1. در مرکز پزشکی هسته ای دکتر دباغ – دکتر صادقی
در خدمت شما هستیم
مشهد، ملاصدرا 11 ، پلاک 1/4
Tel:+98(51) ; +98(51)

2. Clinical Applications of Nuclear Medicine in Gastrointestinal Tract
a brief review
DSNMC
Nuclear Medicine Research Center (NMRC; MUMS)
V. R. Dabbagh, DSNMC;

3. Salivary Gland Scintigraphy
This is a functional and morphologic test which will outline the gland and also assess function with Technetium 99m.

4. In a patient with normal salivary glands :
- both the parotid and submandibular glands are nicely depicted
- Good excretion after lemon juice

5. Clinical Applications
Tumors and cysts.
Infection and inflammation.
Sialolithiasis.
Function evaluation following radiation therapy.

6. and mixed cell tumor

7. Warthin’s Tumor (Papillary cyst adenoma)
This tumor appears as a hot lesion
The tumor tissue traps the Tc99m since it dose not communicate with the ductal system of the gland
The tumor are better outlined after stimulation with lemon juice

9. Esophageal Transit Scintigraphy
The scan provides functional information on esophageal motility.
It is most often used to screen symptomatic patients.
Evaluate the effectiveness of therapy for esophageal disorders ( Achalasia, diffuse esophageal spasm, Scleroderma).

10. Esophageal Transit Scintigraphy: Normal

11. Esophageal Transit Scintigraphy: Stenosis due to tumor

12. Radionuclide Gastric emptying study
Choice and Standard procedure
Noninvasive
Uses a physiologic meal
Quantitative
Easy
Serial testing can determine the effectiveness of therapy

13. Stasis syndromes
Mechanical causes: obstruction by tumor or peptic ulcer
Functional causes:
Diabetic gastroparesis
Gastroeneritis
Hyperalimentation
Metabolic disorders
Drugs: opiates, anticholinergics, OCP,
Hypothyroidism
PSS
SLE
Dermatomyositis
Amyloidosis
Post vagotomy
Etc

14. Solid versus liquid
The solid gastric emptying study is more sensitive than liquid emptying for detection of abnormal gastric emptying
Liquid emptying is usually normal when solid emptying is normal

16. Time-Activity Curve of Normal Solid Gastric emptying study

17. Time-Activity Curve of Solid Gastric emptying study: Diabetic Gastroparesis

19. Scintigraphic Evaluation of Gastro-Esophageal Reflux
Indications:
Persistent, recurrent heartburn (the most common symptoms)
Esophagitis
Regurgitation of stomach content into mouth
Dysphagia
Chest pain (not related to cardiac)
Nocturnal aspiration (primary in children)
Evaluation of therapy for reflux

20. Advantages It is relatively accurate and sensitive It is quantitative
It is technically easy to performed
It is non invasive
The radiation dose to patient is fairly low

21. Image Interpretation
A simple semiquantitative method of interpretation is to grade each reflux as
Low level (less than mid esophagus)
High level (greater than mid esophagus)
by its duration( less than 10 seconds or greater than 10 seconds)

22. Image Interpretation
The total number of reflux events can be summed in four categories:
Low level,<10sec
Low level,≥10sec
High level,<10sec
High level≥10sec
The greater the number of high events and the longer the reflux events, the more severe is the disease

23. Postprandial GER
Rav

24. Gastro-esophageal Reflux with aspiration in mid portions of the left and right lungs

25. Gastrointestinal Bleeding
Successful management of patient’s with acute GI bleeding depends on accurate localization of the bleeding site.
The history and clinical examination can often distinguish upper from lower tract bleeding.

26. GI Bleeding
Endoscopy is the primary diagnostic tool in patient’s with upper GI hemorrhage.
Scintigraphy has no significant role in detection of upper GI bleeding.
Scintigraphy is an established diagnostic and complementary technique to endoscopy and angiography for detection of active lower GI bleeding.

30. Lower GL Bleeding
In patients with acute lower GI bleeding , colonoscopy is the initial test of choice. But when colonoscopy gives intermediate results or cannot be performed, either radionuclide imaging or angiography is indicated
Radionuclide scanning is noninvasive and it is useful in Pt’s who are stable and have suspected low or intermediate rate of hemorrhage

31. Radionuclide Scanning
Two radionuclide methods are most commonly used.
Tc-99m sulfur colloid scintigraphy
Tc-99m red blood cell scintigraphy (choice)

32. Advantages High sensitivity. To view the entire of abdomen.
Sensitivity to low rates of bleeding.
No patient’s preparation is required.
Safety.
Noninvasive.
No risk of contrast injection.
Low cost.
Repeatable.

