Gastrointestinal Bleeding Case Study

Clinical History

A 28 year old female presented with abdominal trauma following a motor vehicle accident. Trauma management required limited resection of the lacerated small bowel. In the immediate post operative period, the patient’s hemoglobin started to drop without any clinical evidence of internal bleeding or hemoperitoneum. Gastrointestinal bleeding was suspected and the patient underwent CT angiography which failed to show any vascular abnormality or bleeding site. Due to a progressive drop in hemoglobin (Hgb) the patient was taken for a conventional catheter angiography. However, esenteric and aortic angiography still failed to show any vascular bleeding.

A progressive drop in hemoglobin continued. The patient’s Hgb level went as low at 2.6 gm/dl (normal range 12-15 gm/dl) and she slipped into a coma and was intubated and put on a respirator. She was referred for a GI Bleed study using radiolabeled RBC.

Imaging Findings

Examination Protocol:
GI Bleed study was performed using a dynamic 30 sec/frame study during the injection phase followed by sequential planar and SPECT acquisition.*

Findings:

In the dynamic study there was a slight blush of tracer in the left upper abdomen which was difficult to differentiate from the blush in the left kidney (Fig. 1).

SPECT•CT images showed a small amount of focal bloodpool activity in the small intestinal lumen just distal to the anastomosis for the previous small bowel resection, which suggested active bleeding.

The SPECT•CT study of GI Bleed showed focal uptake in the small bowel loop (white & yellow arrows), adjacent to the site of the previous anastomosis (red arrows).

Diagnosis

The small amount of focal bloodpool activity in the small intestinal lumen suggested active bleeding.

Treatment

The patient was rushed to surgery based on this finding. A laparotomy was performed and initial visual inspection of the bowel loop failed to reveal any sign of active bleeding either luminal or serosal.

In view of the SPECT•CT demonstration of active bleeding, the surgeon decided to resect the portion of the bowel adjacent to the previous resection site and reanastomose the bowel lumen.

Discussion

Following surgery there was a dramatic improvement in the patient’s condition and there was gradual increase in the Hgb level. The patient regained consciousness in a couple of days and showed signs of recovery.

SPECT•CT localization of a focal gastrointestinal bleed within the bowel lumen adjacent to site of previous anastomosis was critical in guiding the surgeon to the site of active bleeding. The decision to resect and reanastomose the part of small bowel was based on the exact localization of the bloodpool in the small bowel lumen adjacent to the site of previous anastomoses identifiable on CT by the sutures. Since rebleeding from an anastomotic site is not uncommon as sequelae to abdominal surgery, the decision to resect and reanastomose was straightforward after SPECT•CT localization even though on inspection during surgery there was no visual evidence of luminal bleeding.

SPECT•CT localization of focal intestinal bleeding thus saved the patients life by guiding the surgery.

Data courtesy of The Moncton Hospital, Moncton, New Brunswick, Canada

* Any of the protocols presented herein are for informational purposes and are not meant to substitute for clinician judgment in how best to use any medical devices. It is the clinician that makes all diagnostic determinations based upon education, learning and experience.