Helical CT angiography in gastrointestinal bleeding of obscure origin

Usefulness of contrast-enhanced multi-detector computed tomography in identifying upper gastrointestinal bleeding: A retrospective study of patients admitted to the emergency department

Upper gastrointestinal bleeding (UGIB) is a major cause of clinical deterioration worldwide. A large number of patients with UGIB cannot be diagnosed through endoscopy, which is normally the diagnostic method of choice. Therefore, this study aimed to investigate the diagnostic value of multi-detector computed tomography (MDCT) for patients with suspected UGIB. In this retrospective observational study of 386 patients, we compared contrast-enhanced abdominopelvic MDCT to endoscopy to analyze the performance of MDCT in identifying the status, location of origin, and etiology of UGIB. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were examined. In the assessment of bleeding status, MDCT was able to accurately identify 32.9% (21.9–43.9, 95% confidence interval [CI]) of patients with active bleeding, 27.4% (18.9–35.9, 95% CI) of patients with recent bleeding, and 94.8% (91.8–97.8, 95% CI) of patients without bleeding evidence (P<0.001). MDCT showed an accuracy of 60.9%, 60.6%, and 50.9% in identifying bleeding in the esophagus, stomach, and duodenum, respectively (P = 0.4028). The accuracy in differentiating ulcerative, cancerous, and variceal bleeding was 58.3%, 65.9%, and 56.6%, respectively (P = 0.6193). MDCT has limited use as a supportive screening method to identify the presence of gastrointestinal bleeding.

Combined Use of Computed Tomography Enterography/Enteroclysis and Capsule Endoscopy Improves the Accuracy of Diagnosis of Small Bowel Bleeding

Objective CT enterography/enteroclysis (CTE) is listed in the clinical practice guidelines as a method for diagnosing small bowel bleeding, as is capsule endoscopy (CE), but there are no real-world data yet available on CTE in Japan. This study aimed to investigate the diagnostic ability of CTE and long-term prognosis after CTE in Japan. Patients We conducted a retrospective cohort study of patients suspected of having small bowel bleeding who underwent both CTE and CE within 30 days between April 2008 and March 2019. The number of patients free from rebleeding for up to 24 months was thus determined. Results Seventy-one patients were extracted from the database. The 43 patients (60.6%) with a definite and suspicious source of bleeding in the small bowel were detected by CTE. When the 31 patients with a definite source of bleeding in the small bowel were analyzed, the sensitivity of CTE was 19/31 (61.3%) and that of CE was 24/31 (77.4%), thus indicating no significant difference (p=0.332). However, the sensitivity when CTE and CE were used in combination was 30/31 (96.8%), which was significantly higher than that of CE alone (p=0.0412). No rebleeding was observed in the CTE and CE negative group (p=0.0965). Conclusion The combined use of CTE and CE increased the detection rate of small bowel bleeding. Therefore, in patients with suspected tumor/polyp lesions, not only CE, but also CTE should be performed. This study provides the first real-world data on the diagnostic accuracy of CTE for small bowel bleeding in Japan.

Unusual bleeding from hepaticojejunostomy controlled by side-to-side splenorenal shunt: A case report

RATIONALE

Ectopic variceal bleeding due to hepaticojejunostomy (HJ) is unusual and difficult to manage. Reports on the use of side-to-side splenorenal shunt for severe bleeding from varices at HJ anastomosis are lacking.

PATIENT CONCERNS

A 43-year-old man was admitted to our hospital with repeated episodes of hematemesis. He has a history of right hemihepatectomy with HJ reconstruction to the left hepatic duct for hilar cholangiocarcinoma. Two years after surgery, he presented with repeated episodes of hematemesis and underwent blood transfusion.

DIAGNOSES

Imaging tests and endoscopic investigation failed to identify the bleeding source. When conservative management failed to control his bleeding, he underwent emergency laparotomy, which revealed hemorrhage from ectopic varices at the HJ anastomosis.

INTERVENTIONS

To arrest the bleeding, a side-to-side venovenal anastomosis was created between the splenic and left renal veins to form a shunt for decompression of the varices at the HJ anastomosis.

OUTCOMES

After the surgery, the patient's symptoms ceased, and a no bleeding in the digestive tract was noted at 2-year follow-up.

LESSONS

The present patient is the first reported case of unusual bleeding from HJ controlled by a side-to-side splenorenal shunt. We believe this approach is a useful and effective surgical treatment for severe bleeding from varices at the HJ anastomosis.

Intraoperative Enteroscopy: Is There Still a Role?

Intraoperative enteroscopy (IOE) to explore obscure gastrointestinal bleeding is now rarely indicated. IOE allows complete small bowel exploration in 57% to 100% of cases, finds a bleeding source in 80% of cases, allows the recurrence-free management of gastrointestinal bleeding in 76% of cases, but carries a high morbidity and mortality. IOE only remains indicated to guide the intraoperative treatment of preoperatively identified small bowel lesions when nonoperative treatments are unavailable and/or when intraoperative localization by external examination is impossible.

Optimal Diagnostic Approaches for Patients with Suspected Small Bowel Disease

While the domain of gastrointestinal endoscopy has made great strides over the last several decades, endoscopic assessment of the small bowel continues to be challenging. Recently, with the development of new technology including video capsule endoscopy, device-assisted enteroscopy, and computed tomography/magnetic resonance enterography, a more thorough investigation of the small bowel is possible. In this article, we review the systematic approach for patients with suspected small bowel disease based on these advanced endoscopic and imaging systems.

Prospective evaluation of contrast-enhanced computed tomography for the detection of colonic diverticular bleeding

BACKGROUND AND AIMS

To prospectively evaluate the role of contrast-enhanced computed tomography (CE-CT) in the detection of colonic diverticular bleeding (CDB).

PATIENTS AND METHODS

Consecutive patients who presented with hematochezia and were clinically suspected of CDB were prospectively enrolled. Those who could undergo both CE-CT and total colonoscopy, and who were finally diagnosed as CDB, were included in the analysis.

