Red Blood Cell Scan Research Articles

(99m)Tc-Labeled RBC Scan in a Patient with Blue Rubber Bleb Nevus Syndrome: A Case Report.

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder characterized by cutaneous and gastrointestinal vascular malformations. We report here the case of a 13-year-old patient with BRBNS who was suffering from chronic anemia. His chief complaint was melena. Contrast-enhanced abdominal computed tomography showed multiple hemangiomas in the small bowel. (99m)Tc-labeled red blood cell (RBC) scan identified the bleeding sites in the small bowel. The patient underwent exploratory laparotomy with segmental resection and multiple wedge resection of the small bowel. The pathological results confirmed the multiple cavernous hemangiomas. This case confirms the critical role of the (99m)Tc-labeled RBC scan in localizing the bleeding sites in patients with BRBNS.

Technetium-labeled erythrocyte scintigraphy in acute gastrointestinal bleeding

Optimal management of acute gastrointestinal (GI) bleeding requires accurate localization of the bleeding source. The role of technetium-labeled erythrocyte scintigraphy (tagged red blood cell (TRBC) scan) in evaluating acute GI bleeding has been controversial, though recent literature suggests that it is a reliable tool and may be used as a first-line diagnostic test. We evaluated our recent experience with and the clinical outcomes of the TRBC scan in patients presenting with acute GI bleeding. A retrospective study of 100 consecutive TRBC scans performed between April 2006 and January 2009 was conducted. Medical records of each corresponding patient were queried for pertinent data. Twenty TRBC scans performed for occult GI bleeding or >48 h after hospital admission were excluded. Of the 80 TRBC scans, 29 (36%) were positive and 51 (64%) were negative for bleeding. Eight (10%) were incorrect positive (leading to five incorrect operations), 12 (15%) true positive, 9 (11%) unconfirmed positive, 17 (21%) false negative, and 34 (43%) unconfirmed negative. The cause of bleeding was confirmed in 31 cases, of which the scan result was incorrect positive in 2 (7%), true positive in 12 (39%), and false negative in 17 (55%). TRBC scans have low positive yield as well as high incorrect positive and high false negative rates in patients with acute GI bleeding. Further research is needed to improve scan technique, refine patient selection, and determine in what setting TRBC scanning may be more clinically useful.

Combined Intrathoracic and Intraperitoneal Splenosis after Splenic Injury: Case Report and Review of the Literature

Splenosis is defined as an autotransplantation of the splenic tissue after splenic rupture or splenectomy, and occurs most frequently in the peritoneal cavity. Splenosis is usually asymptomatic and is found incidentally. We report a case of combined intrathoracic and intraperitoneal splenosis in a 54-year-old male who worked as a miner for 10 years in his twenties, and was a current smoker. He was referred to our hospital for further evaluation of an incidental left diaphragmatic mass. Positron emission tomography-computed tomography and bronchoscopy were performed to evaluate the possibility of malignancy. There was no evidence of malignancy, but the spleen was not visualized. Reviewing his medical history revealed previous splenectomy, following a dynamite explosion injury. Therefore, splenosis was suspected and technetium-99m-labeled heat-damaged red blood cell scan confirmed the diagnosis. Radionuclide imaging is a useful diagnostic tool for splenosis, which could avoid unnecessary invasive procedures.

Maternal GIST in twin pregnancy: Case report of a rare and complex management challenge

► Twin pregnancy ► GIST tumour ► Multidisciplinary team.

Small bowel endoscopy: Cost-effectiveness of the different approaches

Obscure gastrointestinal haemorrhage is defined the presence of overt or occult bleeding in the setting of a normal endoscopic examination of the upper and lower gastrointestinal tracts. While obscure bleeding is not common, the evaluation and management of these patients often incurs considerable expense. Potential options for small bowel evaluation include traditional radiographic studies, push enteroscopy, video capsule endoscopy, deep enteroscopy, tagged red blood cell scans, angiography, and enterography examinations with either computed tomography and/or magnetic resonance imaging. The decision regarding which modality to employ depends on the cost of the procedure, its effectiveness in rendering a diagnosis, and the potential for administration of therapy. This article will discuss determination of costs associated with technology for small bowel imaging, quality of life data associated with chronic GI haemorrhage, and available cost-effectiveness studies comparing the options for small bowel exploration.

