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Martyak M, Soult A, Britt LD. Diagnosis and management of gastrointestinal hemorrhage: What you need to know. J Trauma Acute Care Surg 2025:01586154-990000000-00961. [PMID: 40205645 DOI: 10.1097/ta.0000000000004599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2025]
Abstract
ABSTRACT Acute gastrointestinal (GI) hemorrhage is a common cause for hospital admission that requires prompt diagnosis and multidisciplinary management to optimize clinical outcomes. Acute gastrointestinal bleeding (GIB) includes both upper and lower GI tract sources with an extensive list of differential pathologies. This review provides a systematic approach to both upper and lower GIB management, emphasizing initial resuscitation, stabilization, diagnostic evaluation to identify the source, and treatment modalities. Endoscopy remains the cornerstone for diagnostic and interventional purposes, significantly reducing the need for surgical procedures. However, lower GIB and severe or refractory cases may necessitate additional imaging and interventions, including surgical management. Integrating clinical guidelines, evidence-based strategies, and individualized care, this review delineates what you need to know to diagnose and manage acute GI hemorrhage. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Michael Martyak
- From the Surgery Department, Eastern Virginia Medical School, Old Dominion University, Norfolk, Virginia
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Jiang Y, Li Y, Xiong Z, Morelli JN, Shen Y, Hu X, Hu D, Li Z. Localization and etiological stratification of non-neoplastic small bowel bleeding via CT imaging: a 10-year study. Insights Imaging 2024; 15:189. [PMID: 39090483 PMCID: PMC11294299 DOI: 10.1186/s13244-024-01778-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 07/10/2024] [Indexed: 08/04/2024] Open
Abstract
OBJECTIVES The purpose of this study is to assess the diagnostic efficacy of contrast-enhanced CT scans for small bowel bleeding. METHODS This retrospective study evaluated patients diagnosed with non-neoplastic small intestinal bleeding (including duodenum) who underwent abdominal CT at our institution from December 2013 to March 2023. Patients were categorized into diverticulum and non-diverticulum groups based on the cause of bleeding. Active bleeding was defined on the CT images as extravasation of contrast material in the intestinal lumen during the arterial phase and/or progressive accumulation of contrast material during the venous phase. We have documented the original report (extracted from the medical record system and additional consultation opinions from senior radiologists), including the presence of active bleeding and its potential bleeding location. Furthermore, two radiologists reassessed the CT images, seeking consensus on the diagnosis between them. RESULTS The study included 165 patients, predominantly male, with a median age of 30 years. Active bleeding was identified in 48.3% of patients. Notably, all identified bleeding diverticula in the diverticulum group exhibited cul-de-sac termination. Among the identified causes of bleeding, Crohn's disease was most prevalent (46.7%, N of causes = 64). Significant differences were observed in the diagnostic methods between the diverticulum and non-diverticulum groups, with surgery predominantly applied in the diverticulum group, and endoscopy in the non-diverticulum group (n = 49 vs n = 15, p = 0.001). Contrast agent extravasation was significantly higher in the diverticulum group (n = 54 vs n = 16, p = 0.001), and Meckel's diverticulum cases appearing tubular were significantly higher than in other diverticulum cases (n = 25 vs n = 3, p < 0.001). CONCLUSION CT allows for a higher detection rate of diverticular bleeding, even if asymptomatic, guiding classification into multiple potentially clinically relevant categories. CRITICAL RELEVANCE STATEMENT Contrast-enhanced CT imaging is effective in determining the location and cause of non-neoplastic small bowel bleeding, especially diverticular bleeding. Therefore, the use of enhanced CT should be prioritized in the diagnosis and management of small bowel bleeding. KEY POINTS CT has potential value in the diagnosis of small bowel bleeding. CT imaging suggests possible surgical intervention for active bleeding detection. CT diagnoses and localizes small bowel bleeding, aiding in treatment and prioritizing in guidelines.
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Affiliation(s)
- Yuchen Jiang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanqiu Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ziman Xiong
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - John N Morelli
- Department of Radiology, St. John's Medical Center, Tulsa, OK, USA
| | - Yaqi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xuemei Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Daoyu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Yaxley KL, Mulhem A, Godfrey S, Oke JL. The Accuracy of Computed Tomography Angiography Compared With Technetium-99m Labelled Red Blood Cell Scintigraphy for the Diagnosis and Localization of Acute Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. Curr Probl Diagn Radiol 2023; 52:546-559. [PMID: 37271638 DOI: 10.1067/j.cpradiol.2023.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/26/2023] [Accepted: 05/08/2023] [Indexed: 06/06/2023]
Abstract
Imaging tests are commonly used as an initial or early investigation for patients presenting with suspected acute gastrointestinal bleeding (AGIB). However, controversy remains regarding which of two frequently used modalities, computed tomography angiography (CTA) or technetium-99m labelled red blood cell scintigraphy (RBCS), is most accurate. This systematic review and meta-analysis was performed to compare the accuracy of CTA and RBCS for the detection and localization of AGIB. Five electronic databases were searched with additional manual searching of reference lists of relevant publications identified during the search. Two reviewers independently performed screening, data extraction and methodological assessments. Where appropriate, the bivariate model was used for meta-analysis of sensitivities and specificities for the detection of bleeding and Freeman-Tukey double-arcsine transformation used for meta-analysis of proportions of correctly localized bleeding sites. Forty-four unique primary studies were included: twenty-two investigating CTA, seventeen investigating RBCS and five investigating both modalities. Meta-analysis produced similar pooled sensitivities; 0.83 (95% CI 0.74-0.90) and 0.84 (0.68-0.92) for CTA and RBCS respectively. Pooled specificity for CTA was higher than RBCS; 0.90 (0.72-0.97) and 0.84 (0.71-0.91) respectively. However, differences were not statistically significant. CTA was superior to RBCS in correctly localizing bleeding; pooled proportions of 1.00 (0.98-1.00) and 0.90 (0.83-0.96) respectively (statistically significant difference, P < 0.001). There is no evidence that CTA and RBCS have different diagnostic performance with respect to the detection of AGIB. However, CTA is superior to RBCS in terms of correctly localising the bleeding site, supporting usage of CTA over RBCS as the first line imaging investigation.