RESULTS

Fifty-two cases were finally included in the analysis. The detection rate of CDB by CT was 15.4 % (8/52). Univariate analysis showed that the interval from the latest episode of hematochezia to the performance of CT and the presence of a past history of CDB were contributing factors for detection. The interval was 1.6 ± 4.6 h (mean ± SD) in patients detected by CT, and 3.4 ± 3.2 h in those without detection. The detection rate of CDB by total colonoscopy was 38.5 % (20/52). The overall detection rate was 46.2 % (24/52), which was superior to what CT or colonoscopy alone achieved.

CONCLUSIONS

CE-CT may play a complementary role to colonoscopy in patients with suspected CDB, but is not recommended for all cases due to its low detection rate. Patients who can be examined within 2 h of last hematochezia would be candidates for urgent CT.

Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding has long been a diagnostic challenge because of the relative inaccessibility of small bowel to standard endoscopic evaluation. Intraoperative enteroscopy indications have been reduced by the development of deep enteroscopy techniques and video capsule endoscopy. In light of the current advances, this review aimed at evaluating the intraoperative enteroscopy technical aspects, study results and an ongoing role for intraoperative enteroscopy in obscure gastrointestinal bleeding management. Intraoperative enteroscopy allows complete small bowel exploration in 57-100% of cases. A bleeding source can be identified in 80% of cases. Main causes are vascular lesions (61%) and benign ulcers (19%). When a lesion is found, intraoperative enteroscopy allows successful and recurrence-free management of gastrointestinal bleeding in 76% of cases. The reported mortality is 5% and morbidity is 17%. The recurrence of bleeding is observed in 13-52% of cases. With the recent development of deep enteroscopy techniques, intraoperative enteroscopy remains indicated when small bowel lesions (i) have been identified by a preoperative work-up, (ii) cannot be definitively managed by angiographic embolization, endoscopic treatment or when surgery is required and (iii) cannot be localized by external examination during surgical explorations. Surgeons and endoscopists must exercise caution with intraoperative enteroscopy to avoid the use of a low yield, highly morbid procedure.

The American Society for Gastrointestinal Endoscopy (ASGE) diagnostic algorithm for obscure gastrointestinal bleeding: eight burning questions from everyday clinical practice

The diagnosis and management of patients with obscure gastrointestinal bleeding are often long and challenging processes. Over the last 10 years the introduction in clinical practice of new diagnostic and therapeutic procedures (i.e. Capsule Endoscopy, Computed Tomographic Enterography, Magnetic Resonance Enterography, and Device Assisted Enteroscopy) has revolutionized the diagnostic/therapeutic work-up of these patients. Based on evidence published in the last 10 years, international scientific societies have proposed new practice guidelines for the management of obscure gastrointestinal bleeding, which include these techniques. However, although these algorithms (the most recent ones are endorsed by the American Society for Gastrointestinal Endoscopy - ASGE) allow the management of the large majority of patients, some issues still remain unsolved. The present paper reports the results of the discussion, based on the literature published up to September 2011, among a panel of experts and gastroenterologists, working with Capsule Endoscopy and with Device Assisted Enteroscopy, attending the 6th annual meeting of the Italian Club for Capsule Endoscopy and Enteroscopy. Eight unresolved issues were selected: each of them is presented as a "Burning question" and the "Answer" is the strategy proposed to manage it, according to both the available evidence and the discussion among participants.

CT enterography in obscure gastrointestinal bleeding: a systematic review and meta-analysis

The objective of this article is to provide a comprehensive and update overview of clinical application of CT enterography (CTE) in the evaluation of obscure gastrointestinal bleeding (OGIB). We performed a systematic review of relevant literatures in PubMed, EMBASE and The Cochrane Library and pooled the yield of CTE and the incremental yield (IY) of CTE over an alternate modality. A total of 18 studies (n = 660) reported the yield of CTE in evaluating OGIB and the pooled yield was 40% (95% confidence interval (CI): 33-49%). Seven studies (n = 279) compared the yield of CTE with capsule endoscopy (CE). The yield for CTE and CE for all findings was 34% and 53%, respectively (IY = -19%, 95% CI = -34% to -4%). When considering the types of identified lesions, the yield was significantly different for vascular and inflammatory lesions but not significantly different for neoplastic or other lesions. Two studies (n = 63) compared the yield of CTE with double-balloon enteroscopy (DBE). The yield for CTE and DBE was 38% and 78%, respectively (IY = -40%, 95% CI = -55% to -25%). Three studies (n = 49) compared the yield of CTE with digital subtraction angiography. The yield for CTE and digital subtraction angiography was 64% and 60%, respectively (IY = 4%, 95% CI = -40% to 47%). CTE is an excellent diagnostic tool in patients with OGIB. It may play a complementary role to CE and can be used as a triage tool prior to DBE in evaluating OGIB.

Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis

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.

Small bowel endoscopy: cost-effectiveness of the different approaches

Obscure gastrointestinal haemorrhage is defined the presence of overt or occult bleeding in the setting of a normal endoscopic examination of the upper and lower gastrointestinal tracts. While obscure bleeding is not common, the evaluation and management of these patients often incurs considerable expense. Potential options for small bowel evaluation include traditional radiographic studies, push enteroscopy, video capsule endoscopy, deep enteroscopy, tagged red blood cell scans, angiography, and enterography examinations with either computed tomography and/or magnetic resonance imaging. The decision regarding which modality to employ depends on the cost of the procedure, its effectiveness in rendering a diagnosis, and the potential for administration of therapy. This article will discuss determination of costs associated with technology for small bowel imaging, quality of life data associated with chronic GI haemorrhage, and available cost-effectiveness studies comparing the options for small bowel exploration.

Diagnostic yield of dual-phase computed tomography enterography in patients with obscure gastrointestinal bleeding and a non-diagnostic capsule endoscopy

BACKGROUND AND AIM

In patients with obscure gastrointestinal (GI) bleeding, capsule endoscopy is widely used to determine the source of bleeding. However, there is currently no consensus on how to further evaluate patients with obscure GI bleeding with a non-diagnostic capsule endoscopy examination. This study aims to determine the diagnostic yield of dual-phase computed tomographic enterography (CTE) in patients with obscure GI bleeding and a non-diagnostic capsule endoscopy.

