CT for Evaluation of Acute Gastrointestinal Bleeding

CT-based nomogram predicts esophageal gastric variceal bleeding in noncirrhotic portal hypertension caused by hepatic schistosomiasis

BACKGROUND

To construct a nomogram combining CT varices vein evaluation and clinical laboratory tests for predicting the risk of esophageal gastric variceal bleeding (EGVB) in patients with noncirrhotic portal hypertension (NCPH).

METHODS

A total of 315 NCPH patients with non-EGVB and EGVB were retrospectively enrolled and randomly divided into training and testing cohorts. Thirteen collateral vessels were identified and evaluated after CT portal vein system reconstruction. Multivariate binary logistic regression analysis was used to choose CT images and clinical predictors of EGVB. The varices score of each patient was calculated. A nomogram was built by combining the varices score with the selected clinical predictors of EGVB. The receiver operating characteristic (ROC) curve was used to evaluate the predictive performance of the nomogram.

RESULTS

Platelet count and prothrombin time were selected as clinical predictors; the esophageal vein, gastroepiploic vein and omental vein were selected as CT image predictors for predicting EGVB. A reduced platelet count, prolonged prothrombin time, severe esophageal and gastroepiploic vein tortuosity and less omental vein tortuosity were predictors of EGVB in NCPH patients. The specificity, sensitivity, negative predictive value, positive predictive value and AUC of the ROC of the nomogram were 0.82, 0.81, 0.89, 0.70, and 0.88 (95% CI: 0.84-0.93) in the training cohort and 0.87, 0.86, 0.88, 0.84, and 0.91 (95% CI: 0.84-0.97) in the testing cohort, respectively.

CONCLUSIONS

The nomogram combining CT images and clinical predictors could be useful to individualize and predict the risk of EGVB in NCPH patients.

CLINICAL RELEVANCE STATEMENT

Results showed that the nomogram combining CT-evaluated collateral vessels (varices score) and clinical laboratory tests could be used to realize personalized prediction of first-time EGVB in NCPH patients.

Clinical management of active bleeding: what the emergency radiologist needs to know

Active bleeding is a clinical emergency that often requires swift action driven by efficient communication. Extravasation of intravenous (IV) contrast on computed tomography (CT) is a hallmark of active hemorrhage. This can be seen on exams performed for a variety of indications and can occur anywhere in the body. As both traumatic and non-traumatic etiologies of significant blood loss are clinical emergencies, exams demonstrating active bleeding are often performed in emergency departments and read by emergency radiologists. Prompt communication of these findings to the appropriate emergency medicine and surgical providers is crucial. Although many types of active hemorrhage can be managed by interventional radiology techniques, endoscopic and surgical management or clinical observation may be appropriate in certain cases. To facilitate optimal care, it is important for emergency radiologists to understand the scope of indications for embolization of bleeding by interventional radiologists (IR) and when an IR consultation is warranted. Similarly, timely comprehensive diagnostic radiology reporting including pertinent positive and negative findings tailored for IR colleagues can expedite the appropriate intervention.

Prediction of gastrointestinal active arterial extravasation on computed tomographic angiography using multivariate clinical modeling

AIMS

To evaluate the ability of logistic regression and machine learning methods to predict active arterial extravasation on computed tomographic angiography (CTA) in patients with acute gastrointestinal hemorrhage using clinical variables obtained prior to image acquisition.

MATERIALS AND METHODS

CT angiograms performed for the indication of gastrointestinal bleeding at a single institution were labeled retrospectively for the presence of arterial extravasation. Positive and negative cases were matched for age, gender, time period, and site using Propensity Score Matching. Clinical variables were collected including recent history of gastrointestinal bleeding, comorbidities, laboratory values, and vitals. Data were partitioned into training and testing datasets based on the hospital site. Logistic regression, XGBoost, Random Forest, and Support Vector Machine classifiers were trained and five-fold internal cross-validation was performed. The models were validated and evaluated with the area under the receiver operating characteristic curve.

RESULTS

Two-hundred and thirty-one CTA studies with arterial gastrointestinal extravasation were 1:1 matched with 231 negative studies (N=462). After data preprocessing, 389 patients and 36 features were included in model development and analysis. Two hundred and fifty-five patients (65.6%) were selected for the training dataset. Validation was performed on the remaining 134 patients (34.4%); the area under the receiver operating characteristic curve for the logistic regression, XGBoost, Random Forest, and Support Vector Machine classifiers was 0.82, 0.68, 0.54, and 0.78, respectively.

CONCLUSION

Logistic regression and machine learning models can accurately predict presence of active arterial extravasation on CTA in patients with acute gastrointestinal bleeding using clinical variables.

A comprehensive review and update on acute severe lower gastrointestinal bleeding in Crohn's disease: a management algorithm

Acute severe lower gastrointestinal bleeding is a rare but potentially fatal complication of Crohn's disease (CD), affecting between 0.6% and 5.5% of CD patients during their lifelong disease course. Managing bleeding episodes effectively hinges on vital resuscitation. Endoscopic evaluation and computed tomography play crucial roles in accurate identification and intervention. Fortunately, most bleeding episodes can be successfully managed through appropriate conservative treatment. Medical therapies, particularly infliximab, aim to induce and maintain mucosal healing and serve as the leading treatment approach. Minimally invasive procedures, such as endoscopic hemostasis and angio-embolization, can achieve immediate hemostasis. Surgical treatment is only considered a last resort when conservative therapies fail. Despite achieving hemostasis, the risk of rebleeding ranges from 19.0% to 50.5%. The objective of this review is to provide a comprehensive and updated overview of the clinical manifestations, diagnostic methods, therapeutic approaches, and prognostic outcomes associated with acute severe gastrointestinal bleeding in CD. Furthermore, we aimed to propose a management algorithm to assist clinicians in the effective management of this condition.

ACR Appropriateness Criteria® Nonvariceal Upper Gastrointestinal Bleeding: 2024 Update

This document summarizes the relevant literature for the selection of the initial imaging in five clinical scenarios in patients with suspected or known nonvariceal upper gastrointestinal bleeding (UGIB). These clinical scenarios include suspected nonvariceal UGIB without endoscopy performed; endoscopically confirmed nonvariceal UGIB with clear source but treatment not possible or continued bleeding after endoscopic treatment; endoscopically confirmed nonvariceal UGIB without a confirmed source; suspected nonvariceal UGIB with negative endoscopy; and postsurgical or post-traumatic nonvariceal UGIB when endoscopy is contraindicated. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios of nonvariceal UGIB. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

[Chinese guidelines for emergency management of bleeding in hemophilia patients (2024)]

Hemophilia is a X-linked recessive hemorrhagic disease. Bleeding is the most common complication of hemophilia, and it is also the main cause leading to death and disability or reducing the quality of life of hemophilia patients. Rapid identification and standardized management of the bleeding events is of great significance to improve the prognosis of hemophilia patients. Emergency department is the frontline department for hemophilia patients with bleeding. The emergent management process of hemophilia hemorrhage is complex and often needs multidisciplinary team cooperation. To increase the awareness of the related professionals who may involve in the management of bleeding events of hemophilia patients, in collaboration with the Thrombosis and Hemostasis Group, Chinese Society of Hematology, Chinese Medical Association, Hemophilia Treatment Center Collaborative Network of China issued the Chinese guidelines for emergency management of bleeding in hemophilia patients.

