o 2 t T : ,.ti - Prof. Dr. İbrahim ULMAN
Transkript
o 2 t T : ,.ti - Prof. Dr. İbrahim ULMAN
I EgeOnivccital T9 Fek0ltai Ocryid Oh:28, Sryt: l, 1989 I ILETANISI M€CKELOIVTRTIKOLONON RAOYOIZOTOP SINTIGRAf (8lR OLGU) M.ONLO... l. gur|Aperor E 8AL|K.."" H.OzKlLlC. C. YAMAN.. M. TUNCY0REK""' .o 2 t T Ntcltl dfuedl\ii0i omfolomcz nuhoto lutrih Nicnleri catclil lhtiw cdcr. Pcttclntot tool\trd.an latulm blt Lolmtst obp, lcncfiliLb cltopi\ iyonu (Tc99-mO" ) t3'ltrit 6zcl olat:o'l- tutuAulutdon Neclcl mu*ozonrn mu'.otd diwdihii/lldi g6rintiilcmc\ miinlJndib. &r grhgnudr 1,5 yegtnd: McclcJ divcrtikirlE bir crtck hrruyr ebdornin:l pcrrek. ncot tintigr.fisi yrprldr. 3 mG lik Tc-jcrtckncot intrncndz yolle heruy: vcrildi vc cnikriyond:n 15 d.likr rcnre dntignml:r clde cdildi. Srt rlt kdanda kilg0k, y.rverhk bir ektivite u.rtulugunpandl. 8u bulgu pozitif ohaft deterlcndirildi. *lest: daha tonn op€yccdildi vc histopetobiik incclcnr divcrti&fl igindeektopik tanrik mukozr olduluru do!rulrdr. Bu tcknik, bezr gnrdem:lrrr olnrune kergrnMeckeldivenikiilijn[n invzzivolmey:n lmrsnda gok defedkJir. : Mec*el divertildlii crnbriyonun ornfrlomcrentcrik kenelnrn kehnttcr olup, rkhkle ilarnx.rn dirtil 100 cm lik bitlijmOnde lokrlirc olur- Gcnel populesyonun % l-3 buluru.rr vc Mcckel divertik0tE olgulann % 25-40 t t.O-T.F. " rrr r'r' \ r.a. Nijklctr Trp Anabilim | rmptom iinde verir. Stmp(om verm Dalr Ogrerim Oyesi F.O.T.F. NJkler Trp Anabilinr l):lr Llzmznr -lrir l ( _ l . TF I ' i r ! . l a - r Analrili'r. I)alr {r:,,r.rnjrl i)1,,;q1i1; f (l T.F f,ocut. Crrr":hiri An:5illm i) {l:n:rlr'.. F f , ) T F p ; r . , | < , i iA e : . l . i l i , r O a l r f 1 i ; c l i r I r I I { , . , . 1 t ( ' a . r . , i , : r i . 1 : : r l , i l , , : :3 O!rcniiri l11q1i iJgrr:i;;; U; cri ,.ti lllcckcl divertildllcrinin % 57 sindcekropik gerrrik m.rkor: mcvcuttur. E&topikgasrrik rnrkorenrn 6mmll mikrerhn veren hidroklorik lir vc peprin ckroyonu biriliktckl Opereryon ronnr ebcnn midc mukoxr, rnrctiyrr picsinin petoloiik ferkikindc lcryon, Mcckel divcnikijb, pcptik 0lrr olerek deferlmdirildi intcstinel m.rkoann 0lrcresyonune yol egrr. Etgha komplikrsyonrckul krnenudr. Nedircnobtr0krlyonvc'z pcrforxyon olebilir (7). TARTtSMA Pcnckncut Mcckel divcrtlHll0 tlnrrrnd: brryumlu lontrett ctAyogru;fiv. r.lckraf rncriojafi 6o[ ka begrnrz q)nuglrntr. Tr 99m-pcrtekm0r ilc yeprbn ebdominrlrinrigrefitcrilc Meckcl divcrtikiil8 olgulen 9690 orenrndt trnr koynu olrnrlr verdrr (20). Pcrrehncut .nyotil trtrrlk mrkorenrn m.rkoidtr6crtlcrindcrclektif obrek rt ekrif bir mckenirru ilc birikir vc drlu ronn brrek $rntninc clrkrttc cdilir (2). Bu y{hdcn Mcclcl divcrrild} (Renm 2). iyoru ih (Tc99m6a fonkriyonu dclertcrrdirnrdc ) ebdorrfnel imrjl:nu vc 3rnrcktomi rcknifi llkdnccleri3esrrik rcnresr rcridijcl 3enrik dokuyrr 6(rncdc &ulbnrlmrl vc oldukqe rrnrrlrbir tulhnrm ehnr lgindc kelmrllr (10). 