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Unusual intestinal and urinary tract accumulation on bone scan: A case with indiana pouch
U n u s u a l I n t e s t i n a l a n d U r i n a r y Tract A c c u m u l a t i o n on B o n e S c a n : A Case W i t h I n d i a n a P o u c h Shih-Chuan Tsai, Chia-Hung Kao, Wan-Yu Lin, and Shyh-Jen Wang HE RADIONUCLIDE BONE scan is an important diagnostic tool in the evaluation of patients with a variety of osseous abnormalities. However, localization of bone-seeking radiotracers outside of the skeletal system has also been reported in various physical and pathologic states. Therefore, it is important that these causes of extraskeletal accumulation of bone-seeking radiotracers are kept in mind when bone-imaging studies are reviewed so that mistakes in interpretation are not made. The current case showed right abdominal radioactivity during the performance of a whole-body bone scan. This was caused by stasis of radio-labeled urine in an Indiana pouch. A 47-year-old female patient with a history of transitional cell carcinoma of the urinary bladder and left kidney was treated with a radical cystectomy and nephrectomy. She was referred to our department for a whole-body bone scan to exclude skeletal metastasis. A technetium (Tc)-99m methylene diphosphonate (MDP) bone scan revealed no evidence of skeletal metastasis. The scan did show significant accumulation of radiotracer in the right abdomen, however (Fig 1). Review of the patient's history showed that she had undergone neobladder reconstruction (Indiana pouch). An intravenous pyelogram showed accumulation of contrast media in the Indiana pouch, localizing in the right abdomen (Fig 2). The scintigraphic findings are thought to be secondary to stasis of radio-labeled urine in the Indiana pouch. An Indiana pouch is a cutaneous urinary diversion that involves the use of an ileocecal valve and a portion of the ascending colon to form a neobladder. It has been performed in patients who have had a cystectomy. In radionuclide bone scans, abnormal
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From the Departments of Nuclear Medicine, Show-Chwan Memorial Hospital Changhua and Taichung Veterans General Hospital Taichung, Taiwan, R.O.C. Address reprint requests to Chia-Hung Kao, MD, Department of Nuclear Medicine, Taichang Veterans General Hospital, 160 Taichang Harbor Road, Section 3, Taichung40705, Taiwan,R.O.C. Copyright 9 2000 by W.B. Saunders Company 0001-2998/00/3004-0008510. 00/0 doi: l O.l O53/snuc.2000.165 95
310
Fig 1. A Tc-99m MDP whole-body bone scan showed no definite evidence of bone metastasis. Significant radiotracer stasis in the right abdomen (black arrows) was observed, however.
accumulation of radiotracer in the intestine has been seen in ileal conduit, a urinary diversion surgical procedure. Accumulation of radiotracer in urinary reservoirs, such as Kock pouch and sigmoid loop augmentation, also has been reported. To our knowledge, however, seeing intestinal accumulation on bone scan in patients with an Indiana pouch has not been reported. The causes of accumulation of bone-seeking radiotracers in the fight abdomen, likely intestinal and urinary tracts, are listed in the following section.
INTESTINAL TRACT UPTAKE Common
1. Ileal conduit 1,2 2. Enterovesical fistula 3-12
Seminars in Nuclear Medicine, Vol XXX, No 4 (October), 2000: pp 310-312
INDIANA POUCH ON BONE SCAN
311
Uncommon 1. Neonatal necrotizing enterocolitis 15 2. Normal intestine in children 16 Rare 1. 2. 3. 4. 5.
Neuroblastoma 17 Protein-losing enteropathy as Metastatic calcification 19 Primary intestinal lymphangiectasia 2~ Systemic amyloid light-chain--derived amyloid o s i s 21
6. High aluminum content in eluent from the Tc-99m generator 22 7. Oral intake of radio-labeled urine 23,24 URINARY TRACT UPTAKE Common 1. Rupture with extravasation of urine e527 2. Dilation of urinary-collecting systema8,29 3. Ureterostomy bag 3~ 4. Bladder diverticulum 31 Fig 2. An intravenous pyelography showed accumulation of contrast media in Indiana pouch, localizing in the right abdomen (white arrows).
