| 1. Peery AF, Crockett SD, Barritt AS, et al. Burden of Gastrointestinal, Liver, and Pancreatic Diseases in the United States. Gastroenterology. 149(7):1731-1741.e3, 2015 Dec. |
Review/Other-Dx |
N/A |
To estimate the burden and cost of GI and liver disease in the United States. |
There were 7 million diagnoses of gastroesophageal reflux and almost 4 million diagnoses of hemorrhoids in the ambulatory setting in a year. Functional and motility disorders resulted in nearly 1 million emergency department visits in 2012; most of these visits were for constipation. GI hemorrhage was the most common diagnosis leading to hospitalization, with >500,000 discharges in 2012, at a cost of nearly $5 billion dollars. Hospitalizations and associated charges for inflammatory bowel disease, Clostridium difficile infection, and chronic liver disease have increased during the last 20 years. In 2011, there were >1 million people in the United States living with colorectal cancer. The leading GI cause of death was colorectal cancer, followed by pancreatic and hepatobiliary neoplasms. |
4 |
| 2. Ghassemi KA, Jensen DM. Lower GI bleeding: epidemiology and management. [Review]. Curr Gastroenterol Rep. 15(7):333, 2013 Jul. |
Review/Other-Dx |
N/A |
To discuss the colonoscopic diagnosis, risk stratification, and definitive treatment of colonic hemorrhage in patients presenting with severe hematochezia. |
No results stated in abstract. |
4 |
| 3. Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. [Review] [35 refs]. Hepatology. 28(4):1154-8, 1998 Oct. |
Review/Other-Tx |
N/A |
To present a systematic approach for any patient presenting with bleeding from possible ectopic varices. |
No results stated in abstract. |
4 |
| 4. Zuccaro G Jr.. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol. 93(8):1202-8, 1998 Aug. |
Review/Other-Dx |
N/A |
To present practice guidelines for the management of lower gastrointestinal bleeding in adult patients |
No abstract available. |
4 |
| 5. Teng HC, Liang HL, Lin YH, et al. The efficacy and long-term outcome of microcoil embolotherapy for acute lower gastrointestinal bleeding. Korean J Radiol. 14(2):259-68, 2013 Mar-Apr. |
Observational-Tx |
26 patients |
To evaluate the clinical efficacy as well as long-term clinical outcomes of superselective microcoil embolization for lower gastrointestinal bleeding (LGIB). |
Twenty-two bleeding sources were in the territory of superior mesenteric artery and four in the inferior mesenteric artery. Technical success was achieved in 22 patients (84.6%). The target vessel of embolization was vasa recta in seventeen patients and marginal artery in the remaining five patients. Early rebleeding occurred in two patients (7.7%) and bowel ischemia in two patients, of whom the embolized points were both at the marginal artery. Delayed recurrent bleeding (> 30 days) occurred in two angiodysplasia patients. Five patients (19.2%) died within the first 30 days of intervention. Long-term follow-up depicted estimated survival rates of 58.2 and 43.1% after one, and five years, respectively. |
4 |
| 6. Rossetti A, Buchs NC, Breguet R, Bucher P, Terraz S, Morel P. Transarterial embolization in acute colonic bleeding: review of 11 years of experience and long-term results. Int J Colorectal Dis. 28(6):777-82, 2013 Jun. |
Observational-Dx |
24 patients |
To evaluate the short-term and long-term outcomes after selective embolization for colonic bleeding. |
Twenty-four patients underwent colonic embolization. There were 6 men and 18 women with a median age of 80 years (range, 42-94 years). The underlying etiologies included diverticular disease (41.9 %), post-polypectomy bleeding (16.7 %), malignancy (8.2 %), hemorrhoid (4.1 %), and angiodysplasia (4.1 %). In 23 patients, bleeding stopped (95.8 %) after selective embolization. One patient presented a recurrence of bleeding with hemorrhagic shock and required urgent hemorrhoidal ligature. Four patients required an emergent surgical procedure because of an ischemic event (16.7 %). One patient died of ileal ischemia (mortality, 4.1 %). The level of embolization and the length of hypoperfused colon after embolization were the only risk factors for emergent operation. Mean hospital stay was 18 days (range, 9-44 days). After a mean follow-up of 28.6 months (range, 4-108 months), no other ischemic events occurred. |
4 |
| 7. Kim JH, Shin JH, Yoon HK, et al. Angiographically negative acute arterial upper and lower gastrointestinal bleeding: incidence, predictive factors, and clinical outcomes. Korean J Radiol. 10(4):384-90, 2009 Jul-Aug. |
Observational-Dx |
143 patients |
To evaluate the incidence, predictive factors, and clinical outcomes of angiographically negative acute arterial upper and lower gastrointestinal (GI) bleeding. |
The angiographies revealed a negative bleeding focus in 75 of 143 (52%) patients. The incidence of an angiographically negative outcome was significantly higher in patients with a stable hemodynamic status (p < 0.001), or in patients with lower GI bleeding (p = 0.032). A follow-up of the 75 patients (range: 0-72 months, mean: 8 +/- 14 months) revealed that 60 of the 75 (80%) patients with a negative bleeding focus underwent conservative management only, and acute bleeding was controlled without rebleeding. Three of the 75 (4%) patients underwent exploratory surgery due to prolonged bleeding; however, no bleeding focus was detected. Rebleeding occurred in 12 of 75 (16%) patients. Of these, six patients experienced massive rebleeding and died of disseminated intravascular coagulation within four to nine hours after the rebleeding episode. Four of the 16 patients underwent a repeat angiography and the two remaining patients underwent a surgical intervention to control the bleeding. |
4 |
| 8. Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2001;12(12):1399-1405. |
Review/Other-Tx |
48 patients; 2 mesenteric artery catheterization procedures |
To evaluate technical success, efficacy and ischemic complications of embolization. |
35/48 patients underwent technically successful embolization, and 33/35 achieved initial hemostasis. 12/33 had a recurrence of bleeding and most of these were then treated by surgery. Asymptomatic ischemia occurred in 24% of fully evaluated patients. Embolization provided definitive treatment in 21/48 (44%) patients. Superselective embolization is a feasible, safe, and effective technique for treating acute LGIB. |
4 |
| 9. d'Othee BJ, Surapaneni P, Rabkin D, Nasser I, Clouse M. Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol. 2006;29(1):49-58. |
Review/Other-Tx |
19 patients |
To retrospectively assess outcomes after microcoil embolization for LGIB. |
Technical success was 89% with clinical success in 84%. 11% rate of colonic ischemia. Microcoil embolization for active LGIB is safe and effective in most patients, with high technical and clinical success rates, no procedure-related mortality, and a low risk of bowel ischemia and late rebleeding. |
4 |
| 10. Funaki B, Kostelic JK, Lorenz J, et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol. 2001;177(4):829-836. |
Observational-Tx |
27 patients |
To evaluate efficacy of embolization for severe colonic hemorrhage. |
Initial hemostasis achieved in 26/27 patients (96%). 3/26 rebled within 24 hours. One patient developed bowel infarction requiring left hemicolectomy. Prolonged clinical success was seen in 22/27 (81%). Therapeutic microcoil embolization for severe colonic hemorrhage is an effective and well-tolerated procedure. |
2 |
| 11. Gillespie CJ, Sutherland AD, Mossop PJ, Woods RJ, Keck JO, Heriot AG. Mesenteric embolization for lower gastrointestinal bleeding. Dis Colon Rectum. 2010;53(9):1258-1264. |
Observational-Tx |
78 patients |
To determine the outcome of angiography and embolization and its influencing factors. |
There were 107 angiograms performed during 83 episodes of LGIB in 78 patients. Active bleeding was identified in 40 episodes (48%), and embolizations were performed in 37 (45%). One patient without active bleeding on angiogram also underwent embolization, making a total of 38 embolizations. Overall mortality was 7% with 4 deaths due to rebleeding and 2 deaths due to a medical comorbidity (respiratory failure, pneumonia). Short-term complications of angiography were false aneurysm (1 patient) and Enterobacter sepsis (1 patient). Long-term complications were groin lymphocele (1 patient) and late rebleed from collateralization (1 patient). In 43 episodes, angiography did not demonstrate active bleeding. 12 (28%) of these patients continued to bleed, 9 of whom had successful surgery. Of the 38 patients who had embolizations, all had immediate cessation of bleeding. 9 patients (24%) later rebled; 5 of these patients required surgery and 3 had reembolizations. Of the 3 patients who underwent reembolization, 2 developed ischemic bowel and 1 stopped bleeding; surgery was required in 1 patient. |
