Gastrointestinal bleeding

The potential role of spiral computed tomography in acute gastrointestinal bleeding

We present four cases of profuse gastrointestinal (GI) bleeding where the site of haemorrhage was demonstrated using multi-slice computed tomography (MSCT), with concordant findings at laparotomy and pathological examination. A review of the current literature is undertaken and the role of spiral computed tomography as a method of sourcing the bleeding point is discussed in relation to other management modalities.

Retrospective study of the utility of nuclear scintigraphic-labelled red cell scanning for lower gastrointestinal bleeding

BACKGROUND

The aim of the present study was to evaluate the utility of nuclear scintigraphic-labelled red cell scanning in the management of bleeding in patients with acute lower gastrointestinal haemorrhage (GIH) who require surgery.

METHODS

A prospective database was used to source data on all patients with lower GIH who underwent technetium-99m (99mTc)-labelled red cell scanning over a 10-year period. A subgroup was identified from cross-reference with the medical records identifying only those patients who continued to bleed and subsequently required laparotomy for further detailed retrospective study. One key question was asked: did the labelled red cell scan influence the type of operation performed by the operating surgeon?

RESULTS

The study identified 249 patients who underwent 287 labelled red cell scans for GIH. Forty patients (16%) underwent laparotomy for ongoing bleeding; 28/40 (70%) of the red cell scans were positive for bleeding. Six patients (15%) died postoperatively, none because of continued bleeding. The 99mTc-labelled red cell scan was deemed to have been unhelpful in 22 (55%) cases. Twelve of the 22 scans were negative and 10 of the 22 scans were positive but were ignored by the surgeon. The 99mTc-labelled red cell scan influenced the choice of operation in 18 out of 40 patients (45% of the operated group but only 7.2% of the total scanned group). Of these, 15 patients underwent colonic resection and three patients underwent small bowel resection.

CONCLUSION

The present study demonstrates that labelled red cell scanning has only a small role to play in managing lower GIH. The 99mTc-labelled red cell scanning should be used much more selectively. Its use should be limited to patients who continue to bleed after conservative management; it may allow these patients to be effectively treated by segmental bowel resection. Its most critical role, however, is probably to prevent suspected small bowel bleeding from being missed at operation.

Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia

Major breakthroughs in catheter, guidewire, and other angiographic equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. Similarly, the interventional radiologist can treat acute intestinal ischemia safely and effectively with selective catheterization and papaverine administration and treat chronic mesenteric ischemia by percutaneous angioplasty and stent placement. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is critical in managing GI bleeding and intestinal ischemia, particularly in patients at high risk or presenting as diagnostic dilemmas.

Radiology in the diagnosis and therapy of gastrointestinal bleeding

Major breakthroughs in catheter and guidewire design as well as improvements in angiographic x-ray equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. For chronic or recurrent GI bleeding, when endoscopy is unrevealing or equivocal, barium studies, CT scanning, nuclear medicine studies, and angiography can help determine the cause of bleeding. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is extremely helpful in managing GI bleeding, particularly in high-risk patients or patients presenting as diagnostic dilemmas.

Acute gastrointestinal bleeding in the intensive care unit. The intensivist's perspective

Gastrointestinal (GI) hemorrhage is a common and potentially lethal medical emergency that is a common cause for intensive care unit admission. The intensivist plays an important role as a member of the medical team managing the patient with GI bleeding who is at high risk because of severe bleeding, comorbidity, or the presence of endoscopic stigmata of recent hemorrhage. This article presents the intensivist's approach to GI hemorrhage in initial patient assessment, triage, resuscitation, specialist consultation, diagnostic evaluation, and medical therapy. This article focuses on types of GI bleeding of particular concern to the intensivist, including esophageal variceal bleeding, stress-related GI bleeding, and GI bleeding associated with myocardial infarcation.

Management of gastrointestinal bleeding induced by gastrointestinal endoscopy

Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.

Evaluation of the patient with gastrointestinal bleeding: an evidence based approach

Gastrointestinal bleeding is a common and potentially life-threatening problem. The incidence of upper gastrointestinal bleeding (UGIB) is 40 to 150 episodes per 100,000 population per year. Mortality in large series is 6% to 10% for UGIB and has remained unchanged over the past 30 to 60 years. The incidence of hospitalization for acute lower gastrointestinal bleeding is about 20 to 27 episodes per 100,000 population per year, with a 200-fold increase with advancing age from the third to ninth decades. The mortality rate is 4% to 10% or higher. The evaluation of overt or acute gastrointestinal bleeding in the ED is reviewed here from the perspective of evidence-based medicine.

BUN/creatinine ratios: aid to decision making about delayed imaging in Tc-99m red blood cell scans for gastrointestinal hemorrhage

In patients with gastrointestinal hemorrhage, delayed or late scans with Tc-99m labeled red blood cells are readily performed and have prognostic impact when early images are negative. Nevertheless, there have been no indicators for the likelihood of detecting bleeding on such images. In a review of all gastrointestinal bleeding scans over an 8-year period, 73 patients had delayed images (> 3 hours) following early negative exams. For these patients, determinations of serum blood urea nitrogen (BUN) and creatinine (Cr) were evaluated as the BUN/Cr ratio and were compared against delayed scan findings and confirmed diagnoses. Patients with significant renal failure were excluded from analysis. There were 34 late positive (46%) and 39 late negative (54%) studies. Mean BUN/Cr was 26.5 and 20.0 in patients with late positive and late negative scans, respectively (p < 0.05). Occurrence of late positive scans was 38% (19/50) for BUN/Cr < 25.0 vs. 65% (15/23) for BUN/Cr > 25.0 (p < 0.05). Patients with early negative images and a BUN/Cr ratio of 25 or greater have a greater likelihood of a positive delayed image. Late imaging should be encouraged in patients with elevated BUN/Cr and early negative scintigraphy.

Acute gastrointestinal bleeding

Acute gastrointestinal bleeding is responsible for 1% to 2% of all hospital admissions in the United States annually. An awareness of common and uncommon pathologies will allow the clinician to develop a plan for the diagnostic evaluation that will lead to a diagnosis and localization of the bleeding site. Successful diagnosis and subsequent treatment are dependent on selecting the diagnostic tests that pinpoint the bleeding source accurately and in the most cost-effective manner.