1967 dc Hrrdcn vc ertld:1lert bu rrdyoriiklidi ilt kcr Mec&cl divcrtikiilij unrrrndr kullenmrllerdr (8). 8u trrihtcn rcnre ydnrcm klinik parige drhil cdilmig vc klinik 6ncminl wrjuhyen pck g o k g e h l m : y r p r l m r l t r r ( 3 , J , I l , | 2 , | 3 . I 5 . 1 6 ,1 t , 2 5 ) . Sndehi ektoplk rnrkoredr mukur relgrhytn liicrclcr verrr bu b6lgcninebdomin:lrio lignmlerle jbr0ntiilcnmcriniimki,in?0r.Anctk cktopik trnrik lrUkotr yrlnrra Meclct divertikiililncdr olmtyrp, kinler. cnterik duplikeryonhr,duplik^rsyonkinlcri vcyr normrl incc brrnfn hcrhengibir ycrirdc bulun:bilir (21). Ayncr McckcldiveniHlE llc ilgili olm:krrm lnorrur.priyon, intcninel ob;triikriyon, rqlonel cnlerit, cnflrnuryo.l 3ibi 9ok gelitll durumlrrdr pcrtllncur gthgnuhn ile poritif rcnrg rlrn$itir. 8u yud: Pcrtckncut iyocrn:n eltrndr Mcclel divcrtiliiliin0n irwerivolrruyen trntJtnd: 1.99 m -pcrt krEul ile irnei- rkrtryonu ckrc ultnfiltrrfi olulturufi'rrten mlkoid tilcre ekreryomna gestrik nukou drhil olur vc pcrtcknctrlt urtrn tiicrclerinin 6iiriintiilenrr*rinc ohruk verir (1,2). Atktlm cvmrn tponun olmekh birlikrc br.rr dm3hr vc hormonrl rtim.rlurlerdtn ctkilcnir. 8u iirellik dikkzt elrrurek drhe iyi bir 3briintT cldc cdcbilnrck ,cin pcntrgrnrin. rimc- ridin vc afuk4ond:n yzrttlznrlrr. Penr-t:rtrin direkt ohrek rckrtsyoru rnr. ll9,2l nr. Kuwetfi bir herumin H2 -<egti5r:nt'gonisti ohn drnetidin pctt krEutrn brrrrk OLGU goork. $oark Gcrrehiri prot No:498 Anemncrinde 2 ay dncoinc tctkil odcr. Meckcl divenildlihdcki vc d:he ronrr bune nokur il:ve odilereh pH t 7,61 yc tyerlenrr. Pcrt kncur pl.urru cktolk Y.U. 1,5 pSrndr cttct mukore Hjcrclerindc &onrrntre odilnr 6rclll{i Mec- plk 3urrik mukouye dt rrukoid lijcrtlcr rrpkr 3rnrik mukor:deki 3ibi etkrlcn bir rrvr €ktkrclc eder. Eu rlkelcn rvr iyon bilelimi beJrrnunden plrrnu uhnfiltr.trnr bcruct Mcclel divcnikiilii oldufu prtoloiik incclerrrlcdc krnrrlenrrrl bir olgununopcnrryon dnccrindekirbdominel icrteknd:t irnejlenneeit bulgller vcrilmig vc lircntiiriin rgrlr lerru tckni!i gdrdengcAirilmistir. grtrik krl divcnikiilijriin rinri3refik t nrrnrn 6'qnr bnrcninc slgrlanmernr rit 6 gin dircn rcktel kanam: 6yldsii ver. 8ol mikundr hem:toclrczir'n olrnesr nedeniyle f 0TF $ocuk €crrehid Anrbilim Drhnr yatrnldr. Her inhibc cder. Gtubgon |r inrcrtin:l perirt:ttizmi dnleyerck Iimen igindeki elrivitenin diliiryonunu ijnler. Pcrkloret ayonu pcrteknchtrn lok:liras y o n u r x J6 n l e d i g i n d c n g a t r 5 m ai i n c c t i n d e k u l l e n r l m e g k o n r r c