The abdominal technetium scan (a decade of experience)

The Abdominal Technetium Scan (A Decade of Experience) By Donald R. Cooney, Diane O. Duszynski, Edgar Carnboa, Melvyn P. Karp, and Theodore C. Jewett, Jr. Buffalo, N e w York

9 Out of 2 7 0 children with gastrointestinal symptoms, the indications for technitium scanning were: gastrointestinal tract bleeding (165 patients), abdominal pain (g9 patients) and a history of intussusception (6 patients). Thirty children had abnormal findings, while the remaining 2 4 0 patients had "'normal" scans. Four of the 30 children with positive scans were not explored, while the others underw e n t laparotomy. Of the 26 operated patients, 12 (46%) had a Meckel's diverticulum. Nine patients (34%) had other pathologic lesions that w e r e detected by the scan. Five had true "false positives" as no pathologic lesions w e r e found. Of the 240 children with negative scans, 19 w e r e eventually explored because of persistent symptoms or clinical findings. Two of these had a Meckel's diverticulum. Eleven had a negative exploration while six had other surgical lesions. Technitium scan should reliably detect around 8 0 % - 9 0 % of Meckel's diverticula, It will also accurately exclude the diagnosis of i e c k el's diverticulum in over 9 0 % of patients. INDEX WORDS: Abdominal technetium scan; Meekel's diverticulum.

H E FIRST CASE of Meckel's diverticulum

to be detected by Technetium 99m pertechT netate scan was diagnosed at The Children's Hospital of Buffalo in 1969. ~ During the last decade, 269 additional scans have been performed in children with gastrointestinal symptoms to rule out or confirm the diagnosis of Meckel's diverticulum as the etiology of their symptomatology. MATERIALS AND METHODS Two hundred and seventy children, ranging in age from 3 days to 17 yr (mean: 7.09 yr) underwent an abdominal technetium scan at The Children's Hospital of Buffalo from 1969 to 1980. There were 176 males (65%) and 94 females (35%). The indications for scanning were: gastrointestinal tract bleeding (165 patients), abdominal pain (99 patients), and a history of intussusception (6 patients). Forty-five of the 270 patients who were scanned eventually underwent exploratory laparotomy. The clinical records of all patients were reviewed with reference to clinical findings, scan results, preoperative diagnosis, operative findings, histologic interpretation, and long-term follow-up. To gain a perspective as to the role of the technetium scan in the diagnosis and treatment of Meckel's diverticulum, the clinical records of all cases of Meckel's diverticulum removed surgically during the same period (1969 to 1980) were also reviewed with reference to the clinical presentation and clinical applicability of the technetium scan in each of these patients. Journal of Pediatric Surgery, Vol. t 7, No. 5 (October), 1982

Technical Considerations Patients were medicated to minimize the absorbed radiation dose to the thyroid gland with the blocking agent potassium percholorate 4 mg/kg (maximum 200 mg) 30-60 min after administration of the isotope. Patients were kept N.P.O. after midnight, or their stomachs were decompressed with a nasogastric tube prior to the procedure. In addition an attempt was made to have the children void before and then prior to the 60-min scan. Occasionally it was necessary to empty the bladder with a catheter during the scanning procedure. These measures are necessary to minimize the gastric and bladder images to improve interpretation. Since barium may interfere with the recording of the emission image, barium contrast studies were avoided whenever possible prior to each scan. All patients received Tc 99m pertechnetate (or 99m Tcsulfur colloid) 75-100/LCi/kg intravenously 15 min prior to the first film. The isotope that concentrates in the thyroid gland, salivary glands, stomach and choroid plexus, has a half-life of 6.02 hr and is readily excreted by the kidneys. Anterior abdominal views were taken by a Searle Pho Gamma 111 scanner at 15, 30, 45, and 60 min. Additional anterior and lateral views were often performed and when deemed necessary, repeat scans at 4 and 24 hr. Since 1978, the scans have been performed utilizing a Searle Pho Gamma V with a MDS computer. In addition, during the last 4 yr, vascular flow studies using 99m To-sulfur colloid have been used to facilitate detection of the Meckel's diverticulum during period of active hemorrhage. The Tc-sulfur colloid is detected by the streaming and pooling of the isotope in the area of the bleeding lesion.

