Scintiangiographic
Diagnosis
of Acute
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R. WESLEY
SMITH’
AND
Scintiangiographic findings of prolongedmesenteric activof acute mesenteric thrombosis is described and 105 cases with abdominal scmntiangiogrphy are reviewed. Usual peak mesenteric blush occurred 5-15 sec after initial visualization of the aorta. Normal clearance of this activity was 15-30 sec. Future cases should confirm the importance of this observation In early diagnosis of mesenteric venous thrombosis.
for
differentiating
vascular
and
mality. before.
camera
was
To our
useful
Case Of
105
patients
this
Material
who
had
has
not
liver-spleen
seen
in
75.
This
appeared
as
a localized
area
caused
included
“show-through,”
and
poor
with
arterial
findings
but will
showed
frequently
cirrhosis
of unknown portal
with
cause.
An
after
collimator
no
clear
pattern.
The
of
However,
no
patterns
abdomen,
diarrhea
can be used
with
initial
visualization
mild
The
died
Autopsy
portal,
or “blush.” more than 1 B). Subsequent
(fig.
and
and
132:67-69,
© 1 979 American
January Roentgen
1979 Ray Society
ascites
without
of cardiorespiratory
revealed splenic
was 50 sec static
lasted
hepatomegaly
patient
cameras,
activity, that
of the aorta
demonstrated
mesenteric,
area
standard
failure
thrombosis
veins,
5
of the supe-
chronic
pancreatitis
massive
Discussion Mesenteric
venous
counts for about vein thrombosis type
of mesenteric
lead
to
ment
bowel
may
quired
cess
preserve
been
occur
of
with
carcinoma,
portal
injury,
genic
[7, 8].
or spontaneous
superior
tolazoline
67
type
hypertension,
is
re-
evaluation
occlusion
hypercoaguable sepsis,
contraceptive which
can
develop-
However, good sucmesenteric artery
venous
and
form,
ac-
[7].
mesenteric
and
and
Splenoportography
with with
of
This
collateral
in preoperative
polycythemia
sion,
direct
[5].
procedures
forms
rare
[6].
although
reported
not
thrombosis
flow
augmented
Severe
is
ischemia cases [5]. Portal origin of the more diffuse
obstruction
shunt
has
injection as-
venous infarction,
to exclude
of optimal as
thrombosis
10% of bowel is often the
tumor
pills
can states,
compres-
[9]. An agno-
is usually
Received June 6, 1978; accepted after revision October 5, 1978. , Department of Radiology. Medical University of South Carolina, Charleston, South Carolina 29401 . Present address: Department Francis xavier Hospital, 135 Rutledge Avenue, Charleston, South Carolina 29403. Address reprint requests to R. W. Smith. 2 Nuclear Medicine Service, veterans Administration Hospital. Charleston, South Carolina 29403. AJR
with
and dehydration.
pseudocyst formation, chemical peritonitis, and ascites (14) without gangrenous changes of the bowel.
patients tended to diminish scintiangioand normal patterns of mesenteric flow encountered.
admitted
with
ascites,
presence
from
midabdominal
splenomegaly.
15-30
such
in the
images
In patients
hypertension,
distended
exhibit poorer resolution.) unexpected area of increased
revealed
with patchy uptake, and splenomegaly nuclide trapping, the scintiangiographic
cites in these graphic quality, were
filling
suggesting
hepatomegaly with increased findings
marked
a
by hypovolemia
(A diverging
of
sec. Residual body background from recirculation contributed to a persistent low level of activity that did not interfere with interpretation. Visualization of the portal vein to the porta hepatis could sometimes be demonstrated, as well as an occasional splenic artery or vein and mesenteric veins. Less often, the inferior vena cava could be demonstrated, usually if the aorta was tortuous and deviated to the left (fig. 1A). Problems with visualization of mesenteric flow arose mainly from poor bolus injection, poor positioning, thin patients with marked renal
was
hepato-
findings
nor
was
Report
man
The dynamic phase of the study consisted of 5 sec sequential scintiscans obtained after rapid intravenous injection of 4.5 mCi of 9’#{176}Tcsulfur colloid with the patient supine and the camera positioned over the abdomen. With the large field of view camera, a low energy, all-purpose parallel hole collimator gives adequate area coverage with good quality and resolution.
flow
Hos“blush”
region
alcoholic
tases.
