NUCLEAR IMAGING STUDIES OF

THE GUT
Dr. Loquiano
December 17, 2014
TigbaONE!
NUCLEAR MEDICINE
Medical specialty that uses SAFE, PAINLESS and
COST-EFFECTIVE techniques to both image the body
and treat disease.
A sensitive way to gather information that may
otherwise be unavailable, require surgery, or
necessitate more expensive and risky diagnostic
tests.
Body is imaged from the inside out
Radiotracers, in the form of radiopharmaceuticals,
administered internally (intravenous, inhalation or
orally)
*unlike other procedures, it does not need the use of
dyes so you dont have to check kidney functions like
creatinine level after administration.
Diagnostic inference is gained by recording the
distribution of radioactive materials in the body
Sequence of events - to understand nuclear med
procedures
Physics of radioactivity
Process of detecting radiation
Selection of appropriate radiopharmaceuticals
Uptake and distribution of radiopharmaceuticals in
health and disease
TYPES OF RADIATION IMPORTANT IN NUCLEAR
MEDICINE
Gamma rays photons originating in the nucleus
Characteristic x-rays photons originating outside
the nucleus
Negatrons (beta particles) high radiation dose; ex.
Iodine-131 for tx of thyroid cancer and
hyperthyroidism
Positrons (beta+ particles)
Alpha particles helium nuclei; undesirable in
diagnostic applications due to high radiation to
patient
Gamma camera - Specialized equipment that detects,
records and process radioactivity emanating from the
patient in order to create scintigraphic images does
not emit radiation unlike X-ray machines

RADIONUCLIDES AND THEIR RADIATIONS

Alpha decay
Alpha particles are essentially helium nuclei with a
+2 charge and atomic mass number of 4;
undesirable in diagnostic application because they
result in high radiation to the patient
Common in higher atomic number range of the
periodic table of elements
Not
currently
used
as
diagnostic
radiopharmaceuticals; only in therapeutic agents
ex. Radium-226 decays to radon-222 by emitting an
alpha particle
Negatron decay
Also called beta decay or beta- decay
Electron is ejected from the atomic nucleus, thereby
giving the decay process its name
Involves the conversion of a neutron into a proton,
an electron, and an antineutrino
Ex. Stable iodine has mass number of 127 (53
protons, 75 neutrons); I-131 has 78 neutrons (higher
number than stable iodine); I-131 undergoes a betadecay
Disadvantage of beta emitters high radiation dose
received by the px; for radioactive I-131, this
disadvantage becomes an advantage when the
radionuclide is used in the therapy of thyroid cancer
and hyperthyroidism
Positron decay
positive electron or positively charged beta
particle is ejected from the nucleus; Ex.
Fluorine-18
Electron capture
Electron from one of the orbital shells (typically
close to the nucleus) is incorporated into the
nucleus, converting a proton into a neutron

 Energy released from this transition appears either

as x-radiation or as kinetic energy of an Auger
electron
Some radionuclides decay by multiple modes,
including electron capture, positron decay and
negatron decay
Isomeric transition and internal conversion
Most gamma rays are emitted almost immediately
(<10-12 seconds) after the primary decay, whether it
be alpha decay, negatron decay, positron decay or
electron capture
Metastable - when the intermediate excited state
lasts longer than 10-9 sec; an m is placed after the
mass number to indicate the phenomenon
Most important example of metastable state:
technetium-99m decay of molybdenum-99 to
technetium-99; pure gamma emitter
Gamma ray emission
Result of many radioactive decay processes
Ionizing electromagnetic radiations that originate in
the excited, unstable atomic nucleus
Have discrete energies defined by the decay scheme
for the respective radionuclide
Occur over a wide range of energies
Energies between 80 keV and 400 keV - most useful
in conventional nuclear medicine
Terminologies, Units and Conversions
CGS Unit SI Unit

Conversion
Factor

Joule (J)

107

Radioactivity Curie (Ci)

Becquerel
(Bq)

3.7x1010

Radiation
Absorbed
Dose

Rad

Gray (Gy)

