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. 1996 Jul;224(1):29–36. doi: 10.1097/00000658-199607000-00005

Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy.

M S Suzman 1, M Talmor 1, R Jennis 1, B Binkert 1, P S Barie 1
PMCID: PMC1235243  PMID: 8678614

Abstract

OBJECTIVE. There is disagreement over the reliability of technetium Tc 99m (99mTc)-labeled erythrocyte scintigraphy in the localization of active lower gastrointestinal hemorrhage. A previous study at The New York Hospital-Cornell Medical Center that showed a superior sensitivity for localization of scintigraphy versus angiography in surgical patients led the authors to emphasize scintigraphy as the diagnostic test of first choice in the clinical diagnostic algorithm. The authors hypothesized that tagged erythrocyte scintigraphy can be used accurately as the primary diagnostic modality in localizing acute bleeding and guiding surgical intervention. METHODS. The authors conducted a 5-year, retrospective analysis of 224 inpatients who underwent scintigraphic imaging for diagnosis and localization of active lower gastrointestinal bleeding. Using scintigraphy as the primary diagnostic test, with colonoscopy, upper endoscopy, and angiography as adjunctive studies, 99mTc-labeled erythrocyte scans were performed at the clinician's discretion and were reviewed again for study purposes by two nuclear radiologists who were blinded to clinical outcome. Adjunctive diagnostic tests also were ordered for clinical indications. RESULTS. Using delayed periodic scintigraphic imaging, results of 115 scans (51.3%) demonstrated bleeding, with 96 scans (42.9%) localizing to a specific anatomic site. Patients with positive scans were five times more likely to require surgery (p < 0.005) than patients with negative scans, and surgical patients were twice as likely to localize by scintigraphy (p < 0.0001). Fifty patients (22.3%) required surgical intervention to control hemorrhage and had a bleeding site confirmed by both clinical and pathologic examinations. Forty-eight of those patients (96%) had a bleeding site determined preoperatively. For 37 patients with bleeding sites localized preoperatively by scintigraphy, 36 (97.3%) had correct localization based on surgical pathology. Only one patient required a subtotal colectomy solely because of nonlocalized bleeding. No patient bled postoperatively, and there was no mortality in either operated or nonoperated patients. The mean volume of transfused erythrocytes was similar in both scan-localized and nonlocalized surgical patients. CONCLUSION. When performed correctly and interpreted conservatively, scintigraphy is a useful and safe means of guiding segmental resection, and should be the primary tool used in the diagnosis of patients with active lower gastrointestinal bleeding.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Alavi A., Ring E. J. Localization of gastrointestinal bleeding: superiority of 99mTc sulfur colloid compared with angiography. AJR Am J Roentgenol. 1981 Oct;137(4):741–748. doi: 10.2214/ajr.137.4.741. [DOI] [PubMed] [Google Scholar]
  2. Bearn P., Persad R., Wilson N., Flanagan J., Williams T. 99mTechnetium-labelled red blood cell scintigraphy as an alternative to angiography in the investigation of gastrointestinal bleeding: clinical experience in a district general hospital. Ann R Coll Surg Engl. 1992 May;74(3):192–199. [PMC free article] [PubMed] [Google Scholar]
  3. Bentley D. E., Richardson J. D. The role of tagged red blood cell imaging in the localization of gastrointestinal bleeding. Arch Surg. 1991 Jul;126(7):821–824. doi: 10.1001/archsurg.1991.01410310031003. [DOI] [PubMed] [Google Scholar]
  4. Bentley D. E., Richardson J. D. The role of tagged red blood cell imaging in the localization of gastrointestinal bleeding. Arch Surg. 1991 Jul;126(7):821–824. doi: 10.1001/archsurg.1991.01410310031003. [DOI] [PubMed] [Google Scholar]
