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Radiologie up2date 2023; 23(01): 13-29
DOI: 10.1055/a-1949-7143
Abdominelle und gastrointestinale Radiologie

Diagnose und Therapie gastrointestinaler Blutungen

Diagnosis and Therapy of Gastrointestinal Bleeding
Andreas H. Mahnken
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Zusammenfassung

Gastrointestinale Blutungen sind komplexe Krankheitsgeschehen mit einer jährlichen Inzidenz von bis zu 100/100 000 Personen, die mit einer Mortalität von etwa 10% einhergehen. Jenseits der Endoskopie sind die kontrastangehobene CT und die interventionell-radiologische Therapie zentrale Bestandteile leitliniengerechter Diagnose- und Therapiealgorithmen.

Abstract

Gastrointestinal bleedings are a complex group of conditions with an annual incidence of up to 100/100 000 and a mortality of approximately 10%. Contrast enhanced computed tomography and interventional radiology treatment are cornerstones of guideline-based diagnosis and therapy beyond endoscopy. This article summarizes the current evidence on radiologic diagnosis and interventional radiologic treatment in the different types of gastrointestinal bleedings.

Kernaussagen

  • Gastrointestinale Blutungen sind ein komplexes Krankheitsgeschehen mit einer jährlichen Inzidenz von bis zu 100/100000 Personen und gehen mit einer Mortalität von etwa 10% einher.

  • Die Endoskopie dominiert die frühe Diagnostik. Die mehrphasig kontrastangehobene CT hat sich aufgrund ihrer Verfügbarkeit und guten diagnostischen Aussagekraft zum wichtigsten bildgebenden Verfahren in der Diagnostik gastrointestinaler Blutungen entwickelt.

  • Für die Diagnose einer gastrointestinalen Blutung sind neben dem direkten Nachweis einer Kontrastmittelextravasation weitere diagnostische Zeichen wie z. B. Pseudoaneurysmen, eine umschriebene Darmwandhyperämie oder hypervaskularisierte Tumoren relevant.

  • Die Katheterangiografie hat diagnostische Bedeutung zur Lokalisation der Blutungsquelle bei overten gastrointestinalen Blutungen. Transarterielle Therapietechniken sind nicht nur bei Versagen endoskopischer Blutstillungsmaßnahmen der Therapieansatz der Wahl für nicht variköse Blutungen.

  • Bei varikösen Blutungen kommt sowohl bei primärem Versagen endoskopischer Verfahren als auch in der Sekundärprophylaxe zunehmend die Anlage eines TIPS zur Anwendung.

Schlüsselwörter

Blutung - gastrointestinale Blutung - Computertomografie - CT-Angiografie - Embolisation

Key words

bleeding - gastrointestinal bleeding - computertomography - CT angiography - embolization


