Hospital: Hospital Universitario Central de Asturias (H U C A).
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Aut@r o Autores: D. Vizcaíno Domínguez, N. Sordo Alonso, J. Calvo Blanco, C. Suárez Arcay, S. Martín García, A. Mesa Álvarez.,
Presentación:
A 44 year-old-male with history of crhon disease for more than 10 years with transmural chronic inflammation of the caecum and a long segment of ileum with enteroenteric fistula complicated with inflammatory plastron. After changes of immunosuppressive treatment without improvement surgery was performed with cecal and ileal resection with terminal ileostomy. As he had good evolution surgery was performed 6 months later with ileostomy closure and ileocolic anastomosis. Unexpectedly, 24 hours later the patient has acute anemia so abdominal CT is requested with active bleeding suspiction. A Dual- energy CT was performed in arterial and portal venous phase with two different energy leves (80 – 140 kv). Post-processing is carried out, identifying close to the suture material (confirmed in virtual nonenhanced images) focal area of high attenuation within the ascending colon in arterial phase that increases in portal venous phase compatible with active bleeding. Surgery is performed with suture of the bleeding point with good evolution.
Discusión:
Acute gastrointestinal bleeding is a common major medical emergency causing sustantial morbidity and mortality. Clinical suspiction is based on the presence of signs like tachycardia and hypotension associated with altered analytical values. CT angiography has been used successfully as a firstline diagnostic examination and is a rapid method for detection and localization of acute bleeding. The diagnosis is made when extravasated contrast material with focal area of high attenuation is seen during the arterial phase and increases during the portal venous phase. In postoperative patients suture material or clips may be mistaken for acute bleeding. To avoid these pitfalls must be performed an unhenhanced CT before inject intravenous contrast. Dual-energy CT represents the most recent major advance in CT technology and allow characterization of materials on the basis of their differential attenuation when imaged acquired at two different energy levels (80 and 140 kV). Dual-energy CT postprocessing techniques allows to creating virtual nonenhanced images after the pixels containing iodine are excluded. Thisallows to obviate the need for a true nonenhaced acquisition so decreases radiation to the patient compared with conventional triphasic protocols. Dual-energy CT iodine-specific images can increase the conspicuity of small areas of active extravasation of intravenous iodinated contrast material within the intestinal lumen.
Conclusión:
Acute gastrointestinal bleeding is a common major medical emergency causing sustantial morbidity and mortality. Clinical suspiction is based on the presence of signs like tachycardia and hypotension associated with altered analytical values. CT angiography has been used successfully as a firstline diagnostic examination and is a rapid method for detection and localization of acute bleeding. The diagnosis is made when extravasated contrast material with focal area of high attenuation is seen during the arterial phase and increases during the portal venous phase. In postoperative patients suture material or clips may be mistaken for acute bleeding. To avoid these pitfalls must be performed an unhenhanced CT before inject intravenous contrast. Dual-energy CT represents the most recent major advance in CT technology and allow characterization of materials on the basis of their differential attenuation when imaged acquired at two different energy levels (80 and 140 kV). Dual-energy CT postprocessing techniques allows to creating virtual nonenhanced images after the pixels containing iodine are excluded. Thisallows to obviate the need for a true nonenhaced acquisition so decreases radiation to the patient compared with conventional triphasic protocols. Dual-energy CT iodine-specific images can increase the conspicuity of small areas of active extravasation of intravenous iodinated contrast material within the intestinal lumen.
Bibliografía:
-Wells ML, Hansel SL, Bruining DH, Fletcher JG, Froemming AT, Barlow JM, et al. CT for Evaluation of Acute Gastrointestinal Bleeding. RadioGraphics 2018,38:1089-1107. -Murray N, Darras KE, Walstra FE, Mohammed MF, McLauglin PD. DualEnergy CT in Evaluati