Pictorial reviewMulti-detector CT: review of its use 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
References (25)
- et al.
Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia
Med Clin North Am
(2002) - et al.
Angiography in gastrointestinal bleeding
Lancet
(1982) - et al.
An initial experience using helical CT imaging to detect obscure gastrointestinal bleeding
J Clin Imaging
(2004) - et al.
Limited value of technetium-99m-labeled red cell scintigraphy in localization of lower gastrointestinal bleeding
Am J Surg
(1990) - et al.
Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage
BMJ
(1995) - et al.
Endoscopy of the upper gastrointestinal tract
N Engl J Med
(1999) Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population based study
Am J Gastroenterol
(1997)- et al.
Colonoscopy: the initial test for acute lower gastrointestinal bleeding
Am Surg
(1998) Value of early capsular endoscopy for severe gastrointestinal bleeding
J Natl Med Assoc
(2004)- et al.
Wireless-capsule diagnostic endoscopy for recurrent small bowel bleeding
N Engl J Med
(2001)
AGA technical review on the evaluation and management of occult and obscure gastrointestingal bleeding
Gastroenterology
Diverticular disease of the colon
Cited by (39)
Management of Upper Gastrointestinal Hemorrhage
2020, Image-Guided Interventions: Expert Radiology Series, Third EditionAcute lower gastrointestinal bleeding
2015, Medicine (United Kingdom)Citation Excerpt :Logistical factors, available expertise and the likelihood of a localized source of bleeding predicate the use of early colonoscopy in the evaluation of acute LGI haemorrhage.12 Multi-section abdominal CT scan with intravenous contrast (CT angiography) will often demonstrate a bleeding source with a blush of contrast in the bowel lumen if the patient is actively bleeding (Figure 2).13,14 It may also give additional information such as the extent of colitis, presence of malignancy, staging of metastatic disease or mesenteric vessel occlusion.
Computed tomography angiography in acute gastrointestinal and intra-abdominal bleeding in children: Preliminary experience
2013, Canadian Association of Radiologists JournalGastrointestinal bleeding: The role of radiology
2011, RadiologiaAcute lower gastrointestinal bleeding
2011, MedicineCitation Excerpt :Logistical factors, available expertise and the likelihood of a localized source of bleeding predicate the use of early colonoscopy in the evaluation of acute LGI haemorrhage.11 Multi-section abdominal CT scan with intravenous contrast (CT angiography) will often demonstrate a bleeding source with a blush of contrast in the bowel lumen if the patient is actively bleeding (Figure 2).12,13 It may also give additional information such as the extent of colitis, presence of malignancy, staging of metastatic disease or mesenteric vessel occlusion.