Diagnostic Imaging Pathways Article

Diagnostic Imaging Pathways - Gastrointestinal Bleeding
(Acute)
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Diagnostic Imaging Pathways - Gastrointestinal Bleeding (Acute)
Population Covered By The Guidance

This pathway provides guidance on the investigation of adult patients with acute gastrointestinal bleeding,
with emphasis on endoscopy and non-invasive imaging modalities.
Last reviewed: May 2016

Date of next review: May 2019
Published: May 2017
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SYMBOL RRL EFFECTIVE DOSE RANGE

None 0
Minimal < 1 millisieverts
Low 1-5 mSv
Medium 5-10 mSv
High >10 mSv
Pathway Diagram
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Image Gallery
Note: These images open in a new page
1a Gastrointestinal Bleeding
Image 1a (Computed Tomography Angiography): Extravasated contrast in

the lumen of the sigmoid colon.
1b
Image 1b (Computed Tomography Angiography): Coronal views of the same

patient. Extravasated contrast is seen in the lumen of the sigmoid colon.
1c
Image 1c (Mesenteric Angiogram): Selective inferior mesenteric

catheterisation demonstrates a 'blush' of extravasated contrast indicating the
site of bleeding.
1d
Image 1d (Mesenteric Embolisation): Bleeding has ceased with coils

deployed in the bleeding artery.
Image 2a (Computed Tomography Angiography): Active extravasation of IV

contrast into the lumen of the transverse colon in the region of hepatic
flexure (arrow).
2b Image 2b (Digital Subtraction Angiography): Selective superior mesenteric

artery angiography of the same patient showing contrast extravasation from
a right colic artery branch (arrow).
2c
Image 2c (Digital Subtraction Angiography): Super-selective angiogram of

same vessel.
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2d Image 2d (Mesenteric Embolisation): Post-embolisation image

demonstrates shows no further extravasation after coiling (arrow).
Image 3a (Radionuclide RBC Scan): Extravasation of tracer in ascending

colon with accumulation over time in the proximal colon.
3b Image 3b (Angiography): Angiography of same patient demonstrating

extravasation of contrast medium from a branch of the superior mesenteric
artery in the ascending colon.
Teaching Points
Usually, endoscopy is the first line modality to evaluate, localise and treat patients with suspected
upper GI haemorrhage.
Usually, catheter angiography is the first line modality to evaluate, localise and treat
haemodynamically unstable patients with suspected lower GI haemorrhage and unprepared bowel.
Triphasic CT Angiogram is a rapid, non-invasive investigation that can accurately localise the site
and aetiology of bleeding in patients with active bleeding.
RBC Scintigraphy is recommended for intermittent bleeding as it allows repeated imaging over a 24
hour period.
Individualised Management
Endoscopy is the first line modality to evaluate, localise and treat patients with suspected upper GI
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haemorrhage 3, 6
Catheter angiography is the first line modality to evaluate, localise and treat haemodynamically
unstable patients with suspected lower GI haemorrhage 2, 7, 8
Consider a preceding CT Angiogram for localisation. 2 Massive bleeding is significantly associated
with a positive CTA result 9, 10
Colonoscopy is not recommended as brisk haemorrhage and an unprepared colon can obscure the
gastroenterologist’s vision. 2 The sensitivity of colonoscopy is 21% in an unprepared colon 5
Endoscopy
Endoscopy is the first line modality to evaluate, localise and treat patients with suspected upper GI
haemorrhage 3, 6
Sensitivity of 92-98% 5
Specificity of 30-100% 5
Advantages:
Widely available
Allows visualisation of the bleeding site and endoscopic haemostatic therapy 5
Does not require active bleeding for diagnosis of aetiology 1
Disadvantages:
Risk of aspiration, perforation and side effects from sedation 5
Colonoscopy
First line modality where feasible for haemodynamically stable patients with suspected lower GI
haemorrhage 2
Highest sensitivity in patients who have been fasted, had adequate bowel preparation and bleeding
has stopped or slowed down 11
Advantages:
Widely available
Allows visualisation of the bleeding site and endoscopic haemostatic therapy 5
Does not require active bleeding for diagnosis of aetiology 1
Disadvantages:
Cannot assess the small bowel
Risk of aspiration, perforation and side effects from sedation
TIPS or Surgical Shunt

