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   Table of Contents      
CASE REPORT
Year : 2019  |  Volume : 18  |  Issue : 3  |  Page : 310-313

Unusual presentation of jejunal hemangioma on Tc-99m pertechnetate scan with single-photon emission computerized tomography-computed tomography


1 Department of Nuclear Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2 Department of Pediatric Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
3 Department of Pediatrics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Date of Submission18-Feb-2019
Date of Acceptance01-Mar-2019
Date of Web Publication9-Aug-2019

Correspondence Address:
Mudalsha Ravina
Department of Nuclear Medicine, C1 Block, Lower Ground Floor, AIIMS Raipur, GE Road, Tatibandh, Raipur, Chhattisgarh
India
Nitinkumar Borkar
Department of Pediatric Surgery, B1 Block, First Floor, AIIMS Raipur, GE Road, Tatibandh, Raipur, Chhattisgarh
India
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DOI: 10.4103/wjnm.WJNM_13_19

PMID: 31516379

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   Abstract 


Small bowel hemangioma is a rare benign tumor in the pediatric population. The usual presentation of these tumors is melena, anemia, or hematochezia. Our case demonstrates the usefulness of Meckel's/Tc-99m pertechnetate scan with single-photon emission computerized tomography/computerized tomography in diagnosing a vascular lesion in the small bowel in a child presenting with melena, unresponsive to medical management. We present a case of incidentally detected jejunal hemangioma during Tc-99m pertechnetate scintigraphy which would help the nuclear medicine physician and surgeon, to be cognizant of this atypical presentation in their clinical practice.

Keywords: Hemangioma, jejunum, laparotomy, Meckel's scan, small bowel, Tc-99m pertechnetate


How to cite this article:
Peepre K, Borkar N, Jondhale SN, Ravina M, Moideen A, Yadav V, Dey S. Unusual presentation of jejunal hemangioma on Tc-99m pertechnetate scan with single-photon emission computerized tomography-computed tomography. World J Nucl Med 2019;18:310-3

How to cite this URL:
Peepre K, Borkar N, Jondhale SN, Ravina M, Moideen A, Yadav V, Dey S. Unusual presentation of jejunal hemangioma on Tc-99m pertechnetate scan with single-photon emission computerized tomography-computed tomography. World J Nucl Med [serial online] 2019 [cited 2019 Dec 10];18:310-3. Available from: http://www.wjnm.org/text.asp?2019/18/3/310/264151




   Introduction Top


Gastrointestinal (GI) hemangioma is a rare benign tumor accounting for approximately 5% of all GI neoplasms.[1],[2] Moreover, they are rarely found and suspected in the pediatric population, presenting with melena. The major symptom of small bowel hemangioma is overt GI bleeding.[1],[2],[3] Clinical experience in detection and diagnosis of ectopic gastric mucosa and few other congenital anomalies by Tc-99m pertechnetate scintigraphy is well known. However, there are certainly false positives which may be incidentally detected on Meckel's study, for example, vascular anomalies such as hypervascular tumors, arteriovenous malformation, hemangioma, bowel ulcerations, Crohn's disease, ulcerative colitis, appendicitis, intestinal obstruction, intussusception, and volvulus. These false-positive results are thought to be due to hyperemia caused by these conditions.[4],[5],[6] Timely, accurate diagnosis and treatment of aforementioned lesions are critical to the successful outcome. Herein, we describe a rare case of pediatric jejunal hemangioma with anemia and melena, wherein the functional nature of Tc-99m pertechnetate scan with single-photon emission computerized tomography/computerized tomography (SPECT-CT) raised suspicion of the presence of highly vascular lesion.


   Case Report Top


A 9-year-old male child born to a nonconsanguineous marriage couple was diagnosed to be severely anemic during evaluation for diarrhea at 8 months of age, needing blood transfusion. At around 1 year of age, the parents noted blackish discoloration of stools. Similar episodes of blood in stools were noted at 2 years and again at 5 years of age. He underwent multiple blood transfusions for severe anemia. The general physician could not clinch the diagnosis. During evaluation, ultrasonogram of the abdomen, barium meal follow through, and Meckel's scan without SPECT-CT were done and interpreted as normal. He was asked by the family doctor to continue on iron supplements.

