images in clinical medicine Wien Klin Wochenschr DOI 10.1007/s00508-014-0648-8
Detection of necrosis of the gastric fundus after blunt abdominal trauma by PET-CT A. Hofer · H. Kratochwill · A. Pentsch · M. Gabriel
Received: 22 July 2014 / Accepted: 15 October 2014 © Springer-Verlag Wien 2014
Summary Positron emission tomography with [18F]fluorodeoxyglucose provides functional and anatomic information by visualising the uptake of radiolabelled glucose in tumour and inflammatory cells. We report delayed diagnosis of necrosis of the gastric fundus after blunt abdominal trauma in a 73-year-old man. After a car accident with head-on collision, the patient was stabilised in our emergency room. His femur was treated by internal fixation, his ellbow was stabilised by a fixateur externe. During surgery his status deteriorated. The patient was in need of high dosage of inotrops during the following days. He had a biventricular pacemaker implanted because of ischemic myocardiopathy, and he suffered from renal insufficiency. Over the next days, his haemodynamics improved. A central venous line had to be removed because of ensuing septic fever. The patient complained of upper abdominal pain and nausea. A sonography and computer tomography without contrast medium were performed with negative result. Because of contamination of the central venous line with Staphy-
Dr. A. Hofer () Department of Anaesthesiology and Intensive Care, General Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria e-mail: [email protected] Dr. H. Kratochwill Department of Radiology, General Hospital Linz, Linz, Austria Dr. A. Pentsch Department of Surgery, General Hospital Linz, Linz, Austria Prof. M. Gabriel Department of Nuclear Medicine, General Hospital Linz, Linz, Austria
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lococcus epidermidis the pacemaker was evaluated for infection by transoesophageal echocardiography, again without any findings. Because of ongoing fever and positive inflammatory markers a positron emission tomography was indicated, as a contrast examination and a magnetic resonance examination were not feasible because of the renal insufficiency and the pacemaker, respectively. Prophylactic removal of the pacemaker would have been a substantial risk for the patient due to his underlying myocardiopathy. Positron emission tomography showed an increased tracer uptake in the gastric fundus, which turned out to be necrotic by endoscopy. A laparoscopic resection followed, and drainage of an abscess, which had evolved subsequently between stomach and spleen stopped the inflammatory process. This case report demonstrates that positron emission tomography may be an alternative to computer tomography with contrast medium and magnetic resonance imaging to detect an inflammatory process in patients with preexisting disease. Keywords [18F]-Fluorodeoxyglucose/diagnostic use · Positron emission tomography · Shock septic · Radionuclide imaging
Diagnose einer Magenperforation nach stumpfem Bauchtrauma mittels 18F-FDG PET-CT Zusammenfassung Die Positronen-Emissions-Tomographie mit 18F-Fluorodeoxyglucose erzeugt Bilder mit anatomischer und funktioneller Information durch Sichtbarmachung der Aufnahme radioaktiv markierter Glukose in Tumorzellen und durch Entzündung aktivierte Granulozyten. Wir schildern die verzögerte Diagnose einer Magenfundusnekrose nach stumpfem Bauchtrauma bei einem 73-jährigen Mann. Nach einem Verkehrsunfall mit Frontalzusammenstoß wurde der
Detection of necrosis of the gastric fundus after blunt abdominal trauma by PET-CT
1
images in clinical medicine Fig. 1 The arrows indicate the abnormal fluorodeoxyglucose uptake in the gastric wall of the fundus. Please also note that enhanced tracer accumulation at the site of the pacemaker was supposed; however, this finding was of technical reason, caused by the attenuation correction (AC). Acquisition without AC was negative for this finding