METHODS

Patients with obscure GI bleeding who were referred for capsule endoscopy were prospectively enrolled. Obscure GI bleeding was defined as overt if there was obvious GI bleeding; otherwise it was defined as occult. Patients with a non-diagnostic capsule endoscopy and no contraindications underwent a CTE.

RESULTS

Capsule endoscopy was performed in 52 patients; 26 patients (50%) had occult GI bleeding and 26 patients (50%) had overt GI bleeding. CTE was then performed in 25 of the 48 patients without a definitive source of bleeding seen on capsule endoscopy. The diagnostic yield of CTE was 0% (0/11) in patients with occult bleeding versus 50% (7/14) in patients with overt bleeding (P < 0.01). Using clinical follow up as the gold standard, for the 25 patients with a non-diagnostic capsule, CTE had a sensitivity of 33% (95% confidence interval 0.15, 0.56) and a specificity of 75% (95% confidence interval 0.22, 0.99).

CONCLUSIONS

In patients with a non-diagnostic capsule endoscopy examination, CTE is useful for detecting a source of GI bleeding in patients with overt, but not occult, obscure GI bleeding.

[Gastrointestinal bleeding: the role of radiology]

Gastrointestinal bleeding represents a diagnostic challenge both in its acute presentation, which requires the point of bleeding to be located quickly, and in its chronic presentation, which requires repeated examinations to determine its etiology. Although the diagnosis and treatment of gastrointestinal bleeding is based on endoscopic examinations, radiological studies like computed tomography (CT) angiography for acute bleeding or CT enterography for chronic bleeding are becoming more and more common in clinical practice, even though they have not yet been included in the clinical guidelines for gastrointestinal bleeding. CT can replace angiography as the diagnostic test of choice in acute massive gastrointestinal bleeding, and CT can complement the endoscopic capsule and scintigraphy in chronic or recurrent bleeding suspected to originate in the small bowel. Angiography is currently used to complement endoscopy for the treatment of gastrointestinal bleeding.

Detection of intestinal bleeding with multi-detector row CT in an experimental setup. How many acquisitions are necessary?

The purpose of the study was to evaluate multi-detector computed tomography (MDCT) acquired in different acquisitions (unenhanced, and arterial and portal venous phase following intravenous contrast medium) for detection of intestinal bleeding using an experimental bowel model. The model consisted of an injector tube with a perforation placed in a 7-m-long small bowel of a pig. The bowel was filled with water/contrast medium solution of 30–40 HU and was incorporated in a phantom model. Intestinal bleeding in different locations and bleeding velocities varying from zero to 0.75 ml/min (0.05 ml/min increments) were simulated. Twenty-six datasets in simulated unenhanced, arterial and portal venous contrast phase using increasing bleeding velocities and ten negative controls were measured using 64-row MDCT. Two radiologists blinded to the experimental settings evaluated the datasets in a random order. The likelihood of intestinal bleeding was assessed using a 5-point scale with subsequent ROC analysis. The overall sensitivity for detecting bleeding was 0.44 for an arterial acquisition alone, 0.68 for a portal venous acquisition, 0.68 for the combination unenhanced/arterial, 0.72 for unenhanced/portal venous and 0.80 for arterial/portal. Bleeding velocities of above 0.25 ml/min were detected with a sensitivity of 0.59 for arterial, 0.88 for portal venous, 0.85 for unenhanced/arterial, 0.94 for unenhanced/portal venous and 0.97 for arterial/portal venous contrast phase protocols, respectively. The specificity was 1.00. MDCT provides the highest sensitivity and specificity in the detection of intestinal bleeding using arterial and portal venous acquisition in comparison to mono-phase protocols.

Prospective blinded comparison of wireless capsule endoscopy and multiphase CT enterography in obscure gastrointestinal bleeding

PURPOSE

To compare the performance of multiphase computed tomographic (CT) enterography with that of capsule endoscopy in a group of patients with obscure gastrointestinal bleeding (OGIB).

MATERIALS AND METHODS

This prospective HIPAA-compliant study was approved by the institutional review board and the institutional conflict of interest committee. All patients provided written informed consent. Two radiologists, blinded to clinical data and results of capsule endoscopy, interpreted images from CT enterography independently, with discordant interpretations resolved by consensus. Results were compared with those from a reference standard (surgery or endoscopy) and clinical follow-up. Sensitivity and 95% confidence intervals were calculated for each modality.

RESULTS

Fifty-eight adult patients, referred for the evaluation of OGIB (occult, 25 patients [43%]; overt, 33 patients [57%]), underwent both tests. A small bowel bleeding source was identified in 16 of the 58 patients (28%). The sensitivity of CT enterography was significantly greater than that of capsule endoscopy (88% [14 of 16 patients] vs 38% [six of 16 patients], respectively; P = .008), largely because it depicted more small bowel masses (100% [nine of nine patients] vs 33% [three of nine patients], respectively; P = .03). No additional small bowel tumors were discovered during the follow-up period (range, 5.6-45.9 months; mean, 16.6 months).

CONCLUSION

In this referral population, the sensitivity of CT enterography for detecting small bowel bleeding sources and small bowel masses was significantly greater than that of capsule endoscopy. On the basis of these findings, the addition of multiphase CT enterography to the routine diagnostic work-up of patients with OGIB should be considered, particularly in patients with negative findings at capsule endoscopy.

Obscure gastrointestinal bleeding: diagnostic performance of multidetector CT enterography

PURPOSE

To evaluate the diagnostic performance of computed tomographic (CT) enterography in identifying the source of obscure gastrointestinal bleeding and to determine clinical features associated with a higher diagnostic yield of CT enterography.

MATERIALS AND METHODS

The institutional review board approved this study, with waiver of informed consent. CT enterographic images in 65 patients (46 men [mean age, 54 years; range, 18-85 years] and 19 women [mean age, 62.1 years; range, 33-79 years]) who presented with obscure gastrointestinal bleeding between August 2005 and July 2007 were reviewed retrospectively and independently by two radiologists. The diagnostic performance of CT enterography was assessed by using the results of endoscopic and other imaging examinations, surgery, and clinical follow-up as the reference standard. Differences in the diagnostic yield of CT enterography according to patient demographic and clinical features, including age, sex, type and episode of bleeding (occult, initial overt, and recurrent overt), occurrence of recent bleeding, and history of massive bleeding, were evaluated by using univariate and multivariate logistic regression analyses.