Interventional Radiology for Bleeding Ectopic Varices: Individualized Approach Based on Vascular Anatomy

Ectopic varices are rare but potentially life-threatening conditions usually resulting from a combination of global portal hypertension and local occlusive components. As imaging, innovative devices, and interventional radiologic techniques evolve and are more widely adopted, interventional radiology is becoming essential in the management of ectopic varices. The interventional radiologist starts by diagnosing the underlying causes of portal hypertension and evaluating the afferent and efferent veins of ectopic varices with CT. If decompensated portal hypertension is causing ectopic varices, placement of a transjugular intrahepatic portosystemic shunt is considered the first-line treatment, although this treatment alone may not be effective in managing ectopic variceal bleeding because it may not sufficiently resolve focal mesenteric venous obstruction causing ectopic varices. Therefore, additional variceal embolization should be considered after placement of a transjugular intrahepatic portosystemic shunt. Retrograde transvenous obliteration can serve as a definitive treatment when the efferent vein connected to the systemic vein is accessible. Antegrade transvenous obliteration is a vital component of interventional radiologic management of ectopic varices because ectopic varices often exhibit complex anatomy and commonly lack catheterizable portosystemic shunts. Superficial veins of the portal venous system such as recanalized umbilical veins may provide safe access for antegrade transvenous obliteration. Given the absence of consensus and guidelines, a multidisciplinary team approach is essential for the individualized management of ectopic varices. Interventional radiologists must be knowledgeable about the anatomy and hemodynamic characteristics of ectopic varices based on CT images and be prepared to consider appropriate options for each specific situation. ©RSNA, 2024 Supplemental material is available for this article.

Role of Device-Assisted Enteroscopy in Crohn's Disease

Crohn's Disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract, posing diagnostic and management challenges due to its potential involvement of any segment from the mouth to the anus. Device-assisted enteroscopy (DAE) has emerged as a significant advancement in the management of CD, particularly for its ability to access the small intestine-a region difficult to evaluate with conventional endoscopic methods. This review discusses the pivotal role of DAE in the nuanced management of CD, emphasizing its enhanced diagnostic precision and therapeutic efficacy. DAE techniques, including double-balloon enteroscopy (DBE), single-balloon enteroscopy (SBE), and the now-withdrawn spiral enteroscopy, enable comprehensive mucosal assessment, targeted biopsies, and therapeutic interventions like stricture dilation, bleeding control, and foreign body removal. Despite its benefits, DAE carries risks such as perforation, bleeding, and pancreatitis, which require careful procedural planning and a skilled execution. The review highlights DAE's impact on reducing surgical interventions and improving patient outcomes through minimally invasive approaches, thereby enhancing the quality of life for patients with CD. Continuous improvement and research are essential in order to maximize DAE's utility and safety in clinical practice.

Radiological findings in poisoning by synthetic cannabinoids adulterated with brodifacoum

OBJECTIVES

Severe coagulopathy due to consumption of synthetic cannabinoids adulterated with brodifacoum, a long-acting anticoagulant, is an emerging worldwide hazard. Here, we review the spectrum of imaging findings in adulterated cannabinoid poisoning.

MATERIALS AND METHODS

In this retrospective study, we used the Israeli Poison Information Center database to identify patients with cannabinoid-associated coagulopathy who presented to the Rambam Health Care Campus, where most patients were treated during an outbreak in northern Israel between September 2021 and June 2022. All relevant imaging studies for these patients were reviewed. We estimated the sensitivity of findings for cannabinoid-associated coagulopathy. Associations between a continuous variable and a dichotomous outcome were assessed with the Mann-Whitney U test.

RESULTS

We identified 48 patients (mean age 40 years ± 9 [SD], 43 males) with 54 hospitalizations due to cannabinoid-associated coagulopathy. Symptomatic hemorrhage was documented in 50 (93%) cases at presentation, most of whom (78%) had hemorrhage from multiple systems. The most common bleeding site was the genitourinary collecting system, with a characteristic sign of suburothelial bleeding in 16/18 of performed abdominal CTs (sensitivity 89% [CI 65-99%] for cannabinoid-associated coagulopathy). Intramural bowel hematomas were noted in 70% (7/10) of CTs of patients with gastrointestinal bleeding. Incidental bleeding sites were identified on imaging in 24% of patients. An increased number of bleeding sites was associated with need for vasopressors (difference in bleeding sites 3.00 [95% CI 0.99-4.00], p = 0.026).

CONCLUSION

CT plays a key role in the diagnosis and work-up of adulterated cannabinoid-associated coagulopathy. Characteristic signs include suburothelial hemorrhage and intramural bowel hematomas.

CLINICAL RELEVANCE STATEMENT

Recognition of radiological signs of adulterated synthetic cannabinoid-associated coagulopathy is critical for optimizing outbreak control on the public health level and ensuring timely treatment on the individual patient level.

KEY POINTS

• Severe coagulopathy due to consumption of synthetic cannabinoids adulterated with brodifacoum, a long-acting anticoagulant, is an emerging worldwide threat. • Characteristic imaging signs include suburothelial bleeding, intramural bowel hematomas, and rare incidental bleeding sites. • Imaging has a pivotal role in optimizing outbreak control and ensuring timely and appropriate treatment.

Small bowel intramural hematoma caused by warfarin: case report and literature review

BACKGROUND

Intramural hematoma of the small bowel is a rare yet acute gastrointestinal condition typically linked with impaired coagulation function, often posing diagnostic challenges. It is principally encountered in patients undergoing prolonged anticoagulant therapy, specifically warfarin.

CASE PRESENTATION

We reported a case of intramural hematoma associated with warfarin use. The patient was admitted to hospital with abdominal pain and had received anticoagulant therapy with warfarin 2.5 mg/day for 4 years. Laboratory examination showed decreased coagulation function, abdominal CT showed obvious thickening and swelling of part of the jejunal wall, and abdominal puncture found no gastroenteric fluid or purulent fluid. We treated the patient with vitamin K and fresh frozen plasma. The patient was discharged after the recovery of coagulation function. Then we undertaook a comprehensive review of relevant case reports to extract shared clinical features and effective therapeutic strategies.

CONCLUSION

Our analysis highlights that hematoma in the small intestinal wall caused by warfarin overdose often presents as sudden and intense abdominal pain, laboratory tests suggest reduced coagulation capacity, and imaging often shows thickening of the intestinal wall. Intravenous vitamin K and plasma supplementation are effective non-surgical strategies. Nevertheless, in instances of severe obstruction and unresponsive hemostasis, surgical resection of necrotic intestinal segments may be necessary. In the cases we reported, we avoided surgery by closely monitoring the coagulation function. Therefore, we suggest that identifying and correcting the impaired coagulation status of patient is essential for timely and appropriate treatment.

