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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 4  |  Page : 144-146

Importance of single-photon emission computed tomography/computed tomography in detection of meckel's diverticulum in a 19-year-old female patient


Department of Nuclear Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia

Date of Submission12-May-2019
Date of Acceptance26-Sep-2019
Date of Web Publication26-Dec-2019

Correspondence Address:
Dr. Intidhar El Bez Ghanem
Department of Nuclear Medicine, King Fahad Medical City, PO Box: 59046, Riyadh 11525
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_31_19

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  Abstract 


Planar scintigraphy using technetium-99m pertechnetate is widely used in the diagnosis of Meckel's diverticulum. Single-photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging may help to localize the Meckel's diverticulum lesion. We present a case of a 19-yearold lady with recurrent lower gastrointestinal tract bleeding. She underwent Tc-99m pertechnetate scintigraphy. The planar images showed two foci of increased uptake located in the lower abdomen and at the level of the right kidney. The one located at the right kidney level could be physiological uptake or by an ectopic gastric mucosa. Using SPECT/CT technique, we confirmed that the lower part of the concentration was from a Meckel's diverticulum from the small intestine based on the functional and anatomical information together; however, the upper uptake was physiological right proximal ureteric uptake. Our case study suggests that SPECT/CT imaging needs to be considered to obtain a definitive diagnosis, mainly with cases with ambiguous planar scintigraphy images.

Keywords: Meckel's diverticulum, scintigraphy, single-photon emission computed tomography/computed tomography


How to cite this article:
Ghanem IE, Alqadhi M, Munir I, Tulbah R, Alghmlas F, Alharbi M. Importance of single-photon emission computed tomography/computed tomography in detection of meckel's diverticulum in a 19-year-old female patient. Libyan J Med Sci 2019;3:144-6

How to cite this URL:
Ghanem IE, Alqadhi M, Munir I, Tulbah R, Alghmlas F, Alharbi M. Importance of single-photon emission computed tomography/computed tomography in detection of meckel's diverticulum in a 19-year-old female patient. Libyan J Med Sci [serial online] 2019 [cited 2020 Apr 9];3:144-6. Available from: http://www.ljmsonline.com/text.asp?2019/3/4/144/274099




  Introduction Top


Meckel's diverticulum, first described by Fabricius Hildanus in 1598, is a 1–11 cm remnant of the embryonic omphalomesenteric duct situated 40–130 cm from the ileocecal valve and localizes to the right lower quadrant.[1] This congenital variant is present in 1%–3% of the population[2] and poses a 4% lifetime risk of becoming symptomatic with gastrointestinal (GI) bleeding, inflammation, or obstruction.[3] Classically, children present more commonly with GI bleeding adjacent to acid-producing gastric mucosa and adults develop obstruction.[2],[4],[5] Tc-99m pertechnetate scan is a commonly performed procedure for the detection of Meckel's diverticulum.[4],[6] We present the usefulness of single-photon emission computed tomography/computed tomography (SPECT/CT) co-registration that helps in better localization of the pathology.


  Case Report Top


A 19-year-old female patient was admitted to our institution due to recurrent lower GI tract bleeding. No active bleeding was found by gastroscopy, colonoscopy, or abdominal/pelvic CT. The patient underwent Tc-99m pertechnetate scintigraphy as per our department protocol. A dynamic 30-min anterior and posterior acquisition of the abdomen and pelvis was performed after intravenous injection of 185 MBq technetium-99m pertechnetate. SPECT/CT of the abdomen and pelvis was acquired as well.

The initial dynamic images demonstrate a fixed focal radiotracer uptake at the mid-lower abdomen which is seen simultaneously with the normal physiologic stomach activity and increases in intensity over time. This focal activity is most likely corresponding to a Meckel's diverticulum at the distal-to-mid-ilial bowel loop [Figure 1]. However, there is also a second focal activity, seen simultaneously with the normal physiologic stomach activity, at the right abdominal upper quadrant. We could not determine whether it was caused by physiological uptake of the right kidney or by an ectopic gastric mucosa. The delayed planar images demonstrate the same findings [Figure 2].
Figure 1: 5 min (a) and 30 min (b) after administering 185 MBq of technetium-99m pertechnetate intravenously, dynamic images demonstrate two foci of radiotracer uptake seen simultaneously with the normal physiologic stomach activity: one at the mid-lower abdomen (green arrow) and the second one at the right abdominal upper quadrant (red arrow)

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Figure 2: Delayed planar images were performed 2 hours after administering 185 MBq of technetium-99m pertechnetate intravenously. Anterior (a) and posterior (b) images showed persistent two foci of increased activity: one at the midlower abdomen (green arrow) and the second one at the right abdominal upper quadrant (red arrow)

