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Yaxley KL, Mulhem A, Godfrey S, Oke JL. 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. Curr Probl Diagn Radiol 2023; 52:546-559. [PMID: 37271638 DOI: 10.1067/j.cpradiol.2023.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/26/2023] [Accepted: 05/08/2023] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Kaspar L Yaxley
- University of Oxford, 1 Wellington Square, Oxford, OX1 2JA, UK; Department of Medical Imaging, Flinders Medical Centre, Flinders Drive, Bedford Park, SA, 5042, Australia.
| | - Ali Mulhem
- University of Oxford, 1 Wellington Square, Oxford, OX1 2JA, UK
| | - Sean Godfrey
- University of Oxford, 1 Wellington Square, Oxford, OX1 2JA, UK
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Mohammadinejad P, Kwapisz L, Fidler JL, Sheedy SP, Heiken JP, Khandelwal A, Wells ML, Froemming AT, Hansel SL, Lee YS, Inoue A, Halaweish AF, McCollough CH, Bruining DH, Fletcher JG. The utility of a dual-phase, dual-energy CT protocol in patients presenting with overt gastrointestinal bleeding. Acta Radiol Open 2021; 10:20584601211030658. [PMID: 34377539 PMCID: PMC8323435 DOI: 10.1177/20584601211030658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/15/2021] [Indexed: 12/03/2022] Open
Abstract
Background Due to their easy accessibility, CT scans have been increasingly used for
investigation of gastrointestinal (GI) bleeding. Purpose To estimate the performance of a dual-phase, dual-energy (DE) GI bleed CT
protocol in patients with overt GI bleeding in clinical practice and examine
the added value of portal phase and DE images. Materials and Methods Consecutive patients with GI bleeding underwent a two-phase DE GI bleed CT
protocol. Two gastroenterologists established the reference standard.
Performance was estimated using clinical CT reports. Three GI radiologists
rated confidence in GI bleeding in a subset of 62 examinations, evaluating
first mixed kV arterial images, then after examining additional portal
venous phase images, and finally after additional DE images (virtual
non-contrast and virtual monoenergetic 50 keV images). Results 52 of 176 patients (29.5%) had GI bleeding by the reference standard. The
overall sensitivity, specificity, and positive and negative predictive
values of the CT GI bleed protocol for detecting GI bleeding were 65.4%,
89.5%, 72.3%, and 86.0%, respectively. In patients with GI bleeding,
diagnostic confidence of readers increased after adding portal phase images
to arterial phase images (p = 0.002), without additional
benefit from dual energy images. In patients without GI bleeding, confidence
in luminal extravasation appropriately decreased after adding portal phase,
and subsequently DE images (p = 0.006, p =
0.018). Conclusion A two-phase DE GI bleed CT protocol had high specificity and negative
predictive value in clinical practice. Portal venous phase images improved
diagnostic confidence in comparison to arterial phase images alone.
Dual-energy images further improved radiologist confidence in the absence of
bleeding.
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Affiliation(s)
| | - Lukasz Kwapisz
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeff L Fidler
- Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA
| | - Shannon P Sheedy
- Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA
| | - Jay P Heiken
- Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA
| | | | - Michael L Wells
- Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA
| | - Adam T Froemming
- Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA
| | - Stephanie L Hansel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Yong S Lee
- Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA
| | - Akitoshi Inoue
- Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA
| | | | | | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic Minnesota, Rochester, MN, USA
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Lee HS, Kang SH, Rou WS, Eun HS, Joo JS, Kim JS, Lee ES, Moon HS, Kim SH, Sung JK, Lee BS, Jeong HY. Computed tomography versus lower endoscopy as initial diagnostic method for evaluating patients with hematochezia at emergency room. Medicine (Baltimore) 2020; 99:e20311. [PMID: 32481401 DOI: 10.1097/md.0000000000020311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
For acute lower gastrointestinal bleeding (LGIB), lower gastrointestinal endoscopy is the preferred initial diagnostic test. However, it is difficult to perform urgently. Computed tomography (CT) is a convenient alternative.This study aimed to determine the diagnostic performance of CT compared to lower endoscopy as an initial test for evaluating acute LGIB.The medical records of 382 patients who visited our emergency department with hematochezia between January 2012 and January 2017 were retrospectively analyzed. Of them, 112 underwent CT, 65 underwent colonoscopy, and 205 underwent sigmoidoscopy as an initial test. For each method, sensitivity, specificity, positive predictive value, and negative predictive value were calculated upon active bleeding site detection and LGIB etiology diagnosis.The sensitivity, specificity, positive predictive value, and negative predictive value of CT for active bleeding site detection were 85.7%, 100%, 100%, and 96.9%, respectively, while those for identifying the etiology of LGIB were 87.4%, 40.0%, 83.5, and 47.6%, respectively.CT was not inferior to lower endoscopy for active bleeding site detection. Early localization and the exclusion of active bleeding were possible with CT. Etiology was diagnosed with high sensitivity and PPV by CT. Thus, CT can be an alternative initial diagnostic tool for evaluating acute LGIB.
