|
1
|
Agarwal D, Gupta S, Bhattacharjee HK, Das CJ. Imaging and interventions in vascular malformations of the gastrointestinal tract. Abdom Radiol (NY) 2025:10.1007/s00261-025-04880-5. [PMID: 40095013 DOI: 10.1007/s00261-025-04880-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2025] [Revised: 02/13/2025] [Accepted: 03/03/2025] [Indexed: 03/19/2025]
Abstract
Vascular malformations of the gastrointestinal (GI) tract are a rare yet significant cause of GI bleeding, that can present at any age and require a high index of suspicion for timely diagnosis. While the majority of lesions may be asymptomatic and detected incidentally on imaging, they may also present with anemia if there is occult blood loss, as acute GI bleeding, or as lead points for intussusception. The presence of multiple vascular malformations may be associated with underlying syndromes, such as Hereditary Hemorrhagic Telangiectasia syndrome and Klippel-Trénaunay syndrome. While luminal endoscopy is the first-line diagnostic test to evaluate overt and occult GI bleeding, imaging plays a very significant role in detecting these vascular malformations and planning the best treatment approach. In this review, we describe the various imaging findings of GI tract vascular malformations and available treatment options, focusing on endovascular interventional treatments where possible.
Collapse
Affiliation(s)
- Divij Agarwal
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanchita Gupta
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanga K Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Chandan J Das
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India.
| |
Collapse
|
|
2
|
Chen Y, Liu X, Guo L, Tang Y, Meng X. Contrast-enhanced computed tomography assisted diagnosis of bleeding caused by colonic angiodysplasia: A case report. Medicine (Baltimore) 2024; 103:e39984. [PMID: 39465753 PMCID: PMC11460880 DOI: 10.1097/md.0000000000039984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Indexed: 10/29/2024] Open
Abstract
RATIONALE Angiodysplasia (AD) in the gastrointestinal tract is a degenerative vascular condition characterized by vascular dilation, tortuosity, and arteriovenous connections within the mucosal and submucosal layers. AD is a significant cause of lower gastrointestinal bleeding in the elderly, often presenting as chronic, intermittent hemorrhage. The research challenge lies in the potential for multiple and minute AD lesions to be missed during endoscopy, which may lead to post-hemostatic rebleeding. PATIENT CONCERNS An 82-year-old female with a history of coronary artery disease treated with aspirin, presenting with recurrent melena and anemia. The patient exhibited a suboptimal response to blood transfusions and octreotide therapy. DIAGNOSIS After excluding tumorous bleeding in the initial contrast-enhanced computed tomography (CECT), we suspect vascular bleeding as the most probable etiology. INTERVENTIONS The initial colonoscopy was unsuccessful due to the occurrence of ventricular tachycardia. Considering the patient's advanced age, cardiac dysfunction, and frailty, a repeat CECT were conducted during episodes of suspected active bleeding. Vascular dilatation within the colonic hepatic flexure wall was visualized during the venous phase, accompanied by contrast agent extravasation into the intestinal lumen. The subsequent urgent colonoscopy and pathological specimens from surgical resection supported the diagnosis of colonic AD. OUTCOMES After the surgery, the patient did not experience melena thereafter. LESSONS We highlight that CECT for diagnosing AD-related bleeding offers higher safety and convenience, potentially superior to digital subtraction angiography, particularly in critically ill elderly patients.
Collapse
Affiliation(s)
- Yinze Chen
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
- Department of Gastroenterology, Henan Province Chest Hospital, Chest Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaomin Liu
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Liang Guo
- Department of Pathology, The First Hospital of Jilin University, Changchun, China
| | - Ying Tang
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Xiangwei Meng
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
|
3
|
Nilojan JS, Raviraj S, Anniestan A. Successful management of ileocecal angiodysplasia with an overt bleeding with supra selective transcatheter embolization-case report. Int J Surg Case Rep 2024; 118:109617. [PMID: 38636160 PMCID: PMC11027573 DOI: 10.1016/j.ijscr.2024.109617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 04/20/2024] Open
Abstract
INTRODUCTION Angiodysplasia is the most common vascular abnormality in gastrointestinal tract, commonly occurs in right colon. CASE PRESENTATION 42-year-old male presented with massive per rectal bleeding for one day duration. He is a known type 2 diabetes mellitus patient and not known to having any bleeding disorders or on any anticoagulant medication. He had no gastrointestinal red flag symptoms. He was hemodynamically stable, and rest of the examination was unremarkable. His hemoglobin level was dropped from 7.9 g/dl on admission to 4.1 g/dl. His biochemical investigations including coagulation profile were within normal limits and had unremarkable Oesophago-gastro-duodenoscopy (OGD) and colonoscopy. Computerised tomography mesenteric angiogram (CTA) revealed angiodysplasia at ileocecal junction and proceeded with supra selective trans cather angiography which showed bleeding from a branch of ileocecal artery for which the glue embolization done. Homeostasis achieved successfully and patient well recovered. DISCUSSION Presentation of angiodysplasia can be range from incidental finding to overt bleeding with varying degree of anaemia. Endoscopy is the preferred first line of investigation, although it has its limitations such as requiring bowel preparation and stable hemodynamic status for the procedure. CTA has a value in such circumstances to identify the site of bleeding and to guide angiographic intervention. Trans catheter angiography and embilozation is one of the suitable options in similar situation. CONCLUSION Ileocecal angiodysplasia which presents as an overt per-rectal bleeding where proceeding to surgery is difficult, can be managed successfully with supraselective transcatheter angiography and embolization.
Collapse
|
|
4
|
Molineros Barón C, Roa Ballestas PA. Epidemiología, diagnóstico y tratamiento de las angiectasias gastrointestinales. UNIVERSITAS MÉDICA 2023. [DOI: 10.11144/javeriana.umed64-1.edta] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Las angiectasias son las malformaciones vasculares mas comunes en el tracto gastrointestinal en la población general. Hasta el momento, la patogénesis de este tipo de malformaciones vasculares no ha esclarecida totalmente. Su incidencia ha venido en aumento debido a la mayor disponibilidad de métodos diagnósticos en gastroenterología, principalmente la videocápsula endoscópica (VCE) y la enteroscopia profunda asistida para el estudio del intestino delgado.
La terapia endoscópica es la estrategia de tratamiento inicial más efectiva, sin embargo existen otras alternativas terapéuticas como lo son la terapia farmacológica, la angiografía más embolización selectiva o la resección quirúrgica.