Cutoff CT value can identify upper gastrointestinal bleeding on postmortem CT: Development and validation study

This study aimed to establish the diagnostic criteria for upper gastrointestinal bleeding (UGIB) using postmortem computed tomography (PMCT). This case-control study enrolled 27 consecutive patients with autopsy-proven UGIB and 170 of the 566 patients without UGIB who died in a university hospital in Japan after treatment and underwent both noncontrast PMCT and conventional autopsy between 2009 and 2020. Patients were randomly allocated to two groups: derivation and validation sets. Imaging findings of the upper gastrointestinal contents, including CT values, were recorded and evaluated for their power to diagnose UGIB in the derivation set and validated in the validation set. In the derivation set, the mean CT value of the upper gastrointestinal contents was 48.2 Hounsfield units (HU) and 22.8 HU in cases with and without UGIB. The optimal cutoff CT value for diagnosing UGIB was ≥27.7 HU derived from the receiver operating characteristic curve analysis (sensitivity, 91.7%; specificity, 81.2%; area under the curve, 0.898). In the validation set, the sensitivity and specificity in diagnosing UGIB for the CT cutoff value of ≥27.7 HU were 84.6% and 77.6%, respectively. In addition to the CT value of ≥27.7 HU, PMCT findings of solid-natured gastrointestinal content and intra/peri-content bubbles ≥4 mm, extracted from the derivation set, increased the specificity for UGIB (96.5% and 98.8%, respectively) but decreased the sensitivity (61.5% and 38.5%, respectively) in the validation set. In diagnosing UGIB on noncontrast PMCT, the cutoff CT value of ≥27.7 HU and solid gastrointestinal content were valid and reproducible diagnostic criteria.

Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon

Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.

Extravasated contrast volumetric assessment on computed tomography angiography in gastrointestinal bleeding: A useful predictor of positive angiographic findings

BACKGROUND

Gastrointestinal bleeding (GIB) is a severe and potentially life-threatening condition, especially in cases of delayed treatment. Computed tomography angiography (CTA) plays a pivotal role in the early identification of upper and lower GIB and in the prompt treatment of the haemorrhage.

AIM

To determine whether a volumetric estimation of the extravasated contrast at CTA in GIB may be a predictor of subsequent positive angiographic findings.

METHODS

In this retrospective single-centre study, 35 patients (22 men; median age 69 years; range 16-92 years) admitted to our institution for active GIB detected at CTA and further submitted to catheter angiography between January 2018 and February 2022 were enrolled. Twenty-three (65.7%) patients underwent endoscopy before CTA. Bleeding volumetry was evaluated in both arterial and venous phases via a semi-automated dedicated software. Bleeding rate was obtained from volume change between the two phases and standardised for unit time. Patients were divided into two groups, according to the angiographic signs and their concordance with CTA.

RESULTS

Upper bleeding accounted for 42.9% and lower GIB for 57.1%. Mean haemoglobin value at the admission was 7.7 g/dL. A concordance between positive CTA and direct angiographic bleeding signs was found in 19 (54.3%) cases. Despite no significant differences in terms of bleeding volume in the arterial phase (0.55 mL vs 0.33 mL, P = 0.35), a statistically significant volume increase in the venous phase was identified in the group of patients with positive angiography (2.06 mL vs 0.9 mL, P = 0.02). In the latter patient group, a significant increase in bleeding rate was also detected (2.18 mL/min vs 0.19 mL/min, P = 0.02).

CONCLUSION

In GIB of any origin, extravasated contrast volumetric analysis at CTA could be a predictor of positive angiography and may help in avoiding further unnecessary procedures.

Variceal and Nonvariceal Upper Gastrointestinal Bleeding Refractory to Endoscopic Management: Indications and Role of Interventional Radiology

For over 60 years, diagnostic and interventional radiology have been heavily involved in the evaluation and treatment of patients presenting with gastrointestinal bleeding. For patients who present with upper GI bleeding and have a contraindication to endoscopy or have an unsuccessful attempt at endoscopy for identifying or controlling the bleeding, interventional radiology is often consulted for evaluation and consideration of catheter-based intervention.

The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.

Differentiation of Hamartomas and Malignant Lung Tumors in Single-Phased Dual-Energy Computed Tomography

This study investigated the efficacy of single-phase dual-energy CT (DECT) in differentiating pulmonary hamartomas from malignant lung lesions using virtual non-contrast (VNC), iodine, and fat quantification. Forty-six patients with 47 pulmonary lesions (mean age: 65.2 ± 12.1 years; hamartomas-to-malignant lesions = 22:25; male: 67%) underwent portal venous DECT using histology, PET-CT and follow-up CTs as a reference. Quantitative parameters such as VNC, fat fraction, iodine density and CT mixed values were statistically analyzed. Significant differences were found in fat fractions (hamartomas: 48.9%; malignancies: 22.9%; p ≤ 0.0001) and VNC HU values (hamartomas: -20.5 HU; malignancies: 17.8 HU; p ≤ 0.0001), with hamartomas having higher fat content and lower VNC HU values than malignancies. CT mixed values also differed significantly (p ≤ 0.0001), but iodine density showed no significant differences. ROC analysis favored the fat fraction (AUC = 96.4%; sensitivity: 100%) over the VNC, CT mixed value and iodine density for differentiation. The study concludes that the DECT-based fat fraction is superior to the single-energy CT in differentiating between incidental pulmonary hamartomas and malignant lesions, while post-contrast iodine density is ineffective for differentiation.

Clinical Predictors of Gastrointestinal Bleeding Source before Computed Tomography Angiography

BACKGROUND

Acute gastrointestinal bleeding (GIB) is a commonly encountered medical emergency. In cases of negative endoscopic evaluations, computed tomography angiography (CTA) is usually the next diagnostic step. To date, data regarding positive CTA examinations are lacking. We aimed to assess the clinical and laboratory parameters that predict a positive CTA examination, as demonstrated by the extravasation of contrast material into the bowel lumen.

METHODS

We performed a single-center retrospective study, including all patients who were admitted with GIB and who underwent CTA. Analysis was performed to compare patients' characteristics, and logistic regression was used to explore parameters associated with a positive CTA.

RESULTS

We included 154 patients. Of them, 25 patients (16.2%) had active GIB on CTA vs. 129 patients (83.8%) who did not. On univariate analysis, several parameters were positively associated with active GIB, including congestive heart failure (OR 2.47, 95% CI 1.04-5.86, p = 0.04), warfarin use (OR 4.76, 95% CI 1.49-15.21, p = 0.008), higher INR (OR 1.33, 1.04-1.69, p = 0.02), and low albumin level (OR 0.37, 95% CI 0.17-0.79, p = 0.01). On multivariate logistic regression analysis, only high INR (OR 1.34, 95% CI 1.02-1.76, p = 0.03) and low albumin (OR 0.3, 95% CI 0.12-0.7, p = 0.005) kept their positive association with active bleeding, while a high ASA score was negatively associated with an active GIB.

