CT enteroclysis in the diagnosis of obscure gastrointestinal bleeding: initial results
Introduction
Bleeding from the gastrointestinal (GI) tract can be overt when blood loss is obvious, such as haematemesis, melaena or haematochezia; or occult when the bleeding is not obvious and patients present with unexplained iron deficiency anaemia and/or a positive faecal occult blood test. When the cause of GI bleeding is not found even after the endoscopic examination of both the upper and lower GI tract, such patients are designated as having obscure GI bleeding (OGIB). It is estimated that up to 5% of patients with GI bleeding have OGIB.1 The management of patients with OGIB is generally difficult and requires repeated hospitalizations, multiple blood transfusions, and repetitive investigations, both invasive and non-invasive, because of the elusive aetiology and intermittent nature of the blood loss. The important causes of small bowel OGIB include angiodysplasia, small bowel tumours, non-steroidal anti-inflammatory drug-induced mucosal erosions, vasculitic syndromes, radiation enteritis, Meckel's diverticulum, Crohn's disease, and Dieulafoy's lesions.2, 3
CT enteroclysis performed using multisection CT combines the advantages of enteral volume challenge to achieve optimal bowel distention, cross-sectional imaging, multiplanar reformatted imaging, and imaging in both the arterial and venous phases.4 It not only demonstrates luminal lesions, but extra-luminal disease can also be seen. CT enteroclysis is a fusion of enteroclysis, CT of the abdomen, and abdominal CT angiography; therefore, it is a useful technique for the evaluation of the small intestine. There is a paucity of literature on the use of CT enteroclysis in patients with OGIB. Therefore, in a prospective, pilot study, CT enteroclysis was evaluated for use in the detection of sources of bleeding in patients with OGIB.
Section snippets
Patients
In a prospective study, 21 consecutive patients (median age 50 years; range 13–71 years) with OGIB, in whom the source of GI bleeding could not be detected using upper GI endoscopic and colonoscopic examinations, underwent CT enteroclysis. Pregnant women, patients with bleeding disorders, thrombocytopaenia, and those with previous history of allergic reaction to iodinated contrast media were excluded from the study. Patients were classified as having overt OGIB, when they had presented with
Image analysis
Images were analysed primarily in the axial plane and then multiplanar reconstruction (MPR) and maximum intensity projection (MIP) images were generated in the coronal and sagittal planes. All the CT enteroclysis images were viewed independently both at the CT workstation and also on hard copy by two experienced abdominal radiologists having 10 years (M.S.G.) and 8 years (S.B.) experience of abdominal CT. A consensus opinion was then made on the findings of the CT enteroclysis.
The distension of
Results
CT enteroclysis was performed successfully in all the patients. Adequate distension of the intestine was achieved in 20 of 21 (95.2%) patients. Distension of the colon and even rectum was observed in 13 of 21 (61.9%) patients; therefore, in these patients, evaluation of the rectum and colon could also be performed. Administration of an additional 200 ml of 0.5% methylcellulose into the duodenum and stomach during withdrawal of the jejunal catheter also enabled radiological evaluation of these
Discussion
In the present study, potential causes of bleeding were identified using CT enteroclysis in 47.6% (10 of 21) patients with OGIB. Re-examination in patients with OGIB often reveals lesions, within the reach of standard upper GI endoscopy or colonoscopy, which were overlooked at the initial endoscopic examination. Such lesions include erosions within hiatus hernias (Cameron's erosions), peptic ulcers on the antero-posterior wall, vascular ectasias, angiodysplasias, and small neoplasms. Hence, a
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Cited by (32)
Enteroscopy in diagnosis and treatment of small bowel bleeding: A Delphi expert consensus
2023, Digestive and Liver DiseaseCitation Excerpt :Patients with brisk suspected SBB and hemodynamic instability might not be suitable for endoscopy. In this setting, or in case of overt midgut bleeding [26] and failed endoscopic hemostasis, the multiphasic CT-scan (CT angiography) should be promptly considered because is rapid, broadly available and allows detection and characterization of the site and etiology of the active hemorrhage with high accuracy (sensitivity 89%, specificity 85%) [27,28]. After the radiological identification of the site of active hemorrhage, angiography and subsequent embolization represent the optimal treatment option in most cases of massive midgut bleeding.
ACR Appropriateness Criteria<sup>®</sup> Nonvariceal Upper Gastrointestinal Bleeding
2017, Journal of the American College of RadiologyContrast-Enhanced Cross Sectional Imaging and Capsule Endoscopy: New Perspectives for a Whole Picture of the Small Bowel
2016, GE Portuguese Journal of GastroenterologyCitation Excerpt :Studies have shown that SBCE is associated with an increase in diagnostic yield of 20–40%64,65 when compared to CTE, and this advantage was even more pronounced in superficial lesions with no luminal repercussion, such as vascular malformations,65 the most frequently observed origin of OGIB (20–55%).66 However, CTE may be the superior diagnostic modality in some cases, particularly during massive overt OGIB, where SBCE may be unable to locate or define the origin of the bleeding,67 and in patients with small bowel tumours.68 Few studies have reported on the usefulness of MRE in the context of OGIB, but its use it limited by a lower spatial resolution than CTE,5 reduced availability in the urgent setting,6 and cost.69
Computed Tomography Enteroclysis
2014, Textbook of Gastrointestinal Radiology: Volumes 1-2, Fourth EditionRole of CT enterography in obscure gastrointestinal bleeding
2013, Egyptian Journal of Radiology and Nuclear MedicineCitation Excerpt :The role of CT in the diagnosis of causes of gastrointestinal bleeding continues to grow because of improvements in scanning technology and favorable diagnostic outcomes in many articles (24–28). Several studies, however, vary with the type of scanning performed, that is single phase (3), dual phase (4,29,30), or triple phase (2). Our study focused on the use of dual phase CT enterography for the detection of an obscure gastrointestinal bleed.