Chronic recurrent multifocal osteomyelitis; manifestation, imaging and diagnosis

Chronic recurrent multifocal osteomyelitis [CRMO] is an inflammatory bone disease usually affecting children. A 9-year old boy presented with recurrent lower extremities pain and discomfort lasting for two years. In every time, symptoms vanished after several weeks. The patient received antibiotics only in one period of bone pain. In other occasions the patient didn't received any antibiotics. In last episode of bone pain, symptoms disappeared by use of naproxen. In patient's X-rays, there were multifocal areas of sclerosis with a wide transitional zone accompanied by a fine periosteal reaction. Regarding his history and MRI, bone scan findings were more in favor of active inflammatory process in the involved regions. In needle biopsy and bone curetting of left and right tibiae, osteonecrosis, mild inflammatory fibrosis, and scattered chronic inflammatory cells consistent with chronic osteomyelitis were noticed. No malignant neoplastic tissue was identified. In 2-year follow-up, diagnosis of CRMO was confirmed by serial laboratory tests, three-phase bone scan, CT and MRI findings. This diagnosis was proved by pathology evaluation following needle bone biopsy

value of lateral lymphoscintigraphy images of the pelvis for gynecological cancers: are they necessary?

In the current study we evaluated the incremental value of lateral pelvic lymphoscintigraphy imaging of endometrial or cervical cancer patients who underwent sentinel node mapping. Operable endometrial and cervical cancer patients without clinical or paraclinical evidence of lymph node involvement were included in the study. The day before surgery the patients were sent to the nuclear medicine department for injection of the radiotracer. All patients received two intra-cervical injection of 1 mCi/0.2 cc radiotracer in the 6 and 12 hour locations. 18-24 hours after the radiotracer, lymphoscintigraphy imaging in anterior/posterior and lateral views was done. After induction of anesthesia, 2 mL Methylene blue in two aliquots was injected intra-cervically in the same location as the radiotracers. During operation, any hot and/or blue node was harvested as sentinel nodes. Overall 40 patients were included in the study [30 endometrial and 10 cervical cancers]. Sentinel node visualization was achieved in 30 patients. These sentinel nodes were all visualized on the ANT/POST views. Only in 7 patients sentinel nodes could be visualized on the lateral views. Intra-operative sentinel node detection rate was 38 out of 40 [95%]. Radiotracer detection rate was 37/40 [92.5%] and blue dye detection rate was 17/40 [42.5%]. Anterior/Posterior pelvic lymphoscintigraphy imaging is sufficient for imaging in cervical and endometrial cancer patients undergoing sentinel node mapping. Lateral views can be omitted due to limited valued of these projections

Is [99m]Tc-MIBI scintigraphy a predictor of response to pre-operative neoadjuvant chemotherapy in osteosarcoma?

Multidrug resistance [MDR], which may be due to the over expression of P-glycoprotein [Pgp] and/or MRP, is a major problem in neoadjuvant chemotherapy of osteosarcoma. The aim of this study was to investigate the role of Tc-99m MIBI scan for predicting the response to pre-operative chemotherapy. Twenty-five patients [12 males and 13 females, aged between 8 and 52y] with osteosarcoma were studied. Before the chemotherapy, planar [99m]Tc-MIBI anterior and posterior images were obtained 10-min [tumor-to-background ratio: [T[1]/B[1]][10min]] and 3-hr after tracer injection. After completion of chemotherapy, again [99m]Tc-MIBI scan was performed at 10-min after tracer injection. In addition to calculation of decay corrected tumor to background [T/B] ratios, using the 10-min and 3-hr images of the pre-chemotherapy scintigraphy, percent wash-out rate [WR%] of [99m]Tc-MIBI was calculated. Using the 10-min images of the pre- and post-chemotherapy scans, the percent reduction in uptake at the tumor site after treatment [Red%] was also calculated. Then after surgical resection, tumor response was assessed by percentage of necrosis. All patients showed significant [99m]Tc-MIBI uptake in early images. Only 9 patients showed good response to chemotherapy [necrosis >/= 90%] while 16 patients were considered as non-responder [necrosis <90%]. There was no statistical significant difference between non-responders and responders in [T[1]/B[1]] [10min].There was a significant negative correlation between WR% and percentage of necrosis [P=0.001]. On the other hand, there was a significant correlation between Red% and percentage of necrosis [P<0.001].There was also statistical significant difference in WR% and Red% between non-responders and responders [both P< 0.001]. Washout rate of [99m]Tc-MIBI in pre-chemotherapy scintigraphy as well as Red% using pre- and post-chemotherapy MIBI scintigraphy are useful methods for predicting response to neoadjuvant chemotherapy