Publication History

Article published online:
28 February 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Hreinsson JP, Kalaitzakis E, Gudmundsson S. et al. Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013; 48: 439-447
    CrossrefPubMedSearch in Google Scholar
  • 2 Kurien M, Lobo AJ. Acute upper gastrointestinal bleeding. Clin Med (Lond) 2015; 15: 481-485
    CrossrefPubMedSearch in Google Scholar
  • 3 Zuckerman GR, Prakash C. Acute lower intestinal bleeding: part I: clinical presentation and diagnosis. Gastrointest Endosc 1998; 48: 606-617
    CrossrefPubMedSearch in Google Scholar
  • 4 Garcia-Tsao G, Sanyal AJ, Grace ND. et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol 2007; 102: 2086-2102
    CrossrefPubMedSearch in Google Scholar
  • 5 Srygley FD, Gerardo CJ, Tran T. et al. Does this patient have a severe upper gastrointestinal bleed?. JAMA 2012; 307: 1072-1079
    CrossrefPubMedSearch in Google Scholar
  • 6 de Franchis R. Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
    CrossrefPubMedSearch in Google Scholar
  • 7 Brett BT, Hayes PC, Jalan R. Primary prophylaxis of variceal bleeding in cirrhosis. Eur J Gastroenterol Hepatol 2001; 13: 349-358
    CrossrefPubMedSearch in Google Scholar
  • 8 Aoki T, Nagata N, Shimbo T. et al. Development and Validation of a Risk Scoring System for Severe Acute Lower Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2016; 14: 1562-1570.e2
    CrossrefPubMedSearch in Google Scholar
  • 9 Götz M, Anders M, Biecker E. et al. S2k-Leitlinie Gastrointestinale Blutung. Z Gastroenterol 2017; 55: 883-936
    Search in Google Scholar
  • 10 Repaka A, Atkinson MR, Faulx AL. et al. Immediate unprepared hydroflush colonoscopy for severe lower GI bleeding: a feasibility study. Gastrointest Endosc 2012; 76: 367-373
    CrossrefPubMedSearch in Google Scholar
  • 11 Dulai GS, Jensen DM. Severe gastrointestinal bleeding of obscure origin. Gastrointest Endosc Clin N Am 2004; 14: 101-113
    CrossrefPubMedSearch in Google Scholar
  • 12 Zuckier LS. Acute gastrointestinal bleeding. Semin Nucl Med 2003; 33: 297-311
    CrossrefPubMedSearch in Google Scholar
  • 13 Zuckerman GR, Prakash C, Askin MP. et al. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology 2000; 118: 201-221
    CrossrefPubMedSearch in Google Scholar
  • 14 Baum S, Athanasoulis CA, Waltman AC. et al. Gastrointestinal hemorrhage. II. Angiographic diagnosis and control. Adv Surg 1973; 7: 149-198
    PubMedSearch in Google Scholar
  • 15 Rahn 3rd NH, Tishler JM, Han SY. et al. Diagnostic and interventional angiography in acute gastrointestinal hemorrhage. Radiology 1982; 143: 361-366
    CrossrefPubMedSearch in Google Scholar
  • 16 Vernava 3rd AM, Moore BA, Longo WE. et al. Lower gastrointestinal bleeding. Dis Colon Rectum 1997; 40: 846-858
    CrossrefPubMedSearch in Google Scholar
  • 17 Textor HJ, Wilhelm K, Strunk H. et al. Diagnostik intraabdomineller Blutungen mit CO2 als Kontrastmittel. Rofo 1997; 166: 51-53
    Thieme ConnectPubMedSearch in Google Scholar
  • 18 Johnston C, Tuite D, Pritchard R. et al. Use of provocative angiography to localize site in recurrent gastrointestinal bleeding. Cardiovasc Intervent Radiol 2007; 30: 1042-1046
    CrossrefPubMedSearch in Google Scholar
  • 19 Lee EW, Laberge JM. Differential diagnosis of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7: 112-122
    CrossrefPubMedSearch in Google Scholar
  • 20 Miyakuni Y, Nakajima M, Ohbe H. et al. Angiography versus colonoscopy in patients with severe lower gastrointestinal bleeding: a nation-wide observational study. Acute Med Surg 2020; 7: e533
    CrossrefPubMedSearch in Google Scholar
  • 21 Defreyne L, Vanlangenhove P, De Vos M. et al. Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology 2001; 218: 739-748
    CrossrefPubMedSearch in Google Scholar
  • 22 Kwon JH, Kim MD, Han K. et al. Transcatheter arterial embolisation for acute lower gastrointestinal haemorrhage: a single-centre study. Eur Radiol 2019; 29: 57-67
