Your SlideShare is downloading. ×
0
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Radionuclide imaging for GI system
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Radionuclide imaging for GI system

1,910

Published on

Published in: Education
0 Comments
4 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,910
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
130
Comments
0
Likes
4
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. RADIONUCLIDE STUDIES OFTHE GASTROINTESTINAL SYSTEM Jiraporn Sriprapaporn, M.D. Nuclear Medicine, Radiology, Siriraj Hospital
  • 2. GASTROINTESTINAL SYSTEM Eso transit timeEsophagus GE reflux (milk scan) Gastric emptying studyStomach: Ectopic gastric mucosa localizationIntestine GI bleeding study J SRIPRAPAPORN
  • 3. GASTROINTESTINAL SYSTEMLiver-spleen Nonspecific SOL Tumor/infection HemangiomaBiliary system Hepatobiliary imaging J SRIPRAPAPORN
  • 4. THE LIVER The biggest organ, 1500 g Anatomy: 4 parts- Right, Left, Caudate, and Quadrate lobes Histology: Hepatocytes or polygonal cells RE cells (Kupffer’s cells) Blood Supply: Portal vein 75 % Hepatic artery 25 % J SRIPRAPAPORN
  • 5. FUNCTIONS OF LIVER Bile formation (Hepatocytes) Phagocytosis (RE cells) Protein synthesis, eg. albumin, fibrinogen Metabolizes substances J SRIPRAPAPORN
  • 6. LIVER-SPLEEN SCAN(Routine Liver Scan)Tracer: 99mTc-sulfur colloid/ phytateRoute : IV injectionMechanism : Phagocytosis by RE cells (liver, spl, BM)Visualization : Liver and SpleenTechnique: Patient preparation : none Imaging : 15-20 min. Pi. : Static 6 views- Ant, Post, RL, LL, RAO, LAODiagnosis : Diffuse & focal lesions focal defect(s) -nonspecific (abscess, metastasis, cyst etc.) J SRIPRAPAPORN
  • 7. Colloid Particles < 100 nm Bone marrow 200-1,000 nm Liver 1-5 um Spleen J SRIPRAPAPORN
  • 8. Tc-99m Sulfur Colloid Size: 100-500 nm (1-5 um) Distribution of Uptake Liver: 80-85 % Spleen: 12 % Bone marrow: The rest J SRIPRAPAPORN
  • 9. NORMAL LIVER SCAN Liver and spleen visualization Normal colloid distribution Uniform colloid distribution (no defect) J SRIPRAPAPORN
  • 10. LIVER SCAN: Clinical ApplicationsEvaluate shape,size,positionSOL in the liver-spleen: Cold defect*: nonspecific (metasastases***) Hot lesionDiffuse hepatocellular disease : COLLOIDSHIFT (Decreased hepatic, increased splenic& BM uptake) Ex. Cirrhosis J SRIPRAPAPORN
  • 11. COLLOID SHIFTPathophysiology Change in blood flow Hepatocellular impairment Stimulation of RE systemFindings Decreased hepatic uptake Increased splenic & BM uptakeEx. Cirrhosis J SRIPRAPAPORN
  • 12. LIVER SCAN ROUTINE LIVER SCAN : Tc-99m sulfur colloid (SC) or Tc-99m phytate LIVER SCAN with other R’pharmaceuticals Tc-99m RBC for Hepatic Hemangioma Tc-99m HMPAO-WBC for infection img. Ga-67 scan for tumor/infection imaging Tl-201, Tc-99m MIBI for tumor imaging J SRIPRAPAPORN
  • 13. Hepatic Blood Pool Scan (99mTc-RBC) Aim : To Dx hepatic hemangioma Sensitivity: SPECT almost 100% for > 1.5 cm lesions Technique : Flow: normal or decreased Static images: may be cold initially Delayed images *** hot lesions Positive : Increased activity in the lesion with time J SRIPRAPAPORN
  • 14. HEPATIC HEMANGIOMA SPECTVascular Study 3-D image J SRIPRAPAPORN
  • 15. HEPATIC HEMANGIOMA Planar RBC SPECTU/S Tc-99m RBC Scan J SRIPRAPAPORN
  • 16. LIVER SCAN U/SSimple RapidNot operator-dependent Operator-dependentMinimally invasive Absolutely noninvasiveNot expensive Not expensiveLess sensitive More sensitiveLess specific More specificNature: nonspecific Nature: Cystic vs solidDiffuse & focal dis. Focal > diffuseMinimal radiation No radiationAnatomy: intrahepatic Anatomy: intra-extrahep. J SRIPRAPAPORN
  • 17. CT SCAN MRIMore expensive Most expensiveMore radiation No radiationGood anatomic Excellent anatomicdetails details Intrahepatic Intrahepatic Extrahepatic ExtrahepaticMor available Less available J SRIPRAPAPORN