Gated [99m]Tc-MIBI myocardial perfusion SPECT in patients with right bundle branch block but without evidence of coronary artery disease

We aimed to investigate the effect of right bundle branch block [RBBB] on perfusion and functional parameters in dipyridamole stress/rest Tc99m-MIBI gated myocardial perfusion SPECT [GSPECT] which may be helpful in interpretation of myocardial perfusion imaging. We studied 73 patients with low pre-test likelihood of coronary artery disease in two groups: 38 patients with RBBB and 35 subjects with normal ECG. Both groups underwent two-day dipyridamole stress-rest Tc99m-MIBI GSPECT. Two groups were matched. There was no significant difference in sex and age variable between two groups. Visual calculated SSS and SRS in all patients were between 0 and 3. Regarding the prone images, diaphragmatic attenuation and breast attenuation, all patients GSPECT findings were within normal limits. There was no significant difference in TID ratio between two groups: RBBB group: TID ratio= 1.02 +/- 0.16 and control group: TID ratio= 0.96 +/- 0.14 [P=0.09]. There was no significant difference in left ventricular end-systolic volume, end-diastolic volume, ejection fraction, summed stress and rest motion and thickening scores between RBB patients group and control group. No regional LV wall motion abnormality was noticed in any patient in either group. High normality rate of the LV myocardial perfusion and functional indices in the presence of RBBB was noticed in gated Dipyridamole stress/rest Tc-99m sestamibi myocardial perfusion SPECT. No remarkable false positive perfusion findings or abnormal LV functional indices acquired by GSPECT in this group of patients

Gated myocardial perfusion SPECT in patients with left bundle block but having low probability of coronary artery disease; as compared to the patients with normal electrocardiogram

We aimed to investigate of effect of left bundle branch block [LBBB] on perfusion and functional parameters in dipyridamole Tc99m-MIBI gated myocardial perfusion SPECT which may be helpful in interpretation of myocardial perfusion imaging. We studied 70 patients with low pre-test probability of coronary artery disease in two groups: 35 patients with LBBB and 35 subjects with normal ECG. Both groups underwent two-day dipyridamole stress-rest Tc99m-MIBI GSPECT. From 35 patients with LBBB, 6, 12, and 3 patients had reversible, fixed and partially reversible defects respectively. In 35 patients with LBBB, 8 [22.9%], 6[17.1%] 15[42.9%] and 10 [28.6%] patients had perfusion defects in the apicoseptal, mid-anterior segments, mid-anteroseptal and mid-inferoseptal segments respectively. There was significant difference in TID ratio between two groups: LBBB group: 1.07 +/- 0.21 and control group: 0.96 +/- 0.14 [P=0.01]. There was a significant difference in end systolic volume and ejection fraction between LBBB patients group and control group, while no significant difference was noticed in end-diastolic volume. Nineteen, 14 and 2 from 35 patients with LBBB had normal LV wall motion, paradoxical septal wall motion, and septal hypokinesia, respectively. False positive septal, anterior and apicoseptal perfusion abnormalities are frequently seen on Tc99m-MIBI GSPECT, in patients with LBBB without CAD. Moreover reversible defects are frequently seen with Tc99m-MIBI. Even Tc99-MIBI and vasodilator stress do not increase diagnostic accuracy to clinically useful levels. Lower systolic performance and higher TID ratio could be seen in these patients

Sentinel node mapping for early breast cancer patients using[99m]Tc-phytate: Single center experience on 165 patients