RESULTS

CT enterography helped identify the source of obscure gastrointestinal bleeding in 16 (24.6%) of 65 patients. The sensitivity, specificity, positive predictive value, and negative predictive value of CT enterography were 55.2% (16 of 29), 100% (32 of 32), 100% (16 of 16), and 71.1% (32 of 45), respectively. Among patients' clinical features, a history of massive bleeding (diagnostic yield, 58.3% [seven of 12]; adjusted odds ratio, 7.2; P = .01) was independently associated with a higher diagnostic yield for CT enterography.

CONCLUSION

CT enterography has a potential role in the evaluation of obscure gastrointestinal bleeding. Despite the limited sensitivity of CT enterography, positive CT enterographic findings can reliably indicate the true source of obscure gastrointestinal bleeding. CT enterography is particularly effective in helping identify the source of bleeding in patients with a history of massive bleeding.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11101936/-/DC1.

Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review

AIM

To assess the published evidence on the endovascular treatment of non-variceal upper gastrointestinal haemorrhage.

MATERIALS AND METHODS

An Ovid Medline search of published literature was performed (1966-2009). Non-English literature, experimental studies, variceal haemorrhage and case series with fewer than five patients were excluded. The search yielded 1888 abstracts. Thirty-five articles were selected for final analysis.

RESULTS

The total number of pooled patients was 927. The technical and clinical success of embolization ranged from 52-100% and 44-100%, respectively. The pooled mean technical/clinical success rate in primary upper gastrointestinal tract haemorrhage (PUGITH) only, trans-papillary haemorrhage (TPH) only, and mixed studies were 84%/67%, 93%/89%, and 93%/64%, respectively. Clinical outcome was adversely affected by multi-organ failure, shock, corticosteroids, transfusion, and coagulopathy. The anatomical source of haemorrhage and procedural variables did not affect the outcome. A successful embolization improved survival by 13.3 times. Retrospective comparison with surgery demonstrated equivalent mortality and clinical success, despite embolization being applied to a more elderly population with a higher prevalence of co-morbidities.

CONCLUSIONS

Embolization is effective in this very difficult cohort of patients with outcomes similar to surgery.

The role of endoscopy in the management of obscure GI bleeding

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, we performed a search of the medical literature by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).(1) The strength of individual recommendations is based both upon the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as "we suggest," whereas stronger recommendations are typically stated as "we recommend." This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: A meta-analysis

AIM: To analyze the accuracy of computed tomography (CT) angiography in the diagnosis of acute gastrointestinal (GI) bleeding.

METHODS: The MEDLINE, EMBASE, Cancerlit, Cochrane Library database, Sciencedirect, Springerlink and Scopus, from January 1995 to December 2009, were searched for studies evaluating the accuracy of CT angiography in diagnosing acute GI bleeding. Studies were included if they compared CT angiography to a reference standard of upper GI endoscopy, colonoscopy, angiography or surgery in the diagnosis of acute GI bleeding. Meta-analysis methods were used to pool sensitivity and specificity and to construct summary receiver-operating characteristic.

RESULTS: A total of 9 studies with 198 patients were included in this meta-analysis. Data were used to form 2 × 2 tables. CT angiography showed pooled sensitivity of 89% (95% CI: 82%-94%) and specificity of 85% (95% CI: 74%-92%), without showing significant heterogeneity (χ² = 12.5, P = 0.13) and (χ² = 22.95, P = 0.003), respectively. Summary receiver operating characteristic analysis showed an area under the curve of 0.9297.

CONCLUSION: CT angiography is an accurate, cost-effective tool in the diagnosis of acute GI bleeding and can show the precise location of bleeding, thereby directing further management.

Unexplained iron deficiency anaemia: Is it worthwhile to perform capsule endoscopy?

BACKGROUND

In around 30% of iron deficiency anaemia (IDA) cases a definite diagnosis cannot be made.

AIM

To investigate the role of capsule endoscopy (CE) in detecting lesions in patients with unexplained IDA after a negative endoscopic, serologic and haematologic diagnostic work up and its possible role in influencing clinical outcome.

METHODS

138 patients suffering from IDA were identified among 650 consecutive patients undergoing CE at our unit.

RESULTS

CE revealed the following positive findings in 91/138 patients: angiodysplasias in 51 patients; jejunal and/or ileal micro-ulcerations in 12; tumours/polyps in 9; erosive gastritis in 4; Crohn's disease in 5; jejunal villous atrophy in 5; a solitary ileal ulcer in 1 and active bleeding in the last 4 patients. Follow up data were available for 80/91 patients (87.9%). In 15 out of 46 patients with angiodysplasias IDA spontaneously resolved without any treatment; 9 patients required iron supplementation; 10 patients healed after lanreotide administration; APC was performed in 9 out of 46 patients and 3 patients underwent regular blood transfusion without any success on IDA. 10 out of the 12 patients with small bowel micro-ulcers spontaneously recovered from IDA whilst 2 patients after iron supplementation. All 9 patients affected by tumours/polyps were surgically addressed. In all erosive gastritis cases, patients recovered from IDA after PPI and Helicobacter pylori eradication. Four patients with Crohn's disease diagnosis restored to health with medical therapy. One out of the 4 patients with jejunal villous atrophy and the sole patient with a solitary ileal ulcer spontaneously healed. In 1 out of 3 patients with active bleeding IDA resolved without further treatment after blood transfusion whilst 2 patients were referred for surgical treatment. At follow up, complete resolution of IDA was achieved in 96.25%.

CONCLUSIONS

Small bowel investigation is a matter of great importance in IDA patients after negative upper and lower gastrointestinal endoscopy.

The value of multidetector-row computed tomography for localization of obscure acute gastrointestinal bleeding

PURPOSE

There are no simple guidelines on when to perform multidetector-row computed tomography (MDCT) for diagnosis of obscure acute gastrointestinal bleeding (AGIB). We used a risk scoring system to evaluate the diagnostic power of MDCT for patients with obscure AGIB.

