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

Extravasated contrast volumetric assessment on computed tomography angiography in gastrointestinal bleeding: A useful predictor of positive angiographic findings

BACKGROUND

Gastrointestinal bleeding (GIB) is a severe and potentially life-threatening condition, especially in cases of delayed treatment. Computed tomography angiography (CTA) plays a pivotal role in the early identification of upper and lower GIB and in the prompt treatment of the haemorrhage.

AIM

To determine whether a volumetric estimation of the extravasated contrast at CTA in GIB may be a predictor of subsequent positive angiographic findings.

METHODS

In this retrospective single-centre study, 35 patients (22 men; median age 69 years; range 16-92 years) admitted to our institution for active GIB detected at CTA and further submitted to catheter angiography between January 2018 and February 2022 were enrolled. Twenty-three (65.7%) patients underwent endoscopy before CTA. Bleeding volumetry was evaluated in both arterial and venous phases via a semi-automated dedicated software. Bleeding rate was obtained from volume change between the two phases and standardised for unit time. Patients were divided into two groups, according to the angiographic signs and their concordance with CTA.

RESULTS

Upper bleeding accounted for 42.9% and lower GIB for 57.1%. Mean haemoglobin value at the admission was 7.7 g/dL. A concordance between positive CTA and direct angiographic bleeding signs was found in 19 (54.3%) cases. Despite no significant differences in terms of bleeding volume in the arterial phase (0.55 mL vs 0.33 mL, P = 0.35), a statistically significant volume increase in the venous phase was identified in the group of patients with positive angiography (2.06 mL vs 0.9 mL, P = 0.02). In the latter patient group, a significant increase in bleeding rate was also detected (2.18 mL/min vs 0.19 mL/min, P = 0.02).

CONCLUSION

In GIB of any origin, extravasated contrast volumetric analysis at CTA could be a predictor of positive angiography and may help in avoiding further unnecessary procedures.

The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

Review article: Advances in the management of lower gastrointestinal bleeding

BACKGROUND

Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved.

AIMS

To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion.

RESULTS

The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients.

CONCLUSIONS

The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.

The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.

Canadian Association of Radiologists Gastrointestinal Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Gastrointestinal Expert Panel consists of radiologists, a gastroenterologist, a general surgeon, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 20 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 58 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 85 recommendation statements specific to the adult population across the 20 scenarios. This guideline presents the methods of development and the referral recommendations for dysphagia/dyspepsia, acute nonlocalized abdominal pain, chronic abdominal pain, inflammatory bowel disease, acute gastrointestinal bleeding, chronic gastrointestinal bleeding/anemia, abnormal liver biopsy, pancreatitis, anorectal diseases, diarrhea, fecal incontinence, and foreign body ingestion.

Computed Tomography Angiography and Conventional Angiography for the Diagnosis and Treatment of Non-variceal Gastrointestinal Bleeding at a Tertiary Cancer Center

INTRODUCTION

To evaluate the diagnostic value of computed tomography angiography (CTA) and conventional angiography (CA) and the therapeutic value of transarterial embolization for acute gastrointestinal bleeding in patients with malignancy.

METHODS

A retrospective review of 100 patients who underwent CTA and/or CA for gastrointestinal bleeding at a comprehensive cancer center between the years 2011-2021 was performed. Clinical and patient outcome data were collected and analyzed using Kruskal-Wallis tests for continuous variables and chi-square tests or Fisher's exact tests (whichever is appropriate) for categorical variables in univariate analysis. All tests were two-sided at a significance level of 0.05. Analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC).

RESULTS

Fifty-two percent of our patients underwent CTA alone, 29% underwent CA alone, and 19% underwent both procedures. Overall, CTA was positive in 11.3% (8/71) of patients and CA was positive in 22.9% (11/38) of patients. Of patients who underwent both studies, 52.6% (10/19) were positive for both. ICU admission was associated with CTA and/or CA positivity (p=0.015). Of 48 patients with data for embolization, 50% of patients underwent transarterial embolization for bleeding, 11 patients had identifiable bleeding on CA, and 13 patients underwent prophylactic embolization at the site of suspected bleeding. Rebleeding following embolization was found in 33.3% (8/24) of patients, including six patients who underwent prophylactic embolization and two patients who were treated for visualized bleeding.

CONCLUSION

CTA and CA are two critical studies for patients with GI bleeding and a history of malignancy. Neither alone can effectively exclude an identifiable source of bleeding. In patients with a history of malignancy, transarterial embolization may be an effective treatment of both angiographically visible and occult sources of GI bleeding.

The Accuracy of Computed Tomography Angiography Compared With Technetium-99m Labelled Red Blood Cell Scintigraphy for the Diagnosis and Localization of Acute Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