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Affiliation(s)
- Kaspar L Yaxley
- University of Oxford, 1 Wellington Square, Oxford, OX1 2JA, UK; Department of Medical Imaging, Flinders Medical Centre, Flinders Drive, Bedford Park, SA, 5042, Australia.
| | - Ali Mulhem
- University of Oxford, 1 Wellington Square, Oxford, OX1 2JA, UK
| | - Sean Godfrey
- University of Oxford, 1 Wellington Square, Oxford, OX1 2JA, UK
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Newman C, Nandurkar R, Holcdorf D, Gerstenmaier J, Tagkalidis P, Clements W. Role of CT angiography and therapeutic anticoagulation in patients presenting to the emergency department with acute gastrointestinal bleeding. J Med Imaging Radiat Oncol 2023; 67:37-44. [PMID: 35394116 DOI: 10.1111/1754-9485.13410] [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: 03/24/2021] [Revised: 02/24/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Acute gastrointestinal bleeding (GIB) is associated with morbidity and mortality. There can be a low threshold for practitioners to assess for active GIB and computed tomography angiography (CTA) examinations are performed frequently, even for stable patients and those who are therapeutically anticoagulated. We aimed to assess the predictive value of CTA for acute GIB and the influence of CTA on treatment. METHODS Retrospective single-centre study over a 2-year period. RESULTS A total of 227 patients with mean age 67.7 years (SD 17.86), 58.6% male. 84.4% were for lower GIB. 49 patients were on therapeutic anticoagulation (21.6%). 45 CTAs were positive (19.8%). 22 patients received embolisation, and 15 received acute endoscopic treatment. CTA sensitivity was 68.6% and specificity 89.1%. The PPV was 53.3% and NPV 93.9%. The odds ratio of a positive CTA requiring treatment for patients on therapeutic anticoagulation was 1.1 (P = 0.932) compared with the odds of patients not taking therapeutic anticoagulation 21.5 (P < 0.001). The risk ratio for requiring treatment if not taking anticoagulation was 6.2. A total of 19 patients (9.1%) met the definition of CI-AKI as a result of the CTA. A pre-existing eGFR of less than 20 was associated with significantly increased odds of developing CI-AKI (OR 3.95, P = 0.031, 95%CI 1.135-13.782). CONCLUSIONS The presence of anticoagulation has a significant impact on the decision not to perform interventional treatments on patients with acute GIB when CTA is positive. Anticoagulant reversal and volume resuscitation are important front-line measures, and CTA may have a role for those anticoagulated who are haemodynamically unstable after resuscitation.
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Affiliation(s)
- Chris Newman
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Rohan Nandurkar
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - David Holcdorf
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jan Gerstenmaier
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Tagkalidis
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
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Khalil Ali MA, Bergman H, Di Saverio S, Butt MA, Griffiths EA. Acute Lower Gastrointestinal Bleeding. TEXTBOOK OF EMERGENCY GENERAL SURGERY 2023:1049-1065. [DOI: 10.1007/978-3-031-22599-4_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Kate V, Sureshkumar S, Gurushankari B, Kalayarasan R. Acute Upper Non-variceal and Lower Gastrointestinal Bleeding. J Gastrointest Surg 2022; 26:932-949. [PMID: 35083723 DOI: 10.1007/s11605-022-05258-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/17/2022] [Indexed: 01/31/2023]
Abstract
Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.
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Affiliation(s)
- Vikram Kate
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
| | - Sathasivam Sureshkumar
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Balakrishnan Gurushankari
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Raja Kalayarasan
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
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Snelling S, Ghaffar R, Ward ST. CT angiograms for lower GI bleeding: the experience of a large UK teaching hospital. Ann R Coll Surg Engl 2022; 104:100-105. [PMID: 34730424 PMCID: PMC9773912 DOI: 10.1308/rcsann.2021.0127] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The clinical presentation of lower gastrointestinal bleeding (LGIB) is variable in severity, cause and potential investigations. The British Society of Gastroenterology recently published LGIB guidelines, recommending CT angiography (CT-A) for haemodynamically unstable patients, defined by shock index (SI) greater than 1. The aim of this study was to assess the use and role of CT-A in diagnosing LGIB, by assessing the pickup rate of active LGIB defined by contrast extravasation or 'blush' and to determine any association between positive CT-A with various patient and clinical characteristics. METHODS A retrospective analysis was carried out of 4 years of LGIB admissions. Demographics, inpatient observations and use of blood products were acquired. Vital signs nearest the time of CT-A plus abnormal vital signs preceding imaging were used to calculate SI, Age SI, National Early Warning Score 2 (NEWS2) and Standardised Early Warning Score (SEWS). A consultant gastrointestinal radiologist further reviewed all consultant-reported scans. RESULTS In total, 930 patients were admitted with LGIB. Median age was 71 years and 51% were male; 179 (19.2%) patients received red blood cell transfusion and 93 patients (10%) underwent CT-A, who were older and were likely to be hypotensive and receive red cell transfusions. Following exclusions, 92 CT-As were included in the analysis. Nine (9.8%) were positive. Univariate analysis showed no association between positive CT-A and any scoring system. A multivariate analysis, including age and gender, showed association between both NEWS2 and SEWS scores with positive CT-A. CONCLUSION In our analysis of the typical LGIB population, CT-A has shown relatively low pick up rate of active bleeding. CT-A clearly has a role in the investigation of LGIB, but selection remains challenging.
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Affiliation(s)
- S Snelling
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - R Ghaffar
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - ST Ward
- University Hospitals Birmingham NHS Foundation Trust, UK
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Jafari MD, Bleier JIS. Lower GI Hemorrhage. THE ASCRS TEXTBOOK OF COLON AND RECTAL SURGERY 2022:699-713. [DOI: 10.1007/978-3-030-66049-9_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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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: 1.5] [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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Triantafyllou K, Gkolfakis P, Gralnek IM, Oakland K, Manes G, Radaelli F, Awadie H, Camus Duboc M, Christodoulou D, Fedorov E, Guy RJ, Hollenbach M, Ibrahim M, Neeman Z, Regge D, Rodriguez de Santiago E, Tham TC, Thelin-Schmidt P, van Hooft JE. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:850-868. [PMID: 34062566 DOI: 10.1055/a-1496-8969] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.