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We performed a SPECT/CT fusion imaging to the patient [Figure 3]. Based on the fused image, we found that the focal right upper concentration was from the right kidney, whereas the focal uptake in the lower abdomen was compatible with ectopic gastric mucosa at the distal-to-mid-ilial bowel loop. Therefore, a diagnosis of Meckel's diverticulum was confirmed. In addition to that, the low-dose CT scan of the SPECT-CT shows the incidental finding of spina bifida of S1.
Figure 3: Single-photon emission computed tomography/computed tomography images of the Meckel's diverticulum. (a) Single-photon emission computed tomography/computed tomography shows two foci of concentration in the right abdomen (red arrow) and the mid-lower abdomen (green arrow). (b) the low dose non-diagnostic computed tomography showed that it was in front of the kidney that the focal concentration lays (red arrow). (c) Axial singlephoton emission computed tomography/computed tomography fusion image showed that it was physiological uptake (red arrow). (d) Computed tomography demonstrated a blind-ending tubular structure in the lower abdomen (green arrow). (e) Axial single-photon emission computed tomography/computed tomography fusion image showed that it was in keeping with ectopic gastric mucosa at the distal-to-mid-ilial bowel loop

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  Discussion Top


Technetium-99m pertechnetate planar scintigraphy is widely used in the diagnosis of Meckel's diverticulum.[4],[6] Because technetium-99m pertechnetate is excreted by the urinary system, kidney and urinary tract are normally with concentrations, which may overlap with that in Meckel's diverticulum on the planar image and lead to false result. In our case, we had two foci of increased uptake. A diagnosis of Meckel's diverticulum has been made by a former planar scintigraphy for focal uptake in the lower abdomen. However, we were unable to determine whether the focal concentration in the right upper abdomen, which also appears simultaneously with the normal physiologic stomach activity, was caused by physiological uptake of the right kidney or by ectopic gastric mucosa. To look for the exact anatomic site of the concentration, we performed a SPECT/CT scan to the patient. The educational significance of our report was that, for the possible Meckel's diverticulum of the kidney level, SPECT/CT should be always performed to avoid false result due to physiological uptake of the kidney. There is one case report of a 10-year-old child diagnosed with Meckel's diverticulum of the kidney level that was ambiguous planar scintigraphy images, and SPECT-CT imaging provided the final diagnosis.[4],[7] For concentrations about the kidney level, planar scintigraphy is not enough to be diagnostic of Meckel's diverticulum. SPECT/CT imaging may be beneficial for a definitive diagnosis. Furthermore, fusion images may provide precise localization of the lesion.

The use of SPECT/CT fusion imaging provided valuable diagnostic information and avoided false-negative study.[7],[8],[9] Once a Meckel's diverticulum was missed, the patient would not receive effective treatment and suffer serious further complications. Furthermore, SPECT/CT fusion imaging may provide functional and anatomical information together to help surgeons to plan the surgery.[7],[8],[9],[10] In our case, in addition to that, the low-dose CT scan of the SPECT-CT shows the incidental finding of spina bifida of S1.

In conclusion, for cases with ambiguous planar scintigraphy images, SPECT/CT imaging needs to be considered to obtain a definitive diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Turgeon DK, Barnett JL. Meckel's diverticulum. Am J Gastroenterol 1990;85:777-81.  Back to cited text no. 1
    
2.
Soderlund S. Meckel's diverticulum. A clinical and histologic study. Acta Chir Scand Suppl 1959;Suppl 248:1-233.  Back to cited text no. 2
    
3.
Soltero MJ, Bill AH. The natural history of meckel's diverticulum and its relation to incidental removal. A study of 202 cases of diseased meckel's diverticulum found in king county, Washington, over a fifteen year period. Am J Surg 1976;132:168-73.  Back to cited text no. 3
    
4.
Xie Q, Ma Q, Ji B, Gao S, Wen Q. Incremental value of SPECT/CT in detection of meckel's diverticulum in a 10-year-old child. Springerplus 2016;5:1270.  Back to cited text no. 4
    
5.
Ymaguchi M, Takeuchi S, Awazu S. Meckel's diverticulum. Investigation of 600 patients in Japanese literature. Am J Surg 1978;136:247-9.  Back to cited text no. 5
    
6.
Turgeon DK, Brenner D, Brown RK, Dimagno MJ. Possible role of meckel's scan fused with SPECT CT imaging: Unraveling the cause of abdominal pain and obscure-overt gastrointestinal bleeding. Case Rep Gastroenterol 2008;2:83-90.  Back to cited text no. 6
    
7.
Swaniker F, Soldes O, Hirschl RB. The utility of technetium 99m pertechnetate scintigraphy in the evaluation of patients with meckel's diverticulum. J Pediatr Surg 1999;34:760-4.  Back to cited text no. 7
    
8.
Dillman JR, Wong KK, Brown RK, Frey KA, Strouse PJ. Utility of SPECT/CT with meckel's scintigraphy. Ann Nucl Med 2009;23:813-5.  Back to cited text no. 8
    
9.
Sfakianakis GN, Conway JJ. Detection of ectopic gastric mucosa in meckel's diverticulum and in other aberrations by scintigraphy: Ii. Indications and methods – A 10-year experience. J Nucl Med 1981;22:732-8.  Back to cited text no. 9
    
10.
Even-Sapir E, Keidar Z, Bar-Shalom R. Hybrid imaging (SPECT/CT and PET/CT) – Improving the diagnostic accuracy of functional/metabolic and anatomic imaging. Semin Nucl Med 2009;39:264-75.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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