Korean Journal of Radiology

The Korean Society of Radiology (대한영상의학회)
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Diagnostic Value of Computed Tomography in Crohn's Disease Patients Presenting with Acute Severe Lower Gastrointestinal Bleeding

  • Lee, Sunyoung (Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Ye, Byong Duk (Department of Gastroenterology and Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Park, Seong Ho (Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Lee, Kyung Jin (Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Kim, Ah Young (Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Lee, Jong Seok (Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Kim, Hyun Jin (Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Yang, Suk-Kyun (Department of Gastroenterology and Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center)
  • Received : 2018.02.24
  • Accepted : 2018.05.30
  • Published : 2018.12.01
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Abstract

Objective: To investigate the diagnostic yield of contrast-enhanced computed tomography (CT) in Crohn's disease (CD) patients presenting with acute severe lower gastrointestinal bleeding (LGIB), and the role of CT in predicting the risk of rebleeding. Materials and Methods: A consecutive series of 110 CD patients presenting with acute severe LGIB between 2005 and 2016 were analyzed. Among them, 86 patients who had undergone contrast-enhanced CT constituted the study cohort. The diagnostic yield of CT for detecting contrast extravasation was obtained for the entire cohort and compared between different CT techniques. In a subgroup of 62 patients who had undergone CT enterography (CTE) and showed a negative result for extravasation on CTE, the association between various clinical and CTE parameters and the risk of rebleeding during subsequent follow-up was investigated using Cox regression analysis. Results: The diagnostic yield of CT was 10.5% (9 of 86 patients). The yield did not significantly differ between single-phase and multiphase examinations (p > 0.999), or between non-enterographic CT and CTE (p = 0.388). Extensive CD (adjusted hazard ratio [HR], 3.27; 95% confidence interval [CI], 1.09-9.80; p = 0.034) and bowel wall-to-artery enhancement ratio (adjusted HR, 2.81; 95% CI, 1.21-6.54; p = 0.016) were significantly independently associated with increased rebleeding risks, whereas anti-tumor necrosis factor-${\alpha}$ therapy after the bleeding independently decreased the risk of rebleeding (adjusted HR, 0.26; 95% CI, 0.07-0.95; p = 0.041). Conclusion: The diagnostic yield of contrast-enhanced CT was not high in CD patients presenting with acute severe LGIB. Nevertheless, even a negative CTE may be beneficial as it can help predict the risk of later rebleeding.

