ETIOLOGY AND SEVERITY OF UPPER GI TRACT HEMORRHAGE

Source
Esophagus Esophagitis Ulcer Mallory-Weiss tear Esophageal varices Total esophagus Stomach Gastric ulcer Prepyloric ulcer Pyloric channel ulcer Gastric erosions Gastritis Varices Portal-hypertensive gastropathy Gastric cancer Polyp Dieulafoy lesion Total stomach Duodenum Ulcer Duodenitis Aortoenteric fistula Pancreatic pseudocyst Post-sphincterotomy Total duodenum

Mild-mod
12% 2% 5% 5% 24% 15% 2% 4% 2% 7% 1% 2% 2% 0 0 35% 30% 8% 0 2% 1% 41% 100%

Severe
7% 2% 19% 31% 59% 14% 4% 2% 0 0 2% 0 0 2% 0 24% 15% 0 2% 0 0 17% 100%

ETIOLOGY OF HEMATOCHEZIA IN 72 HOSPITALIZED PATIENTS SOURCE OF HEMORRHAGE PERCENTAGE

Colonic cancer Colonic polyps Diverticula Colitis Vascular ectasia Large hemorrhoids only Ulcer tear (rectum)
Upper GI or small bowel source

7 11 23 11 1 12 10 10 15 100

No site identified

Red Blood Cell Labeling Techniques:

In vivo: 75-85%, but the effective labeling efficiency is somewhat higher due to the renal excretion of some of the unlabeled pertechnetate). In vitro: efficiency of greater than 95% Modified in vivo: "In vivtro" :labeling efficiency of about 90-95%

In vivo
Stannous pyrophosphate (10-15ug/kg) is injected intravenously directly into a vein (injection via an indwelling catheter will generally result in poor labeling). The stannous ion (Sn+2) is the reducing agent and it diffuses into the red blood cells where it becomes bound to a cellular component

In vivo,cont
After 15-30 minutes, Tc99m-pertechnetate is injected IV and the tracer freely diffuses into the RBC's. The Tc-pertechnetate which enters the RBC's is then reduced from its +7 valence to +4. Reduced technetium then binds predominantly to the beta-chain of hemoglobin (76-79%), and a small amount binds to the heme portion of the molecule (19-21%). Any stannous ion present outside the RBC will reduce any free extracellular Tc-pertechnetate and this free reduced tech will degrade images by increasing background and urinary activity (confirm the presence of free tech by demonstrating stomach and thyroid activity).

In vitro
Previously, 50cc of whole blood was placed in a centrifuge and the RBC's were separated from the plasma. SnPYP was added to the cells which were then incubated with technetium pertechnetate. The Ultra-tag kit method is now most commonly used and has a labeling efficiency of greater than 95%.

 About 3cc of the patients blood is placed in a vial with SnPYP. Sodium hypochlorite (an oxidizing agent) which cannot pass through the red cell membrane is then added to oxidize the extracellular stannous ion prior to the addition of Tc-pertechnetate. Although ACD (anticoagulant citrate dextrose solution) is preferred over heparin as the anticoagulant because it yields a higher labeling efficiency and reduced urinary activity (see below), excess ACD can decrease labeling efficiency by impairing the diffusion of the stannous ion across the RBC membrane.

Modified in vivo: "In vivtro" method

This method has a labeling efficiency of about 90-95%. Sn-PYP is given intravenously. After 10 to 30 minutes (for best results) 5 to 10cc of blood is withdrawn and technetium pertechnetate (20mCi) is added. After Incubating with the technetium for at least 20 minutes, the blood is replaced. ADC solution is the recommended anticoagulant.

Causes of Poor Red Blood Cell Labeling:

1. Heparinized patient
Heparin may form complexes with Tcpertechnetate in the presence of stannous ion which will undergo renal excretion and accumulate in the bladder.

5. Injection through IV line

Due to adherence to wall

6. Improper syringe flushing

Always use saline rather than dextrose

2. Chemotherapy Doxorubicin 3. Medications:

Digoxin: Decreases labeling rate Dipyridamole Propranolol: Increases dissociation

7. Iodinated contrast Given within

preceding 24 hours

8. Decreased hematocrit 9. Excess stannous ion

Tc-99m reduced outside RBC

4. Generator ingrowth time > 24 hours:

Probably related to the presence of excessive Tc99 (Due to Tc99m decay). If generator in-growth is greater than 24 hours, then a 2nd elution should be obtained 1-2 hours after the first and used for erythrocyte labeling.