RESULTS

Thirty of the 270 children (11%) undergoing the scan had abnormal or positive findings. The remaining 240 patients (89%) had "normal" or negative scans. Positive Scans Four of the thirty children with positive scans were not explored (Fig. 1). Gastrointestinal tract bleeding resolved in three of these patients. Operation was deferred in the fourth because of

From the Children's Hospital of Buffalo, Buffalo, N.Y. Presented before the 30th Annual Meeting of the Surgical Section of the American Society of Pediatrics, New Orleans, La,, October 31-November I, 1981. Address reprint requests to Donald R. Cooney, Department of Pediatric Surgery, Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, N.Y. 14222 9 1982 by Grune & Stratton, Inc. 0022-3468/82/1705-0034501.00/0 611

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COONEY ET AL.

PATIENIS

children revealed an obvious area of increased isotope uptake in the right lower quadrant or mid-abdomen (Fig. 2). Histologically, 7 of these 12 specimens contained ectopic gastric mucosa while 2 contained both gastric and pancreatic muscosa. In 3, no gastric mucosa was identified.

WIIHA PO~ITI~SO~I

26 , ~ l l . I ~

tl ~ I I . I ~

OPERATED

NOTO P m ~

False Positive Scans

14 CHIt.I~

12 CHILDREN

No MECm.'sFaro

I~cm.'s

5~ Fig. 1. Exploratory laporatory findings in patients with a positive scan result,

pulmonary complications and his rectal bleeding subsequently resolved. These four patients have been followed and each has remained well. Repeat scans have not been performed in any of these children. Twenty-six of the patients with positive scans underwent laparotomy (Fig. 1). Twelve of these children had a Meckel's diverticulum that was removed. The Meckel's diverticular scan in these

Fourteen children had "false positive" scans in which no Meckel's diverticulum was identified (Fig. 3). Nine of the twenty-six children (35%) with a "false positive" scan had other pathologic lesions that were detected by the scan. Three patients had small bowel duplications (Fig. 4), two of which contained ectopic gastric mucosa. Three children had an intussusception (Fig. 5), and one child an inflammatory perforation of the terminal ileum. Another case was found to have an anterior meningomyelocoele, and one child a pelvic kidney (Fig. 6). Five of the twenty-six children (19%) had no significant pathologic lesions demonstrated at the time of laparotomy and represent the true "false positive" scans.

PATIENTS WITH A

F/ESEPOSITIVE ~I OIHE~ P A ~ : C O G Y / ~ ~ P A

Y

FamAT t~P~mTOMY

FormAr L~*mrn~

9 CH!WREN

5 ~i= POSITIVES

KIIINE

1- ICEIT! Pm P~FO~TIO. ]Fig. 2.

Abdominal scan of s child with Meckel's divertistomach (S) the bladder

culum (M). Technetium is progressing from the to the jejunum (J) and being concentrated in (Sl.

I)JPLICATIONS

1~

INTUSSUSCEPTION

P/YERIOR

Fig. 3, Exploratory laporatory findings "false positive" scan results.

in patients with

ABDOMINAL TECHNETIUM SCAN

613

Fig. 4. Abdominal Tc scan of child w i t h small bowel duplication (D).

Fig. 6. Ectopic pelvic kidney (K) detected by technetium scan.