n d i k c d i r - tr .anemik, hafif dercccde dehidntc idi. Rektel rrr.raycrrede r: miktarda bol kanh fcaes rcspit cdildi, Hcnutokrit %midi. Diler ristcrn murycncleri norrneldi. Deneyscl galrSnular ekropik gastril mukor:ntn cn tz I cm2 lik bir elenr iggal ameri ( 19 ) vc mutl2La mukoid hiioe talrmasr halindc ( I ), Mcckel divertikiil0nih sintigrafih Sintigrafik incclcme igin 3 mG Tc di. Eniksiyondan pcrtekntat 15 dekika ronrr im.rihmrya cdildi. 30. dekikayr ait sintigramda q! rady'orktivitc birikimi intraveniiz yolle hastayaveril- ba5landr ve l5 cr dakikr er:hrle danm ah kedranda ki4iik yrn.arlak birodak halindc irlendi. Bu gorlnol Meckel divcrtikllij olarak de!crlcndirildi ( R c s i ml ) . olarak saptarubilecciini ortaya koynukradrr. Ekropik ga.Jtrikmukoza gastrojenik kistferde ( l4 ), entcrik duplibsyonlarda (9,24 ckropik x3strik mukoz: ile i l g i l i o l m a k s r ur n d a d r v e r t i k i j l i l l e r ,i n t e s r i n a l o b s t r O k s i y o n ,i u v e n i l p o l i p l c r . h e m a i i o m a , leiomyosarkom, normel utertrs ( 7 ), intususscpsiyon ( 4 ), inflanutuvar lezyonlar { 6 ) a r ( c r i o r e n i i z r r o l { o r s q 1 y o q l a ,( l l l l : s l a n r ' . g c n c l d u r u n r u t J r i r c l t i l r l rllo ) , d u p l i b s y o n k i s t l c r i n d e( 2 6 ) v e n o r m a l ince barsairn hertungi bir yerinde ( I ) bulunabilir. Ay'ra r { } n r a c l * s p l o r ; r r i r l a ; . a r a t o m i; , a p r l t 1 r| r 1 r c i . c t d j r c : , i l i r \ t l , : ; r y j r D i r c t l ' i L t c i . l ' r r n r r, c ; . i t ; ) . r n , f , r l l 1 1 ( , t i . , (t i \ f , i j l t n a " tI ' { } r : , ) ; r r . 2 ' . r \ f 'I () ' '1: t r;i!Tr l.an rcrilili l..o,rr;.lrl;*on i. 5clilrrr\cn tr.rti; 6r:r 1i1: ilt ulr.rr. . ) , i r l r e r l r r( I ) r ' t h a r r t r a r r r ! .r l r : r , r l e 1 ( 1 7 ) , u r i n e r t r a l l u s a n o r m a l l i [ . l e r id e n o n s p r s i f i l . o l a r : l ' . f r e r t c l . n ( t ; t r t { , ! r r F l , rr u : r d t ' na l . d r i c r , rui fxrl.lrrrlrl q a l r 5 n u b r r M e r f . e l< j r r r t i L u l u r r u ni n r a r i v o l n . : r ' z r ru n r r r n d z o n t n r l i c l m a k l : h i r l r l ' . i :1 ' a n l r ;J r o z i t i f l r i er r r l . : 1 a n i , , , . i i ' , ! i a , , nd i k t : t l r r i c i c r l r n d i r i l m c r is a r l r r r Bit g:hSrnryr g6rc ( 20 ) ndyoriiklid 3ulenn t6 ti rcrniklcrlc Mc<kcl divtrrikiilii oldutu r6ylencn ol- inin Mcckcl divcrtik0lii oldulu divertikOli,i olnudrfr oruye konmrl ( rcnsirivirc 9685 ), Mcckct rdylcncn oljuterde irc 96 5 onnrnde Meckcl divcrtikijli.i saptinmrt. rrr. Eune gikc rpesifirc 96 9J tir. Tcnin gcf ctlilifii 190 olenk hcrepbnrr. Tclnilin &cmmclleltirilnrsi vc yorumlerrn dikkrtli mii- yeprlnnsr ilc bu or-erunrrtnusr mi,imLi.inrdii. SUMMARY OIAGNOSIS OF MICKEL'5 OIVTRIICUTUM 8Y R,AOIOISOTOPI SCANN|NG ( A CASI RTFORT ) Mc<kcl'r dlvcrticulum contrinr rr,ucoid ccllr of 3rrric Rcsln - I .t In lhc pr:lcnt i lbdornlnal Tc99t-per..