3 |
| 12. Huang CC, Lee CW, Hsiao JK, et al. N-butyl cyanoacrylate embolization as the primary treatment of acute hemodynamically unstable lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2011;22(11):1594-1599. |
Review/Other-Tx |
27 patients |
To evaluate NBCA embolization as the primary treatment for patients with severe and acute hemodynamically unstable LGIB. |
The procedure was technically successful in all patients. 26 patients were treated solely with NBCA, and 1 required microcoil embolization. Embolization was performed at the level of the arteria recta or as close as possible to the point of bleeding. Immediate hemostasis occurred in all cases. 4 patients experienced repeat hemorrhage, 1 of whom died. The other 3 were treated successfully with repeat NBCA embolization. None of the surviving patients had evidence of bowel ischemia. In addition, none of the patients with severe underlying disease died during the follow-up period (range, 3 months to 2 years). |
4 |
| 13. Hur S, Jae HJ, Lee M, Kim HC, Chung JW. 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):10-19. |
Observational-Tx |
112 patients |
To assess the safety and efficacy of transcatheter arterial embolization for LGIB and to determine the prognostic factors that affect clinical outcome. |
A total of 112 patients were included (36 with small-bowel LGIB, 36 with colon LGIB, and 40 with rectal LGIB). NBCA was the embolic agent for 84 patients (75.0%), whereas gelatin sponge pledgets (n = 20), microcoils (n = 2), polyvinyl alcohol particles with adjunctive gelatin sponge pledgets (n = 1), and blood clots (n = 1) were used in the other patients. The technical success rate was 96.4%. For the entire group, the rates of early recurrent bleeding, major complications, clinical success, and in-hospital mortality were 17.4%, 4.6%, 74.5%, and 25.0%, respectively. These were 15.2%, 4.8%, 75.3%, and 26.2%, respectively, in the NBCA group. Hematologic malignancy, immobilization status, and coagulopathy were significant prognostic factors for clinical outcomes. |
2 |
| 14. Khanna A, Ognibene SJ, Koniaris LG. Embolization as first-line therapy for diverticulosis-related massive lower gastrointestinal bleeding: evidence from a meta-analysis. J Gastrointest Surg. 2005;9(3):343-352. |
Meta-analysis |
25 publications and unpublished series of 12 consecutive patients |
To determine which etiologies of LGIB are best treated with embolization. |
Multiple regression analysis demonstrated no significant difference in pooled outcomes when varying the included study, age, or embolization method on the outcome of rebleeding. The pooled OR for arteriovenous dysplastic lesions and other diseases was 3.53 compared with rebleeding after localization and embolization for diverticular disease (95% CI, OR, 1.33, 9.41; P<0.01). Embolization for diverticular bleeding was successful in 85% of patients. In contrast, rebleeding after embolization for nondiverticular bleeding occurred in >40% of patients and over a more protracted period. Embolization for LGIB is most effective for the treatment of diverticular bleeding. Caution should be used when applying embolization therapy for nondiverticular causes due to the considerably higher associated failure rate. An inpatient observation period of 2 days is suggested following embolization for diverticular bleeding. |
M |
| 15. Kickuth R, Rattunde H, Gschossmann J, Inderbitzin D, Ludwig K, Triller J. Acute lower gastrointestinal hemorrhage: minimally invasive management with microcatheter embolization. J Vasc Interv Radiol. 2008;19(9):1289-1296 e1282. |
Observational-Tx |
20 patients |
To assess the efficacy of superselective embolization for LGIB. |
100% technical success and 90% clinical success. Had 1 case of colonic infarction. Clinical success attributed to transcatheter arterial embolization was documented in 18/20 patients (90%). Superselective embolization may be used for effective, minimally invasive control of acute LGIB. |
2 |
| 16. Kuo WT, Lee DE, Saad WE, Patel N, Sahler LG, Waldman DL. Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 2003;14(12):1503-1509. |
Review/Other-Tx |
22 patients |
To evaluate the safety and effectiveness of superselective microcoil embolization for LGIB. |
Postembolization objective follow-up was performed in 64% of patients (14/22 patients). 10 patients underwent follow-up colonoscopy; 1 patient received a follow-up barium enema; and 3 patients underwent subsequent surgery. Initial success in 100%, but 3 (14%) rebled. There was no major ischemia and 1 case (4.5%) with minor ischemia. Superselective microcoil embolization is a safe and effective treatment for LGIB. |
4 |
| 17. Lipof T, Sardella WV, Bartus CM, Johnson KH, Vignati PV, Cohen JL. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum. 2008;51(3):301-305. |
Review/Other-Tx |
71 patients |
To evaluate the short and long term efficacy and safety of superselective embolization for LGIB. |
90% were colon or rectal bleeds, only 10% small bowel. PVA exclusive agent in 67%. Immediate hemostasis was seen in 97%. Rebleeding occurred in 16% and 7% developed post embolization ischemia. This large series reaffirms the high success rate (97%) and relatively low acute ischemia risk (7%) of superselective embolization for LGIB. Furthermore, only 15% of patients ultimately required readmission for recurrent bleeding. It is recommended that superselective embolization be used as the primary therapeutic modality in the treatment of angiogram positive LGIB. |
4 |
| 18. Neuman HB, Zarzaur BL, Meyer AA, Cairns BA, Rich PB. Superselective catheterization and embolization as first-line therapy for lower gastrointestinal bleeding. Am Surg. 2005;71(7):539-544; discussion 544-535. |
Review/Other-Tx |
23 patients |
To study the efficacy of embolization for LGIB. |
5 patients (22%) had recurrent bleeding. Symptomatic ischemia was uncommon. Long-term (mean 19 months) follow-up was available for 17 patients. In this series, superselective catheterization and embolization was an effective first-line therapy for LGIB. |
4 |
| 19. Tan KK, Strong DH, Shore T, Ahmad MR, Waugh R, Young CJ. The safety and efficacy of mesenteric embolization in the management of acute lower gastrointestinal hemorrhage. Ann Coloproctol. 2013;29(5):205-208. |
Review/Other-Tx |
27 patients |
To highlight our experience after adopting mesenteric embolization in the management of acute LGIB. |
27 patients with a median age of 73 years (range, 31 to 86 years) formed the study group. More than half (n = 16, 59.3%) of the patients were on either antiplatelet and/or anticoagulant therapy. The underlying etiology included diverticular disease (n = 9), neoplasms (n = 5) and postprocedural complications (n = 6). The colon was the most common bleeding site and was seen in 21 patients (left, 10; right, 11). The median hemoglobin prior to the embolization was 8.6 g/dL (6.1 to 12.6 g/dL). A 100% technical success rate with immediate cessation of hemorrhage at the end of the session was achieved. There were 3 clinical failures (11.1%) in our series. 2 patients re-bled, and both underwent a successful repeat embolization. The only patient who developed an infarcted bowel following embolization underwent an emergency operation and died 1-week later. There were no factors that predicted clinical failure. |
4 |
| 20. Tan KK, Wong D, Sim R. Superselective embolization for lower gastrointestinal hemorrhage: an institutional review over 7 years. World J Surg. 2008;32(12):2707-2715. |
Observational-Tx |
32 patients |
To retrospectively assess the results of embolization for LGIB and analyze factors that correlate with treatment failure. |
Technical and clinical success for embolization was 97% and 63%. Rebleeding was more likely to occur if the site of bleeding was located in the small bowel compared to the colon (OR: 8.33, 95% CI, 1.03–66.67). It was also more likely in patients with a hematocrit level =20.0% (OR: 7.52, 95% CI: 1.14–50.00) and a platelets level =140 x 10(9)/l (OR: 9.35, 95% CI: 1.36–62.5) just before the procedure. Surgical resection was also more likely in patients with a hematocrit level =20.0% just before embolization (OR: 12.66, 95% CI: 1.96–83.33), and it appeared to be more likely if the underlying cause was diverticular disease (OR 8.70, 95% CI: 0.93–83.33). The use of superselective mesenteric embolization for the treatment of LGIB is highly successful and relatively safe 97% technical success and 3% postembolization ischemia in our series. In 63% of cases it is definitive without any further intervention. Greater vigilance must be adopted in treating patients who have active hemorrhage from the small bowel and in those with a hematocrit =20.0%. |
2 |