3. Occult gastric bleeding u 4. Intestinal infarction 12-14
Uncommon 1. Urinary reservoir (Kock pouch, sigmoid loop augmentation) 32,33 2. Urinoma 34 3. Congenital renal anomaP ~ 4. Extrophy of the bladder 35
REFERENCES 1. Ackennan L, Elam E, Bushnell D, et al: Bowel visualization in bone scintigraphy. Semin 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 99mTc-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 ileo-vesical 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 T, Togawa T: Vesicoenteric fistula discovered during routine bone scintigraphy. Clin Nucl Med 6:422-423, 1981
9. Ran 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. L e e VW, Leiter BE, Weitzman E 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: 99mTcpyrophosphate 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 radionnclide scanning in early diagnosis of intestinal infarction. J Pediatr Surg 13:616-621, 1978 15. Sfakianakis G, Ortiz VN, Haase GM, et al: 99mTcdiphosphonate abdominal imaging in necrotizing enterocolitis: A prospective study. J Nucl Med 19:691-692, 1978
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16. Conway JJ, Weiss SC, Khentigan J, etal: Gallbladder and bowel localization of bone imaging radiopharmaceuticals. J Nucl Med 20:622, 1979 (ahstr) 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 19:1114-1116, 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, et al: 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 99mTc-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 99mTc-HMDP: An unusual finding in bone scintigraphy. Nuklearmedizin 33:142-1 44, 1994 24. Tsai SC, Kao CH, Lin WY, et al: Intestinal accumulation of 99mTc-MDP on bone scan. Semin Nucl Med 29:80-81, 1999 25. Lecklitner ML, Tanxe WN: Bone scintigraphy and post-
TSAI ET AL
operative ureteropelvic urine extravasation. Eur J Nucl Med 8:346-347, 1983 26. Shiozaki H, Kamoi I, Oshiumi Y, et al: Perirenal urinary extravasation demonstrated by bone scintigraphy--A case report. Kaku Igaku 18:245-247, 1981 27. Shah PJ, Shreeve WW, Murthy BN: Iatrogenic rupture of urinary bladder: Incidental finding on bone scan. J Nucl Med 22:564-565, 1981 28. Van der Wall H, Murray IP: Visualization of megacystis on bone scan. Clin Nucl Med 16:369-371, 1991 29. Maher FT: Evaluation of renal and urinary tract abnormalities noted on scintiscans. Mayo Clin Proc 50:370-378, 1975 30. Ryo UV, Beckerman C, Pinsky SM: Arias of Nuclear Medicine Artifacts and Variants: The Skeletal System. Chicago, IL, Yearbook Medical, pp 159-189, 1985 31. Silberstein EB, NcAfee JG: Differential Diagnosis in Nuclear Medicine. New York, NY, McGraw Hill, p 305, 1984 32. Barakos JA, Colletti PM, Siegel ME, et al: Kock continent ileal urinary reservoir. Anatomy and potential pitfalls of radionuclide imaging. Clin Nucl Med 12:744-750, 1987 33. dn Cret RP, Boudreau RJ, Maguire FP, et al: Sigmoid augmentation artefact in skeletal imaging. Clin Nucl Med 13:375, 1988 34. Glazebrook GA, Lentle BC: Urinoma diagnosed on a bone scan. J Can Assoc Radiol 30:66-67, 1979 35. Rao BK, Weir JG, Lieberman LM: Extrophy of the bladder: Diagnosis on a bone scan. Clin Nucl Med 6:552-553, 1981
T
From the Departments of Nuclear Medicine, Show-Chwan Memorial Hospital Changhua and Taichung Veterans General Hospital Taichung, Taiwan, R.O.C. Address reprint requests to Chia-Hung Kao, MD, Department of Nuclear Medicine, Taichang Veterans General Hospital, 160 Taichang Harbor Road, Section 3, Taichung40705, Taiwan,R.O.C. Copyright 9 2000 by W.B. Saunders Company 0001-2998/00/3004-0008510. 00/0 doi: l O.l O53/snuc.2000.165 95
310
Fig 1. A Tc-99m MDP whole-body bone scan showed no definite evidence of bone metastasis. Significant radiotracer stasis in the right abdomen (black arrows) was observed, however.
accumulation of radiotracer in the intestine has been seen in ileal conduit, a urinary diversion surgical procedure. Accumulation of radiotracer in urinary reservoirs, such as Kock pouch and sigmoid loop augmentation, also has been reported. To our knowledge, however, seeing intestinal accumulation on bone scan in patients with an Indiana pouch has not been reported. The causes of accumulation of bone-seeking radiotracers in the fight abdomen, likely intestinal and urinary tracts, are listed in the following section.
