ACR Appropriateness Criteria® Radiologic Management of Lower Gastrointestinal Tract Bleeding: 2021 Update

Abstract

Diverticulosis remains the commonest cause for acute lower gastrointestinal tract bleeding (GIB). Conservative management is initially sufficient for most patients, followed by elective diagnostic tests. However, if acute lower GIB persists, it can be investigated with colonoscopy, CT angiography (CTA), or red blood cell (RBC) scan. Colonoscopy can identify the site and cause of bleeding and provide

Gastrointestinal Bleeding in Patients with SARS-CoV-2 Infection Managed by Interventional Radiology

“…Indication for the procedure of embolization was established after a multidisciplinary consensus among gastroenterologist, radiologist, and surgeon on the basis of CT and/or endoscopic findings in association with clinical and laboratory data. In some cases, embolization was proposed after an unconclusive endoscopy or when endoscopy was not feasible [19,20].…”

Clinical progress note: Diagnostic approach to lower gastrointestinal bleeding

“…In the case of a previously confirmed location, an alternate therapy (e.g., endoscopic clipping if previously treated with embolization, or vice versa) can be employed. This is consistent with ACR guidelines but is not addressed by ACG guidelines 3 . For those without prior localization, CTA should be performed as rapidly as possible at the start of the rebleeding given the difficulty of locating an intermittently bleeding diverticulum on colonoscopy.…”

“…Therapeutic angiography without initial CTA is typically reserved for those patients who are hemodynamically unstable. The American College of Radiology (ACR) appropriateness guidelines state that in hemodynamically stable patients, CTA is “usually appropriate” while direct arteriography “may be appropriate,” further emphasizing a CTA‐first approach in the majority of patients 3 . However, in unstable patients (>5 units of blood in 24 h OR hemodynamic instability), both direct arteriography and CTA are “usually appropriate.” 3 Prior radiologic methods of inducing vasospasm (e.g., infusion of vasopressin) have been almost entirely replaced by the use of highly selective embolization.…”

“…This is consistent with ACR guidelines but is not addressed by ACG guidelines. 3 For those without prior localization, CTA should be performed as rapidly as possible at the start of the rebleeding given the difficulty of locating an intermittently bleeding diverticulum on colonoscopy. Available data indicate that the yield on repeat evaluations during the same admissions decreases but that an alternative method may be able to identify a source where prior investigation has failed.…”

“…Most frequently presenting as hematochezia, LGIBs are typically colonic in origin and can also present as melena for slower proximal colonic or terminal ileal bleeds. Although mortality can be up to 10%, 3 there is insufficient data to guide clinicians in choosing first line and subsequent testing for suspected or known LGIB 2 . Diagnostic and therapeutic options can be categorized as endoscopic, radiologic, and surgical, leading to a need for a multidisciplinary approach to the management 1 .…”