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Scintigraphic Detection of Hemobilia Complicating Angiodysplasia

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Scintigraphic Detection of Hemobilia Complicating Angiodysplasia Scintigraphic Detection of Hemobilia Complicating Angiodysplasia William M. Yudt, Eugene D. Silverman and Aaron M. Kistler DivL@ionofNuclear Medicine, National Naval Medical Center; and the Unifonned Se,vices University ofthe Health Sciences,Betherda, Ma,yland was performedby intravenousadministrationof 15 mgof stan A 78-yr-oldmanunderwent@9―1c-IabeIedredcellexamination nous pyrophosphate, harvesting of 10 ml of red cells 20 rain later fora gaStrOinteStinatbleedingepisode.Gallbladdervisuat@ation andincubationwith1.110x 1O@MBq(30mCi) @“Tc-pertechne wasnotedduringtheexamination.Hemobihahasbeenreported tate for 20 mm before reinjection.Early imagesof the abdomen in a vailetyof pathologicconditions;santigraphicgallbladderrevealedtypicaldistributionoflabeledredcellsintheheart,great visualizationhasalsobeenreportedas a resultof the unusual vessels and abdominal viscera, with some attenuation of activity radiolabelingcharacteristicsof @rcduringred cell scintigra becauseof a largebodyhabitusandpossiblesplanchnicvasocon phy. Postmortem examination revealed angiodysplasia of the striction in response to blood loss. Activity in the gallbladder, gallbladderand othersitesinthe gastrOinteStinaltract.Mgiod noted within 60 mm of injection, intensified in a delayed image yspiasiamust be consideredin the pathologicspectrumof (Fig. 1). Intravenous injection of 1.5 @tgof cholecystokinin re causesof hemobilia sultedinpromptevacuationoftracer fromthegallbladder(Fig.2). At no timewas freepertechnetateseeninthestomach.Anultra KeyWords:hemobillaangiodysplaaia;gaStrOinteStinalhemor sonicexaminationof the hepatobiiaryregionexcludedcholeithi @age asis, a dilated bile duct and thickening of the gallbladder wall. J Nuci Mod 1994; 35:870-871 Endoscopicgastroduodenoscopyrevealedsmallerosionsbutno ulcersor blood.Colonoscopyto thececumrevealeddiverticulosis of the sigmoidregionandblood-tingedfluidbutno evidenceof activebleeding. By the second day, the hematocrithad dropped to 0.26, and cintigraphic techniques to identify gastrointestinal two units of packed red blood cells were transfused. There were hemorrhage are well documented. In particular, @Fc no clinicalor laboratoryfindingsof hemolysis.Signsof alcohol labeled red cell scintigraphy offers an advantage of delayed withdrawal and delirium tremens intervened. The patient became imaging (1,2). When the examination with labeled red cells hypotensivebut responsiveto pressortherapy.He hada fatal reveals radiotracer within the gallbladder, the pathologic cardiac arrest. causes of hemobilia must be considered as well as the Necropsyestablishedsevere coronaryatherosclerosiscompi possibility of altered biodistribution of @“@Tc.A case of cated by acute myocardialinfarctionas the cause of death. The early visualization of the gallbladderis described with the anatomic diagnosis of angiodysplasia involving the stomach, gall bladder,intestineandcecumwasmade.Thegastrointestinaltract attendantpathologic findingsof angiodysplasiaof the gall contained no evidence of recent active hemorrhage.Petechiae bladder and gastrointestinaltract. were present diffuselyin the gastricmucosaand in patchy distri butioninthegallbladder,duodenum,jejunum,ileum,cecumand CASE REPORT ascending colon. The liver was passively congested. No calculi A 78-yr-oldmanpresentedwithrectalbleeding.Therewas no were present in the biliarytract. The gallbladdercontaineddark historyof similarepisodes. On admission,his pulse rate was greenbile. Microscopyrevealedmultipleectaticbloodvessels in 122/mm,and his bloodpressurewas 160/90mmHg,with a nega the submucosaof the gallbladder(Fig. 3), stomachand small tive tilt test result. The abdomen was soft and nontender with intestine.In the cecum, transversecolonand sigmoidcolon, the normally active bowel sounds. Digital rectal examination yielded ectatic blood vessels in the lamina propria included arterioles and dark red blood. venules. Laboratoiy tests on admission yielded a hemoglobin level of 139 giliter, hematocrit of 0.428, normal erythrocyte indices, a whitebloodcellcountof 8.2 x 1O@/liter,prothrombintimeof 11.4 DISCUSSION sec, partialthromboplastintimeof 21.7see, thetotalbilirubinof Hemobilia is uncommon. It may result from hepatic 10.3@nnole/liter(O.6mi/di),bloodureanitrogenof 11.8pmole/liter trauma and vascular malformations of the hepatic vessels (33mg/cU)andcreatinineof 186 imole/liter (2.1mg/cU). (3,4). Hemobilia has been reported in papillaiy cystadeno A modifiedin vitro @Tc-labeledredbloodcell examination carcinoma of the bile ducts and in heterotopic stomach in the gallbladderneck (5,6). Visualization of the gallbladder ReceivedSept 20, 1993;revisionneceptadJan. 