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CTA与消化道出血

时间:2018-06-07 23:09来源:未知 作者:Mr.Editor 点击:
至少20年前我们诊断消化道出血依赖血管造影(angiography),内窥镜(endoscopy)和核素小苗(scintigraphy)。但如果没有这些依赖专门人员操作的检查时,怎么办? CTA血管造影诊断消化道出血究竟是一种向往或渴望,还是消化道诊断策略中的要求,甚至强制。

至少20年前我们诊断消化道出血依赖血管造影(angiography),内窥镜(endoscopy)和核素扫描(scintigraphy)。但如果没有这些依赖专门人员操作的检查时,怎么办?

CTA血管造影诊断消化道出血究竟是一种向往或渴望,还是消化道诊断策略中的要求,甚至强制。

有关血管造影的历史(angiography history)


年代 命名 诊断消化道出血的敏感性
60 conventional angio 0.5mL/min -sensitivity 40-86%
80 digital substraction angio >0.5mL/min(?) -sensitivity 62%
90 Tc-99m labelled RBC scinti-angio 0.2mL/min -sensitivity 93% (false localization rate of 22%)
2000 computer tomography angio 0.3mL/min (animal studies -Kuhle et al 2003)


CTA 对于消化道出血的诊断又分为

CTA可以用于任何形式的消化道出血
  • 急性消化道出血
  • 慢性消化道出血
CTA可以用于任何部位消化道出血
  • 上消化道出血
  • 下消化道出血
阳性CTA扫描可预测血管造影的阳性可能
  • 有临床症状包括血压下降,脉搏增加
  • 内镜下发现活动性出血
  • 每分钟出血>0.5-1.5ml或3个单位红细胞/24hrs
  • 高休克指数
  • CT扫描阳性

CTA提示:十二指肠发现造影剂外溢   血管造影可见造影剂外溢
相关文献
Yoon et al. Acute massive GI bleeding: detection and localization with arterial phase MDCT.  Radiology, 2006: 239, 160-7
 Scheffel et al. Acute GI bleeding: detection of source and etiology with MDCT. Eur Radiol. 2007: 17,1555-65
Ko et al. Localialization of bleeding using MDCT in patietns with signs of acute GI hemorrhage.  Rofo 2005: 177, 1649-54

CT血管造影在诊断急性消化道出血有用性(阴性的有用性,阳性的有用性)如下表

CTA诊断急性消化道出血meta分析(2008)有关文献记载急性消化道CTA的结果(P. Goffette, CIRSE 2009)
  N=      
Bleeding site
Localization(%)
 Active
Extravasation
# of CT Detect -# phases
Ernst
(2003)
19 79% 20% SDCT -triphasic
Tew
(2004)
7 100% 43%
4 -biphasic
unenhanced / art
Yoon
(2006)
26 91% 81%
4 -biphasic
unenhanced / Art
Scheffel
(2007)
18 83% 67% 4-16-64 triphasic
Jaeckle
(2008)
26 96% 83%
16-40-biphasic
art / portal

from Jaeckle T, Eur Radiol, 2008, 18:1406


另外一篇文章可看

Diagnostic accuracy of CT angiography in acute gastrointestinal bleedingby Angela Chua and Ridley (Sidney) in J Medical Imaging and Radiation Oncology 2008

CTA诊断急性消化道出血meta分析(2011)from Wu et al. World Journal of Gastroenterology 2011
copycat

  • pooled sensitivity = 89%
  • pooled specificity = 85%
  • high accuracy (overall area under curve SROC=0.9297)

该文建议在符合急性消化道出血标准的患者的初次X线检查中常规使用CT血管造影。因为它对急性消化道出血的诊断准确,能准确显示出血的部位和病因,从而指导进一步的治疗。然而,在其他研究无法提供诊断的情况下,需要进一步的前瞻性研究来确定CT在急性消化道出血中的作用。Wu et al. World Journal of Gastroenterology 2011

