Contrast-enhanced CT for Colonic Diverticular Bleeding before Colonoscopy: A Prospective Multicenter Study

Abstract

Purpose To demonstrate the usefulness of precolonoscopy intravenous contrast material-enhanced CT for colonic diverticular bleeding (CDB). Materials and Methods A prospective, multicenter, observational study was performed. Patients with acute-onset hematochezia who were admitted to hospital were included, and those without CDB were excluded. CT was performed before colonoscopy. A Mann-Whitney U test, χ test, and multivariable logistic regression analysis were performed to determine the accuracy of CT before colonoscopy. Results A total of 442 patients (mean age, 71.2 years; 302 male patients; 68.3% men) were included between January 2014 and December 2015, and 202 patients were diagnosed as having CDB. The positive extravasation rate during CT was 50 of 202 (24.7%) among all patients and five of nine (55.6%) among patients who underwent CT within 1 hour of the last hematochezia. At multivariable analysis, the interval from the last hematochezia until CT was a predictor of extravasation (beta coefficient, -.0038 ± 0.0014 [standard deviation]). Extravasation at CT had a sensitivity of 38 of 66 (57.6%; 95% confidence interval: 44.8%, 69.7%) and a specificity of 124 of 136 (91.2%; 95% confidence interval: 85.1%, 95.4%) for the prediction of stigmata of recent hemorrhage of diverticula during colonoscopy. The sensitivity was higher in patients who underwent CT examination within 4 hours of hematochezia, compared with those examined after 4 hours (64.7% [33 of 51] vs 33.3% [five of 15]; P < .01). Conclusion Extravasation findings for CT with intravenous contrast material had high specificity for the prediction of stigmata of recent hemorrhage of diverticula during colonoscopy, regardless of the timing of the CT examination. Although the sensitivity was relatively low, it was higher when the CT examination was performed within 4 hours after the last hematochezia. Therefore, urgent precolonoscopy CT may contribute to decision making regarding whether an urgent colonoscopy should be performed.

Effectiveness of risk scoring systems in predicting endoscopic treatment in colonic diverticular bleeding

“…The usefulness of contrast‐enhanced CT in SRH identification has been shown in the previous reports, and in cases of extravasation observed at CT, sensitivity and specificity for SRH identification were 57.6 (95% CI, 44.8–69.7) and 91.2 (95% CI, 85.1–95.4), respectively . However, contrast‐enhanced CT in cases of ALGIB is currently not routinely performed, except in some high‐volume centers.…”

Initial management for acute lower gastrointestinal bleeding

“…Furthermore, several studies have focused on the association between extravasation on CT and definitive diverticular bleeding on colonoscopy (Table 4). The colonoscopic detection rate of bleeding diverticula is significantly higher in patients with extravasation on CT than in those without (60%-76% vs 18%-31%)[54-56], suggesting that extravasation on CT is a reasonable indication for urgent colonoscopy to detect SRH. However, CT is not recommended for all cases due to the low rate of positive extravasation (15%-25%) documented in prospective studies of diverticular bleeding[56,57].…”

Epidemiology of colonic diverticula and recent advances in the management of colonic diverticular bleeding

“…Extravasation findings by eCT had high specificity for the prediction and location of SRH. Two retrospective studies 32,51 and one prospective study 52 showed that SRH detection rates were significantly higher in extravasation-positive patients (60-76%) compared to extravasation-negative patients (18-31%). Extravasation-positive rates were not so high, ranging from 25% to 36%, among the three studies.…”

“…Extravasation‐positive rates were not so high, ranging from 25% to 36%, among the three studies. The prospective study showed that positivity rate of CT for extravasation was dependent on the timing of CT in relation to the last episode of hematochezia. Of patients who underwent CT within 1 h of the last hematochezia episode, the extravasation rate was 55.6% compared with 30% if the timing was 1–4 h after the last episode, and just 12% if greater than 4 h after.…”