Negative Scans

rent abdominal pain (8 patients), continuing gastrointestinal hemorrhage (7 children), recurrent intussusception (3 patients), and small bowel obstruction (1 patient). The findings at surgery in these 19 operated patients with negative scans are summarized in Table 1. Eleven children with negative scans had no pathologic lesions found at the time of laparotomy. Two of these patients with a negative scan were found to have a Meckel's diverticulum. One child's diver-

Two hundred and forty of the 270 scanned patients had a negative scan (Fig. 7). The symptoms in 221 of these children resolved and no operation was performed. Long-term follow-up of this group of patients indicate that all these children have remained well. Nineteen of the 240 children with a negative scan underwent operation. The indications for surgery included: recur-

PATIENTS WITHA NEGATIVESCAN ~1 NOT0PERA'r~

2 CHIL~RB~ Pr=cm.'s RBr

19 (PaZ~TED

17 CHILZ~RB No I~-cm.'s Fou~

"FPLSE~ T I ~ " <11 Fig. 5.

Scan of patient w i t h jejunal intussusception (I).

Fig. 7, Clinical and operative findings in children w i t h a negative or normal technetium scan.

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COONEY ET AL.

Table 1. Exploratory Laboratory Findings in Children W i t h Negative or "Normal" Abdominal Technetium Scans

Negative exploration--

11

I Meckel's diverticulum--2 Adhesions-- 1 Volvulus-- 1

Paraovarian c y s t - - I I Duodenal ulcer-- 1 Intussusception-- 1 Acute jejunitis-- 1

ticulum had no evidence of ulceration or hemorrhage and contained only a 1 • 2 cm strip of gastric mucosa with sparsely distributed parietal cells. The other patient had a full urinary bladder that retrospectively appeared to obscure the lesion on scan (Fig. 8). The lateral projection scan may be helpful as illustrated in Fig. 9 to eliminate this interpretive error. Oecassionally it may be necessary to empty the bladder by a catheter to decrease the size of the bladder image to be able to identify the Meckel's diverticulum (Fig. 10). The above two patients represent the false negative scan results in the study which is less than 1%. Six of the remaining 19 patients with negative scans who were operated on had a variety of other lesions that included: diffuse adhesions with partial intestinal obstruction, nonrotation with midgut volvulus, a paraovarian cyst, a duodenal ulcer, jejunal intussusception, and Crohn's jejunitis (Table 1). The role of the technetium scan in the diagnosis and treatment of children with symptomatic Meckel's diverticular disease is illustrated by an

analysis of the cases of Meckel's diverticulum removed during the same period as the scan review. During this period 37 patients with Meckel's diverticula were operated upon. There were 24 males (69%) and 11 females (31%). The age ranged from 6 days to 17 yr (mean: 6.17 yr). Gastrointestinal tract bleeding was the most common clinical presentation and was noted in 12 patients (34%). Each of these patients had a Meckel's scan which was positive (Table 2). Intestinal obstruction was the second most common presenting finding (24%).

Fig. 8. A n t e r i o r v i e w of child whose Meckel's diverticulum (M) represented by the increased area of isotope uptake (arrow), lies adjacent to the bladder (B) image.

Fig. 10. An anterior v i e w of a Tc scan in which the bladder (B) had to be emptied by catheter to reveal the Meckel's diverticulum (M),

Fig. 9. The lateral projection of child with Meckel's diverticulum (M) urinary bladder (S).

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615

Table 2. The Clinical Presentation and Preoperative Diagnosis of 37 Children Undergoing Operation Who Had a Meckel's Diverticulum Preoperative Diagnosis Scan diagnosed Meckel's diverticula Clinically diagnosed Meckel's diverticula Acute appendicitis Intussusception Small bowel obstruction Umbilical anomaly Incidental removal

Patients 12 (32%) 4 6 6 4 3 2

(12%) (16%) (16%) (9%) (8%) (7%)