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Affiliation(s)
- Hee Sung Lee
- Division of Gastroenterology, Department of Internal medicine, Chungnam National University School of Medicine, Daejeon, Korea
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4
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Society of abdominal radiology gastrointestinal bleeding disease-focused panel consensus recommendations for CTA technical parameters in the evaluation of acute overt gastrointestinal bleeding. Abdom Radiol (NY) 2019; 44:2957-2962. [PMID: 31346741 DOI: 10.1007/s00261-019-02131-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To formulate consensus recommendations for CT angiography technical parameters used to evaluate overt gastrointestinal (GI) bleeding. METHODS An electronic questionnaire consisting of 17 questions was sent to a panel of 16 radiologists with expertise on the imaging of GI bleeding from the Society of Abdominal Radiology GI Bleeding disease-focused panel to obtain consensus agreement on issues related to CTA technical parameters for imaging overt GI bleeding. A multi-round Delphi method of voting was performed to obtain consensus which was defined as ≥ 80% agreement. RESULTS Consensus agreement was reached in 15/17 (89%) of the questions including the technique for the administration of IV contrast, the number of phases, scan timing, and image reconstruction. CONCLUSIONS A panel of experts on the imaging of GI bleeding from the Society of Abdominal Radiology was able to reach consensus on the majority of technical parameters used for CTA of overt GI bleeding. These recommendations should improve the quality of patient care by adopting these minimal technical requirements for optimal exam performance and lead to less variation in the performance of these exams which will facilitate collecting and comparing published data from different centers. These recommendations will need revisions as additional scientific data become available.
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5
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Diagnosis of lower gastrointestinal bleeding by multi-slice CT angiography: A meta-analysis. Eur J Radiol 2017; 93:40-45. [DOI: 10.1016/j.ejrad.2017.05.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/24/2017] [Accepted: 05/17/2017] [Indexed: 12/15/2022]
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6
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Shotar E, Soyer P, Barat M, Dautry R, Pocard M, Placé V, Camus M, Eveno C, Barret M, Dohan A. Diagnosis of acute overt gastrointestinal bleeding with CT-angiography: Comparison of the diagnostic performance of individual acquisition phases. Diagn Interv Imaging 2017; 98:857-863. [PMID: 28754326 DOI: 10.1016/j.diii.2017.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE To compare the respective values of arterial phase, portal venous phase and combination of phases using 64-section multidetector computed tomography (MDCT) for diagnosing acute overt gastrointestinal bleeding (AOGIB). PATIENTS AND METHODS Forty-nine patients with AOGIB were included. There were 30 men and 19 women, with a mean age of 65.4±15.6 (SD) years [range, 34-91years]. Two observers reviewed MDCT examinations in consensus for presence of active bleeding, location of bleeding site and nature of causative lesion. The different acquisition phases were reviewed independently. RESULTS AOGIB was identified in 28/49 patients (57%) with the multiphasic set, in 26/49 patients (53%) with arterial phase and in 25/49 patients (51%) with portal venous phase. Multiphasic set helped locate the bleeding site in 40/49 patients (82%). The cause was elucidated in 23/49 patients (47%) with multiphasic set. The differences between set performances were not statistically significant. Sensitivity for depicting AOGIB with the multiphasic set was 92% and specificity was 76%. CONCLUSION Multiphasic 64-section MDCT has high diagnostic performances in patients with AOGIB. Further studies with a larger population are needed to reach statistical significance and demonstrate better diagnostic performance of multiphasic MDCT in comparison with the arterial or portal phase alone.