| 21. Kohler G, Koch OO, Antoniou SA, et al. Relevance of surgery after embolization of gastrointestinal and abdominal hemorrhage. World J Surg. 38(9):2258-66, 2014 Sep. |
Observational-Tx |
54 patients with 55 bleeding events |
To evaluate the role of surgery in the management of patients after embolization. |
Fifty-four patients with 55 bleeding events were included. The bleeding source could be localized angiographically in 80 %, and the primary clinical success rate of embolization was 81.8 % (45/55 cases). Early recurrent bleeding (<30 days) occurred in 18.2 % (10/55) of the patients, and delayed recurrent hemorrhage (>30 days) developed in 3.6 % (2/55). The mean follow-up was 8.4 months, and data were available for 85.2 % (46/54) of the patients. Surgery after embolization was required in 20.4 % of these patients (11/54). Failure to localize the bleeding site was identified as predictive of recurrent bleeding (p = 0.009). More than one embolization effort increased the risk of complications (p = 0.02) and rebleeding (p = 0.07). |
2 |
| 22. Kim PH, Tsauo J, Shin JH, Yun SC. Transcatheter Arterial Embolization of Gastrointestinal Bleeding with N-Butyl Cyanoacrylate: A Systematic Review and Meta-Analysis of Safety and Efficacy. [Review]. J Vasc Interv Radiol. 28(4):522-531.e5, 2017 Apr. |
Meta-analysis |
440 patients |
To evaluate the safety and efficacy of transcatheter arterial embolization with N-butyl cyanoacrylate (NBCA) for the treatment of gastrointestinal (GI) bleeding via a meta-analysis of published studies. |
The cases of 440 patients (mean age, 63.8 y ± 14.3; 319 men [72.5%] and 121 women [27.5%]) from 15 studies were evaluated. Of these patients, 261 (59.3%) had upper GI bleeding (UGIB) and 179 (40.7%) had lower GI bleeding (LGIB). Technical success was achieved in 99.2% of patients with UGIB (259 of 261) and 97.8% of those with LGIB (175 of 179). The pooled clinical success and major complication rates in the 259 patients with UGIB in whom technical success was achieved were 82.1% (95% confidence interval [CI], 73.0%-88.6%; P = 0.058; I2 = 42.7%) and 5.4% (95% CI, 2.8%-10.0%; P = 0.427; I2 = 0.0%), respectively, and those in the 175 patients with LGIB in whom technical success was achieved were 86.1% (95% CI, 79.9%-90.6%; P = 0.454; I2 = 0.0%) and 6.1% (95% CI, 3.1%-11.6%; P = 0.382; I2 = 4.4%), respectively. |
Good |
| 23. Urbano J, Manuel Cabrera J, Franco A, Alonso-Burgos A. Selective arterial embolization with ethylene-vinyl alcohol copolymer for control of massive lower gastrointestinal bleeding: feasibility and initial experience. J Vasc Interv Radiol. 25(6):839-46, 2014 Jun. |
Review/Other-Tx |
31 patients |
To evaluate the efficacy, safety, and clinical outcomes of superselective embolization using ethylene-vinyl alcohol copolymer (Onyx Liquid Embolic System; ev3 Neurovascular, Irvine, California) as the primary treatment for acute and massive lower gastrointestinal bleeding (LGIB). |
Active bleeding was detected in all cases. A colonoscopy was performed in 11 patients. The correlation between multidetector computed tomography and angiography findings was 96.7%. The causes of bleeding were diverticula in 15 patients, iatrogenic in 7 patients, neoplasia in 3 patients, hemorrhoids in 2 patients, angiodysplasia in 2 patients, and unknown in 2 patients. Embolization was not possible in one patient, who required urgent left hemicolectomy. The technical success rate was 93.5%. The embolic material refluxed in one patient, causing an undesired embolization, without any clinical consequences. In the 30 patients who received embolization, the immediate bleeding control rate was 100%. Rebleeding at 30 days occurred in three patients (10%). There were no major complications, intestinal ischemia, or deaths attributable to the treatment. No patient needed surgery or new embolization during a mean follow-up period of 23.7 months (range, 1-71 mo). |
4 |
| 24. Yi WS, Garg G, Sava JA. Localization and definitive control of lower gastrointestinal bleeding with angiography and embolization. Am Surg. 2013;79(4):375-380. |
Review/Other-Dx |
152 patients |
To evaluate the efficacy of angiography and embolization for localizing and treating LGIB as well as to evaluate the occurrence of bowel ischemia after embolization. |
159 angiograms were performed on 152 patients. Mean age was 72 years. Angiographic localization was successful in 23.7% of patients. Although embolization after angiographic localization achieved definitive control of bleeding in 50% of patients, the success rate was only 8.6% of all patients who had angiography. 1 patient developed postembolization ischemia requiring laparotomy. Angiographic localization of LGIB is successful in only 23.7% of patients. Definitive hemostasis through embolization was successful in only 8.6% of patients who underwent angiography for LGIB. |
4 |
| 25. Peck DJ, McLoughlin RF, Hughson MN, Rankin RN. Percutaneous embolotherapy of lower gastrointestinal hemorrhage. J Vasc Interv Radiol. 1998;9(5):747-751. |
Review/Other-Tx |
21 patients |
To retrospectively evaluate embolization for the treatment of LGIB. |
Initial success was achieved in 15 patients (71%), but prolonged hemostasis was seen in only 10 (48%). All embolizations distal to the cecum resulted in prolonged hemostasis, but 3 of 4 jejunal and 3 of 4 cecal embolizations rebled. There were no ischemic complications. Based on these data, it would appear that the risk of bowel ischemia/infarction in the LGI tract may not be as high as has been suggested. 2 regions (cecum and proximal jejunum) were associated with poor results, suggesting these areas may not be as responsive to embolotherapy as other sites in the LGI tract. |
4 |
| 26. Kodani M, Yata S, Ohuchi Y, Ihaya T, Kaminou T, Ogawa T. Safety and Risk of Superselective Transcatheter Arterial Embolization for Acute Lower Gastrointestinal Hemorrhage with N-Butyl Cyanoacrylate: Angiographic and Colonoscopic Evaluation. J Vasc Interv Radiol. 27(6):824-30, 2016 Jun. |
Observational-Tx |
16 patients |
To retrospectively evaluate the safety and risk of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) for urgent acute arterial bleeding control in the lower gastrointestinal tract by angiography and colonoscopy. |
The procedure was successful in all patients. No ischemic change was observed in any patients in group Ia and in two patients in group Ib. Ischemic changes were observed in six group Ib patients and both group II patients. Group Ib patients experienced ischemic complications that improved without treatment. One patient in group II underwent resection for intestinal perforation after embolization of three vasa recta. One patient in group II with sigmoid stricture with embolization of six vasa recta required prolonged hospitalization. |
4 |
| 27. Kim CY, Suhocki PV, Miller MJ, Jr., Khan M, Janus G, Smith TP. Provocative mesenteric angiography for lower gastrointestinal hemorrhage: results from a single-institution study. J Vasc Interv Radiol. 2010;21(4):477-483. |
Observational-Dx |
34 patients |
To retrospectively evaluate the safety and effectiveness of provocative angiography. |
Tissue-type plasminogen activator infusion yielded extravasation of contrast in 31% of patients all of whom had negative prior studies. No bleeding complications occurred. In this series, provocative mesenteric angiography was safe and effective for eliciting the source of occult LGIB, leading to definitive therapy in about one third of patients. |
4 |
| 28. Widlus DM, Salis AI. Reteplase provocative visceral arteriography. J Clin Gastroenterol. 2007;41(9):830-833. |
Review/Other-Dx |
9 patients |
A retrospective study reporting the results of using reteplase for provocative angiography. |
Colonic bleeding was stimulated in 8 patients (89%) allowing embolization or surgery to treat the bleeding in 7 patients. Reteplase may prove safe and effective as a provocative agent, stimulating bleeding to allow localization, in patients with occult, recurrent, massive LGIB. |
4 |
| 29. Kuhle WG, Sheiman RG. Detection of active colonic hemorrhage with use of helical CT: findings in a swine model. Radiology. 2003;228(3):743-752. |
Review/Other-Dx |
16 exams in 14 swine |
To evaluate the feasibility of helical CT as an imaging modality for depicting active colonic hemorrhage in a swine model. |
16 swine exams yielded 16 contrast material-enhanced blood dilution curves. An excellent fit of the model to each dilution curve was achieved (mean R2 value of 0.8402). Helical CT has the potential to depict active colonic hemorrhage at rates of 0.5 mL/min or less. |
4 |
| 30. Wildgruber M, Wrede CE, Zorger N, et al. Computed tomography versus digital subtraction angiography for the diagnosis of obscure gastrointestinal bleeding. Eur J Radiol. 88:8-14, 2017 Mar. |
Observational-Dx |
24 patients |
To prospectively evaluate the diagnostic yield of computed tomography angiography (CTA) versus digital subtraction angiography (DSA) for the diagnosis of major obscure gastrointestinal bleeding (OGIB). |
