381
Fig. 2. CT during SMA angiography. CT during SMA angiography shows extravasation of contrast media (large arrows) within the jejunal lumen. This finding was not noted on initial CT and angiography (not shown). Catheter is seen in abdominal aorta (small arrow). A B Fig. 1. Extravasation of contrast media within the bowel lumen. A. Contrast-enhanced CT well depicts extravasation of contrast media (arrow) within the lumen of the proximal jejunum on arterial phase. B. On two-minute delayed image, the amount of extravasated contrast media (arrow) are increased. 382
Table 1. Radiologic and Pathologic Results of Each Case Patient MDCT Angiography Operation No. Age/Sex Finding Location Finding Pathology 01 56/F Ma D. Jejunum * GIST 02 59/F E P, Jejunum * 03 64/F E Duodenum Diverticulum 04 61/M * 05 33/F E D. Ileum * 06 49/F E,Ma P. Jejunum * GIST 07 78/M E D. IleumE E CMV infection 08 70/M Ma D. Ileum * GIST 09 54/F * 10 45/M E P. Jejunum E * 11 51/M E Rt. Colon E * 12 71/F E,Ma P. Jejunum * GIST 13 42/M Lymphangioma 14 33/M Lymphangioma 15 44/M E Lt. Colon E * 16 71/F E D. Jejunum E * 17 51/M E Rt. Colon E * CMV: cytomegalovirus, D.: distal, E: extravasation of contrast media, F: female, GIST: gastointestinal stromal tumor, M: male, Ma: mass, No.: number, -: negative finding, *: not performed, P.: proximal 383
A B Fig. 3. GIST in a 72-year-old man presenting acute GI bleeding. A. Angiography performed at outside hospital showed no bleeding foci. B. When this patient was transferred to our hospital, CT was performed, first. Small bowel intussusception (large arrow) and mass (small arrow) were detected. After surgical resection without additional angiography, this mass was confirmed as GIST. 1.,,,,,,.. 2003;42:27-34 2. Eisen GM, Dominitz JA, Faigel DO, Goldstein JL, Kalloo AN, Petersen BT, et al. An annotated algorithmic approach to acute lower gastrointestinal bleeding. Gastrointest Endosc 2001;53:859-863 3. Gunderman R, Leef J, Ong K, Reba R, Metz C. Scintigraphic screening prior to visceral arteriography in acute lower gastrointestinal bleeding. J Nucl Med 1998;39:1081-1083 4. Grassi R, Di Mizio R, Romano S, Cappabianca S, Del Vecchio W, Severini S. Multiple jejunal angiodysplasia detected by enema-helical CT. Clin Imaging 2000;24:61-63 5. Junquera F, Quiroqa S, Saperas E, Perez-Lafuente M, Videla S, Alvarez-Castells A, et al. Accuracy of helical computed tomographic angiography for the diagnosis of colonic angiodysplasia. Gastroenterology 2000;119:293-299 384
6. Lefkovitz Z, Cappell MS, Kaplan M, Mitty H, Gerard P. Radiology in the diagnosis and therapy of gastrointestinal bleeding. Gastroenterol Clin North Am 2000;29:489-512 7. Ernst O, Bulois P, Saint-drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol 2003;13:114-117 8. Rajan R, Dhar P, Praseedom RK, Sudhindran S, Moorthy S. Role of contrast CT in acute lower gastrointestinal bleeding. Dig Surg 2004;21:293-296 9. Duchesne J, Jacome T, Serou M, Tighe D, Gonzales A, Hunt JP, et al. CT-Angiography for the detection of a lower gastrointestinal bleeding source. Am J Surg 2005;71:392-397 10. Tew K, Davies RP, Jadun CK, Kew J. MDCT of acute lower gastrointestinal bleeding. AJR Am J Roentgenol 2004;182:427-430 11. Myers RT. Diagnosis and management of occult gastrointestinal bleeding: visualization of the small bowel lumen by fiberoptic colonoscope. Am J Surg 1976;42:92-95 12. Zuckerman GR, Prakash C, Askin MP, Lewis BS. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology 2000;118:201-221 13. Alavi A, Dann RW, Baum S, Biery DN. Scintigraphic detection of acute gastrointestinal bleeding. Radiology 1977;124:753-756 14. Sos TA, Lee JG, Wixson D, Sniderman KW. Intermittent bleeding from minute to minute in acute massive gastrointestinal hemorrhage: arteriographic demonstration. AJR Am J Roentgenol 1978;131:1015-1017 15. Bloomfeld RS, Rockey DC. Diagnosis and management of lower gastrointestinal bleeding. Curr Opin Gastroenterol 2000;16:89-97 16. Zuckerman DA, Bocchini TP, Birnbaum EH. Massive hemorrhage in the lower gastrointestinal tract in adults: diagnostic imaging and intervention. AJR Am J Roentgenol 1993;161:703-711 17. Rollins ES, Picus D, Hicks ME, Darcy MD, Bower BL, Kleinhoffer MA. Angiography is useful in detecting the source of chronic gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol 1991; 156:385-388 18. Zuckerman GR, Prakash C. Acute lower intestinal bleeding: part I: clinical presentation and diagnosis. Gastrointest Endosc 1998;48: 606-617 19. Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc 1999;49: 228-238 20. Jensen DM,, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988;95:1569-1574 21. Kuhle WG, Sheiman RG. Detection of active colonic hemorrhage with use of helical CT: findings in a swine model. Radiology 2003;228:743-752 22. Ettorre GC, Francioso G, Garribba AP, Fracella MR, Greco A, Farchi G. Helical CT angiography in gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol 1997;168:727-731 23. Ugwonali O, Coady M, Saxena R, Robert M, Horowitz N, Topazian M. Intraoperative enteroscopy for diagnosis of a bleeding jejunal lymphangioma. J Clin Gastroenterol 2000;31:333-335 385
The Usefulness of MDCT in Acute Intestinal Bleeding 1 Kum Rae Kim, M.D., Won Kyu Park, M.D., Jae Woon Kim, M.D., Jay Chun Chang, M.D., Han Won Jang, M.D. 1 Department of Diagnostic Radiology, College of Medicine, Yeungnam University Purpose: We wanted to evaluate the usefulness of MDCT for localizing a bleeding site and for helping make a decision on further management for acute intestinal bleeding. Materials and Methods: We conducted a retrospective review of 17 consecutive patients who presented with acute intestinal bleeding and who also underwent MDCT before angiography or surgery. The sensitivity of MDCT for detecting acute intestinal bleeding was assessed and compared with that of conventional angiography. Results: The sensitivity of MDCT for the detection of acute intestinal bleeding was 77% (13 of 17), whereas that of angiography was 46% (6 of 13). All the bleeding points that were subsequently detected on angiography were visualized on MDCT. In three cases, the bleeding focus was detected on MDCT and not on angiography. In four cases, both MDCT and angiogphy did not detect the bleeding focus; for one of these cases, CT during SMA angiography was performed and this detected the active bleeding site. Conclusion: In patients with acute intestinal bleeding, MDCT is a useful image modality to detect the bleeding site and to help decide on further management before performing angiography or surgery. When tumorous lesions are detected, invasive angiography can be omitted. Index words : Gastrointestinal tract, hemorrhage Computed tomography (CT) Angiography Address reprint requests to : Jae Woon Kim, M.D., Department of Diagnostic Radiology, College of Medicine, Yeungnam University, 317-1, Daemyungdong, Namgu, Daegu 705-717, Korea. Tel. 82-53-620-3428 Fax. 82-53-653-5484 E-mail: sungho1999@yumail.ac.kr 386