Gastrointestinal Imaging • Original Research

Feuerstein et al.
CT and Scintigraphy of Lower Gastrointestinal Hemorrhage

Gastrointestinal Imaging
Original Research

Localizing Acute Lower

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Gastrointestinal Hemorrhage:
CT Angiography Versus Tagged
RBC Scintigraphy
Joseph D. Feuerstein1 OBJECTIVE. Lower gastrointestinal hemorrhage is a common cause of hospitalization
Gyanprakash Ketwaroo1 and has substantial associated morbidity and financial cost. CT angiography (CTA) is emerg-
Sumeet K. Tewani1 ing as an alternative to 99mTc-labeled RBC scintigraphy (RBC scintigraphy) for the localiza-
Antonio Cheesman1 tion of acute lower gastrointestinal bleeding (LGIB); however, data on comparative efficacy
Juan Trivella1 are scant. The aim of this study was to assess the utility of CTA compared with RBC scintig-
raphy in the overall evaluation and management of acute LGIB.
Vassillios Raptopoulos 2
MATERIALS AND METHODS. We retrospectively reviewed images from all CTA
Daniel A. Leffler 1 examinations performed for suspected acute LGIB at our tertiary care hospital from January
Feuerstein JD, Ketwaroo G, Tewani SK, et al. 2010 through November 2011. The comparison group was determined by retrospective review
of twice the number of RBC scintigraphic scans consecutively obtained from June 2008 to
November 2011 for the same indication. All CTA and RBC scintigraphic scans were reviewed
for accurate localization of the site and source of suspected active LGIB.
RESULTS. In total, 45 CTA and 90 RBC scintigraphic examinations were performed
during the study period. Seventeen (38%) CTA scans showed active gastrointestinal bleeding
compared with 34 (38%) RBC scintigraphic scans (p = 1.000). However, the site of bleeding
was accurately localized on 24 (53%) CTA scans. This proportion was significantly greater
than the proportion localized on RBC scintigraphic scans (27 [30%]) (p = 0.008). There were
no significant differences between the two groups in average hospital length of stay, blood
transfusion requirement, incidence of acute kidney injury, or in-hospital mortality.
CONCLUSION. Both CTA and RBC scintigraphy can be used to identify active bleed-
ing in 38% of cases. However, the site of bleeding is localized with CTA in a significantly
higher proportion of studies.

ower gastrointestinal bleeding in patients with active hemorrhage. Thus, the

Keywords: angiography, CT, lower gastrointestinal

bleeding, tagged RBC scintigraphy
DOI:10.2214/AJR.15.15714
Received October 16, 2015; accepted after revision
March 31, 2016.
1
Department of Medicine, Division of Gastroenterology,
Beth Israel Deaconess Medical Center, Harvard
Medical School, 110 Francis St, 8E, Boston, MA 02215.
Address correspondence to J. D. Feuerstein
(jfeuerst@bidmc.harvard.edu).
2
Department of Radiology, Beth Israel Deaconess Medical
Center, Harvard Medical School, Boston, MA.
AJR 2016; 207:578–584
0361–803X/16/2073–578
© American Roentgen Ray Society
L (LGIB) accounts for approxi-
mately 24% of cases of gastroin-
testinal hemorrhage [1]: the inci-
dence of hospitalization is approximately 22
cases per 100,000 population in the United
States [2]. The disease spectrum varies from
chronic and intermittent blood loss to severe
acute hemorrhage. Overall mortality ranges
from 4% to 5% [2] but can be as high as 23%
depending on age, comorbid conditions, and
severity of hemorrhage [3].
Although most cases of acute LGIB are
self-limited, ongoing or recurrent hemorrhage
constitutes a diagnostic and therapeutic chal-
lenge. In these cases, effective management
requires a multidisciplinary team of hospi-
talists, intensivists, gastroenterologists, radi-
ologists, and surgeons. Colonoscopy remains
an important diagnostic and potentially ther-
apeutic procedure but is technically difficult
timing of colonoscopy relative to the onset of
bleeding remains debatable [4, 5]. Techne-
tium-99m-labeled RBC scintigraphy (RBC
scintigraphy or tagged RBC scan) is often
used in such situations because of its high sen-
sitivity for the detection of ongoing bleeding
[6]. However, limited availability during off-
hours when an on-call medical technologist
is required [7] and wide variation in reported
successful localization of the site of bleeding,
ranging from 19% to 96% [6, 8, 9], reduce the
clinical utility of RBC scintigraphy.
Several reports have described the poten-
tial role of CT angiography (CTA) as an al-
ternative to RBC scintigraphy in evaluating
acute ongoing LGIB [10–13]. CTA can be per-
formed quickly, is noninvasive, and is excellent
at depicting the mesenteric anatomy [10]. Con-
sequently, CTA is beginning to replace RBC
scintigraphy in the evaluation of acute LGIB.