Of these 37 cases of Meckel's diverticulum, an incorrect or nonspecific diagnosis were made in 56% of these children. These included: appendicitis in 6 patients and "intestinal obstruction" in 4 children. Six patients presented with intestinal obstruction in which the Meckel's diverticulum was the lead point of an intussusception. Three children were operated on because of an umbilical omphalomesenteric duct anomaly. In these three cases, the diagnosis of Meckel's diverticulum was considered preoperatively. Of the 37 operative cases, the preoperative diagnosis of Meckel's diverticulum was correctly made in 16 patients (44%). In 4 instances, the diagnosis was made clinically. One of these 4 children had a technetium scan that failed to detect the diverticulum. Twelve patients had positive scans; the Meckel's diverticulum was diagnosed by scan in 32% of children with this anomaly (Table 2). DISCUSSION

Meckel's diverticulum is a diagnosis that should always be considered in children with abdominal pain or gastrointestinal bleeding. Conventional contrast radiographic techniques have proven to be unreliable in establishing or excluding this diagnosis, vs Angiography has been useful in identifying these lesions particularly during acute bleeding episodes. 6-9 In 1970, Jewett and Duszynski reported the visualization of a Meckel's diverticulum with 99m Technetium pertechnetate. ~ Since this original description, a number of authors have documented the value of the abdominal technetium scan in detecting this lesion. 1w26 Reported sensitivity rates for detection of Meckel's diverticula have ranged from 60% to 100%. 11'14'15'25'27A number of

false-negative and false-positive scan results have been reported in the literature. 28-32This fact has resulted in concern regarding the reliability and clinical applicability of the technetium scan. The analysis of the evolution of abdominal technetium scanning at our institution over the last decade brings into better prospective the proper role of this diagnostic procedure. One if the conclusions that can be drawn from the analysis of this large series of patients regards the indications for scanning and clinical application. Thirty children of the 270 patients undergoing this diagnostic procedure has a positive scan. In addition, even fewer (46%) of these children actually had a Meckel's diverticulum. This relatively low yield of positive results would suggest that patient selection and indications for scan should be stricter to ensure that this test is used in the most efficient and cost effective manner. Our experience does not appear to be a unique one in that similar positive scan yield results have been reported by a number of other authors.~i.12.14.15.20 Gastrointestinal bleeding was the commonest indication for technetium scanning in our series. However, the nature of the bleeding and the clinical presentation of a majority of these patients was not characteristic of Meckel's diverticular hemorrhage. Patient selection would be improved if the test was reserved for children in which the gastrointestinal bleeding was rapid, life threatening, or recurrent and more characteristic of Meckel's diverticular hemorrhage. In our series, a number of patients would have profitted more from standard diagnostic procedures such as endoscopy or barium contrast studies. If these tests fail to identify the source of bleeding then an abdominal technetium scan would be the next logical step. The second most frequent indication for technetium scan was abdominal pain. Many times this test was one of the first diagnostic procedures proposed during the work-up. Our data reveals that only a small percentage of the Meckel's diverticula detected by scan and removed presented with abdominal pain. The majority of these symptomatic patients had gastrointestinal bleeding suggesting that the expected yield rate from scans of patients with abdominal pain will be relatively low. This observation again, indicates the need to reserve this test until other diagnostic procedures have been completed,