24 consecutive patients (11 men; median age 64 years) were included. CTA and DSA identified an active bleeding or a potential bleeding lesion in 92% (22 of 24 patients; 95% CI 72%-99%) and 29% (7 of 24 patients; 95% CI 12%-49%) of patients, respectively (p<0.001). CTA and DSA identified an active bleeding in 42% (10 of 24; 95% CI 22%-63%) and 21% (5 of 24; 95% CI 7%-42%) of patients, respectively (p=0.06). |
4 |
| 31. Kennedy DW, Laing CJ, Tseng LH, Rosenblum DI, Tamarkin SW. Detection of active gastrointestinal hemorrhage with CT angiography: a 4(1/2)-year retrospective review. J Vasc Interv Radiol. 2010;21(6):848-855. |
Observational-Dx |
74 patients; 86 CT angiograms |
To retrospectively evaluate the ability of CT to detect and localize GI bleeding. |
26% of CTs were positive for hemorrhage. Of the negative CTs, 92% required no further therapy. Sensitivity and specificity were 79% and 95%, respectively. CTA provides valuable information that can be used to determine the appropriateness of catheter angiography and guide mesenteric catheterization if a bleeding source is localized. The authors’ experience with this study cohort supports its use before angiography in those patients with acute GI bleeding of an unknown source who are being considered for catheter-directed intervention. |
3 |
| 32. Marti M, Artigas JM, Garzon G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 262(1):109-16, 2012 Jan. |
Observational-Dx |
47 patients |
To assess the diagnostic performance of CTA as the initial diagnostic examination for patients presenting to the emergency room with acute LGIB. |
CTA demonstrated active bleeding in 14 patients and intraluminal hyper attenuating material in 6 patients. The sensitivity, specificity, PPV, and NPV of CTA in depicting active or recent bleeding were 100% (19/19), 96% (27/28), 95% (19/20), and 100% (27/27), respectively. Findings of CTA and the standard of reference were concordant for determining definite or potential cause of bleeding in 44/47 patients (93% accuracy). |
2 |
| 33. Shih SL, Liu YP, Tsai YS, Yang FS, Lee HC, Chen YF. Evaluation of arterial phase MDCT for the characterization of lower gastrointestinal bleeding in infants and children: Preliminary results. AJR. American Journal of Roentgenology. 194(2):496-9, 2010 Feb.AJR Am J Roentgenol. 194(2):496-9, 2010 Feb. |
Observational-Dx |
27 patients |
To prospectively evaluate the efficacy of CT for detecting occult LGIB in pediatric patients. |
The sensitivity, specificity, and diagnostic accuracy of MDCT were 82%, 50%, and 74%. MDCT can be used to identify the location and source of LGIB in infants and children. |
2 |
| 34. Sun H, Jin Z, Li X, 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. |
Observational-Dx |
113 consecutive patients |
To prospectively assess the utility of MDCT angiography in the diagnosis of active GI bleeding. |
Positive CT findings for active GI bleeding were identified in 80/113 patients (70.8%), all of which were confirmed by 1 or more reference standard. Negative MDCT angiography results were obtained in 33 patients (29.2%). Of these, 27 patients did not require any further intervention and were discharged without incident. The overall sensitivity, specificity, PPV and NPV, and accuracy of MDCT angiography was 86.0%, 100%, 100%, 60.6%, and 88.5%, respectively. |
3 |
| 35. Yoon W, Jeong YY, Shin SS, et al. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology. 2006;239(1):160-167. |
Observational-Dx |
26 consecutive patients |
To prospectively evaluate accuracy of arterial phase MDCT for detection and localization of acute massive GI bleeding, with angiography as reference standard. |
Overall location-based sensitivity, specificity, accuracy, PPV and NPV values of MDCT for detection of GI bleeding were 90.9% (20/22), 99% (107/108), 97.6% (127/130), 95% (20/21), and 98% (107/109), respectively. Overall patient-based accuracy of MDCT for detection of acute GI bleeding was 88.5% (23/26). Arterial phase MDCT is accurate for detection and localization of bleeding sites in patients with acute massive GI bleeding. |
3 |
| 36. He B, Yang J, Xiao J, et al. Diagnosis of lower gastrointestinal bleeding by multi-slice CT angiography: A meta-analysis. Eur J Radiol. 93:40-45, 2017 Aug. |
Meta-analysis |
14 articles |
To estimate the diagnostic value of multi-slice spiral CT angiography (CTA) in lower gastrointestinal bleeding by a meta-analysis. |
A total of 14 articles including 549 patients with lower gastrointestinal bleeding were enrolled in the meta-analysis. The combined PLR, NLR and DOR were respectively 8.149, 0.158 and 56.213. There were significant heterogeneities in all estimations but we could not find the sources by meta-regression based on study design, study location, CT slices and sample size. The AUC and Q index under the fixed effect model was respectively 0.9463 and 0.8856. |
Inadequate |
| 37. Chan V, Tse D, Dixon S, et al. Outcome following a negative CT Angiogram for gastrointestinal hemorrhage. Cardiovasc Intervent Radiol. 38(2):329-35, 2015 Apr. |
Observational-Dx |
180 patients |
To evaluate the role of a negative CTA in patients who present with GI hemorrhage. |
A total of 180 patients had 202 CTAs during the 8-year period: 87 CTAs were performed for upper GI hemorrhage (18 positive for active bleeding, 69 negative) and 115 for LGIB (37 positive for active bleeding, 78 negative); 58.7% (37/63) of patients with upper GI bleed and 77.4% (48/62) of patients with LGIB who had an initial negative CTA did not rebleed without the need for radiological or surgical intervention. This difference was statistically significant (P=0.04). The relative risk of rebleeding, following a negative CTA, in LGIB vs upper GI bleeding patients is 0.55 (95% CI, 0.32–0.95). |
3 |
| 38. Shukla PA, Zybulewski A, Kolber MK, Berkowitz E, Silberzweig J, Hayim M. No catheter angiography is needed in patients with an obscure acute gastrointestinal bleed and negative CTA. Clin Imaging. 43:106-109, 2017 May - Jun. |
Observational-Dx |
20 patients |
To evaluate the negative predictive power of computed tomography angiography (CTA) for the identification of obscure acute gastrointestinal (GI) bleeding (GI bleeding not visualized/treated by endoscopy) on subsequent mesenteric angiography (MA) with the intention to treat. |
20 patients (14 male, 6 female; average age: 73.1±12.8years) underwent 20 negative CTA examinations for the evaluation and treatment of GI bleeding followed by mesenteric angiography. Eighteen of 20 patients had negative subsequent MA (negative predictive value, NPV=90%). Both false negative cases were upper GI bleed (vs 0 lower GI bleed); this difference was significant (p<0.05). |
4 |
| 39. 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. |
Review/Other-Dx |
20 patients |
A retrospective review of the results of using MDCT angiography to localize LGIB. |
Out of the 20 patients examined, 10 had positive CTAs demonstrating the bleeding site. 9 were hemodynamically unstable at the time of the study. 4 patients with positive CT angiograms were able to be treated directly with surgery and avoided invasive angiography. 10 patients had negative CTAs. 4 of these were hemodynamically unstable, 6 hemodynamically stable. Only 1 required intervention to secure hemostasis, the rest stopped spontaneously. No hemodynamically stable patient who had a negative CTA required intervention. CTA is a useful noninvasive technique for localizing the site of LGIB. In our patient population, in the absence of hemodynamic instability, the diagnostic yield of CTA was low and bleeding was likely to stop spontaneously. In hemodynamically unstable patients, a positive CTA allowed patients to be triaged to surgery or angiography, whereas there was a strong association between a negative CTA and spontaneous cessation of bleeding. |
4 |
| 40. Zink SI, Ohki SK, Stein B, et al. Noninvasive evaluation of active lower gastrointestinal bleeding: comparison between contrast-enhanced MDCT and 99mTc-labeled RBC scintigraphy. AJR Am J Roentgenol. 2008;191(4):1107-1114. |
Observational-Dx |
41 patients |
To compare CT and Tc-99m-labeled RBC scanning for the evaluation of active LGIB. |
Findings were positive on contrast-enhanced MDCT and negative on Tc-99m-labeled RBC in 2 patients; findings were negative on contrast-enhanced MDCT and positive on Tc-99m-labeled RBC in 11 patients. Statistics showed significant disagreement, with simple agreement (68.3%, kappa = 0.341, and P=0.014). 16/60 (26.7%) contrast-enhanced MDCT scans were positive prospectively, with all accurately localizing the site of bleeding and identification of the underlying lesion in 8/16 (50%). 19/41 (46.3%) Tc-99m-labeled RBC scans were positive. 18/41 matched patients went on to angiography. In 4/18 (22.2%) patients, the site of bleeding was confirmed by angiography, but in 14/18 (77.8%), the findings were negative. Contrast-enhanced MDCT and Tc-99m-labeled RBC scanning show significant disagreement for evaluation of active LGIB. Contrast-enhanced MDCT appears effective for detection and localization in cases of active LGIB in which hemorrhage is active at the time of CT. |