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Affiliation(s)
- E Shotar
- Department of Body and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise Paré, 75475 Paris cedex 10, France
| | - P Soyer
- Université Paris 5, Sorbonne Paris Cité, rue de l'école de médecine, 75006 Paris, France; UMR Inserm 965, hôpital Lariboisière, 2, rue Amboise-Paré, 75010 Paris, France; Department of Radiologie, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - M Barat
- Department of Body and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise Paré, 75475 Paris cedex 10, France
| | - R Dautry
- Department of Body and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise Paré, 75475 Paris cedex 10, France
| | - M Pocard
- Université Paris 5, Sorbonne Paris Cité, rue de l'école de médecine, 75006 Paris, France; UMR Inserm 965, hôpital Lariboisière, 2, rue Amboise-Paré, 75010 Paris, France; Department of Surgical Oncology, hôpital Lariboisière, AP-HP, 2, rue Ambroise Paré, 75475 Paris cedex 10, France
| | - V Placé
- Department of Body and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise Paré, 75475 Paris cedex 10, France
| | - M Camus
- Department of Gastroenterology, hôpital Saint-Antoine, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - C Eveno
- Université Paris 5, Sorbonne Paris Cité, rue de l'école de médecine, 75006 Paris, France; UMR Inserm 965, hôpital Lariboisière, 2, rue Amboise-Paré, 75010 Paris, France; Department of Surgical Oncology, hôpital Lariboisière, AP-HP, 2, rue Ambroise Paré, 75475 Paris cedex 10, France
| | - M Barret
- Department of Gastroenterology, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - A Dohan
- Department of Body and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise Paré, 75475 Paris cedex 10, France; Université Paris 5, Sorbonne Paris Cité, rue de l'école de médecine, 75006 Paris, France; UMR Inserm 965, hôpital Lariboisière, 2, rue Amboise-Paré, 75010 Paris, France.
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Accuracy of 99mTechnetium-labeled RBC Scintigraphy and MDCT With Gastrointestinal Bleed Protocol for Detection and Localization of Source of Acute Lower Gastrointestinal Bleeding. J Clin Gastroenterol 2016; 50:754-60. [PMID: 26646804 DOI: 10.1097/mcg.0000000000000462] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute lower gastrointestinal bleeding (LGIB) is a major cause of morbidity and mortality. Multidetector row computed tomography (CT) with gastrointestinal (GI) bleed protocol is a novel diagnostic technique for detecting and localizing LGIB. Being rapid and noninvasive, it may be useful as a first-line modality to investigate cases of acute LGIB. GOALS To assess and compare diagnostic accuracy of (99M)Technetium (Tc)-labeled red blood cell (RBC) scintigraphy and multidetector row CT with GI bleed protocol for detection and localization of source of acute LGIB. STUDY Requirement of informed consent was waived for this retrospective study. Seventy-six patients had undergone either RBC scintigraphy, CT with GI bleed protocol, or both, followed by conventional angiography for evaluation of acute persistent LGIB between January 2010 and February 2014 at our institution. Accuracy of both modalities was assessed using conventional angiography as reference standard and compared using the 2-tailed, Fisher exact test. A P-value of <0.05 was considered statistically significant. RESULTS Fifty-one, 20, and 5 patients had undergone RBC scintigraphy only, CT with GI bleed protocol only, and both modalities, respectively. Fourteen of 25 patients in the CT group had angiographic evidence of active bleeding as compared with 32 of 56 patients in the scintigraphy group. CT with GI bleed protocol had higher accuracy (96%) than (99M)Tc-labeled RBC scintigraphy (55.4%, P<0.001). CONCLUSIONS CT with GI bleed protocol was more accurate in detecting and localizing the source of acute LGIB as compared with (99M)Tc-labeled RBC scintigraphy.