100

Radiation
Exposure

Roentgen Coulomb/kg 2.58x10-4

(R)

Dose
Equivalent
man

Rem (R Sievert (Sv)

equiv.
man)

Work

Erg

100

Radionuclides or Tracers AKA Radioisotopes,

Radioactive Elements, Radioactive Isotopes or
Radioactive Materials
Isotopes attempting to reach stability by emitting
radiation
NOT DYE but RADIOTRACERS!
matched
with
different
compounds
->
Radiopharmaceuticals ex.99mTc+monodiphosphate
travels to specific organs and tissues producing
morphologic images
*will easily know whether there is misadministration or
not since what is given is avid to a specific organ
*no significant fluid overload, no siginificant
hypersensitivity, very minute amounts of radiation
*very organ specific (heart, bones, thyroid)
Terminologies
Radionuclide
o refers to radioactive atom
o all radionuclides are produced in either
nuclear reactors or cyclotrons or other
types of accelerators
Radiochemical
o when a radionuclide is combined with a
chemical molecule to confer desired
location properties
Radiopharmaceutical
o radioactive materials that have met the
legal requirements for the registration for
administration to patients or subjects
HALF-LIFE
PHYSICAL HALF-LIFE (t 1/2)
o amount of time for a radionuclide to be
reduced to half of its existing activity
o Ex: t of 99mTc = 6 hours
o 5 mCi 99mTc 2.5 mCi 99mTc after 6 hrs
BIOLOGICAL HALF-LIFE
o time for an organism to eliminate half of
an administered compound on a strictly
biologic basis
EFFECTIVE HALF-LIFE
o physical and biological half-lives

Common Radionucleotides
RADIONUCLIDE HALF-LIFE

TARGET
ORGAN/DISEASE

Technetium99m

6 hrs

Thyroid, heart,
bone,
lungs,
kidneys

Iodine-131

8 days

Thyroid

Thallium-201

73 hrs

Heart

Gallium-67
78 hrs
lymphoma
in radionuclides with high half-life, increase fluid intake
to enhance radionuclide excretion so that before 60 hrs
or at least 24 hours, radioactive materials are totally
excreted
Technetium 99m (99mTc)
ideal radionuclide
>70% nuclear imaging procedures
no particulate emission
6-hour t1/2
predominant 140-keV photon
rapidly concentrates in salivary glands, choroid
plexus, thyroid gland, gastric mucosa,
functioning breast tissue, placenta
excretion - GIT, kidneys and GUT
Nuclear Medicine Procedures
Identify abnormalities very early in the progression
of a disease long before some medical problems
are apparent with other diagnostic tests
e.g. breast cancer px complaining of back pain may
have normal CXR but when subjected to bone scan,
early changes in bones may show signs of metastasis
Early detection allows disease to be treated early in
its course when there may be a more successful
prognosis
Is it safe? Yes, it is among the safest means
available.
How much radiation does a Px Receive for a Nuclear
Med Procedure?
Comparable to, or often times, less than that of a
diagnostic X-Ray
Patient receives about the same amount of radiation
as that required in a few months of normal leaving
e.g. traveling from Ph to US/Europe through airplane
exposes you to more UV Radiation compared to that
of a nuclear medicine procedure

Scope of Nuclear Medicine

Nuclear Imaging imaging or scanning
Radioimmunoassay sensitive blood examinations
using radioisotopes
Radioactive Iodine Therapy toxic goiter and
differentiated thyroid CA
Bone Palliation uncontrolled pain of carcinoma
Bone Densitometry diagnosis and management of
osteoporosis
PET for diagnosing metastasis of thyroid CA
Nuclear Imaging procedures
Cardiac scintigraphy
Renal scintigraphy
Bone scintigraphy
Scintimammography
Hepatobiliary scintigraphy
-radionuclide hepatobiliary scan esp. If ultrasound
does not provide positive frindings
GI bleeding scan-RBC tagging
-RBC tagging can localize source of bleed in the GIT
Liver/Spleen scintigraphy
Ventilation-Perfusion scintigraphy
Thyroid Uptake scintigraphy
Total body scintigraphy I131
Testicular scintigraphy
Radioimmunoassay procedures
T3T4
TSH IRMA
Estrogen, estradiol, LH, FSH
Testosterone
Cortisol
Insulin
Lanoxin assay
Radioactive Iodine (RAI) Therapy
Graves disease
Toxic nodular goiter
For ablative treatment of residual thyroid tissue
post-thyroidectomy in patients with differentiated
thyroid CA: papillary and follicular thyroid CA
For treatment of distant metastasis of thyroid
metastasis
Bone pain palliation
Strontium-89 or Samarium-153
Single IV administration that delivers high local
radiation dose directly to the sites of bony
metastasis
60-80% response rate, 20% pain-free

