Clinical Efficacy of Dynamic Contrastenhanced Multidetector-row Computed Tomography in Patients with Obscure Gastrointestinal Bleeding

Jaemin Jo; Hyun Joo Song; Sun-Jin Boo; Soo-Young Na; Heung Up Kim; Seung Hyoung Kim

doi:10.4166/kjg.2016.67.4.198

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Jo, Song, Boo, Na, Kim, and Kim: Clinical Efficacy of Dynamic Contrastenhanced Multidetector-row Computed Tomography in Patients with Obscure Gastrointestinal Bleeding

Original Article

Korean J Gastroenterol 2016;67(4):198-206.

Published online: 4 October 2016

DOI: https://doi.org/10.4166/kjg.2016.67.4.198

Clinical Efficacy of Dynamic Contrastenhanced Multidetector-row Computed Tomography in Patients with Obscure Gastrointestinal Bleeding

Jaemin Jo, Hyun Joo Song, Sun-Jin Boo, Soo-Young Na, Heung Up Kim, Seung Hyoung Kim¹

Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea

¹Department of Radiology, Jeju National University School of Medicine, Jeju, Korea

Correspondence to: Hyun Joo Song, Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju 63241, Korea. Tel: +82-64-754-8142, Fax: +82-64-717-1131, E-mail: songhj@jejunu.ac.kr

Received 4 January 2016 Revised 6 March 2016 Accepted 15 March 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Obscure gastrointestinal bleeding (OGIB) accounts for 5% of all gastrointestinal (GI) bleeding cases. Dynamic contrast-enhanced multidetector-row CT (DCE-MDCT) is not generally recommended in OGIB patients due to its low sensitivity. However, it can be used to quickly and simply diagnose OGIB according to some guidelines. The aim of this study was to evaluate the clinical efficacy of DCE-MDCT in OGIB patients.

Methods

We retrospectively analyzed the medical records of 362 patients who underwent DCE-MDCT between March 2009 and January 2014. A total of 45 patients diagnosed with OGIB were included in this study. Their baseline characteristics and treatment procedure were analyzed retrospectively. The positive rates of DCE-MDCT for the detection of bleeding and associated factors were assessed.

Results

The mean age of the patients was 59 years, and males represented 51.1%. Melena was the most common symptom (44.4%). Positive rate of DCE-MDCT findings was 20.0% (9/45). Among these patients, intraluminal contrast extravasation was found in 5 patients (55.6%) and intraluminal hematoma or mass lesions were found in 2 patients each (22.2%). Thirty nine patients (86.7%) underwent conservative management, and 6 patients (13.3%) underwent specific treatment, such as endoscopic treatment, embolization, or surgery. Patients who showed positivity in DCE-MDCT more frequently received specific treatment compared with those who were negative (44.4% vs. 5.6%, p=0.010).

Conclusions

Although DCE-MDCT showed a low positive rate (20.0%), positive findings of DCE-MDCT could lead to specific treatment. Positive DCE-MDCT findings play a useful role in the management of patients with OGIB.

Keywords: Gastrointestinal hemorrhage, Multidetector computed tomography

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Fig. 1.

Patient enrollment. Data on a total of 45 patients were collected retrospectively. DCE-MDCT, dynamic contrast-enhanced multidetector-row CT; GI, gastrointestinal; EGD, esophagogastroduodenoscopy; CFS, colonoscopy.

Fig. 2.

Dynamic contrast-enhanced multidetector-row CT image of a 61-year-old female with recurrent hematochezia. (A) Intraluminal contrast extravastion was noted in ileal loop (arrow). (B) Subsequent angiography revealed active contrast extravasation from ileal artery distal branch (arrow). (C) Successful arterial embolization was done (arrow).

Fig. 3.

Dynamic contrast-enhanced multidetector-row CT and capsule endoscopic image of a 73-year-old male with hematochezia. (A) Hyper-attenuating blood clot was visualized in ascending colon (asterisk). (B) Active ulcer (arrow) with fresh and old blood clot (arrowhead) was seen on the middle jejunum. Conservative management was performed and he did not experience recurrent bleeding after discontinuation of aspirin.

