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British Journal of Radiology (2005) 78, 714-720
© 2005 British Institute of Radiology
doi: 10.1259/bjr/16678420
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Diagnosis of ectopic gastric mucosa using 99Tcm-pertechnetate: spectrum of scintigraphic findings

R Kumar, DRM, DNB, M Tripathi, MD, DNB, N Chandrashekar, MD, S Agarwala, MS, MCh, A Kumar, MS, J B Dasan, MD and A Malhotra, DRM, PhD

Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Correspondence: Dr Rakesh Kumar, F-74, Ansari Nagar (West), AIIMS Campus, New Delhi- 110029, India


   Abstract
Top
 Abstract
Introduction
 Materials and methods
 Results
 Discussion
 References
 
We highlight the spectrum of scintigraphic findings likely to be encountered in patients with ectopic gastric mucosa with illustrative cases for each such finding. 11 children (aged 4 months to 120 months, all males) underwent 99Tcm-pertechnetate scintigraphic evaluation for ectopic gastric mucosa. Functioning ectopic gastric mucosa was detected in Meckel's diverticulae in three patients, in small bowel duplications in four, in a gastric duplication in one, and in intrathoracic foregut duplication cysts in three. Ectopic functioning gastric mucosa in Meckel's diverticulum, and gastric duplication is visualized simultaneously with the stomach while in intestinal duplications tracer activity can be visualized in the dynamic sequence and even before gastric tracer visualization. In the three patients with intrathoracic duplication cysts, the functioning ectopic gastric mucosa was evident only in the delayed 99Tcm-pertechnetate images, much later than the visualization of stomach activity. Therefore, acquisition of delayed images are useful when the initial images are equivocal or negative in children with intrathoracic foregut duplication cysts. In addition, we suggest a hypothesis of a possible mechanism for the uptake of pertechnetate in ectopic gastric mucosa in some patients with intrathoracic forget duplication cysts. In conclusion, a variety of scintigraphic patterns may be found in patients with ectopic gastric mucosa undergoing 99Tcm-pertechnetate scintigraphy depending upon the location and size of the ectopic tissue.


   Introduction
Top
 Abstract
 Introduction
Materials and methods
 Results
 Discussion
 References
 
The utility of 99Tcm-pertechnetate scintigraphy in the diagnosis of ectopic gastric mucosa is well established, particularly in the case of Meckel's diverticulum [1, 2]. However, there is substantial variation in the reported sensitivity of 99Tcm-pertechnetate scintigraphy for the diagnosis of ectopic gastric mucosa other than Meckel's diverticulum [1, 3–5]. The sensitivity of 99Tcm-pertechnetate scintigraphy for the diagnosis of ectopic gastric mucosa has been reported to be 91% by Sfakianakis and Hasse [3] and 85% by Sfakianakis and Conway [1] from their analysis of a large number of studies. However, Rosenthal et al reported a 50% incidence of false negatives in their study [4]. Likewise Dixon et al and Schwarz et al [5, 6] also reported a lower sensitivity from their analysis of 99Tcm-pertechnetate scintigraphy in surgically proven cases with ectopic gastric mucosa. None of these authors used delayed imaging. In this paper we highlight the spectrum of scintigraphic findings likely to be encountered in patients with ectopic gastric mucosa with illustrative cases for each such finding. In addition, we discuss the utility of delayed imaging for the diagnosis of ectopic gastric mucosa in patients with intrathoracic foregut duplication cysts. We also discuss the possible mechanism, which may underlie the need for delayed imaging.