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Affiliation(s)
- Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare, London, UK
| | - Gianpiero Manes
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese and Rho, Milan, Italy
| | | | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Marine Camus Duboc
- Gastroenterology Department, Saint-Antoine Hospital, APHP Sorbonne University, Paris, France
| | - Dimitrios Christodoulou
- Division of Gastroenterology, University Hospital & Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Evgeny Fedorov
- Department of Gastroenterology, Moscow University Hospital, Pirogov Russia National Research Medical University, Moscow, Russia
| | - Richard J Guy
- Department of Emergency General Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, Leipzig, Germany
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Daniele Regge
- Radiology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Peter Thelin-Schmidt
- Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Werner DJ, Baar T, Kiesslich R, Wenzel N, Abusalim N, Tresch A, Rey JW. Endoscopic hemostasis makes the difference: Angiographic treatment in patients with lower gastrointestinal bleeding. World J Gastrointest Endosc 2021; 13:221-232. [PMID: 34326943 PMCID: PMC8311471 DOI: 10.4253/wjge.v13.i7.221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/17/2021] [Accepted: 07/07/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The large majority of gastrointestinal bleedings subside on their own or after endoscopic treatment. However, a small number of these may pose a challenge in terms of therapy because the patients develop hemodynamic instability, and endoscopy does not achieve adequate hemostasis. Interventional radiology supplemented with catheter angiography (CA) and transarterial embolization have gained importance in recent times. AIM To evaluate clinical predictors for angiography in patients with lower gastrointestinal bleeding (LGIB). METHODS We compared two groups of patients in a retrospective analysis. One group had been treated for more than 10 years with CA for LGIB (n = 41). The control group had undergone non-endoscopic or endoscopic treatment for two years and been registered in a bleeding registry (n = 92). The differences between the two groups were analyzed using decision trees with the goal of defining clear rules for optimal treatment. RESULTS Patients in the CA group had a higher shock index, a higher Glasgow-Blatchford bleeding score (GBS), lower serum hemoglobin levels, and more rarely achieved hemostasis in primary endoscopy. These patients needed more transfusions, had longer hospital stays, and had to undergo subsequent surgery more frequently (P < 0.001). CONCLUSION Endoscopic hemostasis proved to be the crucial difference between the two patient groups. Primary endoscopic hemostasis, along with GBS and the number of transfusions, would permit a stratification of risks. After prospective confirmation of the present findings, the use of decision trees would permit the identification of patients at risk for subsequent diagnosis and treatment based on interventional radiology.
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Affiliation(s)
- David John Werner
- Radiologie Rhein-Nahe, Krankenhaus am St. Marienwörth, Bad Kreuznach 55543, RLP, Germany
- Department of Radiology, Helios Dr. Horst-Schmidt-Clinic, Germany, Wiesbaden 65199, Hessen, Germany
| | - Till Baar
- Institute for Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Germany, Cologne 50923, NRW, Germany
| | - Ralf Kiesslich
- Department of Internal Medicine II, Helios Dr. Horst-Schmidt-Clinic, Wiesbaden, Germany, Wiesbaden 65199, Hessen, Germany
| | - Nicolai Wenzel
- Department of Radiology, Helios Dr. Horst-Schmidt-Clinic, Germany, Wiesbaden 65199, Hessen, Germany
| | - Nael Abusalim
- Department of Radiology, Helios Dr. Horst-Schmidt-Clinic, Germany, Wiesbaden 65199, Hessen, Germany
- Department of Diagnostic and Interventional Radiology, Medical Center Hanau, Germany, Hanau 63450, Hessen, Germany
| | - Achim Tresch
- Institute for Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Germany, Cologne 50923, NRW, Germany
- CECAD, University of Cologne, Germany, Cologne 50923, NRW, Germany
- Center for Data and Simulation Science, University of Cologne, Germany, Cologne 50923, NRW, Germany
| | - Johannes Wilhelm Rey
- Department of Gastroenterology and Endoscopy, Medical Center Osnabrueck, Germany, Osnabrueck 49076, Niedersachsen, Germany
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12
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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: 8] [Impact Index Per Article: 2.0] [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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13
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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: 18] [Impact Index Per Article: 4.5] [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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14
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Ferrante B, Baroni C, Torres L, Catão-Dias J, Pinto A. Nankeen ink model for histological distribution of solutions used in post mortem CT-angiography. FORENSIC IMAGING 2020. [DOI: 10.1016/j.fri.2020.200387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Cho KJ. CT Angiography versus Red Blood Cell Scintigraphy Prior to Catheter Angiography for Lower Gastrointestinal Bleeding: Timing Is Everything. J Vasc Interv Radiol 2019; 30:1733-1735. [PMID: 31655762 DOI: 10.1016/j.jvir.2019.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kyung J Cho
- Department of Radiology, Vascular & Interventional Radiology, Frankel Cardiovascular Center, University of Michigan Health System, Rm #5582, 1500 E Medical Center Drive, SPC 5868, Ann Arbor, MI 48109.
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16
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Murphy B, Winter DC, Kavanagh DO. Small Bowel Gastrointestinal Bleeding Diagnosis and Management-A Narrative Review. Front Surg 2019; 6:25. [PMID: 31157232 PMCID: PMC6532547 DOI: 10.3389/fsurg.2019.00025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/24/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Small bowel bleeding accounts for 5-10% of all gastrointestinal bleeding. Despite advances in imaging, endoscopy and minimally invasive therapeutic techniques, its diagnosis and treatment remains a challenge and a standardized algorithm for approaching suspected small bowel bleeding remains elusive. Furthermore, the choice of investigation is subject to timing of presentation and accessibility to investigations. The aim of this study was to construct a narrative review of recent literature surrounding the diagnosis and management of small bowel bleeding. Methods: A literature review was conducted examining the database pubmed with the following key words and Boolean operators: occult GI bleed OR mesenteric bleed OR gastrointestinal hemorrhage OR GI hemorrhage AND management. Articles were selected and reviewed based on relevance to the research topic. Where necessary, the full text was sought to further assess relevance. Results: In overt GI bleeding, CT angiography and red cell scintigraphy are both feasible and reliable diagnostic imaging modalities if standard endoscopy is negative. Red cell scintigraphy may be advantageous through detection of lower bleeding rates but it is subject to availability. Overt bleeding and a positive CT angiogram or red cell scan improves the diagnostic yield of formal angiography ± embolization. Video capsule endoscopy or double balloon endoscopy can be considered in occult GI bleeding following normal upper and lower endoscopy. Conclusions: Small bowel bleeding remains a rare but significant diagnostic and therapeutic challenge. Technological advances in diagnostics have aided evaluation but have not broadened the range of therapeutic interventions.
