Population Covered By The Guidance
This pathway provides guidance on the investigation of adult patients with acute gastrointestinal bleeding, with emphasis on endoscopy and non-invasive imaging modalities.
Lead Researcher: Michael Truong
Experts & Contributors: Shashini Dissanayake, Geoffrey Forbes, Richard Mendelson, Duncan Ramsay
Editorial Panel: Core membership
Link to Editorial Panel
Date reviewed: May 2016
Date Published: May 2017
Gastrointestinal Bleeding
Gastrointestinal Bleeding
Gastrointestinal Bleeding
Gastrointestinal Bleeding
Gastrointestinal Bleeding
Gastrointestinal Bleeding
Gastrointestinal Bleeding
Gastrointestinal Bleeding
Gastrointestinal Bleeding
Gastrointestinal Bleeding
- Usually, endoscopy is the first line modality to evaluate, localise and treat patients with suspected upper GI haemorrhage.
- Usually, catheter angiography is the first line modality to evaluate, localise and treat haemodynamically unstable patients with suspected lower GI haemorrhage and unprepared bowel.
- Triphasic CT Angiogram is a rapid, non-invasive investigation that can accurately localise the site and aetiology of bleeding in patients with active bleeding.
- RBC Scintigraphy is recommended for intermittent bleeding as it allows repeated imaging over a 24 hour period.
Date of literature search: May 2016
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Moss A, Tuffaha H, Malik A. Lower GI bleeding: a review of current management, controversies and advances. Int J Colorectal Dis. 2016;31(2):175-88. (Review article) View the reference
- Strate L, Gralnek I. ACG clinical guideline: Management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol. 2016;111(4):459-74. (College guidelines) View the reference
- Hwang J, Fisher D, Ben Menachem T, Chandrasekhara V, Chathadi K, Decker GA, et al. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc. 2012;75(6):1132-8. (Clinical practice guidelines) View the reference
- Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol. 2007;62(10):938-49. (Level III evidence) View the reference
- Kim BSM, Li B, Engel A, Samra J, Clarke S, Norton I, et al. Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World J Gastrointest Pathophysiol. 2014;5(4):467-78. (Review article) View the reference
- Laine L, Jensen D. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345-60; quiz 61. (College guidelines) View the reference
- Barkun A, Bardou M, Kuipers E, Sung J, Hunt R, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101-13. (International consensus guidelines) View the reference
- Darcy MD CB, Feig BW, Fidelman N, Hara AK, Kapoor BS, Knuttien MG, Lambert DL, Minocha J, Rochon PJ, Shaw CM, Ray CE Jr, Lorenz JM. Expert Panel on Interventional Radiology. ACR Appropriateness Criteria® radiologic management of lower gastrointestinal tract bleeding. J Am Coll Radiol. 2014:8. (College guidelines)
- Kim J, Kim Y, Lee K, Lee Y, Park J. Diagnostic performance of CT angiography in patients visiting emergency department with overt gastrointestinal bleeding. Korean J Radiol. 2015;16(3):541-9. (Level III evidence) View the reference
- 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. (Level IV evidence) View the reference
- Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding. J Med Imaging Radiat Oncol. 2008;52(4):333-8. (Level II evidence) View the reference
- Khan S, et al. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database Syst Rev. 2006:CD000553-CD. (Level I evidence) View the reference
- Deltenre P, Trépo E, Rudler M, Monescillo A, Fraga M, Denys A, et al. Early transjugular intrahepatic portosystemic shunt in cirrhotic patients with acute variceal bleeding: a systematic review and meta-analysis of controlled trials Eur J Gastroenterol Hepatol. 2015;27(9):e1-e9. (Level I evidence) View the reference
- Huang L, Yu Q-S, Zhang Q, Liu J-D, Wang Z. Transjugular intrahepatic portosystemic shunt versus surgical shunting in the management of portal hypertension. Chin Med J (Engl). 2015;128(6):826-34. (Level I evidence) View the reference
- Kennedy D, Laing C, Tseng L, Rosenblum D, Tamarkin S. Detection of active gastrointestinal hemorrhage with CT angiography: a 4(1/2)-year retrospective review J Vasc Interv Radiol. 2010;21(6):848-55. (Level III evidence) View the reference
- Lee S, Welman CJ, Ramsay D. Investigation of acute lower gastrointestinal bleeding with 16- and 64-slice multidetector CT J Med Imaging Radiat Oncol. 2009;53(1):56-63. (Level IV evidence) View the reference
- Kuhle W, Sheiman R. Detection of active colonic hemorrhage with use of helical CT: findings in a swine model. Radiology. 2003;228(3):743-52. (Animal study) View the reference
