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Acute Abdominal Bleeding: Detection with MDCT

Nordic Forum - Trauma & Emergency Radiology

Borut MarincekInstitute of Diagnostic Radiology

University Hospital Zurich, Switzerland

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Trend in emergency radiology:

Greater use of MDCT in suspected acute abdominalbleeding to detect

• organ injuries• vascular anomalies• source of bleeding

Multidetector Row Computed Tomography (MDCT)

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• Trauma- blunt- penetrating

• Nontraumatic conditions- vascular: rupture of aneurysm- nonvascular: rupture of neoplasm- upper & lower gastrointestinal tract

Acute Abdominal Bleeding: Role of MDCT

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• Evidence of CM pooling caused by vascularor visceral organ pathologies

• Attenuation of CM pooling- similar aorta / major adjacent arteries- greater than surrounding parenchyma

• Types of CM pooling:- focal or diffuse, extravasated CM surroundedby hematoma

- „jet“ of extravasated CM

Diagnostic Criteria of Acute Bleeding on MDCT

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Focal

Diffuse

“Jet”

(Willmann, AJR 2002)

Acute Bleeding: Types of CM Pooling

� Blunt Trauma: Intrasplenic Lacerations

„Jet“ type of acute bleeding

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� Blunt Trauma: Mesenteric Avulsions

„Jet“ type of acute bleeding

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• Prevalence of acute bleeding detected on MDCT afterBAT 13-18% (Willmann, AJR 2002; Yao, AJR 2002)

• Spleen > liver > kidney > adrenal > mesentery• MDCT diagnosis requires rapid i.v. (>3.0 ml/sec) CM

bolus via automated power injector• Exact bleeding rate for diagnosis unknown• When visualized on MDCT: significant finding, may

mandate immediate surgery or image-guidedembolization

Acute Bleeding after Blunt Abdominal Trauma

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22/165 pts (13%) acute bleeding on MDCT after BAT(Willmann, AJR 2002)

Surgery13 (59%)

Selectiveembolization

3 (14%)

Emergency therapy16 (73%)

Conservative therapy6 (27%)

Delayed selectiveembolization

1 (5%)

Death5 (22%)

Clinical Outcome of Acute Abdominal Bleeding

� Acute Bleeding after Penetrating Trauma

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� Acute Bleeding after Penetrating Trauma

Replaced righthepatic artery

� Acute Bleeding: Rupture Infrarenal AAA

1-year incidences AAA rupture:5.5-5.9 cm 9.4%6.0-6.9 cm 10.2%

(6.5-6.9 cm 19.1%)>7 cm 32.5%

(Lederle, JAMA 2002)

MPRM

MIP VR

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� Acute Bleeding: Rupture Infrarenal AAA

� Acute Bleeding: Rupture HCC

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� Acute Bleeding: Rupture Renal Angiomyolipoma

� Acute Bleeding: Rupture Renal Angiomyolipoma

Aneurysm of arteryfeeding angiomyolipoma

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� Acute Bleeding: Complication of ESWL

Subcapsular, peri- & pararenal hematoma

Incidence rate 0.28% (Collado, Scand J Urol Nephrol 1999)

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• Right tube: ectopic pregnancy• Left tube: hydrosalpinx• ß-HCG 15’034

Acute Bleeding: Rupture Ectopic Pregnancy

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• Upper GI bleeding / lower GI bleeding: proximal / distal ligament of Treitz

• Overt: hematemesis, hematochezia, melena

• Obscure: persisting or recurring bleeding of unknown origin after negative endoscopy of upper and lower GI tract (AGA, Gastroenterology 2000)

Acute Gastrointestinal (GI) Bleeding: Definitions

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• Small bowel barium examination• Enteroclysis• Tc-labeled RBC scintigraphy• Catheter angiography• Wireless capsule endoscopy• CT enteroclysis• Catheter-directed CT angiography• MDCT: (1) acquisition of separated arterial and portal

venous phase images localization of extravasatedCM into bowel lumen before dilution; (2) animal model: bleeding rate for CT diagnosis 0.3 ml/min

(Kuhle, Radiology 2003)

Obscure GI Bleeding: Diagnostic Imaging Modalities

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Melana since 3 weeks, aorta-bifemoral Y-graft 11 years ago

Aortoduodenal Fistula

� Acute Upper & Lower GI Bleeding

• Acute = hematemesis, melena or hemochezia within 24 hours before MDCT

• Severe = hemodynamic instability (systol. pressure <100 / pulse rate >100); mild = no hemodynamic instability

• MDCT (pts) January 2001 - May 2006 :4-row (6), 16-row (11), 64-row (1)

• MDCT protocol: iv CM, arterial & portal venous phase(additional unenhanced scans in 9 pts), no oral CM