Several radiotracers are being used for sentinel node mapping in patients with breast cancer. In the current study, we reported our experience with 99m-Tc Phytate for sentinel node mapping in Mashhad University of Medical Sciences. All breast cancer patients who underwent sentinel node mapping using 99m-Tc Phytate were included. All patients received intradermal peri-areolar injection of 0.5 mCi/0.lcc 99m-Tc Phytate. Lymphoscintiraphy was performed for 145 patients 5-10 minutes post-injection. The sentinel nodes were found during surgery using a hand-held gamma probe as well as blue dye technique. In total 165 patients were evaluated. Lymphoscintigraphy showed axillary sentinel nodes in 135 out of 145 patients [93%] following imaging. At least one sentinel node could be detected in all these 135 patients during surgery. In the remaining 10 patients with sentinel node non-visualization, 5 had sentinel node harvesting failure during surgery. Median number of sentinel nodes on the lymphoscintigraphy images was 1. Sentinel node detection rate was 95% [157/165]. In the 8 patients with sentinel node harvesting failure, 7 had pathologically involved axilla. Median number of harvested sentinel nodes was 1. Mean sentinel node to background count ratio was 10 +/- 2. 99m-Tc Phytate is an effective and highly successful radiotracer for sentinel node mapping. Sentinel node can be visualized in a short time after 99m-Tc Phytate injection on the lymphoscintigraphy images. The sentinel to background count during surgery is high which results in more convenient sentinel node harvesting and high detection rate

Urinary reflux to the non-functioning previous renal graft

Nuclear medicine imaging is routinely used for evaluation of perfusion and function of the transplanted kidneys. At present, the radiopharmaceutical of choice for this study in our center is Tc 99m-Ec. Complications of the kidney graft are demonstrable in the early and delayed images. One of these complications is vesicoureteral reflux to the graft or to the native kidneys. We present a 27 year old patient with elevated BUN and Cr ten days after kidney transplantation. He previously had failed renal transplantation due to rejection. Tc-99m EC renal scan revealed decreased perfusion and function suggesting acute rejection. In the late functional images [at 24 minute], vesicoureteral reflux to the previous non-functioning graft was also noticed on the right side of the pelvis. We recommend considering vesicouretral reflux while interpreting renal transplant imaging since this can be easily mistaken with other complications such as urine leakage

Can gallbladder ejection fraction measured by fatty meal cholescitigraphy diagnose chronic cholecystitis?

Despite presence of a body of evidence in support of high accuracy of cholecystokinin cholescintigraphy [CCK-CS], for diagnosis of chronic cholecystitis[CC], some authors have claimed that gallbladder ejection fraction [GBEF] has poor predictive diagnostic values. The purpose of this study was to determine if there is any difference in GBEF between normal individuals and patients with CC. In a prospective case-control study, we studied 36 subjects as control group who did not have any abdominal symptoms, or history of abdominal disease or gallstone. Patients group were 42 with established choronic calcalous cholecystitis[CCC] who complaining of chronic biliary-like pain and had gallstone on ultrasonography. All subjects underwent gallbladder scintigraphy and GBEF was calculated at 30 and 60 minutes after fatty meal [FM] ingestion. In control group GBEF at 30-minute and at 60-minute after FM ingestion were 69.54% +/- 21.04% and 84.26% +/- 11.41% respectively while in patients group GBEF at 30-minute was 61.21% +/- 16.01% and at 60-minute was 80.22% +/- 12.57%. No significant difference was noticed between control and patient groups. GBEF didn't show significant difference between different groups based on the number of gallbladder stone, severity of chronic inflammatory [lymphoplasma] cell infiltration, wall thickness and evidence of fibrosis in the gallbladder wall. Our data are against the diagnostic value of the GBEF as measured by FM-CS in the workup of patients with CC. Thus, interpretation of GBEF should take the proper clinical context into consideration

Comparison between early and delayed images of [67]Ga scintigraphy for evaluation of recurrent lymphoma

Despite widespread use of [67]Gallium for lymphoma evaluation, timing of imaging after injection is a matter of controversy and to the extent of our knowledge no direct comparison has been made between early and delayed gallium images. We aimed to compare 24 and 48 hours post injection planar gallium imaging for evaluation of lymphoma recurrence. 255 patients suspicious of recurrent lymphoma were included in the study. Twenty four and 48 hours post injection [10 mCi] whole body Gallium imaging was performed. Semi-quantitative evaluation [background corrected] was carried out in positive whole body [67]Gallium scans. Diagnosis of recurrence was made by combination of clinical or pathologic examination if possible. In 59 patients the final diagnosis was made by tissue biopsy. In case of uncertain diagnosis, follow up of the patients [mean duration of 13 months] was used. The diagnosis was finally made by the referring hematologist. Whole body gallium scintigraphy was positive in 115 out of 150 patients with recurrence [sensitivity of 76%]. Comparison of the 24 and 48 hour images did not show any new lesion in the 48 hour images. However, delayed 48 hours images were required for definite detection of the gallium avid lesions in the abdominal and pelvic areas in 40 patients. Semi-quantitative evaluation of the lesion showed higher lesion to background ratio for 48 compared to the 24 hour images [p<0.001]. Considering higher lesion to background activity in the 48 hour images, delayed whole body [67]Gallium imaging may be more desirable for diagnosis of recurrent lymphoma, however 24 hour images may be sufficient. Delayed imaging can be reserved for suspicious activities [such as in abdominal images]. The strategy can save time and is more convenient for the imaging centers

