Swaniker F, Soldes O, Hirschl R B
Department of Surgery and C.S. Mott Children's Hospital, University of Michigan Medical Center, Ann Arbor 48109-0245, USA.
J Pediatr Surg. 1999 May;34(5):760-4; discussion 765. doi: 10.1016/s0022-3468(99)90370-6.
The aim of this study was to assess the utility of technetium (Tc) 99m pertechnetate scintigraphy in the diagnostic workup of the pediatric patient with gastrointestinal (GI) bleeding and a suspected Meckel's diverticulum.
The charts of 235 consecutive patients evaluated with a Meckel's scan (n = 165) or with the discharge diagnosis of Meckel's diverticulum (n = 70) between January 1975 and October 1997 were reviewed for presenting symptoms, bleeding characteristics, diagnostic studies and pathological diagnosis. Those patients with lower GI bleeding and a serum hemoglobin level less than 11.0 g/dL who underwent a 99mTc pertechnetate scan (n = 43) were assessed for utility of the scan.
In all patients the Meckel's scan had a positive and negative predictive value of 0.93. However, in patients with lower GI bleeding and a hemoglobin less than 11.0 g/dL the Meckel's scan had a sensitivity of 0.60, a positive predictive value of 1.0, a specificity of 0.96, but only a negative predictive value of 0.74. As such, the probability that a child who presents with GI bleeding and a serum hemoglobin less than 11 g/dL will have a Meckel's diverticulum despite a negative Meckel's scan of 0.26. We further evaluated the eight patients with a false-negative scan: ectopic gastric mucosa was present on pathological examination in all eight patients. Pentagastrin stimulation was performed at the time of scintigraphic study in three of eight. Six of these eight patients had duplicate scans that also were negative. Patients with a false-negative (FN) scan had significantly increased hospital charges when compared with those with a true positive (TP) scan (TP = $5012 +/- 1992; FN = $8554 +/- 1506; P = .0001). Clinical suspicion had a major effect on the decision-making process in these patients independent of the results of the Meckel's scan, and all eight patients ultimately underwent exploratory laparoscopy-laparotomy with Meckel's diverticulectomy despite the scan results.
The relatively low negative predictive value of the Meckel's scan may result in the need for operative evaluation despite the scan data. As such, the contribution of the scan to clinical decision making is low. These findings suggest that exploratory laparotomy or laparoscopy may be indicated instead of scintigraphic scanning in the assessment of the anemic (hemoglobin less than 11 g/dL) pediatric patient with lower GI bleeding, especially in patients in whom a high suspicion for a bleeding Meckel's diverticulum exists.
本研究的目的是评估锝（Tc）99m高锝酸盐闪烁扫描在患有胃肠道（GI）出血且疑似梅克尔憩室的儿科患者诊断检查中的效用。
回顾了1975年1月至1997年10月间连续接受梅克尔扫描（n = 165）或出院诊断为梅克尔憩室（n = 70）的235例患者的病历，以了解其呈现的症状、出血特征、诊断研究和病理诊断。对43例接受99mTc高锝酸盐扫描的下消化道出血且血清血红蛋白水平低于11.0 g/dL的患者评估该扫描的效用。
在所有患者中，梅克尔扫描的阳性和阴性预测值为0.93。然而，在下消化道出血且血红蛋白低于11.0 g/dL的患者中，梅克尔扫描的敏感性为0.60，阳性预测值为1.0，特异性为0.96，但阴性预测值仅为0.74。因此，尽管梅克尔扫描结果为阴性，但出现胃肠道出血且血清血红蛋白低于11 g/dL的儿童患有梅克尔憩室的概率为0.26。我们进一步评估了8例扫描结果为假阴性的患者：所有8例患者的病理检查均发现异位胃黏膜。8例中有3例在闪烁扫描研究时进行了五肽胃泌素刺激。这8例患者中有6例重复扫描结果也为阴性。与扫描结果为真阳性（TP）的患者相比，扫描结果为假阴性（FN）的患者住院费用显著增加（TP = 5012美元±1992美元；FN = 8554美元±1506美元；P = 0.0001）。临床怀疑对这些患者的决策过程有重大影响，与梅克尔扫描结果无关，并且尽管扫描结果如此，所有8例患者最终均接受了探索性腹腔镜 - 剖腹手术及梅克尔憩室切除术。
梅克尔扫描相对较低的阴性预测值可能导致尽管有扫描数据仍需要进行手术评估。因此，该扫描对临床决策的贡献较低。这些发现表明，在评估患有下消化道出血的贫血（血红蛋白低于11 g/dL）儿科患者时，尤其是高度怀疑出血性梅克尔憩室的患者，可能应选择探索性剖腹手术或腹腔镜检查而非闪烁扫描。