Inverted Meckel's diverticulum as a cause of occult lower gastrointestinal hemorrhage

Meckel's diverticulum is a common asymptomatic congenital gastrointestinal anomaly, but rarely it can present with hemorrhage. Over the last few years inverted Meckel's diverticulum has been reported in the literature with increasing frequency as an occult source of lower gastrointestinal hemorrhage. Here, we report a case of a 54-year-old male, who was referred for surgical evaluation with persistent anemia and occult blood per rectum after a work up which failed to localize the source over 12 mo, including upper and capsule endoscopy, colonoscopy, enteroclysis, Meckel scan, and tagged nuclear red blood cell scan. An abdominal computed tomography scan showed a possible mid-ileal intussusception and intraluminal mass. During the abdominal exploration, inverted Meckel's diverticulum was diagnosed and resected. We review the literature, discuss the forms in which the disease presents, the diagnostic modalities utilized, pathological findings, and treatment. Although less than 40 cases have been reported in the English literature from 1978 to 2005, 19 cases have been reported in the last 6 years alone (2006-2012) due to improved diagnostic modalities. Successful diagnosis and treatment of this disease requires a high index of clinical suspicion, which is becoming increasingly relevant to general gastroenterologists.

Jejunal Amyloidosis: A Rare Cause of Severe Gastrointestinal Bleeding

1Department of Medicine; 2Division of Pathology; 3Division of Gastroenterology, University of British Columbia, Royal Columbian Hospital, New Westminster, British Columbia Correspondence: Dr Justin Cheung, Department of Gastroenterology, Royal Columbian Hospital, 410-301 East Columbia Street, New Westminster, British Columbia V3L 3W5. Telephone 604-525-0155, fax 604-525-1699, e-mail justa48@hotmail.com Received for publication December 22, 2011. Accepted December 29, 2011 CASE PRESENTATION An 81-year-old Jamaican woman presented with melena and severe anemia, and a hemoglobin level of 47 g/L (normal range 115 g/L to 160 g/L). A gastroscopy and colonoscopy were negative for any lesions. Duodenal biopsies were normal. A subsequent computed tomography scan of the abdomen with contrast showed diffuse thickening from the jejunum to the distal small bowel and a small area of active bleeding in the mid small bowel. A technetium-99m red blood cell scan demonstrated active bleeding in the proximal jejunum. Push enteroscopy (120 cm to 150 cm below incisor) revealed mild diffuse friability starting from the proximal jejunum, as well as erosions, nodularities, polypoid protrusions and valvulae conniventes thickening in the remaining jejunum (Figures 1A and 1B). Jejunal biopsies showed extensive amyloid deposition in the lamina propria and submucosa, with Congo red stain demonstrating apple-green birefringence under polarized light (Figure 2), and hematoxylin counterstain revealing amorphous, salmon-pink, sparsely cellular hyaline material (Figure 3). Serum protein electrophoresis, immunofixation and a serum-free light chain assay confirmed the presence of monoclonal immunoglobulin G lambda paraprotein. The patient was transfused with packed red blood cells as needed (average one unit per day), and treated with bortezomib and dexamethasone for primary amyloidosis. By day 17 of hospitalization, the bleeding had resolved and the patient was subsequently discharged without any further bleeding episodes. DISCUSSION Amyloidosis is a multisystem disease characterized by extracellular deposition of abnormal protein fibrils in various tissues and organs. The protein fibrils are derived from monoclonal immunoglobulin light chains in primary amyloidosis (AL), acute phase reactant serum amyloid A in secondary amyloidosis (AA), and beta2-microglobulin in dialysis-related amyloidosis (Ab2m). Clinical manifestations in amyloidosis are variable, but the heart and kidneys are most commonly involved. Gastrointestinal symptoms due to bleeding, dysmotility and malabsorption are present in up to 60% of AA (1), but in only 1% of AL (2). The diagnosis of amyloidosis can only be confirmed by tissue biopsy because endoscopic and radiologic findings are nonspecific. Therapy is directed at the underlying cause in AL (plasma cell dyscrasia) and AA (infection, inflammation and malignancy), whereas treatment in Ab2m involves alteration of dialysis mode or consideration of renal transplantation (3). Severe gastrointestinal bleeding rarely occurs as the sole or initial manifestation of systemic amyloidosis (4). Mechanisms by which hemorrhage occurs in gastrointestinal amyloidosis have been postulated, including intestinal ischemia, necrotic ulceration, mucosal tearing, vascular fragility, abnormal platelet aggregation, and factor IX and X deficiencies (5,6). In addition to supportive care for bleeding, treatment must be tailored to the specific type of amyloidosis, as determined by endoscopy and histology. Endoscopy classically shows polypoid protrusions and valvulae conniventes thickening in AL; a imAge of the month

