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Acute Gastrointestinal Bleeding: Emerging Role of Multidetector CT Angiography and Review of Current Imaging Techniques¹

¹ From the Department of Radiology, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Dr, Cleveland, OH 44109. Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received May 8, 2006; revision requested September 11 and received October 16; accepted October 16. All authors have no financial relationships to disclose.

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Active sigmoid bleeding in a 94-year-old woman who presented with bright red blood from the rectum. (a, b) Axial (a) and coronal (b) CT angiograms demonstrate active contrast material extravasation into the sigmoid colon (arrow). Note the multiple colonic diverticuli in this region and the contrast material–filled diverticulum that is optimally demonstrated on the coronal image, presumably representing the site of hemorrhage. (c) Findings on an IMA angiogram confirm the presence of active sigmoid bleeding (arrowheads). The patient was treated successfully with coil embolization.

 

View larger version (153K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Active sigmoid bleeding in a 94-year-old woman who presented with bright red blood from the rectum. (a, b) Axial (a) and coronal (b) CT angiograms demonstrate active contrast material extravasation into the sigmoid colon (arrow). Note the multiple colonic diverticuli in this region and the contrast material–filled diverticulum that is optimally demonstrated on the coronal image, presumably representing the site of hemorrhage. (c) Findings on an IMA angiogram confirm the presence of active sigmoid bleeding (arrowheads). The patient was treated successfully with coil embolization.

 

View larger version (165K): [in this window] [in a new window] [Download PPT slide]   Figure 1c.  Active sigmoid bleeding in a 94-year-old woman who presented with bright red blood from the rectum. (a, b) Axial (a) and coronal (b) CT angiograms demonstrate active contrast material extravasation into the sigmoid colon (arrow). Note the multiple colonic diverticuli in this region and the contrast material–filled diverticulum that is optimally demonstrated on the coronal image, presumably representing the site of hemorrhage. (c) Findings on an IMA angiogram confirm the presence of active sigmoid bleeding (arrowheads). The patient was treated successfully with coil embolization.

 

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  Active gastrointestinal bleeding in a hemodynamically unstable 71-year-old man who presented with massive hematemesis that obscured endoscopic findings. (a) Coronal CT angiogram through the gastric body and antrum shows a large amount of clotted blood within the distended stomach (*) and pooling of extravasated contrast material (arrow). These findings allowed direction of the catheter toward the left gastric artery. (b) Angiogram obtained after injection of the left gastric artery shows a bleeding gastric branch (arrow). The patient was treated successfully with microcoil embolization.

 

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  Active gastrointestinal bleeding in a hemodynamically unstable 71-year-old man who presented with massive hematemesis that obscured endoscopic findings. (a) Coronal CT angiogram through the gastric body and antrum shows a large amount of clotted blood within the distended stomach (*) and pooling of extravasated contrast material (arrow). These findings allowed direction of the catheter toward the left gastric artery. (b) Angiogram obtained after injection of the left gastric artery shows a bleeding gastric branch (arrow). The patient was treated successfully with microcoil embolization.

 

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  Active ileal bleeding in a 75-year-old woman. (a) Unenhanced CT scan shows no hyperattenuating material within the terminal ileum (arrow). (b) CT angiogram obtained immediately after a demonstrates pooling of contrast material within the terminal ileum (arrow). (c) Coronal oblique CT angiogram shows a prominent ileocolic branch coursing toward the bleeding terminal ileum (arrow). (d) Catheter angiogram shows active bleeding from an ileocolic branch of the SMA and pooling of contrast material within the terminal ileum (arrow), thereby helping confirm the CT angiographic findings. The patient was treated successfully with coil embolization.

 

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  Active ileal bleeding in a 75-year-old woman. (a) Unenhanced CT scan shows no hyperattenuating material within the terminal ileum (arrow). (b) CT angiogram obtained immediately after a demonstrates pooling of contrast material within the terminal ileum (arrow). (c) Coronal oblique CT angiogram shows a prominent ileocolic branch coursing toward the bleeding terminal ileum (arrow). (d) Catheter angiogram shows active bleeding from an ileocolic branch of the SMA and pooling of contrast material within the terminal ileum (arrow), thereby helping confirm the CT angiographic findings. The patient was treated successfully with coil embolization.

