleeding meckel's diverticulum: A study of the accuracy of pertechnetate scintigraphy as a diagnostic tool". Eur J Radiol. 96: 27–30. doi:10.1016/j.ejrad.2017.09.008. PMID 29103471.
- ↑ Rerksuppaphol S, Hutson JM, Oliver MR (2004). "Ranitidine-enhanced 99mtechnetium pertechnetate imaging in children improves the sensitivity of identifying heterotopic gastric mucosa in Meckel's diverticulum". Pediatr. Surg. Int. 20 (5): 323–5. doi:10.1007/s00383-004-1189-4. PMID 15241619.
- ↑ Petrokubi RJ, Baum S, Rohrer GV (1978). "Cimetidine administration resulting in improved pertechnetate imaging of Meckel's diverticulum". Clin Nucl Med. 3 (10): 385–8. PMID 729309.
- ↑ "File:Meckel's Diverticulum by Technetium-99m Pertechnetate Scan.jpg - Wikimedia Commons".
- ↑ Routh WD, Lawdahl RB, Lund E, Garcia JH, Keller FS (1990). "Meckel's diverticula: angiographic diagnosis in patients with non-acute hemorrhage and negative scintigraphy". Pediatr Radiol. 20 (3): 152–6. PMID 2352792.
- ↑ García-Blázquez V, Vicente-Bártulos A, Olavarria-Delgado A, Plana MN, van der Winden D, Zamora J (2013). "Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis". Eur Radiol. 23 (5): 1181–90. doi:10.1007/s00330-012-2721-x. PMID 23192375.
- ↑ Dillman JR, Wong KK, Brown RK, Frey KA, Strouse PJ (2009). "Utility of SPECT/CT with Meckel's scintigraphy". Ann Nucl Med. 23 (9): 813–5. doi:10.1007/s12149-009-0301-1. PMID 19784878.
