Abstract
Background
The clinical significance of performing computed tomography (CT) for acute lower gastrointestinal bleeding (LGIB) remains unknown. This study aimed to evaluate the role of urgent CT in acute LGIB settings.
Methods
The cohort comprised 223 patients emergently hospitalized for LGIB who underwent early colonoscopy within 24 h of arriving at the hospital, including 126 who underwent CT within 3 h of arrival. We compared the bleeding source rate between two strategies: early colonoscopy following urgent CT or early colonoscopy alone.
Results
No significant differences in age, sex, comorbidities, vital signs, or laboratory data were observed between the strategies. The detection rate was higher with colonoscopy following CT for vascular lesions (35.7 vs. 20.6 %, p = 0.01), leading to more endoscopic therapies (34.9 vs. 13.4 %, p < 0.01). Of the 126 who underwent colonoscopy following CT, 26 (20.6 %) had extravasation and 34 (27.0 %) had nonvascular findings. The sensitivity and specificity of CT extravasation and nonvascular findings for predicting vascular lesions and inflammation or tumors were 37.8 and 88.9 and 81.3 and 80.9 %, respectively. A high κ agreement (0.83, p < 0.01) for active bleeding locations was found between CT and subsequent colonoscopy. There were no cases of contrast-induced nephropathy after 1 week of CT.
Conclusions
Urgent CT before colonoscopy had about 15 % additional value for detecting vascular lesion compared to colonoscopy alone and thus enabled subsequent endoscopic therapies. Contrast-enhanced CT in acute LGIB settings was safe and correctly identified the presence and location of active bleeding, as well as severe inflammation or tumor stenosis, facilitating decision making.
Similar content being viewed by others
References
Lhewa DY, Strate LL. Pros and cons of colonoscopy in management of acute lower gastrointestinal bleeding. World J Gastroenterol. 2012;18:1185–90.
ASGE Standards of Practice Committee, Pasha SF, Shergill A, et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc. 2014;79:875–85.
Kaltenbach T, Watson R, Shah J, et al. Colonoscopy with clipping is useful in the diagnosis and treatment of diverticular bleeding. Clin Gastroenterol Hepatol. 2012;10:131–7.
Jensen DM, Machicado GA, Jutabha R, et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. 2000;342:78–82.
Yamaguchi T, Yoshikawa K. Enhanced CT for initial localization of active lower gastrointestinal bleeding. Abdom Imaging. 2003;28:634–6.
Amarteifio E, Sohns C, Heuser M, et al. Detection of gastrointestinal bleeding by using multislice computed tomography—acute and chronic hemorrhages. Clin Imaging. 2008;32:1–5.
Jaeckle T, Stuber G, Hoffmann MH, et al. Detection and localization of acute upper and lower gastrointestinal (GI) bleeding with arterial phase multi-detector row helical CT. Eur Radiol. 2008;18:1406–13.
Yoon W, Jeong YY, Shin SS, et al. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology. 2006;239:160–7.
Obana T, Fujita N, Sugita R, et al. Prospective evaluation of contrast-enhanced computed tomography for the detection of colonic diverticular bleeding. Dig Dis Sci. 2013;58:1985–90.
Barrett BJ, Parfrey PS. Clinical practice. preventing nephropathy induced by contrast medium. N Engl J Med. 2006;354:379–86.
Ell C, Fischbach W, Bronisch HJ, et al. Randomized trial of low-volume PEG solution versus standard PEG + electrolytes for bowel cleansing before colonoscopy. Am J Gastroenterol. 2008;103:883–93.
Niikura R, Nagata N, Aoki T, et al. Predictors for identification of stigmata of recent hemorrhage on colonic diverticula in lower gastrointestinal bleeding. Gastroenterol: J Clin; 2014.
Strate LL. Lower GI bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am. 2005;34:643–64.
Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc. 1999;49:228–38.
Green BT, Rockey DC, Portwood G, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005;100:2395–402.
Sim J, Wright CC. The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther. 2005;85:257–68.
Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. the role of urgent colonoscopy after purge. Gastroenterology. 1988;95:1569–74.
Strate LL, Syngal S. Predictors of utilization of early colonoscopy vs. radiography for severe lower intestinal bleeding. Gastrointest Endosc. 2005;61:46–52.
Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding. J Med Imaging Radiat Oncol. 2008;52:333–8.
Hur S, Jae HJ, Lee M, et al. Safety and efficacy of transcatheter arterial embolization for lower gastrointestinal bleeding: a single-center experience with 112 patients. J Vasc Interv Radiol. 2014;25:10–9.
Gady JS, Reynolds H, Blum A. Selective arterial embolization for control of lower gastrointestinal bleeding: recommendations for a clinical management pathway. Curr Surg. 2003;60:344–7.
Tan KK, Nallathamby V, Wong D, et al. Can superselective embolization be definitive for colonic diverticular hemorrhage? An institution’s experience over 9 years. J Gastrointest Surg. 2010;14:112–8.
Foutch PG. Diverticular bleeding: are nonsteroidal anti-inflammatory drugs risk factors for hemorrhage and can colonoscopy predict outcome for patients? Am J Gastroenterol. 1995;90:1779–84.
Nagata N, Niikura R, Aoki T, et al. Lower GI bleeding risk of nonsteroidal anti-inflammatory drugs and antiplatelet drug use alone and the effect of combined therapy. Endosc: Gastrointest; 2014.
Strate LL, Orav EJ, Syngal S. Early predictors of severity in acute lower intestinal tract bleeding. Arch Intern Med. 2003;163:838–43.
Acknowledgments
We thank the clinical research coordinators Ms. Hisae Kawashiro, Sawako Iijima, Yoko Tanigawa, Aiko Gotannda, and Yaeko Sawada for help with data collection. This study was partly supported by a grant for research and development from the National Center for Global Health and Medicine (26A-201).
Conflict of interest
The authors declare that they have no conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Nagata, N., Niikura, R., Aoki, T. et al. Role of urgent contrast-enhanced multidetector computed tomography for acute lower gastrointestinal bleeding in patients undergoing early colonoscopy. J Gastroenterol 50, 1162–1172 (2015). https://doi.org/10.1007/s00535-015-1069-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00535-015-1069-9