Nuclear Renal Imaging in Acute Pyelonephritis

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RADIOLOGY, NUCLEAR MEDICINE AND SONOGRAPHY

mild inflammatory reaction that was no longer present at 12 and 24 weeks. Of group C specimens (nontoothed forceps) 30 to 40 per cent and of group D specimens (hemostat) 100 per cent demonstrated muscle disruption at all intervals to 6 months. Additionally, 30 per cent of group D had an associated abscess, even though a mucosal tear was not evident. The muscle defects were void of elastin fibers in 100 per cent of the 6, 12 and 24week specimens. There were no detectable collagen fibers in 100 per cent at 6 and 12 weeks, and in 95 per cent of the 24week specimens. The authors cite Sparkman's report that on long-term followup of patients undergoing unilateral inguinal herniorrhaphy only 16 per cent had a contralateral hernia. This fact and their experimental data lead the authors to believe that children with unilateral hernias should undergo unilateral groin exploration only. H. M. S. 4 figures, 1 table, 10 references

Editorial comment. This followup study supports the conclusions of the original experimental study and proves that the rat vas often is permanently damaged by minor trauma as might occur during surgical exploration of the inguinal area. The human vas may be more resilient in this regard but these experiments make a clear case against manipulations of the vas whenever this can be avoided. Parenthetically, the ureter seems just the opposite. Attempts to produce hydronephrosis by clamping the ureter for varying periods almost always fail and the ureter returns to a normal histological appearance. L. R. K.

RADIOLOGY, NUCLEAR MEDICINE AND SONOGRAPHY Nuclear Medicine and Complementary Modalities in Renal Trauma B. C. BERG, JR., Peoria School of Medicine, University of Illinois and Division of Nuclear Medicine, St. Francis Hospital-Medical Center, Peoria, Illinois Semin. Nucl. Med., 12: 280-300 (July) 1982 New modalities now available for imaging the kidney may alter somewhat the conventional schema for the evaluation of patients with renal trauma. After a routine chest x-ray and plain film of the kidneys, ureters and bladder renovascular scintigraphy using 99 ~echnetium glucoheptonate allows evaluation of the general blood flow to the kidney. This study can be followed by delayed imaging of the parenchyma for evidence of fracture, nonvisualized segments or deformity of the renal substance by hematoma and so forth. Computerized tomography (CT) scan is used commonly after this study if there is a need to evaluate hematomas, extravasation or injury to adjacent organs. In cases of nonvisualization of the kidney sonography or CT scan may determine whether a kidney is present, while arteriography may be required to determine if there is an injury to the renal pedicle. Digital subtraction arteriography may be adequate for this but it requires a cooperative patient to avoid blurring of the image. Active bleeding in the retroperitoneum may be diagnosed by nuclear scanning techniques, using sulfur colloid compounds. One limitation to the use of some of these techniques is the ready availability of a radiologist at all hours but telephone transmission techniques are now available and allow the radiologist to monitor these studies on a satellite unit

at home, and direct and interpret them by telephone. 17 figures, 30 references

T. D. A.

Editorial comment. Renal scintillation camera studies have provided useful information to evaluate renal injuries and quantitation has provided an excellent means of noninvasive patient followup. The study is invaluable in the case of potential renal arterial injuries, especially if only 1 kidney visualizes on excretory urography. A quantitative camera study under these conditions would provide rapid determination of total renal function, which if normal would indicate that a pre-existing abnormality or congenital absence of the nonvisualizing kidney was present. G. D. F.

Nuclear Medicine in Acute and Chronic Renal Failure R. A. SHERMAN AND K. J. BYUN, Division of Nephrology, Department of Medicine, University of Medicine and Dentistry-Rutgers Medical School, Piscataway, New Jersey, and the Department of Nuclear Medicine, Albert Einstein College of Medicine, Bronx, New York Semin. Nucl. Med., 12: 265-279 (July) 1982 Nuclear medicine techniques have potential benefits in the evaluation of acute and chronic renal disease in a variety of ways. In patients with acute renal failure renal size often is a guide to pre-existing disease but it may be difficult to determine by conventional techniques. 9 9m Technetium (99mTc) scans generally provide adequate visualization of the kidney but dimercaptosuccinic acid (DMSA) is a longer lived chelate and may prove to offer better imaging in patients with renal failure. 123 Iodine orthoiodohippurate (1 21 I-OIH) also may prove to be helpful in this regard. Nuclear medicine techniques may help as well in predicting recovery in renal failure. Uptake by 13110IH has proved to be a fair guide in that kidneys that exhibit no uptake generally do not show much in the way of recovery. When renal f'_ailure is in great measure a function of blood flow problems 99mTc-diethylenetriaminepentaacetic acid may be helpful in the evaluation. Acute pyelonephritis may be evaluated by 99mTc-DMSA or glucoheptonate when the infection is severe enough to produce significant parenchymal damage but 67 gallium has been studied more extensively for this and for interstitial nephritis not associated with bacterial infection. Chronic pyelonephritis and reflux nephropathy may be associated with scarring that can be well defined by 99mTc-DMSA scanning, while the reflux itself can be detected by radionuclide cystography. A thorough understanding of the wide variety of conditions that can be studied profitably by radionuclide imaging is essential for its most effective use. T. D. A. 6 figures, 1 table, 92 references

Editorial comment. The use of radionuclide imaging and/or quantitative techniques in evaluating patients with renal failure is well presented in this review article. It is recommended reading for all urologists who are asked to evaluate patients with azotemia. G. D. F.