Fig. 4.

Dynamic contrast-enhanced multidetector-row CT (DCE-MDCT) and capsule endoscopic image of a 17-year-old male with recurrent iron deficiency anemia. (A) A small bowel hemangioma (arrow) with heterogeneous enhancement and small phleboliths were noted in the left side of pelvic cavity on DCE-MDCT. (B) A large pedunculated mass (arrows) with purplish surface was noted in the middle jejunum on capsule endoscopy. Surgical resection of the small bowel hemangioma was performed.

Fig. 5.

(A) Cumulative rebleeding rates of patients. (B) Cumulative rebleeding rates according to dynamic contrast-enhanced multidetector-row CT results.

Table 1.

Baseline Characteristics of the Patients (n=45)

Variable	Data
Age (yr)	59.1±20.6
BMI (kg/m²)	23.4±3.6
Male	23 (51.1)
Comorbidity
Diabetes mellitus	7 (15.6)
Hypertension	17 (37.8)
Malignancy	8 (17.8)
Ischemic heart disease	3 (6.7)
Cerebrovascular disease	4 (8.9)
Medication
Aspirin	10 (22.2)
Clopidogrel	3 (6.7)
Warfarin	1 (2.2)
NSAIDs	7 (15.6)
Duration of symptom (day)	143.2±561.2
Symptom
Melena	20 (44.4)
Hematochezia	15 (33.3)
Iron deficiency anemia	10 (22.2)
OGIB subtype
Obscure OGIB	10 (22.2)
Overt OGIB	35 (77.8)
Systolic blood pressure (mmHg)	127.1±22.5
Heart rate (beat/min)	89.1±18.6
Laboratory finding
Hemoglobin (g/dL)	8.4±2.6
Platelet (10³/μ L)	233.2±104.6
Stool occult blood (+)	11 (24.4)
Diagnostic or treatment procedure
Capsule endoscopy	20 (44.4)
Red blood cell scan	1 (2.2)
Angiography	1 (2.2)
Meckel's scan	3 (6.7)
Operation	2 (4.4)
Transfusion of RBC for 24 hr (unit)	1.5±1.5
Massive bleeding	5 (11.1)
Treatment plan
Conservative management	39 (86.7)
Specific treatment	6 (13.3)
Endoscopic treatment	2 (4.4)
Embolization	1 (2.2)
Surgery	3 (6.7)
Follow-up duration (mo)	18.4±16.9

Values are presented as mean±SD or n (%).

OGIB, obscure gastrointestinal bleeding.

Table 2.

Clinical Characteristics of DCE-MDCT Positive Nine Patients

No.	Age (yr)	Sex	Symptom	CT finding	Location	Active bleeding on subsequent endoscopy	Final diagnosis	Treatment	Follow-up duration (mo)	Rebleeding
1	82	Female	Melena	Intraluminal contrast extravasation	Descending colon	None	Colonic bleeding	Observation (hold aspirin)	15	None
2	78	Female	Melena	Intraluminal contrast extravasation	Jejunum	None	Small bowl ulcer bleeding	Observation (hold warfarin)	12	Yes
3	25	Male	Melena	Intraluminal contrast extravasation	Jejunum	None	Small bowel ulcer bleeding	Observation (hold aspirin)	28	None
4	52	Female	Hematochezia	Intraluminal constrast extravasation	Colon	Yes	Colonic diverticular bleeding	Endoscopic hemostasis	3	None
5	61	Female	Hematochezia	Intraluminal contrast extravasation	Ileum	Not done	Small bowel arterial bleeding	Embolization	3	Yes
6	49	Male	Hematochezia	Intraluminal hematoma	Ascending colon	None	Colonic diverticular bleeding	Observation	23	Yes
7	73	Male	Hematochezia	Intraluminal hematoma	Jejunum	None	Small bowel ulcer bleeding	Observation (hold aspirin)	49	None
8	57	Male	Hematochezia	Mass lesion	Ileum	Not done	Gastrointestinal stromal tumor bleeding	Small bowel resection	0	None
9	17	Male	IDA	Mass lesion	Jejunum	None	Small bowel hemangioma bleeding	Surgery	41	None

DCE-MDCT, dynamic contrast-enhanced multidetector-row CT; IDA, iron deficiency anemia.