  5. Britt L. G., Warren L., Moore O. F., 3rd Selective management of lower gastrointestinal bleeding. Am Surg. 1983 Mar;49(3):121–125. [PubMed] [Google Scholar]
  6. Browder W., Cerise E. J., Litwin M. S. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg. 1986 Nov;204(5):530–536. doi: 10.1097/00000658-198611000-00004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Cussons P. D., Berry A. R. Comparison of the value of emergency mesenteric angiography and intraoperative colonoscopy with antegrade colonic irrigation in massive rectal haemorrhage. J R Coll Surg Edinb. 1989 Apr;34(2):91–93. [PubMed] [Google Scholar]
  8. Dusold R., Burke K., Carpentier W., Dyck W. P. The accuracy of technetium-99m-labeled red cell scintigraphy in localizing gastrointestinal bleeding. Am J Gastroenterol. 1994 Mar;89(3):345–348. [PubMed] [Google Scholar]
  9. Friedman H. I., Hilts S. V., Whitney P. J. Use of technetium-labeled autologous red blood cells in detection of gastrointestinal bleeding. Surg Gynecol Obstet. 1983 Apr;156(4):449–452. [PubMed] [Google Scholar]
  10. Gupta S., Luna E., Kingsley S., Prince M., Herrera N. Detection of gastrointestinal bleeding by radionuclide scintigraphy. Am J Gastroenterol. 1984 Jan;79(1):26–31. [PubMed] [Google Scholar]
  11. Hunter J. M., Pezim M. E. Limited value of technetium 99m-labeled red cell scintigraphy in localization of lower gastrointestinal bleeding. Am J Surg. 1990 May;159(5):504–506. doi: 10.1016/s0002-9610(05)81256-5. [DOI] [PubMed] [Google Scholar]
  12. Jacobson A. F., Cerqueira M. D. Prognostic significance of late imaging results in technetium-99m-labeled red blood cell gastrointestinal bleeding studies with early negative images. J Nucl Med. 1992 Feb;33(2):202–207. [PubMed] [Google Scholar]
  13. Jensen D. M. Current management of severe lower gastrointestinal bleeding. Gastrointest Endosc. 1995 Feb;41(2):171–173. doi: 10.1016/s0016-5107(05)80606-6. [DOI] [PubMed] [Google Scholar]
  14. Jensen D. M., Machicado G. A. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology. 1988 Dec;95(6):1569–1574. doi: 10.1016/s0016-5085(88)80079-9. [DOI] [PubMed] [Google Scholar]
  15. Kester R. R., Welch J. P., Sziklas J. P. The 99mTc-labeled RBC scan. A diagnostic method for lower gastrointestinal bleeding. Dis Colon Rectum. 1984 Jan;27(1):47–52. doi: 10.1007/BF02554077. [DOI] [PubMed] [Google Scholar]
  16. Leitman I. M., Paull D. E., Shires G. T., 3rd Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg. 1989 Feb;209(2):175–180. doi: 10.1097/00000658-198902000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Markisz J. A., Front D., Royal H. D., Sacks B., Parker J. A., Kolodny G. M. An evaluation of 99mTc-labeled red blood cell scintigraphy for the detection and localization of gastrointestinal bleeding sites. Gastroenterology. 1982 Aug;83(2):394–398. [PubMed] [Google Scholar]
  18. McKusick K. A., Froelich J., Callahan R. J., Winzelberg G. G., Strauss H. W. 99mTc red blood cells for detection of gastrointestinal bleeding: experience with 80 patients. AJR Am J Roentgenol. 1981 Dec;137(6):1113–1118. doi: 10.2214/ajr.137.6.1113. [DOI] [PubMed] [Google Scholar]
  19. Nath R. L., Sequeira J. C., Weitzman A. F., Birkett D. H., Williams L. F., Jr Lower gastrointestinal bleeding. Diagnostic approach and management conclusions. Am J Surg. 1981 Apr;141(4):478–481. doi: 10.1016/0002-9610(81)90143-4. [DOI] [PubMed] [Google Scholar]
  20. Nicholson M. L., Neoptolemos J. P., Sharp J. F., Watkin E. M., Fossard D. P. Localization of lower gastrointestinal bleeding using in vivo technetium-99m-labelled red blood cell scintigraphy. Br J Surg. 1989 Apr;76(4):358–361. doi: 10.1002/bjs.1800760415. [DOI] [PubMed] [Google Scholar]
  21. Ohri S. K., Desa L. A., Lee H., Patel T., Jackson J., Lavender J. P., Spencer J. Value of scintigraphic localization of obscure gastrointestinal bleeding. J R Coll Surg Edinb. 1992 Oct;37(5):328–332. [PubMed] [Google Scholar]