< rretst Ok)a 1;arot edllen -,l5edel:l ir r remnem of rhc omphelomocntc.ic ducl rnd it often Gctoplc Astric mucoril. PcrtcchrrUte rnion lr rclectirtly eccumuletcd by thc rynr(rrrr, ro it an bc dcrccrcd by tnrglng. ; riudy. pcrtechncotc rbdomirul rcinti3rern ves pcrformed on e 1r5 yczr old boy with Meckel'r divcrtlculum. The p:tient wrs 3ittn 3 mCl of 1.99!o-tcchncutc intnvcnously end t .nr wcrc obr:ined 15 mintnc rfta Inicoion- A rm:ll rnd tutulugu Meckel'dlvertlktJliJne .lt8t tSlundekl ekt 1v1tc nldeyd roundcd .rca of upoke wes identified in fhc righi-lowcr riudrent. Thus xinrigremr alttakl wcrc interprctcd es poritivc- Thc pttient wrj opcr.red on conrcqucntly end hisropetho. aktlvlte ' lse neaarieye 1-' rA {*2 logir cr.rmimtion confirmed thc prernct Although, tfiis tchnique 'fl{,', of ectopic tzJtric nrrcore in ihc divcrtjculum. tre5 clrtein limiutions h is of r jrerr'nlue in the noninvusivr' diagnosisof Meckel's divmiculum. KAYNAKLAR Berquist TH, Nobn NG, Stephenr DH, Cerlrcn C : Spccificity o1 l69nlpcrtechneute in rintigraphic 1t1-\ diagnosis of Meckel'r diverticulum. Rcvic'wof 100 cascs-J N M 1l :465469.1976. Chaudhuri TK : Cellu lar sire of Tc$nQsccrction in the rtomach. J N M 1 7 : 756- 7s1,1976. C c i o p r cM r : D i a g n o s i so f t r l c c l e l d i v e r r i c u l u m b y s o d i u m p c r t e r h n r u r c l . 9 t ! . r n . I A ['l A 1f5 :1411 1 4 1 ?. 1 9 ] 6 O u s uv n r l i O C ) .A n t h o n c R r-..' 1r';:' r 11;, : ,.,iil:O:a:l , / f.i r I;. f : I . t r \ r - r a 1a( 'n d : b d o m r n a l \ r r n n r ( ) f A n r I R o r n r g e ' r r rllO 9 I j i'.:'l.'l:r.r,- f r j u r r : l i n l u s r , r qr r - . t i ( )dr . n p n 1 1 r z l c llj. \ I ' ,.1 . -1 qltl' , 72q l Jl lal{) 6", t. FeggiLM, EiSftiSM : Technicrfnot6 for 5cinrigraphyof Mcckcl'sdivcniculum.f . Nucl.Mcd,20 :888J89, 1979. 5. Gclf:nd Mf, Silbcctcin fB, Cox f : Diegnosiso{ Meckcl.t divcniculumby rinrignphy : Clinicalerd perholo3icel corrcbrion. .f N M l7 : 553, 1976" 7. Hrrbcn f, Dr Roch: AF : Tcxtbookof Nucle.rrMcdicincVol tt : Clinial Apptiorions,SccondEd. 1984LtA end Febi3er,Philedclphies :225-278 8. Her&n R McG, Alcxrndcr WD, Kcnncdy'l , trorop. upukc rnd r<:nningof io rrucfi in rnenwith l.9mpcrrcchncutc. Ltn<cr. : t 105-1307, 1967. 9. Ho f t, Gkercn WA, Thomprcnf S : Thc expendingrp.ctrum of dirar dcrnonltrrblc by Tc-9*rpcrrcchncarcrMomin:l irruging., N M l9 :691 1978. 