   Materials and methods
Top
 Abstract
 Introduction
 Materials and methods
Results
 Discussion
 References
 
11 children (aged 4 months to 120 months, all males) recruited over a period of 10 years (1993–2003), underwent scintigraphic evaluation for ectopic gastric mucosa. Two children (case 1 and case 2) were being evaluated for complaints of blood streaked stools for the past 4 and 6 months, respectively. Case 3 was admitted to casualty with fresh bleeding per rectum. Cases 4–7 were referred for recurrent episodes of haematochesia. Colonoscopy in all the above cases failed to localize the bleeding site. Case 8 was referred with an abdominal mass and melaena. Case 9 was referred following complaints of repeated chest infections and crying due to suspected abdominal pain, CT of the chest revealed a left intrathoracic cyst. Case 10 was referred with complaints of recurrent respiratory tract infections and dysphagia a CT scan revealed a left intrathoracic cyst in this child as well. Case 11 was referred with complaints of recurrent chest infections and pain in the right side of chest. A chest radiograph and CT scan revealed an intrathoracic right sided mass. Cases 9–11 had been referred for exclusion of duplication with ectopic gastric mucosa. As per institutional protocol all children with thoracic cysts undergo scintigraphy to rule out ectopic gastric mucosa. A positive scan will rule out the differential diagnosis of hydatid cyst and hence, Albendazole treatment before surgery. Cases 1, 2 and 8–11 were referred from paediatric surgery outpatients whereas Cases 3–7 were seen in casualty.

All the children underwent scintigraphic evaluation for ectopic gastric mucosa with 99Tcm-pertechnetate. The children were positioned supine and imaging was started with the camera positioned anteriorly, using a low energy all-purpose collimator. Energy level was set at 140 keV photopeak with a ±10% window. 99Tcm-pertechnetate was administered in a dose of 0.1 mCi kg–1 (3.7 MBq kg–1), up to a maximum of 5 mCi (185 MBq) intravenously. Initial radionuclide angiograms (flow phase images) were acquired for the first minute post injection in a 64 x 64 matrix with 30 frames of 2 s each. Subsequently static images were obtained in 256 x 256 matrix, for duration of 1 min each every 5 min for 60 min. In the three cases with intrathoracic duplication cyst, delayed images were obtained at 6 h and 24 h post injection if there was no evidence of abnormal tracer localization 1 h post injection. No pharmacological intervention with pentagastrin, histamine or glucagon was performed in any of the 11 cases.

The diagnosis of ectopic gastric mucosa on 99Tcm-pertechnetate scintigraphy was based on the appearance of radiotracer activity at an ectopic location, simultaneous to the appearance of gastric activity and which increased in intensity with the passage of time. The final diagnosis of ectopic gastric mucosa in all cases was confirmed on operative finding and subsequent histology.


   Results
Top
 Abstract
 Introduction
 Materials and methods
 Results
Discussion
 References
 
Table 1Go, shows the scintigraphic findings, their relation to the appearance of radioisotope in the stomach and the final diagnosis in all cases. In Case 1, scintigraphy revealed abnormal tracer uptake over a focal area in the hypogastrium, which was seen in the early and delayed anterior views (Figure 1a,bGo). Case 2 showed a focus of abnormal tracer accumulation just to the right of the midline. The uptake in Case 1 and Case 2 appeared at the same time as normal gastric uptake, and increased in intensity with the passage of time. Based on these findings, a diagnosis of Meckel's diverticulum with ectopic gastric mucosa was made in both cases. Scintigraphy in Case 3 revealed a focal area of abnormal tracer accumulation in the right lower quadrant very close to the midline, which appeared simultaneous with gastric visualization (Figure 2a–cGo). Ectopic functioning gastric mucosa in a Meckel's diverticulum was diagnosed scintigraphically and since the patient was admitted to an emergency ward, the decision to perform immediate surgery was taken. A remnant of the omphalomesentric duct still connected to the umbilicus was resected (Figure 2dGo). In Case 4, a large abnormal area of tracer uptake was noted in the lower abdominal region, which appeared at the same time as the gastric mucosa and increased in intensity with the passage of time (Figure 3Go). A linear area of abnormal 99Tcm-pertechnetate uptake was noted in the infraumbilical area along the midline in Case 5 (Figure 4a,bGo). A diagnosis of ectopic gastric mucosa in intestinal duplication was made in both cases. Dynamic images showed a blush of tracer activity in the lower abdomen in Cases 6 and 7 much before the visualization of tracer activity in the stomach (Figure 5aGo). Subsequent static images revealed intense tracer accumulation in the lower abdomen equal in intensity to gastric uptake (Figure 5b,cGo). Intestinal duplication with ectopic functioning gastric mucosa was diagnosed and surgery performed on both patients. More than 1 m long tubular ileal duplication was resected in each case (Figure 5dGo). Abdominal CT and ultrasound (US) were unable to detect any gut abnormality in these cases. In Case 8, scintigraphy revealed an area of abnormal tracer uptake inferomedial to the stomach (adjacent to the greater curvature), showing tracer uptake at the same time as the stomach (Figure 6Go). A diagnosis of gastric duplication cyst was made. In Cases 9–11, initial 99Tcm-pertechnetate images revealed a photopaenic area in the thorax corresponding to the location of the duplication cysts on CT. On delayed imaging (6 h) the photopaenic area was seen to progressively fill up with radiotracer activity (Figure 7a,bGo). In Case 11 the initially photopaenic right-sided thoracic mass showed good filling in of radiotracer on 24 h image (Figure 8a–cGo). A posteroanterior (PA) chest radiograph showed a well-defined posterior mediastinal mass in the right paratracheal region (Figure 8dGo). Contrast enhanced axial CT chest showed a well circumscribed fluid attenuating, non-enhancing mass in the right paratracheal location (Figure 8eGo). A diagnosis of intrathoracic foregut duplication cyst lined with gastric mucosa was made based upon the scintigraphy, X-ray and CT findings. None of these cases showed evidence of any other sites of ectopic functioning gastric mucosa. The cysts were surgically excised.


