Outcome Following a Negative CT Angiogram for Gastrointestinal Hemorrhage

Abstract

Objective This study was designed to evaluate the role of a negative computed tomography angiogram (CTA) in patients who present with gastrointestinal (GI) hemorrhage. Methods A review of all patients who had CTAs for GI hemorrhage over an 8-year period from January 2005 to December 2012 was performed. Data for patient demographics, location of hemorrhage, hemodynamic stability, and details of angiograms and/or the embolization procedure were obtained from the CRIS/PACS database, interventional radiology database, secure electronic medical records, and patient's clinical notes. Results A total of 180 patients had 202 CTAs during the 8-year period: 87 CTAs were performed for upper GI hemorrhage (18 positive for active bleeding, 69 negative) and 115 for lower GI hemorrhage (37 positive for active bleeding, 78 negative); 58.7 % (37/63) of patients with upper GI bleed and 77.4 % (48/62) of patients with lower GI bleed who had an initial negative CTA did not rebleed without the need for radiological or surgical intervention. This difference was statistically significant (p = 0.04). The relative risk of rebleeding, following a negative CTA, in lower GI bleeding versus upper GI bleeding patients is 0.55 (95 % confidence interval 0.32-0.95). Conclusions Patients with upper GI bleed who had negative CTAs usually require further intervention to stop the bleeding. In contrast, most patients presenting with lower GI hemorrhage who had a negative first CTA were less likely to rebleed.

Lower gastrointestinal bleeding—Computed Tomographic Angiography, Colonoscopy or both?

“…found that 77% of patients with negative studies did not need further intervention. In 68% of cases the exam did not show features of active bleeding, which is consistent with the present findings [7]. …”

“…reporting about 90% of patients with LGIB and positive CTA needing intervention for bleeding control. However, surgery was performed in 24% of cases whereas embolization was successful in 64% of patients [7]. In a study from Nagata & al., early colonoscopy following CTA resulted in a higher detection rate of colonic vascular lesions than colonoscopy alone [19].…”

“…Chan & al. proposed a management pathway including CTA after negative endoscopic evaluation [7]. The fact that so much various algorithms are proposed suggests that further research is needed.

Fig.

…”

Topical haemostatic powder as a novel endoscopic therapy for severe colonic diverticular bleeding

“…CTMAs can be falsely negative when bleeding is <0.5 mL/min or in the presence of intermittent bleeding, and should be used in those with brisk ongoing bleeding that is not amenable or not effectively treated by colonoscopy . In a study evaluating outcomes following negative CTMA, 22% of 115 cases developed subsequent acute bleeding requiring further radiological or surgical intervention within the same admission . The overall yield of CTMA is 50–70%, with 65–85% of these resulting in haemostasis if mesenteric angiograms and angioembolization were successful .…”

“…Whilst most resolve spontaneously, 20–30% continue to bleed torrentially, necessitating invasive interventions such as angioembolization, endoscopic haemostatic techniques or emergency surgery . Angioembolization following a positive computed tomography mesenteric angiogram (CTMA) is useful, but a negative CTMA in the setting of intermittent severe bleeding limits its role . As the identification of specific culprit diverticulum during colonoscopy is difficult, direct therapeutic options such as clipping, adrenaline injection and band ligation are limited.…”