578 AJR:207, September 2016

 CT and Scintigraphy of Lower Gastrointestinal Hemorrhage
TABLE 1: Baseline Characteristics of Patients Undergoing CT ­Angiography
or RBC Scintigraphy for Assessment of Acute Lower
­Gastrointestinal Bleeding
Characteristic CT Angiography
No. of patients 44
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No. of examinations 45
Sex (%)
Men 61
Women 39
Mean age (y) 68
Use of aspirin only (no.) 18 (41)
Use of clopidogrel only (no.) 1 (2)
Use of aspirin and clopidogrel (no.) 7 (16)
Use of warfarin (no.) 7 (16)
Note—Values in parentheses are percentages.
However, the efficacy of CTA in comparison
with RBC scintigraphy in localizing the site
of LGIB is not known, leading to variation in
which test is recommended for the initial as-
sessment of acute LGIB. The aim of this study
was to assess the utility of CTA compared with
RBC scintigraphy in the overall evaluation and
management of acute LGIB.
Materials and Methods
Subjects
We reviewed all CTA scans completed at our ter-
tiary referral center from January 2010 through No-
vember 2011. We included only CTA examinations
performed for acute LGIB suspected on the basis of
medical documentation, including gastroenterolo-
gy consult notes and CTA order requisition records.
All CTA examinations were performed to localize
the site and source of active LGIB. The comparison
group of RBC scintigraphic scans comprised twice
the number of CTA scans consecutively obtained
from June 2008 to November 2011 for evaluation
of suspected acute LGIB. For both CTA and RBC
scintigraphy, the original reports and findings were
used as interpreted by the resident and attending
radiologist at the time of the study. Each test was
considered its own reference standard, a positive
test result confirming localization of gastrointes-
tinal bleeding. If, however, a therapeutic interven-
tional procedure was performed, the source found
was considered the true source, and any discrepan-
cy from the initial testing source localization was
considered a false-positive finding. Corresponding
medical records of all patients included in the study
were reviewed.
CT Angiography
CTA scans were obtained with standard 64-MDCT
scanners (VCT and 750HD, GE Healthcare). The
AJR:207, September 2016 579
ing was detected earlier. For the blood flow study,
2-second-per-frame images were obtained for
64 seconds (32 frames). For the dynamic study,
1-minute-per-frame images were obtained for 60
RBC Scintigraphy p
minutes (60 frames). At the end, a static left lateral
81 image of the pelvis was obtained at 5 minutes per
90 frame. All scans were reviewed by both a resident
0.819 and an attending radiologist.
59
Statistical Analysis
41 The CTA group served as the case subjects and
71 0.337 the RBC scintigraphy group as the control sub-
24 (30) 0.202 jects. Comparisons between groups were made
with the t test for continuous variables and Fisher
2 (2) 0.945
exact test for categoric variables. All values of p <
12 (15) 0.871 0.05 were considered statistically significant. This
15 (18) 0.714 study was approved by the committee on clini-
cal investigations at our institution. All authors
had access to the study data and reviewed and ap-
CTA protocol consisted of injection of 350 mg I/mL proved the final manuscript.
iohexol (Omnipaque 350, GE Healthcare) at 4–5
mL/s. The amounts of contrast medium per body Results
weight were as follows: ≤ 45 kg, 80 mL; 46–60 kg, In total, 45 CTA and 90 RBC scintigraph-
100 mL; 61–90 kg, 130 mL; > 90 kg, 150 mL. The ic examinations were performed for patients
contrast bolus was followed by an injection of 30 mL presenting with hematochezia and suspected
of normal saline solution. No high-attenuation oral LGIB. Nine patients underwent both CTA
contrast medium was administered. Images were ac- and RBC scintigraphy during their hospital-
quired helically with a 64 × 0.625 mm collimator set- izations. The baseline characteristics of the
ting and displayed in axial, coronal, and sagittal planes study population are shown in Table 1.
at 3-mm slice thickness. All images were reviewed by The site of LGIB was accurately local-
both a resident and an attending radiologist. ized on images in a total of 24 (53%) CTA
examinations (Fig. 1). Seventeen (38%) CTA
RBC Scintigraphy examinations revealed intraluminal extrava-
RBCs were labeled by means of the standard sation of contrast material. In 16 (36%) ex-
nuclear medicine in vitro technique (UltraTag, aminations the site of ongoing bleeding was
Covidien). Examinations were performed with correctly identified at the time of imaging
standard 15-mCi (± 10%) 99mTc-labeled autolo- (Table 2). Findings in one CTA examina-
gous RBCs. After IV injection, blood flow was tion were thought to be consistent with ac-
assessed on dynamic images of the abdomen ac- tive extravasation from the rectum, but an-
quired for up to 60 minutes, unless acute bleed- giography confirmed active bleeding in the
Fig. 1—88-year-old
man who presented
with brisk acute
lower gastrointestinal
bleeding in right colon.
A, Unenhanced CT
angiographic scan
shows no intestinal
contrast or high-
attenuation material in
colon.
A
(Fig. 1 continues on next page)
 Feuerstein et al.

