Integrating urgent multidetector CT scanning in the diagnostic algorithm of active lower GI bleeding

Endoscopic Diagnosis and Treatment of Colonic Diverticular Bleeding

This is a description and critical analysis of current diagnosis and treatment of diverticular hemorrhage. The focus is on colonoscopy for identification and treatment of stigmata of recent hemorrhage (SRH) in diverticula. A classification of definitive, presumptive, and incidental diverticular hemorrhage is reviewed and recommended. The approach to definitive diagnosis with urgent colonoscopy is put into perspective of other management strategies including angiography (of different types), nuclear medicine scans, surgery, and medical treatment. Advancements in diagnosis, risk stratification, and colonoscopic hemostasis are described including those that obliterate arterial blood flow underneath SRH and prevent diverticular rebleeding. Recent innovations are discussed.

Importance of communication of CT indication for imaging yield in patients with gastrointestinal bleed

PURPOSE

The indications for requesting a diagnostic test are important for the selection and timing of imaging protocols. We sought to evaluate the diagnostic yield and impact on patient disposition when evaluating computed tomography (CT) of the abdomen and pelvis in adult patients presenting with gastrointestinal bleeding (GIB) to the Emergency Department (ED).

METHODS

This study was an observational cohort study of consecutive adult ED patients with ICD10 codes related to GIB between 5/5/2018 and 6/1/2020. CT reports were reviewed for indications, exam type and findings. Reports were classified as positive (active bleeding, recent bleeding or suspected etiology for GIB), negative or other significant findings. Methodological guidelines for reporting observational studies were followed (STROBE).

RESULTS

Among 943 patients with GIB during the study period, 33% (n = 312) had an abdominopelvic CT ordered. Most CTs included contrast, 64.1% (n = 200) used a single portal venous phase and 28.9% (n = 90) were multi-phase. CT identified active bleeding in 4.2% (n = 13/312) and intraluminal blood in 2.9% (n = 9/312) patients. Patients that had GIB indications on the CT order (n = 142) were more likely to receive a multiphase study compared to those without GIB indication (n = 94) (43.0% vs. 8.5%, difference 34.5%, 95% CI 23.7% to 43.7%, p < 0.0001). Patients that received multiphase studies were more likely to have a source of GIB identified compared to single-phase (18.9% vs 1.5%, OR 15.3, 95% CI 4.4 to 53.7, p < 0.0001). In 40.3% (n = 117/290) of patients without bleeding, an intra-abdominal cause for their symptoms was identified. Those with GIB or with an identified cause were more likely to be admitted.

CONCLUSIONS

One-third of patients evaluated in the ED with GIB had a CT ordered. Active GIB was detected more often when multiphase exams were performed. Multiphase exams are done more often if GIB is listed in the CT indication. When a CT is positive, patients are more likely to be admitted or observed. Accurate indications are critical to optimize exam performance.

Contrast extravasation on computed tomography angiography in patients with hematochezia or melena: Predictive factors and associated outcomes

PURPOSE

The purpose of this study was to identify variables associated with extravasation on computed tomography angiography (CTA) in patients with hematochezia/melena and compare the outcome of patients with extravasation on CTA to those without extravasation.

MATERIAL AND METHODS

Ninety-four patients (51 men, 38 women; mean age, 69 ± 16 [SD] years) who underwent CTA within 30 days of hematochezia/melena were included. Variables associated with extravasation on CTA were searched using univariable and multivariable analyses. Outcomes of patients with visible extravasation on CTA were compared with those without visible extravasation.

RESULTS

One hundred and one CTA examinations were included. Extravasation was observed on 26/101 CTA examinations (26%). At multivariable analysis the need for vasopressor drugs (odds ratio [OR], 7.6; P = 0.040), high transfusion requirements (> 2 blood units) (OR, 7.1; P = 0.014), CTA performed on the day of a hemorrhagic event (OR, 46.2; P = 0.005) and repeat CTA (OR, 27.8; P = 0.011) were independently associated with extravasation on CTA. Extravasation on CTA was followed by a therapeutic procedure in 25/26 CTAs (96%; 26 patients) compared to 13/75 CTAs (17%; 68 patients) on which no extravasation was present (P < 0.001). No patients (0/26; 0%) with contrast extravasation on CTA died while 8 patients (8/61; 13%) without contrast extravasation died, although the difference was not significant (P = 0.099).

CONCLUSION

Extravasation on CTA in the setting of hematochezia or melena is especially seen in clinically unstable patients who receive more than two blood units. Presence of active extravasation on CTA leads to more frequent application of a therapeutic procedure; however, this does not significantly affect patient outcome.

Lower gastrointestinal bleeding-Computed Tomographic Angiography, Colonoscopy or both?

Background

Lower endoscopy (LE) is the standard diagnostic modality for lower gastrointestinal bleeding (LGIB). Conversely, computed tomographic angiography (CTA) offers an immediate non-invasive diagnosis visualizing the entire gastrointestinal tract. The aim of this study was to compare these 2 modalities with regards to diagnostic value and bleeding control.