Argon Plasma Coagulation-Induced Enteritis: Visualizing an Uncommonly Reported Complication of Double Balloon Enteroscopy (DBE)

Purpose: Argon plasma coagulation (APC) is a form of non-contact electrocoagulation in which argon gas forms a plasma and conducts monopolar current to the treatment site. Specifically, once a lesion is visualized, pressurized argon gas is released through a probe directly overlying the lesion. High voltage electrical current then passes through the probe, ionizing the gas and causing superficial coagulation of the tissue. Coagulation is usually 2-4mm deep and therefore, complications should be rare. When combined with double balloon enteroscopy (DBE), this technique can be highly effective for hemostasis of mucosa more prone to perforation. This is a case of a 65-yearold woman on anticoagulation for mechanical aortic and mitral heart valves presenting with persistent melena for three weeks' duration. A tagged red blood cell scan and angiography revealed no obvious source of bleeding, however, the pancreaticoduodenal and gastroduodenal arteries were empirically embolized. Despite embolization, she had persistent melena, necessitating a total of 15 units packed red blood cells transfusions. She was then transferred to our medical center and a capsule enteroscopy (CE) on hospital day 1 noted fresh heme at the proximal jejunum without any obvious underlying lesion. Antegrade DBE on hospital day 2 showed an actively oozing Dieulafoy lesion at the jejunum, which was marked with a tattoo. This was then treated with APC at a small bowel setting with a straight-fire catheter. After hemostasis, the patient did well without any abdominal discomfort, fevers, ongoing overt bleeding, or need for repeat blood transfusions. A repeat antegrade DBE performed 48 hours later revealed changes both macroscopically and histologically consistent with enteritis at the site where APC had been performed, as verified by the aforementioned tattoo mark; neither fresh nor old heme was noted within the small bowel. A repeat CE 10 days later was consistent with healing enteritis at the area where APC was performed. At 10 week follow-up, the patient reported no further hospitalizations, transfusions, or recurrent bleeding with repeat CE showing complete resolution of the APC-induced enteritis. This is a case of a rarely documented complication of DBE. Based on a safety and feasibility study, the overall complication rate for DBE is as high as 3.4%, with APC-induced enteritis being the only significant acute adverse event related to APC. This occurred in 0.9% of cases. Therefore, the actual incidence of APC and/or DBE related complications may be higher than previously reported, and as in our case, the complication may be clinically silent.