MATERIALS AND METHODS

Ninety-two patients with obscure AGIB who were referred for an MDCT scan after unsuccessful endoscopic treatment at presentation were studied. We recorded clinical data and calculated Blatchford score for each patient. Patients who required transfusion more than 500mL of blood to maintain the vital signs were classified as high-risk patients. Two radiologists independently reviewed and categorized MDCT signs of obscure AGIB. Discordant findings were resolved by consensus. One-way ANOVA was used to compare clinical data between two groups; kappa statistics were used to estimate agreement on MDCT findings between radiologists.

RESULTS

Of the 92 patients, 62 (67.4%) were classified as high-risk patients. Blatchford scores of high-risk patients were significantly greater than those of low-risk patients. Sensitivity for MDCT diagnosing obscure AGIB was 81% in high-risk patients, as compared with 50% in the low-risk. When used in conjunction with selection of the cut-off value of 13 in Blatchford scoring system, the sensitivity and specificity of MDCT were 70.9% and 73.7%, respectively. Contrast extravasation was the most specific sign of AGIB (k=.87), recognition of which would have improved diagnostic accuracy.

CONCLUSIONS

With the aid of Blatchford scoring system for evaluating the disease severity, MDCT can localize the bleeders of obscure AGIB more efficiently.

Detection of active gastrointestinal hemorrhage with CT angiography: a 4(1/2)-year retrospective review

PURPOSE

To retrospectively evaluate the performance of computed tomography (CT) angiography in the detection and localization of clinically active gastrointestinal (GI) hemorrhage of an unknown source.

MATERIALS AND METHODS

Eighty-six CT angiograms were obtained in 74 patients with the clinical diagnosis of acute GI hemorrhage of an unknown source. Results of CT angiography were recorded, and the patients' electronic medical records were reviewed for documentation of subsequent interventional procedures performed within 24 hours of the reference CT angiogram to diagnose or control ongoing GI hemorrhage. Surgical, endoscopic, and final pathologic reports, if available, were reviewed.

RESULTS

Twenty-two of the 86 CT angiograms (26%) were positive for active hemorrhage, with findings confirmed in 19 of the 22 cases (86%). Thirteen cases were confirmed with angiography, five cases were confirmed with surgery, and one case was confirmed with autopsy. Sixty-four of the 86 CT angiograms were negative, and 59 (92%) of the CT angiograms required no further intervention. These patients were discharged without incident. There were no cases in which CT angiography was negative and subsequent angiography within 24 hours was positive. The overall sensitivity, specificity, accuracy, and positive and negative predictive value of CT angiography in the detection of active GI hemorrhage within this study population were 79%, 95%, 91%, 86%, and 92%, respectively.

CONCLUSIONS

CT angiography provides valuable information that can be used to determine the appropriateness of catheter angiography and guide mesenteric catheterization if a bleeding source is localized. The authors' experience with this study cohort supports its use before angiography in those patients with acute GI bleeding of an unknown source who are being considered for catheter-directed intervention.

Evaluation of arterial phase MDCT for the characterization of lower gastrointestinal bleeding in infants and children: Preliminary results

OBJECTIVE

The purpose of this study was to prospectively evaluate the accuracy of MDCT for the characterization of occult lower gastrointestinal bleeding in infants and children.

SUBJECTS AND METHODS

MDCT examinations were prospectively performed on 27 patients (2l boys, six girls; age range, 2 months-18 years). Patients with known causes of lower gastrointestinal bleeding were excluded from the study. Nonionic contrast medium was administered in an amount based on body weight. Images were obtained with a 16-MDCT scanner. For the arterial phase the section thickness was 1 mm; beam pitch, 1; and reconstruction interval, 0.7 mm. The scans were examined for abnormal vessels and extravasation of contrast medium. Two radiologists independently reviewed the images. The sensitivity, specificity, and diagnostic accuracy of MDCT were assessed with the pathologic findings or the final diagnosis as the reference standard.

RESULTS

Twenty of 27 patients had abnormal MDCT findings: arteriovenous malformation in 17 patients and Meckel's diverticulum in three patients. Contrast extravasation was identified in four patients. Surgery was performed on 13 of the 27 patients, and the diagnosis was otherwise confirmed in two additional patients. In these 15 cases, the sensitivity, specificity, and diagnostic accuracy of MDCT were 82%, 50%, and 74%. The interobserver difference was not significant (McNemar exact test, p = 0.063).

CONCLUSION

MDCT can be used to identify the location and source of lower gastrointestinal bleeding in infants and children.

Risk factors for rebleeding after angiographically negative acute gastrointestinal bleeding

AIM: To identify possible predictive factors for rebleeding after angiographically negative findings in patients with acute non-variceal gastrointestinal bleeding.

METHODS: From January 2000 to July 2007, 128 patients with acute non-variceal gastrointestinal bleeding had negative findings after initial angiography. Clinical and laboratory parameters were analyzed retrospectively.

RESULTS: Among 128 patients, 62 had no recurrent gastrointestinal bleeding and 66 had recurrent gastrointestinal bleeding within 30 d. As determined by the use of multivariate analysis, an underlying malignancy, liver cirrhosis and hematemesis were significant factors related to recurrent gastrointestinal bleeding.

CONCLUSION: Clinical factors including underlying malignancy, liver cirrhosis, and hematemesis are important predictors for rebleeding after angiographically negative findings in patients with acute non-variceal gastrointestinal bleeding.