Administration mesenteric
this
in this
Physical
Maximal
from
seen
weight month.
days after admission.
of activity
Case
formerly
increased activity that was more than the expected renal “show-through.” This blush was usually localized to the left mid and lower quadrants of the abdomen. Occasionally, right lower abdominal patterns were seen. The usual peak mesenteric blush determined from initial visualization of the abdominal aorta varied from 5 to 15 sec. clearance
were
muscle weakness, dyspnea, increasing abdominal girth, loss, and a change in bowel habits over the previous
lieved
abnor-
with
activity
Abdominal radiography demonstrated only ascites. Carcinoma of the pancreas was suspected, and a liver-spleen scan with scintiangiography was performed to exclude hepatic metas-
described
scans
mesenteric
megaly, and 4+ pedal edema. Laboratory tests revealed elevated alkaline phosphatase and decreased serum potassium and albumin. Total bilirubin was 1.1 mgIlOO ml. Abdominal paracentesis revealed ascitic fluid with a markedly elevated amylase. Initial oliguria was subsequently controlled, and be-
and Findings
studies at the Charleston Veterans pital, visualization of a characteristic was
the
been
increased
Representative
avascular
in demonstrating
knowledge,
Thrombosis
SELBY2
A 49-year-old
lesions involving the liver [1-4]. A case of portal, splenic, and superior mesenteric venous thrombosis is reported in which abdominal scintiangiography with a large field of view
B.
Venous
group.
Some lesions are often evaluated with 99mTc sulfur colloid liver-spleen imaging. Dynamic scintigraphy has primarily used
JOHN
persistent
ity in a case
been
Mesenteric
segmental,
of Radiology,
o361-803x/79/1321-oo67
St.
$0.00
68
SMITH
AND
SELBY
132, January 1979
AJR:
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,.B S
S
;A
I
L
ant5ssc
U Fig.
1 -Serial
5 sec scans.
has a gradual fort, anorexia, days. In these intervention
A, Normal
to tortuous
50 sec and evidence
comparison
study.
aorta (arrowhead).
of ascites
(large
B, Patient
Mesenteric “blush” with mesenteric
if the
high
mortality
rate
of this
this
preliminary
would
be
useful,
subjecting knowledge,
venous
especially
in critically
them to more scintiangiographic
occlusion
have
not
ill
invasive profindings
previously
alone
thrombotic
occlusion
is rarely
a cause
of the
Despite
hindered, patient,
and was seen to occur within with little clearance throughout
flow study. This activity correlates venous
of the
[19].
visualization
mesenteric
inferior up to
mesenteric allow
a positive
should
cases. vein,
rapid
study
be
not
by future
with
collateral
clearance
would
tested
In patients
chronic
development
of the
radiocolloid
be obtained.
With a dose of 4-5 mCi of Tc sulfur colloid information on the mesenteric venous drainage as the vascularity of liver-spleen lesions could Therefore,
protocol teric
for
we
believe
liver-spleen
venous
this
imaging,
disease
thrombotic
useful as well be ob-
should
be
routine
especially
if
mesen-
is suspected.
REFERENCES illustrates
ascites,
the bid
of aorta; arrowheads)
been supe-
nor mesenteric, portal, and splenic veins secondary to chronic pancreatitis, which in itself is a rare phenomenon [17]. The poorly defined symptomatology may have hindered diagnosis and appropriate treatment. The massive ascites was believed to be caused by chronic pancreatitis and chemical peritonitis [18], since portal hypertension
S.
similar
of the probably
tamed.