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  		Table 1. Showing scintigraphic patterns of ectopic gastric mucosa, their relation to appearance of tracer in stomach and final diagnosis

 


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  		Figure 1. Case 1: Meckel's diverticulum. (a,b) 99Tcm-pertechnetate scintigraphy images showing focal area of intense abnormal tracer accumulation in the hypogastrium appearing at the same time as gastric mucosal uptake, this pattern is characteristic of Meckel's diverticulum.

 


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  		Figure 2. Case 3: Meckel's diverticulum. (a–c) Serial 99Tcm-pertechnetate scintigraphic images showing a small focus of abnormal tracer accumulation in the right lower quadrant near the midline that appears with appearance of stomach and increases roughly in synchrony with gastric accumulation. (d) The remnant of the omphalomesenteric duct still connected to the umbilicus is seen in the photo taken at surgery.

 


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  		Figure 3. Case 4: Intestinal duplication. 99Tcm-pertechnetate scintigraphy (dynamic images) showing abnormal tracer accumulation in the lower abdominal region appearing at the same time as gastric mucosal uptake and progressively increasing in intensity.

 


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  		Figure 4. Case 5: Intestinal duplication. 99Tcm-pertechnetate scintigraphic (a) early and (b) 60 min delayed images showing a linear area of abnormal uptake in the infraumbilical region along the midline appearing at the same time as gastric mucosal uptake and progressively increasing in intensity.

 


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  		Figure 5. Cases 6 and 7: Intestinal duplication. (a) 99Tcm-pertechnetate scintigraphic images show an initial blush of tracer activity on the dynamic flow images. (b) The early images then show intense tracer accumulation in the lower abdomen simultaneous to gastric visualization. (c) The tracer localization changes configuration on the delayed images. (d) The long tubular ileal duplication is seen in the photo taken at surgery.

 


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  		Figure 6. Case 8: Gastric duplication cyst. 99Tcm-pertechnetate scintigraphic 60 min delayed image showing abnormal tracer accumulation infero-medial to the stomach appearing at the same time as gastric mucosal uptake.

 


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  		Figure 7. Cases 9 and 10: Thorasic duplication cyst. 99Tcm-pertechnetate scintigraphy in (a) the early phase shows an intrathorasic photodeficient area in the chest, which fills with tracer in (b) the 6 h delayed image.