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Affiliation(s)
- B. Murphy
- Department of Colorectal Surgery, University Hospital Tallaght, Dublin, Ireland
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - D. C. Winter
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - D. O. Kavanagh
- Department of Colorectal Surgery, University Hospital Tallaght, Dublin, Ireland
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17
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Oakland K, Chadwick G, East JE, Guy R, Humphries A, Jairath V, McPherson S, Metzner M, Morris AJ, Murphy MF, Tham T, Uberoi R, Veitch AM, Wheeler J, Regan C, Hoare J. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019; 68:776-789. [PMID: 30792244 DOI: 10.1136/gutjnl-2018-317807] [Citation(s) in RCA: 197] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/07/2019] [Accepted: 01/16/2019] [Indexed: 01/28/2023]
Abstract
This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.
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Affiliation(s)
| | | | - James E East
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford, UK
| | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Vipul Jairath
- Robarts Clinical Trials, Inc., London, Ontario, Canada.,Medicine and Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | | | - Magdalena Metzner
- Department of Gastroenterology, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - A John Morris
- Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Tony Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, UK
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - James Wheeler
- Department of Colorectal Surgery, Addenbrooke's Hospital, Cambridge, UK
| | | | - Jonathan Hoare
- Department of Surgery and Cancer, Imperial College, London, UK
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18
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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: 1.0] [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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19
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Mohammed Ilyas MI, Szilagy EJ. Management of Diverticular Bleeding: Evaluation, Stabilization, Intervention, and Recurrence of Bleeding and Indications for Resection after Control of Bleeding. Clin Colon Rectal Surg 2018; 31:243-250. [PMID: 29942215 DOI: 10.1055/s-0037-1607963] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Diverticular bleeding is the most common cause of lower gastrointestinal bleeding with nearly 200,000 admissions in the United States annually. Less than 5% of patients with diverticulosis present with diverticular bleeding and present usually as painless, intermittent, and large volume of lower gastrointestinal bleeding. Management algorithm for patients presenting with diverticular bleeding includes resuscitation followed by diagnostic evaluation. Colonoscopy is the recommended first-line investigation and helps in identifying the stigmata of recent hemorrhage and endoscopic management of the bleeding. Radionuclide scanning is the most sensitive but least accurate test due to low spatial resolution. Angiography is helpful when patients are actively bleeding and therapeutic interventions are performed with angioembolization. Surgery for diverticular bleeding is necessary when associated with hemodynamic instability and after failed endoscopic or angiographic interventions. When the bleeding site is localized preoperatively, partial colectomy is sufficient, but subtotal colectomy is necessary when localization is not possible preoperatively.
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Affiliation(s)
| | - Eric J Szilagy
- Department of Colon and Rectal Surgery, West Bloomfield Hospital, Henry Ford Health System, Detroit, Michigan
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20
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Werner DJ, Manner H, Nguyen-Tat M, Kloeckner R, Kiesslich R, Abusalim N, Rey JW. Endoscopic and angiographic management of lower gastrointestinal bleeding: Review of the published literature. United European Gastroenterol J 2017; 6:337-342. [PMID: 29774146 DOI: 10.1177/2050640617746299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/06/2017] [Indexed: 12/13/2022] Open
Abstract
Lower gastrointestinal bleeding is common and occurs often in elderly patients. In rare cases it is associated with hemorrhagic shock. A large number of such bleedings, which are often caused by colon diverticula, subside spontaneously. Alternatively they can be treated by endoscopic procedures successfully. Given the aging population of our society, the rising incidence of lower gastrointestinal tract bleeding and new anticoagulant therapies, some of the bleedings tend to be severe. Colonoscopy is the established standard procedure for the diagnosis and treatment of lower gastrointestinal bleeding. However, a small number of patients experience re-bleeding or shock; their bleeding does not resolve spontaneously and cannot be treated successfully by endoscopic procedures. In such patients, interventional radiology is very useful for the detection of bleeding and the achievement of hemostasis. Against this background we performed a literature search using PubMed to identify all relevant studies focused on the endoscopic and radiological management of lower gastrointestinal bleeding and present recent conclusions on the subject.
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Affiliation(s)
- David J Werner
- RNS Joint Practice, Department of Radiology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Hendrik Manner
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Marc Nguyen-Tat
- First Department of Internal Medicine, University Medical Center, Mainz, Germany
| | - Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, University Medical Center, Mainz, Germany
| | - Ralf Kiesslich
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Nael Abusalim
- RNS Joint Practice, Department of Radiology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Johannes W Rey
- Department of Gastroenterology, Helios Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
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21
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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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22
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Noise-Optimized Virtual Monoenergetic Dual-Energy CT Improves Diagnostic Accuracy for the Detection of Active Arterial Bleeding of the Abdomen. J Vasc Interv Radiol 2017; 28:1257-1266. [DOI: 10.1016/j.jvir.2017.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 06/01/2017] [Accepted: 06/05/2017] [Indexed: 01/22/2023] Open
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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: 0.9] [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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24
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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: 23] [Impact Index Per Article: 2.9] [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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25
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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: 46] [Impact Index Per Article: 5.8] [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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Çolak B, Şakalak H, Çavuşoğlu H, Yavuz MS. Novel capsules for potential theranostics of obscure gastrointestinal bleedings. Med Hypotheses 2016; 94:99-102. [DOI: 10.1016/j.mehy.2016.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/25/2016] [Accepted: 07/10/2016] [Indexed: 10/21/2022]
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Soto JA. Commentary to "ACG clinical guideline: diagnosis and management of small bowel bleeding". Abdom Radiol (NY) 2016; 41:1217-8. [PMID: 27108125 DOI: 10.1007/s00261-016-0739-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Jorge A Soto
- Department of Radiology, Boston Medical Center, Boston University School of Medicinte, 820 Harrison Av., 3rd Floor, Boston, MA, 02118, USA.