 

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 3c.  Active ileal bleeding in a 75-year-old woman. (a) Unenhanced CT scan shows no hyperattenuating material within the terminal ileum (arrow). (b) CT angiogram obtained immediately after a demonstrates pooling of contrast material within the terminal ileum (arrow). (c) Coronal oblique CT angiogram shows a prominent ileocolic branch coursing toward the bleeding terminal ileum (arrow). (d) Catheter angiogram shows active bleeding from an ileocolic branch of the SMA and pooling of contrast material within the terminal ileum (arrow), thereby helping confirm the CT angiographic findings. The patient was treated successfully with coil embolization.

 

View larger version (119K): [in this window] [in a new window] [Download PPT slide]   Figure 3d.  Active ileal bleeding in a 75-year-old woman. (a) Unenhanced CT scan shows no hyperattenuating material within the terminal ileum (arrow). (b) CT angiogram obtained immediately after a demonstrates pooling of contrast material within the terminal ileum (arrow). (c) Coronal oblique CT angiogram shows a prominent ileocolic branch coursing toward the bleeding terminal ileum (arrow). (d) Catheter angiogram shows active bleeding from an ileocolic branch of the SMA and pooling of contrast material within the terminal ileum (arrow), thereby helping confirm the CT angiographic findings. The patient was treated successfully with coil embolization.

 

View larger version (153K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  Hyperattenuating bowel loop mimicking active hemorrhage. (a, b) Axial (a) and coronal (b) unenhanced CT scans demonstrate hyperattenuating material completely filling a small bowel loop within the right lower quadrant (arrow). (c, d) Axial (c) and coronal (d) CT angiograms obtained immediately after a and b demonstrate a hyperattenuating loop in the right lower quadrant (arrow) that mimics active hemorrhage. Unfortunately, the CT angiograms were not compared with the unenhanced scans, resulting in incorrect interpretation of this hyperattenuating loop as active hemorrhage. The patient was immediately transferred to the angiography suite for transcatheter embolization. Angiography failed to help detect active hemorrhage.

 

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  Hyperattenuating bowel loop mimicking active hemorrhage. (a, b) Axial (a) and coronal (b) unenhanced CT scans demonstrate hyperattenuating material completely filling a small bowel loop within the right lower quadrant (arrow). (c, d) Axial (c) and coronal (d) CT angiograms obtained immediately after a and b demonstrate a hyperattenuating loop in the right lower quadrant (arrow) that mimics active hemorrhage. Unfortunately, the CT angiograms were not compared with the unenhanced scans, resulting in incorrect interpretation of this hyperattenuating loop as active hemorrhage. The patient was immediately transferred to the angiography suite for transcatheter embolization. Angiography failed to help detect active hemorrhage.

 

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 4c.  Hyperattenuating bowel loop mimicking active hemorrhage. (a, b) Axial (a) and coronal (b) unenhanced CT scans demonstrate hyperattenuating material completely filling a small bowel loop within the right lower quadrant (arrow). (c, d) Axial (c) and coronal (d) CT angiograms obtained immediately after a and b demonstrate a hyperattenuating loop in the right lower quadrant (arrow) that mimics active hemorrhage. Unfortunately, the CT angiograms were not compared with the unenhanced scans, resulting in incorrect interpretation of this hyperattenuating loop as active hemorrhage. The patient was immediately transferred to the angiography suite for transcatheter embolization. Angiography failed to help detect active hemorrhage.

 

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 4d.  Hyperattenuating bowel loop mimicking active hemorrhage. (a, b) Axial (a) and coronal (b) unenhanced CT scans demonstrate hyperattenuating material completely filling a small bowel loop within the right lower quadrant (arrow). (c, d) Axial (c) and coronal (d) CT angiograms obtained immediately after a and b demonstrate a hyperattenuating loop in the right lower quadrant (arrow) that mimics active hemorrhage. Unfortunately, the CT angiograms were not compared with the unenhanced scans, resulting in incorrect interpretation of this hyperattenuating loop as active hemorrhage. The patient was immediately transferred to the angiography suite for transcatheter embolization. Angiography failed to help detect active hemorrhage.

 

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.  Active left colonic diverticular hemorrhage. (a, b) Axial (a) and coronal (b) 3-mm maximum-intensity-projection (MIP) CT angiographic images demonstrate a swirling jet of extravasated contrast material within the lumen of the descending colon (arrow). Multiple colonic diverticuli were also seen, and diverticular bleeding was suspected. (c) Angiogram obtained during microcoil embolization of bleeding left colic artery branches shows puddling of contrast material within the left colon (arrow), a finding that represents hemorrhage. Subsequent colonoscopy performed after bowel preparation revealed multiple large diverticuli within the descending colon, several of which contained blood. No active hemorrhage was seen at colonoscopy.