2 |
| 41. Tan KK, Shore T, Strong DH, Ahmad MR, Waugh RC, Young CJ. Factors predictive for a positive invasive mesenteric angiogram following a positive CT angiogram in patients with acute lower gastrointestinal haemorrhage. Int J Colorectal Dis. 28(12):1715-9, 2013 Dec. |
Observational-Tx |
27 patients |
To evaluate our institution’s experience in the adoption of super-selective embolization as a primary therapeutic modality in the control of acute lower GI hemorrhage. |
Twenty-seven patients with a median age of 73 years (range, 31 to 86 years) formed the study group. More than half (n = 16, 59.3%) of the patients were on either antiplatelet and/or anticoagulant therapy. The underlying etiology included diverticular disease (n = 9), neoplasms (n = 5) and postprocedural complications (n = 6). The colon was the most common bleeding site and was seen in 21 patients (left, 10; right, 11). The median hemoglobin prior to the embolization was 8.6 g/dL (6.1 to 12.6 g/dL). A 100% technical success rate with immediate cessation of hemorrhage at the end of the session was achieved. There were three clinical failures (11.1%) in our series. Two patients re-bled, and both underwent a successful repeat embolization. The only patient who developed an infarcted bowel following embolization underwent an emergency operation and died one week later. There were no factors that predicted clinical failure. |
3 |
| 42. Jacovides CL, Nadolski G, Allen SR, et al. Arteriography for Lower Gastrointestinal Hemorrhage: Role of Preceding Abdominal Computed Tomographic Angiogram in Diagnosis and Localization. JAMA Surg. 150(7):650-6, 2015 Jul. |
Observational-Dx |
161 angiographic procedures |
To determine if preceding visceral arteriography with computed tomographic angiography (CTA) in acute lower gastrointestinal hemorrhage increases hemorrhage identification and localization and to determine if CTA was superior to nuclear scintigraphy when used as a pre-angiogram test. |
A total of 161 angiographic procedures were performed during the study period (78 before and 83 after protocol implementation). Use of CTA increased from 3.8% to 56.6%, and use of nuclear scintigraphy decreased from 83.3% to 50.6% following protocol implementation (P?<?.001). Preceding angiography with CTA resulted in similar angiography contrast administration (mean [SD] amount for CTA prior to visceral arteriogram (VA), 135 [63] vs 160 [77] mL; P?=?.18) and fluoroscopy time (mean [SD], 26.3 [16.8] vs 32.2 [34.9] minutes; P?=?.34). Although nuclear scintigraphy and CTA had similar sensitivity and specificity, localization of hemorrhage site by CTA was more precise and consistent with angiography findings. As a pre-angiography test, compared with nuclear scintigraphy, CTA reduced overall the number of imaging studies required (mean [SD] number per patient admission, 2.1 [0.3] vs 2.5 [0.8]; P?=?.005) and resulted in administration of more overall contrast (mean [SD], 220 [80] vs 130 [70] mL; P?<?.001) without worsening renal function. |
4 |
| 43. Green BT, Rockey DC, Portwood G, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005;100(11):2395-2402. |
Experimental-Tx |
50 patients |
Prospective randomized study to compare urgent colonoscopy to standard care. |
A total of 50 patients were randomized to each group. A definite source of bleeding was found more often in urgent colonoscopy patients (diverticula, 13; angioectasia, 4; colitis, 4) than in the standard care group (diverticula, 8; colitis, 3) (the OR for the difference among the groups was 2.6; 95% CI, 1.1–6.2). In the urgent colonoscopy group, 17 patients received endoscopic therapy; in the standard care group, 10 patients had angiographic hemostasis. There was no difference in outcomes among the 2 groups-including: mortality 2% vs 4%, hospital stay 5.8 vs 6.6 days, ICU stay 1.8 vs 2.4 days, transfusion requirements 4.2 vs 5 units, early rebleeding 22% vs 30%, surgery 14% vs 12%, or late rebleeding 16% vs 14% (mean follow-up of 62 and 58 months). |
1 |
| 44. Lhewa DY, Strate LL. Pros and cons of colonoscopy in management of acute lower gastrointestinal bleeding. World J Gastroenterol. 2012;18(11):1185-1190. |
Review/Other-Dx |
N/A |
To discuss the advantages and disadvantages of colonoscopy in the management of acute LGIB. |
Colonoscopy has the ability to diagnose all sources of bleeding from the colon and, unlike the radiologic modalities, does not require active bleeding at the time of the examination. In addition, therapeutic interventions such as cautery and endoclips can be applied to achieve hemostasis and prevent recurrent bleeding. Studies suggest that colonoscopy, particularly when performed early in the hospitalization, can decrease hospital length of stay, rebleeding and the need for surgery. However, results from available small trials are conflicting and larger, multicenter studies are needed. Compared to other management options, colonoscopy is a safe procedure with complications reported in <2% of patients, including those undergoing urgent examinations. The requirement of bowel preparation (typically 4 or more liters of polyethylene glycol), the logistical complexity of coordinating after-hours colonoscopy, and the low prevalence of stigmata of hemorrhage complicate the use of colonoscopy for LGIB, particularly in urgent situations. |
4 |
| 45. Sugiyama T, Hirata Y, Kojima Y, et al. Efficacy of Contrast-enhanced Computed Tomography for the Treatment Strategy of Colonic Diverticular Bleeding. Intern Med. 54(23):2961-7, 2015. |
Observational-Dx |
124 patients |
To investigate the efficacy of contrast-enhanced computed tomography (CECT) to determine the indication for urgent colonoscopy to achieve hemostasis. |
Clinical behavior: Bleeding diverticula were identified in 23 of 124 (19%) patients and most of them (16/23; 70%) were located in the ascending colon. Hemostasis was achieved in all 23 cases, however, six (26%) developed early rebleeding. Factors for detecting bleeding diverticula: In patients in whom extravasation was detected using CECT, the endoscopic detection rate of bleeding diverticula was 60% (12/20), while bleeding diverticula were detected in only 31% (11/35) of patients in whom extravasation was not detected using CECT (p<0.05). The interval between the first hematochezia and colonoscopy in which the bleeding point was detected by colonoscopy (median 23.5 hours) was shorter than that in which bleeding diverticula were not detected (median 43.6 hours) (p<0.01). Risk factors for short term rebleeding: Using a univariate analysis, atherosclerotic comorbidity, anti-inflammatory drugs including low-dose aspirin, antithrombotic agents, vital signs on admission, hemoglobin level on hospitalization, and extravasation on CECT were not found to be significant risk factors. |
4 |
| 46. Nakatsu S, Yasuda H, Maehata T, et al. Urgent computed tomography for determining the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding. Intern Med. 54(6):553-8, 2015. |
Observational-Dx |
1,604 patients |
To evaluate the diagnostic performance of computed tomography (CT) as an initial radiologic test for assessing the optimal timing of colonoscopy in patients with acute lower gastrointestinal bleeding (LGIB) and investigate the effectiveness of contrast-enhanced (CE) CT for detecting colonic diverticular bleeding. |
Among the 1,604 patients presenting with LGIB, 879 (55%) underwent a CT scan. Elective colonoscopy was considered in cases in which typical colonic wall thickening was observed on CT, suggesting colonic inflammation or malignancy (239 patients; 27%). The diagnoses in the elective cases included ischemic colitis (38%), infectious colitis (8%), inflammatory bowel disease (8%) and malignancy (5%). Urgent colonoscopy was performed after the CT examination in 640 cases (73%). The most common presumptive CT diagnosis was diverticulum (402/640; 63%). Of the 638 patients who underwent CE-CT, diverticula were observed in 346 cases, including 104 cases of extravasation indicating ongoing diverticular bleeding. Among these 104 patients, the site of bleeding was identified in 71 subjects (68%) during colonoscopy. The rate of detection of the bleeding source on colonoscopy was significantly higher in the patients with extravasation on CE-CT than in those without extravasation on CE-CT (68% vs. 20%, respectively; p<0.001). |
3 |