Patient primär im Schockraum stabilisiert und im Operationssaal chirurgisch mittels Femurnagel und Fixateur externe des Ellbogens versorgt. Bereits intraoperativ verschlechterte sich die hämodynamische Situation drastisch. Der Patient war in den folgenden Tagen hoch katecholaminpflichtig. Er hatte wegen ischämischer Myokardiopathie einen biventrikulären Schrittmacher und eine eingeschränkte Nierenfunktion. Unter hochdosierter Katecholamintherapie stabiliserte sich der Kreislauf über einige Tage. Wegen darauffolgender septischer Fieberzacken wurde der zentralvenöse Katheter gewechselt. Der Patient klagte über Oberbauchbeschwerden und Übelkeit. Eine Oberbauchsonographie und eine CT Untersuchung ohne Kontrastmittel brachten kein Ergebnis. Die Kontamination des zentralvenösen Katheters mit Staphylokokkus epidermidis erforderte eine Evaluierung des implantierten Schrittmachers bezüglich Infektion mittels transösophagealem Echo ohne Ergebnis. Bei weiter bestehendem Fieber und hohen Entzündungsparametern wurde die Indikation zur Positronen-Emissions-Tomographie gestellt, da eine Kontrastmitteluntersuchung bei bestehender Niereninsuffizienz und eine MRT Untersuchung wegen des implantierten Schrittmachers nicht möglich war. Eine Entfernung des Schrittmachers ex iuvantibus stellte wegen der bestehenden Kardiomyopathie ein Risiko dar. Durch die Positronen-Emissions-Tomographie wurde eine Anreicherung im Magenfundus sichtbar, welche sich in der Endoskopie als Magenfundusnekrose darstellte. Nach darauffolgender Magenteilresektion war die Infektion zunächst vorrübergehend, nach Drainage eines zwischen Restmagen und Milz aufgetretenen Abszesses entgültig abgeklungen. Unser Fall zeigt, dass die Positronen-Emissions-Tomographie eine Alternative zur Computertomographie mit Kontrastmittel und Magnetresonanzuntersuchung zur Auffindung von Entzündungsherden bei Patienten mit vorbestehenden Erkrankungen darstellt. Schlüsselwörter 18F-Fluorodeoxyglukose · PET-CT · Stumpfes Bauchtrauma · Septischer Schock
Because of an increased glucose metabolism in inflammatory cells, [18F]-fluorodeoxyglucose-([18F]-FDG) positron emission tomography (PET)/computer tomography (CT) has been used to identify infectious foci in intensive care patients [1]. For this reason, we also used this imaging modality for localisation diagnosis in a septic patient after blunt abdominal trauma. The 73-year-old male patient was admitted with left femoral fracture, fracture of the left elbow, lung contusions and splenic rupture. He also had a biventricular pacemaker implanted. After primary post-operative recovery recurrent fever was observed. Elevated white blood cell count, C-reactive peptide and procalcitonin indicated persistent inflammation. The patient’s upper abdomen was painful. The central venous line showed non-specific contamination with Staphylococcus epidermidis. Ultrasound, CT scan without contrast medium, because of renal insufficiency, and transoesophageal echcardiography showed also no infectious foci. As all these results were negative, PET-CT was initiated as the next step. Surprisingly, beside abnormal post-traumatic uptake in the left elbow there was suspicious tracer uptake in the stomach. Particularly, a hypermetabolic rim in the fundus was detected. Further endoscopic work-up revealed a necrosis of the gastric fundus. As a consequence, a larger part of the stomach was resected immediately. Under specific antibiotic therapy, the patient’s condition gradually improved. Figure 1 should illustrate that although positive [18F]FDG PET-CT cannot discriminate between sterile and septic inflammation [2], it is an easy-to-perform noninvasive imaging modality to further guide specific intervention. This concerns especially patients with reduced general condition and pre-existing diseases of an intensive care unit. Conflict of interest Anna Hofer, Heinz Kratochwill, Andreas Pentsch and Prof Michael Gabriel declare that they have no conflict of interest.
2 Detection of necrosis of the gastric fundus after blunt abdominal trauma by PET-CT
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images in clinical medicine References 1. Kluge S, Braune S, Nierhaus A, et al. Diagnostic value of positron emission tomography combined with computed tomography for evaluating patients with septic shock of unknown origin. J Crit Care. 2012;27(3):316.e1–7.
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2. Gotthardt M, Bleeker-Rovers CP, Boerman OC, Oyen WJ. Imaging of inflammation by PET, conventional scintigraphy, and other imaging techniques. J Nucl Med. 2010;41(3):157–69.