Collapse
|
|
5
|
Chung CS, Lee TH, Chou JW, Feng CL, Huang SF, Chen CK, Shih YS, Huang WH, Yen HH, Chen YY, Su MY, Lin WP, Chiu CT, Tai CM, Chang IW, Wang HP, Huang HC, Lin TY, Huang TY, Hu CT, Chen CL, Chang CW, Chang CW, Lai JH, Chen MJ, Liu CY, Shih SC, Wang HY, Cheng KS, Chuang SC. Miscellaneous Disorder of the Small Intestines. ATLAS OF SMALL INTESTINAL DISORDERS 2023:85-108. [DOI: 10.1007/978-981-99-6682-0_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
|
|
6
|
Johnson AM, Chovwen PE, Akpan EJ, Patel A. Aortic Valve Stenosis, a Precipitating Factor of Recurrent Bleed in Colonic Angiodysplasia: A Literature Review. Cureus 2021; 13:e15903. [PMID: 34322347 PMCID: PMC8310456 DOI: 10.7759/cureus.15903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 12/16/2022] Open
Abstract
Angiodysplasia (also known as angioectasia) is a lesion characterized by abnormal, dilated small blood vessels in the mucosa and submucosal layers of the GI tract. With the estimated low incidence of active GI bleeding from these lesions, angiodysplasia can be challenging to diagnose. The presence of aortic stenosis has increased the recognition rate of angiodysplasia, especially in the elderly. Despite the associations between aortic stenosis and angiodysplasia (Heyde's syndrome) revealed in several studies, the etiology of Heyde syndrome is still debatable, which has led to the proposition of several hypotheses that are reviewed in this article. This activity will help review the meaning of Heyde's syndrome, epidemiology, proposed pathophysiology, diagnosis, and management by surveying articles published between 1955 and 2021 on PubMed. We used search terms such as "colonic angiodysplasia," "arteriovenous malformation," "Heyde syndrome," "refractory gastrointestinal bleed," "aortic valve stenosis," and "acquired von Willebrand disease." Findings revealed an association between aortic stenosis and lower gastrointestinal (GI) bleed.
Collapse
Affiliation(s)
| | | | - Ezekiel J Akpan
- Medicine, All Saints University College of Medicine, Kingstown, VCT
| | - Anna Patel
- Gastroenterology and Hepatology, Community First Medical Center, Chicago, USA
| |
Collapse
|
|
7
|
Lew LZW, Cohen R, Watanabe Y. Sigmoid colon arteriovenous malformation causing spontaneous haemoperitoneum: a case report. ANZ J Surg 2021; 91:E760-E761. [PMID: 33885216 DOI: 10.1111/ans.16884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/04/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Leslie Zhi Wei Lew
- Department of General Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Ryan Cohen
- Department of General Surgery, Royal Perth Hospital, Perth, Western Australia, Australia.,School of Biomedical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Colorectal Research Unit, St John of God Healthcare, Perth, Western Australia, Australia.,School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Yuki Watanabe
- Department of General Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| |
Collapse
|
|
8
|
Fijasri NH, Keenoo MS, Oaris I, Zakaria AD, Zakaria Z, Hussain FA, Wong MPK. Massive lower gastrointestinal bleeding in a young postpartum lady: A management dilemma. POLISH ANNALS OF MEDICINE 2021. [DOI: 10.29089/2020.20.00166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 03/29/2021] [Indexed: 10/21/2024]
Abstract
Introduction:
Lower gastrointestinal (GI) bleeding secondary to bleeding colonic angiodysplasia in a young population is rare. The prevalence of angiodysplasia in healthy asymptomatic adult was 0.8% and increases in elderly population, chronic renal failure, pulmonary disease, aortic stenosis, and von Willebrand disease.
Aim:
We are reporting a case of a young, postpartum woman who presented to us with massive lower GI bleeding secondary to bleeding angiodysplasia. Angiodysplasia is rare in this group of patients, making the detection and treatment challenging.
Case study:
A fit 25-year-old woman presented with type IV hypovolemic shock due to massive lower GI bleeding on postpartum day 15. Emergency colonoscopy was attempted with no evidence of active bleeding detected until splenic flexure. The patient was rushed to the operation theatre for exploratory laparotomy due to unstable condition. Segmental colonic clamping was performed and due to persistent blood pooling at different segments throughout the colon, subtotal colectomy and end ileostomy were performed. Patient recovered well post-operatively.
Results and discussion:
Physiological changes during pregnancy may has aggravated the risk of bleeding in GI angiodysplasia. Following resuscitation, a lesion causing lower GI bleed can be identified and treated with a variety of endoscopic procedures, radiological and surgical interventions. In our case, the role of surgery comes in place due to massive life-threatening lower GI bleeding not responding to resuscitation.
Conclusions:
Postpartum gastrointestinal bleeding from multiple colonic angiodysplasia is rare. It poses a challenge in diagnostic and treatment strategies. A timely individualized intervention either via endoscopy, interventional radiology or surgery is crucial and life-saving.
Collapse
Affiliation(s)
- Nurul Hafiez Fijasri
- Department of Surgery, School of Medical Sciences, University Sains Malaysia, Kelantan, Malaysia
| | - Muhammad Sajjaad Keenoo
- Department of Surgery, School of Medical Sciences, University Sains Malaysia, Kelantan, Malaysia
| | - Iqtidaar Oaris
- Department of Surgery, School of Medical Sciences, University Sains Malaysia, Kelantan, Malaysia
| | | | - Zaidi Zakaria
- Department of Surgery, School of Medical Sciences, University Sains Malaysia, Kelantan, Malaysia
| | - Faezahtul Arbaeyah Hussain
- Pathology Department, School of Medical Sciences and Hospital, University Sains Malaysia, Kelantan, Malaysia
| | - Michael Pak-Kai Wong
- Department of Surgery, School of Medical Sciences, University Sains Malaysia, Kelantan, Malaysia
| |
Collapse
|
|
9
|
Kido M, Nakamura K, Kuwahara T, Yasui Y, Okajima H, Kurose N, Kohno M. Arteriovenous malformation that caused prolapse of the colon and was treated surgically in an infant: a case report. Surg Case Rep 2020; 6:67. [PMID: 32270382 PMCID: PMC7142189 DOI: 10.1186/s40792-020-00824-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background Various terms have been used to describe vascular lesions in the intestine, including angiodysplasia, arteriovenous malformation, and telangiectasia. Such lesions are common in adults and are typified by angiodysplasia, a type of arteriovenous malformation. In contrast, these lesions are rarely seen in the pediatric population. Angiodysplasia may cause gastrointestinal bleeding, which is sometimes an indication for treatment. Considering the high rate of recurrence after surgical treatment, conservative treatments are mainly chosen. We herein report an extremely rare case of a prolapsed colon due to an arteriovenous malformation successfully treated by resection in a 1-year-old girl. We also highlight the differences between pediatric and adult cases. Case presentation A girl developed bloody stools at 7 months of age. She visited another hospital at 1 year of age because of continuing moderate hematochezia and recent onset of rectal prolapse. Colonoscopy showed a protruding lesion located 15 cm from the anal verge, suggesting a submucosal vascular abnormality. Contrast-enhanced computed tomography and magnetic resonance imaging at our hospital revealed the localized lesion with dilated blood vessels in part of the sigmoid colon; no other lesions were present in the gastrointestinal tract. Laparoscopic-assisted sigmoidectomy was performed. A subserosal vascular lesion was visualized and resected using end-to-end anastomosis. Pathologic examination of the 2.2 × 2.7-cm segment revealed several abnormally enlarged and ectatic blood vessels in the submucosa extending into the subserosa. The lesion was diagnosed as an arteriovenous malformation. The patient had a good clinical course without recurrence at the 2-year follow-up. Conclusions An arteriovenous malformation in the sigmoid colon may rarely cause intussusception and prolapse of the colon. Complete resection is a radical and potentially effective treatment. Computed tomography and colonoscopy were useful for evaluation of the lesion in the present case.
