Journal of the Royal Society of Medicine Volume 83 July 1990

negative 3 h after isotope injection, but imaging the following morning (19 h) showed radioactivity in the caecum and ascending colon (Figure 1). A superior mesenteric arteriogram performed immediately failed to demonstrate a lesion or the site of bleeding. After 22 days the haemoglobin was 4.6 gldl despite having received three blood transfusions totalling 10 units. Over this time the haemoglobin did not rise above 6.5 g/dl. At no time was melaena or frank bleeding observed. She then developed left arm pain and examination revealed a tender pulsatile axillary swelling. Afteriography showed an axillary artery aneurysm with arterio-venous communication (Figure 2). This was repaired surgically. Subsequent enquiry revealed that the patient had requested needles and straws from friends. She had been using the needles to venesect herself from the axilla and ingesting the blood via a straw.

Discussion Radio-isotope labelled red cell studies are a non-invasive and highly specific diagnostic test in the investigation of obscure gastrointestinal bleeding3. We are not aware of the ingestdon of blood as a cause of a positive scan. However, as little as 5 ml of ingested labelled blood can be detected in the gastrointestinal tract4. Fasting after ingestion of a meal results in its accumulation in the terminal ileum. A subsequent meal causes ileal

emptying into the caecum5. We would suggest that in this patient radio-isotope awcumulated in the terminal ileum after the ingestion of her own blood in the evening, with subsequent movement into the caecum after breakfast. Acknowledgment. We thank Mr J M A Northover for allowing us to report this case and to Drs Granowska and Britton for help with the nuclear scan. References 1 Thompson JN, Salem RR, Hemingway AP, et alc Specialist investigation of obscure gastrointestinal bleeding. Gut 1987; 28:47-51 2 Markisz JA, Front DA, Royal HD, Sacks B, Parker JA, Kolodny GM. An evahlation of 99mTc-labelled red blood cell scintigraphy for the detection and localisation of gastrointestinal bleeding sites. Gastroenterology 1982;83:394-8 3 Bunker SR, Lull JR, Tanasescu DE, et al. Scintigraphy of gastrointestinal haemorrhage: superiority of 99mTc red blood cells over 99mTc sulphur colloid. An J Roentgenol 1984; 143:543-8 4 Smith K, Arterburn G. Detection and localisation of gastr intestinal bleeding using Tc-99m-pyrophosphate in vivo labelled red blood cells. Clin Nuci Med 1980;5:55-60 5 Trotman IF, Price CC. Bloated irritable bowel syndrome defined by dynamic 99mTc bran scan. Lancet 1986;ii:364-6

(Accepted 25 July 1989. Correspondence to Dr M A Kamm)

Presentation of maligant pleural mesothelioma with cerebral metastases

W M McNaughton FRCPA M E Broughton MBBB Department of Pathology, Dandenong & District Hospital, David Street, Dandenong 3175, VictoriaAustralia G C Toner MBBS M A Schwarz FRACP FACP Medical Oncology Department, Alfred Hospit Commercial Road, Prahran 3181, Australia Keywords: mesothelioma; plera; cerebral



Malignant pleural meeothelioma

Presentation of malignant pleural mesothelioma with cerebral metastases.

466 Journal of the Royal Society of Medicine Volume 83 July 1990 negative 3 h after isotope injection, but imaging the following morning (19 h) show...
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