Diagnosis of Acute Gastrointestinal Hemorrhage and Acute Mesenteric Ischemia in the Era of Multi-Detector Row CT

Usefulness of contrast-enhanced multi-detector computed tomography in identifying upper gastrointestinal bleeding: A retrospective study of patients admitted to the emergency department

Upper gastrointestinal bleeding (UGIB) is a major cause of clinical deterioration worldwide. A large number of patients with UGIB cannot be diagnosed through endoscopy, which is normally the diagnostic method of choice. Therefore, this study aimed to investigate the diagnostic value of multi-detector computed tomography (MDCT) for patients with suspected UGIB. In this retrospective observational study of 386 patients, we compared contrast-enhanced abdominopelvic MDCT to endoscopy to analyze the performance of MDCT in identifying the status, location of origin, and etiology of UGIB. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were examined. In the assessment of bleeding status, MDCT was able to accurately identify 32.9% (21.9–43.9, 95% confidence interval [CI]) of patients with active bleeding, 27.4% (18.9–35.9, 95% CI) of patients with recent bleeding, and 94.8% (91.8–97.8, 95% CI) of patients without bleeding evidence (P<0.001). MDCT showed an accuracy of 60.9%, 60.6%, and 50.9% in identifying bleeding in the esophagus, stomach, and duodenum, respectively (P = 0.4028). The accuracy in differentiating ulcerative, cancerous, and variceal bleeding was 58.3%, 65.9%, and 56.6%, respectively (P = 0.6193). MDCT has limited use as a supportive screening method to identify the presence of gastrointestinal bleeding.

Duodenal angiodysplasia: a case report

Background

Angiodysplasia (AD) is an abnormal, ectatic dilated, tortuous blood vessel that is found in the mucosa and the submucosa of the gastro-intestinal tract (GIT). While colonic angiodysplasia is a recognized finding of the lower intestinal tract in the elderly, small intestinal angiodysplasia is rare. However, it is an important reason of GIT bleeding so its detection and proper management can be a challenge. It should be considered among the differential diagnosis in the scenario of mild or intermittent GIT bleedings of obscure cause.

Case presentation

A 71-year-old woman was presented to our emergency department with hypovolemic shock due to lower GIT bleeding, and she was suffering of melena and severe anemia. The revision of past medical history revealed a history of hypertension, diabetes mellitus, and chronic renal disease. After stabilization, she underwent abdominal computed tomography (CT) which revealed a small abnormal vascular lesion along the anterior and posterior wall of the 2nd part of the duodenum. It appeared as blush of contrast in the arterial phase (representing dilated mucosal capillaries draining into tortuous submucosal vein) suggestive of vascular lesion (duodenal angiodysplasia). The patient was transferred to undergo an angiogram which confirmed the diagnosis of duodenal angiodysplasia. Super selective cannulation of the feeding artery was performed followed by post coiling angiogram which revealed successful embolization. No acute complications were encountered during or immediately after procedure.

Conclusion

AD is a rare but important cause that should be considered in the differential diagnosis of GIT bleeding especially in the older patients. It should be looked for in CT angiography done in such a clinical situation. Superselective coil embolization is a safe and effective technique to manage bowel AD.

CT for Evaluation of Acute Gastrointestinal Bleeding

Acute gastrointestinal (GI) bleeding is common and necessitates rapid diagnosis and treatment. Bleeding can occur anywhere throughout the GI tract and may be caused by many types of disease. The variety of enteric diseases that cause bleeding and the tendency for bleeding to be intermittent may make it difficult to render a diagnosis. The workup of GI bleeding is frequently prolonged and expensive, with examinations commonly needing to be repeated. The use of computed tomography (CT) for evaluation of acute GI bleeding is gaining popularity because it can be used to rapidly diagnose active bleeding and nonbleeding bowel disease. The CT examinations used to evaluate acute GI bleeding include CT angiography and multiphase CT enterography. Understanding the clinical evaluation of acute GI bleeding, including the advantages and limitations of endoscopic evaluation, is necessary for the appropriate selection of patients who may benefit from CT. Multiphase CT enterography is used primarily to evaluate stable patients who have undergone upper and lower endoscopy without identification of a bleeding source. CT angiography is used to examine stable and unstable patients who respond to resuscitation, are believed to be actively bleeding, and are considered unlikely to have an upper GI source of hemorrhage. In the emergent setting, CT may yield critical information regarding the presence, location, and cause of active bleeding-data that can guide the choice of subsequent therapy. Recent developments in the use of and techniques for performing CT angiography have made it a potential first-line tool for evaluating acute GI bleeding. ^©RSNA, 2018.

ACR Appropriateness Criteria® Nonvariceal Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding (UGIB) remains a significant cause of morbidity and mortality with mortality rates as high as 14%. This document addresses the indications for imaging UGIB that is nonvariceal and unrelated to portal hypertension. The four variants are derived with respect to upper endoscopy. For the first three, it is presumed that upper endoscopy has been performed, with three potential initial outcomes: endoscopy reveals arterial bleeding source, endoscopy confirms UGIB without a clear source, and negative endoscopy. The fourth variant, "postsurgical and traumatic causes of UGIB; endoscopy contraindicated" is considered separately because upper endoscopy is not performed. When endoscopy identifies the presence and location of bleeding but bleeding cannot be controlled endoscopically, catheter-based arteriography with treatment is an appropriate next study. CT angiography (CTA) is comparable with angiography as a diagnostic next step. If endoscopy demonstrates a bleed but the endoscopist cannot identify the bleeding source, angiography or CTA can be typically performed and both are considered appropriate. In the event of an obscure UGIB, angiography and CTA have been shown to be equivalent in identifying the bleeding source; CT enterography may be an alternative to CTA to find an intermittent bleeding source. In the postoperative or traumatic setting when endoscopy is contraindicated, primary angiography, CTA, and CT with intravenous contrast are considered appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

[Nonocclusive mesenteric ischemia (NOMI): Modern diagnostic and therapeutic interventional strategies from a radiological point of view]

BACKGROUND

Nonocclusive mesenteric ischemia (NOMI), a rare form of mesenteric perfusion, is associated with a high mortality rate, especially when the diagnosis is delayed.

OBJECTIVE

Optimizing the diagnostic workup and the use of modern diagnostic possibilities are needed to reduce mortality and morbidity.

RECOMMENDED APPROACH

Recent studies recommend not yet standardized integration of computed tomography into the diagnostic workup. This paper gives an overview of the current data for the diagnosis of NOMI.

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.