Collapse
Affiliation(s)
- Miori Kido
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Kiyokuni Nakamura
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Tsuyoshi Kuwahara
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Yoshitomo Yasui
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Hideaki Okajima
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Nozomu Kurose
- Department of Pathology and Laboratory Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Miyuki Kohno
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan.
| |
Collapse
|
|
10
|
Ghodasara N, Liddell R, Fishman EK, Johnson PT. High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know. Radiographics 2020; 39:559-577. [PMID: 30844348 DOI: 10.1148/rg.2019180131] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The superior mesenteric artery (SMA) provides vital blood supply to the midgut, and an acute abnormality can rapidly precipitate bowel ischemia and infarction and lead to morbidity and mortality. Vascular diseases that acutely compromise the SMA threaten its tributaries and include occlusion, dissection, aneurysm rupture, pseudoaneurysm, vasculitis, and SMA branch hemorrhage into the bowel. Emergency medicine physicians rely on the radiologist to identify SMA abnormalities, to characterize them, and to detail findings that guide the appropriate triage of these patients. As such, radiologists must be cognizant of the features that influence patient treatment to assist vascular surgeons and interventional radiologists in decision making. Some patients can be treated medically, while clinical and radiographic findings may suggest the need for interventional or surgical repair of the artery. In the latter case, multidetector CT findings aid in determining which of the various surgical and endovascular treatment options is optimal, and both vascular and gastrointestinal sequelae of acute SMA abnormalities contribute to these determinations. The authors review acute life-threatening conditions involving the SMA including acute occlusion, dissection, aneurysm, pseudoaneurysm, and hemorrhage and discuss the vascular and gastrointestinal multidetector CT findings in each of these conditions that help to guide surgical and interventional management. ©RSNA, 2019.
Collapse
Affiliation(s)
- Nevil Ghodasara
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
| | - Robert Liddell
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
| | - Elliot K Fishman
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
| | - Pamela T Johnson
- From the Divisions of Body CT (N.G., E.K.F., P.T.J.) and Interventional Radiology (R.L.), Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins Hospital, 601 N Caroline St, Room 4223, Baltimore, MD 21287
| |
Collapse
|
|
11
|
Shafqet MA, Tonthat A, Esparragoza P, Toro B, Ehrlich AC, Friedenberg FK. Recent use of NSAID and NOAC medications are associated with a positive CT arteriogram. Abdom Radiol (NY) 2019; 44:2632-2638. [PMID: 30949782 DOI: 10.1007/s00261-019-02005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Computed tomography angiography (CTA) is a diagnostic modality utilized in patients with suspected active lower gastrointestinal (GI) bleeding. CTA use in clinical practice is limited by the risk of contrast-induced nephropathy, and the loss of patients from direct physician observation while undergoing the test. Identifying clinical predictors of a positive result would be useful in guiding physician utilization of CTA studies. METHODS We performed a single-center retrospective study to determine which clinical predictors are associated with a positive CTA. Binary logistical regression modeling was used to identify the independent predictors and the results were expressed as adjusted odds ratios with corresponding 95% CI . RESULTS 262 patients met inclusion criteria and there were 61 (23.3%) positive CTA exams. In unadjusted analysis those who were CTA positive were more likely to require management in the intensive care unit (85.2% vs. 14.8%, p < 0.01) and being CTA positive was associated with a significantly increased in-hospital mortality (14.8% vs. 4.5%, p < 0.01). The use of a novel oral anticoagulant (NOAC) in the week prior to presentation was associated with a positive CTA after adjustment for confounders (adjusted odds ratio = 3.89; 95% CI 1.05-14.43). Similarly, the use of a non-steroidal anti-inflammatory drug (NSAID) was associated with a positive CTA (OR 2.36; 1.03-5.41). Only 8% of patients experienced contrast-induced nephropathy. CONCLUSION Use of either NOACs or NSAIDs in the previous week is independently associated with a positive CTA in the setting of acute lower GI bleeding. CTA exams appear to confer a low risk of contrast-induced nephropathy.
Collapse
Affiliation(s)
- Muhammad A Shafqet
- Section of Gastroenterology and Hepatology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Alexander Tonthat
- School of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Paola Esparragoza
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Butros Toro
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Adam C Ehrlich
- Section of Gastroenterology and Hepatology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Frank K Friedenberg
- Section of Gastroenterology and Hepatology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA.
| |
Collapse
|
|
12
|
García-Compeán D, Del Cueto-Aguilera ÁN, Jiménez-Rodríguez AR, González-González JA, Maldonado-Garza HJ. Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points. World J Gastroenterol 2019; 25:2549-2564. [PMID: 31210709 PMCID: PMC6558444 DOI: 10.3748/wjg.v25.i21.2549] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/19/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient's quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.
Collapse
Affiliation(s)
- Diego García-Compeán
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Ángel N Del Cueto-Aguilera
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Alan R Jiménez-Rodríguez
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - José A González-González
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Héctor J Maldonado-Garza
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| |
Collapse
|
|
13
|
Filograna L, Filograna E, D'Onofrio A, Flor N, Haddad Y, Floris R. Colonic angiodysplasia on CT colonography: case report and characteristic imaging findings. Radiol Case Rep 2018; 12:693-696. [PMID: 29484051 PMCID: PMC5823384 DOI: 10.1016/j.radcr.2017.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 06/26/2017] [Accepted: 07/17/2017] [Indexed: 12/13/2022] Open
Abstract
Gastrointestinal angiodysplasia represents the cause of 6% of lower gastrointestinal tract bleeding, particularly in the elderly. Because of the common presentation and age range of affected patients, often patients with occult or massive gastrointestinal bleedings are investigated with colonoscopy, in the suspect of colonic cancer. Other methods are capsule enteroscopy, angiography, double-contrast barium enema, computed tomography angiography, and radionuclide scanning. In this contribution, we describe a case of colonic angiodysplasia first suspected during computed tomography colonography performed after an incomplete colonoscopy in a patient with recent anemization. The purpose is to highlight the computed tomography colonography imaging characteristics of this rare finding during such examination performed due to suspected colon carcinoma as a complementary or substitutive method of colonoscopy.
