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Di Serafino M, Martino A, Manguso F, Ronza R, Zito FP, Giurazza F, Pignata L, Orsini L, Niola R, Romano L, Lombardi G. Value of multidetector computed tomography angiography in severe non-variceal upper gastrointestinal bleeding: a retrospective study in a referral bleeding unit. Abdom Radiol (NY) 2024; 49:1385-1396. [PMID: 38436701 DOI: 10.1007/s00261-024-04208-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Non-variceal upper gastrointestinal bleeding is a common gastroenterological emergency associated with significant morbidity and mortality. Upper gastrointestinal endoscopy is currently recommended as the gold standard modality for both diagnosis and treatment. As historically played a limited role in the diagnosis of acute non-variceal upper gastrointestinal bleeding, multidetector-row computed tomography angiography is emerging as a promising tool in the diagnosis of non-variceal upper gastrointestinal bleeding, especially for severe cases. However, to date, evidence concerning the role of multidetector-row computed tomography angiography in the non-variceal upper gastrointestinal bleeding diagnosis is still lacking. AIM The purpose of this study was to retrospectively investigate the diagnostic performance of emergent multidetector-row computed tomography angiography performed prior to any diagnostic modality or following urgent upper endoscopy to identify the status, the site, and the underlying etiology of severe non-variceal upper gastrointestinal bleeding. METHODS Institutional databases were reviewed in order to identify severe acute non-variceal upper gastrointestinal bleeding patients who were admitted to our bleeding unit and were referred for emergent multidetector-row computed tomography angiography prior to any hemostatic treatment (< 3 h) or following (< 3 h) endoscopy, between December 2019 and October 2022. The study aim was to evaluate the diagnostic performance of multidetector-row computed tomography angiography to detect the status, the site, and the etiology of severe non-variceal upper gastrointestinal bleeding with endoscopy, digital subtraction angiography, surgery, pathology, or a combination of them as reference standards. RESULTS A total of 68 patients (38 men, median age 69 years [range 25-96]) were enrolled. The overall multidetector-row computed tomography angiography sensitivity, specificity, and accuracy to diagnose bleeding status were 77.8% (95% CI: 65.5-87.3), 40% (95% CI: 5.3-85.3), and 75% (95% CI: 63.0-84.7), respectively. Finally, the overall multidetector-row computed tomography angiography sensitivity to identify the bleeding site and the bleeding etiology were 92.4% (95% CI: 83.2-97.5) and 79% (95% CI: 66.8-88.3), respectively. CONCLUSION Although esophagogastroduodenoscopy is the mainstay in the diagnosis and treatment of most non-variceal upper gastrointestinal bleeding cases, multidetector-row computed tomography angiography seems to be a feasible and effective modality in detecting the site, the status, and the etiology of severe acute non-variceal upper gastrointestinal bleeding. It may play a crucial role in the management of selected cases of non-variceal upper gastrointestinal bleeding, especially those clinically severe and/or secondary to rare and extraordinary rare sources, effectively guiding timing and type of treatment. However, further large prospective studies are needed to clarify the role of multidetector-row computed tomography angiography in the diagnostic process of acute non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Marco Di Serafino
- Department of General and Emergency Radiology, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy.
| | - Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy.
| | - Francesco Manguso
- Department of Gastroenterology and Digestive Endoscopy, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| | - Roberto Ronza
- Department of General and Emergency Radiology, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| | - Francesco Paolo Zito
- Department of Gastroenterology and Digestive Endoscopy, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| | - Francesco Giurazza
- Department of Interventional Radiology, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| | - Luca Pignata
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| | - Raffaella Niola
- Department of Interventional Radiology, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, "Antonio Cardarelli" Hospital, Antonio Cardarelli St 9, 80131, Naples, Italy
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Gaballah AH, Kazi IA, Zaheer A, Liu PS, Badawy M, Moshiri M, Ibrahim MK, Soliman M, Kimchi E, Elsayes KM. Imaging after Pancreatic Surgery: Expected Findings and Postoperative Complications. Radiographics 2024; 44:e230061. [PMID: 38060424 DOI: 10.1148/rg.230061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Pancreatic surgery is considered one of the most technically challenging surgical procedures, despite the evolution of modern techniques. Neoplasms remain the most common indication for pancreatic surgery, although inflammatory conditions may also prompt surgical evaluation. The choice of surgical procedure depends on the type and location of the pathologic finding because different parts of the pancreas have separate vascular supplies that may be shared by adjacent organs. The surgical approach could be conventional or minimally invasive (laparoscopic, endoscopic, or robotic assisted). Because of the anatomic complexity of the pancreatic bed, perioperative complications may be frequently encountered and commonly involve the pancreatic-biliary, vascular, lymphatic, or bowel systems, irrespective of the surgical technique used. Imaging plays an important role in the assessment of suspected postoperative complications, with CT considered the primary imaging modality, while MRI, digital subtraction angiography, and molecular imaging are considered ancillary diagnostic tools. Accurate diagnosis of postoperative complications requires a solid understanding of pancreatic anatomy, surgical indications, normal postoperative appearance, and expected postsurgical changes. The practicing radiologist should be familiar with the most common perioperative complications, such as anastomotic leak, abscess, and hemorrhage, and be able to differentiate these entities from normal anticipated postoperative changes such as seroma, edema and fat stranding at the surgical site, and perivascular soft-tissue thickening. In addition to evaluation of the primary operative fossa, imaging plays a fundamental role in assessment of the adjacent organ systems secondarily affected after pancreatic surgery, such as vascular, biliary, and enteric complications. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the supplemental material. See the invited commentary by Winslow in this issue.
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Affiliation(s)
- Ayman H Gaballah
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Irfan A Kazi
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Atif Zaheer
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Peter S Liu
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Mohamed Badawy
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Mariam Moshiri
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Mohamed K Ibrahim
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Moataz Soliman
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Eric Kimchi
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Khaled M Elsayes
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
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3
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Sagar S, Kaushik P, Phulia A, Khan D, Sarswat S, Reddy KS, Kundu N, Roy A, V R, Y S M. Diagnostic accuracy of RBC scintigraphy and CTA for detection of patients with suspected lower gastrointestinal bleeding: a systematic review and meta-analysis. Nucl Med Commun 2023; 44:1074-1079. [PMID: 37779432 DOI: 10.1097/mnm.0000000000001759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Detection of lower gastrointestinal bleeding (LGIB) through noninvasive modalities is very important in the successful management of LGIB. RBC scintigraphy and CT have a role in the detection of LGIB and guiding the management of patient by localization of the bleeding site. However, only a small number of studies have evaluated the role of RBC scintigraphy and CT in the diagnosis of LGIB. This systematic review was conducted to evaluate the diagnostic performance of RBC scintigraphy and CT in the detection of LGIB in patients with clinical or biochemical findings suspicious of LGIB. METHODS This systematic review followed PRISMA guidelines. Searches in PubMed, Scopus, and Embase were conducted using relevant keywords, and articles published through 30 April 2022, were included. Using endoscopy or surgical outcomes as the reference standard, the numbers of true and false positives and true and false negatives were extracted. Pooled estimates of diagnostic test accuracy - including sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and summary ROC (SROC) curve - were generated using bivariate random-effects meta-analysis. RESULTS Three studies comprising 171 patients were included in the systematic review and meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the detection of LGIB using RBC scintigraphy were 0.787 (95% CI, 0.643-0.893), 0.289 (95% CI, 0.164-0.443), 1.214 (95% CI, 0.923-1.597) and 0.576 (95% CI, 0.296-1.121) respectively. The area under the SROC curve was 0.73. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the detection of LGIB using CT were 0.931 (95% CI, 0.772-0.992), 0.870 (95% CI, 0.737-0.951), 6.085 (95% CI, 0.840-44.097), 0.126 (95% CI, 0.006-2.509) respectively. The area under the SROC curve was 0.095. CONCLUSION RBC scintigraphy has overall good sensitivity and CTA has excellent sensitivity specificity, positive and negative likelihood ratio in the detection of LGIB in patients with clinical or biochemical findings suspicious for LGIB.CTA along with RBC scintigraphy can be used algorithmically to rule out patients who do not have a localization for the site of LGIB thereby helping these patients to avoid invasive procedures like endoscopy or surgical explorations.
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Affiliation(s)
| | | | | | | | | | | | | | - Arup Roy
- Department of Nuclear Medicine, AIIMS,
| | - Rahul V
- Department of Nuclear Medicine, AIIMS,
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4
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Sindayigaya R, Barat M, Tzedakis S, Dautry R, Dohan A, Belle A, Coriat R, Soyer P, Fuks D, Marchese U. Modified Appleby procedure for locally advanced pancreatic carcinoma: A primer for the radiologist. Diagn Interv Imaging 2023; 104:455-464. [PMID: 37301694 DOI: 10.1016/j.diii.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most prevalent pancreatic neoplasm accounting for more than 90% of pancreatic malignancies. Surgical resection with adequate lymphadenectomy remains the only available curative strategy for patients with PDAC. Despite improvements in both chemotherapy regimen and surgical care, body/neck PDAC still conveys a poor prognosis because of the vicinity of major vascular structures, including celiac trunk, which favors insidious disease spread at the time of diagnosis. Body/neck PDAC involving the celiac trunk is considered locally advanced PDAC in most guidelines and therefore not eligible for upfront resection. However, a more aggressive surgical approach (i.e., distal pancreatectomy with splenectomy and en-bloc celiac trunk resection [DP-CAR]) was recently proposed to offer hope for cure in selected patients with locally advanced body/neck PDAC responsive to induction therapy at the cost of higher morbidity. The so-called "modified Appleby procedure" is highly demanding and requires optimal preoperative staging as well as appropriate patient preparation for surgery (i.e., preoperative arterial embolization). Herein, we review current evidence regarding DP-CAR indications and outcomes as well as the critical role of diagnostic and interventional radiology in patient preparation before DP-CAR, and early identification and management of DP-CAR complications.