 

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.  Active left colonic diverticular hemorrhage. (a, b) Axial (a) and coronal (b) 3-mm maximum-intensity-projection (MIP) CT angiographic images demonstrate a swirling jet of extravasated contrast material within the lumen of the descending colon (arrow). Multiple colonic diverticuli were also seen, and diverticular bleeding was suspected. (c) Angiogram obtained during microcoil embolization of bleeding left colic artery branches shows puddling of contrast material within the left colon (arrow), a finding that represents hemorrhage. Subsequent colonoscopy performed after bowel preparation revealed multiple large diverticuli within the descending colon, several of which contained blood. No active hemorrhage was seen at colonoscopy.

 

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 5c.  Active left colonic diverticular hemorrhage. (a, b) Axial (a) and coronal (b) 3-mm maximum-intensity-projection (MIP) CT angiographic images demonstrate a swirling jet of extravasated contrast material within the lumen of the descending colon (arrow). Multiple colonic diverticuli were also seen, and diverticular bleeding was suspected. (c) Angiogram obtained during microcoil embolization of bleeding left colic artery branches shows puddling of contrast material within the left colon (arrow), a finding that represents hemorrhage. Subsequent colonoscopy performed after bowel preparation revealed multiple large diverticuli within the descending colon, several of which contained blood. No active hemorrhage was seen at colonoscopy.

 

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Retained barium mimicking active bleeding in a hemodynamically stable 77-year-old man who presented with bright red blood from the rectum. Transverse (a) and sagittal (b) CT angiograms show retained colonic barium from a prior examination (arrow). No contrast material jet is seen, and the barium is hyperattenuating relative to extravasated contrast material. Results from subsequent catheter angiography were also negative. Retained contrast material can mimic active bleeding or limit the CT angiographic evaluation of lower gastrointestinal bleeding.

 

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Retained barium mimicking active bleeding in a hemodynamically stable 77-year-old man who presented with bright red blood from the rectum. Transverse (a) and sagittal (b) CT angiograms show retained colonic barium from a prior examination (arrow). No contrast material jet is seen, and the barium is hyperattenuating relative to extravasated contrast material. Results from subsequent catheter angiography were also negative. Retained contrast material can mimic active bleeding or limit the CT angiographic evaluation of lower gastrointestinal bleeding.

 

View larger version (145K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.  Mucosal enhancement. (a) Coronal unenhanced CT scan shows multiple colonic diverticuli without any hyperattenuating material within the bowel. (b) CT angiogram demonstrates diffuse mucosal enhancement throughout the descending colon (arrowheads), within the stomach (large arrow), and in portions of the small bowel. Such a finding can mimic acute hemorrhage, but the contracted appearance of the bowel, the striated peripheral enhancement pattern (small arrows), and the diffuse multifocal appearance support the correct diagnosis of mucosal enhancement. (c, d) Unenhanced CT scan (c) and CT angiogram (d) demonstrate the typical striated appearance of mucosal enhancement within the stomach.

 

View larger version (180K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.  Mucosal enhancement. (a) Coronal unenhanced CT scan shows multiple colonic diverticuli without any hyperattenuating material within the bowel. (b) CT angiogram demonstrates diffuse mucosal enhancement throughout the descending colon (arrowheads), within the stomach (large arrow), and in portions of the small bowel. Such a finding can mimic acute hemorrhage, but the contracted appearance of the bowel, the striated peripheral enhancement pattern (small arrows), and the diffuse multifocal appearance support the correct diagnosis of mucosal enhancement. (c, d) Unenhanced CT scan (c) and CT angiogram (d) demonstrate the typical striated appearance of mucosal enhancement within the stomach.

 

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 7c.  Mucosal enhancement. (a) Coronal unenhanced CT scan shows multiple colonic diverticuli without any hyperattenuating material within the bowel. (b) CT angiogram demonstrates diffuse mucosal enhancement throughout the descending colon (arrowheads), within the stomach (large arrow), and in portions of the small bowel. Such a finding can mimic acute hemorrhage, but the contracted appearance of the bowel, the striated peripheral enhancement pattern (small arrows), and the diffuse multifocal appearance support the correct diagnosis of mucosal enhancement. (c, d) Unenhanced CT scan (c) and CT angiogram (d) demonstrate the typical striated appearance of mucosal enhancement within the stomach.

