Ahmad, M N

Hussain, R

Sajjad, Z

Zaman, M U

English

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eCommons@AKUDepartment of Radiology Medical College, PakistanSeptember 2004Localization of upper GI bleed on delayed imagingwith 99mTc tagged RBC angiogramM U. Zamanumber.zaman@aku.eduR HussainZ SajjadM N. AhmadAga Khan University, nadeem.ahmed@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Radiology CommonsRecommended CitationZaman, M. U., Hussain, R., Sajjad, Z., Ahmad, M. N. (2004). Localization of upper GI bleed on delayed imaging with 99mTc taggedRBC angiogram. Journal of Pakistan Medical Association, 54(9), 490-491.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/207Localization of Upper GI Bleed on Delayed Imaging with 99mTc tagged RBCangiogramM. U. Zaman, R. Hussain, Z. Sajjad, M. N. AhmadNuclear Medicine Section, Department of Radiology, Aga Khan University Hospital, Karachi.Gastrointestinal bleeding is a frequently encounteredclinical entity, the incidence of which has remained relative-ly constant at approximately 70 episodes per 100,000 popu-lation per year.1 Although the treatment of gastrointestinalbleeding is often straightforward, the identification and local-ization of the source of bleeding is more challenging. Due tointermittent nature of bleeding, detection efficiency dependsupon the active bleeding during the diagnostic procedure likecontrast angiography or nuclear medicine studies.Radionuclide imaging with tagged RBC study has an advan-tage of sequential imaging up to 24 hours after the injectionand hence increases the detection efficiency without extraradiation exposure to the patient, at the same time being costeffective and non-invasive. We are presenting an interesting case of recurrentupper GI bleeding detected by sequential imaging withtagged RBCs.Case ReportAn 80 years old male presented with recent historyof malena and severe anemia. Past history documented aCABG in1996.  His initial hemoglobin was 5.4 mg/dl andupper GI endoscopy revealed no bleeding focus and lowerGI endoscopy showed clots of altered blood in the ascend-ing colon. He was managed conservatively with transfu-sions. Next day he again dropped his hemoglobin with pas-sage of malenetic stool. A Tc-99m tagged RBC study wasperformed  which revealed no evidence of activeintra-abdominal bleeding till 4 hrs after the injection(Figure 1a). Again patient was transfused and managed con-servatively. After 2 days he had another episode of hemo-globin drop and malena and a repeat tagged RBC study wasperformed. The initial study till 2 hours after the tracerinjection showed no active bleeder (Figure 1b). However,sequential images at 4 hours after tracer injection revealedabnormal tracer accumulation in the left hypochondriumwith progressive increase in tracer intensity and distal andmedial traveling (Figure 1c-d). These findings were consis-tent with bleeding from the duodeno-jujenal region.Immediately patient was transferred to catheterization labo-ratory.  Selective angiogram of duodenal artery revealedextra-vasation of the contrast into the second part of theduodenum (Figure 2a). Embolization of the bleeder wasperformed with platinum coil and poly-vinyl alcohol (PVA)with complete disappearance of spill (Figure 2b). Patientstayed in hospital for 5 more days with no further episodeof malena.Discussion Recent advances in red blood cell labeling havemade scintigraphy a sensitive test for detecting both acuteand intermittent GI bleeding.2 Another important advantageis that bleeding rates as low as 0.1 ml/min can be detectedwith scintigraphy, as compared with higher rates of 0.5ml/min detected by angiography.3 Localization of GI bleed-ing is a real diagnostic dilemma as detection depends uponthe active bleeding at the time of procedure. Contrastangiogram is the most accurate method with added advan-tage of therapeutic embolization but it is invasive, expen-sive and false negative study if bleeding is not active duringthe angiographic procedure. Radionuclide tagged RBCstudy is a very sensitive technique and has an advantage ofsequential imaging till 24 hours with single tracer injection.Therefore, if the first study is negative,  intermittent bleed-er can be detected using the sequential imaging with lessradiation burden to the patient and cost effective as well. References1. Peter D, Dougherty J. Evaluation of the patient with gastrointestinal bleeding:an evidence based approach. Emerg Med Clin North Am 1999;17:239-61.2. Winzelberg CG, McKussick KA, Froelich JW, et al: Detection of gastroin-testinal bleeding with 99m Tc-labelled red blood cells. Semin Nucl Med1982;7:139-46.3. Alavi A, Ring EJ. Localization of gastrointestinal bleeding: superiority of99m Tc sulfur colloid compared with angiography. Am J Roentgenol1981;137:741-8. 

Localization of upper GI bleed on delayed imaging with 99mTc tagged RBC angiogram

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Localization of upper GI bleed on delayed imaging with 99mTc tagged RBC angiogram

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