Detection of necrosis of the gastric fundus after blunt abdominal trauma by PET-CT
3
Detection of necrosis of the gastric fundus after blunt abdominal trauma by PET-CT A. Hofer · H. Kratochwill · A. Pentsch · M. Gabriel
Received: 22 July 2014 / Accepted: 15 October 2014 © Springer-Verlag Wien 2014
Summary Positron emission tomography with [18F]fluorodeoxyglucose provides functional and anatomic information by visualising the uptake of radiolabelled glucose in tumour and inflammatory cells. We report delayed diagnosis of necrosis of the gastric fundus after blunt abdominal trauma in a 73-year-old man. After a car accident with head-on collision, the patient was stabilised in our emergency room. His femur was treated by internal fixation, his ellbow was stabilised by a fixateur externe. During surgery his status deteriorated. The patient was in need of high dosage of inotrops during the following days. He had a biventricular pacemaker implanted because of ischemic myocardiopathy, and he suffered from renal insufficiency. Over the next days, his haemodynamics improved. A central venous line had to be removed because of ensuing septic fever. The patient complained of upper abdominal pain and nausea. A sonography and computer tomography without contrast medium were performed with negative result. Because of contamination of the central venous line with Staphy-
Dr. A. Hofer () Department of Anaesthesiology and Intensive Care, General Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria e-mail: [email protected] Dr. H. Kratochwill Department of Radiology, General Hospital Linz, Linz, Austria Dr. A. Pentsch Department of Surgery, General Hospital Linz, Linz, Austria Prof. M. Gabriel Department of Nuclear Medicine, General Hospital Linz, Linz, Austria
13
lococcus epidermidis the pacemaker was evaluated for infection by transoesophageal echocardiography, again without any findings. Because of ongoing fever and positive inflammatory markers a positron emission tomography was indicated, as a contrast examination and a magnetic resonance examination were not feasible because of the renal insufficiency and the pacemaker, respectively. Prophylactic removal of the pacemaker would have been a substantial risk for the patient due to his underlying myocardiopathy. Positron emission tomography showed an increased tracer uptake in the gastric fundus, which turned out to be necrotic by endoscopy. A laparoscopic resection followed, and drainage of an abscess, which had evolved subsequently between stomach and spleen stopped the inflammatory process. This case report demonstrates that positron emission tomography may be an alternative to computer tomography with contrast medium and magnetic resonance imaging to detect an inflammatory process in patients with preexisting disease. Keywords [18F]-Fluorodeoxyglucose/diagnostic use · Positron emission tomography · Shock septic · Radionuclide imaging
Diagnose einer Magenperforation nach stumpfem Bauchtrauma mittels 18F-FDG PET-CT Zusammenfassung Die Positronen-Emissions-Tomographie mit 18F-Fluorodeoxyglucose erzeugt Bilder mit anatomischer und funktioneller Information durch Sichtbarmachung der Aufnahme radioaktiv markierter Glukose in Tumorzellen und durch Entzündung aktivierte Granulozyten. Wir schildern die verzögerte Diagnose einer Magenfundusnekrose nach stumpfem Bauchtrauma bei einem 73-jährigen Mann. Nach einem Verkehrsunfall mit Frontalzusammenstoß wurde der
Detection of necrosis of the gastric fundus after blunt abdominal trauma by PET-CT
1
images in clinical medicine Fig. 1 The arrows indicate the abnormal fluorodeoxyglucose uptake in the gastric wall of the fundus. Please also note that enhanced tracer accumulation at the site of the pacemaker was supposed; however, this finding was of technical reason, caused by the attenuation correction (AC). Acquisition without AC was negative for this finding