However, the patient now presented to the pediatric department of our tertiary care center with generalized swelling, intermittent abdominal pain, fatigue, and exertional dyspnea. Diagnosed as a severe anemia (hemoglobin [Hb]: 3.3 gm%), 250 ml of packed red blood cells was transfused in view of low Hb. A provisional diagnosis of Meckel's diverticulum with bleeding per rectum was made, and the patient was referred to the nuclear medicine department for Tc-99m pertechnetate scintigraphy. Tc-99m pertechnetate was injected 45 min after transfusion of intravenous ranitidine at the dose of 1 mg/kg body weight for 20 min. Dynamic [Figure 1] Tc-99m pertechnetate scintigraphy depicted tracer accumulation in the right hypochondrium, and static [Figure 2] images revealed gradual accumulation of tracer in the left hypochondrium and lumbar region. It was a changing position which was suggestive of its small bowel origin. SPECT with low-dose CT [Figure 3] localized the tracer focus in jejunal loops. The activity seen in the dynamic images was confirmed to be in the duodenum. Based on planar and SPECT-CT findings, we suggested a possible vascular lesion in the small bowel.
Figure 1: (a) Tc-99m pertechnetate scintigraphy was performed. Serial images (1 min/frame for 60 frames) depicted tracer accumulation in the right hypochondrium (multiple arrows) along with tracer uptake in the stomach. (b) Tim–activity curve (a) of the stomach (pink curve) depicts a rising curve. Time–activity curve of the lesion in the left hypochondrium and lumbar region (green curve) shows a flat curve as the activity gradually increased in intensity in delayed images only

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Figure 2: Delayed static images (anterior views) taken at different time intervals 1 h (top left), 1 h 15 min (top right), 2 h (lower left), and 2 h 30 min (lower right) confirm the early findings. In addition, mild tracer uptake is noted in the left hypochondrium and lumbar region which gradually increased in intensity (multiple arrows). The activity described in dynamic images in the right hypochondrium merged with stomach activity suggestive of its duodenal origin

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Figure 3: Single-photon emission computerized tomography/computerized tomography (b and d) fused with low-dose noncontrast computerized tomography (a and c) localized the tracer focus in jejunal loops (multiple arrows)

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Based on the findings, the child was taken up for diagnostic laparoscopy. Telescope was inserted through 5-mm primary port. Diagnostic laparoscopy revealed around 12–15-cm long hemangioma involving the distal jejunum [Figure 4]. There was no Meckel's diverticulum. Resection of involved segment of bowel and end-to-end anastomosis of the involved segment was done by minilaparotomy. The lesion was actively bleeding and invaded the wall of the small bowel. The histopathology report reaffirmed our clinical diagnosis of hemangioma. On 2-week follow-up, the Hb levels and stools were normal.
Figure 4: Operative specimen shows 12–15-cm long hemangioma involving the distal jejunum

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In this case report, the authors wish to highlight the interestingly discovered rare pediatric jejunal hemangioma on Tc-99m pertechnetate scan, suggesting a potential diagnostic role.[7]

Pediatric patients rarely present with melena and anemia, due to intestinal hemangioma. We wish to highlight that hemangioma may be considered as a differential diagnosis in pediatric patients when we have ruled out the common causes, and the patient is not responding to medical management. Hemangiomas usually have a syndromic association, however this was not seen in our case.

The routine investigations in diagnostic armamentarium of GI hemangioma rely on scintigraphy, computed tomography, magnetic resonance imaging, angiography, and abdominal ultrasonography. These tools are accurate regardless of the patient's age or presentation. Depending on the location and features of the lesion, esophagogastroduodenoscopy or colonoscopy can be used to isolate a GI hemangioma.[8] However, in our case, as the scintigraphy findings were positive, the pediatric surgeon without much ado went ahead with diagnostic laparoscopy and further laparoscopic-assisted resection.[9]

As noted in the present case, it needs to be highlighted that the timing of appearance of activity and delayed static images may help Nuclear medicine physicians differentiate between false-positive causes from Meckel's diverticulum. It is a well-known fact that Technetium accumulates in areas of increased perfusion or hyperemia. To our understanding, this is the best possible explanation of the appearance of activity in a jejunal hemangioma in our case.