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Affiliation(s)
- Rémy Sindayigaya
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France.
| | - Maxime Barat
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Stylianos Tzedakis
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Raphael Dautry
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Anthony Dohan
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Arthur Belle
- Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Romain Coriat
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Philippe Soyer
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Ugo Marchese
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
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5
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Martino A, Di Serafino M, Amitrano L, Orsini L, Pietrini L, Martino R, Menchise A, Pignata L, Romano L, Lombardi G. Role of multidetector computed tomography angiography in non-variceal upper gastrointestinal bleeding: A comprehensive review. World J Gastrointest Endosc 2022; 14:739-747. [PMID: 36567823 PMCID: PMC9782566 DOI: 10.4253/wjge.v14.i12.739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/30/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Upper gastrointestinal endoscopy is currently recommended as the gold standard modality for both diagnosis and treatment, with computed tomography traditionally playing a limited role in the diagnosis of acute NVUGIB. Following the introduction of multidetector computed tomography (MDCT), this modality is emerging as a promising tool in the diagnosis of NVUGIB. However, to date, evidence concerning the role of MDCT in the NVUGIB diagnosis is still lacking. The aim of our study was to review the current evidence concerning the role of MDCT in the diagnosis of acute NVUGIB.
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Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Lucio Amitrano
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Lorena Pietrini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Rossana Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Antonella Menchise
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luca Pignata
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples “Federico II”, Napoli 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
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6
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Lee HA, Jung HK, Kim TO, Byeon JR, Jeong ES, Cho HJ, Tae CH, Moon CM, Kim SE, Shim KN, Jung SA. Clinical outcomes of acute upper gastrointestinal bleeding according to the risk indicated by Glasgow-Blatchford risk score-computed tomography score in the emergency room. Korean J Intern Med 2022; 37:1176-1185. [PMID: 36375488 PMCID: PMC9666247 DOI: 10.3904/kjim.2022.099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/18/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND/AIMS Acute upper gastrointestinal (UGI) bleeding is a significant emergency situation with a mortality rate of 2% to 10%. Therefore, initial risk stratification is important for proper management. We aimed to evaluate the role of contrast-enhanced multidetector computed tomography (MDCT) for risk stratification in patients with acute UGI bleeding in the emergency room (ER). METHODS This retrospective study included patients with UGI bleeding in the ER. Glasgow-Blatchford risk score-computed tomography (GBS-CT) was assessed using a combination of GBS and the MDCT scan scoring system. RESULTS Of the 297 patients with UGI bleeding, 124 (41.8%) underwent abdominal MDCT. Among them, 90.3% were classified as high-risk by GBS, and five patients died (4.0%). Rebleeding occurred in nine patients (7.3%). The high-risk GBS-CT group had significantly higher in-hospital mortality (10.5% in high-risk vs. 1.4% in moderate risk vs. 0% in low-risk, p = 0.049), transfusion amount (p < 0.001), and endoscopic hemostasis (p < 0.001) compared to the moderate- and low-risk groups. CONCLUSION Adding MDCT scans to the existing validated prognosis model when predicting the risk of UGI bleeding in patients in the ER plays a significant role in determining in-hospital mortality, transfusions, and the need for endoscopic hemostasis.
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Affiliation(s)
- Hyun Ae Lee
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Tae Oh Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Ju-Ran Byeon
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Eui-Sun Jeong
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Hyun-Ji Cho
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Chang Mo Moon
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Sung-Ae Jung
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
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7
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Kucharzik T, Tielbeek J, Carter D, Taylor SA, Tolan D, Wilkens R, Bryant RV, Hoeffel C, De Kock I, Maaser C, Maconi G, Novak K, Rafaelsen SR, Scharitzer M, Spinelli A, Rimola J. ECCO-ESGAR Topical Review on Optimizing Reporting for Cross-Sectional Imaging in Inflammatory Bowel Disease. J Crohns Colitis 2022; 16:523-543. [PMID: 34628504 DOI: 10.1093/ecco-jcc/jjab180] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The diagnosis and follow up of patients with inflammatory bowel disease [IBD] requires cross-sectional imaging modalities, such as intestinal ultrasound [IUS], magnetic resonance imaging [MRI] and computed tomography [CT]. The quality and homogeneity of medical reporting are crucial to ensure effective communication between specialists and to improve patient care. The current topical review addresses optimized reporting requirements for cross-sectional imaging in IBD. METHODS An expert consensus panel consisting of gastroenterologists, radiologists and surgeons convened by the ECCO in collaboration with ESGAR performed a systematic literature review covering the reporting aspects of MRI, CT, IUS, endoanal ultrasonography and transperineal ultrasonography in IBD. Practice position statements were developed utilizing a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥80% of the participants agreed on a recommendation. RESULTS Twenty-five practice positions were developed, establishing standard terminology for optimal reporting in cross-sectional imaging. Assessment of inflammation, complications and imaging of perianal CD are outlined. The minimum requirements of a standardized report, including a list of essential reporting items, have been defined. CONCLUSIONS This topical review offers practice recommendations to optimize and homogenize reporting in cross-sectional imaging in IBD.
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Affiliation(s)
- Torsten Kucharzik
- Department of Gastroenterology, Klinikum Lüneburg, University of Hamburg, Bögelstr. 1, 21339 Lüneburg, Germany
| | - Jeroen Tielbeek
- Department of Radiology, Spaarne Gasthuis, Boerhaavelaan 22, Haarlem, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hasomher, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Radiology Department, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, UK
| | - Rune Wilkens
- Gastrounit, Division of Medicine, Hvidovre University Hospital, Copenhagen, Denmark; Copenhagen Centre for Inflammatory Bowel Disease in Children, Adolescents and Adults, University of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark
| | - Robert V Bryant
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - Christine Hoeffel
- Department of Abdominal Radiology, CHU Reims and CRESTIC, URCA, 51100 Reims, France
| | - Isabelle De Kock
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - Christian Maaser
- Outpatient Department of Gastroenterology, Department of Geriatrics, Klinikum Lüneburg, University of Hamburg, Bögelstr. 1, 21339 Lüneburg, Germany
| | - Giovanni Maconi
- Gastroenterology Unit, 'Luigi Sacco' University Hospital, Milan, Italy
| | - Kerri Novak
- Department of Radiology and Medicine, Division of Gastroenterology, University of Calgary, Alberta, Canada
| | - Søren R Rafaelsen
- Department of Radiology, University Hospital of Southern Denmark, Vejle, Denmark
| | - Martina Scharitzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Division of Colon and Rectal Surgery, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Jordi Rimola
- IBD unit, Radiology Department, Hospital Clínic Barcelona, Barcelona, Catalonia, Spain
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Usefulness of contrast-enhanced multi-detector computed tomography in identifying upper gastrointestinal bleeding: A retrospective study of patients admitted to the emergency department. PLoS One 2022; 17:e0266622. [PMID: 35390082 PMCID: PMC8989213 DOI: 10.1371/journal.pone.0266622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/23/2022] [Indexed: 11/19/2022] Open
Abstract
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.
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Pouw ME, Albright JW, Kozhimala MJ, Baird GL, Nguyen VT, Prince EA, Scappaticci AA, Ahn SH. Adding non-contrast and delayed phases increases the diagnostic performance of arterial CTA for suspected active lower gastrointestinal bleeding. Eur Radiol 2022; 32:4638-4646. [PMID: 35147778 DOI: 10.1007/s00330-022-08559-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 12/23/2021] [Accepted: 01/03/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES When assessing for lower gastrointestinal bleed (LGIB) using CTA, many advocate for acquiring non-contrast and delayed phases in addition to an arterial phase to improve diagnostic performance though the potential benefit of this approach has not been fully characterized. We evaluate diagnostic accuracy among radiologists when using single-phase, biphasic, and triphasic CTA in active LGIB detection. METHOD AND MATERIALS A random experimental block design was used where 3 blinded radiologists specialty trained in interventional radiology retrospectively interpreted 96 CTA examinations completed between Oct 2012 and Oct 2017 using (1) arterial only, (2) arterial/non-contrast, and (3) arterial/non-contrast/delayed phase configurations. Confirmed positive and negative LGIB studies were matched, balanced, and randomly ordered. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive and negative predictive values, and time to identify the presence/absence of active bleeding were examined using generalized estimating equations (GEE) with sandwich estimation assuming a binary distribution to estimate relative benefit of diagnostic performance between phase configurations. RESULTS Specificity increased with additional contrast phases (arterial 72.2; arterial/non-contrast 86.1; arterial/non-contrast/delayed 95.1; p < 0.001) without changes in sensitivity (arterial 77.1; arterial/non-contrast 70.2; arterial/non-contrast/delayed 73.1; p = 0.11) or mean time required to identify bleeding per study (s, arterial 34.8; arterial/non-contrast 33.1; arterial/non-contrast/delayed 36.0; p = 0.99). Overall agreement among readers (Kappa) similarly increased (arterial 0.47; arterial/non-contrast 0.65; arterial/non-contrast/delayed 0.79). CONCLUSION The addition of non-contrast and delayed phases to arterial phase CTA increased specificity and inter-reader agreement for the detection of lower gastrointestinal bleeding without increasing reading times. KEY POINTS • A triphasic CTA including non-contrast, arterial, and delayed phase has higher specificity for the detection of lower gastrointestinal bleeding than arterial-phase-only protocols. • Inter-reader agreement increases with additional contrast phases relative to single-phase CTA. • Increasing the number of contrast phases did not increase reading times.