 


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  		Figure 8. Case 11: Thoracic duplication cyst. 99Tcm-pertechnetate scintigraphic serial images at (a) 15 min, (b) 4 h and (c) 24 h showing an intrathoracic photopenic area in the right hemithorax on the early image, which is seen to fill up with tracer on the 24 h delayed image. (d) Chest radiograph posteroanterior view shows a well-defined posterior mediastinal mass in the right paratracheal region. (e) Contrast enhanced axial CT chest seen on the mediastinal window shows a well circumscribed fluid attenuating, non-enhancing mass in right paratracheal location.

 

   Discussion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
References
 
A variety of congenital gastrointestinal malformations are associated with ectopic gastric mucosa. These include Meckel's diverticulum [7] and gastrointestinal tract duplication [8]. Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract and is the most common site for ectopic gastric mucosa [9]. In two recent studies, the incidence of Meckel's diverticulum was 2.2% in general population [2, 11]. The presence of functioning ectopic gastric mucosa is often associated with symptoms like pain, bleeding and perforation due to acid secretion and ulceration of the gut wall [10, 11]. According to Raymond et al, the likelihood of finding heterotopic mucosa in a Meckel's diverticulum is higher in symptomatic patients (65–90% of patients) [12]. In 1967, Harden et al proposed the use of the pertechnetate for the non-invasive diagnosis of Meckel's diverticulum with ectopic gastric mucosa [15]. In 1970, the method was introduced into clinical practice by Daszynski et al [16]. Pentagastrin, histamine and glucagon may enhance the detection of ectopic gastric mucosa in Meckel's diverticulum by 99Tcm-pertechnetate scintigraphy [17]. Cases 1–3 illustrate the classical scintigraphic findings of a Meckel's diverticulum with functioning ectopic gastric mucosa.

Gastrointestinal duplications are seen in one of every 4500 autopsies [12]. These duplications are uncommon congenital lesions of unknown aetiology [8]. The presentation of gastrointestinal duplication depends on their location, size and other factors, such as the presence of heterotopic gastric mucosa [18]. 20–30% of such duplications will contain ectopic gastric mucosa [8]. The ileum is the most common location for duplication of the alimentary tract whereas rectal, duodenal, gastric and thoraco-abdominal locations are extremely rare [18]. Duplications may be cystic or tubular, non-communicating, or more rarely communicating [19]. Ectopic gastric mucosa is more commonly associated with tubular duplications [20, 21]. We had four such cases of tubular ileal duplication cysts with intense accumulation of 99Tcm-pertechnetate appearing either before or at the same time as the uptake in the stomach.

Gastric duplication cysts are located on the greater curvature and have no communication with the stomach [22]. Most patients with gastric duplication present before 1 year of age with symptoms of vomiting, poor feeding and a mass on physical examination. In infants it is often misdiagnosed as hypertrophic pyloric stenosis [23]. The mucosal lining is often gastric and can lead to melaena or haematemesis with anaemia. Poor drainage and inadequate neutralization of acid secretions can lead to acute local inflammation, perforation or even intraperitoneal haemorrhage. 99Tcm-pertechnetate scanning is helpful in demonstrating the ectopic gastric mucosa but normal stomach uptake may conceal a lesser sac duplication [24]. Case 8 illustrates the scintigraphic findings in a gastric duplication cyst, entirely lined by gastric mucosa. In this case the ectopic gastric mucosa was visualised simultaneously with the stomach.

Ectopic gastric mucosa may also be present in intrathoracic duplication of the gastrointestinal tract. Approximately 20% of mediastinal masses in children are of foregut origin. These are commonly located in the posterior mediastinum [18]. Overall thoracic and thoracoabdominal duplications make up 24% of gastrointestinal duplications [18, 25, 26]. Younger patients usually present with respiratory distress caused by compression of the airway, whereas older patients may complain of heartburn or melaena probably caused by the ectopic gastric mucosa. Approximately a third of foregut cysts are lined by gastric mucosa, which secretes acid [26]. Peptic ulceration of these cysts occurs with erosion into the adjacent lung, bronchus or oesophagus with subsequent haemorrhage [27].