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28
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Localizing Acute Lower Gastrointestinal Hemorrhage: CT Angiography Versus Tagged RBC Scintigraphy. AJR Am J Roentgenol 2016; 207:578-84. [PMID: 27303989 DOI: 10.2214/ajr.15.15714] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Lower gastrointestinal hemorrhage is a common cause of hospitalization and has substantial associated morbidity and financial cost. CT angiography (CTA) is emerging as an alternative to (99m)Tc-labeled RBC scintigraphy (RBC scintigraphy) for the localization of acute lower gastrointestinal bleeding (LGIB); however, data on comparative efficacy are scant. The aim of this study was to assess the utility of CTA compared with RBC scintigraphy in the overall evaluation and management of acute LGIB. MATERIALS AND METHODS We retrospectively reviewed images from all CTA examinations performed for suspected acute LGIB at our tertiary care hospital from January 2010 through November 2011. The comparison group was determined by retrospective review of twice the number of RBC scintigraphic scans consecutively obtained from June 2008 to November 2011 for the same indication. All CTA and RBC scintigraphic scans were reviewed for accurate localization of the site and source of suspected active LGIB. RESULTS In total, 45 CTA and 90 RBC scintigraphic examinations were performed during the study period. Seventeen (38%) CTA scans showed active gastrointestinal bleeding compared with 34 (38%) RBC scintigraphic scans (p = 1.000). However, the site of bleeding was accurately localized on 24 (53%) CTA scans. This proportion was significantly greater than the proportion localized on RBC scintigraphic scans (27 [30%]) (p = 0.008). There were no significant differences between the two groups in average hospital length of stay, blood transfusion requirement, incidence of acute kidney injury, or in-hospital mortality. CONCLUSION Both CTA and RBC scintigraphy can be used to identify active bleeding in 38% of cases. However, the site of bleeding is localized with CTA in a significantly higher proportion of studies.
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Park HJ, Shin JH, Han KC, Yoon HK, Ko GY, Sung KB. Transcatheter Arterial Embolization of Angiographically Visible and Occult Renal Capsular Artery Hemorrhage in 28 Patients. J Vasc Interv Radiol 2016; 27:973-80. [PMID: 27234483 DOI: 10.1016/j.jvir.2016.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 03/13/2016] [Accepted: 03/13/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of transcatheter arterial embolization to control bleeding from the renal capsular artery (RCA). MATERIALS AND METHODS Embolization was performed in 28 patients (14 men; mean age, 49.7 y). Presence and type of previous invasive procedures, initial presentation, and coagulation profile were reviewed. Any preceding abdominal computed tomography (CT) findings were analyzed. Angiographic findings were categorized as active bleeding, suspicious for bleeding, or no bleeding. Technical and clinical success and clinical outcomes were evaluated. Changes in hemoglobin level and transfusion volume of packed red blood cells (pBRCs) before and after embolization were evaluated with the paired t test and Wilcoxon signed-rank test, respectively. RESULTS Technical and clinical success rates of therapeutic embolization for active bleeding (n = 11) were 90.9% and 80%, respectively. One case of technical failure (5.9%) and 3 cases of postembolization bleeding (18.7%) were noted in the prophylactic embolization group in patients with suspicion of bleeding (n = 13) or no bleeding (n = 4). Transient renal insufficiency occurred in 4 patients (14.3%). The average hemoglobin level and volume of transfused pBRCs changed from 8.1 g/dL to 9.9 g/dL and from 871 mL to 543 mL, respectively (P < .05). Extravasation of contrast media or acute hematoma in the right subhepatic or perirenal space on CT was noted in 21 patients (78%). CONCLUSIONS Embolization can provide an effective and safe method to control RCA bleeding. Perirenal invasive procedures and signs of active or recent right subhepatic or perirenal hemorrhage should raise the suspicion of an RCA source.
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Affiliation(s)
- Hyo Jung Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea.
| | - Ki-Chang Han
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Kyu-Bo Sung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
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Moss AJ, Tuffaha H, Malik A. Lower GI bleeding: a review of current management, controversies and advances. Int J Colorectal Dis 2016; 31:175-88. [PMID: 26454431 DOI: 10.1007/s00384-015-2400-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Lower gastrointestinal (GI) bleeding is defined as bleeding distal to the ligament of Treitz. In the UK, it represents approximately 3 % of all surgical referrals to the hospital. This review aims to provide review of the current evidence regarding the management of this condition. METHODS Literature was searched using Medline, Pubmed, and Cochrane for relevant evidence by two researchers. This was conducted in a manner that enabled a narrative review of the evidence covering the aetiology, clinical assessment and management options of continuously bleeding patients. FINDINGS The majority of patients with acute lower GI bleeding can be treated conservatively. In cases where ongoing bleeding occurs, colonoscopy is still the first line of investigation and treatment. Failure of endoscopy and persistent instability warrant angiography, possibly preceded by CT angiography and proceeding to superselective embolisation. Failure of embolisation warrants surgical intervention. CONCLUSIONS There are still many unanswered questions. In particular, the development of a more reliable predictive tool for mortality, rebleeding and requirement for surgery needs to be the ultimate priority. There are a small number of encouraging developments on combination therapy with regard to angiography, endoscopy and surgery. Additionally, the increasing use of haemostatic agents provides an additional tool for the management of bleeding endoscopically in difficult situations.
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Affiliation(s)
- Andrew J Moss
- Department of Surgery, Peterborough City Hospital, Peterborough, Cambridgeshire, PE3 9GZ, UK
| | - Hussein Tuffaha
- Department of Surgery, Ipswich Hospital NHS Trust, Ipswich, IP4 5PD, UK.
| | - Arshad Malik
- Department of Surgery, Ipswich Hospital NHS Trust, Ipswich, IP4 5PD, UK
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Reis FRS, Cardia PP, D'Ippolito G. Computed tomography angiography in patients with active gastrointestinal bleeding. Radiol Bras 2016; 48:381-90. [PMID: 26811556 PMCID: PMC4725400 DOI: 10.1590/0100-3984.2014.0014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Gastrointestinal bleeding represents a common medical emergency, with
considerable morbidity and mortality rates, and a prompt diagnosis is essential
for a better prognosis. In such a context, endoscopy is the main diagnostic
tool; however, in cases where the gastrointestinal hemorrhage is massive, the
exact bleeding site might go undetected. In addition, a trained professional is
not always present to perform the procedure. In an emergency setting, optical
colonoscopy presents limitations connected with the absence of bowel
preparation, so most of the small bowel cannot be assessed. Scintigraphy cannot
accurately demonstrate the anatomic location of the bleeding and is not
available at emergency settings. The use of capsule endoscopy is inappropriate
in the acute setting, particularly in the emergency department at night, and is
a highly expensive method. Digital angiography, despite its high sensitivity, is
invasive, presents catheterization-related risks, in addition to its low
availability at emergency settings. On the other hand, computed tomography
angiography is fast, widely available and minimally invasive, emerging as a
promising method in the diagnostic algorithm of these patients, being capable of
determining the location and cause of bleeding with high accuracy. Based on a
critical literature review and on their own experience, the authors propose a
computed tomography angiography protocol to assess the patient with
gastrointestinal bleeding.