33. The role of radionuclide scanning
The radionuclide study ensures that the patients has active bleeding.
The study localizes the bleeding site so the angiographer can infuse the contrast into the appropriate artery.
This method can decreased the duration of the study and the amount of the contrast agent used.

35. Figure 6-79 Colonic bleeding from a diverticulum
Figure 6-79 Colonic bleeding from a diverticulum. A nuclear medicine gastrointestinal bleeding study done by tagging red cells with a small amount of radioactive material has images of the abdomen obtained at 5, 10, and 20 minutes. The aorta (Ao), inferior vena cava (IVC), and a transplanted kidney (K) are visible. In the left lower quadrant, increasing activity (black arrow) appears on the sequential images as a result of bleeding into the colon from a diverticulum.

37. Tc99m-RBC Scan versus contrast angiography
SCAN: Easy, no preparation, high sensitivity at low bleeding rates, the ability to provide continuous monitoring of the entire GI tract over several hours and detect intermittent bleeding, , prognostic information, detect: bleeding rates as low as :
ml/min, only 2-3 ml blood is necessary
Contrast angiography: detect: 1 ml/min( 10-fold), Each contrast injection lasts only s.

38. Meckel’s Scan
Meckel’s diverticulum (MD) represent the remnant of the omphalomesenteric duct and occurs in approximately 2% of population.
Most patients with MD are asymptomatic.
There is strong male preponderance , and the majority cause symptoms in children younger than 10 years.

39. Meckel’s Scan
Approximately 30% of MD contain gastric mucosa which increased the likelihood of complication.
In diverticula complicated by GI bleeding the incidence of gastric mucosa increased to over 95%.

40. Meckel’s Scan
Interavenous Tc-99m is secreted by the gastric mucosa in to the GI tract.
Technetium also is secreted by the ectopic gastric mucosa located in MD.
Meckel’s diverticulum seen as a solitary focus of increased activity , usually located in RLQ of abdomen.
Activity in the focus should appear at the same time that activity appear in the stomach.

42. Gastric mucosa
Bladder

43. Radionuclide Colon Transit
DSNMC

44. Radionuclide Colon Transit
V. R. Dabbagh Kakhki, NMRC, MUMS

45. Interpretation the images
1- Visual : from the anterior images
1 of 5 patterns:
Rapid transit,
Intermediate transit
Generalized delay
Right-sided delay
Left-sided delay
V. R. Dabbagh Kakhki, NMRC, MUMS

46. V. R. Dabbagh Kakhki, NMRC, MUMS

47. V. R. Dabbagh Kakhki, NMRC, MUMS

48. V. R. Dabbagh Kakhki, NMRC, MUMS

49. V. R. Dabbagh Kakhki, NMRC, MUMS

50. V. R. Dabbagh Kakhki, NMRC, MUMS

51. Three schematic colon diagrams:
four regions of interest with the activity in the faeces represented as a 'pot'.
The percent of activity in each region is shown besides the region.
Regions are coloured in a grey shade, which represents the percentage of activity in that region: white if there is no activity to black for 100% activity.
The graphics package allows us to paint in the appropriate grey shade in the region of interest by typing in the percentage activity. With laser printers it is possible to have tens of grey shades to reflect the per cent activity accurately.
V. R. Dabbagh Kakhki, NMRC, MUMS

52. Helicobacter pylori infection
Infects the gastric mucosa of most patients with duodenal ulcer, gastric ulcer and gastritis.
H. pylori is the causal agent in most cases
Bacterial eradication is critical in theses diseases.

53. Urea Breath Test (UBT) H.pylori has urease enzyme . Urea CO2+Ammonia
Simple, noninvasive, accurate, inexpensive
urease

54. UBT Tracer: 14C Radiopharmaceutical: 14C-Urea, 1 μCi , PO,
Urease from H.pylori splits urea molecule to from CO2 and NH3 in the stomach
The 14CO2 is absorbed into the blood and exhaled in the breath.

55. V.R.Dabbagh; DSNMC; www.DSNMC.ir