  • 18. CONCLUSION: LIVER SCAN Liver metastases** Role of radionuclide study Role of U/S , CT, MR Tc-99m RBC for hemangioma ! SPECT/CT will enhance sensitivity & specificity of the test. J SRIPRAPAPORN
  • 19. SLLEEN SCAN Radiopharmaceuticals: Tc-99m sulfur colloid, Tc-99m phytate: phagocytosis by RE cells Tc-99m heat-denatured red cell: cell sequestration (specific for splenic function) Indication: Accessory spleen, splenic infarct J SRIPRAPAPORN
  • 20. A 56-year-old woman who underwent splenectomy two yearsago for idiopathic thrombocytopenic purpura (ITP) continuesto have thrombocytopenia Planar and SPECT images of the abdomen ( Tc-99m in vitro- labeled heat-damaged red blood cells) Two foci of increased activity are seen in the posterior aspect of the left upper quadrant consistent with residual splenic tissue. http://nucmed.richis.org/case/Infec/MIRsi0201.htm J SRIPRAPAPORN
  • 21. HEPATOBILIARY IMAGING
  • 22. Radiopharmaceuticals forHepatobiliary ImagingTc-99m Iminodiacetic acid) IDA derivatives Tc-99m diisopropyl IDA (DISIDA or Disofenin) Tc-99m trimethylbromo IDA (Mebrofenin) J SRIPRAPAPORN
  • 23. HEPATOBILIARY SCANTracers : Tc-99m IDA derivatives (Tc-99m DISIDA,Mebrofenin)Route : IV injectionMechnism : Carrier-mediated, non sodium dependentorganic anion transport processTecnique : -Fasting 4-6 hr -Dynamic study for at least 1 hour +/- delayed imagingVisualization : Liver and biliary system includinggallbladder until excretion into small bowel (Normalwithin 1 hour) J SRIPRAPAPORN
  • 24. HEPATOBILIARY SCAN:IndicationsGallgladder disease Acute cholecystitis*Biliary tract obstruction DDx biliary atresia vs neonatal hepatitisBiliary leakage J SRIPRAPAPORN
  • 25. NORMAL HEPATOBILIARY SCANVisualization :Liver and biliary system including Right & left hepatic ducts Common hepatic duct Common bile duct Gallbladder Until excreted into small bowelWithin 1 hour J SRIPRAPAPORN
  • 26. NORMAL HEPATOBILIARY SCAN Tc-99m DISIDA J SRIPRAPAPORN J SRIPRAPAPORN
  • 27. NONVISUALIZED GALLBLADDER Acute cholecystitis Severe chronic cholecystitis Prolonged fasting Intercurrent severe illness Acute pancreatitis Severe liver disease J SRIPRAPAPORN
  • 28. BILIARY ATRESIA Early images 24-hr image J SRIPRAPAPORN
  • 29. NEONATAL HEPATITIS 1 hr 4 hr J SRIPRAPAPORN J SRIPRAPAPORN
  • 30. GI BLEEDING STUDY Lower GI tract Active bleeding Tc-99m SC or Tc-99m RBC* (intermittent) More sensitive than angiography but less anatomical details Less specific in nature J SRIPRAPAPORN
  • 31. GI BLEEDING STUDY: TECHNIQUE Preparation: NPO Position: Supine Region: Anterior- lower abdomen Imaging: Flow 1 min Dynamic imaging for 1-2 hr with additional delayed images as required. J SRIPRAPAPORN
  • 32. POSITIVE FINDINGS •Tc-99m RBC •Hepatic flexureExtravasation of the tracer into bowel lumen Focal area of increased activity, move // bowelmovementPattern depends on site of bleeding & bowelperistalsis J SRIPRAPAPORN
  • 33. Tc-99m RBC Tc-99m SCBleeding 500+ ml/ 24 T1/2 in bl pool 2.5-3 minhr. Bleeding rate 0.05-0.1Bleeding rate 0.1-0.5 ml/min*ml/min Intetrmittent bleedingIntermittent bleeding- requires reinjection24h F/U wo reinjection Higher T/B ratio (lowerLower T/B ratio (higher Bcg)Bcg) Upper abd interfered byUpper & lower GI liver-spleen activitybleeding J SRIPRAPAPORN
  • 34. Meckel’s Scan Meckel’s diverticulum represents a persistence of the omphalomesenteric (vitelline) duct at its junction with the ileum. Meckel’s diverticulum is the most common cause of lower GI bleeding in small children. Meckels are disease of “2” Most of the patients are asymptomatic (80%). Gastric mucosa is most commonly found mucosal lining in the Meckel’s. Most common Sx is painless blood per rectum- gastric mucosa was found in 95% of bleeding lesions. J SRIPRAPAPORN
  • 35. No need for active bleeding during the scanMeckel’s Scan Indication: bleeding per rectum in small children Radiopharm: Tc-99m pertechnetate, IV Mechanism: Localization of ectopic gastric mucosa Imaging: Patient preparation: NPO 4 hr Sequential abdominal imaging for 1-2 hr. Positive findings: Focal hot spot (RLQ) // stomach activity Sen 85%, spec 95% J SRIPRAPAPORN
