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Intestinal accumulation of Tc 99m MDP on bone scan
GAMUTS
Edited by Robert C. Stadalnik
I n t e s t i n a l A c c u m u l a t i o n of Tc 9 9 m M D P on B o n e S c a n Shih-Chuan Tsai, Chia-Hung Kao, Wan-Yu Lin, and Shyh-Jen Wang HE BONE SCAN is an important modality to evaluate skeletal pathological conditions. Occasionally, it is also used for the examination of soft-tissue abnormality, such as myositis ossificans, myositis, and so on. Therefore, the recognition of specific conditions with extraskeletal accumulation of bone-seeking radiotracers greatly enhances the diagnostic value of the study. However, the extraskeletal uptake of bone-seeking radiotracers is still an unexpected finding in most cases. Intestinal accumulation of bone-seeking radiotracers is rarely seen during routine whole body bone scans and occurs in only few conditions. We report an unusual case in which intense intestinal visualization was noted during the performance of a bone scan, due to ingestion of radiolabeled urine.
T
CASE REPORT
urine following radiotracer injection and prior to the bone scan. We present a patient with demonstrated abnormal accumulation of radiotracer in the stomach and intestine during Tc-99m MDP skeletal scan. Intestinal radioactivity was not seen in other patients who underwent bone scans using the same vial of Tc-99m MDP. No gastrointestinal symptoms or signs were noted in the patient. Although the patient had undergone an operation previously, the incidental imaging findings were not thought to be attributed to his operative procedures. In Taiwan and certain countries, ingestion of infant or one's own urine (urine-therapy) is thought to be a helpful folk remedy for improving the health and treating some diseases. Later, the patient told us that he had drank his own urine following injection of the radiotracer and prior to imaging.
A 58-year-old male patient with a history of carcinoma of the rectum was referred to our department for bone scan due to multiple bone pain. A Tc-99m methylene diphosphonate (MDP) whole body bone scan failed to demonstrate any skeletal abnormality. However, the scan did show significant radiotracer stasis in the gastrointestinal tract (Fig 1). Except for surgical resection of the lesion (lower anterior resection of the rectum), he had not undergone any surgical process. The incidental imaging finding was not thought to be attributed to enterovesical fistula or other complications of his operative procedures by consulting a urologist and following up for 1 year. The patient later admitted that he had orally ingested his own From the Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C. Address reprint requests to Chia-Hung Kao, MD, Department of Nuclear Medicine, Taichung Veterans General Hospital, No. 160, Sec. 3, Taichung Harbor Road, Taichung 40705, Taiwan, R.O.C. Copyright 9 1999 by W.B. Saunders Company 0001-2998/98/2804-0007510.00/0
80
Fig 1. Case 1: A Tc-99m MDP whole body bone scan showed no definite skeletal abnormality. However, marked radiotracer stasis in the gastrointestinal tract was observed.
Seminars in Nuclear Medicine, Vol XXlX, No 1 (January), 1999: pp 80-81
INTESTINAL Tc 99m MDP ON BONE SCAN
81
The scans showed incidental findings of intestinal accumulation of the radiolabeled urine. In a review of previous publications, the causes of intestinal accumulation of bone-seeking radiotracers were as follows:
Common 1. Urinary diversion surgical procedures ~,2 2. Enterovesical fistula 3-12 3. Occult gastric bleeding I~ 4. Intestinal infarction t2-14
Uncommon 1. Neonatal necrotizing enterocolitis ~5 2. Normal intestine in children ~6 Rare 1, 2. 3. 4. 5. 6.