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Affiliation(s)
- Matthew E Pouw
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA.
| | | | - Meagan J Kozhimala
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Grayson L Baird
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
| | - Van T Nguyen
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
| | - Ethan A Prince
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
| | - Albert A Scappaticci
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
| | - Sun H Ahn
- Department of Diagnostic Imaging, Rhode Island Hospital/Brown University, Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
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Havlichek DH, Kamboj AK, Leggett CL. A Practical Guide to the Evaluation of Small Bowel Bleeding. Mayo Clin Proc 2022; 97:146-153. [PMID: 34996546 DOI: 10.1016/j.mayocp.2021.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 07/13/2021] [Accepted: 09/13/2021] [Indexed: 02/07/2023]
Abstract
Gastrointestinal bleeding is a common clinical problem encountered in both the inpatient and outpatient settings. Although the evaluation of upper and lower gastrointestinal bleeding is often straightforward, bleeding from the small bowel may pose a clinical challenge. In this article, we review the indications, modalities, and differential diagnoses of small bowel bleeding. On completion of the article, clinicians should be able to identify common causes of small bowel bleeding, understand the advantages and disadvantages of the modalities used to evaluate small bowel bleeding, and enact a stepwise management approach to the patient with presumed small bowel bleeding.
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Affiliation(s)
| | - Amrit K Kamboj
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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11
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Ali TA, Ibrahim W, Tawab MA, ElHariri MAG. Duodenal angiodysplasia: a case report. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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12
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Barat M, Marchese U, Shotar E, Chousterman B, Barret M, Dautry R, Coriat R, Kedra A, Fuks D, Soyer P, Dohan A. Contrast extravasation on computed tomography angiography in patients with hematochezia or melena: Predictive factors and associated outcomes. Diagn Interv Imaging 2021; 103:177-184. [PMID: 34657834 DOI: 10.1016/j.diii.2021.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Maxime Barat
- Department of Radiology A, Hôpital Cochin, APHP, Paris 75014, France; Faculté de Médecine, Université de Paris, Paris 75006, France.
| | - Ugo Marchese
- Faculté de Médecine, Université de Paris, Paris 75006, France; Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris 75014, France
| | - Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, AP-HP, Boulevard de l'Hôpital, Paris 75014, France
| | - Benjamin Chousterman
- Faculté de Médecine, Université de Paris, Paris 75006, France; Intensive Care unit, Hôpital Lariboisière, AP-HP, Paris 75010, France
| | - Maximilien Barret
- Faculté de Médecine, Université de Paris, Paris 75006, France; Department of Gastroenterology, Hôpital Cochin, APHP, Paris 75014, France
| | - Raphael Dautry
- Department of Radiology A, Hôpital Cochin, APHP, Paris 75014, France
| | - Romain Coriat
- Faculté de Médecine, Université de Paris, Paris 75006, France; Department of Gastroenterology, Hôpital Cochin, APHP, Paris 75014, France
| | - Alice Kedra
- Department of Radiology A, Hôpital Cochin, APHP, Paris 75014, France
| | - David Fuks
- Faculté de Médecine, Université de Paris, Paris 75006, France; Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris 75014, France
| | - Philippe Soyer
- Department of Radiology A, Hôpital Cochin, APHP, Paris 75014, France; Faculté de Médecine, Université de Paris, Paris 75006, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, APHP, Paris 75014, France; Faculté de Médecine, Université de Paris, Paris 75006, France
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13
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Guglielmo FF, Wells ML, Bruining DH, Strate LL, Huete Á, Gupta A, Soto JA, Allen BC, Anderson MA, Brook OR, Gee MS, Grand DJ, Gunn ML, Khandelwal A, Park SH, Ramalingam V, Sokhandon F, Yoo DC, Fidler JL. Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms. Radiographics 2021; 41:1632-1656. [PMID: 34597220 DOI: 10.1148/rg.2021210043] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Flavius F Guglielmo
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Michael L Wells
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - David H Bruining
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Lisa L Strate
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Álvaro Huete
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Avneesh Gupta
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Jorge A Soto
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Brian C Allen
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Mark A Anderson
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Olga R Brook
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Michael S Gee
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - David J Grand
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Martin L Gunn
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Ashish Khandelwal
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Seong Ho Park
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Vijay Ramalingam
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Farnoosh Sokhandon
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Don C Yoo
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
| | - Jeff L Fidler
- From the Department of Radiology, Thomas Jefferson University, 132 S 10th St, Philadelphia, Pa 19107 (F.F.G.); Department of Radiology (M.L.W., A.K., J.L.F.) and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, Rochester, Minn; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Wash (L.L.S.); Department of Radiology, Pontificia Universidad Católica de Chile, Santiago, Chile (A.H.); Department of Radiology, Boston University Medical Center, Boston, Mass (A.G., J.A.S.); Department of Radiology, Duke University Medical Center, Durham, NC (B.C.A.); Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (M.A.A., M.S.G.); Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass (O.R.B., V.R.); Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI (D.J.G., D.C.Y.); Department of Radiology, University of Washington, Seattle, Wash (M.L.G.); Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (S.H.P.); and Department of Radiology, Beaumont Health, Oakland University William Beaumont School of Medicine, Royal Oak, Mich (F.S.)
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14
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McDonald MJ. Acute Gastrointestinal Bleeding – Locating the Source and Correcting the Disorder. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yu Q, Liu C, Collura B, Navuluri R, Patel M, Yu Z, Ahmed O. Prophylactic transcatheter arterial embolization for high-risk ulcers following endoscopic hemostasis: a meta-analysis. World J Emerg Surg 2021; 16:29. [PMID: 34112185 PMCID: PMC8194167 DOI: 10.1186/s13017-021-00371-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 05/18/2021] [Indexed: 12/21/2022] Open
Abstract
Background To conduct a meta-analysis to assess the safety and efficacy of prophylactic transcatheter arterial embolization (PTAE) for the treatment of high-risk bleeding peptic ulcers after achieving endoscopic hemostasis. Methods PubMed and Cochrane Library were queried for full-text articles published up to December 2019. The following keywords were used: “prophylactic embolization”, “supplement embolization”, “gastrointestinal bleeding”, and “ulcer bleeding”. High-risk ulcers were defined based on endoscopic findings (i.e., large ulcers, Forrest class I-IIb) and/or clinical presentation (i.e., hypotension, decreased hemoglobin during endoscopy). Only comparative studies investigating PTAE versus conservative treatment after achieving endoscopic hemostasis were included. Baseline study characteristics, rebleeding rate, need for surgery, mortality, and PTAE-related complication rates were investigated. Quantitative analyses were performed with Stata 15.1. Results Among the five included original studies, a total of 265 patients received PTAE and 617 were managed conservatively after endoscopy. The rebleeding rate (6.8% vs 14.3%, p = 0.003) and mortality (4.5% vs 8.8%, p = 0.032) of patients from the PTAE group were lower than the control group. PTAE also reduced the cumulative need for future surgical intervention (3.0% vs 14.4%, p = 0.005). The PTAE-related major and minor events were 0.75% and 14.4%, respectively. Conclusion PTAE had therapeutic potentials in reducing rebleeding risk, need for surgical intervention, and morality in high-risk peptic ulcers after achieving endoscopic hemostasis. The embolization-associated adverse events were minimal. Future studies should aim to increase the sample size and resources for performing endovascular interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00371-2.
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Affiliation(s)
- Qian Yu
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan City, Shandong Province, China.,Department of General Surgery, Cleveland Clinic Florida, Florida, USA
| | - Chenyu Liu
- School of Medicine, George Washington University, Washington DC, USA
| | | | - Rakesh Navuluri
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Mikin Patel
- Department of Radiology, University of Arizona Medical Center, Tucson, AZ, USA
| | - Zhiyong Yu
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan City, Shandong Province, China.
| | - Osman Ahmed
- Division of Interventional Radiology, Department of Radiology, University of Chicago, Chicago, IL, USA
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16
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Tse JR, Shen J, Shah R, Fleischmann D, Kamaya A. Extravasation Volume at Computed Tomography Angiography Correlates With Bleeding Rate and Prognosis in Patients With Overt Gastrointestinal Bleeding. Invest Radiol 2021; 56:394-400. [PMID: 33449577 DOI: 10.1097/rli.0000000000000753] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Despite the identification of active extravasation on computed tomography angiography (CTA) in patients with overt gastrointestinal bleeding (GIB), a large proportion do not have active bleeding or require hemostatic therapy at endoscopy, catheter angiography, or surgery. The objective of our proof-of-concept study was to improve triage of patients with GIB by correlating extravasation volume of first-pass CTA with bleeding rate and clinical outcomes. MATERIALS AND METHODS All patients who presented with overt GIB and active extravasation on CTA from January 2014 to July 2019 were reviewed in this retrospective, institutional review board-approved and Health Insurance Portability and Accountability Act-compliant study. Extravasation volume was assessed using 3-dimensional software and correlated with hemostatic therapy (primary endpoint) and with intraprocedural bleeding, blood transfusions, and mortality as secondary endpoints using logistic regression models (P < 0.0125 indicating statistical significance). Odds ratios were used to determine the effect size of a threshold extravasation volume. Quantitative data (extravasation volume, aorta attenuation, extravasation attenuation and time) were input into a mathematical model to calculate bleeding rate. RESULTS Fifty consecutive patients including 6 (12%) upper, 18 (36%) small bowel, and 26 (52%) lower GIB met inclusion criteria. Forty-two underwent catheter angiography, endoscopy, or surgery; 16 had intraprocedural active bleeding, and 24 required hemostatic therapy. Higher extravasation volumes correlated with hemostatic therapy (P = 0.007), intraprocedural active bleeding (P = 0.003), and massive transfusion (P = 0.0001), but not mortality (P = 0.936). Using a threshold volume of 0.80 mL or greater, the odds ratio of hemostatic therapy was 8.1 (95% confidence interval, 2.1-26), active bleeding was 11.8 (2.6-45), and massive transfusion was 18 (2.3-65). With mathematical modeling, extravasation volume had a direct and linear relationship with bleeding rate, and the lowest calculated detectable bleeding rate with CTA was less than 0.1 mL/min. CONCLUSIONS Larger extravasation volumes correlate with higher bleeding rates and may identify patients who require hemostatic therapy, have intraprocedural bleeding, and require blood transfusions. Current CTAs can detect bleeding rates less than 0.1 mL/min.