Variceal haemorrhage has a significant mortality rate of 30-50% for a first bleed 12
Portosystemic shunting compared to endoscopic sclerotherapy/banding alone has demonstrated
significantly less variceal rebleeding (OR 0.25, 95% CI 0.18-0.30) 12
Early TIPS (within 3 days) of variceal bleeding has been shown to lower rates of mortality, failure to
control bleeding and early rebleeding 13 However, it may be deleterious and should be considered
with caution in patients with severe liver failure 13
TIPS has generally replaced surgical shunting as it is less invasive, may not require general
anaesthesia and is cost effective. 14 This is despite TIPS having higher rates of post procedural
complications – early rebleeding, stent stenosis and hepatic encephalopathy – than surgical
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shunting 14
Repeat Endoscopy
For patients who have rebleeding after initial successful endoscopic haemostasis, a second
attempt at endoscopic therapy is the preferred strategy 3, 6, 7
A randomised control trial comparing repeat endoscopy to surgery found that 73% of patients with
recurrent bleeding can be successfully treated with endoscopic therapy 6
CT Angiogram (CTA)
First line radiological modality to assess actively bleeding, haemodynamically stable patients.
A triphasic scan – unenhanced, arterial and delayed phase – is recommended. An unenhanced
scan is necessary to reduce false positives from pre-existing hyperattenuating material in the bowel
15
Oral contrast is not recommended as it increases anaesthetic risk if the patient proceeds to surgery
and may obscure extravasated contrast 9, 16
Porcine models have detected extravasation of contrast into the bowel lumen with active bleeding
as low as 0.3mL/min 17
Sensitivity of 85.2% 11, 18, 19
Specificity of 92.1% 11, 18, 19
A comparison between CTA and RBC Scintigraphy against a reference standard of catheter
angiography, found that CTA had superior sensitivity (100% to 81.2%), specificity (90.9% to 33.3%)
and positive predictive value (93.3% to 61.9%) compared to RBC scintigraphy 20
Advantages:
Widely available
Rapid acquisition time 5
Accessible 24 hours a day allowing expedient assessment when patients are most likely to
be bleeding 16
Non-invasive
No bowel preparation required
Can assess the small bowel
Can guide subsequent management – endoscopy, catheter angiography, surgery or
conservative – due to its high accuracy of localisation and ability to identify the aetiology
even without active haemorrhage 5, 21
Diagnostic yield 61.3% 9
In a prospective case series with CTA as the first diagnostic modality, the
localisation accuracy was 100% and treatment was planned with an accuracy of
93.6% 22
Guides catheter angiography by providing anatomical mapping that identifies
anatomical variability and vascular abnormalities 23 This was shown to reduce
contrast load during catheter angiography however overall contrast load (including
CTA) was greater 23, 24
Watchful waiting is recommended for patients with a negative result as the bleeding
rate is low or intermittent 1 In three case series, 82-92% of patients with a negative
result had successful conservative management 10, 15, 25
If CTA is negative proceeding to an angiogram within 4 hours is not recommended
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25
Disadvantages:
Active haemorrhage is necessary to visualise contrast extravasation
No therapeutic capability
Risk of contrast allergy and contrast induced nephropathy 5
RBC Scintigraphy
Has debatable utility and is best used to assess intermittently bleeding, haemodynamically stable
patients
First line radiological modality for patients with chronic kidney disease and contrast allergy 26
Can show local tracer extravasation into the bowel lumen with rates of bleeding >0.1mL/min 5
Specificity of 30-95% 1
Continuous dynamic sampling with a minimal sampling interval of one frame per minute may allow
accurate definition of the nature, origin and behaviour of the bleeding site, increasing sensitivity
and specificity 27
Advantages:
Non-invasive
Minimal patient preparation
99m
Technechium labelled RBC allows frequent imaging and prolonged detection up to 24
hours post administration 1, 5
Increased sensitivity for diverticular disease 26
Disadvantages:
Active haemorrhage is necessary
Not available after hours
A nuclear technician must be on site
Low yield of a positive result, typically under 50% 28
Low positive predictive value 60%, with 25% of false positives leading to incorrect surgical
procedures 26
Cannot characterise the aetiology of bleeding due to poor spatial resolution 5, 29
Provides evidence of haemorrhage but due conflicting studies reporting poor localisation, it
cannot guide subsequent therapeutic procedures
Blood moves anterograde and retrograde during bowel peristalsis and position
changes 26, 28
A retrospective case series found that 55% of RBC Scintigraphy scans were
‘unhelpful’ to surgeons who ignored the result or performed an operation
incongruent with the scan result 29
A retrospective case series found the bleeding site localised in 74% of patients and
89% of those had resection of that bowel segment 30
Catheter Angiography
Should be preceded by diagnostic localising studies to ensure that there is active bleeding, provide
anatomical mapping and direct angiography of vessels 31
Requires active bleeding >0.5mL/min 5, 21
Sensitivity of 42-86% 5, 21
Specificity of 100% 5, 21
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Advantages:
A diagnostic and therapeutic tool
No bowel preparation required
Catheter angiography is a prelude to super selective embolization with coils, gelatin
sponges, polyvinyl alcohol and cyanoacrylic glues 7
Used frequently in lower GI haemorrhage due to end arteries and is more
challenging in upper GI haemorrhage due to multiple collateral vessels 5
A review of 15 studies on acute non-variceal upper GI bleeding measured a 93%
technical success rate of embolization and 63% clinical success rate 31
The two largest retrospective case series have found technical success rates
96-98% and clinical success rates 82-89% 32, 33
High rates of clinical success (85%) in diverticular haemorrhage 34
Reduces laparotomy frequency benefitting patients who have a high anaesthetic
risk 7, 31
Two retrospective uncontrolled studies showed no significant differences between
embolization therapy and surgery for rates of rebleeding or mortality despite the
embolization cohorts being older and having more comorbidities 7, 31
Disadvantages:
Active haemorrhage is necessary to visualise contrast extravasation
Interventional radiologist must be on site
Embolisation may be impeded in older patients with atherosclerotic disease 33, 35
Complications of access site haematoma, pseudoaneurysm, arterial dissection or spasm,
bowel ischaemia and contrast induced nephropathy or allergy occur in 3% of cases 8
Laparotomy
Should be preceded by diagnostic studies to localise the site and aetiology of bleeding. This
reduces the exploration time required, risk of extensive resection and risk of blind resection with
recurrent bleeding from an unresected culprit lesion 2, 36
It is easier for a surgeon to localise an AVM and perform a targeted resection if a palpable
embolization coil is placed in the arterial branch that supplies the lesion or a microcatheter is
positioned at the site of abnormality for injection with methylene blue at surgery 35, 37
Surgery is the preferred management of neoplastic disease 38
References
Date of literature search: May 2016
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine,
Levels of Evidence. Download the document
1. Moss A, Tuffaha H, Malik A. Lower GI bleeding: a review of current management,