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8
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Localizing Acute Lower Gastrointestinal Hemorrhage: CT Angiography Versus Tagged RBC Scintigraphy. AJR Am J Roentgenol 2016; 207:578-84. [PMID: 27303989 DOI: 10.2214/ajr.15.15714] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Lower gastrointestinal hemorrhage is a common cause of hospitalization and has substantial associated morbidity and financial cost. CT angiography (CTA) is emerging as an alternative to (99m)Tc-labeled RBC scintigraphy (RBC scintigraphy) for the localization of acute lower gastrointestinal bleeding (LGIB); however, data on comparative efficacy are scant. The aim of this study was to assess the utility of CTA compared with RBC scintigraphy in the overall evaluation and management of acute LGIB. MATERIALS AND METHODS We retrospectively reviewed images from all CTA examinations performed for suspected acute LGIB at our tertiary care hospital from January 2010 through November 2011. The comparison group was determined by retrospective review of twice the number of RBC scintigraphic scans consecutively obtained from June 2008 to November 2011 for the same indication. All CTA and RBC scintigraphic scans were reviewed for accurate localization of the site and source of suspected active LGIB. RESULTS In total, 45 CTA and 90 RBC scintigraphic examinations were performed during the study period. Seventeen (38%) CTA scans showed active gastrointestinal bleeding compared with 34 (38%) RBC scintigraphic scans (p = 1.000). However, the site of bleeding was accurately localized on 24 (53%) CTA scans. This proportion was significantly greater than the proportion localized on RBC scintigraphic scans (27 [30%]) (p = 0.008). There were no significant differences between the two groups in average hospital length of stay, blood transfusion requirement, incidence of acute kidney injury, or in-hospital mortality. CONCLUSION Both CTA and RBC scintigraphy can be used to identify active bleeding in 38% of cases. However, the site of bleeding is localized with CTA in a significantly higher proportion of studies.
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Moss AJ, Tuffaha H, Malik A. Lower GI bleeding: a review of current management, controversies and advances. Int J Colorectal Dis 2016; 31:175-88. [PMID: 26454431 DOI: 10.1007/s00384-015-2400-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Lower gastrointestinal (GI) bleeding is defined as bleeding distal to the ligament of Treitz. In the UK, it represents approximately 3 % of all surgical referrals to the hospital. This review aims to provide review of the current evidence regarding the management of this condition. METHODS Literature was searched using Medline, Pubmed, and Cochrane for relevant evidence by two researchers. This was conducted in a manner that enabled a narrative review of the evidence covering the aetiology, clinical assessment and management options of continuously bleeding patients. FINDINGS The majority of patients with acute lower GI bleeding can be treated conservatively. In cases where ongoing bleeding occurs, colonoscopy is still the first line of investigation and treatment. Failure of endoscopy and persistent instability warrant angiography, possibly preceded by CT angiography and proceeding to superselective embolisation. Failure of embolisation warrants surgical intervention. CONCLUSIONS There are still many unanswered questions. In particular, the development of a more reliable predictive tool for mortality, rebleeding and requirement for surgery needs to be the ultimate priority. There are a small number of encouraging developments on combination therapy with regard to angiography, endoscopy and surgery. Additionally, the increasing use of haemostatic agents provides an additional tool for the management of bleeding endoscopically in difficult situations.
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Affiliation(s)
- Andrew J Moss
- Department of Surgery, Peterborough City Hospital, Peterborough, Cambridgeshire, PE3 9GZ, UK
| | - Hussein Tuffaha
- Department of Surgery, Ipswich Hospital NHS Trust, Ipswich, IP4 5PD, UK.
| | - Arshad Malik
- Department of Surgery, Ipswich Hospital NHS Trust, Ipswich, IP4 5PD, UK
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Reis FRS, Cardia PP, D'Ippolito G. Computed tomography angiography in patients with active gastrointestinal bleeding. Radiol Bras 2016; 48:381-90. [PMID: 26811556 PMCID: PMC4725400 DOI: 10.1590/0100-3984.2014.0014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Gastrointestinal bleeding represents a common medical emergency, with
considerable morbidity and mortality rates, and a prompt diagnosis is essential
for a better prognosis. In such a context, endoscopy is the main diagnostic
tool; however, in cases where the gastrointestinal hemorrhage is massive, the
exact bleeding site might go undetected. In addition, a trained professional is
not always present to perform the procedure. In an emergency setting, optical
colonoscopy presents limitations connected with the absence of bowel
preparation, so most of the small bowel cannot be assessed. Scintigraphy cannot
accurately demonstrate the anatomic location of the bleeding and is not
available at emergency settings. The use of capsule endoscopy is inappropriate
in the acute setting, particularly in the emergency department at night, and is
a highly expensive method. Digital angiography, despite its high sensitivity, is
invasive, presents catheterization-related risks, in addition to its low
availability at emergency settings. On the other hand, computed tomography
angiography is fast, widely available and minimally invasive, emerging as a
promising method in the diagnostic algorithm of these patients, being capable of
determining the location and cause of bleeding with high accuracy. Based on a
critical literature review and on their own experience, the authors propose a
computed tomography angiography protocol to assess the patient with
gastrointestinal bleeding.