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Affiliation(s)
- Fatima Regina Silva Reis
- Master, Professional Mastership Program in association with Medical Residency (Meparem), MD, Radiologist, Department of Imaging Diagnosis, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Patricia Prando Cardia
- PhD, MD, Radiologist, Centro Radiológico Campinas, Hospital Vera Cruz, Campinas, SP, Brazil
| | - Giuseppe D'Ippolito
- Private Docent, Associate Professor, Department of Imaging Diagnosis, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
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ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol 2015; 110:1265-87; quiz 1288. [PMID: 26303132 DOI: 10.1038/ajg.2015.246] [Citation(s) in RCA: 439] [Impact Index Per Article: 43.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 06/01/2015] [Indexed: 02/06/2023]
Abstract
Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.
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Kim J, Kim YH, Lee KH, Lee YJ, Park JH. Diagnostic Performance of CT Angiography in Patients Visiting Emergency Department with Overt Gastrointestinal Bleeding. Korean J Radiol 2015; 16:541-9. [PMID: 25995683 PMCID: PMC4435984 DOI: 10.3348/kjr.2015.16.3.541] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 02/16/2015] [Indexed: 01/07/2023] Open
Abstract
Objective To investigate the diagnostic performance of computed tomography angiography (CTA) in identifying the cause of bleeding and to determine the clinical features associated with a positive test result of CTA in patients visiting emergency department with overt gastrointestinal (GI) bleeding. Materials and Methods We included 111 consecutive patients (61 men and 50 women; mean age: 63.4 years; range: 28-89 years) who visited emergency department with overt GI bleeding. They underwent CTA as a first-line diagnostic modality from July through December 2010. Two radiologists retrospectively reviewed the CTA images and determined the presence of any definite or potential bleeding focus by consensus. An independent assessor determined the cause of bleeding based on other diagnostic studies and/or clinical follow-up. The diagnostic performance of CTA and clinical characteristics associated with positive CTA results were analyzed. Results To identify a definite or potential bleeding focus, the diagnostic yield of CTA was 61.3% (68 of 111). The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value were 84.8% (67 of 79), 96.9% (31 of 32), 98.5% (67 of 68), and 72.1% (31 of 43), respectively. Positive CTA results were associated with the presence of massive bleeding (p = 0.001, odds ratio: 11.506). Conclusion Computed tomography angiography as a first-line diagnostic modality in patients presenting with overt GI bleeding showed a fairly high accuracy. It could identify definite or potential bleeding focus with a moderate diagnostic yield and a high PPV. CTA is particularly useful in patients with massive bleeding.
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Affiliation(s)
- Jihang Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Seongnam 436-707, Korea
| | - Young Hoon Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Seongnam 436-707, Korea
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Seongnam 436-707, Korea
| | - Yoon Jin Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Seongnam 436-707, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Seongnam 436-707, Korea
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Sun H, Hou XY, Xue HD, Li XG, Jin ZY, Qian JM, Yu JC, Zhu HD. Dual-source dual-energy CT angiography with virtual non-enhanced images and iodine map for active gastrointestinal bleeding: Image quality, radiation dose and diagnostic performance. Eur J Radiol 2015; 84:884-91. [DOI: 10.1016/j.ejrad.2015.01.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 12/04/2014] [Accepted: 01/14/2015] [Indexed: 01/29/2023]
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Suzuki H, Hasegawa I, Hoshino N, Fukunaga T. Two forensic autopsy cases of death due to upper gastrointestinal hemorrhage: A comparison of postmortem computed tomography and autopsy findings. Leg Med (Tokyo) 2015; 17:198-200. [DOI: 10.1016/j.legalmed.2014.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 12/21/2014] [Accepted: 12/24/2014] [Indexed: 12/27/2022]
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Application of contrast media in post-mortem imaging (CT and MRI). Radiol Med 2015; 120:824-34. [PMID: 25841652 DOI: 10.1007/s11547-015-0532-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 03/12/2015] [Indexed: 01/17/2023]
Abstract
The application of contrast media in post-mortem radiology differs from clinical approaches in living patients. Post-mortem changes in the vascular system and the absence of blood flow lead to specific problems that have to be considered for the performance of post-mortem angiography. In addition, interpreting the images is challenging due to technique-related and post-mortem artefacts that have to be known and that are specific for each applied technique. Although the idea of injecting contrast media is old, classic methods are not simply transferable to modern radiological techniques in forensic medicine, as they are mostly dedicated to single-organ studies or applicable only shortly after death. With the introduction of modern imaging techniques, such as post-mortem computed tomography (PMCT) and post-mortem magnetic resonance (PMMR), to forensic death investigations, intensive research started to explore their advantages and limitations compared to conventional autopsy. PMCT has already become a routine investigation in several centres, and different techniques have been developed to better visualise the vascular system and organ parenchyma in PMCT. In contrast, the use of PMMR is still limited due to practical issues, and research is now starting in the field of PMMR angiography. This article gives an overview of the problems in post-mortem contrast media application, the various classic and modern techniques, and the issues to consider by using different media.