CONCLUSIONS

We could identify high INR and low albumin as strong predictors of active GIB, as demonstrated by positive CTA. On the other hand, comorbid patients classified by a high ASA score did not experience a higher rate of active GIB.

Dual-Energy, Spectral and Photon Counting Computed Tomography for Evaluation of the Gastrointestinal Tract

The use of dual-energy computed tomography (CT) allows for reconstruction of energy- and material-specific image series. The combination of low-energy monochromatic images, iodine maps, and virtual unenhanced images can improve lesion detection and disease characterization in the gastrointestinal tract in comparison with single-energy CT.

Endovascular management of severe lower gastrointestinal bleeding from angiodysplasia in the cecum: A case report

Gastrointestinal angiodysplasias (GIADs) are rare disorder but can cause noticeable issue clinically. Their clinical characteristics can range from being an asymptomatic incidental finding to causing life-threatening bleeding. Many modalities are applied for treating bleeding GIADs include endoscopic therapies, angiography with embolization, surgical resection, and pharmacologic therapy. However, since patients with GIADs are often aged and have many comorbidities, endoscopic therapies may not be the best initial option. Angiography is suitable method for hemodynamically unstable patients with active bleeding, patients with an unknown active bleeding source, and patients who are poor surgical candidates. Angiography not only diagnose the bleeding point but also provide therapeutic endovascular intervention at the same time. We report a case of endovascular management of severe lower gastrointestinal bleeding from a GIAD in the cecum using a mixture of n-butyl cyanoacrylate and lipiodol to embolize the bleeding source. Clinical symptoms improved without prominent complications.

A case of hemorrhagic shock due to massive upper gastrointestinal bleeding: from the differential diagnosis to the correct management

Upper Gastro-Intestinal Bleeding (UGIB) spans from minor bleeding to life-threatening events. Identification of early signs of shock, proper management of hemodynamically unstable patients, and correct risk stratification are essential for an appropriate diagnostic workup and therapy. This case reports a young man admitted to the emergency department with haematemesis. His medical history was unremarkable, without any risk factors for gastrointestinal bleeding. A few hours after admission, further episodes of haematemesis occurred, and the patient's condition rapidly deteriorated to irreversible shock. A contrast-enhanced computed tomography (CECT) revealed morphological features of chronic liver disease and oesophagal varices. The patient underwent upper gastrointestinal endoscopy, confirming oesophagal varices with massive bleeding. Although promptly applied, endoscopic hemostasis was ineffective, and the patient died twenty-four hours after admission. Based on this case, we reviewed the diagnostic and therapeutic approaches for patients with massive UGIB and provided a practical approach to this life-threatening emergency.

Case report: An unusual case of small bowel bleeding and common iliac artery pseudoaneurysm caused by an unnoticed swallowed toothpick

Gastrointestinal (GI) bleeding is a common clinical condition that can be caused by a variety of reasons. Bleeding can occur anywhere in the GI tract, and it usually presents as vomiting of blood, melena or black stools. We herein present a case of a 48-year-old man who was ultimately diagnosed with perforation of the lower ileum, pseudoaneurysm of the right common iliac artery, lower ileum-right common iliac artery fistula, and pelvic abscess caused by accidental ingestion of a toothpick. This case suggests that accidental ingestion of a toothpick may also be the cause of GI bleeding in some patients. For patients with unexplained GI bleeding, especially those with small bowel bleeding, a rational and combined use of gastroduodenoscopy, colonoscopy, unenhanced and contrast-enhanced abdominal CT can help detect the causes of GI bleeding and improve diagnostic accuracy.

Diagnosis and management of small-bowel bleeding

Small-bowel (SB) bleeding is a challenging problem for the clinician, presenting many pitfalls in both diagnosis and subsequent treatment. Videocapsule endoscopy (VCE) and device-assisted enteroscopy (DAE) have revolutionized the approach to the patient with SB bleeding, allowing for the endoscopic diagnosis and management of what was previously only a surgical matter. The patients' assessment in SB bleeding is of foremost importance, as treatment success relies on a detailed evaluation of clinical history, suspicion for underlying lesions, and a careful selection and timing of diagnostic and therapeutic tools. This review will summarize current state-of-the-art evidence and practice points, to provide the clinician with a comprehensive guide towards the management of SB bleeding.

Dual-Energy CT Evaluation of Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is a potentially life-threatening condition accounting for more than 300 000 annual hospitalizations. Multidetector abdominopelvic CT angiography is commonly used in the evaluation of patients with GI bleeding. Given that many patients with severe overt GI bleeding are unlikely to tolerate bowel preparation, and inpatient colonoscopy is frequently limited by suboptimal preparation obscuring mucosal visibility, CT angiography is recommended as a first-line diagnostic test in patients with severe hematochezia to localize a source of bleeding. Assessment of these patients with conventional single-energy CT systems typically requires the performance of a noncontrast series followed by imaging during multiple postcontrast phases. Dual-energy CT (DECT) offers several potential advantages for performing these examinations. DECT may eliminate the need for a noncontrast acquisition by allowing the creation of virtual noncontrast (VNC) images from contrast-enhanced data, affording significant radiation dose reduction while maintaining diagnostic accuracy. VNC images can help radiologists to differentiate active bleeding, hyperattenuating enteric contents, hematomas, and enhancing masses. Additional postprocessing techniques such as low-kiloelectron voltage virtual monoenergetic images, iodine maps, and iodine overlay images can increase the conspicuity of contrast material extravasation and improve the visibility of subtle causes of GI bleeding, thereby increasing diagnostic confidence and assisting with problem solving. GI bleeding can also be diagnosed with routine single-phase DECT scans by constructing VNC images and iodine maps. Radiologists should also be aware of the potential pitfalls and limitations of DECT. ^©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Hemosuccus pancreaticus as a rare cause of gastrointestinal bleeding

Hemosuccus pancreaticus is a life-threatening condition that should be considered in patients with abdominal pain, gastrointestinal hemorrhage and high serum amylase. The varied presentation of hemosuccus pancreaticus and the limited literature evidence due to its rarity make it challenging to diagnose. Diagnostic modalities include contrast-enhanced computed tomography scans, endoscopic procedures (esophagoduodenoscopy and endoscopic retrograde cholangiopancreatography) and angiography. Therapeutic management through an interventional radiology using coil embolization is safe and effective in hemodynamically stable patients with hemosuccus pancreaticus. Endosonography can be an innovative approach for the diagnosis and treatment of patients in whom contrast cannot be administered; however, its safety and efficacy need to be confirmed by future studies. This review presents current views on the diagnosis and treatment of patients with hemosuccus pancreaticus.