Neuroblastoma~7 protein losing enteropathy 18 metastatic calcification ~9 primary intestinal lymphangiectasia 2~ systemic A L amyloidosis 2~ minor defect in the quality of the Tc-99m generator 22 . oral intake of radiolabeled urine 23
REFERENCES I. Ackerman L, Elam E, Bushnell D, et al: Bowel visualization in bone scintigraphy. Sem Nucl Med 17:81-82, 1987 2. Mariani G, Levorato D, Tuoni M, et al: Incidental imaging of the large bowel in patients with uretero-sigmoidostomy during bone scintigraphy with 99m Tc-pyrophosphate. J Nucl Med Allied Sci 22:153-157, 1978 3. Suga K, Ohono Y, Yoneshiro S, et al: A case of squamous cell carcinoma of urinary bladder with an ileovesical fistula detected on bone scintigraphy. Kaku Igaku 29:105-110, 1992 4. Weismuller S, Baum RP, Zoller A, et al: Primary nonHodgkin's lymphoma of the terminal ileum with enterovesical fistula: a case report. Australas Radiol 34:268-270, 1990 5. Bigler ME, Wofford JE, Pratt SM, et al: Serendipitous diagnosis of appendicovesical fistula by bone scan: a case report. J Urol 142:815-816, 1989 6. Togawa T, Yonemoto H, Hoshino T, et al: A case of ileo-vesical fistula, on which bone scan was useful. Rinsho Hoshasen 27:473-476, 1982 7. Engelstad B: Demonstration of a colovesical fistula on a bone scan. Clin Nucl Med 7:131, 1982 8. Kida 1", Togawa T: Vesicoenteric fistula discovered during routine bone scintigraphy. Clin Nucl Med 6:422-423, 1981 9. Rao BK, Pastakia BR, Lieberman LM: Uretero-colic fistula: diagnosis on a bone scan. Clin Nucl Med 5:178, 1980 10. Puri S, Caride V, Spencer RP: Demonstration of a vesicocolonic fistula during a bone scan. A case report. Conn Med 38:527-528, 1974 11. Lee VW, Leiter BE, Weitzman F, et al: Occult gastric bleeding demonstrated by bone scan and Tc-99m-DTPA renal scan. Clin Nucl Med 6:470-473, 1981 12. Schimmel DH, Moss AA, Hoffer PB: Radionuclide imaging of intestinal infarction in dogs. Invest Radiol 11:277281, 1976 13. Barth KH, Alderson PO, Strandberg JD, et al: 99m
Tc-pyrophosphate imaging in experimental mesenteric infarction: relationship of tracer uptake to degree of ischemic injury. Radiology 129:491-495, 1978 14. Ortiz VN, Sfakianakis G, Haase GM, et al: The value of radionuclide scanning in early diagnosis of intestinal infarction. J Pediatr Surg 13:616-62 l, 1978 15. Sfakianakis G, Ortiz VN, Haase GM, et al: 99m Tcdiphosphonate abdominal imaging in necrotizing enterocolitis: a prospective study. J Nucl Med 19:691-692, 1978 16. Conway J J, Weiss SC, Khentigan J, et al: Gallbladder and bowel localization of bone imaging radiopharmaceuticals (abstract). J Nucl Med 20:622, 1979 17. McCarthy KE, Heyman S: Diphosphonate intestinal activity seen on two bone images in neuroblastoma. Clin Nucl Med 11:501-502, 1986 18. Roach PJ, Itrato D, Treves ST: Bowel visualization on bone scan because of protein losing enteropathy. Clin Nucl Med 19:Ill4-1116, 1994 19. Stabler J: Case report: ossifying metastases from carcinoma of the large bowel demonstrated by bone scintigraphy. Clin Radiol 50:730-731, 1995 20. Lee KH, Chung K, Lee DS, Lee MC, Song IS, Koh CS. Intestinal leakage of technetium-99m-MDP in primary intestinal lymphangiectasia. J Nucl Med 37:639-641, 1996 21. Janssen S, van Rijswijk MH, Piers DA, et al: Soft-tissue uptake of 99m Tc-diphosphonate in systemic AL amyloidosis. Eur J Nucl Med 9:538-541, 1984 22. Sherkow L, Ryo UY, Fabich D, et al: Visualization of the liver, gallbladder, and intestine on bone scintigraphy. Clin Nucl Med 9:440-443, 1984 23. Weismuller S, Baum RP, Zoller A, et al: Intestinal accumulation of 99m Tc-HMDP: an unusual finding in bone scintigraphy. Nuklearmedizin 33:142-144, 1994
Edited by Robert C. Stadalnik
I n t e s t i n a l A c c u m u l a t i o n of Tc 9 9 m M D P on B o n e S c a n Shih-Chuan Tsai, Chia-Hung Kao, Wan-Yu Lin, and Shyh-Jen Wang HE BONE SCAN is an important modality to evaluate skeletal pathological conditions. Occasionally, it is also used for the examination of soft-tissue abnormality, such as myositis ossificans, myositis, and so on. Therefore, the recognition of specific conditions with extraskeletal accumulation of bone-seeking radiotracers greatly enhances the diagnostic value of the study. However, the extraskeletal uptake of bone-seeking radiotracers is still an unexpected finding in most cases. Intestinal accumulation of bone-seeking radiotracers is rarely seen during routine whole body bone scans and occurs in only few conditions. We report an unusual case in which intense intestinal visualization was noted during the performance of a bone scan, due to ingestion of radiolabeled urine.