Table 3.

Comparison of Clinical Characteristics according to DCE-MDCT Results

Variable	Positive (n=9)	Negative (n=36)	p-value
Age (yr)	54.9±22.4	60.2±20.3	0.497
Medication
Aspirin	3 (33.3)	7 (19.4)	0.355
Clopidogrel	0 (0)	3 (8.3)	1.000
Warfarin	1 (11.1)	0 (0)	0.186
NSAIDs	1 (11.1)	6 (16.7)	1.000
Duration of symptom (day)	407.2±1216.0	79.4±190.8	0.123
Overt OGIB	7 (77.8)	28 (77.8)	0.659
Systolic blood pressure (mmHg)	124.3±32.3	127.9±19.7	0.683
Heart rate (beat/min)	94.7±16.2	87.6±19.1	0.318
Laboratory finding
Hemoglobin (g/dL)	8.9±2.8	8.3±2.6	0.556
Platelet (10³/μL)	190.7±65.0	243.8±110.5	0.176
Stool occult blood (+)	2 (50.0)	9 (34.6)	0.611
Diagnostic procedure
Capsule endoscopy	6 (66.7)	14 (38.9)	0.157
Transfusion of RBC for 24 hr (unit)	1.4±1.3	1.6±1.6	0.732
Massive bleeding	0 (0.0)	5 (13.9)	0.566
Treatment plan			0.010
Conservative management	5 (55.6)	34 (94.4)
Specific treatment	4 (44.4)	2 (5.6)
Active bleeding on endoscopy	1 (11.1)	2 (5.6)	0.497
Follow-up duration (mo)	21.8±16.9	18.1±17.0	0.586
Recurrent bleeding	3 (33.3)	4 (11.1)	0.106

Values are presented as mean±SD or n (%).

DCE-MDCT, dynamic contrast-enhanced multidetector-row CT; OGIB, obscure gastrointestinal bleeding; RBC, red blood cell.

Table 4.

Clinical Characteristics of Seven Patients with Recurrent Bleeding

No.	Age (yr)	Sex	Symptom	CT finding	Final or possible diagnosis	Initial treatment	Time to recurrent bleeding (mo)	Lesions of rebleeding	Treatment after rebleeding
1	67	Female	IDA	Normal	Small bowel ulcer bleeding	Observation	4	Possible same lesion of 1st episode	Observation
2	73	Male	Melena	Normal	Possible small bowel bleeding	Observation	5	Other lesion (peptic ulcer bleeding)	Endoscopic hemostasis to peptic ulcer bleeding
3	77	Female	Melena	Normal	Small bowel angiodysplasia bleeding	Observation	3	Possible same lesion of 1st episode	Endoscopic hemostasis to angiodysplasia bleeding
4	28	Female	Hematochezia	Normal	Hemorrhoidal bleeding	Observation	1	Possible same lesion of 1st episode	Operation
5	78	Female	Melena	Intraluminal contrast extravasation	Small bowl ulcer bleeding	Observation (hold warfarin)	12	Possible same lesion of 1st episode	Change from Warfarin to clopidogrel
6	61	Female	Hematochezia	Intraluminal contrast extravasation	Small bowel arterial bleeding	Embolization	0.3	Other lesion (ischemic colitis)	Observation
7	49	Male	Hematochezia	Intraluminal hematoma	Colonic diverticular bleeding	Observation	22	Possible same lesion of 1st episode	Endoscopic hemostasis to diverticular bleeding

IDA, iron deficiency anemia; OGIB, obscure gastrointestinal bleeding.

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