controversies and advances. Int J Colorectal Dis. 2016;31(2):175-88. (Review article) View the
reference
2. Strate L, Gralnek I. ACG clinical guideline: Management of patients with acute lower
gastrointestinal bleeding. Am J Gastroenterol. 2016;111(4):459-74. (College guidelines) View
the reference
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3. Hwang J, Fisher D, Ben Menachem T, Chandrasekhara V, Chathadi K, Decker GA, et al. The
role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest
Endosc. 2012;75(6):1132-8. (Clinical practice guidelines) View the reference
4. Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI
haemorrhage. Clin Radiol. 2007;62(10):938-49. (Level III evidence) View the reference
5. Kim BSM, Li B, Engel A, Samra J, Clarke S, Norton I, et al. Diagnosis of gastrointestinal
bleeding: A practical guide for clinicians. World J Gastrointest Pathophysiol. 2014;5(4):467-78.
(Review article) View the reference
6. Laine L, Jensen D. Management of patients with ulcer bleeding. Am J Gastroenterol.
2012;107(3):345-60; quiz 61. (College guidelines) View the reference
7. Barkun A, Bardou M, Kuipers E, Sung J, Hunt R, Martel M, et al. International consensus
recommendations on the management of patients with nonvariceal upper gastrointestinal
bleeding. Ann Intern Med. 2010;152(2):101-13. (International consensus guidelines) View the
reference
8. Darcy MD CB, Feig BW, Fidelman N, Hara AK, Kapoor BS, Knuttien MG, Lambert DL, Minocha J,
Rochon PJ, Shaw CM, Ray CE Jr, Lorenz JM. Expert Panel on Interventional Radiology. ACR
Appropriateness Criteria® radiologic management of lower gastrointestinal tract bleeding.
J Am Coll Radiol. 2014:8. (College guidelines)
9. Kim J, Kim Y, Lee K, Lee Y, Park J. Diagnostic performance of CT angiography in patients
visiting emergency department with overt gastrointestinal bleeding. Korean J Radiol.
2015;16(3):541-9. (Level III evidence) View the reference
10. Foley PT, Ganeshan A, Anthony S, Uberoi R. Multi-detector CT angiography for lower
gastrointestinal bleeding: Can it select patients for endovascular intervention? J Med
Imaging Radiat Oncol. 2010;54(1):9-16. (Level IV evidence) View the reference
11. Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal
bleeding. J Med Imaging Radiat Oncol. 2008;52(4):333-8. (Level II evidence) View the reference
12. Khan S, et al. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in
patients with cirrhosis. Cochrane Database Syst Rev. 2006:CD000553-CD. (Level I evidence)
View the reference
13. Deltenre P, Trépo E, Rudler M, Monescillo A, Fraga M, Denys A, et al. Early transjugular
intrahepatic portosystemic shunt in cirrhotic patients with acute variceal bleeding: a
systematic review and meta-analysis of controlled trials Eur J Gastroenterol Hepatol.
2015;27(9):e1-e9. (Level I evidence) View the reference
14. Huang L, Yu Q-S, Zhang Q, Liu J-D, Wang Z. Transjugular intrahepatic portosystemic shunt
versus surgical shunting in the management of portal hypertension. Chin Med J (Engl).
2015;128(6):826-34. (Level I evidence) View the reference
15. Kennedy D, Laing C, Tseng L, Rosenblum D, Tamarkin S. Detection of active gastrointestinal
hemorrhage with CT angiography: a 4(1/2)-year retrospective review J Vasc Interv Radiol.
16. Lee S, Welman CJ, Ramsay D. Investigation of acute lower gastrointestinal bleeding with
16- and 64-slice multidetector CT J Med Imaging Radiat Oncol. 2009;53(1):56-63. (Level IV
evidence) View the reference
17. Kuhle W, Sheiman R. Detection of active colonic hemorrhage with use of helical CT:
findings in a swine model. Radiology. 2003;228(3):743-52. (Animal study) View the reference
18. García Blázquez V, Vicente Bártulos A, Olavarria Delgado A, Plana MN, van der Winden D,
Zamora J. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding:
systematic review and meta-analysis. Eur Radiol. 2013;23(5):1181-90. (Level II evidence) View
the reference
19. Wu L-M, Xu J-R, Yin Y, Qu X-H. Usefulness of CT angiography in diagnosing acute
gastrointestinal bleeding: a meta-analysis. World J Gastroenterol. 2010;16(31):3957-63. (Level
II evidence) View the reference
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20. Awais M. Accuracy of 99mTechnetium-labeled RBC scintigraphy and MDCT with