Echocardiographic left ventricular functional changes in acute hypothyroidism vs. subclinical hyperthyroidism in patients with differentiated thyroid carcinoma

In order to assess echocardiographic left ventricular functional indices in patients with differentiated thyroid carcinoma [DTC], after L-T4 withdrawal [short-term overt hypothyroidism] and during TSH suppressive therapy, we have evaluated cardiac hemodynamics in a single cohort study. 24 patients with DTC were studied in two phases: 1: at least 4 weeks after L-T[4] withdrawal, 2: at least 8 weeks after beginning TSH suppressive therapy. All patients underwent conventional, Doppler and tissue Doppler echocardiography. Although early diastolic mitral inflow velocity [E wave] [p=0.033], and early diastolic velocity of mitral annulus [E[m]] [p<0.001], were lower in overt hypothyroidism, there were no differences among left ventricular [LV] Dimensions, LV mass and LV mass index, LV Ejection fraction, late diastolic mitral inflow velocity [A wave], E/A ratio, deceleration time [DT], peak systolic velocity of mitral annulus [S[m]], late diastolic velocity of mitral annulus [A[m]], E[m]/A[m] ratio between the two phases. Pulse rate [p<0.001], LV end diastolic volume [p=0.011] and LV end systolic volume [p=0.003] were higher, while QTc Interval was shorter [p <0.001] during TSH suppressive therapy. E/E[m] ratio and pulmonary capillary wedge pressure [p=0.042] were higher in hypothyroidism phase. Three patients developed mild pulmonary artery hypertension and 2 of the patients had mild pericardial effusion during TSH suppressive therapy. Short-term overt hypothyroidism or L-T4 suppressive therapy in patients with DTC may have undesirable cardiovascular effects. So in patients with known history of cardiovascular abnormalities, the caring physician should be aware of the cardiovascular complications during hypothyroidism or suppressive therapy

Sentinel lymph node biopsy in melanoma patients: an experience with Tc-99m antimony sulfide colloid

Sentinel lymph node biopsy is the standard procedure for lymph node staging in intermediate thickness melanoma. In Iran, this procedure has not been addressed sufficiently. In this study, we report our experience in this area. Ten consecutive patients with intermediate thickness melanoma where included in our study. 1.5 mCi of Tc-99m antimony sulfide colloid in two divided dose was injected around the tumor. All patients underwent surgery 2-4 hours after injection of the tracer. Patent blue V dye was also used for 8 patients. Using a hand-held gamma probe, the sentinel nodes were harvested and sent to the pathologist for frozen section and H and E review. For patients with positive sentinel nodes, lymph node dissection was performed. At least one sentinel node could be harvested in all patients. The mean number of sentinel nodes was 1.66. Detection rate with radiotracer and blue dye was 100% and 75% respectively. 30% of the patients had positive sentinel nodes. One patient in the pediatric age range and one head and neck melanoma were included in our study with successful sentinel node mapping. Sentinel lymph node biopsy using Tc-99m antimony sulfide colloid is a reliable and safe method in melanoma patients which can help in treatment planning and patient's ultimate prognosis

Sensitivity of gallium scintigraphy for evaluation of recurrent lymphoma: comparison of planar and SPECT imaging