T
CASE REPORT
urine following radiotracer injection and prior to the bone scan. We present a patient with demonstrated abnormal accumulation of radiotracer in the stomach and intestine during Tc-99m MDP skeletal scan. Intestinal radioactivity was not seen in other patients who underwent bone scans using the same vial of Tc-99m MDP. No gastrointestinal symptoms or signs were noted in the patient. Although the patient had undergone an operation previously, the incidental imaging findings were not thought to be attributed to his operative procedures. In Taiwan and certain countries, ingestion of infant or one's own urine (urine-therapy) is thought to be a helpful folk remedy for improving the health and treating some diseases. Later, the patient told us that he had drank his own urine following injection of the radiotracer and prior to imaging.
A 58-year-old male patient with a history of carcinoma of the rectum was referred to our department for bone scan due to multiple bone pain. A Tc-99m methylene diphosphonate (MDP) whole body bone scan failed to demonstrate any skeletal abnormality. However, the scan did show significant radiotracer stasis in the gastrointestinal tract (Fig 1). Except for surgical resection of the lesion (lower anterior resection of the rectum), he had not undergone any surgical process. The incidental imaging finding was not thought to be attributed to enterovesical fistula or other complications of his operative procedures by consulting a urologist and following up for 1 year. The patient later admitted that he had orally ingested his own From the Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, R.O.C. Address reprint requests to Chia-Hung Kao, MD, Department of Nuclear Medicine, Taichung Veterans General Hospital, No. 160, Sec. 3, Taichung Harbor Road, Taichung 40705, Taiwan, R.O.C. Copyright 9 1999 by W.B. Saunders Company 0001-2998/98/2804-0007510.00/0
80
Fig 1. Case 1: A Tc-99m MDP whole body bone scan showed no definite skeletal abnormality. However, marked radiotracer stasis in the gastrointestinal tract was observed.
Seminars in Nuclear Medicine, Vol XXlX, No 1 (January), 1999: pp 80-81
INTESTINAL Tc 99m MDP ON BONE SCAN
81
The scans showed incidental findings of intestinal accumulation of the radiolabeled urine. In a review of previous publications, the causes of intestinal accumulation of bone-seeking radiotracers were as follows:
Common 1. Urinary diversion surgical procedures ~,2 2. Enterovesical fistula 3-12 3. Occult gastric bleeding I~ 4. Intestinal infarction t2-14
Uncommon 1. Neonatal necrotizing enterocolitis ~5 2. Normal intestine in children ~6 Rare 1, 2. 3. 4. 5. 6.