10. Anti-RBC antibodies

GI Bleeding Scintigraphy:
Massive hemorrhage in the lower GI tract is defined as bleeding distal to the ligament of Treitz in excess of 30ml/hr. It is most commonly seen in patients over age 50. Most episodes of such bleeding stop spontaneously, although intervention to control bleeding is needed eventually in 1025% of patients.

Etiologies of GI bleeding:
Diverticular disease:The dome of the diverticulum displaces the submucosal branch of the vasa recta, which can rupture. Although 80% of diverticular disease is located in the descending colon, approximately 50% of diverticular bleeding is from the ascending colon. Bleeding is the first indication of diverticulosis in 15-20% of patients, and bleeding can be severe in about 5%. Bleeding stops spontaneously in 80-90%, however, rebleeding is seen in about 25% of the cases

Angiodysplasia:
This lesion is felt to be acquired rather than congenital in nature because it is rarely seen in patients under the age of 40y. Repeat partial obstruction of submucosal veins due to transient elevations of intra-luminal pressure has been suggested as an etiologic factor. Concurrent cardiac disease (esp. aortic stenosis) is common. These lesions are most commonly detected in the ascending colon, but about 20% are located elsewhere (descending colon, sigmoid, small bowel). Multiple lesions are seen in about 25% of patients. The bleeding stops spontaneously in more than 90% of patients, but rebleeding is seen to occur in up to 85%. Because vascular ectasias are submucosal they are not routinely identified on barium studies..

Nuclear Medicine GI Bleeding Examination

Scanning is useful for the diagnosis of active gastrointestinal bleeding and for guiding angiography. Either Tc99m Sulfur Colloid or Tagged RBC's can be used as the radiotracer. In general, scintigraphy is about 10 times more sensitive than angiography for the detection of GI bleeding.

Tc-99m Sulfur Colloid: (Dose 10mCi)

The advantages Tc-SC imaging is that the agent is rapidly cleared from the intravascular space by the reticuloendothelial system. The circulating halflife in patients with normal liver function is between 2-3 minutes, and by 15-20 minutes there is effectively none left in the blood. This permits clear visualization of extravasated isotope at bleeding site. The technique is very sensitive and can detect bleeding rates as low as 0.05 to 0.1 cc/min. (Angiography realistically requires a bleeding rate of about 1.5 to 3 ml/min. to be detected. Angiography will detect GI bleeding in 65% of patients when the bleeding rate exceeds 1 ml/min.)

Tc-99m Sulfur Colloid

Unfortunately, the disadvantages of this agent clearly outweigh its benefits. Prominent liver and spleen activity may obscure the bleeding site. The imaging time is markedly limited (probably no more than 10 minutes). Given the characteristic intermittent nature of GI bleeding, unless the patient is actively bleeding at time of study, the site of hemorrhage will not be detected. Reports have indicated that the sensitivity Tc-SC imaging for GI bleeding is about 30% of the labeled RBC technique. Because of this, to improve sensitivity, some centers will administer the agent in 2 mCi doses, every 10 minutes for an hour.

Technetium labeled RBC's: (Dose 20

mCi)

The main advantage of using labeled RBC's is that the agent remains in the intravascular space for 24 (up to 48) hours, thus it is excellent for imaging intermittent or slow bleeds. Liver, spleen, kidneys and bladder (due to excretion of non-erythrocyte bound tech and labeled hemoglobin fragments) are also visualized, but to a lesser degree and thus will probably not obscure the bleeding focus.

 Labeled RBC's are slightly less sensitive than Tc-SC, but are still able to detect bleeding rates as low as 0.1 to 0.5 cc/min. and sensitivities of over 90% have been reported for this procedure (the tagged RBC exam has a sensitivity of 91% and a specificity of 95% of GI bleeding [Datz, p. 349]). Continuous imaging is recommended because it is often difficult to localize the bleeding site with intermittent imaging. In vivo labeling of the RBC's is also not recommended as free tech will be excreted by the gastric mucosa and pass into the small bowel and colon. Continuous gastric suction may be required if the in vivo labeling technique is used. In vitro tagging results in significantly less amounts of free technetium. Presently, many centers employ the use of the ultratag kit for labeling the RBC's prior to GI bleed imaging

 Glucagon may be useful in aiding the detection of small bowel bleeding by producing smooth muscle relaxation. Small bowel bleeds frequently show only brief accumulation with rapid dissipation due to marked small bowel motility. Smooth muscle relaxation in blood vessels will enhance bleeding and decreased intestinal peristalsis will cause tracer to pool at the bleeding site.