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reviewed and correlated with the clinical findings in each ease of abdominal pain. Although in many instances, the scan was at times used excessively as a diagnostic tool, it seems rather paradoxical that only 32% of the 37 symptomatic Meekel's diverticulum patients were diagnosed preoperatively by the technetium scan. Again, this fast reemphasizes the relative failure of proper patient selection. Certainly a number of patients will present as acute surgical emergencies resulting from complications of their Meckel's diverticular disease. In these instances, it is understandable that either a wrong diagnosis such as appendicitis may be entertained and the technetium abdominal scan would not be considered in the patient's diagnositc evaluation. However, it is important to note that in our series a number of patients presented with relatively mild or long-standing symptoms: chronic abdominal pain or recurrent gastrointestinal hemorrhage. In these instances, the patient's clinical condition would allow for a more extensive diagnostic work-up and the abdominal scan should be definitely considered. Not all Meckel's diverticula can be detected utilizing the abdominal technetium scan. The most problematic of these patients, are those in which the lesion contains ectopic gastric mucosa but fails to visualize. Technical considerations are of significant importance to attain results with the greatest degree of sensitivity and specificity. Having the scan performed while the patient is N.P.O. minimizes the size of the gastric image and brings the stomach to a basal emptying state. The amount of technetium emptying from the stomach that contributes to background image is an important consideration. In addition, having the patient void to similarly decrease the size of the urinary bladder image and improve scan interpretation is an important step in proper patient preparation. It is significant that one of the false negative scans was the result of difficulty in interpretation because of the close proximity of the uptake area to the urinary bladder image. In retrospect a lateral scan may have eliminated this interpretive error. Barium should be avoided prior to the technetium scan since it may interfere with recording of the emission image, and result in a false negative scan. At our institution we have continued to administer potassium perchlorate in a dose of 4 m g / k g 30-60 min after the scan. This drug acts

COONEY ET AL.

as a blocking agent to minimize the radiation dose to the thyroid. From the standpoint of the negative false scan result, potassium perchlorate should theorectically increase the circulating pool of technetium pertechnetate but does decrease the gastric mucosal uptake of the isotope. 33~~The low false negative scan rate (1%) of our series speaks for its continued use as a blocking agent as long as it is administered following injection of the isotope. The other false negative result in our study emphasizes the importance of size of the area of the ectopic gastric mucosa. Priebe and his coworkers have shown experimentally that an area of ectopic gastric mucosa less than 2 sq cm cannot be visualized utilizing the technetium pertechnetate scan. 4~ One of our patients with a negative scan result, who later proved to have a Meckel's diverticulum, had only a very small area of ectopic gastric mueosa, which apparently accounted for the nonvisualization. Another factor that may result in a false negative scan result has been referred to as the "wash out" phenomenon. In situations in which the intestinal transit may be relatively rapid, the technetium pertechnetate excreted by the surface cells of the Meckel's diverticulum may be diluted and washed out so rapidly that a definite positive emission image is not visualized. Anderson and his colleagues have shown in an experimental model that glucagon, by slowing intestinal transit may improve scan sensitivity. 42 Other agents that have been suggested to enhance the emission image have included Pentagastrin and Cimetidine 42~6 None of these pharmacologic agents have been used at our institution to achieve scan enhancement. Although many of them appear to have theoretical and experimental merit, more extensive clinical trials are needed to evaluate their applicability. Active bleeding may cause a similar "wash out" phenomenon. Three children in our series had a negative scan during a period of active bleeding. Repeat scans performed after the hemorrhage had ceased were positive. In several cases, we have observed that technetium labeled sulfur colloid appears to be a better agent to be used in these active bleeding patients since it has resulted in a better emission image. Two of the 221 patients with a negative scan, who later were operated on, were found to have a Meckel's diverticulum. The false negative rate in