20, 1994. Forcorrespondenceorreprintscon@ EugeneD.Siverman,MD.DMsionof during @Fc-labeledred blood cell scintigraphy may result NuclearMedicine,NationalNavalMed@ Center,B@hesda,MD20889-5000. presumably from altered biodistribution of @Tc-labeled 870 TheJoumatofNudearMedicine•Vol.35•No.5•May1994 @ ‘ ;@@• @. A@ @ ‘P3. @,. @±j-@ &..,,. @ [email protected];( ..I@l- . .@• @ ;@t@ T@•' @ ,. ..::-@ @ . .1-el : @ @•RLAT ‘‘@-@. @ 270 ,@ y ‘. - FiGURE 1. Scintigramoftheabdomenusing @ro-lab&edau @9 ,• . tologouserythrocytesat 270 mmpostinjectionIn anteriorand ñght lateralprojectionsrevealincreasingactMtywithinthe galbiadder (GB)andkidneys(K).Largebodyhabitusandsplanchnicvasocon FiGURE 3. Postmortemphotomicrographof the gallbladder.Ar strictionareresponsibleforlackofdefinltlonofblood-poolstructures rowsindicatethreeofthemultipleectaticcapIIIadeSw@inthesub seenin the earlyimages. mucosaTheabsenceofepithelkimiscausedbyautolysis(hema toxylinandeosim,x200).Similarfindingsofanglodysplasiaoccurin stomach,smallIntestineandcecum. beta chains which, following hemolysis of redcells, appear as heme moieties in the gallbladder.Artifactualvisualiza tion in the gallbladderfouror more hours postinjectionhas been associated with renal insufficiency, previous transfu be added to the differential diagnosis of hemobilia and sion andanemia(7—10).Caslowitz et al. (11) suggested that should be considered in the unusual cases of gallbladder early (less than 1 hr postinjection) gallbladder visualization visualization during @‘9@c-labeledred cell scintigraphy. in two patients occurred as a result of @“@Tcbinding to plasma proteins, with shapes and net charges altered by ACKNOWLEDGMENTS intravenous contrast. The authorsthankM. Albahra,MD, andR. W. Lieberman, In the present case, gallbladdervisualization was seen MD, for detailedpostmortemexamination,dlinicopathologiccor early in a patient who had no predisposing factors to alter relationandpreparationof photomicrographs.Theopinionsand the biodistribution of the @9@c-labeledred blood cells. assertionscontainedhereinaretheprivateonesoftheauthorsand There was no evidence of renal failure or hemolysis or a are not to be construed as officialpolicy or reflecting the views of historyof a contrastload. No other factorspreviously theDepartmentof theNavyortheDepartmentof Defense. associated with hemobilia were present: trauma, vascular malformation, heterotopic gastric mucosa or tumor. A REFERENCES postmortem examination revealed petechiae in the stom 1. VoellerOR,BunchG,BrittLO.Useof technetium-inbelledredcellscm ach, small bowel and gallbladder,which microscopically tigraphyin the detectionand managementof gastrointestinalhemorrhage. Swgery 1991;11lh799-804. showed submucosal groupings of ectatic vessels of capil 2. AlaviA. Scintigraphicdetection andlocalization in gastrointestinal bleeding laiy, arteriolar and venular size consistent with angiodys sites. h@GottschalkA, HofferPB, PotchenEJ, eds., Dia@jzosticnuclear plasia. Angiodysplasia affectingthe gallbladderwall should medicine, 2nd edition. Baltimore: Williams and Wilkins; 1988:631-662. 3. VlahosL, KalovidourisA, GouliamosA, KailidouE. Post-traumatiche mobilia.EurIRadiol 1991;13:199-202. 4. StaufferJT,WeinmanMD,BynumTE.Hemobiliainapatientwithmultiple hepaticartery aneurysms:a case report and reviewof the literature.AmI Gastmenteml 1989;84:59—62. 5. AlapatiRA,IbrahimMAN,D'AngeloDM,Ctal.Papillarycystadenocarci. nomaof the bileducts resultingin hemobilia.AmI Gasimenterol1989;84: Ga 1564-1566. 6. AdamPA,FabianiB, BismuthH.Hematobiliaresultingfromheterotopic stomachin the gallbladderneck. Suigeiy 1989;105:564-569. 7. WoodMi, HenniganDB. Radionuclidetaggedredbloodcells in thegall bladder.can NUCIMed1984;9:289—290. 8. BrillDR. Gallbladdervisualizationduringtechnetium-99m-labeledred blood cell scintigraphy for gastrointestinal bleeding. I Nuci Med 1985;26: 3 7 1408—1411. 9. KOtIyarcWEV,MattayVS,RebaRC.Gallbladdervisualizationduringtech CCK netium-99mbloodpool imaging.ClinNuciMed 1988;13:515-516. 10.AbelloR,Haynie1?, KimEE.Pitfallsofa @Fc-RBCbleedingstudydue FIGURE 2. Scintigramsusing @‘Tc-labeIedautologouserythro-. to gallbladderand ilealloopvisualization.GasimintestRadiol 1991;16:32- cytesat3and7mmpostinjectionof1.5 @gofcholecystoldnin(cCK@ 34. intravenou&yIndicatepromptevacuationof radbtracerfromthe 11.CaslowitzP, AchongDM.EarlygallbladdervisualizationduringIc-99m gallbladder(GB). RBCSCintigraphy.ClinNuclMed1992;17:364-365. HemObIIIaComplicatingMgiodysplasias •Yudt et at. 871.
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