下消化道出血影像学检查

Vikram S. Kumar Gillian Lieberman, MD Lower GI Bleeds Vikram Sheel Kumar, Harvard Medical School Year III Gillian Lieberman, MD September 2002 2 Vikram S. Kumar Gillian Lieberman, MD Mr. X, 78 years old, presents w/ maroon stool and eighteen hours of prior bleeding per rectum. maroon/bright red: think lower GI bleed And if melena: think upper GI, right? Not necessarily, there is enough overlap between the two groups that you would want further studies! Index Case 3 Vikram S. Kumar Gillian Lieberman, MD A single contrast Barium enema shows multiple outpouches throughout the course of colon. Courtesy Dr. Herbert Gramm What fits the DDX for these? She looks like an Aunt Minny (w/ diverticulosis) to me! Before we order tests, let’s check his history 4 Vikram S. Kumar Gillian Lieberman, MD Diverticulosis of the transverse colon Multiple Diverticula Double contrast barium study Courtesy Dr. Herbert Gramm 5 Vikram S. Kumar Gillian Lieberman, MD Note how the diverticula appear on the mesenteric side of the colon. Source: © 2002 UpToDate Originally from Textbook of Gasteroenterology, Yamada, 95 The Vasa recta penetrate the circular muscle layer of the colon, weakening the wall. Origins of diverticula 6 Vikram S. Kumar Gillian Lieberman, MD • Sigmoid colon most common • Rectum and bladder can mimic sigmoid Source: http://www.vh.org/Providers/Textbooks/ElectricGiNucs/AnatImages/BleedSites.html Most common sites of GI Bleeds Most Common Causes of Lower GI Bleeds Diverticulosis Angiodysplasias IBD Ano-rectal disease Neoplasia 7 Vikram S. Kumar Gillian Lieberman, MD Place a Nasogastric tube No blood Colonoscopy Institute upper GI bleed w/u Identify source Treat as appropriate Negative/>>Blood Scintigraphy Arteriography Blood Approach to locate a Lower GI Bleed (9) Diagnostic accuracy of 72 - 86 % in patients (10) Diagnostic accuracy rates range from 24 to 91 % (11) Success of 14 to 72% 8 Vikram S. Kumar Gillian Lieberman, MD Let us assume we find nothing on colonoscopy.. welcome to nuclear medicine Scintigraphy : radionuclide in, gamma particles out recorded by an external scintillation camera. Scintillation is random fluctuation of EM field strengths about the mean. Source: Introduction to Nuclear Medicine, GE Medical Systems (www.gemedical.com) It can detect blood flow at .1cc/min Vikram S. Kumar Gillian Lieberman, MD What type of Technetium do we use for medical imaging? Isotope Half Life Tc-95 20.0 hours Tc-95m 61.0 days Tc-96 4.28 days Tc-96m 51.5 minutes Tc-97 2600000.0 years Tc-97m 90.0 days Tc-98 4200000.0 years Tc-99 2.13E7 years Tc-99m 6.0 hours Tc-100 14.2 minute Tc-99m 6.0 hours Source: http://www.nobel.se/chemistry/laureates/1951/seaborg-bio.html Source: http://www.atomicmuseum.com/tour/nuclearmedicine.cfm Glenn Seaborg, the proposer of the Actinide series in the Period Table, co- discovered Tc-99m with Emilio Segre. 10 Vikram S. Kumar Gillian Lieberman, MD Companion Patient 1: Mr. Y, a 77 year old man with ESRD, presents with bright blood per rectum Common Iliac Arteries Spleen Liver Aorta IVC Stomach Heart BIDMC PACS Tc-99m is labeled to autologous RBCs 11 Vikram S. Kumar Gillian Lieberman, MD Dynamic scintigraphy performed with a 1 frame/min resolution for 48 minutes There is radioactive uptake ascending from the cecum to the colon. 