INTESTINAL TRACT UPTAKE Common
1. Ileal conduit 1,2 2. Enterovesical fistula 3-12
Seminars in Nuclear Medicine, Vol XXX, No 4 (October), 2000: pp 310-312
INDIANA POUCH ON BONE SCAN
311
Uncommon 1. Neonatal necrotizing enterocolitis 15 2. Normal intestine in children 16 Rare 1. 2. 3. 4. 5.
Neuroblastoma 17 Protein-losing enteropathy as Metastatic calcification 19 Primary intestinal lymphangiectasia 2~ Systemic amyloid light-chain--derived amyloid o s i s 21
6. High aluminum content in eluent from the Tc-99m generator 22 7. Oral intake of radio-labeled urine 23,24 URINARY TRACT UPTAKE Common 1. Rupture with extravasation of urine e527 2. Dilation of urinary-collecting systema8,29 3. Ureterostomy bag 3~ 4. Bladder diverticulum 31 Fig 2. An intravenous pyelography showed accumulation of contrast media in Indiana pouch, localizing in the right abdomen (white arrows).
3. Occult gastric bleeding u 4. Intestinal infarction 12-14
Uncommon 1. Urinary reservoir (Kock pouch, sigmoid loop augmentation) 32,33 2. Urinoma 34 3. Congenital renal anomaP ~ 4. Extrophy of the bladder 35
REFERENCES 1. Ackennan L, Elam E, Bushnell D, et al: Bowel visualization in bone scintigraphy. Semin 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 99mTc-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 ileo-vesical 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 T, Togawa T: Vesicoenteric fistula discovered during routine bone scintigraphy. Clin Nucl Med 6:422-423, 1981
9. Ran 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. L e e VW, Leiter BE, Weitzman E 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: 99mTcpyrophosphate 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 radionnclide scanning in early diagnosis of intestinal infarction. J Pediatr Surg 13:616-621, 1978 15. Sfakianakis G, Ortiz VN, Haase GM, et al: 99mTcdiphosphonate abdominal imaging in necrotizing enterocolitis: A prospective study. J Nucl Med 19:691-692, 1978
312
16. Conway JJ, Weiss SC, Khentigan J, etal: Gallbladder and bowel localization of bone imaging radiopharmaceuticals. J Nucl Med 20:622, 1979 (ahstr) 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 19:1114-1116, 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, et al: 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 99mTc-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 99mTc-HMDP: An unusual finding in bone scintigraphy. Nuklearmedizin 33:142-1 44, 1994 24. Tsai SC, Kao CH, Lin WY, et al: Intestinal accumulation of 99mTc-MDP on bone scan. Semin Nucl Med 29:80-81, 1999 25. Lecklitner ML, Tanxe WN: Bone scintigraphy and post-
TSAI ET AL
operative ureteropelvic urine extravasation. Eur J Nucl Med 8:346-347, 1983 26. Shiozaki H, Kamoi I, Oshiumi Y, et al: Perirenal urinary extravasation demonstrated by bone scintigraphy--A case report. Kaku Igaku 18:245-247, 1981 27. Shah PJ, Shreeve WW, Murthy BN: Iatrogenic rupture of urinary bladder: Incidental finding on bone scan. J Nucl Med 22:564-565, 1981 28. Van der Wall H, Murray IP: Visualization of megacystis on bone scan. Clin Nucl Med 16:369-371, 1991 29. Maher FT: Evaluation of renal and urinary tract abnormalities noted on scintiscans. Mayo Clin Proc 50:370-378, 1975 30. Ryo UV, Beckerman C, Pinsky SM: Arias of Nuclear Medicine Artifacts and Variants: The Skeletal System. Chicago, IL, Yearbook Medical, pp 159-189, 1985 31. Silberstein EB, NcAfee JG: Differential Diagnosis in Nuclear Medicine. New York, NY, McGraw Hill, p 305, 1984 32. Barakos JA, Colletti PM, Siegel ME, et al: Kock continent ileal urinary reservoir. Anatomy and potential pitfalls of radionuclide imaging. Clin Nucl Med 12:744-750, 1987 33. dn Cret RP, Boudreau RJ, Maguire FP, et al: Sigmoid augmentation artefact in skeletal imaging. Clin Nucl Med 13:375, 1988 34. Glazebrook GA, Lentle BC: Urinoma diagnosed on a bone scan. J Can Assoc Radiol 30:66-67, 1979 35. Rao BK, Weir JG, Lieberman LM: Extrophy of the bladder: Diagnosis on a bone scan. Clin Nucl Med 6:552-553, 1981