 Mild toxic effects, generally limited to platelet

depression
Kidney or Renal Scan
To know how the kidney is working
To monitor the flow of urine in mL/min
To check for the degree of any blockage
To assess the effect of recurrent urinary tract
infection
To know how the transplanted kidney is
functioning
Renal Anatomy
lie retroperitoneally between T11 & L3; lower
poles 2-3 cm above iliac crest
average length 12 cm; L slightly larger &
higher than R; R more mobile & ptotic in
women
divided into cortex & medulla
Cortex contains
a. glomeruli
b. proximal & distal convoluted tubules
Medulla contains
a. remaining tubular segments
b. pyramids portion of medulla that
extends from just below outer cortex down
to renal pelvis
c. columns of Bertini cortical projections
between pyramids
Physiology
Blood Supply main renal artery, rarely
duplicated, branches into segmental arteries
arcuateinterlobar arteriesglomeruli
Drugs may be excreted via:
a) Glomerular filtration blood enters
glomerulus through afferent arteriole;
filtration occurs; filtrate moves into
Bowmans Capsule and into PCT
- GFR number of mL of blood
completely cleared of material in 1
min.; 125mL/min (80-120mL/min);
affected by height, weight and BSA of
patient
b) Proximal Convoluted Tubule (PCT)
Function - urine filtrate radically
altered; most of water reabsorbed
plus NA+, Cl-, and HCO3-; glucose,
amino acids reabsorbed; many drugs
including Hippuran actively secreted
c) Loop of Henle electrolytes
reabsorbed; water not

d) Distal Convoluted Tubule (DCT)

resorption of Na under hormonal
control: ADH or Angiotensin System
e) Collecting System final part of
system
Arterial blood pressure affects tubular
function; results in prolonged intrarenal
transit time of hippuran in renal stenosis
Hippuran is a radiopharmaceutical used to
measure the GFR but has a very high dose of
radiation so it is now replaced by newer
radiopharmaceuticals

Radiopharmaceuticals
1. Glomerular Filtration Rate agents should:
completely filtered by glomerulus
not be protein-bound (cant be
filtered if it is)
not be resorbed nor secreted by renal
tubules
be excreted only by kidney (so that
plasma sampling techniques can be
used rather than urine sampling
a.

99m

Tc-DTPA
(technetium
99m
diethylenetriamine pentaacetic acid)
-used in the local setting
completely eliminated by glomerular
filtration; no tubular secretion occurs
- meets the requirement for measuring GFR
except for the 3-5% that is protein-bound
b. Chromium 51 EDTA
- GFR slightly lower than inulin
c. I123/I131 iodothalamate
-radioactive contrast
d. I131 diatrizoate
-radiographic contrast used in xrays and CT
scans
2. Tubular agents
ideal agent for measuring effective renal
plasma flow (ERPF)
Also used for renal function
In the local setting, we only have GFR
radiopharmaceutical agents
a. 131I OIH (Iodine 131 orthoiodohippurate)
chemically similar to paraaminohippuric acid
(PAH)
gold standard for measurement of ERPF

b.