A Rare Case of Jejunal Dieulafoyʼs Lesion in a 21-Year-Old Male

Purpose: Dieulafoy's lesion is a rare and potentially life threatening cause of gastrointestinal bleeding occurring in only 2% of all gastrointestinal bleeds in adults. The most common site is the proximal third of the stomach within 6cm of the gastro-esophageal junction. Other sites include the duodenum, colon, jejunum and esophagus, with the duodenum being the most common extra-gastric site. Mortality rates for these lesions approached 80% prior to the era of endoscopy, however, rates have decreased significantly to less than 10% with use of newly available treatment options. A 21-year-old male presented with complaint of blood in his stools. He had no significant past medical history. Two days prior, he had eaten at a Chinese restaurant. Later, he had 3 heavy bowel movements and noticed fresh blood mixed with his stool. He denied any medication use, smoking or any other substance abuse. His father was diagnosed at 58 years of age with colon cancer. Physical exam revealed a hemodynamically stable, obese male. A rectal exam revealed gross blood. His hemoglobin level was 11.4. An initial CT scan of abdomen was negative for any significant findings. The patient had 3 bloody bowel movements over the next 12 hours and became hemodynamically unstable. He was aggressively resuscitated with fluids and transfused with packed red blood cells. An emergency endoscopy and sigmoidoscopy did not reveal any source of bleeding. A mesenteric angiogram was performed revealing a site of extravasation in left mid-abdomen from a jejunal branch. Embolization was performed. Additional foci of extravasation were located in jejunal branches of superior mesenteric artery where embolization could not be performed due to inaccessibility. Following angiogram, he underwent exploratory laparotomy in which 22cm of jejunum was resected and ‘jejunal polyp' was found. The ‘jejunal polyp' was found to be a dieulafoy's lesion on pathologic examination. The current report of jejunal dieulafoy's lesion is one of less than two dozen appearing in the literature. Before considering this rare diagnosis, upper and lower GI bleeds must be ruled out. Periodic or serial endoscopy and colonoscopy may be needed due to intermittent nature of bleeding. Following this, a tagged red blood cell scan as well as an angiogram may be performed in case of an active bleed. Dieulafoy's lesion must be considered as a part of differential diagnosis and must be acted upon promptly given its life threatening nature. However, this should only be done after an upper or lower GI source is excluded.

CT Angiography is Superior to Tagged Red Blood Cell Scanning for Localizing GI Bleeding and for Guiding Management: 2011 ACG Presidential Poster

Purpose: This is the first study comparing multi-detector CT angiography (CTA) vs. tagged RBC (TRBC) scanning in actual clinical GI practice with confirmatory standard of care (SOC) testing (endoscopy, angiography or surgery) as the gold standard measure. We sought to compare diagnostic parameters of CTA vs. TRBC in the clinical evaluation of patients with acute GI bleeding (GIB) when confirmed by SOC confirmatory testing. Methods: Retrospective cohort of consecutive adult patients having either CTA (n=64) or TRBC (n=62) followed by at least one unblinded SOC confirmatory test at a single, tertiary care medical center. All hospitalized patients with acute GIB that had CTA (2008-10) or TRBC (2007-8) were eligible. Patients lacking SOC testing, had occult instead of acute GIB, or for technical reasons were excluded (n=16 TRBC; n=11 CTA). Admission and nadir hematocrit (HCT), age and gender were variables extracted from chart review. We intentionally utilized strict diagnostic criteria in our study design to define a positive imaging test or a positive confirmatory test. A (+) imaging test required identifying radiotracer (TRBC) or contrast extravasation (CTA) in bowel lumen. A (+) SOC confirmatory test required identification of active bleeding or stigmata of recent hemorrhage and not just blood or clots alone. Results: TRBC scanning: 22 of 46 (48%) were (+) for acute GIB. In 17 of 22 (77%) TRBC's, SOC testing confirmed the location of bleeding to be in the same anatomic region seen by TRBC. The other 5 (+) TRBC's (5/22; 22.7%) identified a completely wrong anatomic location as bleeding. The majority of confirmed (+) TRBC's were in the colorectum (10/17; 59%) and small bowel (7/17; 41%). CT angiography: 17 of 53 (32%) were (+) for acute GIB. In 15 of 17 (88%) CTA's, SOC testing confirmed the location of bleeding to be in exactly the same anatomic region as seen by CTA. The other 2 (+) CTA's (2/17) were counted as negative by SOC confirmatory testing (findings: diverticular disease with blood clots but no active bleeding or stigmata of recent hemorrhage). Most confirmed (+) CTA's were in the colorectum (10/15, 66.7%) followed by upper GI (26.7%, 4/15) and small bowel (6.7%, 1/15). The incorrect localization rate favored CTA as the superior test (CTA 0% vs. TRBC 22.7%) as did the specificity (CTA 86.7% vs. TRBC 50%) and these differences were statistically significant (p < 0.05). Limitations: single academic center, retrospective cohort study, consecutive cohort time periods. Conclusion: CT angiography is superior to TRBC scanning in the evaluation of acute GI bleeding. CTA had significantly greater specificity and no erroneous localizations while finding the correct site of bleeding.Table: Comparison of TRBC ( n =46) and CTA ( n =53), diagnostic parameters

