Elsevier

Clinical Radiology

Volume 62, Issue 10, October 2007, Pages 938-949
Clinical Radiology

Pictorial review
Multi-detector CT: review of its use in acute GI haemorrhage

https://doi.org/10.1016/j.crad.2007.02.019Get rights and content

The advent of multi-section computed tomography (CT) technology allows the non-invasive assessment of the arterial tree. Using current software, it is now possible to produce high-quality, angiographic-like images that can be used to plan and guide therapeutic procedures. One such clinical situation is the assessment of patients with acute gastrointestinal (GI) haemorrhage. Multi-section CT has a number of advantages over conventional angiography in this situation. The simplicity and non-invasive nature of the technique compared with conventional angiography make CT angiography possible in situations where conventional angiography is not available. Movement artefact from respiration and peristalsis is a common problem in the interpretation of conventional angiography; this is essentially abolished with rapid acquisition times and the use of multi-planar images to remove overlying bowel loops. Cross-sectional imaging with the ability for multi-planar reconstruction allows the accurate anatomical localization of the bleeding site, as well as an assessment of the underlying pathology: this can be used to plan therapy (embolization or surgery). The aim of this paper is to review the current use of CT in the investigation of patients with GI haemorrhage, illustrated with images from our Institution. For patients in whom GI endoscopy has failed to establish a diagnosis, we propose multi-section CT angiography as the initial imaging investigation in acute GI haemorrhage.

Introduction

Gastrointestinal (GI) haemorrhage is a serious and often life-threatening condition. It requires a multi-disciplinary team approach, including diagnostic and interventional radiologists. In the majority of patients, the source of the bleeding can be localized and managed by endoscopy. In only a small percentage of patients, the bleeding site remains elusive after endoscopy. Historically these patients may have undergone emergency surgical resection; however, radiological localization of the source of bleeding before treatment avoids blind resections and the associated high morbidity and mortality. With the advent of multi-detector CT, the majority of these patients can be investigated and managed with minimally-invasive techniques.

In this article we review the current imaging pathways in the management of this condition, with particular reference to early use of multi-detector CT. Some of the typical CT angiography (CTA) appearances are demonstrated along with the corresponding appearances on intra-arterial digital subtraction angiography (IADSA).

Section snippets

GI haemorrhage

At presentation, after patient resuscitation, an initial assessment must be made to differentiate between upper and lower GI haemorrhage. Haematochezia usually suggests bleeding from the lower GI tract. Haematemesis and melaena suggest bleeding from the upper GI tract. Profuse bleeding from any site within the GI tract with short transit time may, however, present with bright red rectal bleeding. In this circumstance, early insertion of a naso-gastric tube can help to detect fresh bleeding from

Radiological imaging

Additional strategies are required in the small group of patients where endoscopic techniques fail to detect the source of bleeding in GI haemorrhage. Established radiological methods include radionuclide imaging and conventional catheter angiography with intra-arterial digital subtraction angiography (IADSA).

Methods

A search of the biomedical literature was performed using the MEDLINE database to identify any published series using the search terms CT and acute GI haemorrhage. The period of the search was 1995–2006. The search was restricted to publications in English. These studies were then analysed to ascertain the diagnostic criteria used in each series and to establish a protocol for the use of CTA in acute GI haemorrhage.

Local protocol

After discussion with our clinical colleagues, we established the following protocol based on the findings of the meta-analysis, which includes CTA for the management of patients presenting with acute GI haemorrhage (Fig. 5).

All patients presenting with acute GI haemorrhage in our unit initially undergo endoscopic examination (upper GI endoscopy and sigmoidoscopy/colonoscopy where appropriate). For patients in whom endoscopy has failed to identify the bleeding site, initial radiological

Discussion

CT has several advantages over other more conventional radiological techniques in the initial imaging of patients presenting with acute GI haemorrhage. First, CT is minimally-invasive and widely available. Conventional catheter angiography (IASDA) is both invasive, and only available in units with a vascular radiology team. Even where the facilities exist, there may be delays in performing IADSA because of unavailability of staff or facilities.

The second advantage of CT is that in the absence

Conclusion

We propose the routine use of CTA in the initial radiological investigation of patients who meet the criteria for acute GI haemorrhage, in whom upper and lower GI tract endoscopy has failed to identify the site of bleeding. CTA is a very simple technique that can be employed widely in all centres regardless of local access to nuclear medicine and catheter angiography. CTA still requires active bleeding at the time of imaging, but it may be repeated if the initial examination is negative. In

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