ABSTRACT. Intestinal lymphangiectasia is a well-recognized complication of the Fontan procedure, occurring in up to 24% of patients. Because of the loss of chylous fluid into the gut lumen, protein-losing enteropathy results as well as lymphopenia and hypogammaglobulinaemia. In some cases, dilated lymphatics in the intestinal serosa or mesentery also rupture, causing chylous ascites. Standard medical and cardiac surgical interventions are generally ineffective and the condition is frequently lethal. We report a case of intractable and lifethreatening chylous ascites and chylothorax in a 14-yearold girl, associated with intestinal lymphangiectasia and protein-losing enteropathy after a Fontan procedure for tricuspid atresia. The condition was refractory to all standard medical therapies, including dietary modifications, diuretics, corticosteroid therapy, albumin infusions, octreotide, heparin, bowel rest, and parenteral nutrition. Cardiac surgery to optimize her hemodynamic status was also ineffective and large volume pleural and ascitic fluid losses continued. Having exhausted all other therapeutic modalities, 99m technetium-dextran scintigraphy was performed to assess the extent of intestinal protein loss and the potential for surgical intervention. Scintigraphy suggested localized protein loss from the proximal jejunum and subsequent segmental resection was effective. Postoperatively, ascites and pleural effusions resolved, and there was no evidence of short bowel syndrome. Growth has accelerated and the patient has entered puberty. There is mild persistent intestinal protein loss requiring diuretic therapy. Ascites or pleural effusions are absent, and the patient remains well >2 years after surgery. Intestinal lymphangiectasia postFontan procedures has traditionally been ascribed to hemodynamic factors such as raised systemic venous pressure, which would predispose to a generalized intestinal lesion. However, in this case, scintigraphy demonstrated a localized, surgically correctible lesion. To our knowledge, this is the first reported case of the use of 99m technetium-dextran scintigraphy for this indication and of successful partial small bowel resection in such a case. Pediatrics 2003;112:e242-e247. URL: http://www. pediatrics.org/cgi/content/full/112/3/e242; intestinal lymphangiectasia, resection, Fontan procedure, 99m technetium-dextran, scintigraphy.

Gastrointestinal (GI) bleeding is not uncommon and responsible for considerable morbidity and mortality. Radionuclide red blood cell scintigraphy (RBCS) is a well established imaging modality for identifying patients with ongoing active GI bleeding. However, false positive RBCS are known to occur. The authors report the findings of a RBCS in an elderly female, who developed GI bleeding following the commencement of anticoagulant therapy. Although active GI bleeding was not identified, two abdominal wall hematomata and a cecal adenocarcinoma were detected. Distinguishing features of these lesions are described.

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