Collapse
Affiliation(s)
- Laura Filograna
- Department of Diagnostic and Interventional Radiology, Molecular Imaging and Radiotherapy, PTV Foundation, "Tor Vergata" University of Rome, Viale Oxford 81, 00133 Rome, Italy
| | - Enrica Filograna
- Centro di Diagnostica per Immagini, Via dell'Incoronata 5, Nardò, Lecce 73100, Italy
| | - Adolfo D'Onofrio
- Department of Diagnostic and Interventional Radiology, Molecular Imaging and Radiotherapy, PTV Foundation, "Tor Vergata" University of Rome, Viale Oxford 81, 00133 Rome, Italy
| | - Nicola Flor
- Unità Operativa di Radiologia Diagnostica e Interventistica, Azienda Servizi Socio Territoriali Santi Paolo e Carlo, Via di Rudinì 8, 20142 Milan, Italy
| | - Yusef Haddad
- Unità Operativa di Medicina Interna, Azienda Ospedaliera Cardinale G.Panico, Via San Pio X, 4, Tricase, Lecce 73039, Italy
| | - Roberto Floris
- Department of Diagnostic and Interventional Radiology, Molecular Imaging and Radiotherapy, PTV Foundation, "Tor Vergata" University of Rome, Viale Oxford 81, 00133 Rome, Italy
| |
Collapse
|
|
14
|
Becq A, Rahmi G, Perrod G, Cellier C. Hemorrhagic angiodysplasia of the digestive tract: pathogenesis, diagnosis, and management. Gastrointest Endosc 2017; 86:792-806. [PMID: 28554655 DOI: 10.1016/j.gie.2017.05.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Aymeric Becq
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Gabriel Rahmi
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Guillaume Perrod
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Christophe Cellier
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| |
Collapse
|
|
15
|
Wildgruber M, Wrede CE, Zorger N, Müller-Wille R, Hamer OW, Zeman F, Stroszczynski C, Heiss P. Computed tomography versus digital subtraction angiography for the diagnosis of obscure gastrointestinal bleeding. Eur J Radiol 2017; 88:8-14. [DOI: 10.1016/j.ejrad.2016.12.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/19/2016] [Accepted: 12/25/2016] [Indexed: 12/22/2022]
|
|
16
|
Colonic Angiodysplasia with a Huge Submucosal Hematoma in the Sigmoid Colon. Case Rep Surg 2016; 2016:3457367. [PMID: 27340585 PMCID: PMC4906173 DOI: 10.1155/2016/3457367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 05/11/2016] [Accepted: 05/12/2016] [Indexed: 11/24/2022] Open
Abstract
Colonic angiodysplasia (AD) with bleeding as a comorbidity in the aging population is being increasingly reported. However, to our knowledge, there is no report on colonic AD accompanied by a huge hematoma. Herein, we report a case of colonic AD with a huge submucosal hematoma. A 75-year-old man with sudden melena was referred to our hospital. Helical computed tomographic angiography (CTA) revealed bleeding from the sigmoid colon. Additionally, colonoscopy showed a huge submucosal hematoma with bleeding in the sigmoid colon. As endoscopic hemostasis was difficult, sigmoidectomy was performed. The pathological diagnosis was colonic AD. The present case indicates that colonic AD should be considered in the differential diagnosis for melena. In addition, the case shows that helical CTA, which is a noninvasive imaging modality, is useful for the diagnosis of colonic AD and is as effective as colonoscopy and angiography for diagnosis.
Collapse
|
|
17
|
Eficacia de lanreótido en pacientes con angiodisplasias gastrointestinales refractarias al tratamiento con octreótido. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:213-4. [DOI: 10.1016/j.gastrohep.2015.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 02/09/2015] [Accepted: 02/11/2015] [Indexed: 11/18/2022]
|
|
18
|
Abstract
This article provides an overview of the evaluation and management of lower gastrointestinal bleeding (LGIB) in children. The common etiologies at different ages are reviewed. Conditions with endoscopic importance for diagnosis or therapy include solitary rectal ulcer syndrome, polyps, vascular lesions, and colonic inflammation and ulceration. Diagnostic modalities for identifying causes of LGIB in children include endoscopy and colonoscopy, cross-sectional and nuclear medicine imaging, video capsule endoscopy, and enteroscopy. Pre-endoscopic preparation and decision-making unique to pediatrics is highlighted. The authors conclude with a summary of current and emerging therapeutic hemostatic techniques that can be used in pediatric patients.
Collapse
Affiliation(s)
- Benjamin Sahn
- Division of Pediatric Gastroenterology & Nutrition, Steven & Alexandra Cohen Children's Medical Center of New York, Hofstra North Shore-LIJ School of Medicine, North Shore - Long Island Jewish Health System, 1991 Marcus Avenue, Suite M 100, New Hyde Park, NY 11042, USA.
| | - Samuel Bitton
- Division of Pediatric Gastroenterology & Nutrition, Steven & Alexandra Cohen Children's Medical Center of New York, Hofstra North Shore-LIJ School of Medicine, North Shore - Long Island Jewish Health System, 1991 Marcus Avenue, Suite M 100, New Hyde Park, NY 11042, USA
| |
Collapse
|
|
19
|
Marion Y, Lebreton G, Le Pennec V, Hourna E, Viennot S, Alves A. The management of lower gastrointestinal bleeding. J Visc Surg 2014; 151:191-201. [PMID: 24768401 DOI: 10.1016/j.jviscsurg.2014.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Lower gastrointestinal (LGI) bleeding is generally less severe than upper gastrointestinal (UGI) bleeding with spontaneous cessation of bleeding in 80% of cases and a mortality of 2-4%. However, unlike UGI bleeding, there is no consensual agreement about management. Once the patient has been stabilized, the main objective and greatest difficulty is to identify the location of bleeding in order to provide specific appropriate treatment. While upper endoscopy and colonoscopy remain the essential first-line examinations, the development and availability of angiography have made this an important imaging modality for cases of active bleeding; they allow diagnostic localization of bleeding and guide subsequent therapy, whether therapeutic embolization, interventional colonoscopy or, if other techniques fail or are unavailable, surgery directed at the precise site of bleeding. Furthermore, newly developed endoscopic techniques, particularly video capsule enteroscopy, now allow minimally invasive exploration of the small intestine; if this is positive, it will guide subsequent assisted enteroscopy or surgery. Other small bowel imaging techniques include enteroclysis by CT or magnetic resonance imaging. At the present time, exploratory surgery is no longer a first-line approach. In view of the lesser gravity of LGI bleeding, it is most reasonable to simply stabilize the patient initially for subsequent transfer to a specialized center, if minimally invasive techniques are not available at the local hospital. In all cases, the complexity and diversity of LGI bleeding require a multidisciplinary collaboration involving the gastroenterologist, radiologist, intensivist and surgeon to optimize diagnosis and treatment of the patient.