ABDOMINAL TECHNETIUM SCAN

this study would, therefore, be less than 1%. Even if the false negative rate is calculated based upon the 19 children who were operated on, the false negative rate would still be relatively low at 11%. This date suggests that the technetium scan is an excellent test to exclude the diagnosis of Meckel's diverticulum. The information obtained from the 17 children who had a negative scan, but who were subsequently operated on, because of continued symptomatic abdominal pain, gastrointestinal bleeding, intussusception, or small bowel obstruction add additional information regarding the value of technetium scanning in conditions other than Meckel's diverticulum. It is important to note that six patients had inflammatory or obstructive lesions of the gastrointestinal tract. We have confirmed in our series the observations of other investigators that these lesions at times may be visualized by the t e c h n e t i u m a b d o m i n a l scan.19,47 51 It is most interesting however, that several of these lesions in our series were not visualized by the scan. The scan, therefore, does not appear to be sensitive screening test in the diagnosis of all these inflammatory and obstructive lesions of the gastrointestinal tract. The most difficult problem, however, for clinicians, is the interpretation of the positive technetium abdominal scan. Of the 26 children with a positive scan who were operated on, only 12 patients or 46% were found to have Meckel's diverticulum. In addition, it is significant that three of these lesions did not contain ectopic gastric mucosa. This observation may be explained by the fact that the ectopic gastric cells may have been diffusely distributed and difficult to identify histologically, or as has been proposed by several investigators, the isotope may be excreted by surface mucus secreting cells of the Meckel's diverticulum and not by parietal cells. 38'41'52-85 However, since other inflammatory lesions of the gastrointestinal tract have been visualized by technetium scanning these symptomatic Meckel's diverticulum without identifiable gastric mucosa may have been involved in a inflammatory process causing the symptomatology and resulting in the technetium uptake. Fourteen children with positive scans had no Meckel's diverticula found at the time of operation. These "false positive" scans accounted for 54% of the patients with a positive scan result. A further analysis of these children reveals, how-

617

ever, that approximately two-thirds of these "false positive" scan patients had other pathologic lesions that were detected by the scan. Three patients had enteric duplications, two of which contained ectopic gastric mucosa, 1 patient had a ectopic kidney, 3 patients had intussusception, 1 patient had an inflammatory lesion and perforation of his distal ileum, and 1 child had anterior meningomyleeoele. These lesions that have previously been detected and referred to as "false positive" certainly are lesions that may be amenable to surgical therapy or their existence is of diagnostic importance. Other reports have documented the value of the abdominal technetium scan in detecting a number of these conditions and have included: anomalies or obstructive lesions of the genitourinary tract, enteric duplications, intussusception, inflammatory, ulcerative, vascular or obstructive lesions of the gastrointestinal tract, and occasionally gastrointestinal polyps. 28 31.48.49.51 In many instances, these abnormalities could have been diagnosed preoperatively if other complimentary diagnostic procedures would have been considered in patients with positive technetium scans. Studies such as gastrointestinal contrast radiography, intravenous pyelography, and computed tomography in most instances would have eliminated a number of unnecessary or unplanned operations. The goal of the clinician and the radiologist who deal with children undergoing adbominal technetium scanning is to reliably differentiate and diagnose these nonMeckel's diverticular lesions. The most serious concern with the technetium scan arises from overinterpretation. Five children in our series were subjected to laparotomy on the basis of the scan results and mild symptomatology. In these 5 patients, no apparent source of 'the isotope uptake could be identified. It is important to note that 3 of these negative laparotomies occurred during the first 4 yr of scanning at our hospital. Only 2 negative explorations have been performed as a result o.f a false positive Meckel's scan during the last 5 yr. The 19% negative exploration rate of this study simply points out the need for cautious interpretation of all positive scan results. It again suggests that complimentary radiographic studies be considered to exclude the possibility of another diagnosis. If the patient is only mildly symptomatic and there is not an obvious and definite area of

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COONEY ET AL.

uptake, it m a y be wise to adopt a policy of rep eat i n g the t e c h n e t i u m scan before exploratory surgery is undertaken, In addition, the scan results should be i n t e r p r e t e d in conjunction with the available clinical data. A positive t e c h n e t i u m a b d o m i n a l scan should not serve as the sole indication for operation. T h e m a i n indication for operation should continue to be d e t e r m i n e d by the p at i en t ' s clinical findings.

a p p r o x i m a t e l y 80% to 90% of M e c k e l ' s diverticula. Scans should a c c u r a t e l y ex cl u d e the diagnosis o f M e c k e l ' s d i v e r t i c u l u m in over 90% o f scanned children. O t h e r a b d o m i n a l p at h o l o g y m a y be d e t e c t e d and then c o m p l i m e n t a r y diagnostic studies should be cautiously i n t e r p r e t e d an d considered in conjunction with the av ai l ab l e clinical data.