Diverticular Bleeding: The Imaging-Endoscopy Corroboration

A 78-year-old woman with prior history of lower gastrointestinal (GI) bleeding and known colon diverticulosis on previous colonoscopy presented to the emergency department with severe painless hematochezia. She was hemodynamically stable. An urgent technetium-99m-labeled red blood cell (RBC) scan was obtained, which suggested the site of bleeding to be close to the region of the ileocecal valve in the colon (Figure A). The absence of tagged red cell extravasation elsewhere on delayed images made the possibility of bleeding from elsewhere in the gastrointestinal tract less likely.

Protocol management for patients presenting with lower GI haemorrhage saves costs and maintains outcomes

Lower gastrointestinal (LGI) bleeding is a common medical problem associated with significant morbidity and mortality. Although most patients stop bleeding spontaneously without intervention and most do not re-bleed, a small number have massive haemorrhage that requires intervention to prevent shock and coagulopathy. Many choices are available in managing such patients. The clinician faces decisions regarding the timing and nature of investigations and treatment options. The aim of this study is to analyse the impact of a protocol to improve clinical practice in this area. The protocol was based on a review of investigative patterns, and transfusion at the outset of the project. Length of stay, number of inpatient and outpatient colonoscopies, radiolabelled red blood cell (RBC) scans, blood transfusions, re-admissions, operations and deaths were compared for patients admitted prior to and following implementation of the protocol. The number of transfusions and RBC scans both significantly lessened after implementation of the protocol. There were no demonstrable adverse outcomes by way of mortality, length of stay and number of patients requiring operation, colonoscopies and re-admissions. The implementation of a protocol to manage patients with LGI bleeding is matched by a significant reduction in use of hospital resources for these patients over the same time frame. Low morbidity and mortality outcome was maintained following introduction of the protocol.

A Jejunal Dieulafoy Lesion in a Woman with AML-A Case Report

Purpose: Dieulafoy lesions are responsible for 2 percent of upper gastrointestinal bleeding. The incidence of these lesions in lower gastrointestinal bleeding is unknown, though it is felt to be much lower than the aforementioned value; these lesions are usually apparent only after multiple endoscopic surveys. This case addresses this infrequently encountered disease entity and also posits endoclip placement as a non-surgical alternative for these lesions when they develop in the jejunum. Course: A 76-year-old woman with a past medical history of atrial fibrillation and acute myeloid leukemia with failed remission was admitted for initiation of another course of chemotherapy with Cytarabine and Clofarabine. Her admission labs were significant for a hemoglobin of 8.3 mg/dL and a platelet count of 63 K/μL. On the second hospital day, the patient developed melena. Despite multiple blood transfusions, the patient's hemoglobin remained unstable - the patient was moved to the ICU, and the Gastroentology Service was notified. An EGD was done which revealed antral gastritis; no source of bleeding was identified. Colonoscopy additionally revealed no source of bleeding. The patient was placed on IV acid suppression. Serial CBCs were monitored. Chemotherapy-induced enteritis was posed as a cause of her bleeding, and transfusions were continued. Complicating matters was the inability to perform platelet apheresis, owing to the development of multiple platelet antibodies by the patient. IVIG was given in an attempt to bolster the patient's platelet count, but this was unsuccessful. A tagged red blood cell scan was performed, and this demonstrated bleeding in the proximal jejunum. Embolization in this area was attempted, but the culprit vessel could not be identified. A push enteroscopy was performed, and this showed a Dieulafoy lesion in the proximal jejunum. Epinephrine was injected into the lesion and an endoclip was placed. CBCs were monitored for another 24 hours - as there was a continued decrease in the patient's hemoglobin, a repeat enteroscopy was done and another endoclip was placed with adequate hemostasis as evidenced by a stable hemoglobin trend for the duration of the patient's hospital course. Discussion: In a patient with an inconclusive source of gastrointestinal bleeding despite thorough endoscopic surveys, small bowel pathologies such as Dieulafoy lesions (in this case jejunal Dieulafoy lesions) should be considered. Additionally, endoclip placement may represent a new treatment paradigm for these lesions, thus not subjecting the patient to long-term complications of segmental resections, such as adhesion development and possible small bowel obstruction.