Curved plannar reconstruction with maximum intensity projection in lower gastrointestinal bleeding

A 51-year-old man was admitted to the hospital with a history of hematochezia for the previous 16 hours. Abdominal computed tomography with contrast enhancement showed only slight punctate and linear high density in the ascending colon. Colonic curved plannar reconstruction with maximum intensity projection showed an accumulation of remarkable high-density material in the ascending colon. A colonoscopy revealed a polypoid eminence lesion with bleeding in the same location, 4 cm in the diameter. The patient underwent endoscopic mucosal resection and was discharged 2 days after surgery.

The Role of Endoscopy in the Diagnosis and Management of Small Bowel Pathology in Children

Small bowel evaluation has been transformed by capsule endoscopy and advances in small bowel imaging, which provide reliable and noninvasive means for assessing the mucosal surface. Device-assisted enteroscopy has been critical for histopathological confirmation and endoscopic therapy for a wide range of small bowel pathology that conventional endoscopy cannot reach. The purpose of this review is to provide a comprehensive overview of the indications, techniques, and clinical applications of capsule endoscopy; device-assisted enteroscopy; and imaging studies for small bowel evaluation in children.

A Review of Colonoscopy in Intestinal Diseases

Since the development of the fiberoptic colonoscope in the late 1960s, colonoscopy has been a useful tool to diagnose and treat various intestinal diseases. This article reviews the clinical use of colonoscopy for various intestinal diseases based on present and future perspectives. Intestinal diseases include infectious diseases, inflammatory bowel disease (IBD), neoplasms, functional bowel disorders, and others. In cases of infectious diseases, colonoscopy is helpful in making the differential diagnosis, revealing endoscopic gross findings, and obtaining the specimens for pathology. Additionally, colonoscopy provides clues for distinguishing between infectious disease and IBD, and aids in the post-treatment monitoring of IBD. Colonoscopy is essential for the diagnosis of neoplasms that are diagnosed through only pathological confirmation. At present, malignant tumors are commonly being treated using endoscopy because of the advancement of endoscopic resection procedures. Moreover, the characteristics of tumors can be described in more detail by image-enhanced endoscopy and magnifying endoscopy. Colonoscopy can be helpful for the endoscopic decompression of colonic volvulus in large bowel obstruction, balloon dilatation as a treatment for benign stricture, and colon stenting as a treatment for malignant obstruction. In the diagnosis of functional bowel disorder, colonoscopy is used to investigate other organic causes of the symptom.

Haematological risk factors predicting clinical success in transarterial embolisation for acute gastrointestinal bleeding

OBJECTIVES

Evaluate clinical outcomes in transarterial embolisation (TAE) for acute gastrointestinal bleeding (GIB) and determine risk factors for 30-day reintervention for rebleeding and mortality.

METHODS

TAE cases were retrospectively reviewed between March 2010 and September 2020 at our tertiary centre. Technical success (angiographic haemostasis following embolisation) was measured. Uni- and multivariate logistic regression analysis were performed to identify risk factors for clinical success (absence of 30-day reintervention or mortality) following embolisation for active GIB or empirical embolisation for suspected bleeding.

RESULTS

TAE was conducted in 139 patients (92 (66.2%) male; median age:73, range: 20-95 years) for acute upper GIB (n = 88) and lower GIB (n = 51). TAE was technically successful in 85/90 (94.4%) and clinically successful in 99/139 (71.2%); with 12 (8.6%) reintervention cases for rebleeding (median interval 2 days) and 31 (22.3%) cases of mortality (median interval 6 days). Reintervention for rebleeding was associated with haemoglobin drop > 40 g l^-1 from baseline based on univariate analysis (p = 0.047). 30-day mortality was associated with pre-intervention platelet count < 150×10⁹ l^-1 (p < 0.001, OR 7.35, 95% CI 3.05-17.71) and INR > 1.4 (p < 0.001, OR 4.75, 95% CI 2.03-11.09) on multivariate logistic regression analysis. No associations were found for patient age, gender, antiplatelet/anticoagulation prior to TAE, or when comparing upper and lower GIB with 30-day mortality.

CONCLUSION

TAE had excellent technical success for GIB with relatively high (1-in-5) 30-day mortality. INR > 1.4 and platelet count < 150×10⁹ l^-1 were individually associated with TAE 30-day mortality, and pre-TAE > 40 g l^-1 haemoglobin decline with rebleeding requiring reintervention.

ADVANCES IN KNOWLEDGE

Recognition and timely reversal of haematological risk factors may improve TAE periprocedural clinical outcomes.

Role of CT angiography and therapeutic anticoagulation in patients presenting to the emergency department with acute gastrointestinal bleeding

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.

Clinical Predictors of a Positive Ct Angiogram Study Used for the Evaluation of Acute Gastrointestinal Hemorrhage

BACKGROUND

Acute gastrointestinal (GI) bleeding is one of the leading causes of emergency department visits and hospital admissions. CT angiography (CTA) has had an expanding role in the evaluation of acute GI bleeding because it is rapidly performed, widely available, reasonably sensitive and provides precise localization when positive. We attempted to identify patient and clinical characteristics that predict CTA results in order to help guide the utilization of this modality in patients with acute GI bleeding.