CONCLUSION

ACKNOWLEDGMENT

M o r e careful patient selection is needed for children undergoing a b d o m i n a l t e c h n e t i u m scanning. T e c h n e t i u m scan should reliably detect

T h e authors are indebted to Dr. Lu ci e N o e l G a m b o a for her invaluable assistance in the p r e p a r a t i o n o f this study.

REFERENCES

1. Jewett TC, Duszynski DO, Allen JE: The visualization of Meckel's diverticulum with 99m Tc-pertechnetate. Surgery 68:567-570, 1970 2. White AF, Oh KS, Weber AL, et al: Radiologic manifestations of Meckel's diverticulum. Am J Roentgenol 118:86-94, 1973 3. Valle M, et al: Radiologic demonstration of Meckel's diverticulum. Gastrointest Radiol 3:101-103, 1978 4. Meguid MM, Wilkinson RH, Canty T, et al: Futility of barium sulfate in diagnosis of bleeding Meckel's diverticulum. Arch Surg 108:361-362, 1974 5. Dalinka MK, Wunder JF: Meckel's diverticulum and its complications, with emphasis on roentgenologic demonstration. Radiol 106:295-298, 1973 6. Bree RL, Reuter SR: Angiographic demonstration of a bleeding Meckel's diverticulum. Radiology 108:287-288, 1973 7. Faris JC, Whitley JE: Angiographicdemonstration of a Meckel's diverticulum. Radiology 108:285-286, 1973 8. Takeda I, et al: A bleeding Meckel's diverticulum diagnosed by arteriography. Gastroenteriol Jpn 12:76-77, 1977 9. Ostergaard AH, Fredens M: Arteriographic demonstration of bleeding from Meckel's diverticulum: Report of a case. Scand J Gastroenterol 6:109, 1971 10. Henry JN, Rosenthall L, Murphy DA: The use of radiopertechnetate in the diagnosis of Meckel's diverticulum. J Tenn Med Assoc 65:895-897, 1972 11. Rosenthall L, Henry JN, Murphy DA, et al: Radiopertechnetate imaging of the Meckel's diverticulum. Radiology 105:371-373, 1972 12. Schussheim A, Moskowitz GW, Levy LM: Radionuclide diagnosis of bleeding Meckel's diverticulum in children. Am J Gastroentero168:25-29, 1977 13. Leonidas JC, Germann DR: Technetium-99m pertechnetate imaging in diagnosis of Meckel's diverticulum. Arch Dis Child 49:21-26, 1974 14. Gelfand M J, Silberstein EB, Cox J: Radionuclide imaging of Meckel's diverticulum in children. Clin Nucl Med 3:4-8, 1978 15. Berquist TH, Nolan NG, Stephens DH, et al: Specificity of 99m Tc-pertechnetate in scintigraphic diagnosis of