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Affiliation(s)
- Justin R Tse
- From the Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles
| | | | - Rajesh Shah
- Interventional Radiology, Stanford University School of Medicine, California
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Zheng L, Lee IJ, Shin JH, Chu HH, Li HL. Endovascular Management of Gastric Conduit Hemorrhage following Transthoracic Esophagectomy. J Vasc Interv Radiol 2021; 32:1144-1149. [PMID: 34022402 DOI: 10.1016/j.jvir.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/29/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022] Open
Abstract
Seven patients underwent angiography and attempted embolization for massive hemorrhage of the gastric conduit after transthoracic esophagectomy. Endoscopy revealed ulcers in 5 patients, tumor recurrence in 1 patient, and unknown etiology in 1 patient. Arteriography revealed extravasation, pseudoaneurysm, or tumor blush arising from the intercostal artery (n = 4) or right gastric artery (n = 2), which were successfully embolized. The bleeding source was not identified in 1 patient, who died from persistent hemorrhage.
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Affiliation(s)
- Lin Zheng
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - In Joon Lee
- Department of Radiology, National Cancer Center, Goyang-si, Gyeonggi-do, Korea
| | - Ji Hoon Shin
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China; Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea.
| | - Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Hai-Liang Li
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
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Karuppasamy K, Kapoor BS, Fidelman N, Abujudeh H, Bartel TB, Caplin DM, Cash BD, Citron SJ, Farsad K, Gajjar AH, Guimaraes MS, Gupta A, Higgins M, Marin D, Patel PJ, Pietryga JA, Rochon PJ, Stadtlander KS, Suranyi PS, Lorenz JM. ACR Appropriateness Criteria® Radiologic Management of Lower Gastrointestinal Tract Bleeding: 2021 Update. J Am Coll Radiol 2021; 18:S139-S152. [PMID: 33958109 DOI: 10.1016/j.jacr.2021.02.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
Diverticulosis remains the commonest cause for acute lower gastrointestinal tract bleeding (GIB). Conservative management is initially sufficient for most patients, followed by elective diagnostic tests. However, if acute lower GIB persists, it can be investigated with colonoscopy, CT angiography (CTA), or red blood cell (RBC) scan. Colonoscopy can identify the site and cause of bleeding and provide effective treatment. CTA is a noninvasive diagnostic tool that is better tolerated by patients, can identify actively bleeding site or a potential bleeding lesion in vast majority of patients. RBC scan can identify intermittent bleeding, and with single-photon emission computed tomography, can more accurately localize it to a small segment of bowel. If patients are hemodynamically unstable, CTA and transcatheter arteriography/embolization can be performed. Colonoscopy can also be considered in these patients if rapid bowel preparation is feasible. Transcatheter arteriography has a low rate of major complications; however, targeted transcatheter embolization is only feasible if extravasation is seen, which is more likely in hemodynamically unstable patients. If bleeding site has been previously localized but the intervention by colonoscopy and transcatheter embolization have failed to achieve hemostasis, surgery may be required. Among patients with obscure (nonlocalized) recurrent bleeding, capsule endoscopy and CT enterography can be considered to identify culprit mucosal lesion(s). 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.
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Affiliation(s)
| | | | - Nicholas Fidelman
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Hani Abujudeh
- Detroit Medical Center, Tenet Healthcare and Envision Radiology Physician Services, Detroit, Michigan
| | | | - Drew M Caplin
- Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, Chair, Committee on Practice Parameters Interventional Radiology, American College of Radiology, Program Director, Interventional Radiology Residency, Zucker School of Medicine NSLIJ
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas, American Gastroenterological Association
| | | | - Khashayar Farsad
- Oregon Health and Science University, Portland, Oregon, Vice Chair, Department of Interventional Radiology, Oregon Health & Science University
| | - Aakash H Gajjar
- PRiSMA Proctology Surgical Medicine & Associates, Houston, Texas, American College of Surgeons
| | | | - Amit Gupta
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | | | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - Parag J Patel
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Paul J Rochon
- University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | | | - Pal S Suranyi
- Medical University of South Carolina, Charleston, South Carolina
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Ikeoka S, Yoshizaki T, Matsuda T, Katayama N, Matsumoto M, Takagi M, Momose K, Eguchi T, Morisawa T, Okada A. A rare case of pyogenic granuloma of the jejunum causing gastrointestinal bleeding. Clin J Gastroenterol 2020; 13:1125-1128. [PMID: 32734317 DOI: 10.1007/s12328-020-01187-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022]
Abstract
Pyogenic granulomas (PG) are lobular capillary hemangiomas mostly found in the mucous membranes of the skin and oral cavity, and rarely occur in the gastrointestinal tract. Here we describe a case of an 84-year-old patient with alcoholic cirrhosis who presented with persistent melena and progressive anemia. Endoscopy showed esophageal varices and he underwent endoscopic variceal ligation (EVL) with transient resolution of anemia. However, due to worsening anemia, he underwent capsule endoscopy that revealed a bleeding tumor in the small intestine. We performed double-balloon endoscopy and found a 7-mm polyp with a white coat located in the jejunum and resected it at a later date. Histological characteristics led to the diagnosis of PG, and the patient's melena and anemia subsequently improved.
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Affiliation(s)
- Seitaro Ikeoka
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Tetsuya Yoshizaki
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan.
| | - Tatsuya Matsuda
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Norio Katayama
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Masanori Matsumoto
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Megumi Takagi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Kenji Momose
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Toshiyuki Morisawa
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
| | - Akihiko Okada
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012, Japan
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CT for Gastrointestinal Bleeding: A Primer for Residents. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-00358-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hsu M, Shah N, Bernal-Fernandez M, HonShideler C, Soto J, Anderson S, Ramalingam V. CTA measurements of acute lower gastrointestinal bleeding size predict subsequent positive catheter angiography. Abdom Radiol (NY) 2020; 45:615-622. [PMID: 32040597 DOI: 10.1007/s00261-019-02386-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to determine whether the measured size of active gastrointestinal hemorrhage was useful in predicting subsequent positive findings at catheter angiography. MATERIALS AND METHODS This was a single-institution retrospective study consisting of 32 patients with computed tomography angiography (CTA) positive for gastrointestinal bleeding who went on to receive catheter angiography. Each CTA was reviewed, with axial measurements of the anterior-posterior and transverse dimensions of the largest foci of hemorrhage recorded. Volumetric analysis was used to measure the volume of hemorrhage. These measurements were performed for both the arterial and portal venous phases. Additionally, the interval growth between the arterial and portal venous phase was also calculated. RESULTS There was a statistically significant difference in the absolute size of the maximum transverse dimension on portal venous phase imaging (mean = 19.8 mm, p < 0.001), as well as an interval increase in transverse (mean = 8.5 mm, p < 0.001) and anteriorposterior (mean = 5.4 mm, p = 0.027) size between arterial and portal venous phases in patients with positive catheter angiography versus negative catheter angiography. There was a statistically significant difference in the volume of hemorrhage on arterial (mean = 1.72 cm3, p = 0.020) and portal venous phases (mean = 5.89 cm3, p = 0.016), as well as an interval change in the size of hemorrhage between the two phases (mean = 4.17 cm3, p = 0.020) in patients with positive catheter angiography versus patients in the negative catheter angiography group. CONCLUSIONS The absolute axial size and volume of hemorrhage, as well as the interval change between the arterial and portal venous phases of CTA imaging is predictive of subsequent positive catheter angiography.
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Affiliation(s)
- Michael Hsu
- UCLA Ronald Reagan Medical Center, Los Angeles, USA
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Trabzonlu TA, Mozaffary A, Kim D, Yaghmai V. Dual-energy CT evaluation of gastrointestinal bleeding. Abdom Radiol (NY) 2020; 45:1-14. [PMID: 31728614 DOI: 10.1007/s00261-019-02226-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Gastrointestinal bleeding is a common cause for hospital admissions and is an important cause of morbidity and mortality. Although endoscopy is accepted as the standard initial diagnostic modality for the evaluation of gastrointestinal bleeding, multiphasic computed tomography (CT) imaging has become an alternative diagnostic tool. Dual-energy CT with post-processing techniques may have additional advantages over single-energy computed tomography in evaluation of gastrointestinal bleeding. In this article, we discuss the role of dual-energy CT in the evaluation of gastrointestinal bleeding with potential advantages over conventional CT and limitations.