这一建议实际上改变急性消化道出血的临床诊断路径。



Outcome of negative CTA in acute GIH

  Scans/patient N= Negative CTA Positive angio/total angio N= Only conservative treatment Embolisation N= Endoscopic treatment N= Surgery N=
Kennedy#
(2010)
86/74 74% ND 92% 0 3 2
Foley (2010)(lower GIH) 20 50% 1/10 80% 1/10   2/10
Zink (2008)
(lower GIH)
41 75% 2/13 90% 1/31   2/31
Kim°(2011) 46 32% 5/15 (7+4?) 73% not specified   not specified
# 59/74 lower GIH (80%)
°28/46 lower GIH (60%)

CTA 为阴性的病例,保守治疗的%高。 High % of conservative treatment after neg CTA

CTA阴性的急性下消化道出血,介入的男女们,似乎可以懒床,或打高尔夫或购物

IR man or woman,,it seems you can stay in bed, or go on golfing, or shopping

CTA negative CTA negative CTA negative CTA negative


 

 急性胃肠道出血CTA 阳性的结果(Outcome of positive CTA in acute GIH),我们能够根据急性消化道出血CTA阳性的结果决定是否患者需要外科,或再次内镜治疗,或血管造影,或者仍然等待



* not specified whether in post/neg CTA
# 59/74 lower GIH (80%)
°28/46 lower GIH (60%)


甚至在CTA阳性的情况下,也并没有一个准确的指南可提供,但介入男女们应该开始时刻准备啦!
there is no clear algorithm, even in positive CTA cases, but be ready to intervene, IR man or woman

 


核素扫描与CTA,我们应该联合它们吗? 

patients N positive CTA negative CTA  
positive Tc-99m 8 (20%) 11(27%)* 19
negative Tc-99m 2 (5%) 20 (49%) 22
  10 31 41
* angio + in 2/10;embo in 1; surgery in 2; conservative 8/11

尽管CTA和核素扫描比较不一致,但如果仅仅核素扫描阳性,很多病人似乎保守治疗更合适....,所以

   


在日常工作中,急性消化道出血,CTA是否应该成为常规?一种观点认为,做CTA我们不会是在浪费时间吗? 似乎并不如此,很多CTA是阴性的,有时间决定栓塞/外科/内镜。当CTA时阴性,并不需要积极地进行有创的治疗,可以等着瞧(wait and see...)。我们只需套单行造影剂导致的肾损伤,和电离辐射的影响。尽管发生率低,而且影响是轻微的。

急性消化道出血的方法学

Kim et al, J Comput Assist Tomogr. 2011
1. double blind reading 3 image sets of N=46 cases;  对照组 DSA;

2. ROC曲线中的Az值,就是ROC曲线下的面积,面积越大,诊断价值越高。至于Az值怎么算出来的,是高等数学的问题。

3. diagnostic performance was notdifferent between reading of arterial, portal or combined phase CTA

4. radiation exposure:与DSA比较,剂量减少30mSv to 20mSv

• pre-contrast series: 9.57 mSv
• arterial series: 11.14 mSv
• portal-venous series: 11.54 mSv

我们需要全部都增强吗?Do we need all enhanced series?



P Goffette CIRSE 2009

慢性和不明原因(隐匿性)消化道出血和CTA(do you see CTA?)

from Singh and Alexander, Abdominal Imaging 2008
DBE=double balloon enteroscopy; IOE=intraoperative endoscopy

在慢性或隐匿性消化道出血的诊断路径中,甚至看不出CTA的作用



CTA and chronic/occult/obscure GIH




CTA and chronic/occult GIH(Huprich et al, Radiology, Sept 2011)
  1. Small bowel source:CTE sensitivity = 88%,CE sensitivity =38%; p= .008
  2. Angiodysplasia:CTE sensitivity = 80%,CE sensitivity =60%
  3. CT小肠造影对小肠出血源和小肠肿块的敏感性显著高于胶囊内镜。在这些发现的基础上,应考虑多相CT小肠造影在OGIB患者常规诊断工作中的应用,尤其是在胶囊内镜检查阴性的患者中。




 



CTE扫描技术和CTA技术相似,64-128排,三期CTA;64 x 0.6mm overlapping projections和MPR重建。

Jejunal angioectasias on computed tomography enterography (CTE). Dual-phase CTE showing hyperenhancing lesions (arrows) in the mucosa of the jejunum, suggesting angioectasias. Small bowel varices. A 56-year-old man with cirrhosis with mild portal hypertension and recent episode of hematochezia. Upper and lower endoscopy images were negative. Axial image from the enteric phase of a multiphase CT-enterography study demonstrates a tangle of dilated submucosal veins at the site of a prior small bowel anastomosis.
   