Meckel's diverticulum: Review of 100 cases. J Nucl Med 17:465-469, 1976 16. Lee HK, Schwartz IJ, Nipper T, et al: Preoperative diagnosis of Meckel's diverticulum by sequential 99m technetium pertechnetate scanning. Mt Sinai J Med NY 42:136141, 1975 17. Seltzer MH, Conte PJ, Rickert RR, et al: Diagnosis of a bleeding Meckel's diverticulum using radiopertechnetate. Am J Gastroenterol 67:235-239, 1977 18. Muroff LR, Casarella WJ, Johnson DM: Preoperative diagnosis of Meckel's diverticulum. JAMA 229:1900-1902, 1974 19. Berquist TH, Nolan NG, Carlson HC, et al: Diagnosis of Barrett's esophagus by pertechnetate scintigraphy. Mayo Clin Proc 48:276-279, 1973 20. Ho JE, Konieczny KM: The sodium pertechnetate Tc 99m scan: An aid in the evaluation of gastrointestinal bleeding. Pediatrics 56:34-40, 1975 21. Jaros R, Schussheim A, Levy LM: Preoperative diagnosis of bleeding Meckel's diverticulum utilizing 99m technetium pertechnetate scintigraphy imaging. J Pediatr 82:4549, 1973 22. Kilpatrick ZM, Aseron CA Jr: Radioisotope detection of Meckel's diverticulum causing acute rectal hemorrhage. N Engl J Med 287:653, 1972 23. Martin GI, Kutner FR, Moser L: Diagnosis of Meekel's diverticulum by radioisotope scanning. Pediatrics 57:1112, 1976 24. Wine CR, Nahrwold DL, Waldhausen JA: Role of the technetium scan in the diagnosis of Meckel's diverticulum. J Pediatr Surg 9:885-888, 1974 25. Conway J J: The sensitivity, specificity, and accuracy of radionuclide imaging in Meckel's diverticulum. J Nucl Med 17:553, 1976 26. Kilpatrick ZM: Scanning in diagnosis of Meckers diverticulum. Hosp Pract 131-138, 1974 27. Kilburn E, Gilday DL, Ash L: Meckel's diverticulaserial multiple view imaging. J Nucl Med 17:553, 1976 28. Rodgers BM, Youssef S: "False positive" scan for Meckel's diverticulum. J Pediatr 87:239-240, 1975 29. Chaudhuri TK, Christie JH: False positive Meckel's diverticulum scan. Surgery 71:313, 1972

ABDOMINAL TECHNETIUM SCAN

30. Colbert PM: Problems with radioisotope scan for Meckel's diverticulum. N Engl J Med 291:530-531, 1974 31. Lentle BC, Scott GW: A "false positive" abdominal scan for Meckel's diverticulum. Br J Radio148:59-61, 1975 32. Smith FR, et al: Meckel's diverticulum vagaries of technetium scanning. Am J Gastroenterol 72:655-659, 1979 33. OldendorfWH, Sisson WB, Iisaka Y: Compartmental redistribution of 99m Tc-pertechnetate in the presence of perehlorate ion and its relation to plasma protein binding. J Nucl Med 11:85, 1970 34. Khettery J, Effman E, Grand R J, et al: Effect of pentagastrin, glucagon, secretin and perchlorate on the gastric handling of 99mTc pertechnetate in mice. Radiology 120:629~631, 1976 35. Marsden DS, Priebe C J: Preliminary appraisal of present 99m Tc-pertechnetate techniques for detecting eetopic gastric mucosa. Radiology 113:459460, 1974 36. Marsden DS, Alexander C, Friedman MHF, et al: The secretion of iodide and technetium pertechnetate by various regions of the dog's stomach and clinical implications. J Nuel Med 11:635-636, 1970 37. Harden RM~ Alexander WD, Kennedy I: Isotope uptake and scanning of stomach in man with 99m Tc pertechnetate. Lancet 1305-1307, 1967 38. Keramidas DC, Coran AG, Zaleska RW: An experimental model for assessing the radiopertechnetate diagnosis of gastric mucosa in Meckel's Diverticulum. J Pediatr Surg 9:879-883, 1974 39. Kontzen FN, Goel Y: The effect of iodide and atropine on pertechnetate uptake by the choroid plexus. J Nucl Med 11:635, 1970 40. Lathrop KA, Harper PV: Biologic behavior of 99mTc from 99Tc-pertechnetate ion. Prog Nucl Med 1:145-162, 1972 41. Priebe C J, Marsden DS, Lazarevic B: The use of 99m technetium pertechnetate to detect transplanted gastric mucosa in the dog. J Pediatr Surg 9:605-613, 1974 42. Andeson GF, Sfakianakis G, King DR, et al: Hormonal enhancement of teehnetium-99m perteehnetate

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