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Zhu JY, Huang J, Fan W, Lv X, Ren YP, Yang XL. Massive hemobilia due to a ruptured mycotic hepatic artery aneurysm associated with streptococcal endocarditis: case report. J Int Med Res 2019; 48:300060519883554. [PMID: 31709867 PMCID: PMC7607214 DOI: 10.1177/0300060519883554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Hepatic artery aneurysm rupture is a rare cause of massive hemobilia, which is potentially life-threatening, cause of upper gastrointestinal hemorrhage. Cases of mycotic hepatic artery aneurysm associated with streptococcal endocarditis have rarely been reported. In the present study, we report a case of massive hemobilia that was caused by ruptured mycotic hepatic artery aneurysm in a patient who was infected with streptococcal endocarditis 3 months previously. Transarterial embolization in the patient failed, possibly due to vascular variations. However, surgical treatment was successfully performed, and the patient completely recovered. In conclusion, surgical treatment may be useful in treating massive hemobilia under life-threatening conditions, even in cases of vascular variations and failure of transarterial embolization.
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Affiliation(s)
- Jia-Ying Zhu
- Department of Emergency, Gui Zhou Provincial People's Hospital, Guiyang, China
| | - Jia Huang
- Department of Emergency, Gui Zhou Provincial People's Hospital, Guiyang, China
| | - Wei Fan
- Department of Emergency, Gui Zhou Provincial People's Hospital, Guiyang, China
| | - Xia Lv
- Department of Emergency, Gui Zhou Provincial People's Hospital, Guiyang, China
| | - Yi-Pin Ren
- Department of Emergency, Gui Zhou Provincial People's Hospital, Guiyang, China
| | - Xiu-Lin Yang
- Department of Emergency, Gui Zhou Provincial People's Hospital, Guiyang, China
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Correlation of CT Angiography and 99mTechnetium-Labeled Red Blood Cell Scintigraphy to Catheter Angiography for Lower Gastrointestinal Bleeding: A Single-Institution Experience. J Vasc Interv Radiol 2019; 30:1725-1732.e7. [DOI: 10.1016/j.jvir.2019.04.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 11/24/2022] Open
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Characteristics of patients treated for active lower gastrointestinal bleeding detected by CT angiography: Interventional radiology versus surgery. Eur J Radiol 2019; 120:108691. [PMID: 31589996 DOI: 10.1016/j.ejrad.2019.108691] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 08/07/2019] [Accepted: 09/22/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE To determine radiological or clinical criteria guiding treatment decisions in active lower gastrointestinal bleeding (LGIB). MATERIALS AND METHODS We consecutively and retrospectively included all patients admitted to our emergency department for acute LGIB proven by CT angiography (CTA) from 2004 to 2017. Patients were divided into two groups depending on whether they first underwent interventional radiological (IR) or surgical treatment. Two radiologists reviewed CTA and angiographic images. Patients' hemodynamic and clinical parameters, delay between imaging and treatment, procedure characteristics, and outcomes were investigated to detect differences between the two groups. RESULTS Initial management consisted of IR in 62 cases (70.5%) and surgery in 26 (29.5%). IR cases were older than surgical cases (74.3 vs 64.3y, p = 0.014). Baseline hemodynamic parameters were similar between the two groups. For colonic bleeding sources, the delay between CTA and IR was shorter than between CTA and surgery (p = 0.027), while there was a trend towards a shorter delay for all LGIB taken together (p = 0.061). In cases with hematochezia or melena, IR was more frequently performed than surgery (p = 0.001). Surgical cases showed higher base excesses (p = 0.039) and lactate levels (p = 0.042) after treatment compared with IR cases. Length of hospital stay was similar between the two groups (p = 0.728). During angiography, 41 (66%) cases were embolized. Complications occurred in three cases after IR (7%) and in five after surgery (19%). CONCLUSION Initial management of active LGIB revealed by CTA (i.e. IR versus surgery), may depend on age and clinical signs, rather than hemodynamic parameters.
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Barral M, Pellerin O, Tran VT, Gallix B, Boucher LM, Valenti D, Sapoval M, Soyer P, Dohan A. Predictors of Mortality from Spontaneous Soft-Tissue Hematomas in a Large Multicenter Cohort Who Underwent Percutaneous Transarterial Embolization. Radiology 2019; 291:250-258. [DOI: 10.1148/radiol.2018181187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Impact of Computed Tomography Evaluation Before Colonoscopy for the Management of Colonic Diverticular Hemorrhage. J Clin Gastroenterol 2019; 53:e75-e83. [PMID: 29356785 DOI: 10.1097/mcg.0000000000000988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
GOALS The purpose of this study was to investigate and summarize our experience of a standardized strategy using computed tomography (CT) followed by colonoscopy for the assessment of colonic diverticular hemorrhage with focus on a comparison of CT and colonoscopy findings in patients with colonic diverticular hemorrhage. BACKGROUND Colonic diverticular hemorrhage is usually diagnosed by colonoscopy, but it is difficult to identify the responsible bleeding point among many diverticula. STUDY We retrospectively included 257 consecutive patients with colonic diverticular hemorrhage. All patients underwent a CT examination before colonoscopy. All-cause mortality and rebleeding-free rate after discharge were analyzed by Kaplan-Meier analysis and compared using the log-rank test. RESULTS In CT examinations, 184 patients (71.6%) had definite diverticular hemorrhage with 31.9% showing intraluminal high-density fluid on plain CT, 39.7% showing extravasation, and 31.1% showing arteriovenous increase of extravasation on enhanced CT. In colonoscopy, 130 patients (50.6%) showed endoscopic stigmata of bleeding with 12.1% showing active bleeding, 17.1% showing a nonbleeding visible vessel, and 21.4% showing an adherent clot. A comparison of the locations of bleeding in CT and colonoscopy showed that the agreement rate was 67.3%, and the disagreement rate was 0.8% when the lesion was identified by both modalities patients with definite diverticular hemorrhage identified by CT had a longer hospital stay, higher incidences of hemodynamic instability and rebleeding events than did patients with presumptive diverticular hemorrhage. CONCLUSION CT evaluation before colonoscopy can be a good option for managing patients with colonic diverticular hemorrhage.
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Tarasconi A, Baiocchi GL, Pattonieri V, Perrone G, Abongwa HK, Molfino S, Portolani N, Sartelli M, Di Saverio S, Heyer A, Ansaloni L, Coccolini F, Catena F. Transcatheter arterial embolization versus surgery for refractory non-variceal upper gastrointestinal bleeding: a meta-analysis. World J Emerg Surg 2019; 14:3. [PMID: 30733822 PMCID: PMC6359767 DOI: 10.1186/s13017-019-0223-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/22/2019] [Indexed: 12/19/2022] Open
Abstract
Background Nowadays, very few patients with non-variceal upper gastrointestinal bleeding fail endoscopic hemostasis (refractory NVUGIB). This subset of patients poses a clinical dilemma: should they be operated on or referred to transcatheter arterial embolization (TAE)? Objectives To carry out a systematic review of the literature and to perform a meta-analysis of studies that directly compare TAE and surgery in patients with refractory NVUGIB. Materials and methods We searched PubMed, Ovid MEDLINE, and Embase. A combination of the MeSH terms “gastrointestinal bleeding”; “gastrointestinal hemorrhage”; “embolization”; “embolization, therapeutic”; and “surgery” were used ((“gastrointestinal bleeding” or “gastrointestinal hemorrhage”) and (“embolization” or “embolization, therapeutic”) and “surgery”)). The search was performed in June 2018. Studies were retrieved and relevant studies were identified after reading the study title and abstract. Bibliographies of the selected studies were also examined. Statistical analysis was performed using RevMan software. Outcomes considered were all-cause mortality, rebleeding rate, complication rate, and the need for further intervention. Results Eight hundred fifty-six abstracts were found. Only 13 studies were included for a total of 1077 patients (TAE group 427, surgery group 650). All selected papers were non-randomized studies: ten were single-center and two were double-center retrospective comparative studies, while only one was a multicenter prospective cohort study. No comparative randomized clinical trial is reported in the literature. Mortality. Pooled data (1077 patients) showed a tendency toward improved mortality rates after TAE, but this trend was not statistically significant (OD = 0.77; 95% CI 0.50, 1.18; P = 0.05; I2 = 43% [random effects]). Significant heterogeneity was found among the studies. Rebleeding rate. Pooled data (865 patients, 211 events) showed that the incidence of rebleeding was significantly higher for patients undergoing TAE (OD = 2.44; 95% CI 1.77, 3.36; P = 0.41; I2 = 4% [fixed effects]). Complication rate. Pooling of the data (487 patients, 206 events) showed a sharp reduction of complications after TAE when compared with surgery (OD = 0.45; 95% CI 0.30, 0.47; P = 0.24; I2 = 26% [fixed effects]). Need for further intervention. Pooled data (698 patients, 165 events) revealed a significant reduction of further intervention in the surgery group (OD = 2.13; 95% CI 1.21, 3.77; P = 0.02; I2 = 56% [random effects]). A great degree of heterogeneity was found among the studies. Conclusions The present study shows that TAE is a safe and effective procedure; when compared to surgery, TAE exhibits a higher rebleeding rate, but this tendency does not affect the clinical outcome as shown by the comparison of mortality rates (slight drift toward lower mortality for patients undergoing TAE). The present study suggests that TAE could be a viable option for the first-line therapy of refractory NVUGIB and sets the foundation for the design of future randomized clinical trials. Limitations The retrospective nature of the majority of included studies leads to selection bias. Furthermore, the decision of whether to proceed with surgery or refer to TAE was made on a case-by-case basis by each attending surgeon. Thus, external validity is low. Another limitation involves the variability in etiology of the refractory bleeding. TAE techniques and surgical procedure also differ consistently between different studies. Frame time for mortality detection differs between the studies. These limitations do not impair the power of the present study that represents the largest and most recent meta-analysis currently available.