| 47. Nagata N, Niikura R, Aoki T, et al. Role of urgent contrast-enhanced multidetector computed tomography for acute lower gastrointestinal bleeding in patients undergoing early colonoscopy. J Gastroenterol. 50(12):1162-72, 2015 Dec. |
Observational-Dx |
223 patients |
To evaluate the role of urgent computed tomography (CT) in acute lower gastrointestinal bleeding (LGIB) settings. |
No significant differences in age, sex, comorbidities, vital signs, or laboratory data were observed between the strategies. The detection rate was higher with colonoscopy following CT for vascular lesions (35.7 vs. 20.6%, p = 0.01), leading to more endoscopic therapies (34.9 vs. 13.4%, p < 0.01). Of the 126 who underwent colonoscopy following CT, 26 (20.6%) had extravasation and 34 (27.0%) had nonvascular findings. The sensitivity and specificity of CT extravasation and nonvascular findings for predicting vascular lesions and inflammation or tumors were 37.8 and 88.9 and 81.3 and 80.9%, respectively. A high ? agreement (0.83, p < 0.01) for active bleeding locations was found between CT and subsequent colonoscopy. There were no cases of contrast-induced nephropathy after 1 week of CT. |
3 |
| 48. Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol. 2010;105(12):2636-2641; quiz 2642. |
Experimental-Tx |
85 patients had urgent upper endoscopy; 13 had upper source; 72 patients randomized to urgent (n=36) or elective (n=36) colonoscopy |
Randomized study to determine, in patients with serious hematochezia, the proportion who have an upper GI source and whether urgent colonoscopy improves outcomes as compared with elective colonoscopy in those without an upper source. |
Further bleeding occurred in 8 (22%) vs 5 (14%) of the urgent vs elective groups (difference=8%, 95% CI, -9% to 26%). Units of blood (1.5 vs 0.7), hospital days (5.2 vs 4.8), subsequent diagnostic or therapeutic interventions for bleeding (36% vs 33%), and hospital charges ($27,590 vs $26,633) also were not lower in the urgent group. A major limitation is that the study was terminated before reaching the pre-specified sample size. Patients with clinically serious hematochezia should have upper endoscopy initially to rule out an upper GI source. Use of urgent colonoscopy in a population hospitalized with serious LGIB showed no evidence of improving clinical outcomes or lowering costs as compared with routine elective colonoscopy. |
2 |
| 49. Hanna RF, Browne WF, Khanna LG, Prince MR, Hecht EM. Gadofosveset trisodium-enhanced MR angiography for detection of lower gastrointestinal bleeding. Clin Imaging. 39(6):1052-5, 2015 Nov-Dec. |
Observational-Dx |
4 patients |
To determine if Gadofosveset trisodium-enhanced magnetic resonance angiography (MRA) could be used for detection and localization of acute lower gastrointestinal (LGI) bleed. |
Four patients underwent MRA (4 females, mean age of 65 years) for suspected LGI bleeding. MRA detected an active rectal bleed in one patient. All other patients did not demonstrate active bleeding and these true negatives were confirmed by computed tomography angiography, endoscopy, and tagged-red blood cell scan or digital subtraction angiography. Preliminary results suggest that MRA may serve as an alternative technique for detecting acute LGI bleeding when nuclear scintigraphy is unavailable or in the younger radiosensitive population but further investigation in a larger cohort is required. |
4 |
| 50. Czymek R, Kempf A, Roblick UJ, et al. Surgical treatment concepts for acute lower gastrointestinal bleeding. J Gastrointest Surg. 12(12):2212-20, 2008 Dec. |
Review/Other-Dx |
63 patients |
To evaluate our own data on the group of patients with acute lower gastrointestinal hemorrhage requiring transfusion and to outline our diagnostic and therapeutic regime taking into account the literature of the past 30 years. |
Diagnostic procedures to localize hemorrhage were successful in 61 cases, 41 of which through endoscopy, 12 through angiography, and eight through scintigraphy. Of our group of patients, 32 suffered from a bleeding colonic diverticulum, eight from angiodysplasia, and five from bleeding small bowel diverticula. Five patients had inflammatory bowel disease and three neoplasia. Among the surgical interventions, segmental resections were performed most frequently (15 sigmoidectomies, 11 small bowel segmental resections, 11 left hemicolectomies, seven right hemicolectomies, one proctectomy). Subtotal colectomies were carried out in ten cases. The complication rate for this group of critically ill, negatively selected patients was 60.3% and the mortality rate was 15.9%. |
4 |
| 51. Greco LT, Koller S, Philp M, Ross H. Surgical Management of Lower Gastrointestinal Hemorrhage: An Analysis of the ACS NSQIP Database. Journal of Current Surgery 2017;7:4-6. |
Review/Other-Tx |
38,486 patients |
To examine a cohort of patients who underwent surgery for lower gastrointestinal bleeding to determine the effect of procedure type on postoperative outcomes. |
Of 38,486 colorectal resections performed for bleeding, 85.3% underwent a partial colectomy and 14.7% underwent total colectomy. Patients who had total colectomy were more likely to receive more than four units of blood prior to surgery and have operative times longer than 180 min. Patients who had partial colectomy were more likely to have laparoscopic procedures and to have a stoma created during surgery. On univariate analysis, total colectomy was associated with increased risk of postoperative ileus, cardiac and renal complications, and mortality. On multivariate analysis, total colectomy was associated with increased risk of cardiac and renal complications. |
4 |
| 52. Thorne DA, Datz FL, Remley K, Christian PE. Bleeding rates necessary for detecting acute gastrointestinal bleeding with technetium-99m-labeled red blood cells in an experimental model. J Nucl Med. 28(4):514-20, 1987 Apr. |
Observational-Dx |
14 dogs |
To determine the sensitivity of 99mTc-labeled red blood cells (RBCs) in detecting acute gastrointestinal bleeding in a dog model similar to that used for [99mTc] sulfur colloid. |
Bleeding rates of 4.6-0.2 ml/min were detected within 10 min in the colon and bleeding rates as low as 0.04 ml/min were seen by 55 min. Slower bleeding rates were not detected. Similar findings were noted for proximal jejunal bleeds. Based on the time of appearance, a minimum volume of approximately 2-3 ml labeled blood was necessary to detect bleeding. |
4 |
| 53. Duraiswamy S, Schmulewitz N, Rockey DC. The role of 99m Tc-RBC scintigraphy in lower gastrointestinal hemorrhage. J Investig Med. 64(4):854-60, 2016 Apr. |
Review/Other-Dx |
199 TRBCS studies |
To examine how often 99m Tc-RBC scintigraphy (TRBCS) was performed in lower gastrointestinal hemorrhage (LGIH) and whether it led to specific therapy. |
199 TRBCS studies were performed during 166 patient admissions (a patient admission was defined as an incident LGIH episode in a single patient). Of the 166 patient admissions in which TRBCS was performed, the scan was positive in approximately half (84/166; 51%); if TRBCS themselves were considered, they were positive 42% (84/199) of the time. Of the 84 admissions with a positive TRBCS, angiography was performed 54 times. Among this group, angiography revealed bleeding in only 20 patients (11 patients underwent embolization and 9 had hemostatic therapy). Out of 64 patients with a positive TRBCS who underwent colonoscopy, only 3 patients underwent endoscopic hemostatic therapy. Surgery was performed in 20 patients after a positive TRBCS (including in 17/54 patients after angiogram) and hemostasis was achieved in 16. Angiography, surgery and therapeutic colonoscopy were more commonly performed after positive than after a negative TRBCS. Patients who underwent angiography within 4 h of a positive TRBCS were neither more likely to have active bleeding found nor to undergo successful embolization. Not all patients with a positive TRBCS underwent angiography, and an abnormal TRBCS did not appear to predict successful angiographic therapy; further, a positive TRBCS was not predictive of subsequent definitive therapy. |
4 |
| 54. Dolezal J, Vizda J, Kopacova M. Single-photon emission computed tomography enhanced Tc-99m-pertechnetate disodium-labelled red blood cell scintigraphy in the localization of small intestine bleeding: a single-centre twelve-year study. Digestion. 2011;84(3):207-211. |
Review/Other-Dx |
26 patients |
The authors present their experience with the detection of bleeding in the small intestine by means of scintigraphy with in vivo-labelled RBCs in the period of 1998-2009. |