 Most centers will image patients continuously for 60 to 90 minutes and generally, this time is sufficient to detect about 85% of sites of GI bleeding. Longer imaging times can be used if patients can tolerate it. The tagged RBC study is considered positive if there is a focus of increased activity that changes in location and increases in intensity over time.

 Blood in the bowel lumen will always move both antegrade and retrograde due to intestinal irritation by the intraluminal blood. The retrograde peristalsis can hinder accurate localization of the bleeding site

The tagged cell study may also provide prognostic information

In one study, no patient with a negative exam or an exam which became positive after one hour of imaging required surgery or excessive transfusion (over 700 cc); while patients that demonstrated high visual blood loss (activity within the bowel lumen greater than the liver activity) within one hour of imaging typically required surgery or larger transfusion requirements [Fink-Bennett, Harvard 94].

Active GI Bleeding: The images below show a brisk gastrointestinal hemorrhage which originates in the region of the hepatic flexure (black arrows on initial one and two minute images). The abnormality becomes more intense and propagates in an antegrade fashion over time.

 Delayed scanning (i.e.: at 24 hours) can demonstrate the presence of blood within the bowel lumen, but alone it cannot provide information as to the location of the bleeding site. When delayed GI bleeding images are positive, further views should be obtained to ascertain if the pattern of intraluminal activity is changing (i.e.: is there active hemorrhage). If renewed active hemorrhage is suspected, reinjection with a second dose of labeled RBC's may identify the bleeding site . The activity from the reinjected dose should render the previously identified extravasated RBCs barely visible

Potential False Positives

Vascular Neoplasm: Foci will not move over time Splenosis: Foci will not move over time Varices: (Alcoholics) Blood may pool in dilated venous channels over the abdomen Vascular Grafts: Will appear as tubular structures Bladder/Penile activity: Confirm with lateral view Inflammation: Usually demonstrates an early blush and does not change in location over time.

Vascular Hepatic Lesions:

Cavernous Hemangioma is the most common benign liver tumor with a 3 to 7% incidence from autopsy data. F > M (4:1). They are typically asymptomatic (only about 10% of patients have symptoms). Rupture with hemoperitoneum is a rare, but potentially serious complication. The lesions are most frequently subcapsular (peripheral) in the right lobe. Hemangiomas are typically solitary, but may be multiple (10-20% of cases). Treatment is not usually necessary, but steroids, XRT, and embolization have all been shown to decrease size of the lesion.

Cavernous Hemangioma
On pathologic analysis the internal architecture of the lesion changes with growth, and there may be hemorrhage, myxomatous change, fibrosis, or calcification. Hemangiomas lack a capsule, but are well marginated.

Radiologic Appearance:
On plain film one may see calcification (noted in only 10%)- may see phleboliths or radiating "sunburst" pattern. On ultrasound the lesion is typically homogeneously hyperechoic, well defined, lobulated mass (60%). Increased through transmission may be seen. Other appearances include a hypoechoic mass (20%, particularly in fatty, echogenic livers) or a mixed echo pattern (20%). No flow is detected in the lesions on pulsed/color flow Doppler due to the low velocity through the large cavernous spaces.

MRI has an accuracy of between 90-95% in the detection of hemangiomas

The lesions have very low signal on T1. On T2 weighted images, the lesions have a very bright signal and they remain of high intensity on multiple delayed echo sequences. Unfortunately, all hepatic neoplasms become hyperintense relative to surrounding liver, so it is the degree of hyperintensity that is stated to be characteristic of hemangiomas. This appearance can be mimicked by vascular mets and occasionally by simple cysts. There is about a 10% overlap between hemangiomas and non-hemangiomas. Occasionally, the lesions may have an inhomogeneous appearance

On angiography ,
hemangiomas appear as focal areas of ring, or C-shaped contrast accumulation which persists into the late venous phase. "Puddling" of contrast within the lesion, with markedly delayed clearance- produces cotton-wool appearance. A-V shunting is RARE and implies a MALIGNANT lesion.