Neuroblastoma~7 protein losing enteropathy 18 metastatic calcification ~9 primary intestinal lymphangiectasia 2~ systemic A L amyloidosis 2~ minor defect in the quality of the Tc-99m generator 22 . oral intake of radiolabeled urine 23
REFERENCES I. Ackerman L, Elam E, Bushnell D, et al: Bowel visualization in bone scintigraphy. Sem Nucl Med 17:81-82, 1987 2. Mariani G, Levorato D, Tuoni M, et al: Incidental imaging of the large bowel in patients with uretero-sigmoidostomy during bone scintigraphy with 99m Tc-pyrophosphate. J Nucl Med Allied Sci 22:153-157, 1978 3. Suga K, Ohono Y, Yoneshiro S, et al: A case of squamous cell carcinoma of urinary bladder with an ileovesical fistula detected on bone scintigraphy. Kaku Igaku 29:105-110, 1992 4. Weismuller S, Baum RP, Zoller A, et al: Primary nonHodgkin's lymphoma of the terminal ileum with enterovesical fistula: a case report. Australas Radiol 34:268-270, 1990 5. Bigler ME, Wofford JE, Pratt SM, et al: Serendipitous diagnosis of appendicovesical fistula by bone scan: a case report. J Urol 142:815-816, 1989 6. Togawa T, Yonemoto H, Hoshino T, et al: A case of ileo-vesical fistula, on which bone scan was useful. Rinsho Hoshasen 27:473-476, 1982 7. Engelstad B: Demonstration of a colovesical fistula on a bone scan. Clin Nucl Med 7:131, 1982 8. Kida 1", Togawa T: Vesicoenteric fistula discovered during routine bone scintigraphy. Clin Nucl Med 6:422-423, 1981 9. Rao BK, Pastakia BR, Lieberman LM: Uretero-colic fistula: diagnosis on a bone scan. Clin Nucl Med 5:178, 1980 10. Puri S, Caride V, Spencer RP: Demonstration of a vesicocolonic fistula during a bone scan. A case report. Conn Med 38:527-528, 1974 11. Lee VW, Leiter BE, Weitzman F, et al: Occult gastric bleeding demonstrated by bone scan and Tc-99m-DTPA renal scan. Clin Nucl Med 6:470-473, 1981 12. Schimmel DH, Moss AA, Hoffer PB: Radionuclide imaging of intestinal infarction in dogs. Invest Radiol 11:277281, 1976 13. Barth KH, Alderson PO, Strandberg JD, et al: 99m
Tc-pyrophosphate imaging in experimental mesenteric infarction: relationship of tracer uptake to degree of ischemic injury. Radiology 129:491-495, 1978 14. Ortiz VN, Sfakianakis G, Haase GM, et al: The value of radionuclide scanning in early diagnosis of intestinal infarction. J Pediatr Surg 13:616-62 l, 1978 15. Sfakianakis G, Ortiz VN, Haase GM, et al: 99m Tcdiphosphonate abdominal imaging in necrotizing enterocolitis: a prospective study. J Nucl Med 19:691-692, 1978 16. Conway J J, Weiss SC, Khentigan J, et al: Gallbladder and bowel localization of bone imaging radiopharmaceuticals (abstract). J Nucl Med 20:622, 1979 17. McCarthy KE, Heyman S: Diphosphonate intestinal activity seen on two bone images in neuroblastoma. Clin Nucl Med 11:501-502, 1986 18. Roach PJ, Itrato D, Treves ST: Bowel visualization on bone scan because of protein losing enteropathy. Clin Nucl Med 19:Ill4-1116, 1994 19. Stabler J: Case report: ossifying metastases from carcinoma of the large bowel demonstrated by bone scintigraphy. Clin Radiol 50:730-731, 1995 20. Lee KH, Chung K, Lee DS, Lee MC, Song IS, Koh CS. Intestinal leakage of technetium-99m-MDP in primary intestinal lymphangiectasia. J Nucl Med 37:639-641, 1996 21. Janssen S, van Rijswijk MH, Piers DA, et al: Soft-tissue uptake of 99m Tc-diphosphonate in systemic AL amyloidosis. Eur J Nucl Med 9:538-541, 1984 22. Sherkow L, Ryo UY, Fabich D, et al: Visualization of the liver, gallbladder, and intestine on bone scintigraphy. Clin Nucl Med 9:440-443, 1984 23. Weismuller S, Baum RP, Zoller A, et al: Intestinal accumulation of 99m Tc-HMDP: an unusual finding in bone scintigraphy. Nuklearmedizin 33:142-144, 1994