A total of 26 patients had a positive scintigraphy with in vivo-labelled RBCs and 14 patients had negative scintigraphy. The final diagnosis was confirmed in 20/26 patients with a positive scintigraphy by push enteroscopy (6/20), intraoperative enteroscopy (7/20), surgery (4/20), duodenoscopy (1/20), double-balloon enteroscopy (1/20) and X-ray angiography (1/20). The correct location of the bleeding site was identified by RBC scintigraphy in 15/20 (75%) patients with the confirmed source. The locations of the bleeding site identified by scintigraphy and enteroscopy (push, intraoperative) and surgical investigations were highly correlated in patients with a positive scintigraphy within the first 3 hours. 11/20 correctly localized studies and none of the incorrectly localized studies were positive in the dynamic phase of imaging. In 5 patients (all erroneously localized), scintigraphy was positive only at a period longer than 18 hours. |
4 |
| 55. Tabibian JH, Wong Kee Song LM, Enders FB, Aguet JC, Tabibian N. Technetium-labeled erythrocyte scintigraphy in acute gastrointestinal bleeding. Int J Colorectal Dis. 2013;28(8):1099-1105. |
Observational-Dx |
100 consecutive TRBC scans |
To evaluate the clinical outcomes of the technetium-labeled RBC scan in patients presenting with acute GI bleeding. |
Of the 80 technetium-labeled RBC scans, 29 (36%) were positive and 51 (64%) were negative for bleeding. 8 (10%) were incorrect positive (leading to 5 incorrect operations), 12 (15%) true positive, 9 (11%) unconfirmed positive, 17 (21%) false negative, and 34 (43%) unconfirmed negative. The cause of bleeding was confirmed in 31 cases, of which the scan result was incorrect positive in 2 (7%), true positive in 12 (39%), and false negative in 17 (55%). |
3 |
| 56. Awais M, Haq TU, Rehman A, et al. 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. 50(9):754-60, 2016 10. |
Observational-Dx |
76 Patients |
To assess and compare diagnostic accuracy of (99M)Technetium (Tc)-labeled red blood cell (RBC) scintigraphy and multidetector row computed tomography (CT) with gastrointestinal (GI) bleed protocol for detection and localization of source of acute lower gastrointestinal bleeding (LGIB). |
Fifty-one, 20, and 5 patients had undergone RBC scintigraphy only, CT with GI bleed protocol only, and both modalities, respectively. Fourteen of 25 patients in the CT group had angiographic evidence of active bleeding as compared with 32 of 56 patients in the scintigraphy group. CT with GI bleed protocol had higher accuracy (96%) than (99M)Tc-labeled RBC scintigraphy (55.4%, P<0.001). |
2 |
| 57. Otomi Y, Otsuka H, Terazawa K, et al. The diagnostic ability of SPECT/CT fusion imaging for gastrointestinal bleeding: a retrospective study. BMC Gastroenterol. 18(1):183, 2018 Dec 10. |
Observational-Dx |
20 patients |
To retrospectively assess the capabilities of SPECT/CT in the diagnosis of gastrointestinal bleeding by a comparison with planar imaging alone as well as planar and SPECT. |
The diagnostic ability of the three imaging methods in detecting the presence of gastrointestinal bleeding was as follows. Planar imaging showed 100% sensitivity (3/3), 100% specificity (2/2), and 100% accuracy (5/5). Planar + SPECT imaging showed 85.7% sensitivity (6/7), 100% specificity (2/2), and 88.9% accuracy (8/9). Planar + SPECT/CT imaging showed 100% sensitivity (6/6), 100% specificity (1/1), and 100% accuracy (7/7). The diagnostic ability of the three modalities in detecting the site of bleeding was as follows: planar, 33. 3% (1/3); planar + SPECT, 71.4% (5/7); and planar + SPECT/CT, 100% (6/6). |
3 |
| 58. 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;131:1015-7. |
Review/Other-Dx |
3 |
To report on 3 patients in whom clinically documented acute gastrointestinal hemorrhage was demonstrated by only one of two or three identical selective arteriograms performed within a few minutes. |
Failure to demonstrate active bleeding by angiography therefore may not prove cessation of bleeding or indicate an inadequate examination. |
4 |
| 59. Chung M, Dubel GJ, Noto RB, et al. Acute Lower Gastrointestinal Bleeding: Temporal Factors Associated With Positive Findings on Catheter Angiography After (99m)Tc-Labeled RBC Scanning. AJR Am J Roentgenol. 207(1):170-6, 2016 Jul. |
Observational-Dx |
120 patients |
To determine if time to positive (TTP), defined as the time from the start of (99m)Tc-labeled RBC scanning to the appearance of a radionuclide blush (considered to be a positive finding for acute lower gastrointestinal bleeding [LGIB]), and lag time (LT), defined as the time from the appearance of a radionuclide blush to the start of catheter angiography (CA), affected the yield of CA for the detection of acute LGIB. |
When a TTP threshold of = 9 minutes was used, the sensitivity, specificity, positive predictive value, and negative predictive value for a positive CA study were 92%, 35%, 27%, and 94%, respectively. In addition, the odds of detecting bleeding on CA increased 6.1-fold with a TTP of = 9 minutes relative to a TTP of > 9 minutes (p = 0.020). A significant inverse relationship was found between LT and a positive CA study (p = 0.041). |
4 |
| 60. Kouanda AM, Somsouk M, Sewell JL, Day LW. Urgent colonoscopy in patients with lower GI bleeding: a systematic review and meta-analysis. [Review]. Gastrointest Endosc. 86(1):107-117.e1, 2017 Jul. |
Meta-analysis |
10,172 patients |
To compare several outcomes between urgent and elective colonoscopy in patients hospitalized for lower GI bleeding (LGIB). |
Twelve studies met inclusion criteria, with a total sample size of 10,172 patients in the urgent colonoscopy arm and 14,224 patients in the elective colonoscopy arm. Urgent colonoscopy was associated with increased use of endoscopic therapeutic intervention (RR, 1.70; 95% CI, 1.08-2.67). There were no significant differences in bleeding source localization (RR, 1.08; 95% CI, .92-1.25), adverse event rates (RR, 1.05; 95% CI, .65-1.71), rebleeding rates (RR, 1.14; 95% CI, .74-1.78), transfusion requirement (RR, 1.02; 95% CI, .73-1.41), or mortality (RR, 1.17; 95% CI, .45-3.02). |
Good |
| 61. Feinman M, Haut ER. Lower gastrointestinal bleeding. Surg Clin North Am. 2014;94(1):55-63. |
Review/Other-Dx |
N/A |
To examine causes of occult, moderate and severe LGIB. |
No results stated in abstract. |
4 |
| 62. Yi WS, Vegeler R, Hoang K, Rudnick N, Sava JA. Watch and wait: conservative management of lower gastrointestinal bleeding. J Surg Res. 2012;177(2):315-319. |
Observational-Tx |
194 patients |
To assess outcomes of patients allowed to exceed traditional triggers for surgery because of LGIB. |
194 LGIB patients had scintigraphy during the period of study with 180 meeting inclusion criteria. 56 (31%) patients had at least 1 operative indication, and 32 (60%) were managed nonoperatively without a mortality. There were 2 (8.3%) mortalities in those who had operative management, 1 of which was because of exsanguination. 18 (32%) patients who met operative criteria were unlocalized. |
2 |
| 63. Abbas SM, Bissett IP, Holden A, Woodfield JC, Parry BR, Duncan D. Clinical variables associated with positive angiographic localization of lower gastrointestinal bleeding. ANZ Journal of Surgery. 75(11):953-7, 2005 Nov.ANZ J Surg. 75(11):953-7, 2005 Nov. |
Observational-Dx |
88 patients |
To determine what clinical factors predict positive angiographic demonstration of bleeding site by auditing the Auckland Hospital experience of selective angiography, in localizing LGIB. |
Bleeding site was localized in 50%. Indicators of a positive angiogram were hemodynamic instability, particularly those needing more than 5 units of blood to achieve hemodynamic stability. Catheter angiography for acute LGIB will successfully localize a point of bleeding in approximately 50% of patients. The most useful clinical indicator for positive angiography was hemodynamic instability particularly in those who require transfusion of =5 units of blood to achieve hemodynamic stability. |
4 |
| 64. Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol. 2005;100(11):2407-2418. |
Meta-analysis |
396 patients; 14 studies |
To evaluate the yield of small bowel findings with CE compared to other modalities in patients with occult bleeding. |
CE had a much higher diagnostic yield than other modalities. CE is superior to push enteroscopy and small bowel barium radiography for diagnosing clinically significant small bowel pathology in patients with obscure GI bleeding. In study populations, the incremental yield of CE over push enteroscopy and small bowel barium radiography for clinically significant findings is =30% with a number needed to test of 3, primarily due to visualization of additional vascular and inflammatory lesions by CE. |
M |
| 65. Filippone A, Cianci R, Milano A, Valeriano S, Di Mizio V, Storto ML. Obscure gastrointestinal bleeding and small bowel pathology: comparison between wireless capsule endoscopy and multidetector-row CT enteroclysis. Abdom Imaging. 2008;33(4):398-406. |
Review/Other-Dx |
N/A |
To compare CE and CT in patients with obscure bleeding. |
The 2 modalities were fairly similar in accuracy but complimentary in that each missed different kinds of lesions. |