F-18 FDG PET/CT Imaging of a Parapharyngeal Hemangioma

Tumors of the parapharyngeal space (PPS) are uncommon, comprising 0.5% of all head and neck neoplasms. Hemangiomas are responsible for <1% of all such tumors occurring in the PPS. We present the case report of a 55-year-old woman who presented with sensorineural hearing loss. She was evaluated with an magnetic resonance imaging, which showed an incidental finding of a mass in the right PPS. Tagged red blood cell scan showed increased and progressive attenuation in the lesion, which is diagnostic of hemangioma. PET/CT showed minimal background uptake. This added confidence to the diagnosis, and thus avoided an invasive biopsy.

Images in haematology: Iron deficiency anaemia: an unusual presentation of lymphangioma

A 15-year-old Chinese male with underlying glucose-6-phosphate dehydrogenase deficiency presented with exertional dyspnoea and giddiness. He was not vegetarian and there was no history of bleeding. Physical examination was unremarkable. Full blood count showed microcytic hypochromic anaemia with marked reticulocytosis. A peripheral blood count 2 years previously had been unremarkable. He was found to have iron deficiency anaemia and started on oral iron supplements. Oesophagogastroduodenoscopy and colonoscopy were negative. Despite compliance with iron supplements and administration of intravenous iron, he remained persistently anaemic, requiring regular packed red cell transfusions. Further investigations, including a small bowel follow through, Meckel scan, evaluation for haemolysis and flow cytometric screening for paroxysmal nocturnal haemoglobinuria were all negative. Bone marrow studies showed erythroid hyperplasia with absent iron. A tagged red blood cell scan suggested active intermittent bleeding in the jejunum and proximal ileum. Magnetic resonance imaging of the abdomen showed a sheet-like mass in the mid-retroperitoneum surrounding the coeliac axis, proximal common hepatic and splenic arteries, superior and inferior mesenteric veins and superior mesenteric artery, and abutting the duodenum and proximal jejenum. The patient underwent a laparotomy and was found to have an extensive retroperitoneal lymphangioma extending from the second part of the duodenum to the duodenojejunal flexure. An on-table duodenoscopy showed bleeding lesions in the third part of the duodenum. Because of the high risk involved with a complete resection, only the third part of the duodenum, which had mucosal involvement, was resected. Histology was consistent with a lymphangioma. The patient has been well since, with a normal haemoglobin concentration, red cell indices and iron studies. Lymphangioma is a rare benign cystic tumour occurring mainly in children. It has a variable presentation depending on the site of the tumour, but chronic gastrointestinal blood loss presenting as iron deficiency anaemia is a rare occurrence.

Diagnostic and Therapeutic Tricks in a Rare Case of Pediatric Ileal Congenital Arteriovenous Malformation

Diagnostic and Therapeutic Tricks in a Rare Case of Pediatric Ileal Congenital Arteriovenous Malformation

T1228 Is CT Angiography Better Than Tagged Red Blood Cell Scanning in the Identification of Acute GI Bleeding?

T1228 Is CT Angiography Better Than Tagged Red Blood Cell Scanning in the Identification of Acute GI Bleeding?

Gastroenterologic and Radiologic Approach to Obscure Gastrointestinal Bleeding: How, Why, and When?