Diagnosis of the type of foregut cysts (gastric, enteric, oesophageal duplication or bronchogenic) is often not made pre-operatively. Synchronous multiple duplications are found in up to 15% of patients [18]. 99Tcm-pertechnetate study can be used to evaluate for the presence of ectopic gastric mucosa in the lining of the intrathoracic cyst and also to detect the occurrence of ectopic gastric mucosa in synchronously occurring gastrointestinal duplications elsewhere. Mark et al reported the scintigraphic findings in an intrathoracic gastric cyst with ectopic gastric mucosa [28]. They found that the lesion accumulated 99Tcm-pertechnetate at the same rate, as did the stomach. The differential diagnosis of positive scans in the thoracic region using 99Tcm-pertechnetate includes neurogenic tumours, Barrett's oesophagus and hiatus hernias. We observed an initial photopaenic area in the region of the cyst, which filled up with tracer on delayed imaging of up to 24 h.

A review of the mechanisms for 99Tcm-pertechnetate uptake suggests a possible role for delayed imaging in the diagnosis of ectopic gastric mucosa. Chaudhuri et al, showed that the 99Tcm-pertechnetate is selectively taken up and secreted into the lumen of the organ by the mucoid cells that line the surface of the gastric mucosa whether it is in the stomach or ectopic [29]. Non specific uptake may occur in peptic ulcer, inflammation, intusussception, haemangiomas, arteriovenous malformations, obstructed bowel loops and abnormalities of the urinary tract [1, 30–34]. However, the accumulation of 99Tcm-pertechnetate in the islands of gastric mucosa allows their detection by scintigraphy only if they are functioning and of sufficient size. Experimental studies by Priebe et al revealed that at least 1.8 cm2 of ectopic gastric mucosa is necessary for imaging by gamma camera technique [35]. A false negative study may occur due to non-functioning-necrotic mucosa, small amount of ectopic gastric mucosa, dilution of secreted isotope as a result of haemorrhage or intestinal transit or due to the presence of activity in overlapping organs such as the urinary bladder [1]. The initial photopaenia in the three intrathoracic cysts may be due to dilution of small amount of secreted radiotracer activity in the cyst contents. With continued secretion of radiotracer activity into the cyst enough activity may have accumulated to account for the visualization of the cysts on the delayed images. Sfakianakis et al [1] have suggested such a dilution of tracer activity to be one of the reasons for initial non-visualization of ectopic gastric mucosa by 99Tcm-pertechnetate scintigraphy. But they make no mention of delayed imaging and instead suggest that the appearance of tracer activity at the same time as the stomach is necessary if false positives are to be avoided. In infants there may be other reasons accounting for the finding of initial photopaenia and delayed tracer uptake by ectopic gastric mucosa. In infants the blood disappearance rate of 99Tcm-pertechnetate is prolonged due to renal immaturity and gastric uptake is normally low. In older children the same phenomenon may occur due to hormonal, vascular or stress related factors in the presence of normal renal function [36]. Therefore in infants and children a combination of poor gastric mucosa uptake and high background may cause the cysts lined by gastric mucosa to appear photopaenic on initial images. With time there will be reduction in background activity due to renal excretion of tracer and increase in activity secreted by the stomach ultimately allowing for visualization of the ectopic gastric mucosa on delayed images.

In conclusion, a variety of scintigraphic patterns may be found in patients with ectopic gastric mucosa undergoing 99Tcm-pertechnetate scintigraphy depending upon the location and size of the ectopic tissue. Ectopic functioning gastric mucosa in Meckel's diverticulum, and gastric duplication is visualized simultaneously with the stomach while in intestinal duplications tracer activity can be visualized in the dynamic sequence and even before gastric tracer visualization. In intrathoracic foregut duplication cysts functioning mucosa is usually visualized on delayed imaging, much later than the visualization of stomach activity. Therefore acquisition of delayed images of the chest is useful when the early images are equivocal or negative in a child with suspected intrathoracic foregut duplication cysts.

Received for publication October 1, 2004. Revision received February 16, 2005. Accepted for publication March 21, 2005.


   References
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 

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