ascending colon. In the other 16 CTA exami-

nations, the sites of bleeding were the ileum
in two patients, cecum in three, right colon
in seven, and left colon in four. The cause
of gastrointestinal bleeding was diverticulo-
sis in nine (38%) patients, segmental colitis
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in four (17%), arteriovenous malformation

in one patient (4%), and an anastomotic ul-
cer after ileocecectomy in another patient
(4%). One patient had a Meckel diverticulum,
which was found with intraoperative endos-
copy after CTA showed an ileocolic source
of the site of bleeding. Of the 17 patients
with a CTA finding of active extravasation,
15 (88%) proceeded to angiography. Active
bleeding was seen in nine (53%) and was suc-
cessfully managed by embolization in eight B C
(47%) patients. Five patients (31%) eventual-
ly needed segmental colectomy, all guided in
part by CTA localization (Table 2).
The site of bleeding was identified in the
absence of active intraluminal extravasation
in a further eight CTA examinations. The
sites of bleeding were the small bowel in two
of these patients, the cecum in two, right co-
lon in one, left colon in two, and rectum in
one (Table 2 and Fig. 2). In these cases the
causes identified at imaging that led to local-
ization were an arteriovenous malformation
in one study (4%), a tumor in one (4%), local-
ized colitis and enteritis in two studies (8%),
eroding pseudoaneurysm in one study (4%),
and an internal hemorrhoid with associated
blood and proximal stool in another (4%). In
a patient in whom multiple polyps had been
removed, clotted blood was present at the site
of a postpolypectomy bleed. One CTA scan
showed blood in the small bowel pointing to D E
an upper gastrointestinal source, which was Fig. 1 (continued)—88-year-old man who presented with brisk acute lower gastrointestinal bleeding in right colon.
later confirmed at esophagogastroduodenos- B and C, Coronal arterial (B) and venous (C) phase CT angiographic scans show contrast extravasation (arrows)
copy (Table 2). from junction of cecum and ascending colon.
D and E, Images from catheter angiography show excellent correlation between site of bleeding (arrow, D) and
A total of 34 of the 90 RBC scintigraph- site of control after embolization (arrow, E).
ic examinations (38%) showed active extrav-
asation at the time of imaging, as did 38%
of CTA examinations (p = 1.000) (Fig. 3). TABLE 2: Sites and Causes of Bleeding Identified With CT Angiography and
In two of these cases, however, the actual RBC Scintigraphy
site of bleeding could not be localized (Ta-
CT Angiography (n = 45)
ble 2). In five (15%) cases, localization with RBC Scintigraphy
RBC scintigraphy was reported, but it was Characteristic Active Extravasation No Extravasation (n = 90)
later found that the identification was inac- Site of bleeding
curate (Table 3). Ultimately, the site of hem-
Small bowel 2 2 1
orrhage was accurately localized in 27 RBC
scans (30%) compared with 53% of CTA Cecum 3 2 1
scans (p = 0.008). The sites of hemorrhage Right colon 7 1 8
were small bowel in one patient, cecum in Left colon 4 2 13
one, right colon in eight, left colon in 13,
Rectum 1a 1 4
and rectum in four. Among these 27 cases,
the cause of the bleeding was diverticulosis (Table 2 continues on next page)

