Multiple jejunal angiodysplasia detected by enema-helical CT

Journal of Clinical Imaging 24 (2000) 61 ± 63

Multiple jejunal angiodysplasia detected by enema-helical CT Roberto Grassia,*, Roberto di Miziob, Stefania Romanoc, Salvatore Cappabiancac, Walter del Vecchiod, Sandro Severinib b

a Institute of Radiology, Second University of Naples, Naples, Italy Department of Radiology, ``S. Massimo'' Hospital, Penne (PE), Italy c Institute of Radiology, Second University of Naples, Naples, Italy d ``Federico II'' University, Naples, Italy

Received 15 October 1999; accepted 1 March 2000

Abstract The small bowel angiodysplasia is a rare entity that causes lower intestinal bleeding; the diagnosis is difficult and based on selective angiogram. In our case, an 85-year-old woman was hospitalized after frequent episodes of melena. We performed an enema-helical CT abdominal examination before and after contrast medium administration per venam, detecting some increased intensity areas that surgery confirmed to be a vascular dysplasia on the jejunal first loop. We found the source of hemorrhage without performing an angiographic examination. D 2000 Elsevier Science Inc. All rights reserved. Keywords: Small bowel; Angiodysplasia - Intestinal; Hemorrhage; Helical CT

1. Introduction Small bowel angiodysplasia is a rare entity that causes lower intestinal bleeding. The diagnosis is difficult and usually based on selective angiogram performed during an episode of hemorrhage when other techniquesÐsuch as intestinal enema and endoscopic examinationÐshow negative results. We report a case of intestinal bleeding, diagnosed by abdominal enema-helical CT, which is localized in the small bowel and caused by angiodysplasia. 2. Case report An 85-year-old woman who experienced frequent episodes of melena was admitted for evaluation. The HCT was 26% and the patient was given transfusion. Previous medical problems included a history of hypertensive cardiopathy and left-sided intestinal diverticular diseases. Abdominal plain film, US examination, barium studies, and colonoscopy, which were performed to rule out the cause of bleeding, all turned out negative results. In view of that, * Corresponding author. Via Massimo Stanzione, 18, 80129 Naples, Italy. Tel.: +39-8156-65203; fax: +39-8156-65202.

an enema-helical CT abdominal scanning was performed before and after i.v. contrast medium administration. The exam was performed after gastrointestinal preparation (the same required for traditional intestinal enema), using an Altaras ± Guerbet probe and 21 of methilcellulose. Two series of helical consecutive acquisitions, were obtained using 133 mA s for the initial scan and 139 mA s for the last scan, kVp = 120, pitch of 1.5 and slice thickness of 5.5 mm, with a window width of W = 400; C = 0. After iodinated contrast medium (1.5 ml/kg) per venam automatic injection, with an injection increase of 3 ml/s and a delay of 40 s, we detected some hyperintensity areas on the wall of some jejunal segments (Fig. 1a ±d). Surgery was performed on the patient and multiple jejunal diverticula with vascular dysplasia on the corresponding mesentery were found. Pathologic examination of the specimen indicated the presence of jejunal diverticula associated with vascular congestion and diffuse submucosal angioectasias.

3. Discussion The intestinal angiodysplasia occurs more frequently in the right colon, with a reported incidence in the small bowel as cause of lower intestinal hemorrhage between 7% and 20%

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Fig. 1. (a, b, c, d) EnemaÐi.v. enhanced helical CT. The arrows show the multiple sites of vascular malformation in the jejenal first segment.

[1,2]. These lesions consist of irregularly-shaped clusters of arterial, venous, and capillary vessels located in the submucosa. Clinically, angiodysplasia occurs with higher frequency among older people, associated with aortic stenosis and atherosclerosis, as well as renal failure, cirrhosis, and pulmonary diseases. Cardiovascular disease in such patients may lead to hypoperfusion and ischemic decompensation of the angiodysplasic region, resulting in intestinal bleeding [3]. Usually, in the treatment of patients with gastrointestinal hemorrhage, the arteriography plays an important role in detecting the localization of bleeding [4,5]. Nevertheless, recently, the arterial ± helical CT evaluation of gastrointestinal bleeding of obscure origin has been reported [6,7], proving as a faster and useful technique in this kind of diseaseÐalso serving as guide for subsequent conventional angiography. The value of arterial ± helical-CT seem to be related to the