4 |
| 66. Huprich JE, Fletcher JG, Fidler JL, et al. Prospective blinded comparison of wireless capsule endoscopy and multiphase CT enterography in obscure gastrointestinal bleeding. Radiology. 2011;260(3):744-751. |
Observational-Dx |
58 patients |
To compare the performance of multiphase CT enterography with that of CE in a group of patients with OGIB. |
58 adult patients, referred for the evaluation of OGIB (occult, 25 patients [43%]; overt, 33 patients [57%]), underwent both tests. A small bowel bleeding source was identified in 16/58 patients (28%). The sensitivity of CT enterography was significantly greater than that of CE (88% [14/16 patients] vs 38% [6/16 patients], respectively; P=.008), largely because it depicted more small bowel masses (100% [9/9 patients] vs 33% [3/9 patients], respectively; P=.03). No additional small bowel tumors were discovered during the follow-up period (range, 5.6–45.9 months; mean, 16.6 months). |
2 |
| 67. Wang Z, Chen JQ, Liu JL, Qin XG, Huang Y. CT enterography in obscure gastrointestinal bleeding: a systematic review and meta-analysis. J Med Imaging Radiat Oncol. 2013;57(3):263-273. |
Meta-analysis |
18 studies |
To provide a comprehensive and update overview of clinical application of CT enterography in the evaluation of OGIB. |
A total of 18 studies (n = 660) reported the yield of CT enterography in evaluating OGIB and the pooled yield was 40% (95% CI: 33%–49%). 7 studies (n = 279) compared the yield of CT enterography with CE. The yield for CT enterography and CE for all findings was 34% and 53%, respectively (IY = -19%, 95% CI = -34% to -4%). When considering the types of identified lesions, the yield was significantly different for vascular and inflammatory lesions but not significantly different for neoplastic or other lesions. 2 studies (n = 63) compared the yield of CT enterography with double-balloon enteroscopy. The yield for CT enterography and double-balloon enteroscopy was 38% and 78%, respectively (IY = -40%, 95% CI = -55% to -25%). 3 studies (n = 49) compared the yield of CT enterography with digital subtraction angiography. The yield for CT enterography and digital subtraction angiography was 64% and 60%, respectively (IY = 4%, 95% CI = -40% to 47%). |
M |
| 68. Lee SS, Oh TS, Kim HJ, et al. Obscure gastrointestinal bleeding: diagnostic performance of multidetector CT enterography. Radiology 2011;259:739-48. |
Observational-Dx |
65 patients |
To evaluate the diagnostic performance of computed tomographic (CT) enterography in identifying the source of obscure gastrointestinal bleeding and to determine clinical features associated with a higher diagnostic yield of CT enterography. |
CT enterography helped identify the source of obscure gastrointestinal bleeding in 16 (24.6%) of 65 patients. The sensitivity, specificity, positive predictive value, and negative predictive value of CT enterography were 55.2% (16 of 29), 100% (32 of 32), 100% (16 of 16), and 71.1% (32 of 45), respectively. Among patients' clinical features, a history of massive bleeding (diagnostic yield, 58.3% [seven of 12]; adjusted odds ratio, 7.2; P = .01) was independently associated with a higher diagnostic yield for CT enterography. |
3 |
| 69. Heo HM, Park CH, Lim JS, et al. The role of capsule endoscopy after negative CT enterography in patients with obscure gastrointestinal bleeding. European Radiology. 22(6):1159-66, 2012 Jun.Eur Radiol. 22(6):1159-66, 2012 Jun. |
Observational-Dx |
30 patients |
To evaluate the role of CE in patients with OGIB after negative CT enterography. |
Based on CE results, a definitive diagnosis was made for 17 patients (57%): ulcer in 9 patients (30%), active bleeding with no identifiable cause in 5 (17%), angiodysplasia in 2 (7%) and Dieulafoy's lesion in 1 (3%). 2 patients with jejunal ulcers were diagnosed with Crohn's disease. 7 patients (41%) with positive CE received double balloon enteroscopy and 2 patients (12%) received steroid treatment for Crohn's disease. Patients with overt bleeding, a previous history of bleeding, or who received large amounts of blood transfusions were more likely to show positive CE. |
3 |
| 70. Laine L, Sahota A, Shah A. Does capsule endoscopy improve outcomes in obscure gastrointestinal bleeding? Randomized trial versus dedicated small bowel radiography. Gastroenterology. 2010;138(5):1673-1680 e1671; quiz e1611-1672. |
Experimental-Dx |
136 patients |
Randomized study to compare CE to barium small bowel radiography both in detection of lesions and in long term outcome. |
Diagnostic yield with CE was higher (30% vs 7%) however the rate of subsequent bleeding was essentially equivalent. |
1 |
| 71. Casciani E, Nardo GD, Chin S, et al. MR Enterography in paediatric patients with obscure gastrointestinal bleeding. European Journal of Radiology. 93:209-216, 2017 Aug.Eur J Radiol. 93:209-216, 2017 Aug. |
Observational-Dx |
25 patients |
To evaluate the performance of Magnetic Resonance enterography (MRE) in the diagnostic work-up of children presenting with obscure gastrointestinal bleeding (OGIB). |
25 patients (mean age 10.8±4.5 years, range 4 months to 16 years) were included. MRE was diagnostic in 76% (19 of 25). The most frequent diagnoses were intestinal polyp (28%) and Meckel's diverticulum (16%). Sensitivity and specificity of MRE were 86% and 100% respectively. There were no reported complications during any of the examinations. |
2 |
| 72. Bocker U, Dinter D, Litterer C, et al. Comparison of magnetic resonance imaging and video capsule enteroscopy in diagnosing small-bowel pathology: localization-dependent diagnostic yield. Scand J Gastroenterol. 45(4):490-500, 2010 Apr. |
Observational-Dx |
46 patients |
To compare the diagnostic utility and yield of video-capsule enteroscopy to that of MRI in patients with suspected or established Crohn's disease (Group I), obscure GI blood loss (Group II), or suspected tumors (Group III). |
In Group I, lesions were found by video-capsule enteroscopy in 9/21 patients and by MRI in 6. In 5 patients, both modalities showed pathology. In Group II, pathological changes were detected in 11/20 patients by video-capsule enteroscopy and in 8 patients by MRI. In 5 cases, pathology was found with both modalities. In Group III, neither modality showed small-bowel pathology. For the patient groups combined, diagnostic yield was 43% with video-capsule enteroscopy and 30% with MRI. The diagnostic yield of video-capsule enteroscopy was superior to that of MRI in the upper small bowel in both Groups I and II. |
3 |
| 73. Wiarda BM, Heine DG, Mensink P, et al. Comparison of magnetic resonance enteroclysis and capsule endoscopy with balloon-assisted enteroscopy in patients with obscure gastrointestinal bleeding. Endoscopy. 2012;44(7):668-673. |
Observational-Dx |
38 patients |
To compare the diagnostic yield of MR enteroclysis and CE in patients with obscure GI bleeding, using balloon-assisted enteroscopy as the reference standard. |
Over a period of 26 months, 38 patients were included (20 female [53%]; mean age 58 years, range 28–75 years). 4 patients (11%) did not undergo CE due to high grade small-bowel stenosis at MR enteroclysis (n = 3; 8%) or timing issues (n = 1; 3%). CE was nondiagnostic in 1 patient. The reference standard identified abnormal findings in 20 patients (53%). MR enteroclysis had sensitivity, specificity, and positive and negative likelihood ratios of 21%, 100%, infinity, and 0.79, respectively. The corresponding values for CE were 61%, 85%, 4.1, and 0.46. The reference standard and CE did not differ in percent positive findings (P=0.34), but MRE differed significantly from the reference balloon-assisted enteroscopy (P<0.001). CE was superior to MR enteroclysis for detecting abnormalities (P=0.0015). |
2 |
| 74. de Leusse A, Vahedi K, Edery J, et al. Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding?. Gastroenterology. 132(3):855-62; quiz 1164-5, 2007 Mar. |
Observational-Tx |
78 patients |
To conduct the first randomized study comparing the performances of capsule endoscopy (CE) and push enteroscopy (PE) as first-line explorations for obscure gastrointestinal bleeding (OGIB) to identify a definite bleeding source. |
CE and PE, used as the first-line exploration, identified a bleeding source in 20 of 40 patients and 9 of 38 patients, respectively (50% vs 24%; P = .02). CE missed lesions in 8% of patients, and all these lesions were located in sites accessible to standard endoscopy. PE missed lesions in 26% of patients. At the end of the 12-month follow-up period, the strategy based on CE as first-line exploration followed by PE if necessary only was similar to PE followed by CE in terms of diagnostic yield, clinical outcome, and therapeutic impact, but reduced the percentage of patients needing the alternative exploration (25% vs 79%; P < .001). |
1 |