gastrointestinal bleed protocol for detection and localization of source of acute lower
gastrointestinal bleeding. J Clin Gastroenterol. 2015. (Level II evidence) View the reference
21. Jaskolka J, Binkhamis S, Prabhudesai V, Chawla T Acute gastrointestinal hemorrhage:
radiologic diagnosis and management. Can Assoc Radiol J. 2013;64(2):90-100. (Review
article) View the reference
22. Ren J-Z, Zhang M-F, Rong A-M, Fang X-J, Zhang K, Huang G-H, et al. Lower gastrointestinal
bleeding: role of 64-row computed tomographic angiography in diagnosis and therapeutic
planning. World J Gastroenterol. 2015;21(13):4030-7. (Level II evidence) View the reference
23. Grady E. Gastrointestinal bleeding scintigraphy in the early 21st century. J Nucl Med.
2016;57(2):252-9. (Review article) View the reference
24. Jacovides C, Nadolski G, Allen S, Martin N, Holena D, Reilly P, et al. Arteriography for lower
gastrointestinal hemorrhage: role of preceding abdominal computed tomographic
angiogram in diagnosis and localization. JAMA surgery. 2015;150(7):650-6. (Level III evidence)
View the reference
25. Sun H, Jin Z, Li X, Qian J, Yu J, Zhu F, et al. Detection and localization of active
gastrointestinal bleeding with multidetector row computed tomography angiography: a
5-year prospective study in one medical center. J Clin Gastroenterol. 2012;46(1):31-41. (Level
III evidence) View the reference
26. Tabibian J, Wong Kee Song LM, Enders F, Aguet J, Tabibian N. Technetium-labeled
erythrocyte scintigraphy in acute gastrointestinal bleeding. Int J Colorectal Dis.
27. Currie G, Kiat H, Wheat J. Scintigraphic evaluation of acute lower gastrointestinal
hemorrhage: current status and future directions. J Clin Gastroenterol. 2011;45(2):92-9.
28. Olds G, Cooper G, Chak A, Sivak M, Chitale A, Wong RCK. The yield of bleeding scans in
acute lower gastrointestinal hemorrhage. J Clin Gastroenterol. 2005;39(4):273-7. (Level III
29. Levy R, Barto W, Gani J. Retrospective study of the utility of nuclear scintigraphic-labelled
red cell scanning for lower gastrointestinal bleeding. ANZ J Surg. 2003;73(4):205-9. (Level III
30. Suzman MS, Talmor M, Jennis R, Binkert B, Barie PS. Accurate localization and surgical
management of active lower gastrointestinal hemorrhage with technetium-labeled
erythrocyte scintigraphy. Ann Surg. 1996;224(1):29-36. (Level III evidence) View the reference
31. Loffroy R, Rao P, Ota S, De Lin M, Kwak B-K, Geschwind J-F. Embolization of acute
nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results
and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010;33(6):1088-100.
32. Ali M. Treatment of nonvariceal gastrointestinal hemorrhage by transcatheter
embolization. Radiol Res Pract. 2013(2013):604328-. (Level IV evidence) View the reference
33. Hur S, Jae H, Lee M, Kim H-C, Chung J. Safety and efficacy of transcatheter arterial
embolization for lower gastrointestinal bleeding: a single-center experience with 112
patients. J Vasc Interv Radiol. 2014;25(1):10-9. (Level IV evidence) View the reference
34. Khanna A, Ognibene S, Koniaris L. Embolization as first-line therapy for diverticulosis-
related massive lower gastrointestinal bleeding: evidence from a meta-analysis. J
Gastrointest Surg. 2005;9(3):343-52. (Level II evidence) View the reference
35. Walker TG, Salazar G, Waltman A. Angiographic evaluation and management of acute
gastrointestinal hemorrhage. World J Gastroenterol. 2012;18(11):1191-201. (Review article)
View the reference
36. Frattaroli F, Casciani E, Spoletini D, Polettini E, Nunziale A, Bertini L, et al. Prospective study
comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding World J
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Surg. 2009;33(10):2209-17. (Level III evidence) View the reference
37. Zurkiya O, Walker TG. Angiographic evaluation and management of nonvariceal
gastrointestinal hemorrhage. Am J Roentgenol. 2015;205(4):753-63. (Review article) View the
reference
38. Tan K-K, Shore T, Strong D, Ahmad M, Waugh R, Young C. Factors predictive for a positive
invasive mesenteric angiogram following a positive CT angiogram in patients with acute
lower gastrointestinal haemorrhage. Int J Colorectal Dis. 2013;28(12):1715-9. (Level IV
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Diagnostic Imaging Pathways - Gastrointestinal Bleeding