Investigation of acute lower gastrointestinal bleeding with 16- and 64-slice multidetector CT

We evaluated the usefulness of 16- and 64-slice multidetector CT (MDCT) in the detection of a bleeding site in acute lower gastrointestinal tract (GIT) haemorrhage by conducting a retrospective study of cases of presumed acute lower GIT haemorrhage imaged with CT in two teaching hospitals in an 11-month period. The patients underwent contrast enhanced CT using either a 16 or 64 MDCT. No oral contrast was used. One hundred milliliters of non-ionic intravenous contrast agent was injected at 4.5 mL/s, followed by a 60 mL saline flush at 4 mL/s through a dual head injector. Images were acquired in arterial phase with or without non-contrast and portal phase imaging with 16 x 1.5 mm or 64 x 0.625 mm collimation. Active bleeding was diagnosed by the presence of iodinated contrast extravasation into the bowel lumen on arterial phase images with attenuation greater than and distinct from the normal mucosal enhancement or focal pooling of increased attenuation contrast material within a bowel segment on portal-venous images. Further management and final diagnosis was recorded. Fourteen patients and 15 studies were reviewed. CT detected and localized a presumed bleeding site or potential causative pathology in 12 (80%) of the patients. Seven of these were supported by other investigations or surgery, while five were not demonstrated by other modalities. Eight patients had mesenteric angiography, of which only four corroborated the site of bleeding. CT did not detect the bleeding site in three patients, of which two required further investigation and definitive treatment. We propose that MDCT serves a useful role as the initial rapid investigation to triage patients presenting with lower GIT bleeding for further investigation and management.

Multi-detector row CT of patients with acute intestinal bleeding: a new perspective using multiplanar and MIP reformations from submillimeter isotropic voxels

Acute intestinal bleeding is a severe condition, with a mortality rate of up to 40% in case of associated hemodynamic instability. The diagnosis of acute intestinal bleeding is often challenging and to date, there is no definite consensus upon the most appropriate technique for this specific diagnosis. This pictorial essay illustrates our preliminary use of multiplanar (MPR) and maximum intensity projection (MIP) reformations using MDCT scanner with submillimeter and isotropic voxels as an adjunct to axial images in patients with acute intestinal bleeding. MDCT examinations were routinely performed with 64-slice helical CT scanner and images were reconstructed 0.6-mm thickness at 0.5-mm intervals. Multiplanar reconstructions and MIP views were created with a commercially available workstation. Reformatted images from submillimeter isotropic voxels enhanced the depiction of subtle vascular abnormalities and served as a useful adjunct to the axial plane images to improve diagnostic capabilities. Although we are aware that reformatted images should not replace careful analysis of the axial images in patients with acute gastrointestinal bleeding, reformatted images from submillimeter isotropic voxels may clarify the cause of the bleeding, add confidence to image analysis and help interventional radiologists or surgeons improving planning approach.

Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding

The aim of the study was to carry out a systematic review determining the accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding. A search of published work in Medline and manual searching of reference lists of articles was conducted. Studies were included if they compared CT angiography to a reference standard of upper gastrointestinal endoscopy, colonoscopy, angiography or surgery in the diagnosis of acute gastrointestinal bleeding. Eight published studies evaluating 129 patients were included. Data were used to form 2 x 2 tables. Computed tomography angiography showed pooled sensitivity of 86% (95% confidence interval 78-92%) and specificity of 95% (95% confidence interval 76-100%), without showing significant heterogeneity (chi(2) = 3.5, P = 0.6) and (chi(2) = 5.4, P = 0.6), respectively. Summary receiver operating characteristic analysis showed an area under the curve of 0.93. Computed tomography angiography is accurate in the diagnosis of acute gastrointestinal bleeding and can show the precise location and aetiology of bleeding, thereby directing further management. Strong recommendations for use of CT cannot be made from this review because of the methodological limitations and further large prospective studies are needed to define the role of CT in acute gastrointestinal bleeding.

Evaluation of dual-phase multi-detector-row CT for detection of intestinal bleeding using an experimental bowel model

To evaluate dual-phase multi-detector-row computed tomography (MDCT) in the detection of intestinal bleeding using an experimental bowel model and varying bleeding velocities. The model consisted of a high pressure injector tube with a single perforation (1 mm) placed in 10-m-long small bowel of a pig. The bowel was filled with water/contrast solution of 30-40 HU and was incorporated in a phantom model containing vegetable oil to simulate mesenteric fat. Intestinal bleeding in different locations and bleeding velocities varying from zero to 1 ml/min (0.05 ml/min increments, constant bleeding duration of 20 s) was simulated. Nineteen complete datasets in arterial and portal-venous phase using increasing bleeding velocities, and seven negative controls were measured using a 64 MDCT (3-mm slice thickness, 1.5-mm reconstruction increment). Three radiologists blinded to the experimental settings evaluated the datasets in a random order. The likelihood for intestinal bleeding was assessed using a 5-point scale with subsequent ROC analysis. The sensitivity to detect bleeding was 0.44 for a bleeding velocity of 0.10-0.50 ml/min and 0.97 for 0.55-1.00 ml/min. The specificity was 1.00. The area under the curve was calculated to be 0.73, 0.88 and 0.89 for reader 1, 2 and 3, respectively. Dual-phase MDCT provides high sensitivity and specificity in the detection of intestinal bleeding with bleeding velocities of 0.5-1.0 ml/min. Therefore, MDCT should be considered as a primary diagnostic technique in the management of patients with suspected intestinal bleeding.

Cost-effectiveness analysis of management strategies for obscure GI bleeding

BACKGROUND AND AIMS

Of patients who are seen with GI hemorrhage, approximately 5% will have a small-bowel source. Management of these patients entails considerable expense. We performed a decision analysis to explore the optimal management strategy for obscure GI hemorrhage.

METHODS

We used a cost-effectiveness analysis to compare no therapy (reference arm) to 5 competing modalities for a 50-year-old patient with obscure overt bleeding: (1) push enteroscopy, (2) intraoperative enteroscopy, (3) angiography, (4) initial anterograde double-balloon enteroscopy (DBE) followed by retrograde DBE if the patient had ongoing bleeding, and (5) small-bowel capsule endoscopy (CE) followed by DBE guided by the CE findings. The model included prevalence rates for small-bowel lesions, sensitivity for each intervention, and the probability of spontaneous bleeding cessation. We examined total costs and quality-adjusted life years (QALY) over a 1-year time period.

RESULTS

An initial DBE was the most cost-effective approach. The no-therapy arm cost $532 and was associated with 0.870 QALYs compared with $2407 and 0.956 QALYs for the DBE approach, which resulted in an incremental cost-effectiveness ratio of $20,833 per QALY gained. Compared to the DBE approach, an initial CE was more costly and less effective. The initial DBE arm resulted in an 86% bleeding cessation rate compared to 76% for the CE arm and 59% for the no-therapy arm. The model results were robust to a wide range of sensitivity analyses.