    CrossrefPubMedSearch in Google Scholar
  • 23 Melson GL, Geisse G, Stanley RJ. Selective intraarterial infusion of vasopressin for control of gastrointestinal bleeding: experience with 35 cases. Gastrointest Radiol 1976; 1: 59-65
    CrossrefPubMedSearch in Google Scholar
  • 24 Madoff DC, Wallace MJ, Lichtiger B. et al. Intraarterial platelet infusion for patients with intractable gastrointestinal hemorrhage and severe refractory thrombocytopenia. J Vasc Interv Radiol 2004; 15: 393-397
    CrossrefPubMedSearch in Google Scholar
  • 25 Chang WC, Liu CH, Hsu HH. et al. Intra-arterial treatment in patients with acute massive gastrointestinal bleeding after endoscopic failure: comparisons between positive versus negative contrast extravasation groups. Korean J Radiol 2011; 12: 568-578
    CrossrefPubMedSearch in Google Scholar
  • 26 Tarasconi A, Baiocchi GL, Pattonieri V. et al. Transcatheter arterial embolization versus surgery for refractory non-variceal upper gastrointestinal bleeding: a meta-analysis. World J Emerg Surg 2019; 14: 3
    CrossrefPubMedSearch in Google Scholar
  • 27 Dobritz M, Engels HP, Schneider A. et al. Evaluation of dual-phase multi-detector-row CT for detection of intestinal bleeding using an experimental bowel model. Eur Radiol 2009; 19: 875-881
    CrossrefPubMedSearch in Google Scholar
  • 28 Mohammadinejad P, Kwapisz L, Fidler JL. et al. The utility of a dual-phase, dual-energy CT protocol in patients presenting with overt gastrointestinal bleeding. Acta Radiol Open 2021; 10
    CrossrefPubMedSearch in Google Scholar
  • 29 Feingold DL, Pappou EP, Lee-Kong SA. Diagnostic Modalities in Gastrointestinal Bleeding. Clin Colon Rectal Surg 2020; 33: 5-9
    Thieme ConnectPubMedSearch in Google Scholar
  • 30 García-Blázquez V, Vicente-Bártulos A, Olavarria-Delgado A. et al. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol 2013; 23: 1181-1190
    CrossrefPubMedSearch in Google Scholar
  • 31 Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding. J Med Imaging Radiat Oncol 2008; 52: 333-338
    CrossrefPubMedSearch in Google Scholar
  • 32 Wu LM, Xu JR, Yin Y. et al. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis. World J Gastroenterol 2010; 16: 3957-3963
    CrossrefPubMedSearch in Google Scholar
  • 33 He B, Yang J, Xiao J. et al. Diagnosis of lower gastrointestinal bleeding by multi-slice CT angiography: A meta-analysis. Eur J Radiol 2017; 93: 40-45
    CrossrefPubMedSearch in Google Scholar
  • 34 He B, Yang J, Xiao J. et al. Accuracy of Computed Tomographic Enterography for Obscure Gastrointestinal Bleeding: A Diagnostic Meta-analysis. Acad Radiol 2018; 25: 196-201
    CrossrefPubMedSearch in Google Scholar
  • 35 Wang Z, Chen JQ, Liu JL. et al. CT enterography in obscure gastrointestinal bleeding: a systematic review and meta-analysis. J Med Imaging Radiat Oncol 2013; 57: 263-273
    CrossrefPubMedSearch in Google Scholar
  • 36 Kennedy DW, Laing CJ, Tseng LH. et al. Detection of active gastrointestinal hemorrhage with CT angiography: a 4(1/2)-year retrospective review. J Vasc Interv Radiol 2010; 21: 848-855
    CrossrefPubMedSearch in Google Scholar
  • 37 Martí M, Artigas JM, Garzón G. et al. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology 2012; 262: 109-116
    CrossrefPubMedSearch in Google Scholar
  • 38 Hilfiker PR, Weishaupt D, Kacl GM. et al. Comparison of three dimensional magnetic resonance imaging in conjunction with a blood pool contrast agent and nuclear scintigraphy for the detection of experimentally induced gastrointestinal bleeding. Gut 1999; 45: 581-587
    CrossrefPubMedSearch in Google Scholar
  • 39 Erden A, Bozkaya H, Türkmen Soygür I. et al. Duodenal angiodysplasia: MR angiographic evaluation. Abdom Imaging 2004; 29: 12-14
    CrossrefPubMedSearch in Google Scholar
  • 40 Casciani E, Nardo GD, Chin S. et al. MR Enterography in paediatric patients with obscure gastrointestinal bleeding. Eur J Radiol 2017; 93: 209-216
    CrossrefPubMedSearch in Google Scholar