Collapse
Affiliation(s)
- Y Marion
- Service de chirurgie digestive, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France.
| | - G Lebreton
- Service de chirurgie digestive, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France
| | - V Le Pennec
- Service de radiologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France
| | - E Hourna
- Service de radiologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France
| | - S Viennot
- Service de gastro-entérologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France
| | - A Alves
- Service de radiologie, centre hospitalier universitaire, avenue de la Côte-de-Nacre, 14000 Caen, France; Université de Caen, faculté de médecine, 14000 Caen, France
| |
Collapse
|
|
20
|
Artigas JM, Martí M, Soto JA, Esteban H, Pinilla I, Guillén E. Multidetector CT angiography for acute gastrointestinal bleeding: technique and findings. Radiographics 2014; 33:1453-70. [PMID: 24025935 DOI: 10.1148/rg.335125072] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute gastrointestinal bleeding is a common reason for emergency department admissions and an important cause of morbidity and mortality. Factors that complicate its clinical management include patient debility due to comorbidities; intermittence of hemorrhage; and multiple sites of simultaneous bleeding. Its management, therefore, must be multidisciplinary and include emergency physicians, gastroenterologists, and surgeons, as well as radiologists for diagnostic imaging and interventional therapy. Upper gastrointestinal tract bleeding is usually managed endoscopically, with radiologic intervention reserved as an alternative to be used if endoscopic therapy fails. Endoscopy is often less successful in the management of acute lower gastrointestinal tract bleeding, where colonoscopy may be more effective. The merits of performing bowel cleansing before colonoscopy in such cases might be offset by the resultant increase in response time and should be weighed carefully against the deficits in visualization and diagnostic accuracy that would result from performing colonoscopy without bowel preparation. In recent years, multidetector computed tomographic (CT) angiography has gained acceptance as a first-line option for the diagnosis and management of lower gastrointestinal tract bleeding. In selected cases of upper gastrointestinal tract bleeding, CT angiography also provides accurate information about the presence or absence of active bleeding, its source, and its cause. This information helps shorten the total diagnostic time and minimizes or eliminates the need for more expensive and more invasive procedures.
Collapse
Affiliation(s)
- José M Artigas
- Departments of Radiology, Miguel Servet University Hospital, Paseo de Isabel La Católica 1-3, 50009 Zaragoza, Spain
| | | | | | | | | | | |
Collapse
|
|
21
|
Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2014; 39:15-34. [PMID: 24138285 DOI: 10.1111/apt.12527] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/14/2013] [Accepted: 09/18/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality. AIM To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors. METHODS A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract. RESULTS Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively. CONCLUSIONS Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.
Collapse
Affiliation(s)
- S S Sami
- Nottingham Digestive Diseases Centre & NIHR Biomedical research Unit, Queens Medical Centre, Nottingham, UK
| | | | | |
Collapse
|
|
22
|
Abstract
OBJECTIVE By use of multiphase CT enterography (CTE), small-bowel vascular lesions associated with gastrointestinal bleeding can be classified into three categories--angioectasias, arterial lesions, and venous abnormalities--on the basis of common morphology and enhancement patterns. This article will review the unique patterns of enhancement and lesion morphology seen on multiphase CTE and how those findings enable detection and characterization of specific lesions in many cases. CONCLUSION Because of the high prevalence in nonbleeding patients and frequent multiplicity of angioectasias, determining the clinical benefit from their detection by multiphase CTE and endoscopy is problematic. Although arterial lesions are less commonly encountered clinically, their detection is critically important because of a high risk of life-threatening bleeding. Along with wireless capsule endoscopy and balloon-assisted endoscopy, multiphase CTE is a useful tool for the evaluation of patients with obscure gastrointestinal bleeding due to small-bowel vascular lesions.
Collapse
|
|
23
|
Rossetti A, Buchs NC, Breguet R, Bucher P, Terraz S, Morel P. Transarterial embolization in acute colonic bleeding: review of 11 years of experience and long-term results. Int J Colorectal Dis 2013. [PMID: 23208010 DOI: 10.1007/s00384-012-1621-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Lower gastrointestinal bleeding represents 20 % of all gastrointestinal bleedings. Interventional radiology has transformed the treatment of this pathology, but the long-term outcome after selective embolization has been poorly evaluated. The aim of this study is thus to evaluate the short-term and long-term outcomes after selective embolization for colonic bleeding. METHODS From November 1998 to December 2010, all acute colonic embolizations for hemorrhage were retrospectively reviewed and analyzed. The risk factors for post-embolization ischemia were also assessed. RESULTS Twenty-four patients underwent colonic embolization. There were 6 men and 18 women with a median age of 80 years (range, 42-94 years). The underlying etiologies included diverticular disease (41.9 %), post-polypectomy bleeding (16.7 %), malignancy (8.2 %), hemorrhoid (4.1 %), and angiodysplasia (4.1 %). In 23 patients, bleeding stopped (95.8 %) after selective embolization. One patient presented a recurrence of bleeding with hemorrhagic shock and required urgent hemorrhoidal ligature. Four patients required an emergent surgical procedure because of an ischemic event (16.7 %). One patient died of ileal ischemia (mortality, 4.1 %). The level of embolization and the length of hypoperfused colon after embolization were the only risk factors for emergent operation. Mean hospital stay was 18 days (range, 9-44 days). After a mean follow-up of 28.6 months (range, 4-108 months), no other ischemic events occurred. CONCLUSION In our series, selective transarterial embolization for acute colonic bleeding was clinically effective with a 21 % risk of bowel ischemia. The level of embolization and the length of the hypoperfused colon after embolization should be taken into consideration for emergent operation.
Collapse
Affiliation(s)
- Andrea Rossetti
- Clinic for Visceral Surgery and Transplantation, Department of Surgery, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva, Switzerland
| | | | | | | | | | | |
Collapse
|
|
24
|
Lee SS, Park SH. Computed Tomography Evaluation of Gastrointestinal Bleeding and Acute Mesenteric Ischemia. Radiol Clin North Am 2013. [DOI: 10.1016/j.rcl.2012.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
|
25
|
Yannam GR, Yu DC, Kelly DR, Chen MK, Beierle EA. Angiodysplasia (vascular malformations) of the colon presenting as an acute abdomen. J Pediatr Surg 2012; 47:e37-40. [PMID: 23084229 DOI: 10.1016/j.jpedsurg.2012.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 06/02/2012] [Accepted: 06/24/2012] [Indexed: 10/27/2022]
Abstract
Angiodysplasia (vascular malformations) of the colon is extremely rare in children, and, as in adults, present with lower gastrointestinal hemorrhage. Here we report an unusual pediatric case of angiodysplasia of the terminal ileum and cecum presenting as an acute abdomen with radiological features suggestive of lymphoma.
Collapse
Affiliation(s)
- Govardhana R Yannam
- Pediatric Surgery Division, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | | | | | | | | |
Collapse
|
|
26
|
Kulkarni C, Moorthy S, Sreekumar K, Rajeshkannan R, Nazar P, Sandya C, Sivasubramanian S, Ramchandran P. In the workup of patients with obscure gastrointestinal bleed, does 64-slice MDCT have a role? Indian J Radiol Imaging 2012; 22:47-53. [PMID: 22623816 PMCID: PMC3354358 DOI: 10.4103/0971-3026.95404] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Purpose: The purpose was to prospectively determine the sensitivity of 64-slice MDCT in detecting and diagnosing the cause of obscure gastrointestinal bleed (OGIB). Materials and Methods: Our study included 50 patients (male 30, female 20) in the age range of 3–82 years (average age: 58.52 years) who were referred to our radiology department as part of their workup for clinically evident gastrointestinal (GI) bleed or as part of workup for anemia (with and without positive fecal occult blood test). All patients underwent conventional upper endoscopy and colonoscopy before undergoing CT scan. Following a noncontrast scan, all patients underwent triple-phase contrast CT scan using a 64-slice CT scan system. The diagnostic performance of 64-slice MDCT was compared to the results of capsule endoscopy, 99m-technetium-labeled red blood cell scintigraphy (99mTc-RBC scintigraphy), digital subtraction angiography, and surgery whenever available. Results: CT scan showed positive findings in 32 of 50 patients. The sensitivity, specificity, positive predictive value, and negative predictive values of MDCT for detection of bleed were 72.2%, 42.8%, 81.2%, and 44.4%, respectively. Capsule endoscopy was done in 15 patients and was positive in 10 patients; it had a sensitivity of 71.4%. Eleven patients had undergone 99mTc-RBC scintigraphy prior to CT scan, and the result was positive in seven patients (sensitivity 70%). Digital subtraction angiography was performed in only eight patients and among them all except one patient showed findings consistent with the lesions detected on MDCT. Conclusion: MDCT is a sensitive and noninvasive tool that allows rapid detection and localization of OGIB. It can be used as the first-line investigation in patients with negative endoscopy and colonoscopy studies. MDCT and capsule endoscopy have complementary roles in the evaluation of OGIB.
