Acute gastrointestinal bleeding: detection of source and etiology with multi-detector-row CT

Scheffel, Hans; Pfammatter, Thomas; Wildi, Stefan; Bauerfeind, Peter; Marinček, Borut; Alkadhi, Hatem

doi:10.1007/s00330-006-0514-9

Cited by 110 publications

(86 citation statements)

References 14 publications

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“…Delayed follow-up examinations may be required to localize the bleeding. Therefore, to maximize detection capabilities, it is crucial that CT angiography should be performed as soon as possible while the patient is actively bleeding [7,8]. Indeed, the likelihood of identifying the bleeding source is higher when CT scan is carried out in hemodynamically unstable patients, with monitoring provided by intensive care unit physicians.…”

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confidence: 99%

“…Factors influencing the ability to visualize active bleeding at CT are multiple, as previously described, and include the nature of the bleeding lesion (bleeding rate, intermittence), patient factors (hemodynamic status, body mass index), but also the CT technique (rate of injection, concentration of iodine in contrast material, number of phases, type of scanner, post-processing), and the experience of the radiologist [8,9]. The addition of imaging phases to the CT angiography study may provide more information but also increases the total radiation dose.…”

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confidence: 99%

“…The addition of imaging phases to the CT angiography study may provide more information but also increases the total radiation dose. The highest sensitivity for detecting intestinal bleeding is achieved by means of a dual-phase protocol (arterial and portal venous phases) which improves detection of extravasated contrast medium during the arterial phase and also provides information about the cause of the bleeding [4,8], a technique not used in the accompanying study.…”

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confidence: 99%

“…In summary, the use of multidetector CT angiography in the diagnostic work-up of patients with acute GI bleeding continues to increase due to improvements in scanning technology [4,8]. CT angiography is a noninvasive, rapid, reproducible, and widely available technique that can be performed successfully in the majority of patients presenting with an acute episode of acute lower GI bleeding from colonic diverticula, without the need for colonic preparation.…”

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confidence: 99%

“…Due to the intermittent nature of GI bleeding, CT angiography should be performed as soon as possible after the clinical detection of active bleeding to maximize detection potential. Nevertheless, lesions can be identified even if an active bleeding site is not [8]. Rather than restricting it to cases where colonoscopy fails initially, CT angiography is proposed as a first diagnostic modality in the evaluation of patients with substantial bleeding (Table 1).…”

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Multidetector CT Angiography for the Detection of Colonic Diverticular Bleeding: When, How, and Why?

Loffroy

2013

Dig Dis Sci

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Acute lower GI bleeding is responsible for 1-2 % of hospital emergencies, 15 % of which manifest as massive, lifethreatening bleeding. Initial clinical management focuses on identifying the site and cause of bleeding using scintigraphy, arteriography, and colonoscopy [1][2][3]. Although optical colonoscopy is the procedure of choice, its use poses challenges in the emergency setting [1]. Administration of bowel preparation, not always feasible in cases of massive bleeding, can delay the procedure for several hours; the presence of clots, blood, and stool in patients without preparation may hinder the visualization of the bleeding point, increasing the rate of incomplete studies when compared with nonemergent examinations. Furthermore, in 10-12 % of cases, the source of bleeding may be extracolonic [4]. Angiography is an invasive procedure usually reserved for therapeutic purposes in patients with more severe, life-threatening bleeding. Technetium 99 mlabeled red blood cell scintigraphy is more sensitive than arteriography for identifying lower rate bleeding, although its emergency availability is variable, limiting its usefulness [4]. Computed tomography (CT) and, more specifically, CT enterography is commonly used as a second-line procedure in nonemergent patients with unexplained GI bleeding after negative upper and lower endoscopy examinations [5]. Since CT is rapid, noninvasive, and highly reproducible, it is commonly used in the acute setting for evaluating patients with lower GI bleeding emergencies, although optimal timing and patient characteristics for the diagnosis of colonic diverticular bleeding have not been established. In this issue, Obana et al. [6] prospectively explored the utility of contrast-enhanced CT in 52 patients with colonic diverticular bleeding testing the hypothesis that CT complements colonoscopy in this setting. Favorable patient characteristics, based on univariate analysis, included feasibility of examination within 2 h of the last hematochezia, re-bleeding in hospital, or past history of diverticular bleeding.Detection and localization of the bleeding source enable successful catheter-directed endovascular therapy. Although emergent colonoscopy remains the primary investigation in lower GI bleeding, it is often negative or impractical during the acute phase in hemodynamically unstable patients, as confirmed in the accompanying study [6]. In many centers, CT angiography is performed if endoscopy fails to identify the bleeding source with conventional mesenteric angiography reserved for patients with CT evidence of active contrast extravasatio or hemodynamic instability due to massive hemorrhage. CT may visualize acute lower GI bleeding at a bleeding rate less than the 0.5 ml/min limit cited for mesenteric angiography, perhaps as low as 0.2 ml/min [5]. The additional information provided by CT before attempted therapeutic angiographic procedures improves the preoperative localization and characterization of the bleeding source, expediting the selective catheterization of bleeding ...

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