identification of intestinal hemorrhage from a tomodensitometric examination, increasingly enhancing the blood rate that trespass in the lumen. This result seemed to be difficult to obtain with i.v. contrast medium administration for excessive dilution. However, the volumetric faster data acquisition during helical CT scanning was useful in averting the intense opacization of the gastroenteric vascular district, which could mask the hyperdensity areas from bleeding in the intestinal lumen [6]. In one recent case [8], the use of a biphasic helical CT was described in the detection of some arteriovenous malformations, which differ from vascular ectasia for the thick-walled blood vessels extending through the mucosa and submucosa into the muscle, distorting the adjacent tissues. Some authors [9] suggest that CT enteroclysis is advisable in patients with obstructive symptoms, with known or suspected malignancy; however, in our case (even while using enema-

R. Grassi et al. / Journal of Clinical Imaging 24 (2000) 61±63

helical CT of the abdomen), we had the optimized luminal distension that could help us to show any pathologic neoplasm causing the occult hemorrhages. After contrast medium administration per venam, we found the hyperdensity areas from active bleeding that histology related to angiodysplasic disease, without performing any other diagnostic procedures. Patients with bleeding angiodysplasia are occasionally treated with hormones or by endoscopic methods, but surgical resection is performed much more frequently [10,11]. However, a significant rate of recurrent bleeding is also demonstrated after excision, suggesting that a follow-up work will be necessary to determine the true surgical cure rate [3] and also because of increased incidence of unexplained intestinal bleeding after the resection of angiodysplasic region. We report the i.v. enhanced enema-helical CT examination as a valuable technique in detecting the site of intestinal hemorrhage, proposing it also for an easy follow-up. References [1] Cristin A, Gasparini D, Pappalardo S, Stefanutti C, Aveni F. Angiomatosi digiunale isolata. Una rara causa di emorragia intestinale. Minerva Chir 1990;45:1477 ± 9.

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[2] Afifi R, El Alaoui M, Kerkeb O. Une cause rare d'heÂmorragie digestive basse: l'angiodysplasie du grele. J Chir 1997;134(4):189 ± 92. [3] Meyer CT, Troncale FJ, Galloway S, Sheahan DG. Arteriovenous malformations of the bowel: an analysis of 22 cases and a review of the literature. Medicine 1981;60(1):36 ± 47. [4] Briley CA Jr, Jackson DC, Johnsrude IS, Mills RS. Acute gastrointestinal hemorrhage of small-bowel origin. Radiology 1980;136:317 ± 9. [5] Sos TA, Lee JG, Wixon D, Sniderman KW. Intermittent bleeding from minute to minute in acute massive gastrointestinal hemorrhage: arteriographic demonstration. AJR 1978;131:1015 ± 7. [6] Ettorre GC, Francioso G, Garribba AP, Fracella MR, Greco A, Farchi G. La tomografia computerizzata spirale con arteriografia nella diagnosi delle emorragie dell'apparato digerente con origine oscura. Radiol Med 1995;90:726 ± 33. [7] Ettorre GC, Francioso G, Garribba AP, Fracella MR, Greco A, Farchi G. Helical CT angiography in gastrointestinal bleeding of obscure origin. Radiology 1996;168:727 ± 30. [8] Mindelzun RE, Beaulieu CF. Using biphasic CT to reveal gastrointestinal arteriovenous malformations. AJR 1997;168:437 ± 8. [9] Bender GN, Maglinte DDT, Kloopel VR, Timmons JH. CT Enteroclysis: a superfluous diagnostic procedure or valuable when investigating small-bowel disease? AJR 1999;172:373 ± 8. [10] Foutch PG. Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993;88(6):807 ± 18. [11] Thompson JN, Hemingway AP, McPherson GAD, Rees HC, Allison HJ, Spencer HJ. Obscure gastrointestinal hemorrhage of small bowel origin. Br Med J 1984;288:1663 ± 5.