Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI...
Transcript of Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI...
Upper and Lower GI bleeding CTA and invasive angiogram
Nakarin Inmutto, MD
Chiang Mai University, Thailand
Introduction
• Acute gastrointestinal (GI) bleeding is common .
• Need rapid diagnosis and treatment.
• Bleeding can occur anywhere throughout the GI tract.
• Upper GI tract >>> lower GI tract. (75% vs 25%)
• Hematemesis, coffee ground emesis, melena
• 80%–85% of cases of GI bleeding resolve spontaneously
GI bleeding
GI bleeding
Stability
GI bleeding
Stability
Source of bleeding Upper VS Lower
Common cause of bleeding
Upper GI bleeding
• Esophageal varices
• Gastritis or duodenitis
• Peptic ulcer
• Arteriovenous malformation
Lower GI bleeding
• Diverticular disease
• Colitis and IBD
• Neoplasia
• Coagulopathic hemorrhage
• Angiodysplasia
Current nomenclature
• Upper GI bleeding (UGIB) = bleeding originating proximal to the Treitz ligament.
• Lower GI bleeding (LGIB) = bleeding originating from the colon or rectum.
• Suspected small-bowel bleeding = upper and lower GI tracts have been evaluated (typically with endoscopy) and no bleeding site has been identified.
CT for Evaluation of Acute Gastrointestinal Bleeding; RadioGraphics 2018; 38:1089–1107
CT angiography: Role
• Rapid localizing the source of bleeding
• Differentiating the underlying disease
• Aiding decisions to proceed to endovascular therapies
Diagnostic modalities in acute GI bleeding
Wortman JR, LandmanW, Fulwadhva UP, Viscomi SG, Sodickson AD. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90: 20170076
CT angiography: Role
• Positive result
• Sensitivity 85%, Specificity 92%
• Negative result
• Unlikely to need emergent surgical or angiographic intervention
• Discharge from hospital without intervention
CT technique
• Oral contrast is not administered
• Non-contrast, arterial and venous phase
• The scan range diaphragm to below the inferior pubic rami
• Contrast injection, 100–125 ml , 4–5 ml/ sec
• Reconstruction; 5-mm thickness for non-contrast images and 1.25 mm for arterial and venous phase images.
• Multiplanar reformation images in the sagittal and coronal planes
• Maximum intensity projection images in the sagittal and coronal planes
Renal dysfunction?
• Jacovides , et al.
• JAMA Surg 2015;150(7):650–656.
• Catheter angiogram vs underwent CTA before catheter angiogram
• Received a greater cumulative iv contrast load (130cc – 220cc).
• Additional contrast load was not associated with greater renal dysfunction.
CT findings
• Contrast extravasation
• Non-contrast images; not present
• Arterial phase; intraluminal focus of high attenuation
• Portal venous phase; change in appearance and generally moves distally within the bowel lumen.
Upper GI bleeding
Upper GI bleeding
• Many common causes of bleeding in the esophagus and upper GI cannot be optimally evaluated with CT
CT for Evaluation of Acute Gastrointestinal Bleeding; RadioGraphics 2018; 38:1089–1107
Wortman JR, LandmanW, Fulwadhva UP, Viscomi SG, Sodickson AD. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90: 20170076
Case 1
Case 1
• A 78-year-old woman with UGIH
• S/P EGD (large DU) → adrenaline injection, glue injection and clip
• New episode of massive UGIH
Case 1
• A 78-year-old woman with UGIH
• S/P EGD and clip
• New episode of massive UGIH
Question
Bleeding from vessel?
• Common hepatic artery
• Gastroduodenal artery
• Gastroepiploic artery
• Left gastric artery
Case 2
Case 2
• A 74-year-old female
• Known case of HT, DLP, gout
• She developed UGIH for 2 days ago.
• The last EGD revealed duodenitis and antral gastritis
• Without evidence of bleeding point.
3613131
• A 74-year-old female
• Known case of HT, DLP, gout
• UGIH for 2 days ago
• The last EGD revealed
• Duodenitis and antral gastritis
• No evidence of bleeding point
Question
Point of bleeding
• A
• B
• A + B
• None
A B
A B
Case 3
Case 3
• A 56-year-old man
• CA pancreas S/P chemoradiation therapy and gastrojejunostomy
• He develop UGIH
• Suspected gastric ulcer
• EGD → no lesion, then CTA
Conclusion for Upper GI bleed
• Search site of bleeding
• Pre-treatment for endoscopy or endovascular
Lower GI bleeding
Oakland K, et al. Gut 2019;68:776–789.
Oakland K, et al. Gut 2019;68:776–789.
Case 4
Case 4
• An 80-year-old woman with simple falling and traumatic closed fracture right superior pubic rami.
• Pulmonary embolism S/P enoxaparin.
• Then, she developed lower GI bleeding.
Case 5
Case 5
• A 49-year-old man
• Present with lower GI bleeding.
Diffuse thickening of bowel walls of entire colon down to the rectum
Case 6
Question
Bleeding site?
• A
• B
• C
• D
A B
C D
CT angiography: Role
Case 7
Case 7
• A 75-year-old man, known case of ESRD, with LGIH S/P EGD and colonoscopy. No bleeding point.
• Today he developed hematochezia with hypotension.
• Suspected active bleeding.
Case 8
Case 8
• A 74-year-old female
• Known case factor VIII inhibitor
• Massive LGIH.
• Her EGD and colonoscope; WNL
Case 9
Case 9
• Case 40-year-old woman
• Underlying SLE with lupus nephritis, febrile neutropenia with sepsis and DIC
• Presents with LGIH
Case 10
Case 10
• A 60-year-old female
• Known case ESRD
• Ruptured infrarenal abdominal aortic aneurysm S/P open repair with aortic bifurcated graft
• Presents with abdominal pain and LGIH
Case 11
Case 11
• A 59-year-old man
• LGIH S/P colonoscopy + clip, point of bleeding about 10 cm from anal verge
• PE shows blood pressure 70/50 mmHg, HR 80/min.
• Suspected rebleed
Pre-treatment Post-treatment
What should you do?
• Done, I completed embolization.
• SMA angiography
• Iliac angiography
• Femoral angiography
Rt-iliac a. Lt-iliac a.
• 1 week later
• Re-bleeding of lower GI (fresh blood about 2L.)
Conclusion
• Difference guideline in Acute massive GI bleeding
• CT is a good tool
• Rapid
• Identify point of bleeding
Thank you