CT Evaluation of GI Bleeding
CT Evaluation of GI Bleeding |
Background Data Acute gastrointestinal bleeding is a common medical emergency
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Background Data Upper GI bleeding occurs proximal to ligament of Trietz
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“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.” Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms Flavius F. Guglielmo et al. RadioGraphics 2021; 41:1632–1656 |
Causes of Acute GI Bleeding Upper GI bleeding
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Classic Diagnostic Algorithm for Upper GI Bleeding Any patient with suspected upper GI bleeding should undergo endoscopy first
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“Endoscopy is highly useful for diagnosing the cause of UGIB, with 92%–98% sensitivity and 93%–100% specificity, and enables effective treatment of bleeding in the majority of cases.” CT for Evaluation of Acute Gastrointestinal Bleeding Michael L.Wells et al. Radiographics. 2018 Jul-Aug;38(4):1089-1107 |
“Radiologic methods have a role in assessing UGIB only when upper endoscopy is not feasible or yields inconclusive results. Upper GI endoscopy may be contraindicated in the setting of shock, substantial comorbidity, or massive hemorrhage. Adequate endoscopic evaluation of the bleeding source may not be possible when extensive luminal blood obscures visualization or the bleeding originates from a difficult anatomic location such as the distal duodenum.” CT for Evaluation of Acute Gastrointestinal Bleeding Michael L.Wells et al. Radiographics. 2018 Jul-Aug;38(4):1089-1107 |
ACR Appropriateness Criteria®Nonvariceal Upper Gastrointestinal Bleeding  |
ACR Appropriateness Criteria®Nonvariceal Upper Gastrointestinal Bleeding  |
ACR Appropriateness Criteria®Nonvariceal Upper Gastrointestinal Bleeding  |
”Active GI bleeding is depicted by the accumulation of extrav- asated contrast material in the bowel lumen as a focus, jet, cloud, or blush of variable size, usually appearing during the arterial phase. Contrast extravasation generally changes in size, attenuation, shape, and location on later phase images usually moving downstream. An enhancing focus that changes in attenuation but not shape on later phase images may be a vascular lesion (eg, aneurysm, pseudoaneurysm, or angioectasia). The absence of hyperattenuating material on noncontrast images in the same location of possible contrast extravasation on postcontrast images helps to confirm active bleeding.” Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms Flavius F. Guglielmo et al. RadioGraphics 2021; 41:1632–1656 |
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Normal Gastric Antrum  |
Active Bleed from Gastric Adenocarcinoma: Arterial vs Venous Phase Imaging  |
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GI Bleed due to a Gastric Ulcer in a Patient with H. pylori Gastritis  |
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Chemical Gastritis due to NSAIDs with GI Bleed  |
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GI Bleed Presentation  |
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“The major complications of acute PUD are perforation and bleeding. Intraperitoneal free air is a major sign of perforation. Intravenous contrast media extravasation into the stomach is a sign of active bleeding. High-density gastric contents, with a suspicion of blood clots, can also indicate recent bleeding and are generally found close to the bleeding site. Although many reports have described CT findings of complicated PUD, the CT findings of uncomplicated PUD have not been well documented.” Computed tomography findings of acute gastric peptic ulcer Kanako Oyanagi , Takeshi Higuchi , Norihiko Yoshimura Clinical Imaging 71 (2021) 77–82 |
Acute Abdomen with Perforated Gastric Ulcer  |
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”The most recognized sign of PUD on a CT scan was high-density gastric contents. Of course, this finding was the result of not only bleeding, but also surgical material, foreign bodies, medications, etc. However, high-density gastric contents were suspected of intraluminal bleeding in our study because bleeding was confirmed on endoscopy in up to 93% subjects with high-density gastric contents. In the emergency department, if CT findings in patients with acute abdomen reveal high-density gastric contents, acute PUD should be suspected since it is the most common cause of gastrointestinal bleeding.” Computed tomography findings of acute gastric peptic ulcer Kanako Oyanagi , Takeshi Higuchi , Norihiko Yoshimura Clinical Imaging 71 (2021) 77–82 |
”In conclusion, we found that the most important CT findings of acute-phase gastric ulcer are high-density gastric contents, focal luminal out- pouching, and focal low-attenuation wall thickening. When emergency department patients with nonspecific abdominal symptoms present with these CT findings, acute PUD can be suspected, which is helpful for determining subsequent examinations and appropriate treatment.” Computed tomography findings of acute gastric peptic ulcer Kanako Oyanagi , Takeshi Higuchi , Norihiko Yoshimura Clinical Imaging 71 (2021) 77–82 |
“Esophageal, gastric, and duodenal cancers can all ulcerate and cause GI bleeding. Esophageal cancers can show asymmetric or marked focal wall thickening, often with para-esophageal lymph nodes. Gastric cancer can produce focal or diffuse gastric wall thickening or manifest as an intraluminal polypoid lesion and can be associated with perigastric lymph nodes, liver and pulmonary metastases, and peritoneal disease. Gastric lymphoma can manifest as focal or diffuse wall thickening, an ulcerated mass, or polypoid or nodular fold thickening. Gastric metastatic disease can arise from melanoma, breast cancer, and lung cancer.” Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms Flavius F. Guglielmo et al. RadioGraphics 2021; 41:1632–1656 |