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Affiliation(s)
- Antonio Tarasconi
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Gian Luca Baiocchi
- 2Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Vittoria Pattonieri
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Gennaro Perrone
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Hariscine Keng Abongwa
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
| | - Sarah Molfino
- 2Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Nazario Portolani
- 2Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | | | - Salomone Di Saverio
- 4Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Arianna Heyer
- 5Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Luca Ansaloni
- 6General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- 6General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- 1Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma, Italy
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Bassiouny RH, Khattab RT. Acute non traumatic abdominal pain of small bowel origin: Can multi-detector CT enterography provide a potential contribution to the diagnosis of underlying causes? THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2018. [DOI: 10.1016/j.ejrnm.2018.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Lee CM, Jang JK, Shin JH, Song SY, Kang BK. Role of computed tomography angiography for acute gastrointestinal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Chul-min Lee
- Department of Radiology, Armed Forces Capital Hospital, Seongnam, Korea
| | - Jong Keon Jang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soon-Young Song
- Department of Radiology, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Korea
| | - Bo-kyeong Kang
- Department of Radiology, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Korea
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31
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Raju SA, Mooney PD, Kodali K, Toh C, Kusumawidjaja D, Hersey N, Penny H, Kurien M, Sanders DS. First UK data for CT angiography in persisting upper GI bleeding. Frontline Gastroenterol 2018; 9:331-332. [PMID: 30245799 PMCID: PMC6145429 DOI: 10.1136/flgastro-2017-100914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 02/04/2018] [Accepted: 02/24/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Suneil A Raju
- Department of Infection and Immunity and Cardiovascular Science, Academic Unit of Gastroenterology, The University of Sheffield, Sheffield, UK
| | - Peter D Mooney
- Department of Infection and Immunity and Cardiovascular Science, Academic Unit of Gastroenterology, The University of Sheffield, Sheffield, UK
| | - Karuna Kodali
- Department of Infection and Immunity and Cardiovascular Science, Academic Unit of Gastroenterology, The University of Sheffield, Sheffield, UK
| | - Charmaine Toh
- Department of Infection and Immunity and Cardiovascular Science, Academic Unit of Gastroenterology, The University of Sheffield, Sheffield, UK
| | | | - Naomi Hersey
- Department of Radiology, Northern General Hospital, Sheffield, UK
| | - Hugo Penny
- Department of Infection and Immunity and Cardiovascular Science, Academic Unit of Gastroenterology, The University of Sheffield, Sheffield, UK
| | - Matthew Kurien
- Department of Infection and Immunity and Cardiovascular Science, Academic Unit of Gastroenterology, The University of Sheffield, Sheffield, UK
| | - David S Sanders
- Department of Infection and Immunity and Cardiovascular Science, Academic Unit of Gastroenterology, The University of Sheffield, Sheffield, UK
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Morrison TC, Wells M, Fidler JL, Soto JA. Imaging Workup of Acute and Occult Lower Gastrointestinal Bleeding. Radiol Clin North Am 2018; 56:791-804. [PMID: 30119774 DOI: 10.1016/j.rcl.2018.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Lower gastrointestinal bleeding is defined as occurring distal to the ligament of Treitz and presents as hematochezia, melena, or with anemia and positive fecal occult blood test. Imaging plays a pivotal role in the localization and treatment of lower gastrointestinal bleeds. Imaging tests in the workup of acute lower gastrointestinal bleeding include computed tomography (CT) angiography, nuclear medicine scintigraphy, and conventional catheter angiography. Catheter angiography can also be used to deliver treatment. Imaging tests in the workup of occult lower gastrointestinal bleeding include CT enterography and nuclear medicine Meckel scan.
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Affiliation(s)
- Trevor C Morrison
- Boston University Medical Center, 830 Harrison Avenue, FGH 3rd Floor, Boston, MA 02118, USA
| | - Michael Wells
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Jeff L Fidler
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Jorge A Soto
- Boston University Medical Center, 830 Harrison Avenue, FGH 3rd Floor, Boston, MA 02118, USA.
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Mizuki A, Tatemichi M, Nagata H. Management of Diverticular Hemorrhage: Catching That Culprit Diverticulum Red-Handed! Inflamm Intest Dis 2018; 3:100-106. [PMID: 30733954 DOI: 10.1159/000490387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/24/2018] [Indexed: 12/22/2022] Open
Abstract
Background/Summary Acute colonic diverticular hemorrhage (CDH) represents a significant challenge for gastroenterologists. There are some clinical problems in the diagnosis, treatment, and prevention of CDH. CDH is the most common cause of overt lower gastrointestinal bleeding in adults in Eastern and Western countries. Moreover, CDH imposes significant economic and clinical burdens on the health care system. Colonoscopy is recommended as a useful diagnostic tool for CDH after bowel preparation. Colonoscopy can be used to identify the culprit diverticulum and to provide endoscopic therapy. In most cases, however, the bleeding stops spontaneously. For this reason, it is still controversial whether urgent colonoscopy or elective colonoscopy is "preferable." Key Messages This review aims to highlight the various clinical problems (purge, timing of colonoscopy, CT angiography, and endoscopy) encountered in the attempt to identify and treat the culprit diverticulum red-handed.
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Affiliation(s)
- Akira Mizuki
- Department of Internal Medicine, Keiyu Hospital, Yokohama, Japan
| | - Masayuki Tatemichi
- Department of Community Health, Tokai University School of Medicine, Isehara, Japan
| | - Hiroshi Nagata
- Department of Internal Medicine, Keiyu Hospital, Yokohama, Japan
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Orron DE, Bloom AI, Neeman Z. The Role of Transcatheter Arterial Embolization in the Management of Nonvariceal Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2018; 28:331-349. [PMID: 29933779 DOI: 10.1016/j.giec.2018.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nearly 50 years ago, catheter angiography was introduced as a means of both diagnosing and treating nonvariceal upper gastrointestinal bleeding. Technological advances and innovations have resulted in the introduction of microcatheters that, using a coaxial technique, are capable of selecting third-order arterial branches and of delivering a wide array of embolic agents. This article reviews the imaging diagnosis of nonvariceal upper gastrointestinal bleeding, the techniques of diagnostic and therapeutic angiography, the angiographic appearance of the various etiologies of nonvariceal upper gastrointestinal bleeding, the rationale behind case-specific selection of embolic agents as well as the anticipated outcome of transcatheter arterial embolization.
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Affiliation(s)
- Dan E Orron
- Department of Radiology, Carmel Medical Center, Michal Street, Haifa 34362, Israel
| | - Allan I Bloom
- Department of Radiology, Hadassah University Medical Center, Ein Karem, Jerusalem 91120, Israel
| | - Ziv Neeman
- Medical Imaging Institute, Haemek Medical Center, Izhak Rabin Boulevard, Afula 1834111, Israel.
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Chatani S, Inoue A, Ohta S, Takaki K, Sato S, Iwai T, Murakami Y, Watanabe S, Sonoda A, Nitta N, Maehira H, Tani M, Murata K. Transcatheter Arterial Embolization for Postoperative Bleeding Following Abdominal Surgery. Cardiovasc Intervent Radiol 2018; 41:1346-1355. [PMID: 29955913 DOI: 10.1007/s00270-018-2019-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 06/21/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE We aimed to estimate the usefulness of transcatheter arterial embolization (TAE) in patients with postoperative abdominal hemorrhage and to evaluate the effects of pancreatic fistula on clinical outcomes and angiographic findings. MATERIALS AND METHODS We enrolled 22 patients (20 males and 2 females; mean age 63 years; range 25-86 years), who underwent transarterial angiography for postoperative hemorrhage after abdominal surgery. This group corresponded to 28 procedures. Technical and clinical success rates were calculated, and clinical findings and outcomes were compared between patients with and without a pancreatic fistula. RESULTS Pre-interventional CT was performed in all patients before first angiography, and the location of the bleeding was identified in all but one patient. Active arterial bleeding, identified by extravasation of contrast agent (n = 12), pseudoaneurysm formation (n = 12), and arterial wall irregularity (n = 2) were detected in 28 angiographic procedures, and embolization was performed in 26 instances. Various embolization techniques such as isolation, packing, embolization, and stentgraft implantation were performed. The technical and clinical success rates were 96% (25/26 procedures) and 82% (18/22 patients), respectively. In hemodynamically unstable patients (shock index: heart rate/systolic blood pressure > 1), a 92% (12/13 cases) technical success rate was achieved. There were no significant differences in any evaluated parameters between patients with and without pancreatic fistula. CONCLUSION TAE is a safe and effective for treating postoperative hemorrhage even in patients with hemodynamic instability and pancreatic fistula. Additionally, pre-interventional CT is useful for effective, consecutive interventions.