Collapse
Affiliation(s)
- Chinmay Kulkarni
- Department of Radiology, Amrita Institute of Medical Sciences and Research Center, Elamakkara, Cochin, Kerala, India
| | | | | | | | | | | | | | | |
Collapse
|
|
27
|
Filippone A, Cianci R, Milano A, Pace E, Neri M, Cotroneo AR. Obscure and occult gastrointestinal bleeding: comparison of different imaging modalities. ACTA ACUST UNITED AC 2012; 37:41-52. [PMID: 21912990 DOI: 10.1007/s00261-011-9802-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients with persistent, recurrent, or intermittent bleeding from the gastrointestinal (GI) tract for which no definite cause has been identified by initial esophagogastroduodenoscopy, colonoscopy, or conventional radiologic evaluation are considered to have an obscure GI bleeding (OGIB). The diagnosis and management of patients with OGIB is challenging, often requiring extensive and expensive workups. The main objective is the identification of the etiology and site of bleeding, which should be as rapidly accomplished as possible, in order to establish the most appropriate therapy. The introduction of capsule endoscopy and double balloon enteroscopy and the recent improvements in CT and MRI techniques have revolutionized the approach to patients with OGIB, allowing the visualization of the entire GI tract, particularly the small bowel, until now considered as the "dark continent" . In this article we review and compare the radiologic and endoscopic examinations currently used in occult and OGIB, focusing on diagnostic patterns, pitfalls, strengths, weaknesses, and value in patients' management.
Collapse
Affiliation(s)
- Antonella Filippone
- Department of Neurosciences and Imaging, Section of Radiological Imaging, "G. d'Annunzio" University, Chieti, Italy.
| | | | | | | | | | | |
Collapse
|
|
28
|
Small Bowel Bleeding. GASTROINTESTINAL BLEEDING 2012. [DOI: 10.1002/9781444398892.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
|
29
|
Martí M, Artigas JM, Garzón G, Álvarez-Sala R, Soto JA. Acute Lower Intestinal Bleeding: Feasibility and Diagnostic Performance of CT Angiography. Radiology 2012; 262:109-16. [DOI: 10.1148/radiol.11110326] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
|
30
|
Kochhar GS, Sanaka MR, Vargo JJ. Therapeutic management options for patients with obscure gastrointestinal bleeding. Therap Adv Gastroenterol 2012; 5:71-81. [PMID: 22282709 PMCID: PMC3263978 DOI: 10.1177/1756283x11409280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Obscure gastrointestinal bleeding (OGIB) is one of the most challenging disorders faced by gastroenterologists because of its evasive nature and difficulty in identifying the exact source of bleeding. Recent technological advances such as video capsule endoscopy and small bowel deep enteroscopy have revolutionized the diagnosis and management of patients with OGIB. In this paper, we review the various diagnostic and therapeutic options available for the management of patients with OGIB.
Collapse
Affiliation(s)
- Gursimran S. Kochhar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - John J. Vargo
- Department of Gastroenterology and Hepatology Digestive Disease Institute Cleveland Clinic 9500 Euclid Avenue, Desk A-30 Cleveland, OH, USA
| |
Collapse
|
|
31
|
Al-Saeed O, Kombar O, Morsy M, Sheikh M. Sixty-four multi-detector computerised tomography in the detection of lower gastrointestinal bleeding: A prospective study. J Med Imaging Radiat Oncol 2011; 55:252-8. [PMID: 21696557 DOI: 10.1111/j.1754-9485.2011.02261.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Acute gastrointestinal bleeding (AGIB) is a serious and life-threatening condition. Many diagnostic procedures and tests are being used to detect the site of bleeding with different success rates. The aim of our study is to prospectively evaluate accuracy of 64-slice multi-detector computerised tomography (MDCT) in the diagnosis of lower AGIB. METHODS Between September 2007 and January 2009, patients with presumed lower AGIB were referred to the radiology department of our institution for 64-slice MDCT examination as part of the investigation for the lower AGIB. Any abnormalities to account for bleeding, such as tumours, bowel wall enhancement and increased intraluminal density, were recorded. RESULTS Out of 139 patients with AGIB that were admitted to our casualty department, 27 patients (19 men and 8 women) in the age range of 24-88 years (mean age, 56 years) were suspected to have lower AGIB. Sixty-four-slice MDCT was performed and considered positive for bleeding in 19 (70%) cases, and in all the cases, the bleeding source was indentified in the arterial phase, showing a focal dense wall enhancement in 8 (42%) cases, circumferential wall enhancement in 4 (22%) cases and progressive increasing intraluminal density in 7 (36%) cases. The venous phase scan showed increased dispersion of the contrast within the lumen as an additional clue for active extravasation in 15 (79%) out of the 19 cases. Delayed 5-min scanning showed the same findings as venous phase in all the 19 positive cases and failed to depict any additional findings in the eight cases that were negative on arterial or venous phases. CONCLUSION The study supports the high accuracy of 64-slice MDCT in locating the site of AGIB in patients thought to have a distal source of bleeding. Its accuracy in clinically proximal bleeding is not clear from this study, but MDCT is capable of showing such sources.