  22. Orecchia P. M., Hensley E. K., McDonald P. T., Lull R. J. Localization of lower gastrointestinal hemorrhage. Experience with red blood cells labeled in vitro with technetium Tc 99m. Arch Surg. 1985 May;120(5):621–624. doi: 10.1001/archsurg.1985.01390290095016. [DOI] [PubMed] [Google Scholar]
  23. Ryan P., Styles C. B., Chmiel R. Identification of the site of severe colon bleeding by technetium-labeled red-cell scan. Dis Colon Rectum. 1992 Mar;35(3):219–222. doi: 10.1007/BF02051010. [DOI] [PubMed] [Google Scholar]
  24. Schrock T. R. Colonoscopic diagnosis and treatment of lower gastrointestinal bleeding. Surg Clin North Am. 1989 Dec;69(6):1309–1325. doi: 10.1016/s0039-6109(16)44990-x. [DOI] [PubMed] [Google Scholar]
  25. Setya V., Singer J. A., Minken S. L. Subtotal colectomy as a last resort for unrelenting, unlocalized, lower gastrointestinal hemorrhage: experience with 12 cases. Am Surg. 1992 May;58(5):295–299. [PubMed] [Google Scholar]
  26. Smith R., Copely D. J., Bolen F. H. 99mTc RBC scintigraphy: correlation of gastrointestinal bleeding rates with scintigraphic findings. AJR Am J Roentgenol. 1987 May;148(5):869–874. doi: 10.2214/ajr.148.5.869. [DOI] [PubMed] [Google Scholar]
  27. Szasz I. J., Morrison R. T., Lyster D. M. Technetium-99m-labelled red blood cell scanning to diagnose occult gastrointestinal bleeding. Can J Surg. 1985 Nov;28(6):512–514. [PubMed] [Google Scholar]
  28. Tada M., Shimizu S., Kawai K. Emergency colonoscopy for the diagnosis of lower intestinal bleeding. Gastroenterol Jpn. 1991 Jul;26 (Suppl 3):121–124. doi: 10.1007/BF02779279. [DOI] [PubMed] [Google Scholar]
  29. Udén P., Jiborn H., Jonsson K. Influence of selective mesenteric arteriography on the outcome of emergency surgery for massive, lower gastrointestinal hemorrhage. A 15-year experience. Dis Colon Rectum. 1986 Sep;29(9):561–566. doi: 10.1007/BF02554254. [DOI] [PubMed] [Google Scholar]
  30. Van Geelen J. A., De Graaf E. M., Bronsveld W., Boer R. O. Clinical value of labeled red blood cell scintigraphy in patients with difficult to diagnose gastrointestinal bleeding. Clin Nucl Med. 1994 Nov;19(11):949–952. doi: 10.1097/00003072-199411000-00002. [DOI] [PubMed] [Google Scholar]
  31. Voeller G. R., Bunch G., Britt L. G. Use of technetium-labeled red blood cell scintigraphy in the detection and management of gastrointestinal hemorrhage. Surgery. 1991 Oct;110(4):799–804. [PubMed] [Google Scholar]
  32. Wagner H. E., Stain S. C., Gilg M., Gertsch P. Systematic assessment of massive bleeding of the lower part of the gastrointestinal tract. Surg Gynecol Obstet. 1992 Nov;175(5):445–449. [PubMed] [Google Scholar]
  33. Wang C. S., Tzen K. Y., Huang M. J., Wang J. Y., Chen M. F. Localization of obscure gastrointestinal bleeding by technetium 99m-labeled red blood cell scintigraphy. J Formos Med Assoc. 1992 Jan;91(1):63–68. [PubMed] [Google Scholar]
  34. Wang C. Y., Won C. W., Shieh M. J. Aggressive colonoscopic approaches to lower intestinal bleeding. Gastroenterol Jpn. 1991 Jul;26 (Suppl 3):125–128. doi: 10.1007/BF02779280. [DOI] [PubMed] [Google Scholar]
  35. Winzelberg G. G., McKusick K. A., Froelich J. W., Callahan R. J., Strauss H. W. Detection of gastrointestinal bleeding with 99mTc-labeled red blood cells. Semin Nucl Med. 1982 Apr;12(2):139–146. doi: 10.1016/s0001-2998(82)80005-6. [DOI] [PubMed] [Google Scholar]
  36. Wright H. K., Pelliccia O., Higgins E. F., Jr, Sreenivas V., Gupta A. Controlled, semielective, segmental resection for massive colonic hemorrhage. Am J Surg. 1980 Apr;139(4):535–538. doi: 10.1016/0002-9610(80)90333-5. [DOI] [PubMed] [Google Scholar]
  37. Zuckerman D. A., Bocchini T. P., Birnbaum E. H. Massive hemorrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention. AJR Am J Roentgenol. 1993 Oct;161(4):703–711. doi: 10.2214/ajr.161.4.8372742. [DOI] [PubMed] [Google Scholar]

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