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Affiliation(s)
- Fatima Regina Silva Reis
- Master, Professional Mastership Program in association with Medical Residency (Meparem), MD, Radiologist, Department of Imaging Diagnosis, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Patricia Prando Cardia
- PhD, MD, Radiologist, Centro Radiológico Campinas, Hospital Vera Cruz, Campinas, SP, Brazil
| | - Giuseppe D'Ippolito
- Private Docent, Associate Professor, Department of Imaging Diagnosis, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
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Sun H, Hou XY, Xue HD, Li XG, Jin ZY, Qian JM, Yu JC, Zhu HD. Dual-source dual-energy CT angiography with virtual non-enhanced images and iodine map for active gastrointestinal bleeding: Image quality, radiation dose and diagnostic performance. Eur J Radiol 2015; 84:884-91. [DOI: 10.1016/j.ejrad.2015.01.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 12/04/2014] [Accepted: 01/14/2015] [Indexed: 01/29/2023]
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Nakatsu S, Yasuda H, Maehata T, Nomoto M, Ohinata N, Hosoya K, Ishigooka S, Ozawa S, Ikeda Y, Sato Y, Suzuki M, Kiyokawa H, Yamamoto H, Itoh F. Urgent computed tomography for determining the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding. Intern Med 2015; 54:553-8. [PMID: 25786443 DOI: 10.2169/internalmedicine.54.2829] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE We evaluated the diagnostic performance of computed tomography (CT) as an initial radiologic test for assessing the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding (LGIB) and investigated the effectiveness of contrast-enhanced (CE) CT for detecting colonic diverticular bleeding. METHODS This was a retrospective study of 1,604 consecutive patients who visited or were referred to St. Marianna University Hospital due to acute LGIB and underwent colonoscopy within three months after presentation between September 2004 and December 2012. The clinicopathological data of the subjects were obtained from their medical records. RESULTS Among the 1,604 patients presenting with LGIB, 879 (55%) underwent a CT scan. Elective colonoscopy was considered in cases in which typical colonic wall thickening was observed on CT, suggesting colonic inflammation or malignancy (239 patients; 27%). The diagnoses in the elective cases included ischemic colitis (38%), infectious colitis (8%), inflammatory bowel disease (8%) and malignancy (5%). Urgent colonoscopy was performed after the CT examination in 640 cases (73%). The most common presumptive CT diagnosis was diverticulum (402/640; 63%). Of the 638 patients who underwent CE-CT, diverticula were observed in 346 cases, including 104 cases of extravasation indicating ongoing diverticular bleeding. Among these 104 patients, the site of bleeding was identified in 71 subjects (68%) during colonoscopy. The rate of detection of the bleeding source on colonoscopy was significantly higher in the patients with extravasation on CE-CT than in those without extravasation on CE-CT (68% vs. 20%, respectively; p<0.001). CONCLUSION Urgent CT is useful for determining the optimal timing of colonoscopy in cases of acute LGIB. CE-CT may be used to depict the presence and location of active hemorrhage and provides useful information for subsequent colonoscopy, especially in patients with diverticular bleeding.