10. lrvinc Wf , SrewenAG. Mc lo,u3frlin GP : Apprzis:l qf rpptic.tion of Tc99tL escrmcnr of larric funcrion.Lznc42:648-553, 1967. ll. A, Lcvy LM : Prcopcrerivcdie3noritof btcrdingMeckcl'rdif eror R, S<hursheim (cchncriurn vrriculum uriliring 99 m-pmcchncarc rinrilnuging. f . pcdieu.82 : 4s-49,1973. vrti(ulum :nd othcr ebcrrelionsby rintijrephy. ll. Indicztionslrd rncrhodr-A l0- yar cxpcricncc., N M 22 :732-738, l98l 22. 9gzr V V, PicconcI M : Thc gaJui( uptrkc rnd rccrclionof Tc-99m p€rtcchncrrtc.ftcr H2 rcccptorblobgcin do6. I NM 2l :57, 1980. 23" SrddrqurA, Ryo UY, PinsLy5M : ArrcrbvcnouJflulfornution rimuhting Mcckcl'r divertuculumon TcSm -;rrtcchrrutc rMomin:l rcintiSr.phy.R:diotogy122 : 1 7 31 1 4 .1 9 7 724. Wilron JP, Wcnrcl WW,C:mpbcll J8 : fcchrrtium lc:nl in thc dcrccrion of grrtrolntcsrinelhcmorrhege.Preopcrrrivediegrrcrlrof cntcric duplicrtlon In en infrnt. I A M A L37 :265-266, 1911. 25. t{inc C R, Nrhrword DL, Weldheurn I A : Rolc of thc rcchnctiumtctn ln rhc dir3, norirof Mcckel'rdivcrticulum.l. PcdLtr.Sory.9 : E85J88, 1974. 25. lfintcr P F : Sodium pcrlechndrrc Tc-99 m r:nning of rhc eMon*n. Di4norir o f : n i l q l d u p l i a t l o nc y n . , A M A 2 3 7 : 1 3 5 2 - 1 3 5 3 ,1 9 7 7 . 12. Jcwcn TC, Durry.nrti DO, Alhn JE : The vistreliz:rionof Mcckcl.rdiva-ticulum with 99 m Tc-pcrtcchncure,Surgery6E :567-570, 1970. 13. Kilprtrid 7]1, Allyq CR : Redioirotopcdctcaion of Meckcl't diwrticulum czuring rcutr rccat hcnprrhege.N Eng., Mcd. 287 :65j-554,197?. 14. Merk R, Yourts L, Fcqurcn C : Dignoris of en inrethoocic ;rtrogtnic cyn r.lsing Tc99m pcr-rccfirratc.Rrdiotosy109 :137-138 ,1913. . ' 15. Martin Gl, Kutncr FR, MoscsL : Di4nosis of Meckcl';divcr1is11tg6 by ndioirctop. tcannint.Pcdietria57 :11-12,191616. Muroff LR, Cr.erelleWf, JohnsonPM jPreoperativediagrrosis of Meckel'sdiverticulum. Ar€iogrephicend r:dionuclidciudies in an edult. , A M A 729 .. lgOO1902,197411. PolgaJP,Srrgcntf , DickinsonP : Positiveintesrinalscancau:cdby orcinoid rumor J N M l5 :365-36'6,1974. 18. Roscntlull L, Henry JN, Murphy DA : Rrdiopertechnctrteimagingof the Meckcl's divcrriculum.Rediology105 : 371 -37 3, 1972 19. Sf:hi:nekis Gf AndcrsonGF, King DR, Boles T : The effecr of garuoinresrinal , hormonc on the pcrterhneuteimagingof ectopic gastricmucrsa in exprerimental Meckcl's diverticulum_ J N M 22 :678-683, lglil- 20 S{akian:kis Gn, Conw:y' I | : Dcrecrionof ctropir g:stric mucosain Mt: Lel'<di vrniculumrnd in odrcr:bcnationsby scintigr:pl:1| f'arhophl,rioloql, anrl l0 21 _\tartlrn,ul crtxtrcrxr '-o, 1,i:l*:rnairi:L. i:, ,,,!\{' I f . i f . 1? ? : 6 . 1 1 - 6 i 4 , l,_l5l way .| | : Detcction ol t<loJrrr gasul( .nurola in Mr L,.!s di. l_( 'l