Collapse
Affiliation(s)
- Osama Al-Saeed
- Department of Radiology, Kuwait UniversityDepartments of Radiology Surgery, Amiri Hospital, Kuwait City, Kuwait.
| | | | | | | |
Collapse
|
|
32
|
La tomografía computarizada multidetector como primera opción diagnóstica en la hemorragia digestiva baja aguda en Urgencias. RADIOLOGIA 2011; 53 Suppl 1:43-50. [DOI: 10.1016/j.rx.2011.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Revised: 05/06/2011] [Accepted: 05/06/2011] [Indexed: 01/01/2023]
|
|
33
|
Quiroga Gómez S, Pérez Lafuente M, Abu-Suboh Abadia M, Castell Conesa J. [Gastrointestinal bleeding: the role of radiology]. RADIOLOGIA 2011; 53:406-20. [PMID: 21924440 DOI: 10.1016/j.rx.2011.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 12/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- S Quiroga Gómez
- Servicio de Radiodiagnóstico, Hospital Universitari Vall d'Hebron, Barcelona, España.
| | | | | | | |
Collapse
|
|
34
|
|
|
35
|
Fistule aortoduodénale secondaire : croire n’est pas voir ! ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-011-0074-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
|
36
|
Chuang FJ, Lin JS, Yeung CY, Chan WT, Jiang CB, Lee HC. Intestinal angiodysplasia: an uncommon cause of gastrointestinal bleeding in children. Pediatr Neonatol 2011; 52:214-218. [PMID: 21835367 DOI: 10.1016/j.pedneo.2011.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Revised: 09/21/2010] [Accepted: 09/24/2010] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Angiodysplasia of the gastrointestinal (GI) tract is recognized as an important cause of lower GI bleeding in elderly. It usually involves the cecum and right colon in adults. Unlike the adult group, there has been little experience with the pediatric population. METHODS From July 2004 to October 2008, patients presenting at the Mackay Memorial Hospital with GI hemorrhage diagnosed as angiodysplasia by helical computed tomographic angiography were reviewed. RESULTS Eighteen patients (14 boys and 4 girls) with mean age of 7.1 years (range, 1 month to 17 years) were diagnosed. The time from initial clinical onset to diagnosis of angiodysplasia ranged from 1 week to 11 years, most around 1-2 weeks. All patients except one had anemia and an average hemoglobin level of 7.9 ± 2.1g/dL. The most commonly involved areas were ascending colon and terminal ileum. Four patients received surgery treatment with resection of affected segments. CONCLUSIONS In pediatric patients, angiodysplasia is a rare cause of GI bleeding and may be delayed in diagnosis. This diagnosis should be considered when patients have recurrent GI bleeding. In this study, the final surgical and pathological diagnosis was made in 6 of 18 patients. In six patients, computed tomographic angiography had 66% diagnostic accuracy for angiodysplasia (four of six patients who received operation were compatible with angiodysplasia by confirmation of histology).
Collapse
Affiliation(s)
- Feng-Ju Chuang
- Department of Pediatrics, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | | | | | | | | | | |
Collapse
|
|
37
|
Huprich JE, Fletcher JG, Fidler JL, Alexander JA, Guimarães LS, Siddiki HA, McCollough CH. Prospective blinded comparison of wireless capsule endoscopy and multiphase CT enterography in obscure gastrointestinal bleeding. Radiology 2011; 260:744-51. [PMID: 21642417 DOI: 10.1148/radiol.11110143] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- James E Huprich
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | | | | | | | | | | | | |
Collapse
|
|
38
|
Wu LM, Xu JR, Yin Y, Qu XH. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: A meta-analysis. World J Gastroenterol 2010; 16:3957-63. [PMID: 20712058 PMCID: PMC2923771 DOI: 10.3748/wjg.v16.i31.3957] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
|
39
|
Copland A, Munroe CA, Friedland S, Triadafilopoulos G. Integrating urgent multidetector CT scanning in the diagnostic algorithm of active lower GI bleeding. Gastrointest Endosc 2010; 72:402-5. [PMID: 20674629 DOI: 10.1016/j.gie.2010.04.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 04/13/2010] [Indexed: 02/08/2023]
Affiliation(s)
- Andrew Copland
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Stanford, California, USA
| | | | | | | |
Collapse
|
|
40
|
Graça BM, Freire PA, Brito JB, Ilharco JM, Carvalheiro VM, Caseiro-Alves F. Gastroenterologic and Radiologic Approach to Obscure Gastrointestinal Bleeding: How, Why, and When? Radiographics 2010; 30:235-52. [DOI: 10.1148/rg.301095091] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
|
41
|
Optimized multidetector computed tomographic protocol for the diagnosis of active obscure gastrointestinal bleeding: a feasibility study. J Comput Assist Tomogr 2009; 33:698-704. [PMID: 19820495 DOI: 10.1097/rct.0b013e3181937f1b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The purpose of this feasibility study was to prospectively evaluate an optimized multidetector computed tomographic protocol for the diagnosis of active obscure gastrointestinal bleeding (OGIB). METHODS Between October 2006 and February 2008, patients admitted for active OGIB were included in this prospective unicenter study. Water was administered orally and rectally as neutral luminal contrast material. A contrast-enhanced 16-row multidetector computed tomography (MDCT) was performed in the arterial and venous phases. Mesenteric digital subtraction angiography was carried out immediately after MDCT as standard of reference. RESULTS Six patients were included in this study. Multidetector computed tomography identified the bleeding site and source in 5 (83%) of the patients. Digital subtraction angiography was performed in 4 patients, and the result was positive in 1 (25%) of the patients. Multidetector computed tomography detected the site and source of bleeding in 2 patients whose digital subtraction angiographic result was negative. CONCLUSIONS The results of this feasibility study indicate that optimized MDCT is an excellent diagnostic tool for the diagnosis of active OGIB.
Collapse
|
|
42
|
Abstract
Lower gastrointestinal bleeding (LGIB) can present as an acute and life-threatening event or as chronic bleeding, which might manifest as iron-deficiency anemia, fecal occult blood or intermittent scant hematochezia. Bleeding from the small bowel has been shown to be a distinct entity, and LGIB is defined as bleeding from a colonic source. Acute bleeding from the colon is usually less dramatic than upper gastrointestinal hemorrhage and is self-limiting in most cases. Several factors might contribute to increased mortality, a severe course of bleeding and recurrent bleeding, including advanced age, comorbidity, intestinal ischemia, bleeding as a result of a separate process, and hemodynamic instability. Diverticula, angiodysplasias, neoplasms, colitis, ischemia, anorectal disorders and postpolypectomy bleeding are the most common causes of LGIB. Volume resuscitation should take place concurrently upon initial patient assessment. Colonoscopy is the diagnostic and therapeutic procedure of choice, for acute and chronic bleeding. Angiography is used if colonoscopy fails or cannot be performed. The use of radioisotope scans is reserved for cases of unexplained intermittent bleeding, when other methods have failed to detect the source. Embolization or modern endoscopy techniques, such as injection therapy, thermocoagulation and mechanical devices, effectively promote hemostasis. Surgery is the final approach for severe bleeding.
Collapse
|
|
43
|
Abstract
Multiphase CT enterography is a modification of conventional abdominal CT designed to optimize detection of abnormalities responsible for obscure GI bleeding. This imaging test appears to be complimentary to wireless capsule endoscopy in the evaluation of this difficult group of patients. A description of exam technique, findings, and discussion of results will be presented in this article.