- García Blázquez V, Vicente Bártulos A, Olavarria Delgado A, Plana MN, van der Winden D, Zamora J. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol. 2013;23(5):1181-90. (Level II evidence) View the reference
- Wu L-M, Xu J-R, Yin Y, Qu X-H. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis. World J Gastroenterol. 2010;16(31):3957-63. (Level II evidence) View the reference
- Awais M. 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. 2015. (Level II evidence) View the reference
- Jaskolka J, Binkhamis S, Prabhudesai V, Chawla T Acute gastrointestinal hemorrhage: radiologic diagnosis and management. Can Assoc Radiol J. 2013;64(2):90-100. (Review article) View the reference
- Ren J-Z, Zhang M-F, Rong A-M, Fang X-J, Zhang K, Huang G-H, et al. Lower gastrointestinal bleeding: role of 64-row computed tomographic angiography in diagnosis and therapeutic planning. World J Gastroenterol. 2015;21(13):4030-7. (Level II evidence) View the reference
- Grady E. Gastrointestinal bleeding scintigraphy in the early 21st century. J Nucl Med. 2016;57(2):252-9. (Review article) View the reference
- Jacovides C, Nadolski G, Allen S, Martin N, Holena D, Reilly P, et al. Arteriography for lower gastrointestinal hemorrhage: role of preceding abdominal computed tomographic angiogram in diagnosis and localization. JAMA surgery. 2015;150(7):650-6. (Level III evidence) View the reference
- Sun H, Jin Z, Li X, Qian J, Yu J, Zhu F, 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. (Level III evidence) View the reference
- Tabibian J, Wong Kee Song LM, Enders F, Aguet J, Tabibian N. Technetium-labeled erythrocyte scintigraphy in acute gastrointestinal bleeding. Int J Colorectal Dis. 2013;28(8):1099-105. (Level III evidence) View the reference
- Currie G, Kiat H, Wheat J. Scintigraphic evaluation of acute lower gastrointestinal hemorrhage: current status and future directions. J Clin Gastroenterol. 2011;45(2):92-9. (Review article) View the reference
- Olds G, Cooper G, Chak A, Sivak M, Chitale A, Wong RCK. The yield of bleeding scans in acute lower gastrointestinal hemorrhage. J Clin Gastroenterol. 2005;39(4):273-7. (Level III evidence) View the reference
- Levy R, Barto W, Gani J. Retrospective study of the utility of nuclear scintigraphic-labelled red cell scanning for lower gastrointestinal bleeding. ANZ J Surg. 2003;73(4):205-9. (Level III evidence) View the reference
- Suzman MS, Talmor M, Jennis R, Binkert B, Barie PS. Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy. Ann Surg. 1996;224(1):29-36. (Level III evidence) View the reference
- Loffroy R, Rao P, Ota S, De Lin M, Kwak B-K, Geschwind J-F. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010;33(6):1088-100. (Review article) View the reference
- Ali M. Treatment of nonvariceal gastrointestinal hemorrhage by transcatheter embolization. Radiol Res Pract. 2013(2013):604328-. (Level IV evidence) View the reference
- Hur S, Jae H, Lee M, Kim H-C, Chung J. 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):10-9. (Level IV evidence) View the reference
- Khanna A, Ognibene S, Koniaris L. Embolization as first-line therapy for diverticulosis-related massive lower gastrointestinal bleeding: evidence from a meta-analysis. J Gastrointest Surg. 2005;9(3):343-52. (Level II evidence) View the reference
- Walker TG, Salazar G, Waltman A. Angiographic evaluation and management of acute gastrointestinal hemorrhage. World J Gastroenterol. 2012;18(11):1191-201. (Review article) View the reference
- Frattaroli F, Casciani E, Spoletini D, Polettini E, Nunziale A, Bertini L, et al. Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding World J Surg. 2009;33(10):2209-17. (Level III evidence) View the reference
- Zurkiya O, Walker TG. Angiographic evaluation and management of nonvariceal gastrointestinal hemorrhage. Am J Roentgenol. 2015;205(4):753-63. (Review article) View the reference
- Tan K-K, Shore T, Strong D, Ahmad M, Waugh R, Young C. Factors predictive for a positive invasive mesenteric angiogram following a positive CT angiogram in patients with acute lower gastrointestinal haemorrhage. Int J Colorectal Dis. 2013;28(12):1715-9. (Level IV evidence) View the reference
Pathway User Guide
Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.
White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).
Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.
Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
 |
None | 0 |
 |
Minimal | < 1 millisieverts |
 |
Low | 1-5 mSv |
 |
Medium | 5-10 mSv |
 |
High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
Spotted an error or outdated info? Click to tell us.
CT Angiogram (CTA)
CT Angiogram
- First line radiological modality to assess actively bleeding, haemodynamically stable patients.
- First line radiological modality to assess actively bleeding, haemodynamically stable patients.