Imaging tests are commonly used as an initial or early investigation for patients presenting with suspected acute gastrointestinal bleeding (AGIB). However, controversy remains regarding which of two frequently used modalities, computed tomography angiography (CTA) or technetium-99m labelled red blood cell scintigraphy (RBCS), is most accurate. This systematic review and meta-analysis was performed to compare the accuracy of CTA and RBCS for the detection and localization of AGIB. Five electronic databases were searched with additional manual searching of reference lists of relevant publications identified during the search. Two reviewers independently performed screening, data extraction and methodological assessments. Where appropriate, the bivariate model was used for meta-analysis of sensitivities and specificities for the detection of bleeding and Freeman-Tukey double-arcsine transformation used for meta-analysis of proportions of correctly localized bleeding sites. Forty-four unique primary studies were included: twenty-two investigating CTA, seventeen investigating RBCS and five investigating both modalities. Meta-analysis produced similar pooled sensitivities; 0.83 (95% CI 0.74-0.90) and 0.84 (0.68-0.92) for CTA and RBCS respectively. Pooled specificity for CTA was higher than RBCS; 0.90 (0.72-0.97) and 0.84 (0.71-0.91) respectively. However, differences were not statistically significant. CTA was superior to RBCS in correctly localizing bleeding; pooled proportions of 1.00 (0.98-1.00) and 0.90 (0.83-0.96) respectively (statistically significant difference, P < 0.001). There is no evidence that CTA and RBCS have different diagnostic performance with respect to the detection of AGIB. However, CTA is superior to RBCS in terms of correctly localising the bleeding site, supporting usage of CTA over RBCS as the first line imaging investigation.

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.

Clinical analysis of 99 children with Henoch-Schönlein purpura complicated with overt gastrointestinal bleeding

OBJECTIVE

To analyze and summarize the clinical features, diagnosis, and treatment of children with Henoch-Schönlein purpura (HSP) complicated by overt gastrointestinal bleeding (GI bleeding) for achieving early identification, prevention, and treatment in terms of severe GI bleeding.

METHODS

A retrospective analysis was conducted on children with HSP complicated by overt GI bleeding who were admitted to the Department of Traditional Chinese Medicine of Beijing Children's Hospital from January 2017 to December 2019. According to the severity of GI bleeding, the patients were divided into mild bleeding group (61 cases) and moderate and severe bleeding group (38 cases). Inflammatory parameters, coagulation function, GI ultrasound findings, and clinical features were compared. Logistic regression analysis was used to determine the related variables affecting the severity of GI bleeding, and the ROC curve was used to determine the variable test efficacy.

RESULTS

Onset in summer, wide distribution of skin rash with facial involvement, the elevation of D-dimer and high neutrophil-to-lymphocyte ratio (NLR) had significant effects on the severity of GI bleeding. ROC curve analysis showed that the optimal cut-off points of NLR and D-dimer for predicting severe GI bleeding in children with HSP were 10.56 and 0.89 mg/L, respectively.

CONCLUSION

Facial rash may be a warning sign of GI bleeding. Enhanced monitoring of NLR and D-dimer is helpful for early recognition of GI bleeding as well as assessment of severity.

Acute Gastrointestinal Bleeding

Acute gastrointestinal bleeding (GIB) is a common clinical entity. Expert management of acute GIB requires collaborative care between internists and other specialists. This article reviews the presentation, treatment, and prevention of acute GIB using recommendations from recent guidelines and expert panel reviews. The article acknowledges the pivotal role played by primary care providers in the inpatient and outpatient management of acute GIB.

Duodenal ulcer caused by coil wiggle after digital subtraction angiography-guided embolization: A case report

BACKGROUND

Acute gastrointestinal bleeding (GIB) is a life-threatening medical emergency with high morbidity and mortality. Transcatheter embolization with endovascular coils under digital subtraction angiography guidance is a common and effective method for the treatment of GIB with high technical success rates. Duodenal ulcers caused by coils wiggled from the branch of the gastroduodenal artery, which is a rare complication, have not previously been reported in a patient with right intrathoracic stomach.

CASE SUMMARY

A 62-year-old man had undergone thoracoscopy-assisted radical resection of esophageal cancer and gastroesophageal anastomosis 3 years ago, resulting in right intrathoracic stomach. He was admitted to the hospital 15 mo ago for dizziness and suffered acute GIB during his stay. Interventional surgery was urgently performed to embolize the branch of the gastroduodenal artery with endovascular coils. After 15 mo, the patient was re-admitted with a chief complaint of melena for 2 d, esophagogastroduodenoscopy and abdominal computed tomography revealed that some endovascular coils had migrated into the duodenal bulb, leading to a deep ulcer. Bleeding was controlled after conservative treatment. Seven months later, duodenal balloon dilatation was performed to relieve the stenosis after the removal of a few coils, and the patient was safely discharged with only one coil retained in the duodenum due to difficulties in complete removal and risk of bleeding. Mild melena recurred once during the long-term follow-up.

CONCLUSION

Although rare, coil wiggle after interventional therapy requires careful attention, effective precautionary measures, and more secure alternative treatment methods.

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

Background: This study was conducted to evaluate the technical and clinical success of trans-arterial embolization (TAE) as a treatment of gastrointestinal bleeding (GIB) in Coronavirus Disease 2019 (COVID-19) patients and to describe its safety; moreover, we describe the characteristics of these patients. Methods: Thirty-four COVID-19 hospitalized patients presented with GIB. Risk factors, drugs administered for COVID-19 infection, and clinical and biological parameters were evaluated. Furthermore, intraprocedural data and outcomes of embolization were analyzed. Results: GIB was more frequent in male. Overweight, hypertension, diabetes, previous cardiac disease, and anticoagulation preadmission (48.5%) were frequently found in our population. Previous or actual COVID Acute respiratory distress syndrome (ARDS) and a high level of D-dimer were encountered in most cases. Upper GIB was more frequent than lower GIB. Technical and clinical success rates of embolization were 88.2% and 94.1%, respectively. The complication rate was 5.9%. Conclusions: Our study highlights the most frequent characteristics of COVID-19 patients with GIB. Embolization is feasible, effective, and safe.