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

doi:10.1016/j.crad.2007.01.026

Clinical Radiology

Volume 62, Issue 7, July 2007, Pages 660-667

https://doi.org/10.1016/j.crad.2007.01.026 Get rights and content

Aim

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

Materials and methods

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

Results

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

Conclusions

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

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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Upper gastrointestinal bleeding (UGIB) remains a significant cause of morbidity and mortality with mortality rates as high as 14%. This document addresses the indications for imaging UGIB that is nonvariceal and unrelated to portal hypertension. The four variants are derived with respect to upper endoscopy. For the first three, it is presumed that upper endoscopy has been performed, with three potential initial outcomes: endoscopy reveals arterial bleeding source, endoscopy confirms UGIB without a clear source, and negative endoscopy. The fourth variant, “postsurgical and traumatic causes of UGIB; endoscopy contraindicated” is considered separately because upper endoscopy is not performed. When endoscopy identifies the presence and location of bleeding but bleeding cannot be controlled endoscopically, catheter-based arteriography with treatment is an appropriate next study. CT angiography (CTA) is comparable with angiography as a diagnostic next step. If endoscopy demonstrates a bleed but the endoscopist cannot identify the bleeding source, angiography or CTA can be typically performed and both are considered appropriate. In the event of an obscure UGIB, angiography and CTA have been shown to be equivalent in identifying the bleeding source; CT enterography may be an alternative to CTA to find an intermittent bleeding source. In the postoperative or traumatic setting when endoscopy is contraindicated, primary angiography, CTA, and CT with intravenous contrast are considered appropriate.
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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.
Obscure gastrointestinal bleeding is a radiological challenge where in almost half of the patients; the origin of the blood loss remains unexplained.
To highlight the use of dual phase CT enterography for the detection of obscured gastrointestinal bleed.
Twenty consecutive patients (11 men and 9 women) with OGIB were included in this study; their age ranged from 28 to 67 years (mean age 45.6 years). CT enterography was performed first with a non-contrast scan, followed by biphasic contrast-enhanced CT at 35 and 70 s at a rate of 4 mL/s.
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CT enteroclysis in the diagnosis of obscure gastrointestinal bleeding: initial results

Aim

Materials and methods

Results

Conclusions

Introduction

Section snippets

Patients

Image analysis

Results

Discussion

Gastroenterology

Gastrointest Endosc

Semin Roentgenol

Clin Imaging

Gastroenterology

Gastroenterol Clin North Am