LIMITATIONS

The short time horizon of the model, because of the lack of long-term data about the natural history of rebleeding from small-intestinal lesions.

CONCLUSIONS

An initial DBE is a cost-effective approach for patients with obscure bleeding. However, capsule-directed DBE may be associated with better long-term outcomes because of the potential for fewer complications and decreased utilization of endoscopic resources.

Noninvasive evaluation of active lower gastrointestinal bleeding: comparison between contrast-enhanced MDCT and 99mTc-labeled RBC scintigraphy

OBJECTIVE

The purpose of our study was to compare contrast-enhanced MDCT and (99m)Tc-labeled RBC scanning for the evaluation of active lower gastrointestinal bleeding.

SUBJECTS AND METHODS

Over 17 months, 55 patients (32 men, 23 women; age range, 21-92 years) were evaluated prospectively with contrast-enhanced MDCT using 100 mL of iopromide 300 mg I/mL. Technetium-99m-labeled RBC scans were obtained on 41 of 55 patients and select patients underwent angiography for attempted embolization. Each imaging technique was reviewed in a blinded fashion for sensitivity for detection of active bleeding as well as the active lower gastrointestinal bleeding location.

RESULTS

Findings were positive on both examinations in eight patients and negative on both examinations in 20 patients. Findings were positive on contrast-enhanced MDCT and negative on (99m)Tc-labeled RBC in two patients; findings were negative on contrast-enhanced MDCT and positive on (99m)Tc-labeled RBC in 11 patients. Statistics showed significant disagreement, with simple agreement = 68.3%, kappa = 0.341, and p = 0.014. Sixteen of 60 (26.7%) contrast-enhanced MDCT scans were positive prospectively, with all accurately localizing the site of bleeding and identification of the underlying lesion in eight of 16 (50%). Nineteen of 41 (46.3%) (99m)Tc-labeled RBC scans were positive. Eighteen of 41 matched patients went on to angiography. In four of these 18 (22.2%) patients, the site of bleeding was confirmed by angiography, but in 14 of 18 (77.8%), the findings were negative.

CONCLUSION

Contrast-enhanced MDCT and (99m)Tc-labeled RBC scanning show significant disagreement for evaluation of active lower gastrointestinal bleeding. Contrast-enhanced MDCT appears effective for detection and localization in cases of active lower gastrointestinal bleeding in which hemorrhage is active at the time of CT.

Tratamento de hemorragia intestinal grave decorrente de hipertensão porta, por meio de esplenectomia subtotal e anastomose esplenorrenal proximal

OBJETIVO: Um dos maiores desafios no tratamento da hipertensão porta é o sangramento de varizes intestinais. O objetivo deste artigo é apresentar um novo tratamento para hemorragia entérica grave provocada por hipertensão porta cirrótica, utilizando a esplenectomia subtotal combinada com derivação esplenorrenal proximal. TÉCNICA: Uma paciente de 64 anos apresentou sangramento intenso proveniente de varizes em alça jejunal em Y de Roux, para derivação biliodigestiva, após lesão coledociana, complicada com cirrose hepática. O procedimento consistiu em esplenectomia subtotal, preservando o pólo superior do baço, suprido apenas pelos vasos esplenogástricos, e anastomose término-lateral da veia esplênica, em sua extremidade proximal, à veia renal esquerda. RESULTADOS: Esse procedimento foi seguro, sem sangramento maior, dificuldade técnica ou complicação. No acompanhamento de 30 meses, a paciente não teve novos episódios de sangramento, a cirrose não avançou e, atualmente, encontra-se bem, sob controle. CONCLUSÃO: A esplenectomia subtotal combinada com derivação esplenorrenal proximal é uma boa alternativa operatória para tratar hemorragia proveniente de varizes intestinais, decorrentes de hipertensão porta.

Acute gastrointestinal bleeding: value of MDCT

Contrast-enhanced multidetector row helical computed tomography (MDCT) scanning is establishing itself as a rapid, noninvasive, and accurate diagnostic method in suspected acute gastrointestinal bleeding. Active bleeding can be depicted as an area of focal high attenuation within the bowel lumen on arterial phase MDCT images. New MDCT technologies facilitate three-dimensional image reconstruction, and higher temporal resolution is available with new MDCT scanner generations. This allows for the acquisition of arterial- and portal-venous phase images of the whole abdomen, revealing potential bleeding sources and simultaneously depict morphological changes in the abdomen, such as intestinal tumors. This article gives an overview of available diagnostic modalities in assessing gastrointestinal (GI) tract hemorrhage, with a special emphasis on new MDCT technology.

Computed tomography enteroclysis in the diagnosis of intestinal diseases

The role of computed tomography (CT) enteroclysis in the imaging of small bowel diseases is expanded with recent technological advances in multidetector CT system. Computed tomography enteroclysis is the examination of choice for patients with symptoms of intermittent small bowel obstruction, especially when there is a history of prior complex abdominal surgery, abdominal tumor, radiation therapy, and also in high grade obstructions with suspicion of extraintestinal internal fistula. Computed tomography enteroclysis is becoming the first-line modality for the evaluation of advanced and complicated small bowel Crohn disease. Computed tomography enteroclysis can also become an important complementary imaging technique to capsule endoscopy in the assessment of small bowel neoplasms and occult gastrointestinal hemorrhage. In this study, the technique and clinical applications of CT enteroclysis are reviewed; its advantages and limitations compared with the other imaging techniques and capsule endoscopy are discussed.

Detection and localization of acute upper and lower gastrointestinal (GI) bleeding with arterial phase multi-detector row helical CT

The purpose of this study was to evaluate the accuracy of multi-detector row helical CT (MDCT) for detection and localization of acute upper and lower gastrointestinal (GI) hemorrhage or intraperitoneal bleeding. Thirty-six consecutive patients with clinical signs of acute bleeding underwent biphasic (16- or 40-channel) MDCT. MDCT findings were correlated with endoscopy, angiography or surgery. Among the 36 patients evaluated, 26 were examined for GI bleeding and 10 for intraperitoneal hemorrhage. Confirmed sites of GI bleeding were the stomach (n = 5), duodenum (n = 5), small bowel (n = 6), large bowel (n = 8) and rectum (n = 2). The correct site of bleeding was identifiable on MDCT in 24/26 patients with GI bleeding. In 20 of these 24 patients, active CM extravasation was apparent during the exam. Among the ten patients with intraperitoneal hemorrhage, MDCT correctly identified the bleeding source in nine patients. Our findings suggest that fast and accurate localization of acute gastrointestinal and intraperitoneal bleeding is achievable on MDCT.