12 Vikram S. Kumar Gillian Lieberman, MD Changing lookup color 13 Vikram S. Kumar Gillian Lieberman, MD Companion Patient 2: This patient had an ascending bleed from the cecum. Courtesy: Kevin Donohoe, MD 14 Vikram S. Kumar Gillian Lieberman, MD Companion Patient 3: Notice the bleed through the small bowel Courtesy: Kevin Donohoe, MD 15 Vikram S. Kumar Gillian Lieberman, MD Index case Back to Mr. X. After a positive scintigraph, a mesenteric angiogram is performed AP View Mask Mask subtracted "78 year old man with hx of diverticulosis and right hemicolectomy now with recurrent LGIB of obscure source. Localize the source of GI bleed.” BIDMC PACS Angio can detect blood flow at .5 cc/min 16 Vikram S. Kumar Gillian Lieberman, MD A view of the IMA Source: Henry Gray (1825–1861). Anatomy of the Human Body. 1918. www.bartleby.com 17 Vikram S. Kumar Gillian Lieberman, MD An Angiographers view of the world IMA Ascending branch of the Left Colic Artery Haustra Aorta Small Intestine Catheter injecting Ioversol/Optiray Source: BIDMC PACS and consultation with Dr. Mastromatteo 18 Vikram S. Kumar Gillian Lieberman, MD The mesenteric arteriogram was performed to localize the lesion. 19 Vikram S. Kumar Gillian Lieberman, MD A more oblique view to focus in the area of suspected extravasation Note the extravasation of contrast in the left side of the pelvis. This is the bleeding site. Transcatheter infusion of vasopressin caused cessation of the bleeding with no recurrence on repeat angiogram. 20 Vikram S. Kumar Gillian Lieberman, MD Summary • Use your radiology knowledge to pin-point the etiology of a presentation. • Rule out an Upper GI Bleed via NG aspirate. • Order a colonoscopy to study the bowel and rule out carcinoma. • Use scintigraphy to localize subtle bleeds. • Follow up with angiography and tx. • Do not be afraid to repeat tests if you are surprised by a result. 21 Vikram S. Kumar Gillian Lieberman, MD References 1. Peter D, Dougherty J. Evaluation of the patient with gastrointestinal bleeding: an evidence based approach. Emerg Med Clin North Am. 1999;17:239-261. 2. Cinematic Nuclear Scintigraphy Reliably Directs Surgical Intervention for Patients With Gastrointestinal Bleeding Brian B. O'Neill, MD et al. Archives of Surgery, Vol. 135 No. 9, September 2000 3. Use of technetium-labeled red blood cell scintigraphy in the detection and management of gastrointestinal hemorrhage. Voeller G, Bunch G, Britt L. Surgery. 1991;110:799-804. 4. Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy. Suzman M et al. Ann Surg.1996;224:29-36. 5. Lower Gastrointestinal Bleeding, Burt Cagir, MD and E. Cirincione (http://www.emedicine.com/med/topic2818.htm) 6. Harrison’s Online: Chapter 44: Gastrointestinal Bleeding, Colonic Sources of Bleeding 7. Harrison’s Online: Chapter 283: Gastrointestinal Endoscopy 8. Approach to the patient with Acute Gastrointestinal bleeding, (http://jeffline.tju.edu/CWIS/DEPT/GI/education/pdfs/approach.pdf) 9. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Jensen DM; Machicado GA. Gastroenterology 1988 Dec;95(6):1569-74 10. Imbembo, AL, Bailey, RW. Diverticular disease of the colon. Textbook of Surgery, 14th ed, Sabiston, DC Jr (Ed), Churchill Livingstone 1992. p.910. 11. UpToDate, Colonic diverticular bleeding 22 Vikram S. Kumar Gillian Lieberman, MD Acknowledgements • Gillian Lieberman, MD • Michael Mastromatteo, MD • Kevin Donohoe, MD • Herbert Gramm, MD • Larry Barbaras and Cara Lyn D’amour • Pamela Lepkowski Lower GI Bleeds Slide Number 2 Slide Number 3 Diverticulosis of the transverse colon Slide Number 5 Slide Number 6 Slide Number 7 Let us assume we find nothing on colonoscopy.. welcome to nuclear medicine Slide Number 9 Companion Patient 1: Mr. Y, a 77 year old man with ESRD, presents with bright blood per rectum Dynamic scintigraphy performed with a �1 frame/min resolution for 48 minutes Changing lookup color Companion Patient 2: This patient had an ascending bleed from the cecum. Companion Patient 3: Notice the bleed through the small bowel Index case�Back to Mr. X. After a positive scintigraph, a mesenteric angiogram is performed A view of the IMA An Angiographers view of the world The mesenteric arteriogram was performed to localize the lesion. A more oblique view to focus in the area of suspected extravasation Summary References Acknowledgements