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38
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Sánchez-Capilla AD, De La Torre-Rubio P, Redondo-Cerezo E. New insights to occult gastrointestinal bleeding: From pathophysiology to therapeutics. World J Gastrointest Pathophysiol 2014; 5:271-283. [PMID: 25133028 PMCID: PMC4133525 DOI: 10.4291/wjgp.v5.i3.271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 06/01/2014] [Accepted: 06/18/2014] [Indexed: 02/06/2023] Open
Abstract
Obscure gastrointestinal bleeding is still a clinical challenge for gastroenterologists. The recent development of novel technologies for the diagnosis and treatment of different bleeding causes has allowed a better management of patients, but it also determines the need of a deeper comprehension of pathophysiology and the analysis of local expertise in order to develop a rational management algorithm. Obscure gastrointestinal bleeding can be divided in occult, when a positive occult blood fecal test is the main manifestation, and overt, when external sings of bleeding are visible. In this paper we are going to focus on overt gastrointestinal bleeding, describing the physiopathology of the most usual causes, analyzing the diagnostic procedures available, from the most classical to the novel ones, and establishing a standard algorithm which can be adapted depending on the local expertise or availability. Finally, we will review the main therapeutic options for this complex and not so uncommon clinical problem.
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Artigas JM, Martí M, Soto JA, Esteban H, Pinilla I, Guillén E. Multidetector CT angiography for acute gastrointestinal bleeding: technique and findings. Radiographics 2014; 33:1453-70. [PMID: 24025935 DOI: 10.1148/rg.335125072] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute gastrointestinal bleeding is a common reason for emergency department admissions and an important cause of morbidity and mortality. Factors that complicate its clinical management include patient debility due to comorbidities; intermittence of hemorrhage; and multiple sites of simultaneous bleeding. Its management, therefore, must be multidisciplinary and include emergency physicians, gastroenterologists, and surgeons, as well as radiologists for diagnostic imaging and interventional therapy. Upper gastrointestinal tract bleeding is usually managed endoscopically, with radiologic intervention reserved as an alternative to be used if endoscopic therapy fails. Endoscopy is often less successful in the management of acute lower gastrointestinal tract bleeding, where colonoscopy may be more effective. The merits of performing bowel cleansing before colonoscopy in such cases might be offset by the resultant increase in response time and should be weighed carefully against the deficits in visualization and diagnostic accuracy that would result from performing colonoscopy without bowel preparation. In recent years, multidetector computed tomographic (CT) angiography has gained acceptance as a first-line option for the diagnosis and management of lower gastrointestinal tract bleeding. In selected cases of upper gastrointestinal tract bleeding, CT angiography also provides accurate information about the presence or absence of active bleeding, its source, and its cause. This information helps shorten the total diagnostic time and minimizes or eliminates the need for more expensive and more invasive procedures.
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Affiliation(s)
- José M Artigas
- Departments of Radiology, Miguel Servet University Hospital, Paseo de Isabel La Católica 1-3, 50009 Zaragoza, Spain
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Grabherr S, Grimm J, Dominguez A, Vanhaebost J, Mangin P. Advances in post-mortem CT-angiography. Br J Radiol 2014; 87:20130488. [PMID: 24234582 PMCID: PMC4067028 DOI: 10.1259/bjr.20130488] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 11/04/2013] [Accepted: 11/05/2013] [Indexed: 12/31/2022] Open
Abstract
Performing a post-mortem multidetector CT (MDCT) scan has already become routine in some institutes of forensic medicine. To better visualize the vascular system, different techniques of post-mortem CT-angiography have been explored, which can essentially be divided into partial- and whole-body angiography techniques. Probably the most frequently applied technique today is the so-called multiphase post-mortem CT-angiography (MPMCTA) a standardized method for investigating the vessels of the head, thorax and abdomen. Different studies exist, describing its use for medicolegal investigations, and its advantages as well as its artefacts and pitfalls. With the aim to investigate the performance of PMCTA and to develop and validate techniques, an international working group was created in 2012 called the "Technical Working Group Post-mortem Angiography Methods" (TWGPAM). Beyond its primary perspective, the goals of this group include creating recommendations for the indication of the investigation and for the interpretation of the images and to distribute knowledge about PMCTA. This article provides an overview about the different approaches that have been developed and tested in recent years and an update about ongoing research in this field. It will explain the technique of MPMCTA in detail and give an outline of its indications, application, advantages and limitations.
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Affiliation(s)
- S Grabherr
- University Center of Legal Medicine Lausanne-Geneva, University Hospital of Lausanne, Lausanne, Switzerland
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MDCT and CT angiography evaluation of rectal bleeding: the role of volume visualization. AJR Am J Roentgenol 2013; 201:589-97. [PMID: 23971451 DOI: 10.2214/ajr.12.10357] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE This article reviews several different causes of rectal bleeding and the role of MDCT in diagnosis. CONCLUSION Although colonoscopy remains the first-line modality for the diagnosis of lower gastrointestinal tract bleeding, colonoscopy may not be possible for unstable patients, and moreover, even for patients who undergo colonoscopy, the examination may still fail to diagnose a cause for bleeding. MDCT with CT angiography and 3D mapping now offers a valuable option for diagnosis, not only for patients whose colonoscopy findings were negative, but also as a first-line screening modality for patients with active bleeding and hemodynamic instability. This article reviews the valuable role of MDCT in the diagnosis of multiple different causes of rectal bleeding, including rectal vascular malformations, rectal varices, ischemic colitis, stercoral colitis, inflammatory bowel disease, radiation proctopathy, infectious colitis, and rectal cancer.
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Transcatheter intervention for non-variceal gastrointestinal bleeding: what have we learned in 45 years? Dig Dis Sci 2013; 58:1819-21. [PMID: 23733275 DOI: 10.1007/s10620-013-2724-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Upper gastrointestinal bleeding (UGIB) remains a frequent presentation in the emergency department. There are several causes of UGIB, which can be generally classified into variceal and nonvariceal bleeding. Although most cases of nonvariceal UGIB spontaneously resolve or respond to medical management and/or endoscopic treatment, transcatheter arterial embolization (TAE) remains an important available tool in the emergency evaluation and management of nonvariceal UGIB. In this article, we will discuss the current strategies for rendering a specific diagnosis of nonvariceal UGIB, and we will focus on the various TAE techniques for its management. We will also provide an algorithm for the diagnostic work-up of these patients. The majority of patients with nonvariceal UGIB that is refractory to endoscopic treatment is successfully treated with minimally invasive TAE and can avoid undergoing surgery.