Nuclear Renal Imaging in Acute Pyelonephritis Nuclear Medicine Service, 'Children's Hospital of San Francisco, San Francisco, California

H. HANDMAKER,

Semin. Nucl. Med., 12: 246-253 (July) 1982

RADIOLOGY 1. NUCLEA_R 1'1:EDIC!N:S ~~ND SO:t"TOGRAPIIY

The poor sensitivity of the excretory urogn1m in patients with early, acute pyelonephritis is well known. Several radionuclide procedures have been introduced to assist in the early detection of acute pyelonephritis. These are 19 \nercury chlo:rmerodrin, 67 gallium (67 Ga) citrate, 99 mtechnetium (99 mTc) glucoheptonate, 99mTc dimercaptosuccinic acid and mindiumlabeled white blood cells. The author shows 5 patients with signs and symptoms of acute pyelonephritis whose IVPs were inconclusive. Initial 48-hour 67 Ga citrate scan revealed either suspicious findings or findings compatible with acute pyelonephritis. Subsequent renal cortical imaging with 99mTc glucoheptonate or dimercaptosuccinic acid revealed focal and multifocal defects suggestive of acute pyelonephritis. Followup study with serial 99mTc scan demonstrated dramatic improvement after therapy. The advantages of these techniques are the improved sensitivity and specificity, and the ability to demonstrate the changes in the kidney after therapy in patients with acute pyelonephritis. F. T. A. 7 figures, 33 references

Editorial comment. The low incidence of nonspecific changes using IVPs in uncomplicated acute pyelonephritis again is emphasized. Although gallium scanning often does not differentiate between intrarenal and perinephric processes the addition of renal imaging using 99 mTc-dimercaptosuccinic acid has improved the specificity of renal radionuclides in the diag-nosis of this disorder. Quantitative studies using 131iodine hippuran also have demonstrated similar findings and can be used as a noninvasive means to follow these patients. G. D. F. Multicystic Dysplastic Kidneys Suggesting Hydrone-

phrosis During Tc-DTPA Imaging A. R. SIDDIQUI, M. COHEN AND M. E. MITCHELL, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana J. Nucl. Med., 23: 892-894 (Oct.) 1982 99

mTechnetium

diethylenetriaminepentaacetic

acid

(Tc-

DTP A) has been used to differentiate multicystic dysplastic kidney from hydronephrosis caused by its inability to accumulate Tc-DTPA while the hydronephrotic kidney concentrates this radiotracer in delayed images. The authors present 2 infants with flank masses in whom Tc-DTP A was interpreted as consistent with hydronephrosis because of delayed accumulaof the radiotracer in the initially photon-deficient regions. However, both patients were found to have a multicystic dysplastic after nephrecton1y. It appears that accumulation of Tc-DTP A in the renal mass in the delayed images does not eliminate the µv:,:,,uu,cy of multicystic dysplasia but attention should be forcused more to the location of the functioning cortex. F. T. A. 2 figures, 22 references

The Abdominal Technetium Scan (A Decade of Experience)

R. COONEY, D. 0. DUSZYNSKI, E. CAMBOA, M. P. KARP AND T. C. JEWETT, JR., Children's Hospital of Buffalo, Buffalo, New York

D.

J. Ped. Surg., 17: 611-619 (Oct.) 1982 Experience with abdominal technetium (99mTc) scans to evaluate abdominal symptoms (bleeding 165 cases, pain 99 and history of intussusception 6) during a 10-year period has been

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reviewed. All n".-·"'"rnR received 99"'Tc after blocking thyroid uptake. Since 1978 99 mTc sulfur colloid has been used to detect streaming and pooling in an area of active bleeding. Children were allowed nothing by mouth after midnight or the stomach was emptied by nasogastric tube and the children were instructed to void before the study to avoid pooling in the stomach and bladder that could obscure a lesion. Of 270 children 30 (ll per cent) had abnormal findings. Four of these patients had resolution of the bleeding and were not explored. Of the 26 children who undervvent laparotomy 12 had a Meckel's diverticulum, which had been seen as an area of increased isotope uptake in the right lower quadrant or mid abdomen. Seven diverticula contained gastric mucosa, 2 contained gastric and pancreatic mucosa, and 3 had no gastric mucosa identified. Of the 26 children 9 failed to have a Meckel's diverticulum but did have surgically significant lesions-3 small bowel duplications, 3 intussusceptions, 1 inflammatory perforation of the terminal ileum, 1 anterior meningomyelocele and 1 pelvic kidney-and 5 (19 per cent) had no significant pathological condition-true false positive studies. Of the 240 children with negative studies 19 underwent laparotomy for persistent symptoms. In 11 children no pathological condition was found, while 6 had other surgical pathological conditions. Of the 19 children 2 had a Meckel's diverticulum-1 that on retrospective study was hidden behind the bladder and l that contained only a 1 to 2 cm. strip of ectopic gastric mucosa with sparse parietal cells, which was probably too small an area (<2 cm. 2 ) to be visualized. This is a false negative rate of
Editorial comment. We all see children who present with abdominal pain. Frequently, we have a difficult time in finding