Terminal ileum ulcer on computed tomography enterography (CTE). Dual-phase CTE shows hyper-enhancement of a soft tissue lesion in the terminal ileum (arrow) in a patient presenting with intermittent melena and no findings on capsule endoscopy. This lesion was found to be a terminal ileum ulcer on repeat colonoscopy with ileal intubation to 10 cm; symptoms resolved after endoscopic treatment.


 Computed tomography (CT) enterography in a patient of obscure gastrointestinal bleeding (OGIB) showing enhancing mass lesion in ileum with a feeding vessel
 (a) CT-enterography showing jejunal stricture. (b) Surgical specimen showing stricture (adenocarcinoma)


this should actually be CTA-enterography
from Singh and Alexander, Abdominal Imaging 2008DBE=double balloon enteroscopy; IOE=intraoperative endoscopy

不明原因的消化道出血为什么不能联合CTA的动脉造影?Obscure GIH: why not combining arteriography with CTA?

“we feel that MDCTM cannot be recommended in general...”

CTA-Mesentericography for obscure GIH
ia CTA detection rate retrospective series (%) detection rate prospective series (%) overall detection rate (%)
Heiss et al, 2011 2/6 (33,3%) 1/7 (14%) 3/13 (14%)
retrospective: 2002-2006 N=6
prospective: 2006-2009 N=7

“we feel that MDCTM cannot be recommended in general...”

胃肠道出血是否每个人都需要CTA? GI-hemorrhage; Should all patients be imaged with CTA?
 
1. 主动脉-十二指肠瘘 YES

CTA technique of first choice, sens>90%, spec.>80%

     

Signs: contrast extravastion in duodenum, peri-graft fluid,
peri-graft soft tissue mass, peri-graft air, focal bowel wall
thickening, absence fatplane vessel wall - bowel wall

Mylona et al. Aorto-enteric fistula: CT findings.  Abdominal Imaging 2007; 32: 393-7
 
2. 胆道出血/胰腺出血 Hemobilia / hemosuccus pancreaticus

     

 CTA technique of first choice
 Endoscopy limited value for diagnosis and treatment
 Embolization treatment of choice
 CTA for treatment planning

Hyare et al. MDCT CT angiography compared with DSA in diagnosing major arterial hemorrhage in inflammatory pancreatic disease.  Eur J Radiol. 2006: 59, 295-300

3. 其它原因 Maybe(可能需要进行CTA)

 Endoscopy more often diagnostic in upper than lower GI tract*
 Risk factors for CIN present?
 Radiation risk (young patient)?

*Most common causes: upper GI bleed = ulcer bleed ; lower GI bleed = diverticular bleed

文献中CTA诊断消化道出血的结果

1. 动物实验 

 Animal study GI hemorrhage in pigs
 CT detection of hemorrhage > 0.3 ml./min.
 (Angio detection GI hemorrhage > 0.5 ml./min.)

 Kuhle et al. Detection of active colonic hemorrhage with use of helical CT: findings in a swine model.Radiology 2003; 228: 743-52.

2. Literature results CTA -review

Pooled sens. 86% (95% CI 78–92%)
Pooled spec. 95% (95% CI 76–100%)

   
Chua et al. Diagnostic accuracy of CTA in acute GI bleeding. J Med Imaging Radiat Oncol. . 2008; 52: 333-8

3. DSA作为参考标准,50例病人

Pooled sens. 88%
Pooled spec. 50%

Anthony et al. MDCT: review of its use in acute GIH.  Clin Rad. 2007; 62: 938-49

 
4. 回顾性研究

 Retrospective study, 86 CTA’s in 76 pts.with acute GIH
 Sens. 79%, spec. 95%, accuracy 91% 
 PPV(阳性预测值) 86%, NPV(阴性预测值) 92%

Kennedy et al Active GIH with CTA: a 41/2-year retrospective review. . JVIR 2010; 21: 848-55

 Retrospective study in 26 pts. with confirmed acute GIH
 Sens. 92% (24/26)


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