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Affiliation(s)
- Satoko Nakatsu
- Division of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Japan
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13
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Artigas JM, Martí M, Soto JA, Esteban H, Pinilla I, Guillén E. Multidetector CT angiography for acute gastrointestinal bleeding: technique and findings. Radiographics 2014; 33:1453-70. [PMID: 24025935 DOI: 10.1148/rg.335125072] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- José M Artigas
- Departments of Radiology, Miguel Servet University Hospital, Paseo de Isabel La Católica 1-3, 50009 Zaragoza, Spain
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14
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Chu EW, Harrington AN, Divino CM. The Use of Multidetector Computed Tomography in Lower Gastrointestinal Bleeding. Am Surg 2013. [DOI: 10.1177/000313481307900937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Edward W. Chu
- Department of Surgery Mount Sinai School of Medicine New York, New York
| | | | - Celia M. Divino
- Department of Surgery Mount Sinai School of Medicine New York, New York
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15
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Dual-source dual-energy computed tomography angiography for active gastrointestinal bleeding: A preliminary study. Clin Radiol 2013; 68:139-47. [DOI: 10.1016/j.crad.2012.06.106] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 05/31/2012] [Accepted: 06/11/2012] [Indexed: 01/09/2023]
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Acute gastrointestinal hemorrhage: radiologic diagnosis and management. Can Assoc Radiol J 2012; 64:90-100. [PMID: 23245297 DOI: 10.1016/j.carj.2012.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 08/03/2012] [Indexed: 02/06/2023] Open
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García-Blázquez V, Vicente-Bártulos A, Olavarria-Delgado A, Plana MN, van der Winden D, Zamora J. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol 2012. [PMID: 23192375 DOI: 10.1007/s00330-012-2721-x] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the diagnostic accuracy of computed tomography (CT) angiography in the evaluation of patients with an episode of acute gastrointestinal haemorrhage. METHODS Systematic review and meta-analysis to estimate pooled accuracy indices. A bivariate random effects model was adjusted to obtain a summary receiver-operating characteristic (sROC) curve and the corresponding area under the curve (AUC). RESULTS Twenty-two studies were included and provided data on 672 patients (range of age 5-74) with a mean age of 65 years. The overall sensitivity of CT angiography for detecting active acute GI haemorrhage was 85.2 % (95 % CI 75.5 % to 91.5 %). The overall specificity of CT angiography was 92.1 % (95 % CI 76.7 % to 97.7 %). The likelihood ratios for positive and negative test results were 10.8 (95 % CI 3.4 to 34.4) and 0.16 (95 % CI 0.1 to 0.27) respectively, with an AUC of 0.935 (95 % CI 0.693 to 0.989). The sources of heterogeneity explored had no significant impact on diagnostic performance. CONCLUSIONS CT shows high diagnostic accuracy and is an excellent diagnostic tool for detection and localising of intestinal bleeding sites. It is highly available, provides fast detection and localisation of the bleeding site, and is minimally invasive. KEY POINTS • CT angiography is increasingly used for investigating severe gastrointestinal bleeding. • This systematic review and meta-analysis updates previous ones. • In patients with massive gastrointestinal bleeding, CT angiography/MDCT detects bleeding accurately. • CT angiography is useful in locating the bleeding site and determining appropriate treatment.
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Affiliation(s)
- V García-Blázquez
- Department of Radiology, University Hospital Ramón y Cajal, Madrid, Spain
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Detection and localization of active gastrointestinal bleeding with multidetector row computed tomography angiography: a 5-year prospective study in one medical center. J Clin Gastroenterol 2012; 46:31-41. [PMID: 22064550 DOI: 10.1097/mcg.0b013e31823337ee] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOAL To prospectively assess the utility of multidetector row computed tomography angiography (MDCTA) in the diagnosis of active gastrointestinal bleeding (GIB). BACKGROUND MDCTA is a relatively recent advance in CT scanning technology enabling excellent vascular visualization and detection of various vascular abnormalities. However, there is no prospective study with a large population evaluating the role of MDCTA in the diagnosis of active GIB. STUDY From January 2006 to January 2011, 113 consecutive patients with clinical signs of active GIB underwent MDCTA (16-slice, 64-slice, or dual-source). The criteria for positive CT findings included active extravasation of contrast material within bowel lumen, abnormal bowel mucosal enhancement, vascular malformation, abnormally enhancing polyp or diverticulum, or tumor. Two radiologists reviewed the images and assessed CT findings in consensus. The standards of reference included digital subtraction angiography, endoscopy, surgery, or final pathology reports. Sensitivity, specificity, positive and negative predictive values, and accuracy of MDCTA for detection of active GIB were evaluated. RESULTS Positive CT findings for active GIB were identified in 80 of 113 patients (70.8%), all of which were confirmed by 1 or more reference standard. Negative MDCTA results were obtained in 33 patients (29.2%). Of these, 27 patients did not require any further intervention and were discharged without incident. The overall sensitivity, specificity, positive and negative predictive values, and accuracy of MDCTA was 86.0%, 100%, 100%, 60.6%, and 88.5%, respectively. CONCLUSIONS MDCTA is an accurate first-line screening method for detection and localization of GIB and can guide triage in patients with active GIB.