580 AJR:207, September 2016

 CT and Scintigraphy of Lower Gastrointestinal Hemorrhage

TABLE 2: Sites and Causes of Bleeding Identified With CT Angiography and findings, fewer patients with positive RBC
RBC Scintigraphy (continued) scintigraphic findings proceeded to angiog-
raphy (p = 0.050), but a similar proportion
CT Angiography (n = 45)
RBC Scintigraphy of those referred for angiography had active
Characteristic Active Extravasation No Extravasation (n = 90) bleeding seen at angiography (p = 0.156) and
had successful embolization (p = 0.141). Five
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Cause of bleeding
patients (15%) eventually needed surgery,
Diverticulosis 9 17
which was guided by RBC scintigraphic lo-
Segmental colitis and enteritis 4 2 2 calization in all but one case. Four patients
Arteriovenous malformation 1 1 underwent segmental colectomy. One patient
Ulcer 1 underwent total colectomy after initial seg-
mental resection of the right colon when fur-
Meckel diverticulum 1
ther pathologic findings were identified intra-
Tumor 1 operatively in the rest of the colon.
Pseudoaneurysm 1 The average time to complete an RBC scin-
Internal hemorrhoid 1 1 tigraphic examination was 3 hours 9 minutes
after the order was placed. CTA examinations
Postpolypectomy site 1 1
were completed an average of 1 hour 41 min-
Small bowel 1 1 utes after the initial order (p < 0.001). In the
Unidentified source 0 0 5 CTA group, 32 of 45 (71%) examinations were
aSubsequent angiography showed active bleeding from the ascending colon. completed within 2 hours of initial order, com-
pared with 31 of 90 (34%) RBC scintigraphic
in 17 patients (63%), segmental colitis in two Among the 34 patients with positive RBC examinations (p < 0.001). Among the 32 pa-
(7%), postpolypectomy bleeding in one (4%), scintigraphic findings, 21 (62%) proceed- tients whose CTA examination was completed
a condition originating in the small bowel in ed to angiography, and active bleeding was within 2 hours, 15 (47%) had active bleeding.
one (4%), and hemorrhoids in another (4%). seen in 11 (32%), allowing successful em- Of the 13 CTA examinations performed more
In the other five patients, the cause of bleed- bolization in nine (27%) patients. In com- than 2 hours after the order, only two (15%)
ing was unclear (Table 2). parison with the patients with positive CTA showed active bleeding (p = 0.048) (Table 4).

TABLE 3: Sites of Bleeding Inaccurately Localized on RBC Scintigraphic Scans

Patient No. Site Determined at RBC Scintigraphy Actual Site Modality With Which Site Was Accurately Identified
1 Sigmoid colon Small intestine Angiography
2 Sigmoid colon Terminal ileum Capsule endoscopy
3 Sigmoid colon Rectum Angiography
4 Sigmoid colon Duodenum Angiography
5 Rectum Sigmoid colon Colonoscopy

A B
Fig. 2—86-year-old man who presented with hematochezia. Mesenteric CT angiogram showed no acute bleeding.
A, Venous phase CT angiogram enhancing mass (arrow) is present in proximal transverse colon.
B, Endoscopic image obtained after A shows ulcerating mass (arrow).

