Presentation
Recurrent gastrointestinal bleeding. Negative endoscopy. Blood seen coming through the ileocecal valve on colonoscopy.
Patient Data
Sequential anterior images from a 99mTc-pertechnetate (TCO4-). On initial images there is a faint focus of radiotracer in the lower midline abdomen which is static and increases in intensity over time.
This appears at the same time as is the physiologic stomach activity (partially visible in the left upper quadrant). The stomach activity subsequently passes into the duodenum at 55-minutes.
Faint physiologic is seen initially in the renal pelves and then later in the bladder.
Delayed images show a tubular configuration of the radiotracer activity in the Meckel diverticula on the anterior view (middle) and confirms its anterior location on lateral view (right).
Case Discussion
99mTc-pertechnetate (TCO4-) scintigraphy (also known as a Meckel scan) is a helpful diagnostic tool for evaluating patients with a suspected Meckel diverticulum, providing excellent sensitivity and specificity for its detection.
The mucoid cells of gastric mucosa accumulate and subsequently secrete chloride into the lumen. 99mTc-pertechnetate follows this same pathway and hence will localize to and be secreted by the normal stomach lining as well as any ectopic gastric mucosa such as may be found in a Meckel diverticulum.
On a normal exam, intense accumulation of radioactivity is seen in the stomach during the initial 10-15 minutes. This may subsequently pass into the duodenum and jejunum. Additionally, since a portion of the injected pertechnetate is normally excreted into the urine, less intense activity will be present in the kidneys and ureters with intense accumulation in the bladder.
Meckel diverticula are usually located in the right lower quadrant, but can occur elsewhere. When present, the diverticulum presents as a small round or ovoid focus of activity that appears at the same time as the stomach and increases in intensity with the stomach.
Lateral views should be obtained to confirm the anterior location, as seen with a Meckel diverticulum, and separate it from posterior structures like the kidney/renal pelvis or duodenum.
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