A. Zhong1, C. Divino1 1Mount Sinai School Of Medicine,General Surgery,New York, NY, USA
Introduction:
Diagnostic modalities for lower gastrointestinal bleeds (LGIB) include endoscopy, mesenteric angiography, capsule endoscopy, nuclear RBC scans, and most recently CT angiography (CTA). The advantages of CTA include a sensitivity and specificity of 98.4% and 93.3%, visualization of the entire abdomen, and expediency. There are no clear guidelines to help providers decide on which diagnostic or interventional modality is optimal for their patient with a LGIB, often leading to confusion and unnecessary invasive workup. We propose that CTA’s can safely be used as an initial diagnostic modality in guiding intervention, specifically endoscopy, in acute LGIB’s.
Methods:
A single-institution retrospective chart review was performed of a cohort of patients who had procedure codes for endoscopy, abdominal CT angiography, and an ICD code for lower GI bleed over a period of 18 years (2000-2018).
Results:
185 patients were identified into the cohort. 51 of those patients had a CTA to diagnose an acute LGIB. A total of 69 CTA’s were performed in those 51 patients. 27/69 CTA’s had a subsequent endoscopic intervention. 22/27 CTA’s were negative for intraluminal contrast extravasation on arterial or venous phase, and 5 were positive. 17/22 (77.3%) negative CTA’s had subsequent diagnostically negative endoscopic procedures. 18/22 (81.8%) negative CTA’s had subsequent endoscopic procedures that resulted in unsuccessful intervention. Out of the 69 CTA’s, only 2 resulted in an AKI in dialysis dependent ESRD patients. No patients required surgical intervention. There were no mortalities.
Conclusion:
CTA should be the universal initial diagnostic modality in a patient with an acute LGIB when they present to an inpatient setting. It is fast, safe, and effective in identifying bleeds and potential sources. CTA’s can result within hours of presentation, have a better adverse event profile than other modalities, and have the highest sensitivity and specificity of all modalities. CTA’s have been shown to predict mesenteric angiographical diagnosis and intervention. A negative CTA is predictive of a negative endoscopic intervention, signifying that not all LIGB’s require additional attempts at diagnosis or intervention. A negative CTA can predict that a patient with a LGIB can be safely observed with transfusions as necessary. The results of the CTA should be used to guide clinical decision making in order avoid unnecessary work up, waste of healthcare resources, and potential risk from additional procedures.