 

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 7d.  Mucosal enhancement. (a) Coronal unenhanced CT scan shows multiple colonic diverticuli without any hyperattenuating material within the bowel. (b) CT angiogram demonstrates diffuse mucosal enhancement throughout the descending colon (arrowheads), within the stomach (large arrow), and in portions of the small bowel. Such a finding can mimic acute hemorrhage, but the contracted appearance of the bowel, the striated peripheral enhancement pattern (small arrows), and the diffuse multifocal appearance support the correct diagnosis of mucosal enhancement. (c, d) Unenhanced CT scan (c) and CT angiogram (d) demonstrate the typical striated appearance of mucosal enhancement within the stomach.

 

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.  Bleeding pancreaticoduodenal branch in a 90-year-old man with a history of duodenal ulcers who presented with a 2-day history of melena. Initial work-up included endoscopy, CT angiography, and conventional angiography; results from all studies were negative. Gastrointestinal bleeding recurred the next morning, and repeat CT angiography was performed. (a) Coronal CT angiogram demonstrates active extravasation of contrast material into the second portion of the duodenum (arrow). (b) CT angiogram shows the extravasated contrast material with a swirled appearance (arrow). The hepatic artery was replaced from the SMA; note the two parallel vessels anterior to the aorta (arrowheads). (c) Angiogram obtained during hepatic artery injection shows a bleeding pancreaticoduodenal branch (arrow) arising from the gastroduodenal artery and a small amount of contrast material that has refluxed into the SMA (arrowheads). (d) Angiogram shows successful microcoil embolization of the bleeding vessel (arrow). Preprocedural knowledge of the vascular variant in this case resulted in less delay in finding and embolizing the bleeding vessel.

 

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.  Bleeding pancreaticoduodenal branch in a 90-year-old man with a history of duodenal ulcers who presented with a 2-day history of melena. Initial work-up included endoscopy, CT angiography, and conventional angiography; results from all studies were negative. Gastrointestinal bleeding recurred the next morning, and repeat CT angiography was performed. (a) Coronal CT angiogram demonstrates active extravasation of contrast material into the second portion of the duodenum (arrow). (b) CT angiogram shows the extravasated contrast material with a swirled appearance (arrow). The hepatic artery was replaced from the SMA; note the two parallel vessels anterior to the aorta (arrowheads). (c) Angiogram obtained during hepatic artery injection shows a bleeding pancreaticoduodenal branch (arrow) arising from the gastroduodenal artery and a small amount of contrast material that has refluxed into the SMA (arrowheads). (d) Angiogram shows successful microcoil embolization of the bleeding vessel (arrow). Preprocedural knowledge of the vascular variant in this case resulted in less delay in finding and embolizing the bleeding vessel.

 

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 8c.  Bleeding pancreaticoduodenal branch in a 90-year-old man with a history of duodenal ulcers who presented with a 2-day history of melena. Initial work-up included endoscopy, CT angiography, and conventional angiography; results from all studies were negative. Gastrointestinal bleeding recurred the next morning, and repeat CT angiography was performed. (a) Coronal CT angiogram demonstrates active extravasation of contrast material into the second portion of the duodenum (arrow). (b) CT angiogram shows the extravasated contrast material with a swirled appearance (arrow). The hepatic artery was replaced from the SMA; note the two parallel vessels anterior to the aorta (arrowheads). (c) Angiogram obtained during hepatic artery injection shows a bleeding pancreaticoduodenal branch (arrow) arising from the gastroduodenal artery and a small amount of contrast material that has refluxed into the SMA (arrowheads). (d) Angiogram shows successful microcoil embolization of the bleeding vessel (arrow). Preprocedural knowledge of the vascular variant in this case resulted in less delay in finding and embolizing the bleeding vessel.

 

View larger version (176K): [in this window] [in a new window] [Download PPT slide]   Figure 8d.  Bleeding pancreaticoduodenal branch in a 90-year-old man with a history of duodenal ulcers who presented with a 2-day history of melena. Initial work-up included endoscopy, CT angiography, and conventional angiography; results from all studies were negative. Gastrointestinal bleeding recurred the next morning, and repeat CT angiography was performed. (a) Coronal CT angiogram demonstrates active extravasation of contrast material into the second portion of the duodenum (arrow). (b) CT angiogram shows the extravasated contrast material with a swirled appearance (arrow). The hepatic artery was replaced from the SMA; note the two parallel vessels anterior to the aorta (arrowheads). (c) Angiogram obtained during hepatic artery injection shows a bleeding pancreaticoduodenal branch (arrow) arising from the gastroduodenal artery and a small amount of contrast material that has refluxed into the SMA (arrowheads). (d) Angiogram shows successful microcoil embolization of the bleeding vessel (arrow). Preprocedural knowledge of the vascular variant in this case resulted in less delay in finding and embolizing the bleeding vessel.