Keywords

References

  1. Li G, Ren J, Wang G, Wu Q, Gu G, Ren H, et al. Prevalence and risk factors of acute lower gastrointestinal bleeding in Crohn disease. Medicine (Baltimore) 2015;94:e804 https://doi.org/10.1097/MD.0000000000000804
  2. Kim KJ, Han BJ, Yang SK, Na SY, Park SK, Boo SJ, et al. Risk factors and outcome of acute severe lower gastrointestinal bleeding in Crohn's disease. Dig Liver Dis 2012;44:723-728 https://doi.org/10.1016/j.dld.2012.03.010
  3. Kostka R, Lukas M. Massive, life-threatening bleeding in Crohn's disease. Acta Chir Belg 2005;105:168-174 https://doi.org/10.1080/00015458.2005.11679692
  4. Veroux M, Angriman I, Ruffolo C, Barollo M, Buffone A, Madia C, et al. Severe gastrointestinal bleeding in Crohn's disease. Ann Ital Chir 2003;74:213-215; discussion 216
  5. Pardi DS, Loftus EV Jr, Tremaine WJ, Sandborn WJ, Alexander GL, Balm RK, et al. Acute major gastrointestinal hemorrhage in inflammatory bowel disease. Gastrointest Endosc 1999;49:153-157 https://doi.org/10.1016/S0016-5107(99)70479-7
  6. Driver CP, Anderson DN, Keenan RA. Massive intestinal bleeding in association with Crohn's disease. J R Coll Surg Edinb 1996;41:152-154
  7. Cirocco WC, Reilly JC, Rusin LC. Life-threatening hemorrhage and exsanguination from Crohn's disease. Report of four cases. Dis Colon Rectum 1995;38:85-95 https://doi.org/10.1007/BF02053865
  8. Robert JR, Sachar DB, Greenstein AJ. Severe gastrointestinal hemorrhage in Crohn's disease. Ann Surg 1991;213:207-211 https://doi.org/10.1097/00000658-199103000-00004
  9. Belaiche J, Louis E, D'Haens G, Cabooter M, Naegels S, De Vos M, et al. Acute lower gastrointestinal bleeding in Crohn's disease: characteristics of a unique series of 34 patients. Belgian IBD Research Group. Am J Gastroenterol 1999;94:2177-2181 https://doi.org/10.1111/j.1572-0241.1999.01291.x
  10. Cheifetz AS, Kornbluth AA, Legnani P, Schmelkin I, Brown A, Lichtiger S, et al. The risk of retention of the capsule endoscope in patients with known or suspected Crohn's disease. Am J Gastroenterol 2006;101:2218-2222 https://doi.org/10.1111/j.1572-0241.2006.00761.x
  11. Gerson LB, Fidler JL, Cave DR, Leighton JA. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol 2015;110:1265-1287; quiz 1288 https://doi.org/10.1038/ajg.2015.246
  12. Park SH, Ye BD, Lee TY, Fletcher JG. Computed tomography and magnetic resonance small bowel enterography: current status and future trends focusing on Crohn's disease. Gastroenterol Clin North Am 2018;47:475-499 https://doi.org/10.1016/j.gtc.2018.04.002
  13. Park SH, Yang SK, Park SK, Kim JW, Yang DH, Jung KW, et al. Long-term prognosis of crohn's disease and its temporal change between 1981 and 2012: a hospital-based cohort study from Korea. Inflamm Bowel Dis 2014;20:488-494 https://doi.org/10.1097/01.MIB.0000441203.56196.46
  14. Lennard-Jones JE. Classification of inflammatory bowel disease. Scand J Gastroenterol Suppl 1989;170:2-6; discussion 16-19
  15. Van Assche G, Dignass A, Panes J, Beaugerie L, Karagiannis J, Allez M, et al.; European Crohn's and Colitis Organisation (ECCO). The second European evidence-based consensus on the diagnosis and management of Crohn's disease: definitions and diagnosis. J Crohns Colitis 2010;4:7-27 https://doi.org/10.1016/j.crohns.2009.12.003
  16. Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut 2006;55:749-753 https://doi.org/10.1136/gut.2005.082909
  17. Gomollon F, Dignass A, Annese V, Tilg H, Van Assche G, Lindsay JO, et al.; ECCO. 3rd European evidence-based consensus on the diagnosis and management of Crohn's disease 2016: part 1: diagnosis and medical management. J Crohns Colitis 2017;11:3-25 https://doi.org/10.1093/ecco-jcc/jjw168
