Mayo Clinic Proceedings: Innovations, Quality & Outcomes (Dec 2019)

Multiphase Computed Tomographic Enterography: Diagnostic Yield and Efficacy in Patients With Suspected Small Bowel Bleeding

  • Parakkal Deepak, MBBS, MS,
  • Krishna N. Pundi, MD,
  • David H. Bruining, MD,
  • Jeff L. Fidler, MD,
  • John M. Barlow, MD,
  • Stephanie L. Hansel, MD, MS,
  • William S. Harmsen, MS,
  • Michael L. Wells, MD,
  • Joel G. Fletcher, MD

Journal volume & issue
Vol. 3, no. 4
pp. 438 – 447

Abstract

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Objective: To estimate the diagnostic yield and efficacy of multiphase computed tomographic enterography (mpCTE) for suspected small bowel bleeding in routine clinical practice. Patients and Methods: All mpCTEs performed between January 1, 2006, and December 31, 2014, for suspected small bowel bleeding were included and classified by a gastroenterologist and an abdominal radiologist. The reference standard for a definitive diagnosis was balloon-assisted enteroscopic, angiographic, surgical, or pathologic results. Overall and lesion-specific diagnostic yield (DY), sensitivity, and positive predictive value were calculated. The relationship of mpCTE diagnosis and continued bleeding or iron supplementation was examined using logistic regression in patients with at least 1 year of follow-up. Results: We identified 1087 patients who had an initial mpCTE indication of small bowel bleeding. The overall DY was 31.6% (344 of 1087 patients; 95% CI, 29.0%-35.0%), higher for an indication of small bowel bleeding that was overt or occult with heme-positive stool vs occult with only iron-deficiency anemia (DY, 35.0% [170 of 486] and 35.3% [66 of 187] vs 26.1% [108 of 414]; P=.004 and P=.02, respectively). The highest sensitivity and positive predictive value were for small bowel masses (90.2% [55 of 61] and 98.2% [55 of 56], respectively). Higher risk of future bleeding and iron supplementation was seen with a negative result on mpCTE (odds ratio [OR], 1.91; 95% CI, 1.28-2.86), lack of surgical intervention (OR, 4.37; 95% CI, 2.31-8.29), or discrepant balloon-assisted enteroscopic findings (OR, 2.50; 95% CI, 1.03-6.09). Conclusion: Multiphase computed tomographic enterography has a higher rate of detection in patients with overt bleeding or heme-positive stool. The procedure provides actionable targets for further intervention and leads to substantially reduced rates of rebleeding in long-term follow-up.