Diagnosis of a Lymphoenteric Fistula by Single-Photon Emission Computed Tomography/Computed Tomography Lymphoscintigraphy

Abstract

Protein losing enteropathy can present as an immunodeficiency. This report describes a rare cause of protein losing enteropathy due to a lymphoenteric fistula and how a novel use of a pre-existing combined imaging technique of single-photon emission computed tomography/computed tomography lymphoscintigraphy helped in making the diagnosis.

Figure 1.

Lymphoscintigraphy showing (A) the flow of a tracer at 30 minutes anterior and posteriorly and (B) flow of a tracer at 1 hour anterior and posteriorly. Flow of the tracer is seen in the deep lymphatics, past the groin in (A and B). The yellow highlighted area shows good tracer flow in the left through the inguinal lymph nodes, pelvic lymph nodes, and para-aortic lymph nodes at 30 minutes and 1 hour. The blue highlighted area shows the flow of a tracer at 30 minutes in the right through inguinal and pelvic lymph nodes but no tracer activity in the para-aortic lymph nodes. The green highlighted area shows tracer activity in the mesenteric lymph nodes at 1 hour. Note clear visualization of the liver, shown by the arrow (→).

Figure 2.

Photon emission computed tomography/computed tomography carried out at 2 hours on the left and correlating it with the lymphoscintigraphy on the right. This shows activity in the left inguinal, pelvic, and para-aortic lymph nodes (highlighted yellow) with no activity in the right para-aortic lymph nodes but instead flow into 2 right sided mesenteric nodes (highlighted green) with subsequent activity appearing in an adjacent loop of small bowel (seen on single-photon emission computed tomography/computed tomography as red in color). The appearance is consistent with a blocked lymphatic system above the mid-abdomen with retrograde flow into right mesenteric nodes and adjacent small bowel.