Lower gastrointestinal bleeding CT scan
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Differentiating Lower gastrointestinal bleeding from other Diseases |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Helical CT scanning of the abdomen and pelvis is recommended when a routine workup fails to determine the cause of active gastrointestinal bleeding. Findings of helical CT scan in lower gastrointestinal bleeding include vascular extravasation of the contrast medium, contrast enhancement of the bowel wall, thickening of the bowel wall, hyperdensity of the peri-bowel fat, and vascular dilatations.
Helical CT scan
Helical CT scanning of the abdomen and pelvis is recommended when a routine workup fails to determine the cause of active gastrointestinal bleeding. Helical CT scanning is a safe, convenient, and an accurate diagnostic tool relative to mesenteric angiography and colonoscopy in diagnosing acute lower GI bleeding (LGIB). Findings of helical CT scan in lower gastrointestinal bleeding include:[1][2]
- Vascular extravasation of the contrast medium
- Contrast enhancement of the bowel wall
- Thickening of the bowel wall
- Hyperdensity of the peri-bowel fat, and vascular dilatations.
Multidetector-row CT (MDCT) scanning is also useful in the evaluation of LGIB but its rarely used.
| Sensitivity | MDCT | Endoscopy |
|---|---|---|
| Site | 100% | 88.2% |
| Etiology | 52.9% | 52.9% |
CT Angiography
Procedure
- Contrast (100 mL) is given via peripheral venous access and a CT scan is performed 30 seconds following injection.
- CT scan is then repeated in the portal phase (70 seconds following injection).
- CT Angiography can detect bleeding with a rate of 0.5 mL/min or less whereas catheter angiography detects bleeding with a rate of 0.5 to 1 mL/min. Therefore, CTA is performed before catheter angiography.
- Access into the arterial system is normally via a common femoral artery approach.
- If this is not possible, the brachial artery can be used, although this carries a small risk of stroke.
- A wide range of catheters can be used to access the mesenteric arteries (majority of bleeds due to diverticula or angiodysplasia receive their blood supply from the superior mesenteric artery).
- In practice, the inferior mesenteric artery is selectively catheterized before the superior mesenteric artery to avoid a bladder full of contrast obscuring the inferior mesenteric branches.
- If no bleeding source is identified from these two vessels (SMA, IMA) the celiac axis is catheterized and assessed, as bleeding points may be discovered from the gastroduodenal artery.
Indications
- In patients who are actively bleeding but who are relatively hemo-dynamically stable
Advantages
- Noninvasive
- CT Angiography can pick up findings in the solid organs and soft tissue structures that would not be seen on catheter angiography.
- CT Angiography can potentially detect bleeding from any point in the gastrointestinal tract and may reveal an upper gastrointestinal source of bleeding in a patient thought to have LGIB.
- CT Angiography can also help with planning embolization by revealing any iliac artery or mesenteric ostial atherosclerotic disease.
- CTA also has the advantage that it is widely available 24 hours a day, unlike colonoscopy services in many areas.
- If a patient then becomes unstable and an initial bleeding point is localized on CTA, then the choice has to be made between urgent colonoscopy, angiographic embolization, or surgery.
Findings/Interpretation
- Arterial phase CTA may show thrombus in the superior or inferior mesenteric artery.
- CTA has a sensitivity of 93% to 100% and specificity of 100% in detecting mesenteric ischemia.
- If CTA fails to show a source of bleeding, then catheter angiography is generally not performed.
- If a bleeding point is seen on CTA, then catheter angiography and embolization can be undertaken
Disadvantage
- Poor sensitivity
Contraindications
- Contraindicated in patients with renal failure as the contrast agent may potentially worsen renal function.
References
- ↑ Feuerstein JD, Ketwaroo G, Tewani SK, Cheesman A, Trivella J, Raptopoulos V, Leffler DA (2016). "Localizing Acute Lower Gastrointestinal Hemorrhage: CT Angiography Versus Tagged RBC Scintigraphy". AJR Am J Roentgenol. 207 (3): 578–84. doi:10.2214/AJR.15.15714. PMID 27303989.
- ↑ Yamaguchi T, Yoshikawa K (2003). "Enhanced CT for initial localization of active lower gastrointestinal bleeding". Abdom Imaging. 28 (5): 634–6. PMID 14628865.
- ↑ Geffroy Y, Rodallec MH, Boulay-Coletta I, Jullès MC, Fullès MC, Ridereau-Zins C, Zins M (2011). "Multidetector CT angiography in acute gastrointestinal bleeding: why, when, and how". Radiographics. 31 (3): E35–46. doi:10.1148/rg.313105206. PMID 21721196.
- ↑ Artigas JM, Martí M, Soto JA, Esteban H, Pinilla I, Guillén E (2013). "Multidetector CT angiography for acute gastrointestinal bleeding: technique and findings". Radiographics. 33 (5): 1453–70. doi:10.1148/rg.335125072. PMID 24025935.
- ↑ Foley PT, Ganeshan A, Anthony S, Uberoi R (2010). "Multi-detector CT angiography for lower gastrointestinal bleeding: Can it select patients for endovascular intervention?". J Med Imaging Radiat Oncol. 54 (1): 9–16. doi:10.1111/j.1754-9485.2010.02131.x. PMID 20377709.
- ↑ Wu LM, Xu JR, Yin Y, Qu XH (2010). "Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis". World J. Gastroenterol. 16 (31): 3957–63. PMC 2923771. PMID 20712058.
- ↑ Reis FR, Cardia PP, D'Ippolito G (2015). "Computed tomography angiography in patients with active gastrointestinal bleeding". Radiol Bras. 48 (6): 381–90. doi:10.1590/0100-3984.2014.0014. PMC 4725400. PMID 26811556.