99m

Tc
MAG3
(Technetium
99m
mercaptoacetyltriglycine) 99mTc replacement
for IOH; excreted by PCT like OIH, not retained
in parenchyma; lower radiation dose; superior
quality of renal images than IOH & DTPA

3. Parenchymal Agent
a. 99mTc
DMSA
(Technetium
99m
dimercaptosuccinic acid) taken up by renal
cortex in proximal convoluted tubule; 90%
protein
bound
preventing
significant
glomerular filtration
Technique for doing Nuclear Renal Study
1. Flow study:
-rapid sequential images every 2 seconds for
30-60 seconds
-10-15 mCi of 99mTc-DTPA or 5-10 mCi MAG3
via bolus injection
Unit of radiation is in Curie (Ci). What
is being given to patients is only in
milliCuries (mCi).
2. Excretion study:
-serial 3-minute images for 30 minutes
-Adequate hydration; let px void before the
study
full bladder can simulate upper tract
obstruction if the px is dehydrated-will give
falsely low results
Different types of nuclear medicine studies for kidney
diseases
1. Glomerular Filtration Rate used to monitor
urine flow in mL/min (normal: 80-120mL/min);
goes lower as the person ages; measured
according to the patients height and weight
and body surface area; lasts for 6min
2. Basic Renal Scan native and transplanted
kidneys; usual renal scan; assess renal function
and urodynamics or the excretion of the
kidneys; lasts for 20min; patient has to wait for
one hour before extraction of the blood and for
the third hour for another re-extraction
3. Diuretic renal scan to diagnose or exclude
urinary tract obstruction; diuretic-augmented
renal scan; we give diuretics like furosemide
and observe whether patients excretion
improves with diuresis; if it improves, it means

that the obstruction is just temporary; if

obstruction persists, there is true obstruction
4. Captopril-augmented renal scan captopril is
given one hour prior to doing the renal scan;
helps in diagnosing renovascular hypertension
5. Renal cortex scan (DMSA scan) used for
diagnosing pyelonephritis
6. Radionuclide cystography to detect,
quantitate or follow-up reflux
Radionuclide renal scan
Three Parts:
1. Angiographic images perfusion phase
2. Time activity histograms
a.
Perfusion
b.
excretion
3. Excretory images
A. Perfusion Phase

*in secs.(1-16 secs.)

*w/in 3 secs, aorta should be seen and after 3 secs.,
Kidney should already be seen. Hypoperfusion is
present if it is more than the normal time. The above
image shows that the uptake or number of counts is
very high which is 1800 counts/sec which means that
most of the radioactive materials have been taken up
by that kidneys in that span of time (kidneys have very
good perfusion).

B. Excretory phase

Splenic and liver activity may stimulate

kidney activity
Normal values
- GFR: 125mL/min
- Effective renal plasma flow (ERPF): 500600 mL/min
- Filtration index: 0.2
- Excretory index: 1
Static images
- Smooth renal contour
- Note: normally defects are seen due to
collecting system and irregularities at
corticomedullary junction

*in
NORMAL RENAL CORTEX SCAN

Patient should be adequately hydrated unless the

patient is hypertensive; should void before the study
because a full bladder may mimic obstruction; supine
or prone position is advised; upright position may show
a shortened kidney
0-30seconds; in three seconds, urine should already be
seen in the urinary bladder to say that it has a normal
excretory phase; In 1st -20th minute, there should be
filling up of the bladder and the kidneys should have
decreasing activity until almost none in the end of the
study. In histogram, there is intense uptake in the
aorta and gradual decreases as the tracer is excreted
in the urinary bladder; left kidney is the green graph;
right kidney is the purple graph; black graph is the
aorta; left and right kidney should overshoot the aorta;
activity is measured in counts per second; the count
should be high, like 1200 counts/sec; if it is low, it
means that it has lower perfusion or poor function of
the kidneys
NORMAL SCAN
Renal flow study
- Both kidneys visualize symmetrically and
with similar intensities (differ depending
on renal size); intensity of kidney should
equal or exceed early activity in spleen
- Slope of curve of activity entering each
kidney should parallel aortic curves
- Peak should occur no more than 3
seconds later than aortic peak

*left image: diffuse pyelonephritis on the left kidney;

reduced tracer activity
*right image: abnormal renal cortex study; contracted
right kidney; defect in the superior left kidney
*multiple scars -->contraction --> small kidney