Patient primär im Schockraum stabilisiert und im Operationssaal chirurgisch mittels Femurnagel und Fixateur externe des Ellbogens versorgt. Bereits intraoperativ verschlechterte sich die hämodynamische Situation drastisch. Der Patient war in den folgenden Tagen hoch katecholaminpflichtig. Er hatte wegen ischämischer Myokardiopathie einen biventrikulären Schrittmacher und eine eingeschränkte Nierenfunktion. Unter hochdosierter Katecholamintherapie stabiliserte sich der Kreislauf über einige Tage. Wegen darauffolgender septischer Fieberzacken wurde der zentralvenöse Katheter gewechselt. Der Patient klagte über Oberbauchbeschwerden und Übelkeit. Eine Oberbauchsonographie und eine CT Untersuchung ohne Kontrastmittel brachten kein Ergebnis. Die Kontamination des zentralvenösen Katheters mit Staphylokokkus epidermidis erforderte eine Evaluierung des implantierten Schrittmachers bezüglich Infektion mittels transösophagealem Echo ohne Ergebnis. Bei weiter bestehendem Fieber und hohen Entzündungsparametern wurde die Indikation zur Positronen-Emissions-Tomographie gestellt, da eine Kontrastmitteluntersuchung bei bestehender Niereninsuffizienz und eine MRT Untersuchung wegen des implantierten Schrittmachers nicht möglich war. Eine Entfernung des Schrittmachers ex iuvantibus stellte wegen der bestehenden Kardiomyopathie ein Risiko dar. Durch die Positronen-Emissions-Tomographie wurde eine Anreicherung im Magenfundus sichtbar, welche sich in der Endoskopie als Magenfundusnekrose darstellte. Nach darauffolgender Magenteilresektion war die Infektion zunächst vorrübergehend, nach Drainage eines zwischen Restmagen und Milz aufgetretenen Abszesses entgültig abgeklungen. Unser Fall zeigt, dass die Positronen-Emissions-Tomographie eine Alternative zur Computertomographie mit Kontrastmittel und Magnetresonanzuntersuchung zur Auffindung von Entzündungsherden bei Patienten mit vorbestehenden Erkrankungen darstellt. Schlüsselwörter 18F-Fluorodeoxyglukose · PET-CT · Stumpfes Bauchtrauma · Septischer Schock
Because of an increased glucose metabolism in inflammatory cells, [18F]-fluorodeoxyglucose-([18F]-FDG) positron emission tomography (PET)/computer tomography (CT) has been used to identify infectious foci in intensive care patients [1]. For this reason, we also used this imaging modality for localisation diagnosis in a septic patient after blunt abdominal trauma. The 73-year-old male patient was admitted with left femoral fracture, fracture of the left elbow, lung contusions and splenic rupture. He also had a biventricular pacemaker implanted. After primary post-operative recovery recurrent fever was observed. Elevated white blood cell count, C-reactive peptide and procalcitonin indicated persistent inflammation. The patient’s upper abdomen was painful. The central venous line showed non-specific contamination with Staphylococcus epidermidis. Ultrasound, CT scan without contrast medium, because of renal insufficiency, and transoesophageal echcardiography showed also no infectious foci. As all these results were negative, PET-CT was initiated as the next step. Surprisingly, beside abnormal post-traumatic uptake in the left elbow there was suspicious tracer uptake in the stomach. Particularly, a hypermetabolic rim in the fundus was detected. Further endoscopic work-up revealed a necrosis of the gastric fundus. As a consequence, a larger part of the stomach was resected immediately. Under specific antibiotic therapy, the patient’s condition gradually improved. Figure 1 should illustrate that although positive [18F]FDG PET-CT cannot discriminate between sterile and septic inflammation [2], it is an easy-to-perform noninvasive imaging modality to further guide specific intervention. This concerns especially patients with reduced general condition and pre-existing diseases of an intensive care unit. Conflict of interest Anna Hofer, Heinz Kratochwill, Andreas Pentsch and Prof Michael Gabriel declare that they have no conflict of interest.
2 Detection of necrosis of the gastric fundus after blunt abdominal trauma by PET-CT
13
images in clinical medicine References 1. Kluge S, Braune S, Nierhaus A, et al. Diagnostic value of positron emission tomography combined with computed tomography for evaluating patients with septic shock of unknown origin. J Crit Care. 2012;27(3):316.e1–7.
13
2. Gotthardt M, Bleeker-Rovers CP, Boerman OC, Oyen WJ. Imaging of inflammation by PET, conventional scintigraphy, and other imaging techniques. J Nucl Med. 2010;41(3):157–69.
Detection of necrosis of the gastric fundus after blunt abdominal trauma by PET-CT
3
![[Sonographic detection of splenic injuries after blunt abdominal trauma].](/assets/img/hold.png)