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coilingcystojejunal anastomosis8. Mild / pseudoaneursym lienal art.

embolizationduodenum10. Severe / ischemic anastomotic ulcer

stentgraftduodenum4. Severe / aortoenteric fistula

-duodenum9. Severe / arteriobiliary fistula

coilingbiliodigest. anastomosis5. Severe / pseudoaneurysm hepatic art.

coilingduodenum7. Mild / pseudoaneurysm gastroduod. art.

coilingbiliodigest. anastomosis6. Mild / pseudoaneurysm hepatic art.

stentgraftduodenum3. Severe / aortoenteric fistula

stentgraftduodenum2. Severe / aortoenteric fistula

excisionduodenum1. Severe / aortoenteric fistula

TreatmentBleeding sourceBlood loss / Pathology

Acute Upper GI Bleeding: MDCT Detection

� Aortoduodenal Fistula

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� Pseudoaneurysm Hepatic Artery

7 weeks after laparotomy & biliodigestive anastomosis forpancreatic carcinoma

� Pseudoaneurysm Hepatic Artery

Hypovolemic shocknon-occlusive mesentericischemia & pneumatosis

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� Pseudoaneurysm Hepatic Artery

Coil-embolization,stent-grafting

� Bleeding Complications after Pancreatic Surgery

Postoperative arterial bleeding 3-4% (Sohn, J Gastrointest Surg 2003)

University Hospital Zurich 1998-2004 (Pfammatter, CIRSE 2005)N = 11, average delay surgery – bleeding = 54 days (range 10-250 days)Type of surgery:

Whipple‘s procedure 6Partial pancreatic resection 3Pancreatic head mobilization 1Hepaticojejunostomy 1

Presentation of acute bleeding:Upper GI 2Lower GI 3Intraabdominal 6

Initial diagnosis of bleeding source:MDCT 7DSA 3Scintigraphy 1

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� Pseudoaneurysm Gastroduodenal Artery

Chronic tuberculous ulcerationof duodenum

� Pseudoaneurysm Gastroduodenal Artery

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� Arterio-biliary Fistula

Liver cirrhosis & portal hypertension, 1 week after transjugular liver biopsy

� Arterio-biliary Fistula

Liver cirrhosis & portal hypertension, 1 week after transjugular liver biopsy

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embolizationtransverse colon6. Severe / ischemic ulcer

endoscopical clippingcecum5. Severe / nonocclusive ischemic ulcer

embolizationsigmoid7. Severe / diverticulum

excisionileum3. Mild / neuroendocrine carcinoma

TIPSrectosigmoid8. Mild / varices

embolizationcecum4. Mild / nonocclusive ischemic ulcer

coilingjejunum1. Severe / mucositis

excisionileum2. Mild / stromal tumor

TreatmentBleeding sourceBlood loss / Pathology

Acute Lower GI Bleeding: MDCT Detection

� Ischemic Mucositis Jejunum

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� Ischemic Mucositis Jejunum

� Stromal Tumor Ileum

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� Nonocclusive Ischemic Ulcer Cecum

Anticoagulation, 10 d after myocardial infarction: sepsis, acute abdomen

art

ven

embolization

� Ischemic Ulcer Transverse Colon

Non-steroidal antirheumaticdrugs since 5 weeks

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� Ischemic Ulcer Transverse Colon

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Abdominal aortic aneurysm, Plavix loading dose aftercoronary stent, diverticulosis of sigmoid colon

Sigmoid Diverticulum

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Coil-embolization

Sigmoid Diverticulum

� Ectopic Varices Cecum

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University Hospital Zurich (N=18)• MDCT identification of bleeding source:

prospectively 15/18 (83%)retrospectively 3/18 (17%)

• CM extravsation: 11/11 pts with severe bleeding1/7 pts with mild bleeding

• Identification of underlying pathology:15/18 (83%)

Acute Upper & Lower GI-Bleeding

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Miller, 2 & 4-row ce-MDCT (Clin Imaging 2004):

• Identification of bleeding site in 9/18 pts

Tew, 4-row ce-MDCT (AJR 2004):

• Identification of bleeding site in 7/13 pts

Ko, 4-row ce-MDCT (RöFo 2005):

• Identification of bleeding site in 20/58 pts

Yoon, 4-row ce-MDCT (Radiology 2006):

• Identification of bleeding site in 23/26 ptsOverall accuracy 88.5%

Acute Obscure GI-Bleeding: MDCT

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Contrast-enhanced MDCT

• Rapid, noninvasive, and accurate in localizingacute abdominal bleeding in traumatic and in non-traumatic conditions

• Plays a complementary role to endoscopy for localization of obscure upper or lower GI-bleeding

• Can be used as a guidance for subsequent angiographic intervention

Acute Abdominal Bleeding: Conclusions