Although PET scanning using F-18[FDG] is considered the superior radiotracer for tumor imaging, Gallium-67 is still in use for some malignancies such as lymphoma and hepatoma. One of the strategies to improve the diagnostic accuracy of Gallium is to perform SPECT which is reported to be more sensitive compared to planar imaging. In this study we compared the sensitivity of SPECT and planar imaging in patients suspicious of thoracic recurrent lymphoma. 129 patients with suspicious recurrent lymphoma of the thorax were included into the study. All patients received 10mCi Gallium-67-citrate intravenously. Twenty four and 48 hours post injection whole body and thoracic SPECT imaging was performed. The final diagnosis of recurrence was achieved by combination of clinical and imaging findings or pathologic examination whenever possible. The final diagnosis of 83 [64.3%] patients was recurrence of lymphoma in the thoracic area and the remainder 46 [35.7%] were in remission. The sensitivity of planar and SPECT imaging for diagnosis of recurrent lymphoma was 63% [[52-73%] with 95% confidence intervals] and 87% [[79-94%] with 95% confidence intervals], respectively. In our study, 20 patients with the final diagnosis of lymphoma recurrence in the thoracic area had negative planar despite positive SPECT imaging. This showed an increase of 24% in sensitivity of the scan [from 63% to 87%] by adding SPECT imaging to the procedure. Our recommendation is integrating SPECT modality into all gallium scintigraphy for lymphoma recurrence

Effect of evidence based medicine training in the quality of journal clubs: a road to evidence based journal clubs

Journal clubs play an important role in teaching Evidence Based Medicine [EBM]. Evidence based journal clubs focus on real problems of the group, and set a minimum level of evidence for articles to be presented, and in the end a clinical bottom line is set to be used in the daily clinical practice. In this article, we have explained our experience in running evidence based journal clubs in the previous year and the challenges in the path of this goal are discussed. Before starting the evidence based journal clubs, we set up several lectures on EBM for the teachers of the research center as well as the residents. From September 2010 to November 2010, we ran the journal clubs of our research center by a two-session plan: first identifying an important clinical question, second presenting the best available evidence. The assigned levels of evidence for evidence based journal clubs as well as previous traditional one were compared. Twelve journal clubs were presented in the study period: Five systematic reviews, 2 guidelines, 3 narrative review articles, and 2 individual articles. Ten out of 12 traditional journal club articles were narrative review articles and 2 were clinical guidelines. 41.6% of the evidence based journal clubs were assigned level 1 of evidence. In contrast 83.3% of traditional journal clubs were in the 4[th] level of evidence. Evidence based journal clubs can be very useful in improving the quality of presented articles in the journal clubs and are invaluable for teaching EBM

Minimally invasive radio-guided surgery for hyperparathyroidism: an experience with Tc-99m sestamibi

Radio-guided parathyroid surgery along with other minimally invasive surgeries constitutes the main surgical treatment procedures for different kinds of hyperparathyroidism. In this article we have reported our experience of radio-guided parathyroid surgery using Tc-99m sestamibi. Ten patients with hyperparathyroidism included in our study. Twenty mCi of Tc-99m sestamibi was injected intravenously to the patients in the day of surgery. All patients underwent surgery 4 hours after injection of the tracer. Abnormal parathyroid glands were localized by surgical gamma probe during surgery and were removed. Eight out of 10 patients had single adenoma. One patient had parathyroid hyperplasia secondary to chronic renal failure. The one remaining patient had persistent hyperparathyroidism with previous unsuccessful parathyroid surgeries. Except for the patient with parathyroid hyperplasia, parathyroid hormone [PTH] level of all other patients decreased after surgery including the patient with persistent hyperparathyroidism. Minimally invasive radio-guided parathyroid surgery is an easy and safe method for surgical treatment of hyperparathyroidism. With the increasing availability of surgical gamma probes and nuclear medicine facilities in Iran considering this kind of approach for surgical treatment of hyperparathyroidism seems rational

Normal values of left ventricular functional indices in gated [99m] TC-MIBI myocardial perfusion SPECT

Although left ventricular[LV] function parameters measured by gated myocardial perfusion SPECT [GSPECT] have been validated, experimental data have revealed that the calculated the LV function parameters using GSPECT are affected by patient populations as well as particular acquisition and processing conditions. We tried to determine the normal values of GSPECT in an Iranian population. We studied 3500 Iranian patients who underwent GSPECT in an outpatient setting. To develop normal limits of LV functional indices using GSPECT, 148 patients with a low [<5%] likelihood of coronary disease and normal tomograms were selected. No one of 148 patients had known coronary artery disease, typical angina, history of hypertension, diabetes mellitus, and smoking, any abnormality in echocardiography or hyperlipidemia. They were not taking any medication known to affect LV function at least 2 days before the study. End diastolic volume [EDV], end systolic volume [ESV] and LV ejection fraction [LVEF] were calculated in rest GSPECT using iterative reconstruction and QGS [quantitative gated SPECT] software. Mean EDV, ESV and LVEF were 53.8 +/- 20.2, 14.3 +/- 10.8 and 75.0% +/- 9.6% respectively. These data showed a Gaussian distribution, so mean_2SD would show the upper or lower limits of normal for LV functional parameters. There were the marked sex differences in mean LVVs and LVEF measurements. BMI index had not effect on the measurement of the LV functional parameters. We noticed that 85.4% of our subjects had ESV<25 ml while most of them were women [112/123, 91%]. From a clinical viewpoint, each institute should use a standard protocol for the specific patient population and for the mode of SPECT acquisition and reconstruction. Normal thresholds using GSPECT, OSEM reconstruction and QGS algorithm in men and women were EDV>130, ESV>55 and LVEF<52% and EDV>77, ESV> 26 and LVEF<62% respectively