Methods

Tertiary center retrospective analysis of consecutive patients admitted for LGIB between 2006 and 2012. Comparison of patients with LE vs. CTA as first exam, respectively, with emphasis on diagnostic accuracy and bleeding control.

Results

Final analysis included 183 patients; 122 (66.7%) had LE first, while 32 (17.5%) had CTA; 29 (15.8%) had neither of both exams. Median time to CTA was shorter compared to LE (3 (IQR = 8.2) vs. 22 (IQR = 36.9) hours, P < 0.001). Active bleeding was identified in 31% with CTA vs. 15% with LE (P = 0.031); a non-actively bleeding source was found by CTA and LE in 22 vs. 31%, respectively (P = 0.305). Bleeding control required endoscopy in 19%, surgery in 14% and embolization in 1.6%, while 66% were treated conservatively. Post-interventional bleeding was mostly controlled by endoscopic therapy (57%). 80% of patients with active bleeding on CTA required surgery.

Conclusions

Post-interventional LGIB was effectively addressed by LE. For other causes of LGIB, CTA was efficient, and more available than colonoscopy. Treatment was conservative for most patients. In case of active bleeding, CTA could localize the bleeding source and predict the need for surgery.

Making decisions using radiology in lower GI hemorrhage

Acute lower gastrointestinal bleeding (LGIB) is a common diagnosis in current practice that may warrant hospitalization and invasive management. There is a shift in the paradigm in the management of this condition away from traditional extensive operative intervention to minimally invasive radiological techniques. These newer modalities offer an opportunity to provide more accurate information on location of bleeding and subsequent management. The increased ease of access to interventional radiology units in major teaching hospitals represents an opportunity to adopt its use in the management of gastrointestinal bleeding. Further, with technological improvements, it is becoming an increasingly favoured option. Traditional endoscopic techniques have been fraught with poor vision in the acute setting, requiring the colon to be purged to aide in better visualization. The use of these newer technologies have been the subject of many reviews which highlight their efficacy in providing a road map to the bleeding site and eventual intervention. We aim to review the literature regarding the use of radiology in the management of LGIB, to provide surgeons with a discourse with regards to the approach in synthesizing the data and applying it when deciding its use.

Accurate triage of lower gastrointestinal bleed (LGIB) - A cohort study

INTRODUCTION

Acute lower gastrointestinal bleeding (LGIB) is a common acute presenting complaint to hospital. Unlike upper gastrointestinal bleeding, the diagnostic and therapeutic approach is not well-standardised. Intensive monitoring and urgent interventions are essential for patients with severe LGIB. The aim of this study is to investigate factors that predict severe LGIB and develop a clinical predictor tool to accurately triage LGIB in the emergency department of a busy metropolitan teaching hospital.

METHODS

We retrospectively identified all adult patients who presented to Middlemore Hospital Emergency Department with LGIB over a one year period. We recorded demographic variables, Charlson Co-morbidities Index, use of anticoagulation, examination findings, vital signs on arrival, laboratory test results, treatment plans and further investigations results. We then identified a subgroup of patients who suffered severe LGIB.

RESULTS

A total of 668 patients presented with an initial triage diagnosis of LGIB. 83 of these patients (20%) developed severe LGIB. Binary logistic regression analysis identified four independent risk factors for severe LGIB: use of aspirin, history of collapse, haemoglobin on presentation of less than 100 mg/dl and albumin of less than 38 g/l.

CONCLUSIONS

We have developed a clinical prediction tool for severe LGIB in our population with a negative predictive value (NPV) of 88% and a positive predictive value (PPV) of 44% respectively. We aim to validate the clinical prediction tool in a further cohort to ensure stability of the multivariate model.

Multidetector CT angiography for acute gastrointestinal bleeding: technique and findings

Acute gastrointestinal bleeding is a common reason for emergency department admissions and an important cause of morbidity and mortality. Factors that complicate its clinical management include patient debility due to comorbidities; intermittence of hemorrhage; and multiple sites of simultaneous bleeding. Its management, therefore, must be multidisciplinary and include emergency physicians, gastroenterologists, and surgeons, as well as radiologists for diagnostic imaging and interventional therapy. Upper gastrointestinal tract bleeding is usually managed endoscopically, with radiologic intervention reserved as an alternative to be used if endoscopic therapy fails. Endoscopy is often less successful in the management of acute lower gastrointestinal tract bleeding, where colonoscopy may be more effective. The merits of performing bowel cleansing before colonoscopy in such cases might be offset by the resultant increase in response time and should be weighed carefully against the deficits in visualization and diagnostic accuracy that would result from performing colonoscopy without bowel preparation. In recent years, multidetector computed tomographic (CT) angiography has gained acceptance as a first-line option for the diagnosis and management of lower gastrointestinal tract bleeding. In selected cases of upper gastrointestinal tract bleeding, CT angiography also provides accurate information about the presence or absence of active bleeding, its source, and its cause. This information helps shorten the total diagnostic time and minimizes or eliminates the need for more expensive and more invasive procedures.