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Affiliation(s)
- Shohei Chatani
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan.
| | - Akitoshi Inoue
- Department of Radiology, Higashi-Ohmi General Medical Center, Gochi 255, Higashiohmi, 527-8505, Japan
| | - Shinichi Ohta
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Kai Takaki
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Shigetaka Sato
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Takayasu Iwai
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Yoko Murakami
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Shobu Watanabe
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Akinaga Sonoda
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Norihisa Nitta
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Hiromitsu Maehira
- Department of Gastrointestinal Surgery, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Masaji Tani
- Department of Gastrointestinal Surgery, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Kiyoshi Murata
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa, Otsu, Shiga, 520-2192, Japan
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Umezawa S, Nagata N, Arimoto J, Uchiyama S, Higurashi T, Nakano K, Ishii N, Sakurai T, Moriyasu S, Takeda Y, Nagase H, Komatsu H, Nakajima A, Mizuki A. Contrast-enhanced CT for Colonic Diverticular Bleeding before Colonoscopy: A Prospective Multicenter Study. Radiology 2018; 288:755-761. [PMID: 29893642 DOI: 10.1148/radiol.2018172910] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose To demonstrate the usefulness of precolonoscopy intravenous contrast material-enhanced CT for colonic diverticular bleeding (CDB). Materials and Methods A prospective, multicenter, observational study was performed. Patients with acute-onset hematochezia who were admitted to hospital were included, and those without CDB were excluded. CT was performed before colonoscopy. A Mann-Whitney U test, χ2 test, and multivariable logistic regression analysis were performed to determine the accuracy of CT before colonoscopy. Results A total of 442 patients (mean age, 71.2 years; 302 male patients; 68.3% men) were included between January 2014 and December 2015, and 202 patients were diagnosed as having CDB. The positive extravasation rate during CT was 50 of 202 (24.7%) among all patients and five of nine (55.6%) among patients who underwent CT within 1 hour of the last hematochezia. At multivariable analysis, the interval from the last hematochezia until CT was a predictor of extravasation (beta coefficient, -.0038 ± 0.0014 [standard deviation]). Extravasation at CT had a sensitivity of 38 of 66 (57.6%; 95% confidence interval: 44.8%, 69.7%) and a specificity of 124 of 136 (91.2%; 95% confidence interval: 85.1%, 95.4%) for the prediction of stigmata of recent hemorrhage of diverticula during colonoscopy. The sensitivity was higher in patients who underwent CT examination within 4 hours of hematochezia, compared with those examined after 4 hours (64.7% [33 of 51] vs 33.3% [five of 15]; P < .01). Conclusion Extravasation findings for CT with intravenous contrast material had high specificity for the prediction of stigmata of recent hemorrhage of diverticula during colonoscopy, regardless of the timing of the CT examination. Although the sensitivity was relatively low, it was higher when the CT examination was performed within 4 hours after the last hematochezia. Therefore, urgent precolonoscopy CT may contribute to decision making regarding whether an urgent colonoscopy should be performed.
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Affiliation(s)
- Shotaro Umezawa
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Naoyoshi Nagata
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Jun Arimoto
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Shiori Uchiyama
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Takuma Higurashi
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Kaoru Nakano
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Naoki Ishii
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Toshiyuki Sakurai
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Shiori Moriyasu
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Yuichi Takeda
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Hajime Nagase
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Hirokazu Komatsu
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Atsushi Nakajima
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
| | - Akira Mizuki
- From the Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanagawa-ku, Yokohama 236-0004 Japan (S. Umezawa, S. Uchiyama, T.H., A.N.); Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan (N.N., T.S., S.M.); Department of Gastroenterology, Hiratsuka Citizen Hospital, Kanagawa, Japan (J.A.); Department of Gastroenterology, St. Luke's International Hospital, Tokyo, Japan (K.N., N.I.); Department of Endoscopy, Koritsu Showa Hospital, Tokyo, Japan (Y.T.); Department of Gastroenterology, Yokohama Rosai Hospital, Kanagawa, Japan (H.N.); Department of Gastroenterology, Yokohama Municipal Citizen's Hospital, Kanagawa, Japan (H.K.); and Department of Gastroenterology, Keiyu Hospital, Kanagawa, Japan (A.M.)
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Hafezi-Nejad N, Fishman EK, Zaheer A. Imaging of post-operative pancreas and complications after pancreatic adenocarcinoma resection. Abdom Radiol (NY) 2018; 43:476-488. [PMID: 29094173 DOI: 10.1007/s00261-017-1378-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pancreatic ductal adenocarcinoma is one of the leading causes of cancer-related deaths. With surgical resection being the only definitive treatment, improvements in technique has led to an increase in number of candidates undergoing resection by inclusion of borderline resectable disease patients to the clearly resectable group. Post-operative complications associated with pancreaticoduodenectomy and distal pancreatectomy include delayed gastric emptying, anastomotic failures, fistula formation, strictures, abscess, infarction, etc. The utility of dual-phase CT with multiplanar reconstruction and 3D rendering is increasingly recognized as a tool for the assessment of complications associated with vascular resection and reconstruction such as hemorrhage, pseudoaneurysm, vascular thrombosis, and ischemia. Prompt recognition of the complications and distinction from benign post-operative findings such as hepatic steatosis and mesenteric fat necrosis on imaging plays a key role in helping decrease the morbidity and mortality associated with surgery. We discuss, with case examples, some of such common and uncommon findings on imaging to familiarize the abdominal radiologists evaluating post-operative imaging in both acute and chronic post-operative settings.
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Affiliation(s)
- Nima Hafezi-Nejad
- Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Atif Zaheer
- Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
- Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, 600 North Wolfe Street, Hal B164, Baltimore, MD, 21287, USA.
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38
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Gupton T, Cura M. The case for computed tomographic angiography for initial management of lower gastrointestinal hemorrhage. Proc AMIA Symp 2017; 30:353-354. [PMID: 28670085 DOI: 10.1080/08998280.2017.11929646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Lower gastrointestinal hemorrhage remains a common disease, frequently presenting with acute life-threatening symptoms. Although prompt detection and treatment are imperative, it is difficult to diagnose lower gastrointestinal hemorrhage in an accurate and efficient manner. Most available modalities are time consuming. Computed tomographic angiography of the abdomen and pelvis, on the other hand, has the unique capability of rapidly detecting whether life-threatening hemorrhage is occurring and accurately localizing it, thus facilitating definitive treatment. We present a case in which computed tomographic angiography was invaluable in the detection and subsequent empirical transarterial embolization of a lower gastrointestinal hemorrhage and offer evidence as to why it should be a first-line tool in the management of these patients.
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Affiliation(s)
- Theodore Gupton
- Department of Radiology, Baylor University Medical Center, Dallas, Texas
| | - Marco Cura
- Department of Radiology, Baylor University Medical Center, Dallas, Texas
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39
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Shi ZX, Yang J, Liang HW, Cai ZH, Bai B. Emergency transcatheter arterial embolization for massive gastrointestinal arterial hemorrhage. Medicine (Baltimore) 2017; 96:e9437. [PMID: 29384923 PMCID: PMC6392562 DOI: 10.1097/md.0000000000009437] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
To evaluate the different arteriographic manifestations of acute arterial massive hemorrhage of the gastrointestinal (GI) tract and the efficacy of emergency transcatheter arterial embolization (ETAE).A total of 88 patients with acute massive GI bleeding who experienced failure of initial endoscopy and/or conservative treatment were referred to our interventional department for acute GI arteriography from January 2007 to June 2015. After locating the source of bleeding, appropriate embolic agents, such as spring coil, hydroxyl methyl acrylic acid gelatin microspheres, polyvinyl alcohol (PVA) particles, etc., were used to embolize the targeted vessels. The angiographic manifestations and the effects of embolization of acute arterial massive hemorrhage of the GI tract were retrospectively analyzed.Of the 88 patients, 54 were diagnosed with arterial hemorrhage of the upper GI tract and 34 with arterial hemorrhage of the lower GI tract. Eighty cases were associated with positive angiography, which showed the following: contrast extravasation (only); gastroduodenal artery stenosis; pseudoaneurysm (only); pseudoaneurysm rupture with contrast extravasation; pseudoaneurysms merged with intestinal artery stenosis; GI angiodysplasia; and tumor vascular bleeding. Eight cases were diagnosed with negative angiography. Seven-two patients underwent successful hemostasis, and a total of 81 arteries were embolized. The technical and clinical success rates (no rebleeding within 30 days) in performing transcatheter embolization on patients with active bleeding were 100% and 84.71%, respectively (72 of 85). Within 30 days, the postoperative rebleeding rate was 15.29% (13/85). Of these rebleeding cases, 2 patients were formerly treated with "blind embolization," 7 underwent interventional embolic retreatment, and 3 had surgical operations. All cases were followed-up for 1 month, and 3 patients died from multiple organ failure. No serious complications such as bowel ischemia necrosis were observed.ETAE is a safe, effective, and minimally invasive treatment; because of the diversified arteriographic manifestations of acute GI hemorrhage, the proper selection of embolic agents and the choice of reasonable embolization method are essential for successful hemostasis.
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Affiliation(s)
| | - Jing Yang
- Department of Interventional Radiology
| | | | - Zhen Hua Cai
- Department of Pain, the Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Bin Bai
- Department of Interventional Radiology
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40
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Razik A, Madhusudhan KS, Aggarwal A, Panwar R, Srivastava DN. Gastrointestinal Stromal Tumor of the Jejunum With Active Bleeding Demonstrated on Dual-Energy MDCT Angiography: A Case Report. Curr Probl Diagn Radiol 2017; 48:298-301. [PMID: 29169676 DOI: 10.1067/j.cpradiol.2017.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 10/23/2017] [Indexed: 01/15/2023]
Abstract
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract and may occasionally present with acute gastrointestinal bleed (GIB). Multidetector computed tomography (MDCT) angiography is extremely useful in demonstrating the tumor as well as the presence of active hemorrhage, thereby guiding subsequent interventional or surgical management. We report a case of a 38-year-old man who presented with acute-onset melena and compensated shock, whose source of bleed remained elusive on endoscopy. MDCT angiography performed on a dual-energy scanner showed a jejunal tumor with active intraluminal contrast extravasation. The tumor was subsequently resected and the patient did well on follow-up. This was one of the few instances when MDCT angiography demonstrated active bleeding in a GIST and the first such case demonstrated on a dual-energy scanner.