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Martí M, Artigas JM, Garzón G, Álvarez-Sala R, Soto JA. Acute Lower Intestinal Bleeding: Feasibility and Diagnostic Performance of CT Angiography. Radiology 2012; 262:109-16. [DOI: 10.1148/radiol.11110326] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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La tomografía computarizada multidetector como primera opción diagnóstica en la hemorragia digestiva baja aguda en Urgencias. RADIOLOGIA 2011; 53 Suppl 1:43-50. [DOI: 10.1016/j.rx.2011.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Revised: 05/06/2011] [Accepted: 05/06/2011] [Indexed: 01/01/2023]
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Diagnosis of acute gastrointestinal bleeding: comparison of the arterial, the portal, and the combined set using 64-section computed tomography. J Comput Assist Tomogr 2011; 35:206-11. [PMID: 21412091 DOI: 10.1097/rct.0b013e31820a0ac8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To compare the respective capabilities of the arterial, the portal, and the combined set in the detection and localization of acute gastrointestinal (GI) bleeding with 64-section computed tomography (CT). METHODS A total of 46 patients with acute GI bleeding and who had undergone both 64-section CT and digital subtraction angiography were included in this study. The results of angiography were used as a reference standard. Two radiologists independently reviewed the 3 sets of CT images (arterial set, the unenhanced and arterial-phase images; portal set, the unenhanced and portal venous-phase images; combined set, the unenhanced and arterial-phase and portal venous-phase images). The diagnostic accuracy was assessed by a receiver operating characteristic analysis. RESULTS For each observer, the Az values were 0.915 and 0.931 for the arterial set, 0.903 and 0.933 for the portal set, and 0.919 and 0.911 for the combined set, respectively. The differences were not statistically significant among the 3 data sets for each observer (P > 0.05). Both observers correctly detected the bleeding site in 81.3% and 84.4% on the arterial set, in 81.3% and 84.4% on the portal set, and in 84.4% and 84.4% on the combined set, respectively. CONCLUSIONS Using 64-section CT, the diagnostic performance was not different among the arterial, the portal, and the combined set for the detection and localization of acute GI bleeding.
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Wu LM, Xu JR, Yin Y, Qu XH. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: A meta-analysis. World J Gastroenterol 2010; 16:3957-63. [PMID: 20712058 PMCID: PMC2923771 DOI: 10.3748/wjg.v16.i31.3957] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the accuracy of computed tomography (CT) angiography in the diagnosis of acute gastrointestinal (GI) bleeding.
METHODS: The MEDLINE, EMBASE, Cancerlit, Cochrane Library database, Sciencedirect, Springerlink and Scopus, from January 1995 to December 2009, were searched for studies evaluating the accuracy of CT angiography in diagnosing acute GI bleeding. Studies were included if they compared CT angiography to a reference standard of upper GI endoscopy, colonoscopy, angiography or surgery in the diagnosis of acute GI bleeding. Meta-analysis methods were used to pool sensitivity and specificity and to construct summary receiver-operating characteristic.
RESULTS: A total of 9 studies with 198 patients were included in this meta-analysis. Data were used to form 2 × 2 tables. CT angiography showed pooled sensitivity of 89% (95% CI: 82%-94%) and specificity of 85% (95% CI: 74%-92%), without showing significant heterogeneity (χ2 = 12.5, P = 0.13) and (χ2 = 22.95, P = 0.003), respectively. Summary receiver operating characteristic analysis showed an area under the curve of 0.9297.
CONCLUSION: CT angiography is an accurate, cost-effective tool in the diagnosis of acute GI bleeding and can show the precise location of bleeding, thereby directing further management.
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Application of laparoscopy in the management of obscure gastrointestinal bleeding. Surg Laparosc Endosc Percutan Tech 2010; 20:89-92. [PMID: 20393334 DOI: 10.1097/sle.0b013e3181d84821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Gastrointestinal (GI) bleeding is considered obscure when it persists or recurs after negative endoscopy. Small bowel lesions account for approximately 1-fourth of cases of obscure GI bleeding. These lack specific clinical symtoms and signs, and tend to be inaccessible to routine examinations. The management of patients with intermittent obscure GI bleeding poses both diagnostic and therapeutic challenges. The aim of this study was to report the importance of laparoscopy in diagnosing and treating small bowel lesions responsible for obscure bleeding in 5 patients with subacute presentations. Data were collected from 2 hospitals' in-patient records and a prospective database. All patients underwent laparoscopic exploration. After the identification of the diseased segments, laparoscopy-assisted segmental resection of the small bowel and enteroentorostomy were carried out in all cases. This approach enabled a successful minimally invasive treatment of the obscure GI bleeding. The overall procedure was safe and our results were satisfactory.
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