AJR:207, September 2016 581

 Feuerstein et al.

TABLE 4: Comparison of Outcomes Between Patients Who Underwent CT Angiography or RBC Scintigraphy
Characteristic CT Angiography RBC Scintigraphy p
No. of patients 44 81
No. of examinations 45 90
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Average time to complete scan (h:min) 1:41 3:09 < 0.001

Percentage of examinations of patients with question of hemodynamic instability 53 37 0.065
Average length of stay (d) 8.6 9.0 0.798
Average length of stay in ICU (d) 2.5 3.2 0.380
Average no. of RBC transfusions 7.6 7.5 0.927
Percentage undergoing endoscopy 64 72 0.358
Incidence of acute kidney injury after admission (no.) 1 (2.3) 4 (4.9) 0.468
Mortality during hospital stay (no.) 1 (2.3) 5 (6.2) 0.330
Note—Values in parentheses are percentages.

The outcomes for each group of patients
are summarized in Table 4. The proportions
of patients with hemodynamic instability
were similar in the CTA and RBC scintig-
raphy cohorts. Both groups of patients had
similar packed RBC transfusion require-
ments and hospital lengths of stay, and a sim-
ilar majority in the two cohorts underwent
endoscopy. One patient in each group expe-
rienced acute kidney injury after admission.
The ICU length of stay and in-hospital mor-
tality were higher in the RBC scintigraphy
group, but these differences were not statisti-
cally significant (Table 4).
Discussion
Management of acute LGIB in the hospital
is complex, and many competing diagnostic
and therapeutic modalities exist. The prima-
ry imaging modality in acute LGIB has tra-
ditionally been RBC scintigraphy, which has
high sensitivity in identifying gastrointestinal

A B

C D
Fig. 3—85-year-old man who presented with rectal bleeding, hypotension, and tachycardia.
A and B, Two frames from RBC scintigraphic study show brisk bleeding, probably from sigmoid colon.
C, Angiogram obtained after A and B shows localized bleeding (arrow) in duodenum.
D, Angiogram obtained after A and B shows bleeding has been controlled by embolization (arrow) of gastroduodenal artery branch.