Diagnostic Imaging Pathways - Gastrointestinal Bleeding (Acute)

Population Covered By The Guidance

Last reviewed: May 2016

SYMBOL RRL EFFECTIVE DOSE RANGE

Minimal < 1 millisieverts

Low 1-5 mSv

Medium 5-10 mSv

High >10 mSv

Image 1a (Computed Tomography Angiography): Extravasated contrast in

Image 1b (Computed Tomography Angiography): Coronal views of the same

Image 1c (Mesenteric Angiogram): Selective inferior mesenteric

Image 1d (Mesenteric Embolisation): Bleeding has ceased with coils

Image 2a (Computed Tomography Angiography): Active extravasation of IV

2b Image 2b (Digital Subtraction Angiography): Selective superior mesenteric

Image 2c (Digital Subtraction Angiography): Super-selective angiogram of

2d Image 2d (Mesenteric Embolisation): Post-embolisation image

Image 3a (Radionuclide RBC Scan): Extravasation of tracer in ascending

3b Image 3b (Angiography): Angiography of same patient demonstrating

TIPS or Surgical Shunt

The search methodology is available on request. Email

1. Moss A, Tuffaha H, Malik A. Lower GI bleeding: a review of current management,

Information for Consumers

Consent to Procedure ot Treatment Angiography

Radiation Risks of X-rays and Scans Computed Tomography (CT)

Angiography (Angiogram) Iodine-Containing Contrast Medium

Computed Tomography (CT) Radiation Risk of Medical Imaging During

Powered by TCPDF (www.tcpdf.org)

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