Gastrointestinal (GI) bleeding is a common clinical condition that is increasingly seen in an aging population and frequently requires hospitalization and intervention, with significant morbidity and mortality. Obscure GI bleeding (OGIB) is defined as loss of blood with no source identified after upper endoscopy and colonoscopy. Whether an obscure site of bleeding is clinically evident or silent, it constitutes a diagnostic and therapeutic challenge for the clinician. Gastroenterology and radiology provide the essential diagnostic tools used to evaluate suspected OGIB, each with its strengths and weaknesses. Small bowel series and conventional enteroclysis have a limited role in OGIB. Computed tomographic (CT) enterography and CT enteroclysis are noninvasive techniques with promising results in evaluation of small bowel disease and silent OGIB. CT angiography is a useful triaging tool for diagnosing or excluding active GI hemorrhage, localizing the site of bleeding, and guiding subsequent treatment. Tagged red blood cell scanning is the most sensitive technique for detection of active GI bleeding and allows imaging over a prolonged period, making it useful for detecting intermittent bleeding. Capsule endoscopy has emerged as an important tool for investigating OGIB, but it may soon have competition from double-balloon enteroscopy, a diagnostic technique that can also facilitate therapy.

Portosystemic Collateral Circulation

Abstract: A 42-year-old woman with advanced alcoholic liver cirrhosis was referred for a Tc-99m-labeled red blood cell (RBC) abdominal scan due to tarry stool passage. The Tc-99m RBC scan revealed a tangled linear radioactivity accumulation, extending from the right epigastric area to the right lower pelvic region. The integrated single-photon emission computed tomography/computed tomography (SPECT/CT) with 3D volume rendering imaging and CT bone segmentation display confirmed the portosystemic collateral circulation.

Bleeding Meckelʼs Diverticulum with a Negative Meckelʼs Scan - Uncommon Feature of an Uncommon Entity

Purpose: Case: A 30-year old male presented with a 13-month history of obscure GI bleeding. He initially presented elsewhere after a single episode of maroon colored stools. He had been previously healthy, and used NSAIDs rarely. He was adopted and of Korean descent; his family history was unknown. He denied easy bruising or epistaxis. Initial workup elsewhere revealed iron-deficiency anemia. EGD and colonoscopy were negative. He was advised to avoid NSAIDs, which he did. Two weeks later, he had recurrent bleeding. A capsule enteroscopy, single balloon enteroscopy (SBE), tagged red blood cell scan and Meckel's scan were negative. At our institution, a repeat antegrade SBE showed a single non-bleeding jejunal vascular ectasia that was cauterized. He was well for 9 months, then again developed maroon stools. He denied NSAID use. Workup included a SBE that was unremarkable, a triple-phase CT enterography (CTE) showing a Meckel's diverticulum, a Meckel's scan which was again negative, and a capsule enteroscopy revealing a mid-ileal ulcer. Due to ongoing bleeding, a retrograde double balloon enteroscopy (DBE) was done and revealed a large mid-ileal diverticulum with a 2 cm ulcer at its rim containing a flat pigmented spot, treated endoscopically. Persistent bleeding led to surgical resection of the diverticulum. Pathology confirmed a Meckel's diverticulum, with circumferential ulceration around its neck and a thrombosed artery in the ulcer base. Histologic sampling of the entire diverticulum failed to reveal ectopic gastric mucosa. Discussion: Meckel's diverticulum is the most common congenital anomaly of the GI tract. It affects 2% of the population, but only 2% develop complications, often before age 2. Complications include bleeding (most commonly), obstruction, diverticulitis, intussusception and perforation. Up to 90% of bleeding diverticula contain ectopic gastric mucosa. Our patient had a triple-phase CTE demonstrating a Meckel's diverticulum, and a DBE localizing it as the bleeding source, despite negative Meckel's scans. Histologic evaluation of the surgical specimen failed to reveal ectopic gastric mucosa, ruling out acid-mediated ulceration. The pattern of ulceration suggested the diverticulum had bled from repetitive inversion and eversion of the diverticulum into the ileal lumen, leading to ulceration in the neck. This putative mechanism has not been reported in the literature. This case highlights that a Meckel's diverticulum may be a source of GI bleeding despite absence of ectopic gastric mucosa.