Scintiangiographic

Diagnosis

of Acute

Downloaded from www.ajronline.org by 134.83.1.242 on 10/23/15 from IP address 134.83.1.242. Copyright ARRS. For personal use only; all rights reserved

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:

Downloaded from www.ajronline.org by 134.83.1.242 on 10/23/15 from IP address 134.83.1.242. Copyright ARRS. For personal use only; all rights reserved

,.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

Spiro

Small

terology, pp 449

edited

Turcotte

TG,

pertension 8.

Aldrete

Taylor

A: Diseases HM:

York,

by Spiro

Slaughter

GL,

liver,

Johnstone

Raventos

for ,

disorders, HM, New

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-

neoplastic

1975

FRC,

in Gastroenterology,

McGraw-Hill,

intestinal

Child

DeNardo

scintiangiography Med 16 : 595-601 HE,

of the

in adults. JS,

SJ,

of hepatic liver. J NucI

WC,

Bogoch 6.

DeNardo

Portal

vein

portal thrombosis

hy-

Downloaded from www.ajronline.org by 134.83.1.242 on 10/23/15 from IP address 134.83.1.242. Copyright ARRS. For personal use only; all rights reserved

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

Scintiangiographic diagnosis of acute mesenteric venous thrombosis.

Scintiangiographic Diagnosis of Acute Downloaded from www.ajronline.org by 134.83.1.242 on 10/23/15 from IP address 134.83.1.242. Copyright ARRS. F...
441KB Sizes 0 Downloads 0 Views