To the best of our knowledge, this is a tenth case report of intestinal hemangioma in the pediatric population.[10],[11],[12],[13],[14],[15],[16]


   Conclusion Top


In our case, we conclude that Tc-99m pertechnetate scan with an added advantage of SPECT-CT raised suspicion for a highly vascular lesion in the small bowel. Visceral vascular anomalies have always posed a diagnostic challenge in the pediatric population. In the presence of repeated anemia and melena, it is recommended to consider this vascular anomaly in the differential diagnosis when other routine causes are ruled out.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Magnano A, Privitera A, Calogero G, Nanfito' L, Basile G, Sanfilippo G, et al. Solitary hemangioma of the small intestine: An unusual cause of bleeding diagnosed at capsule endoscopy. J Pediatr Surg 2005;40:e25-7.  Back to cited text no. 1
    
2.
Huber A, Abdel Samie A, Kychenko D, Theilmann L. A rare cause of recurrent iron-deficiency anemia: Cavernous hemangioma of the small intestine. J Gastrointestin Liver Dis 2012;21:343.  Back to cited text no. 2
    
3.
Morgan DR, Mylankal K, el Barghouti N, Dixon MF. Small bowel haemangioma with local lymph node involvement presenting as intussusception. J Clin Pathol 2000;53:552-3.  Back to cited text no. 3
    
4.
Khan NA, Chandramohan M, McDonald S. Meckeldivertculum. Radiol Pediatr 2008;110:205-10.  Back to cited text no. 4
    
5.
Martin JP, Connor PD, Charles K. Meckel's diverticulum. Am Fam Physician 2000;61:1037-42, 1044.  Back to cited text no. 5
    
6.
Rosenthall L, Henry JN, Murphy DA, Freeman LM. Radiopertechnetate imaging of the Meckel's diverticulum. Radiology 1972;105:371-3.  Back to cited text no. 6
    
7.
Papparella A, Nino F, Noviello C, Marte A, Parmeggiani P, Martino A, et al. Laparoscopic approach to Meckel's diverticulum. World J Gastroenterol 2014;20:8173-8.  Back to cited text no. 7
    
8.
Park JH. Role of colonoscopy in the diagnosis and treatment of pediatric lower gastrointestinal disorders. Korean J Pediatr 2010;53:824-9.  Back to cited text no. 8
    
9.
Jones AE, Ainsworth BH, Desai A, Tsang TT. Small bowel hemangioma diagnosed with laparoscopy: Report of two pediatric cases. J Minim Access Surg 2007;3:29-31.  Back to cited text no. 9
    
10.
Bae SJ, Hwang G, Kang HS, Song HJ, Chang WY, Maeng YH, et al. Single cavernous hemangioma of the small bowel diagnosed by using capsule endoscopy in a child with chronic iron-deficiency anemia. Clin Endosc 2015;48:340-4.  Back to cited text no. 10
    
11.
Sakaguchi M, Sue K, Etoh G, Takagishi T, Ezaki T, Nakamura M, et al. A case of solitary cavernous hemangioma of the small intestine with recurrent clinical anemic attacks in childhood. J Pediatr Gastroenterol Nutr 1998;27:342-3.  Back to cited text no. 11
    
12.
Turcotte JF, Prasil P, Gagnon P, Castilloux J. Case 1: Recurrent iron-deficiency anemia in a teenager. Paediatr Child Health 2012;17:21-2.  Back to cited text no. 12
    
13.
Kavin H, Berman J, Martin TL, Feldman A, Forsey-Koukol K. Successful wireless capsule endoscopy for a 2.5-year-old child: Obscure gastrointestinal bleeding from mixed, juvenile, capillary hemangioma-angiomatosis of the jejunum. Pediatrics 2006;117:539-43.  Back to cited text no. 13
    
14.
Stojsic Z, Brasanac D, Kokai G, Vujovic D, Zivanovic D, Boricic I, et al. Intestinal intussusception due to a pyogenic granuloma. Turk J Pediatr 2008;50:600-3.  Back to cited text no. 14
    
15.
Han EC, Kim SH, Kim HY, Jung SE, Park KW. Gastrointestinal hemangioma in childhood: A rare cause of gastrointestinal bleeding. Korean J Pediatr 2014;57:245-9.  Back to cited text no. 15
    
16.
Coleman J, Phillips R, Steiner R. Small bowel hemangioma in a 2-year-old female with recurrent anemia. Ochsner J 2018;18:428-32.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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