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Affiliation(s)
- Abdul Razik
- Department of Radio-diagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Kumble S Madhusudhan
- Department of Radio-diagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
| | - Abhishek Aggarwal
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Rajesh Panwar
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Deep N Srivastava
- Department of Radio-diagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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41
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Konecki D, Grabowska-Derlatka L, Pacho R, Rowiński O. Correlation Between Findings of Multislice Helical Computed Tomography (CT), Endoscopic Examinations, Endovascular Procedures, and Surgery in Patients with Symptoms of Acute Gastrointestinal Bleeding. Pol J Radiol 2017; 82:676-684. [PMID: 29662594 PMCID: PMC5894035 DOI: 10.12659/pjr.902331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/10/2017] [Indexed: 12/16/2022] Open
Abstract
Background Endoscopic methods (gastroscopy and colonoscopy) are considered fundamental for the diagnosis of gastrointestinal bleeding. In recent years, multidetector computed tomography (MDCT) has also gained importance in diagnosing gastrointestinal bleeding, particularly in hemodynamically unstable patients and in cases with suspected lower gastrointestinal tract bleeding. CT can detect both the source and the cause of active gastrointestinal bleeding, thereby expediting treatment initiation. Material/Methods The study group consisted of 16 patients with clinical symptoms of gastrointestinal bleeding in whom features of active bleeding were observed on CT. In all patients, bleeding was verified by means of other methods such as endoscopic examinations, endovascular procedures, or surgery. Results The bleeding source was identified on CT in all 16 patients. In 14 cases (87.5%), bleeding was confirmed by other methods. Conclusions CT is an efficient, fast, and readily available tool for detecting the location of acute gastrointestinal bleeding.
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Affiliation(s)
- Dariusz Konecki
- 2 Department of Radiology, Medical University of Warsaw, Warsaw, Poland
| | | | - Ryszard Pacho
- 2 Department of Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Olgierd Rowiński
- 2 Department of Radiology, Medical University of Warsaw, Warsaw, Poland
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Evans RPT, Mourad MM, Pall G, Fisher SG, Bramhall SR. Pancreatitis: Preventing catastrophic haemorrhage. World J Gastroenterol 2017; 23:5460-5468. [PMID: 28852306 PMCID: PMC5558110 DOI: 10.3748/wjg.v23.i30.5460] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/03/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023] Open
Abstract
Pancreatitis represents nearly 3% of acute admissions to general surgery in United Kingdom hospitals and has a mortality of around 1%-7% which increases to around 10%-18% in patients with severe pancreatitis. Patients at greatest risk were those identified to have infected pancreatic necrosis and/or organ failure. This review seeks to highlight the potential vascular complications associated with pancreatitis that despite being relatively uncommon are associated with mortality in the region of 34%-52%. We examine the current evidence base to determine the most appropriate method by which to image and treat pseudo-aneurysms that arise as the result of acute and chronic inflammation of pancreas. We identify how early recognition of the presence of a pseudo-aneurysm can facilitate expedited care in an expert centre of a complex pathology that may require angiographic, percutaneous, endoscopic or surgical intervention to prevent catastrophic haemorrhage.
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MESH Headings
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/etiology
- Aneurysm, False/therapy
- Angiography/methods
- Contrast Media/administration & dosage
- Embolization, Therapeutic/methods
- Endoscopy, Gastrointestinal
- Hemorrhage/diagnostic imaging
- Hemorrhage/etiology
- Hemorrhage/therapy
- Hospitalization/statistics & numerical data
- Humans
- Incidence
- Magnetic Resonance Imaging
- Necrosis
- Pancreas/blood supply
- Pancreas/pathology
- Pancreatectomy/adverse effects
- Pancreatectomy/methods
- Pancreatitis, Acute Necrotizing/complications
- Pancreatitis, Acute Necrotizing/epidemiology
- Pancreatitis, Acute Necrotizing/pathology
- Pancreatitis, Chronic/complications
- Pancreatitis, Chronic/diagnostic imaging
- Pancreatitis, Chronic/epidemiology
- Pancreatitis, Chronic/pathology
- Time Factors
- Tomography, X-Ray Computed/methods
- United Kingdom/epidemiology
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43
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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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Soyer P, Fohlen A, Dohan A. Acute gastrointestinal bleeding: A slowly changing paradigm. Diagn Interv Imaging 2017; 98:451-453. [DOI: 10.1016/j.diii.2017.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Staerkle RF, Gundara JS, Hugh TJ, Maher R, Steinfort B, Samra JS. Management of recurrent bleeding after pancreatoduodenectomy. ANZ J Surg 2017; 88:E435-E439. [DOI: 10.1111/ans.13976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/20/2017] [Accepted: 02/23/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Ralph F. Staerkle
- Upper Gastrointestinal Surgical Unit; Royal North Shore Hospital, The University of Sydney; Sydney New South Wales Australia
| | - Justin S. Gundara
- Upper Gastrointestinal Surgical Unit; Royal North Shore Hospital, The University of Sydney; Sydney New South Wales Australia
| | - Thomas J. Hugh
- Upper Gastrointestinal Surgical Unit; Royal North Shore Hospital, The University of Sydney; Sydney New South Wales Australia
| | - Richard Maher
- Department of Radiology; Royal North Shore Hospital, The University of Sydney; Sydney New South Wales Australia
| | - Brendan Steinfort
- Department of Radiology; Royal North Shore Hospital, The University of Sydney; Sydney New South Wales Australia
| | - Jaswinder S. Samra
- Upper Gastrointestinal Surgical Unit; Royal North Shore Hospital, The University of Sydney; Sydney New South Wales Australia
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46
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ACR Appropriateness Criteria ® Nonvariceal Upper Gastrointestinal Bleeding. J Am Coll Radiol 2017; 14:S177-S188. [PMID: 28473074 DOI: 10.1016/j.jacr.2017.02.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 02/20/2017] [Accepted: 02/21/2017] [Indexed: 12/18/2022]
Abstract
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.
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Wortman JR, Landman W, Fulwadhva UP, Viscomi SG, Sodickson AD. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90:20170076. [PMID: 28362508 DOI: 10.1259/bjr.20170076] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Acute gastrointestinal (GI) bleeding is a common cause of both emergency department visits and hospitalizations in the USA and can have a high morbidity and mortality if not treated rapidly. Imaging is playing an increasing role in both the diagnosis and management of GI bleeding. In particular, CT angiography (CTA) is a promising initial test for acute GI bleeding as it is universally available, can be performed rapidly and may provide diagnostic information to guide management. The purpose of this review was to provide an overview of the uses of imaging in the diagnosis and management of acute GI bleeding, with a focus on CTA.
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Affiliation(s)
- Jeremy R Wortman
- 1 Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,2 Division of Emergency Radiology, Harvard Medical School, Boston, MA, USA
| | - Wendy Landman
- 1 Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,2 Division of Emergency Radiology, Harvard Medical School, Boston, MA, USA
| | - Urvi P Fulwadhva
- 1 Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,2 Division of Emergency Radiology, Harvard Medical School, Boston, MA, USA
| | - Salvatore G Viscomi
- 1 Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,3 Department of Radiology, Cape Cod Hospital, Hyannis, MA, USA
| | - Aaron D Sodickson
- 1 Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,2 Division of Emergency Radiology, Harvard Medical School, Boston, MA, USA
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Haber ZM, Charles HW, Erinjeri JP, Deipolyi AR. Predictors of Active Extravasation and Complications after Conventional Angiography for Acute Intraabdominal Bleeding. J Clin Med 2017; 6:jcm6040047. [PMID: 28420210 PMCID: PMC5406779 DOI: 10.3390/jcm6040047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/13/2017] [Accepted: 04/14/2017] [Indexed: 12/14/2022] Open
Abstract
Conventional angiography is used to evaluate and treat possible sources of intraabdominal bleeding, though it may cause complications such as contrast-induced nephropathy (CIN). The study’s purpose was to identify factors predicting active extravasation and complications during angiography for acute intraabdominal bleeding. All conventional angiograms for acute bleeding (January 2013–June 2015) were reviewed retrospectively, including 75 angiograms for intraabdominal bleeding in 70 patients. Demographics, comorbidities, vital signs, complications within one month, and change in hematocrit (ΔHct) and fluids and blood products administered over the 24 h prior to angiography were recorded. Of 75 exams, 20 (27%) demonstrated extravasation. ΔHct was the only independent predictor of extravasation (p = 0.017), with larger ΔHct (−17%) in patients with versus those without extravasation (–1%) (p = 0.01). CIN was the most common complication, occurring in 10 of 66 angiograms (15%). Glomerular filtration rate (GFR) was the only independent predictor (p = 0.03); 67% of patients with GFR < 30, 29% of patients with GFR 30–60, and 8% of patients with GFR > 60 developed CIN. For patients with intraabdominal bleeding, greater ΔHct decrease over 24 h before angiography predicts active extravasation. Pre-existing renal impairment predicts CIN. Patients with large hematocrit declines should be triaged for rapid angiography, though benefits can be weighed with the risk of renal impairment.
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Affiliation(s)
- Zachary M Haber
- School of Medicine, New York University, 550 1st Avenue, New York, NY 10016, USA.
| | - Hearns W Charles
- South Florida Vascular Associates, Coconut Creek, FL 33073, USA.
| | - Joseph P Erinjeri
- Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Amy R Deipolyi
- Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
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Wildgruber M, Wrede CE, Zorger N, Müller-Wille R, Hamer OW, Zeman F, Stroszczynski C, Heiss P. Computed tomography versus digital subtraction angiography for the diagnosis of obscure gastrointestinal bleeding. Eur J Radiol 2017; 88:8-14. [DOI: 10.1016/j.ejrad.2016.12.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/19/2016] [Accepted: 12/25/2016] [Indexed: 12/22/2022]
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50
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MDCT angiography and transcatheter embolization in management of acute gastrointestinal bleeding. ALEXANDRIA JOURNAL OF MEDICINE 2016. [DOI: 10.1016/j.ajme.2015.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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