  • 36. Meckel’s Diverticulum Stomach Stomach M Bladder U. Bladder J SRIPRAPAPORN
  • 37. GASTROESOPHAGEAL STUDY1. Esophageal transit study : dysphagia2. Gastroesophageal reflux study (milk scan): GE reflux3. Gastric emptying study : dyspepsia J SRIPRAPAPORN
  • 38. DISEASES OF THE ESOPHAGUS Motility disorders of the esophagus: scleroderma, achalasia Gastroesophageal reflux & related disorders Structural lesions of the esophagus: tumors, rings, webs J SRIPRAPAPORN
  • 39. GASTROESOPHAGEAL STUDY1. Esophageal transit study2. Gastroesophageal reflux study (milk scan)3. Gastric emptying study J SRIPRAPAPORN
  • 40. ESOPHAGEAL TRANSIT STUDY Indications: swallowing difficulty eg. dysphagia, heartburn Radiopharm: Tc-99m SC - neither absorbed nor secreted by esophageal mucosa, 150-500 uCi Technique: 4-6 hr fasting Liquid*: Water = most common, 10 ml bolus Position: Upright* ( more physiological & is preferable or supine ( no effect of gravity) Acquisition: Dynamic imaging 0.8 s x 240 s J SRIPRAPAPORN
  • 41. ESOPHAGEAL TRANSIT STUDY Quantification: 3 regions Time-activity curvesInterpretation: At 15 sec post bolus swallowing, >90% of radioactivity passed into the stomach J SRIPRAPAPORN
  • 42. GASTROESOPHAGEAL STUDY1. Esophageal transit study2. Gastroesophageal reflux study (milk scan)3. Gastric emptying study J SRIPRAPAPORN
  • 43. GE REFLUX STUDY (MILK SCAN)Indication: To detect GE reflux:- regurgitation ofgastric contents esophagusTracers : Tc-99m phytate, Tc-99m SC 300 uCiTechnique : NPO, oral tracer adm. Within 30 s Supine imaging over EG junction Dynamic for >10-20min. Views: anterior ( & posterior)Positive : Activity from the stomach esophagus N < 3 %, Abn >4 % J SRIPRAPAPORN
  • 44. GE REFLUX STUDY (MILK SCAN) J SRIPRAPAPORN
  • 45. GASTROESOPHAGEAL STUDY1. Esophageal transit study2. Gastroesophageal reflux study (milk scan)3. Gastric emptying study J SRIPRAPAPORN
  • 46. THE STOMACHAnatomy Fundus: reservoir Body: grinder Antrum : propeller, grinder Pylorus: particles < 1 mm passPhysiology: Vagus N, ANS J SRIPRAPAPORN
  • 47. Rate of gastric emptyingTypes & compositions of food: Physical state: Liq-exponential, solid-linear Particle size Caloric contents: Fat delays GE0 Fiber contents Liquid Caloric density Acididy & viscosityVolume of foodNeuro regulartory factors Solid J SRIPRAPAPORN
  • 48. Rate of gastric emptying Sex Age Obesity Concomitantdiseases eg. DM Position J SRIPRAPAPORN
  • 49. GASTRIC EMPTYING STUDYClinical indications: Dyspepsia, dumping syndromeTracers : Solid: Tc-99m phytate, Tc-99m SC 1 mCi, Oral Liquid: In-111 Cl 100 uCi CG =[CA . Cp ]1/2Technique : C = Counts calculated G NPO, upright, eat within 10 min by geometric mean Dynamic imaging for 120min. C = Counts in anterior A view Views: anterior & posterior C = Counts in p (geometric means) or LAO posterior view J SRIPRAPAPORN
  • 50. GASTRIC EMPTYING STUDY J SRIPRAPAPORN J SRIPRAPAPORN
  • 51. INTERPRETATION OF GET Half-emptying time (T1/2)= 50 % emptying Normal T1/2 (min)Phase Males FemalesSolid 77 + 32 92 + 7.5Liquid 38 + 26 53.8 + 4.9 J SRIPRAPAPORN
  • 52. NORMAL SOLID-LIQUIDGASTRIC EMPTYING STUDY LIQUID SOLID Lag phase J SRIPRAPAPORN
  • 53. GEOMETRIC MEANATTENUATION CORRECTIONCGM= [CANT . CPOST]1/2 J SRIPRAPAPORN
  • 54. DUAL-PHASE SOLID-LIQ GASTRICEMPTYING STUDY A: Normal subject, N solid & liq emptying B: DM, N solid & liq emptying C: DM, delayed solid, N liq emptying D: DM, delayed both solid & liq emptying J SRIPRAPAPORN
  • 55. DIABETIC GASTROPARESIS A: Baseline study B: 2 wk after metoclopramide Rx C: 1 wk after cisapride Rx J SRIPRAPAPORN
  • 56. SUMMARYEsophagus: Milk scanStomach: Gastric emptyingstudyIntestine: GI bleedingLiver-spleen: Tc-99m SC orphytate, RBCBiliary system: Hepatobiliary J SRIPRAPAPORN

×