 When interpreting GI bleeding scans in anemic patients receiving blood transfusions, awareness of the possibility of gallbladder visualization on delayed images is important to avoid false-positive results [9]. Autohemolysis with resultant accumulation of the breakdown products of labeled heme in the bile seems to be the reason the gallbladder can be visualized in these patients

 Incorrect localizations can be seen in 3 to 60% of cases. It is probably prudent not to base surgery solely on the results of RBC scanning.

On pre-contrast CT scan hemangiomas typically appear as low density lesions (90%).

In the case of fatty infiltration of the liver, the hemangioma may appear hyperdense. Post-contrast there is early peripheral enhancement, which may be nodular, that slowly fills in the lesion and remains for a relatively long period of time. These classic findings are noted in 50 to 75% of cases. Inhomogeneous enhancement can be seen if there are focal zones of thrombosis or fibrosis.

Scintigraphic findings for vascular hepatic lesions

Hemangiomas appear as photon deficient (cold) lesions on sulfur colloid and hepatobiliary scans. Tc-RBC imaging is the most specific test available for the diagnosis of cavernous hemangioma. (Sensitivity 90% for lesions larger than 1.5 to 2cm; Specificity approaches 100%; Accuracy 9095%) With SPECT lesions down to about 1 cm in size can be detected [SPECT sensitivity by size: 1.5 cm (100%), 1 cm (65%), 0.5 cm (20%)].

False negatives
small size of the lesion, lesion adjacent to a vascular structure (vein, liver hilum, or heart), thrombosed/fibrosed lesion Lesions located deep within the liver may not be detected by planar imaging, but are often readily demonstrated with SPECT

 The classic findings on RBC imaging are decreased activity within the lesions on flow and early blood pool images, with increased activity on delayed scans at 1 to 2 hours post injection (hot spot on delayed imaging) [5]. Hepatomas and liver metastases will almost alwats show increased perfusion (i.e.: concurrent with the spleen) due to their predominant arterial blood supply, and decreased uptake on delayed images. However, 80% or more of malignant lesions, primarily metastases, are hypovascular throughout the first phase of the exam and remain photopenic on delayed images. Hepatomas occasionally have uptake equal to, but not more intense than the liver on delayed images

 There are only case reports of false positive exams: Hepatic angiosarcoma, carcinoid metastasis [4], metastatic carcinoma of the colon, and hepatoma. Although it is rare for a hepatoma to demonstrate increased delayed blood pool activity, underlying severe liver disease can be problematic in these patients as there is no normal hepatic blood pool activity for comparison [4]. Also, in 2 of the 4 cases of hepatoma with increased activity on delayed images compared to the adjacent liver, there was increased arterial flow to the lesion on perfusion images [4]. In one review, early flow and delayed filling was seen in 3% of hemangiomas, nonetheless, in these instances a malignant lesion must be excluded

Hemangioendothelioma:
Hemangioendotheliomas typically present in children less than 6 months of age. The classic presentation is one of hepatomegaly associated with CHF, however, the lesion may present as asymptomatic hepatomegaly and simulate a primary hepatic malignancy. The lesion is usually multifocal and will spontaneously regress, but they are also generally responsive to steroid therapy.

Hemangioendothelioma
On Tc-SC imaging, hemangioendotheliomas typically demonstrate increased flow, but appear as defects on later images . On Tc-RBC scintigraphy, these lesions demonstrate increased flow, increased blood pool, and increased activity on delayed images which is equal to or greater than that of the heart .

Hepatoblastomas, nodular hyperplasia, and fibrovascular mesenchymal hamartomas

Hepatoblastomas, nodular hyperplasia, and fibrovascular mesenchymal hamartomas have all been shown to potentially demonstrate increased activity on all 3 phases of the exam, but none of these lesions has been shown to have activity equal to or greater than the heart on delayed images. Neuroblastoma typically produces a cold defect on later images and generally has no associated flow or blood pool abnormality

Hepatoblastoma:
Hepatoblastoma is the most common primary malignant tumor in young children (up to age 5y). About 50% of cases present before 1 year of age. Patients typically present with an asymptomatic RUQ mass, but anemia, weight loss, or jaundice can also be seen. Alphafetoprotein levels are elevated in 60 to 80% of cases. On Tc-SC imaging, the lesion is noted to have hypervascular flow, but will appear as a cold defect on delayed images. Very necrotic lesions may appear cold on both flow and static images. Very rarely, increased Tc-SC uptake has been reported.