METHODS

In this retrospective study, we analyzed all CTAs performed for the evaluation of GI bleeding in the Duke University healthcare system between October 2019 and March 2020. We captured patient characteristics including age, sex, vital signs, hemoglobin, platelets, PT/INR, and anticoagulation status. Study indications were grouped by suspected source of bleeding: upper GI bleeding (hematemesis or coffee-ground emesis) vs small bowel bleeding (melena or "dark stools") vs lower GI bleeding (hematochezia or bright red blood per rectum (BRBPR)). Chi-square, Wilcoxon, t test, and multivariate logistic regression were used to describe and assess the relationship between patient characteristics and study outcomes (Table 1). Table 1 Univariate analysis of patient characteristics by CT angiography outcome Patient Characteristics by Positive CT for GI Bleed No (N = 274) Yes (N = 43) Total (N = 317) p value Gender 0.45¹  Female 138 (50.4%) 19 (44.2%) 157 (49.5%)  Male 136 (49.6%) 24 (55.8%) 160 (50.5%) Age, median (Q1,Q3) 65 (51,75) 70 (62,80) 66 (52, 76)  < 0.01² Heart rate, median (Q1,Q3) 86 (74,100) 89 (72,98) 86 (74, 99) 0.78² MAP, mean (SD) 87.32 (15.52) 81.72 (16.53) 86.56 0.03³ Shock index, median (Q1,Q3) 0.70 (0.58, 0.85) 0.78 (0.55, 1.00) 0.71 (0.58, 0.85) 0.35² Hemoglobin 0.33²  N 273 43 316  Median (Q1, Q3) 8.50 (6.90, 11.00) 7.70 (6.50, 11.30) 8.45 (6.90, 11.00) Baseline hemoglobin 0.20²  N 258 39 297  Median (Q1, Q3) 11.20 (9.40, 13.00) 12.00 (9.40, 14.00) 11.20 (9.40, 13.00) Hemoglobin drop from baseline 0.06²  N 258 39 297  Median (Q1, Q3) 2.10 (0.60, 3.70) 2.70 (1.20, 4.80) 2.20 (0.70, 3.80) Platelets, median (Q1, Q3) 219.5 (141, 301) 183 (139, 246) 217 (139, 282) 0.10² INR 0.27²  N 263 42 305  Median (Q1, Q3) 1.10 (1.00, 1.30) 1.20 (1.00, 1.30) 1.10 (1.00, 1.30) Anticoagulation 0.13¹  No 155 (56.6%) 19 (44.2%) 174 (54.9%)  Yes 119 (43.4%) 24 (55.8%) 143 (45.1%) Upper GI bleeding 0.40¹  No 251 (91.6%) 41 (95.3%) 292 (92.1%)  Yes 23 (8.4%) 2 (4.7%) 25 (7.9%) Small Bowel bleeding 0.76¹  No 216 (78.8%) 33 (76.7%) 249 (78.5%)  Yes 58 (21.2%) 10 (23.3%) 68 (21.5%) Lower GI bleeding 0.09¹  No 134 (48.9%) 15 (34.9%) 149 (47.0%)  Yes 140 (51.1%) 28 (65.1%) 168 (53.0%) ¹Chi-Square ²Wilcoxon ³Equal Variance T-Test RESULTS: A total of 317 patients underwent CTA between October 2019 and March 2020. Forty-three patients (13.6%) had a CTA positive for active bleeding. Multivariable logistic regression showed that after controlling for age, mean arterial pressure (MAP) and indication, only a hemoglobin drop from baseline was significantly associated with a positive CTA. For each 1 g / dL drop in hemoglobin from the patient's baseline, the odds of a positive CT increased by 1.17 (OR 1.17 95% CI 1.00 - 1.36, p = 0.04). Age (OR 1.02 95% CI 0.99 - 1.04, p = 0.06) and hematochezia / BRBPR (OR 2.09 95% CI 0.94-4.64, p = 0.07) approached statistical significance.

CONCLUSIONS

In patients who present to the hospital with GI bleeding, CTA can be a helpful triage tool that is most helpful in older patients with suspected lower GI bleeding with a drop in hemoglobin from baseline. Other clinical factors including MAP and the use of anticoagulants were not predictive of a positive CTA.

The Role of CT-Angiography in the Acute Gastrointestinal Bleeding: A Pictorial Essay of Active and Obscure Findings

Gastrointestinal bleeding is a potentially life-threatening abdominal emergency that remains a common cause of hospitalisation. Although 80–85% of cases of gastrointestinal bleeding resolve spontaneously, it can result in massive haemorrhage and death. The presentation of gastrointestinal bleeding can range from asymptomatic or mildly ill patients requiring only conservative treatments to severely ill patients requiring immediate intervention. Identifying the source of the bleeding can be difficult due to the wide range of potential causes, the length of the gastrointestinal tract and the intermittent nature of the bleeding. The diagnostic and therapeutic approach is fully dependent on the nature of the bleeding and the patient’s haemodynamic status. Radiologists should be aware of the appropriate uses of computed tomography angiography and other imaging modalities in patients with acute gastrointestinal bleeding, as well as the semiotics of bleeding and diagnostic pitfalls in order to appropriately diagnose and manage these patients. The learning objective of this review is to illustrate the computed tomography angiography technique, including the potential role of dual-energy computed tomography angiography, also highlighting the tips and tricks to identify the most common and uncommon features of acute gastrointestinal bleeding and its obscure form.

Immediate coiling of a gastroduodenal arterial bleeding in a case of haemorrhagic shock without haematemesis, a case report

Introduction

and importance: Upper gastrointestinal (GI) bleeding is common in the clinic. In combination with haemorrhagic shock, morbidity is high. Rapid diagnosis and treatment can save lives. With the introduction of precision imaging several treatment options are feasible. Up-to-date diagnosis and treatment requires expertise from interventional radiology, gastroenterology and surgery to form a dedicated intervention team. This is illustrated by a typical case.

Case presentation

We report a 78-year-old otherwise healthy male with a severe diverticulum bleeding. He was initially diagnosed with acute pancreatitis. Approximately 60 minutes after CT scanning, he became haemodynamically instable. He also vomited coffee-like fluid but no clear blood or clots. A repeated CT scan showed active bleeding in the retroperitoneal space highly suspicious for a diverticular bleeding just outside the lumen of the duodenum. An acute multidisciplinary intervention team immediately decided not to perform endoscopy (according to the upper GI bleeding guidelines) but to extend the imaging procedure with digital subtraction angiography (DSA). By this time, active bleeding from a side branch of the gastroduodenal artery was noted and successfully coiled.

Clinical discussion

Guidelines determine day-to-day management in clinical medicine. Still, there is an exception to every rule. The case presented here was typical of upper GI bleeding with haemodynamic instability and signs of shock, but without haematemesis. This combination indicated a bleeding from somewhere outside the lumen of the GI tract. Instead of endoscopy, the acute intervention team decided to perform CT angiography (CTa) with subsequent DSA. On imaging, the bleeding focus was immediately identified and treated by coiling.

Conclusion

Performance of CTa immediately followed by DSA and no endoscopy was decided by an acute intervention team in a patient with upper GI bleeding and haemorrhagic shock. Swift coiling of the bleeding artery outside the GI tract lumen was successful. The team in charge relied on a hybrid multifunctional unit fully equipped to perform interventional radiologic as well as GI procedures.

•

Direct computed tomography angiography could be an option in case the patient vomits no pure blood.

•

Multidisciplinary revaluation is essential in an unstable patient with an upper GI bleeding until the situation is stabilized.

•

The role of coiling is growing, with this important technic a laparotomy could be avoid.

Association of inferior vena cava diameter ratio with outcomes in patients with gastrointestinal bleeding

Objective

To examine the association of inferior vena cava (IVC) diameter ratio measured using computed tomography with outcomes in patients with gastrointestinal bleeding (GIB).

Methods

A single-center retrospective observational study was conducted on consecutive patients with GIB who presented to the emergency department. The IVC diameter ratio was calculated by dividing the maximum transverse and anteroposterior diameters perpendicular to it. The association of the IVC diameter ratio with outcomes was examined using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. The area under the receiver operator characteristic curve (AUC) of the IVC diameter ratio was calculated, and the sensitivity and specificity, including the cutoff values, were computed.

Results

In total, 585 patients were included in the final analysis. The in-hospital mortality rate was 4.6% (n=27). The IVC diameter ratio was significantly associated with higher in-hospital mortality in multivariable logistic regression analysis (odds ratio, 1.793; 95% confidence interval [CI], 1.239–2.597; P=0.002). The AUC of the IVC diameter ratio for in-hospital mortality was 0.616 (95% CI, 0.498–0.735). With a cutoff of the IVC diameter ratio (≥2.1), the sensitivity and specificity for predicting in-hospital mortality were 44% (95% CI, 26%–65%) and 71% (95% CI, 67%–75%), respectively.