Persistent sub diaphragmatic activity on the myocardial perfusion scan with [99m] Tc Sestamibi

We present a female patient with atypical chest pain who was referred to our department for ischemia evaluation. 99mTc-MIBI myocardial perfusion scan with dipyridamole stress was performed. Sub-diaphragmatic activity in the hepatic tissue and then in the bowel loops caused severe overlap on the inferior wall even on consecutive delayed images. Dipyridamole stress was repeated for the patient with 201Tl. The study was interpretable this time without any interfering sub-diaphragmatic activity

need for skin pen marking for sentinel lymph node biopsy: a comparative study

There is a consensus in the literature that sentinel lymph node biopsy is the standard procedure for axillary staging in early stage [I and II] breast cancer patients. Usually during lymphoscintigraphy, the location of the sentinel lymph node is marked on the skin by an indelible ink. In this study we evaluated this issue in our patients. 40 patients with the clinical diagnosis of early stage breast cancer [stage I or II] were included into the study. All patients received periareolar intradermal injections of 18.5 MBq Tc-99m antimony sulfide colloid 2-4 hours before the surgery and 2 ml patent blue V dye in a subdermal and periareolar fashion during surgery. The patients were divided randomly into two groups [20 patients in each group]. In group I, the anterior and lateral locations of the sentinel lymph node were marked on the skin with an indelible ink. In group II, no skin marking was used. A sentinel node was defined as any blue node or any node with an ex vivo radioisotope count of twofold or greater than the axillary background. All patients underwent standard axillary lymph node dissection after sentinel node biopsy. Mean age and tumor size were not significantly different between groups. SLN detection rate and number of detected SLNs were not significantly different either [P > 0.05]. Number of detected lymph nodes was 1.24 +/- 0.43 and 1.28 +/- 0.61 in group I and II of the patients, respectively. False negative rate [negative SLN and positive axillary nodes] for both groups were 0%. Although marking the location of the sentinel lymph node on the skin with an indelible ink can guide the surgeon during surgery, it can not increase the sentinel lymph node detection rate or improve the results of sentinel lymph node biopsy

Diffuse bilateral breast uptake on the myocardial perfusion SPECT of a nursing female

Bilateral diffuse intense breast uptake was noted in a 40 year old female who was evaluated with Tc-99m sestamibi [MIBI] myocardial perfusion scan for possible ischemia. She was breast feeding her 1.5 year old child. The intense uptake in the breasts was superimposed on the apical and anteroapical regions of the myocardium and caused interpretation problem. We recommend considering Tc-99m MIBI breast uptake during breast feeding as a possible cause of non-interpretable, superimposition of radiotracer on the myocardium in myocardial perfusion scan

Delayed imaging for detection of Meckel's diverticulum in Tc-99m pertechnetate scintigraphy

Tc-99m pertechnetate scintigraphy is the modality of choice for diagnosis of Meckel's diverticulum. Interpretation of Meckel's scan identifies a focal area of radiopharmaceutical uptake in the anterior abdomen similar to normal gastric mucosa. The activity must be of the same pattern and intensity as gastric uptake. We present a 13-year-old patient with gastrointestinal bleeding and anemia. Tc-99m pertechnetate scintigraphy was performed and initial images did not show any abnormal tracer activity in the abdomen. However, imaging continued and a focal activity was detected on the right side of the abdomen 60 minutes delayed image. Follow laparascope operation the Meckel's diverticulum was removed and the patient's symptoms disappeared completely. It is suggest to pay special attention to delayed images [60 minutes or beyond] especially when earlier images are negative