OTHER NUCLEAR IMAGING TESTS

1. Bone scan or scintigraphy to evaluate
unexplained bone pain in patients with and
without cancer, to detect arthritis, fractures,
sports injuries, bone tumors and even cases of
child abuse; normal bone scan should appear
symmetrical, no trace of increase tracer
activity; increase in tracer activity in a certain
area may indicate inflammation or
degeneration

2. Scintimammography to more accurately

identify and locate cancerous tissue in the
breasts, especially when the mammograms
are difficult to interpret because of dense
breast tissue, previous biopsy, surgery, silicone
implants

*leftpicture: normal; patient is in prone position;

uniform radiotracer distribution in the breast
*right picture: abnormal; known breast mass with
increased radiotracer activity
3. Hepatobiliary scan to evaluate upper
abdominal pain, know the cause of yellowing
of the skin or jaundice and identify obstruction
in the gallbladder.

*top image: normal scan

*below: abnormal scan

*normal scan; gallbladder should be seen in one hour

*patient with persistent right upper quadrant pain

despite normal hepatobiliary ultrasound; no
appearance of the gallbladder; level of obstruction is at
the cystic duct; prepare the patient for surgery

*acute acalculous cholecystitis; no obstruction

*bile leak; very sensitive and non-invasive

*HIDA scan (hepatobiliary iminodiacetic acid scan);

there is gradual reduction of tracer activity in the liver;
biliary atresia failure of the development of bile
ducts; hepatitis infection in the liver

4. Bleeding scan identify the source of bleeding

in a patient with melena, hematochezia

*active bleeding in the sigmoid colon

5. Meckels diverticulum scan to detect the

presence of a Meckels diverticulum (remnant
of the omphalomesenterial cap; ectopic gastric
mucosa)

*meckels diverticulum should be seen within one

hour; 99% specific
6. Perfusion-ventilation lung scan to diagnose
pulmonary emboli or blood clots in the lungs
- To quantify lung function
- To detect lung transplant rejection

*bleeding hemangioma in the latter portion of the

duodenum

7. Thyroid scan differentiates thyroiditis from

Graves disease
- Differentiates hot vs cold nodulesFinds
96% of nodule; palpation only 60%
- Risk of malignancy in cold nodules: 1020%

*left: thyroiditis; right: toxic goiter

*left: toxic goiter (less background); right: toxic

adenoma (hot nodule as big as 3cm with signs and
symptoms or toxic goiter; treatment includes
medication, radioactive iodine and srugery)

*left: cold nodule; right: hot nodule

8. Testicular scan to detect acute testicular

torsion in patients with testicular pain

10. Parathyroid adenoma scan help localize a

hyperfunctioning parathyroid adenoma before
initial surgery in a patient with primary
hyperparathyroidism
- Help localize a hyperfunctioning adenoma
in
a
patient
with
primary
hyperparathyroidism after parathyroid
surgery

9. Dacryoscintigraphy to know the cause of

frequent tearing of the eyes or to evaluate the
nasolacrimal system
11. Total body scan used for diagnosing patients
with thyroid carcinoma, who has undergone
thyroidectomy and underwent radioactive
iodine treatment for ablating thyroid
carcinoma

*complete obstruction of the right nasolacrimal

system

*isolate those exposed to radiation for two weeks to

one month

RADIOACTIVE IODINE THERAPY (RAI)

- Over-all survival rate is 80-90%
- Patients untreated with I131 ahve
cumulative tumor recurrence rate of 40%
in 30 years
- Higher recurrence rate in tumors >1cm,
poorly differentiated follicular subtypes,
Hurthle cell cancers, lymph node
metastasis, distant metastasis, age <14
and >46 years old
References:
-

Notetakers:
Editor:
-

Doc Audio and Lecture

Notes that were part of the old notes and not the
lecture

Arielle
Boni
Jan
Lauren

Tigbauan Fun Fact: During October they celebrate the Adlaw

sang Tigbauan or otherwise known as the Saludan Festival
coming from the root word salud which was used to describe the
way fishermen caught fish