Collapse
|
|
44
|
Lim LG, Lee YM, Tan L, Chang S, Lim SG. Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices. World J Gastroenterol 2009; 15:3823-6. [PMID: 19673028 PMCID: PMC2726465 DOI: 10.3748/wjg.15.3823] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A 48-year-old Indian male with alcoholic liver cirrhosis was admitted after being found unresponsive. He was hypotensive and had hematochezia. Esophagogastroduodenoscopy (EGD) showed small esophageal varices and a clean-based duodenal ulcer. He continued to have hematochezia and anemia despite blood transfusions. Colonoscopy was normal. Repeat EGD did not reveal any source of recent bleed. Twelve days after admission, his hematochezia ceased. He refused further investigation and was discharged two days later. He presented one week after discharge with hematochezia. EGD showed non-bleeding Grade 1 esophageal varices and a clean-based duodenal ulcer. Colonoscopy was normal. Abdominal computed tomography (CT) showed liver cirrhosis with mild ascites, paraumbilical varices, and splenomegaly. He had multiple episodes of hematochezia, requiring repeated blood transfusions. Capsule endoscopy identified the bleeding site in the jejunum. Concurrently, CT angiography showed paraumbilical varices inseparable from a loop of small bowel, which had herniated through an umbilical hernia. The lumen of this loop of small bowel opacified in the delayed phase, which suggested variceal bleeding into the small bowel. Portal vein thrombosis was present. As he had severe coagulopathy and extensive paraumbilical varices, surgery was of high risk. He was not suitable for transjugular intrahepatic porto-systemic shunt as he had portal vein thrombosis. Percutaneous paraumbilical embolization via caput medusa was performed on day 9 of hospitalization. Following the embolization, the hematochezia stopped. However, he defaulted subsequent follow-up.
Collapse
|
|
45
|
Multi-detector row CT of patients with acute intestinal bleeding: a new perspective using multiplanar and MIP reformations from submillimeter isotropic voxels. ACTA ACUST UNITED AC 2009; 35:296-305. [PMID: 19444501 DOI: 10.1007/s00261-009-9521-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 04/19/2009] [Indexed: 10/20/2022]
Abstract
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.
Collapse
|
|
46
|
Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding. J Med Imaging Radiat Oncol 2009; 52:333-8. [PMID: 18811756 DOI: 10.1111/j.1440-1673.2008.01964.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
Collapse
Affiliation(s)
- A E Chua
- Department of PET registrar, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
| | | |
Collapse
|
|
47
|
Czymek R, Kempf A, Roblick UJ, Bader FG, Habermann J, Kujath P, Bruch HP, Fischer F. Surgical treatment concepts for acute lower gastrointestinal bleeding. J Gastrointest Surg 2008; 12:2212-20. [PMID: 18636299 DOI: 10.1007/s11605-008-0597-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 06/25/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE To this day, the diagnostic and therapeutic strategy for acute lower gastrointestinal hemorrhage requiring transfusion varies among different hospitals. The purpose of this paper was to evaluate our own data on the group of patients presented and to outline our diagnostic and therapeutic regime taking into account the literature of the past 30 years. METHODS Following prospective data collection on 63 patients of a university hospital (40 male, 23 female patients) who received surgical intervention for acute lower intestinal hemorrhage requiring transfusion, we retrospectively analyzed the data. After a medical history had been taken, all patients underwent clinical examination, including digital palpation; 62 patients underwent procto-rectoscopy, 38 gastroscopy and colonoscopy, 52 patients colonoscopy only, and 45 patients gastroscopy only. Angiography was applied in 14 cases and scintigraphy in 20 cases. RESULTS Diagnostic procedures to localize hemorrhage were successful in 61 cases, 41 of which through endoscopy, 12 through angiography, and eight through scintigraphy. Of our group of patients, 32 suffered from a bleeding colonic diverticulum, eight from angiodysplasia, and five from bleeding small bowel diverticula. Five patients had inflammatory bowel disease and three neoplasia. Among the surgical interventions, segmental resections were performed most frequently (15 sigmoidectomies, 11 small bowel segmental resections, 11 left hemicolectomies, seven right hemicolectomies, one proctectomy). Subtotal colectomies were carried out in ten cases. The complication rate for this group of critically ill, negatively selected patients was 60.3% and the mortality rate was 15.9%. CONCLUSIONS Examination and stabilization of the patient is directly followed by diagnostic localization. Today, we primarily rely on nonsurgical control of hemorrhage by endoscopy or angiography; the indication for surgery is mainly limited to peracute, uncontrollable, and recurrent forms. In the case of surgery, intestinal segmental resection is recommended after identification of the lesion; if the localization of colonic hemorrhage is uncertain, subtotal resection is the method of choice. For stable patients with unverifiable small-bowel hemorrhage we recommend regular re-evaluation.
Collapse
Affiliation(s)
- Ralf Czymek
- Department of Surgery, University of Lübeck Medical School, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
|
48
|
Jaeckle T, Stuber G, Hoffmann MHK, Freund W, Schmitz BL, Aschoff AJ. Acute gastrointestinal bleeding: value of MDCT. ACTA ACUST UNITED AC 2008; 33:285-93. [PMID: 17639378 DOI: 10.1007/s00261-007-9263-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- T Jaeckle
- Diagnostic and Interventional Radiology, University Hospitals of Ulm, Ulm, Germany.
| | | | | | | | | | | |
Collapse
|
|
49
|
Sandrasegaran K, Maglinte DDT, Jennings SG, Chiorean MV. Capsule endoscopy and imaging tests in the elective investigation of small bowel disease. Clin Radiol 2008; 63:712-23. [PMID: 18455564 DOI: 10.1016/j.crad.2008.01.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Revised: 01/02/2008] [Accepted: 01/20/2008] [Indexed: 02/07/2023]
Abstract
Capsule endoscopy enables high-resolution depiction of small bowel mucosa and has been shown, by several studies, to have a high diagnostic yield in a variety of small bowel diseases. In this review, we critically assess the contributions of capsule endoscopy and imaging tests in common small bowel disorders. Radiological tests that only assess the small bowel mucosa will be less useful in the era of capsule endoscopy.
Collapse
Affiliation(s)
- K Sandrasegaran
- Department of Radiology, Indiana University School of Medicine, USA.
| | | | | | | |
Collapse
|
|
50
|
Abstract
Acute bleeding from the colon and rectum is less frequent and less dramatic than haemorrhage from the upper gastrointestinal tract. In most cases, bleeding from the colon and rectum is self-limiting and requires no specific therapy. Diverticula and angiectasias are the most frequent sources of bleeding. Malignancy, colitis (inflammatory bowel disease, non-steroidal anti-inflammatory drugs, and infectious colitis), ischaemia, anorectal disorders, postpolypectomy bleeding, and HIV-related problems are less frequent causes. The recurrence rate, especially in diverticular bleeding, is high. Resuscitation and haemodynamic stabilisation of the patient is the first step in the management of colonic bleeding. Urgent colonoscopy is the method of choice for diagnosis and therapy. By analogy with peptic ulcer bleeding, risk stratification using stigmata of haemorrhage is gaining more importance. Modern endoscopic techniques such as injection therapy, thermocoagulation and mechanical devices seem to be effective in achieving haemostasis and avoiding precarious surgery. Angiography and nuclear scintigraphy are reserved for those patients in whom colonoscopy is not possible or has repeatedly failed to localise the bleeding site.
Collapse
Affiliation(s)
- J Barnert
- III. Medizinische Klinik, Klinikum Augsburg, Postfach 101920, D-86009 Augsburg, Germany
| | | |
Collapse
|