Conclusion

The IVC diameter ratio was independently associated with in-hospital mortality in patients with GIB. However, the AUC of the IVC diameter ratio for in-hospital mortality was low.

Imaging findings of spontaneous intraabdominal hemorrhage: neoplastic and non-neoplastic causes

Contrary to traumatic and iatrogenic intraabdominal hemorrhages, spontaneous intraabdominal hemorrhage is a challenging clinical situation. A variety of neoplastic and non-neoplastic conditions may cause spontaneous intraabdominal bleeding. Imaging findings vary depending on the source of bleeding and the underlying cause. In this article, we aim to increase the awareness of imagers to the most common causes of spontaneous intraabdominal hemorrhage by using representative cases.

Patient radiation dose during angiography and embolization for abdominal hemorrhage: the influence of CT angiography, fluoroscopy system, patient and procedural variables

Background

Angiography and embolization (AE) is a lifesaving, high radiation dose procedure for treatment of abdominal arterial hemorrhage (AAH). Interventional radiologists have utilized pre-procedure CT angiography (CTA) and newer fluoroscopic systems in an attempt to reduce radiation dose and procedure time.

Purpose

To study the factors contributing to the radiation dose of AE for AAH and to compare to the reference standard.

Materials and methods

This retrospective single-centre observational cohort study identified 154 consecutive AE procedures in 138 patients (median age 65 years; interquartile range 54–77; 103 men) performed with a C-arm fluoroscopic system (Axiom Artis DTA or Axiom Artis Q (Siemens Healthineers)), between January 2010 and December 2017. Parameters analysed included: demographics, fluoroscopy system, bleeding location, body mass index (BMI), preprocedural CT, air kerma-area product (PKA), reference air kerma (K_a,r), fluoroscopy time (FT) and the number of digital subtraction angiography (DSA) runs. Factors affecting dose were assessed using Mann–Whitney U, Kruskal–Wallis one-way ANOVA and linear regression.

Results

Patients treated with the new angiographic system (NS) had a median PKA, median K_a,r, Q3 PKA and Q3 K_a,r that were 74% (p < 0.0005), 66%(p < 0.0005), 55% and 52% lower respectively than those treated with the old system (OS). This dose reduction was consistent for each bleeding location (upper GI, Lower GI and extraluminal). There was no difference in PKA (p = 0.452), K_a,r (p = 0.974) or FT (p = 0.179), between those who did (n = 137) or did not (n = 17) undergo pre-procedure CTA. Other factors significantly influencing radiation dose were: patient BMI and number of DSA runs. A multivariate model containing these variables accounts for 15.2% of the variance in K_a,r (p < 0.005) and 45.9% of the variance of PKA (p < 0.005).

Conclusion

Radiation dose for AE in AAH is significantly reduced by new fluoroscopic technology. Higher patient body mass index is an independent key parameter affecting patient dose. Radiation dose was not influenced by haemorrhage site or performance of pre-procedure CTA.

Value of multiphase computed tomography for gastrointestinal bleeding before endovascular treatment in hemodynamically unstable patients

BACKGROUND

There has been no practice-based study regarding the multiphase computed tomography (CT) before endovascular treatment in hemodynamically unstable gastrointestinal bleeding (GIB) and concerns exist regarding the time delay.

PURPOSE

To evaluate the clinical efficacy of multiphase CT before endovascular treatment in hemodynamically unstable GIB and to investigate the predictors of angiographic localization and recurrent bleeding.

MATERIAL AND METHODS

The multicenter retrospective study included 93 consecutive hemodynamically unstable patients who underwent conventional angiography for non-variceal GIB after failed endoscopic localization. Enrolled patients were divided into a CT group (n = 61) and a non-CT group (n = 32).

RESULTS

The clinical characteristics did not differ between the two groups except for the time to angiography (CT group, 14.8±15.1 h; non-CT group, 9.2±11.7 h, P = 0.022). The rate of angiographic localization was significantly higher in the CT group than in the non-CT group only for lower GIB (P = 0.049). Indirect sign was significantly more frequent in the CT group than in the non-CT group (P = 0.014). CT localization was positive predictor (odd ratio [OR] = 7.66; 95% confidence interval [CI] = 2.1-27.94; P = 0.002) and prolonged time to angiography was negative predictor (OR = 0.94; 95% CI = 0.9- 0.98; P = 0.001) for angiographic localization. A higher systolic blood pressure until index angiography (OR = 0.95; 95% CI = 0.91-1; P = 0.044) was associated with a reduced risk of recurrent bleeding.

CONCLUSION

In hemodynamically unstable patients, multiphase CT is particularly useful for angiographic localization of lower GIB. It should be considered immediately after failed endoscopic hemostasis to reduce time to angiography.

Hemosuccus Pancreaticus: A Comprehensive Review of Presentation Patterns, Diagnostic Approaches, Therapeutic Strategies, and Clinical Outcomes

Hemosuccus pancreaticus is a rare but potentially torrential and life-threatening cause of acute upper gastrointestinal bleeding. It is described as an intermittent hemorrhage from the major duodenal papilla via the main pancreatic duct. Peripancreatic pseudoaneurysm following chronic pancreatitis is a common underlying etiology. However, gastroduodenal artery pseudoaneurysm-related hemosuccus pancreaticus remains exceedingly rare in the etiological spectrum of upper gastrointestinal bleeding. We hereby delineate a rare case of hemosuccus pancreaticus associated with gastroduodenal artery pseudoaneurysm in a patient who initially presented with abdominal pain and hematochezia. He was successfully managed with coil embolization without recurrence or sequelae. Furthermore, we conducted a search of the MEDLINE (PubMed and Ovid) database for relevant studies on hemosuccus pancreaticus published between inception and September 15, 2021. The available clinical evidence on causes, presentation patterns, diagnosis, and management was analyzed and summarized. This article highlights the rarity, the intermittent nature of hemorrhage, and the lack of a standardized diagnostic approach for this elusive disease. Clinicians should remain cognizant of hemosuccus pancreaticus, especially in patients presenting with symptoms and signs of intermittent gastrointestinal bleeding and abdominal pain. Prompt diagnosis carries paramount importance in saving patients from repeat hospital admissions and disease-associated morbidity and mortality. Conventional angiography with coil embolization may constitute an effective treatment strategy.

Gastrointestinal bleeding after failed endoscopic hemostasis: diagnostic efficacy of angiography compared with computed tomography and treatment outcomes of transcatheter arterial embolization

PURPOSE

This study compared the detection sensitivity of catheter angiography to that of contrast-enhanced multi-detector computed tomography (MDCT) for detecting acute non-variceal gastrointestinal bleeding (GIB) to elucidate the diagnostic efficacy of catheter angiography. We also determined GIB outcomes of transcatheter arterial embolization after failed endoscopic hemostasis.