582 AJR:207, September 2016

 CT and Scintigraphy of Lower Gastrointestinal Hemorrhage
hemorrhage but suboptimal utility for local-
izing the site of hemorrhage and may not be
rapidly available. Mesenteric CTA has been
advocated as an alternative to RBC scintigra-
phy in the evaluation of obscure gastrointes-
tinal bleeding [14]; the benefits include ease
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of acquisition in most radiology departments.
Several studies have shown high sensitivity
of CTA in detecting the source and localizing
the site of LGIB [10, 15], including identifica-
tion of nonbleeding intestinal and vascular le-
sions [16], and the results suggest an advantage
over RBC scintigraphy. However, few studies
have compared the overall effectiveness of
CTA and RBC scintigraphy for the diagnosis
and management of acute LGIB. In a prospec-
tive study [7], 55 patients underwent sequen-
tial CTA followed by RBC scintigraphy, if in
stable condition, after presenting with LGIB
[7]. This study suggested that RBC scintig-
raphy was more sensitive in detecting active
LGIB, but the difference was not statistically
significant (46% vs 27%, p = 0.06). Howev-
er, clinical outcomes were not reported, and
only eight patients had positive r­ esults of both
RBC scintigraphy and CTA, preventing accu-
rate assessment of comparative accuracy in
localizing the site of hemorrhage.
In this study, we found that CTA depict-
ed active bleeding in 38% of subjects, and we
were able to localize the site of bleeding in
more than 50%. Impressively, CTA aided in
localizing the site of bleeding in the absence
of active extravasation by depicting tumors,
vascular malformations, and localized colitis.
In contrast, RBC scintigraphy, with its limit-
ed delineation of intestinal and vascular anat-
omy, frequently had equivocal or incorrect
findings in localization of the site of active
bleeding. Consequently, although RBC scin-
tigraphy was comparable to CTA in show-
ing active intestinal hemorrhage, it had a sig-
nificantly lower accurate localization rate of
30%. In persistent or recurrent severe LGIB,
accurate localization of the site of hemor-
rhage is vital because limited surgical resec-
tion can be performed, and morbidity and
mortality are reduced compared with those of
total and blind colectomy [17, 18]. Our find-
ings suggest that CTA would be preferable to
RBC scintigraphy given its advantages in ac-
curate identification of the site of bleeding.
When used for triage of patients to angi-
ography, assessment of ongoing bleeding
must be prompt. We found that from the time
the order was placed, the mean time to com-
plete CTA was 1 hour 41 minutes, whereas
the time to complete RBC scintigraphy was
AJR:207, September 2016 583
3 hours 9 minutes. We expect this time ad-
vantage of CTA over RBC scintigraphy to be
generalizable given the ubiquity of modern
MDCT scanners in hospitals. It is also not
unusual for many centers to have RBC scin-
tigraphy available only during conventional
working hours. Furthermore, when angiog-
raphy is performed, CTA with its excellent
representation of the mesenteric vasculature
can allow selective angiography for more ac-
curate guidance in the initial approach of the
interventional radiologist.
Although our data strongly suggest that
CTA be considered an alternative to RBC
scintigraphy, CTA has a few notable limita-
tions. Whereas the cumulative billable cost of
CTA was higher than that of RBC scintigraphy
(actual cost difference, $963) at our institution,
we expect this to be substantially reduced with
changes in Medicare and Medicaid reimburse-
ments. This cost difference, however, may re-
main a limiting factor for using CTA in com-
munity hospitals and at other institutions.
The increased radiation dose of CTA com-
pared with RBC scintigraphy is also a poten-
tial concern. The effective radiation dose
estimate for an adult undergoing RBC scin-
tigraphy is approximately 6–7 mSv, whereas
estimates for CTA range from 15 to 25 mSv.
New techniques are already being developed
and used that can decrease the CTA radia-
tion dose to the 5- to 10-mSv range, but these
must be further tested.
In actively bleeding patients with hypovo-
lemia, contrast-induced renal failure is a con-
cern. However, none of the subjects undergo-
ing CTA had contrast-induced nephropathy
during hospitalization. One patient in the
CTA cohort had renal insufficiency requiring
temporary continuous venovenous hemofiltra-
tion. The acute kidney injury occurred several
days after emergency hemicolectomy for on-
going massive gastrointestinal bleeding. Ne-
phrology consultants thought the cause was
multifactorial, possibly attributable to hypo-
tension, antibiotics, and IV contrast material.
They noted a more proximate chest-abdomen-
pelvis CT study that was performed for persis-
tent leukocytosis. At baseline, all patients who
underwent CTA had normal renal function or
had end-stage renal disease and were already
undergoing dialysis. In patients with baseline
chronic renal insufficiency, contrast-induced
nephropathy remains a concern.
Although the groups were similar, our
study was limited by its retrospective design
and derivation from a single referral center.
However, in contrast to previous studies doc-
umenting the efficacy of CTA in detecting ac-
tive LGIB, our study is one of the few that
directly compares the performances of CTA
with RBC scintigraphy in real-world practice.
Our data show that CTA is at least an alter-
native to RBC scintigraphy in the evaluation
of acute LGIB. Furthermore, our study is the
first, to our knowledge, to show that CTA af-
fords superior localization of the site of hem-
orrhage compared with RBC scintigraphy, an
important advantage to patients who need in-
tervention for bleeding cessation.
Conclusion
Our data strongly support CTA as a valu-
able addition to the current modalities for the
evaluation and management of acute LGIB.
We expect that future studies with a larger
sample size and a prospective design will con-
firm our findings and help establish CTA as
the preferred imaging modality in the overall
algorithm for the management of acute LGIB.
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F O R YO U R I N F O R M AT I O N
ARRS 2016 Abdominal and Pelvic MR Imaging Symposium
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September 30–October 1, 2016

584 AJR:207, September 2016