  18. Baker ME, Walter J, Obuchowski NA, Achkar JP, Einstein D, Veniero JC, et al. Mural attenuation in normal small bowel and active inflammatory Crohn's disease on CT enterography: location, absolute attenuation, relative attenuation, and the effect of wall thickness. AJR Am J Roentgenol 2009;192:417-423 https://doi.org/10.2214/AJR.08.1267
  19. Kim C, Park SH, Yang SK, Ye BD, Park SH, Lee JS, et al. Endoscopic complete remission of Crohn disease after antitumor necrosis $factor-{\alpha}$ therapy: CT enterographic findings and their clinical implications. AJR Am J Roentgenol 2016;206:1208-1216 https://doi.org/10.2214/AJR.15.15256
  20. Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol 2010;8:333-343; quiz e44 https://doi.org/10.1016/j.cgh.2009.12.017
  21. Huprich JE, Fletcher JG, Fidler JL, Alexander JA, Guimaraes LS, Siddiki HA, et al. Prospective blinded comparison of wireless capsule endoscopy and multiphase CT enterography in obscure gastrointestinal bleeding. Radiology 2011;260:744-751 https://doi.org/10.1148/radiol.11110143
  22. Lee SS, Oh TS, Kim HJ, Chung JW, Park SH, Kim AY, et al. Obscure gastrointestinal bleeding: diagnostic performance of multidetector CT enterography. Radiology 2011;259:739-748 https://doi.org/10.1148/radiol.11101936
  23. Shin JK, Cheon JH, Lim JS, Park JJ, Moon CM, Jeon SM, et al. Long-term outcomes of obscure gastrointestinal bleeding after CT enterography: does negative CT enterography predict lower long-term rebleeding rate? J Gastroenterol Hepatol 2011;26:901-907 https://doi.org/10.1111/j.1440-1746.2010.06577.x
  24. Soto JA, Park SH, Fletcher JG, Fidler JL. Gastrointestinal hemorrhage: evaluation with MDCT. Abdom Imaging 2015;40:993-1009 https://doi.org/10.1007/s00261-015-0365-4
  25. Korzenik JR. Massive lower gastrointestinal hemorrhage in Crohn's disease. Curr Treat Options Gastroenterol 2000;3:211-216 https://doi.org/10.1007/s11938-000-0024-9
  26. Belaiche J, Louis E. Severe lower gastrointestinal bleeding in Crohn's disease: successful control with infliximab. Am J Gastroenterol 2002;97:3210-3211 https://doi.org/10.1111/j.1572-0241.2002.07143.x
  27. Papi C, Gili L, Tarquini M, Antonelli G, Capurso L. Infliximab for severe recurrent Crohn's disease presenting with massive gastrointestinal hemorrhage. J Clin Gastroenterol 2003;36:238-241 https://doi.org/10.1097/00004836-200303000-00011
  28. Tsujikawa T, Nezu R, Andoh A, Saotome T, Araki Y, Ishizuka Y, et al. Inflixmab as a possible treatment for the hemorrhagic type of Crohn's disease. J Gastroenterol 2004;39:284-287 https://doi.org/10.1007/s00535-003-1290-9
  29. Meyer MM, Levine EJ. Acute hemorrhagic Crohn's disease controlled with infliximab. Inflamm Bowel Dis 2009;15:1456-1457 https://doi.org/10.1002/ibd.20840
  30. Ando Y, Matsushita M, Kawamata S, Shimatani M, Fujii T, Okazaki K. Infliximab for severe gastrointestinal bleeding in Crohn's disease. Inflamm Bowel Dis 2009;15:483-484 https://doi.org/10.1002/ibd.20635
  31. Julian Gomez L, Atienza R, Barrio J, Gil P, Gomez de la Cuesta S, Pinto P, et al. [Infliximab treatment of severe bleeding complicating Crohn's disease]. Rev Esp Enferm Dig 2010;102:57-58
  32. Alcalde Vargas A, Justiniano JM, Carnerero EL, Salado CT, Domingo IG, Galan JL. [Utility of infliximab therapy in severe enterorrhagia associated with Crohn's disease. Report of three cases]. Gastroenterol Hepatol 2011;34:24-28 https://doi.org/10.1016/j.gastrohep.2010.09.004
  33. Aniwan S, Eakpongpaisit S, Imraporn B, Amornsawadwatana S, Rerknimitr R. Infliximab stopped severe gastrointestinal bleeding in Crohn's disease. World J Gastroenterol 2012;18:2730-2734 https://doi.org/10.3748/wjg.v18.i21.2730
  34. D'haens G, Van Deventer S, Van Hogezand R, Chalmers D, Kothe C, Baert F, et al. Endoscopic and histological healing with infliximab anti-tumor necrosis factor antibodies in Crohn's disease: a European multicenter trial. Gastroenterology 1999;116:1029-1034 https://doi.org/10.1016/S0016-5085(99)70005-3

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