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Dual-source dual-energy computed tomography angiography for active gastrointestinal bleeding: A preliminary study. Clin Radiol 2013; 68:139-47. [DOI: 10.1016/j.crad.2012.06.106] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 05/31/2012] [Accepted: 06/11/2012] [Indexed: 01/09/2023]
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Postmortem computed tomography angiography vs. conventional autopsy: advantages and inconveniences of each method. Int J Legal Med 2013; 127:981-9. [PMID: 23292183 DOI: 10.1007/s00414-012-0814-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 12/20/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Postmortem computed tomography angiography (PMCTA) was introduced into forensic investigations a few years ago. It provides reliable images that can be consulted at any time. Conventional autopsy remains the reference standard for defining the cause of death, but provides only limited possibility of a second examination. This study compares these two procedures and discusses findings that can be detected exclusively using each method. MATERIALS AND METHODS This retrospective study compared radiological reports from PMCTA to reports from conventional autopsy for 50 forensic autopsy cases. Reported findings from autopsy and PMCTA were extracted and compared to each other. PMCTA was performed using a modified heart-lung machine and the oily contrast agent Angiofil® (Fumedica AG, Muri, Switzerland). RESULTS PMCTA and conventional autopsy would have drawn similar conclusions regarding causes of death. Nearly 60 % of all findings were visualized with both techniques. PMCTA demonstrates a higher sensitivity for identifying skeletal and vascular lesions. However, vascular occlusions due to postmortem blood clots could be falsely assumed to be vascular lesions. In contrast, conventional autopsy does not detect all bone fractures or the exact source of bleeding. Conventional autopsy provides important information about organ morphology and remains the only way to diagnose a vital vascular occlusion with certitude. CONCLUSION Overall, PMCTA and conventional autopsy provide comparable findings. However, each technique presents advantages and disadvantages for detecting specific findings. To correctly interpret findings and clearly define the indications for PMCTA, these differences must be understood.
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46
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Acute gastrointestinal hemorrhage: radiologic diagnosis and management. Can Assoc Radiol J 2012; 64:90-100. [PMID: 23245297 DOI: 10.1016/j.carj.2012.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 08/03/2012] [Indexed: 02/06/2023] Open
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Taslakian B, Khalife M, Faraj W, Mukherji D, Haydar A. Pancreatitis-associated pseudoaneurysm of the splenic artery presenting as lower gastrointestinal bleeding: treatment with transcatheter embolisation. BMJ Case Rep 2012. [PMID: 23208811 DOI: 10.1136/bcr-2012-007403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Pancreatitis is a known cause of pseudoaneurysms of the peripancreatic arteries, which can rarely rupture into various adjacent structures and become a source of life-threatening bleeding. The management is challenging and requires an individualised approach and multidisciplinary care. Herein, we present the case of a 24-year-old man in whom a splenic pseudoaneurysm ruptured into the adjacent infected pseudocyst, communicating with the colon by a fistulous tract, causing massive lower gastrointestinal bleeding. This was successfully managed by transcatheter arterial embolisation (TAE).
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Affiliation(s)
- Bedros Taslakian
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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48
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García-Blázquez V, Vicente-Bártulos A, Olavarria-Delgado A, Plana MN, van der Winden D, Zamora J. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol 2012. [PMID: 23192375 DOI: 10.1007/s00330-012-2721-x] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the diagnostic accuracy of computed tomography (CT) angiography in the evaluation of patients with an episode of acute gastrointestinal haemorrhage. METHODS Systematic review and meta-analysis to estimate pooled accuracy indices. A bivariate random effects model was adjusted to obtain a summary receiver-operating characteristic (sROC) curve and the corresponding area under the curve (AUC). RESULTS Twenty-two studies were included and provided data on 672 patients (range of age 5-74) with a mean age of 65 years. The overall sensitivity of CT angiography for detecting active acute GI haemorrhage was 85.2 % (95 % CI 75.5 % to 91.5 %). The overall specificity of CT angiography was 92.1 % (95 % CI 76.7 % to 97.7 %). The likelihood ratios for positive and negative test results were 10.8 (95 % CI 3.4 to 34.4) and 0.16 (95 % CI 0.1 to 0.27) respectively, with an AUC of 0.935 (95 % CI 0.693 to 0.989). The sources of heterogeneity explored had no significant impact on diagnostic performance. CONCLUSIONS CT shows high diagnostic accuracy and is an excellent diagnostic tool for detection and localising of intestinal bleeding sites. It is highly available, provides fast detection and localisation of the bleeding site, and is minimally invasive. KEY POINTS • CT angiography is increasingly used for investigating severe gastrointestinal bleeding. • This systematic review and meta-analysis updates previous ones. • In patients with massive gastrointestinal bleeding, CT angiography/MDCT detects bleeding accurately. • CT angiography is useful in locating the bleeding site and determining appropriate treatment.
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Affiliation(s)
- V García-Blázquez
- Department of Radiology, University Hospital Ramón y Cajal, Madrid, Spain
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Osman D, Djibré M, Da Silva D, Goulenok C. Management by the intensivist of gastrointestinal bleeding in adults and children. Ann Intensive Care 2012; 2:46. [PMID: 23140348 PMCID: PMC3526517 DOI: 10.1186/2110-5820-2-46] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 10/05/2012] [Indexed: 12/12/2022] Open
Abstract
Intensivists are regularly confronted with the question of gastrointestinal bleeding. To date, the latest international recommendations regarding prevention and treatment for gastrointestinal bleeding lack a specific approach to the critically ill patients. We present recommendations for management by the intensivist of gastrointestinal bleeding in adults and children, developed with the GRADE system by an experts group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF), with the participation of the French Language Group of Paediatric Intensive Care and Emergencies (GFRUP), the French Society of Emergency Medicine (SFMU), the French Society of Gastroenterology (SNFGE), and the French Society of Digestive Endoscopy (SFED). The recommendations cover five fields of application: management of gastrointestinal bleeding before endoscopic diagnosis, treatment of upper gastrointestinal bleeding unrelated to portal hypertension, treatment of upper gastrointestinal bleeding related to portal hypertension, management of presumed lower gastrointestinal bleeding, and prevention of upper gastrointestinal bleeding in intensive care.
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Affiliation(s)
- David Osman
- AP-HP, Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, Service de réanimation médicale, Le Kremlin-Bicêtre, F-94270, France.
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Prise en charge par le réanimateur des hémorragies digestives de l’adulte et de l’enfant. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0489-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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