- A triphasic scan – unenhanced, arterial and delayed phase – is recommended. An unenhanced scan is necessary to reduce false positives from pre-existing hyperattenuating material in the bowel
- Oral contrast is not recommended as it increases anaesthetic risk if the patient proceeds to surgery and may obscure extravasated contrast ,
- Porcine models have detected extravasation of contrast into the bowel lumen with active bleeding as low as 0.3mL/min
- Sensitivity of 85.2% ,
- Specificity of 92.1% ,
- A comparison between CTA and RBC Scintigraphy against a reference standard of catheter angiography, found that CTA had superior sensitivity (100% to 81.2%), specificity (90.9% to 33.3%) and positive predictive value (93.3% to 61.9%) compared to RBC scintigraphy
- Advantages:
- Widely available
- Rapid acquisition time
- Accessible 24 hours a day allowing expedient assessment when patients are most likely to be bleeding
- Non-invasive
- No bowel preparation required
- Can assess the small bowel
- Can guide subsequent management – endoscopy, catheter angiography, surgery or conservative – due to its high accuracy of localisation and ability to identify the aetiology even without active haemorrhage ,
- Diagnostic yield 61.3%
- In a prospective case series with CTA as the first diagnostic modality, the localisation accuracy was 100% and treatment was planned with an accuracy of 93.6%
- Guides catheter angiography by providing anatomical mapping that identifies anatomical variability and vascular abnormalities This was shown to reduce contrast load during catheter angiography however overall contrast load (including CTA) was greater
- Watchful waiting is recommended for patients with a negative result as the bleeding rate is low or intermittent In three case series, 82-92% of patients with a negative result had successful conservative management ,
- If CTA is negative proceeding to an angiogram within 4 hours is not recommended
- Disadvantages:
- Active haemorrhage is necessary to visualise contrast extravasation
- No therapeutic capability
- Risk of contrast allergy and contrast induced nephropathy
RBC Scintigraphy
RBC Scintigraphy
- Has debatable utility and is best used to assess intermittently bleeding, haemodynamically stable patients.
- First line imaging modality for patients with chronic kidney disease and contrast allergy
- Has debatable utility and is best used to assess intermittently bleeding, haemodynamically stable patients
- First line radiological modality for patients with chronic kidney disease and contrast allergy
- Can show local tracer extravasation into the bowel lumen with rates of bleeding >0.1mL/min
- Sensitivity of 23-97%
- Specificity of 30-95%
- Continuous dynamic sampling with a minimal sampling interval of one frame per minute may allow accurate definition of the nature, origin and behaviour of the bleeding site, increasing sensitivity and specificity
- Advantages:
- Non-invasive
- Minimal patient preparation
- 99mTechnechium labelled RBC allows frequent imaging and prolonged detection up to 24 hours post administration
- Increased sensitivity for diverticular disease
- Disadvantages:
- Active haemorrhage is necessary
- Not available after hours
- A nuclear technician must be on site
- Low yield of a positive result, typically under 50%
- Low positive predictive value 60%, with 25% of false positives leading to incorrect surgical procedures
- Cannot characterise the aetiology of bleeding due to poor spatial resolution ,
- Provides evidence of haemorrhage but due conflicting studies reporting poor localisation, it cannot guide subsequent therapeutic procedures
- Blood moves anterograde and retrograde during bowel peristalsis and position changes
- A retrospective case series found that 55% of RBC Scintigraphy scans were ‘unhelpful’ to surgeons who ignored the result or performed an operation incongruent with the scan result
- A retrospective case series found the bleeding site localised in 74% of patients and 89% of those had resection of that bowel segment
Catheter Angiography
Catheter Angiography
- Should be preceded by diagnostic localising studies to ensure that there is active bleeding, provide anatomical mapping and direct super selective angiography.
- Should be preceded by diagnostic localising studies to ensure that there is active bleeding, provide anatomical mapping and direct angiography of vessels
- Requires active bleeding >0.5mL/min ,
- Sensitivity of 42-86% ,
- Specificity of 100% ,
- Advantages:
- A diagnostic and therapeutic tool
- No bowel preparation required
- Catheter angiography is a prelude to super selective embolization with coils, gelatin sponges, polyvinyl alcohol and cyanoacrylic glues
- Used frequently in lower GI haemorrhage due to end arteries and is more challenging in upper GI haemorrhage due to multiple collateral vessels
- A review of 15 studies on acute non-variceal upper GI bleeding measured a 93% technical success rate of embolization and 63% clinical success rate
- The two largest retrospective case series have found technical success rates 96-98% and clinical success rates 82-89%
- High rates of clinical success (85%) in diverticular haemorrhage
- Reduces laparotomy frequency benefitting patients who have a high anaesthetic risk ,
- Two retrospective uncontrolled studies showed no significant differences between embolization therapy and surgery for rates of rebleeding or mortality despite the embolization cohorts being older and having more comorbidities ,
- Disadvantages:
- Active haemorrhage is necessary to visualise contrast extravasation
- Interventional radiologist must be on site
- Embolisation may be impeded in older patients with atherosclerotic disease
- Complications of access site haematoma, pseudoaneurysm, arterial dissection or spasm, bowel ischaemia and contrast induced nephropathy or allergy occur in 3% of cases