MATERIALS AND METHODS

Data were collected retrospectively from 63 patients managed at four institutions who met the following criteria during a 3-year period: (1) ongoing non-variceal GIB confirmed during endoscopy; (2) failed endoscopic hemostasis; and (3) endoscopy, MDCT, and catheter angiography performed within 24 h. The diagnostic efficacies of MDCT, selective angiography with a 5-Fr catheter (5Fr-angiography), and super-selective angiography with a microcatheter (micro-angiography) were compared using endoscopic diagnosis as the reference method. The rates of technical success, clinical success, and complications were analyzed when arterial embolization was performed.

RESULTS

All transcatheter angiographies were performed after MDCT. Micro-angiography had a significantly higher GIB detection rate (73.0%) than MDCT (57.1%) and 5Fr-angiography (39.7%) (micro-angiography vs. MDCT, P = 0.021; MDCT vs. 5Fr-angiography, P = 0.043). Arterial embolization was attempted in 55 of 63 patients, with technical success achieved in 53 of 55 patients (96.4%) and clinical success in 38 of 42 patients (90.5%). Eleven patients were lost to follow-up. Three patients experienced complications, including bowel infarction (two patients) and common bile duct stricture (one patient).

CONCLUSION

In cases of endoscopic hemostasis failure, angiography can be performed even if MDCT yields negative results but should include micro-angiography; moreover, embolization can be performed safely and effectively.

TRIAL REGISTRATION

None.

Nursing Value Analysis and Risk Assessment of Acute Gastrointestinal Bleeding Using Multiagent Reinforcement Learning Algorithm

Gastrointestinal bleeding (GIB) indicates an issue in the digestive system. Blood can be found in feces or vomiting; however, it is not always visible, even if it makes the stool appear darkish or muddy. The bleeding can range in harshness from light to severe and can be dangerous. It is advised that nursing value analysis and risk assessment of patients with GIB is essential, but existing risk assessment techniques function inconsistently. Machine learning (ML) has the potential to increase risk evaluation. For evaluating risk in patients with GIB, scoring techniques are ineffective; a machine learning method would help. As a result, we present а unique machine learning-based nursing value analysis and risk assessment framework in this research to construct a model to evaluate the risk of hospital-based interventions or mortality in individuals with GIB and make a comparison to that of other rating systems. Initially, the dataset is collected, and preprocessing is done. Feature extraction is done using local binary patterns (LBP). Classification is performed using a fuzzy support vector machine (FSVM) classifier. For risk assessment and nursing value analysis, machine learning-based prediction using a multiagent reinforcement algorithm is employed. For improving the performance of the proposed system, we use spider monkey optimization (SMO) algorithm. The performance metrics like classification accuracy, area under the receiver-operating characteristic curve (AUROC), area under the curve (AUC), sensitivity, specificity, and precision are analyzed and compared with the traditional approaches. In individuals with GIB, the suggested technique had a good-excellent prognostic efficacy, and it outperformed other traditional models.

Multidetector computed tomography: a corner stone imaging modality in evaluation of acute small bowel diseases

Background

The diagnosis of acute small bowel diseases is one of the challenging issues that confronted by the radiologists so accurate diagnosis is essential to determine the appropriate way of management. CT has become the preferred imaging tool to evaluate acute small bowel diseases. Our study aimed to assess the role of MDCT in evaluation of acute abdomen secondary to small bowel origin by identification and differentiation between different acute small bowel pathologies.

Results

Thirty-eight patients presented with acute abdomen of small bowel origin from June 2019 to September 2019. The mean age of incidence was 48 ± 19 years ranged from 4 to 88 years. Males represented by 23 patients (60.5%). Acute exacerbation of inflammatory bowel diseases (Crohn’s disease) represented by (34.2%), small bowel obstruction (31.6%), ischemic bowel diseases (21.1%), small bowel perforation (10.5%) and infectious (TB enteritis) small bowel disease (2.6%). MDCT had an overall high sensitivity (97.3%) in assessment of acute small bowel diseases in correlation with post-operative data and follow-up response to management.

Conclusions

MDCT is a reliable diagnostic imaging tool for assessment of patients with acute abdomen secondary to small bowel origin with high-efficiency in differentiation between different pathological entities that causing acute abdomen.

Review of COVID-19, part 1: Abdominal manifestations in adults and multisystem inflammatory syndrome in children

The coronavirus disease 2019 (COVID -19) pandemic caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) has affected almost every country in the world, resulting in severe morbidity, mortality and economic hardship, and altering the landscape of healthcare forever. Although primarily a pulmonary illness, it can affect multiple organ systems throughout the body, sometimes with devastating complications and long-term sequelae. As we move into the second year of this pandemic, a better understanding of the pathophysiology of the virus and the varied imaging findings of COVID-19 in the involved organs is crucial to better manage this complex multi-organ disease and to help improve overall survival. This manuscript provides a comprehensive overview of the pathophysiology of the virus along with a detailed and systematic imaging review of the extra-thoracic manifestation of COVID-19 with the exception of unique cardiothoracic features associated with multisystem inflammatory syndrome in children (MIS-C). In Part I, extra-thoracic manifestations of COVID-19 in the abdomen in adults and features of MIS-C will be reviewed. In Part II, manifestations of COVID-19 in the musculoskeletal, central nervous and vascular systems will be reviewed.

Hemoperitoneum From Bleeding Intra-Abdominal Varices: A Rare, Life-Threatening Cause of Abdominal Pain in a Patient With Cirrhosis

We report the case of a 54-year-old male with alcoholic cirrhosis who presented several times to the emergency department (ED) with right upper quadrant abdominal pain. Ten days after his initial presentation, the patient represented with hypotension and anemia. An abdominal CT angiogram identified hemorrhage from an ectopic varix successfully treated with emergent glue embolization of mesenteric, omental, and periumbilical varices. Intraperitoneal bleeding from ectopic varices in cirrhosis patients is a rare, life-threatening condition. Consideration and recognition of ectopic variceal hemorrhage in patients with cirrhosis can facilitate prompt life-saving treatment in a population susceptible to significant morbidity and mortality.

Analysis of the Effect of Intelligent Red Blood Cell Distribution Diagnosis Model on the Diagnosis and Treatment of Gastrointestinal Bleeding

In order to explore the role of red blood cell distribution width in the diagnosis and treatment of gastrointestinal bleeding, this paper applies map feature recognition technology to red blood cell distribution broadband and constructs an intelligent red blood cell distribution width diagnosis model. To extract the content-level features of the image safely and effectively, this paper introduces the mechanism of jitter quantization to extract the content-level features at the lowest frequency of the image. In addition, this article employs an experimental approach to investigate the function of red blood cell distribution width in the diagnosis and management of gastrointestinal bleeding in the elderly. Finally, this article establishes an experimental group and a control group and then performs a research study using real-life hospital case studies. According to the statistical findings, the red blood cell distribution width index may play a significant role in the diagnosis and management of gastrointestinal bleeding, particularly in the case of severe bleeding.

Contrast extravasation on computed tomography angiography in patients with hematochezia or melena: Predictive factors and associated outcomes

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.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ^©RSNA, 2021.