 

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  Gastrointestinal bleeding in a 37-year-old woman in whom steroid treatment for severe lupus was complicated by spontaneous jejunal perforation secondary to ulcer disease. The perforated ulcers were oversewn at laparotomy, and the patient subsequently developed severe gastrointestinal bleeding. (a, b) Axial (a) and sagittal (b) CT angiograms help localize the bleeding to a proximal anterior jejunal loop, where pooling of contrast material is seen (arrows). Embolization therapy failed, and the patient developed recurrent gastrointestinal bleeding the next morning. Small bowel resection was subsequently performed. (c) Clinical photograph demonstrates multiple jejunal ulcers (bottom arrowheads), as well as the gastropexy clip (top arrowheads) that was used during CT-guided percutaneous localization of the bleeding loop.

 

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  Gastrointestinal bleeding in a 37-year-old woman in whom steroid treatment for severe lupus was complicated by spontaneous jejunal perforation secondary to ulcer disease. The perforated ulcers were oversewn at laparotomy, and the patient subsequently developed severe gastrointestinal bleeding. (a, b) Axial (a) and sagittal (b) CT angiograms help localize the bleeding to a proximal anterior jejunal loop, where pooling of contrast material is seen (arrows). Embolization therapy failed, and the patient developed recurrent gastrointestinal bleeding the next morning. Small bowel resection was subsequently performed. (c) Clinical photograph demonstrates multiple jejunal ulcers (bottom arrowheads), as well as the gastropexy clip (top arrowheads) that was used during CT-guided percutaneous localization of the bleeding loop.

 

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 9c.  Gastrointestinal bleeding in a 37-year-old woman in whom steroid treatment for severe lupus was complicated by spontaneous jejunal perforation secondary to ulcer disease. The perforated ulcers were oversewn at laparotomy, and the patient subsequently developed severe gastrointestinal bleeding. (a, b) Axial (a) and sagittal (b) CT angiograms help localize the bleeding to a proximal anterior jejunal loop, where pooling of contrast material is seen (arrows). Embolization therapy failed, and the patient developed recurrent gastrointestinal bleeding the next morning. Small bowel resection was subsequently performed. (c) Clinical photograph demonstrates multiple jejunal ulcers (bottom arrowheads), as well as the gastropexy clip (top arrowheads) that was used during CT-guided percutaneous localization of the bleeding loop.

 

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.  Massive rectal bleeding in a 47-year-old man. (a) On an unenhanced CT scan, the rectum (arrow) appears normal. (b) Coronal CT scan demonstrates swirling and pooling of contrast material within the rectum (arrow), a finding that was not seen on the unenhanced scan. (c) CT angiogram shows a large amount of clotted blood that has refluxed into the sigmoid and distal descending colon (arrowheads). The patient underwent surgery, which showed large bleeding hemorrhoids and a bleeding anal condyloma.

 

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.  Massive rectal bleeding in a 47-year-old man. (a) On an unenhanced CT scan, the rectum (arrow) appears normal. (b) Coronal CT scan demonstrates swirling and pooling of contrast material within the rectum (arrow), a finding that was not seen on the unenhanced scan. (c) CT angiogram shows a large amount of clotted blood that has refluxed into the sigmoid and distal descending colon (arrowheads). The patient underwent surgery, which showed large bleeding hemorrhoids and a bleeding anal condyloma.

 

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 10c.  Massive rectal bleeding in a 47-year-old man. (a) On an unenhanced CT scan, the rectum (arrow) appears normal. (b) Coronal CT scan demonstrates swirling and pooling of contrast material within the rectum (arrow), a finding that was not seen on the unenhanced scan. (c) CT angiogram shows a large amount of clotted blood that has refluxed into the sigmoid and distal descending colon (arrowheads). The patient underwent surgery, which showed large bleeding hemorrhoids and a bleeding anal condyloma.

 

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 11a.  Occlusion of the right common iliac artery. Axial (a) and coronal (b) CT angiograms show occlusion of a short segment of the right common iliac artery at its origin (arrow). The occlusion necessitated a left femoral approach to access the mesenteric vasculature for transcatheter intervention.

 

View larger version (70K): [in this window] [in a new window] [Download PPT slide]   Figure 11b.  Occlusion of the right common iliac artery. Axial (a) and coronal (b) CT angiograms show occlusion of a short segment of the right common iliac artery at its origin (arrow). The occlusion necessitated a left femoral approach to access the mesenteric vasculature for transcatheter intervention.

 

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