Obscure gastrointestinal bleeding: evaluation with 64-section multiphase CT enterography--initial experience

This retrospective HIPAA-compliant study was approved by the institutional review board and institutional conflict of interest committee. Patients gave informed consent for use of medical records. The purpose of the study was to retrospectively evaluate the findings depicted at computed tomographic (CT) enterography performed with a 64-section CT system and by using neutral enteric contrast material and a three-phase acquisition in patients with obscure gastrointestinal bleeding (OGIB). Twenty-two outpatients (11 men, 11 women; age range, 37-83 years) with OGIB underwent CT enterography. Findings were compared with capsule and traditional endoscopic, surgical, and angiographic findings. CT enterographic findings were positive for a bleeding source in 10 (45%) of 22 patients. Eight of 10 positive findings at CT enterography were also positive at capsule endoscopy or subsequent clinical diagnosis. CT enterography helped correctly identify three lesions undetected at capsule endoscopy. Study results suggest that multiphase, multiplanar CT enterography may have a role in the evaluation of OGIB.

Subtotal splenectomy and central splenorenal shunt for treatment of bleeding from Roux en Y jejunal loop varices secondary to portal hypertension

PURPOSE

To present subtotal splenectomy and splenorenal shunt as a surgical option to treat severe bleeding from a Roux en Y jejunal loop varices secondary to portal hypertension.

METHOD

A 64-year-old white woman presented severe episodes of bleeding from varices inside a Roux en Y jejunal loop secondary to portal hypertension due to cirrhosis. Subtotal splenectomy was performed with preservation of the upper splenic pole supplied by the splenogastric vessels. This procedure was combined with a central splenorenal shunt to divert part of portal blood to systemic flow.

RESULTS

This procedure was safely performed with no complications. A 2-year post-operative follow-up of the patient has been uneventful. No re-bleeding occurred during this period and she returned to her normal life.

CONCLUSION

Subtotal splenectomy combined with central splenorenal shunt seems to be a safe procedure useful for the treatment of enteral bleedings due to portal hypertension.

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

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.

CT enteroclysis in the diagnosis of obscure gastrointestinal bleeding: initial results

AIM

To evaluate the usefulness of computed tomography (CT) enteroclysis in patients with obscure gastrointestinal (GI) bleeding.

MATERIALS AND METHODS

In a prospective study, CT enteroclysis was performed in 21 patients (median age 50 years; range 13-71 years) with obscure GI bleeding in which the source of the bleeding could not be detected despite the patient having undergone both upper GI endoscopic and colonoscopic examinations. The entire abdomen and pelvis was examined in the arterial and venous phases using multisection CT after distending the small intestine with 2l of 0.5% methylcellulose as a neutral enteral contrast medium and the administration of 150ml intravenous contrast medium.

RESULTS

Adequate distension of the small intestine was achieved in 20 of the 21 (95.2%) patients. Potential causes of GI bleeding were identified in 10 of the 21 (47.6%) patients using CT enteroclysis. The cause of the bleeding could be detected nine of 14 (64.3%) patients with overt, obscure GI bleeding. However, for patients with occult, obscure GI bleeding, the cause of the bleeding was identified in only one of the seven (14.3%) patients. The lesions identified by CT enteroclysis included small bowel tumours (n=2), small bowel intussusceptions (n=2), intestinal tuberculosis (n=2), and vascular lesions (n=3). All vascular lesions were seen equally well in both the arterial and venous phases.

CONCLUSIONS

The success rate in detection of the cause of bleeding using CT enteroclysis was 47.6% in patients with obscure GI bleeding. The diagnostic yield was higher in patients with overt, obscure GI bleeding than in those with occult obscure GI bleeding.

Capsule endoscopy versus computed tomographic or standard angiography for the diagnosis of obscure gastrointestinal bleeding

BACKGROUND AND AIMS

Capsule endoscopy (CE) is superior to push enteroscopy and small bowel barium radiography in detecting the source of obscure GI bleeding. We now compared whether CE has a superior diagnostic yield than CT angiography (CTA) or standard mesenteric angiography (ANGIO) in patients with obscure GI bleeding.

METHODS

From June 2004 to October 2005, consecutive patients admitted for OGIB underwent both CTA and ANGIO, followed by CE, performed blindly by independent examiners within the next 7 days. The primary end point of the study was the diagnostic yield for each technique, defined as the frequency of detection of lesions with a high probability of bleeding.

RESULTS

Twenty-eight patients (16 men and 12 women, mean age 74 +/- 2 yr) with OGIB (overt bleeding in 20 cases and chronic occult in 8) were prospectively evaluated. CTA or standard angiography could be performed in 25 of 28 patients (applicability 86%), because of contrast allergy (1 patient) and chronic renal failure (2 patients). A source of bleeding was detected by CE in a greater proportion of patients, 72% (18 of 25, 95% CI 50.6-87.9%), than CTA, 24% (6 of 25, 95% CI 9.4-45.1%, P= 0.005 vs CE), or ANGIO, 56% (14 of 25, 95% CI 34.9-75.6%, P= NS). Similarly, CE was able to diagnose 100% of patients diagnosed by CTA and 86% of patients diagnosed by ANGIO. Moreover, CE was positive in 12 of 19 (63%) negative cases on CTA and in 6 of 11 (55%) negative cases on ANGIO. As a result of the CE findings, therapeutic intervention was undertaken in 9 of 19 (47%) patients with positive results.

CONCLUSION

CE detects more lesions than CTA or standard mesenteric angiography in patients with obscure GI bleeding and has a therapeutic impact in almost half of the patients with positive findings.