,
may
reported. This case
45
observation
with
occlusion
tiangiography)
in mesenteric
40
disappearance by 30 sec after visualization Persistent midabdominal “blush” (small
experience
and
before To our
1#{149}
arrowhead).
onset of poorly defined abdominal discomand changes in bowel habits over 7-10 instances, early diagnosis and appropriate is essential
with rapid thrombosis.
disease is to be reversed [10, 11]. Radiographic plain film diagnosis of mesenteric yenous occlusion has been well described [12-16]. A simpIe, quick, noninvasive procedure (e.g. mesenteric scmpatients, cedures.
25
:
.
vena cava is adjacent
20
IS
mesenteric
prolonged well with thrombosis
the
blush 20-25 the
and increased angiographic with
slow
massive
was
LM, Mandell CH: Dynamic vascular scintiphotograph of the liver. Semin NucI Med 2 : 133-138, 1972 2. Waxman AD, Apau A, Siemsen JK: Rapid sequential liver imaging. J NucI Med 13:522-524, 1972 3. DeNardo GL, Stadalnik RC, DeNardo SJ Raventos A: Hepatic scintiangiographic patterns. Radiology 121:135-141, 1974 4.
radiocolfindings in flow
on selective superior mesenteric arterial injection [12]. The etiology of the intense radiocolloid accumulation in this region is probably related to slow washout in acute stages prior to collateral development. The validity of
Stadalnik
AC,
cal evaluation
not
sec in this duration of
or absent
1 . Freeman
tumors 5.
of the
McDonald
7.
by Bogoch
A, New
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edited
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GL,
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Raventos
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Han
SY:
Walsh
GC, edited
1973, pp 833 in Clinical GastroenYork, McMillan, 1977,
CG: Ideopathic extrahepatic Am J Surg 123:35-42, 1972 AL,
A: Criti-
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FRC,
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McGraw-Hill,
intestinal
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DeNardo
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SJ,
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WC,
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vein
portal thrombosis
hy-
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AJR:132,
January
1979
SCINTIANGIOGRAPHY
OF
MESENTERIC
resulting in portal hypertension in adults: Am J Gastroenterol 65:236-243, 1976 9. Williams LF: Vascular insufficiency of the intestines. Gastroenterology 61 : 757-777, 1971 10. Roberson G: Mesenteric venous occlusion. J Arkansas Med Soc 64:143-148, 1967 1 1 . Naitove A, Weismann RE: Primary mesenteric venous thrombosis. Ann Surg 161 :51 6- 523, 1965 12. Clemett AR, Chang J: The radiologic diagnosis of spontaneous mesenteric venous thrombosis. Am J Gastroenterol
63:209-215, 1975 13. Hessen I: Roentgen examination in cases of occlusion of the mesenteric vessels. Acta Radio! (Stockh) 44:293-305, 1955
14. Nelson
SW,
Eggleston
W:
Findings
on
plain
roentgeno-
VENOUS
grams
69
THROMBOSIS
of the abdomen
associated
with mesenteric
vascular
occlusion with a possible new sign of mesenteric venous thrombosis.AJR 83:886-894, 1960 1 5. Wang CC, Reeves JD: Mesenteric vascular disease. AJR 83:895-908, 1960 16. Dunbar JD, Nelson SW: Nonangiographic manifestations of intestinal vascular disease. AJR 11 : 127-135, 1967 17. Longstreth GF, NewComer AD, Green PA: Extrahepatic portal hypertension caused by chronic pancreatitis. Ann Intern Med 75:903-908, 1971 18. Donowitz M, Kerstein MD, Spiro HM: Pancreatic ascites. Medicine (Baltimore) 53:183-195, 1974 19. Sherlock 5: The portal venous system and portal hypertension, in Diseases of the Liver and Biliary System, edited by Sherlock S. London, Blackwell Scientific, 1975, pp 161