S653 Assessing the Appropriateness of Computed Tomographic Angiography in Acute GI Bleeding

Abstract

Introduction: Acute gastrointestinal bleeding (GIB) is a common cause for hospital admission with significant mortality. Multidetector computed tomographic angiography (CTA) has emerged as an important tool in the evaluation of GIB. CTAs are indicated for lower GIB in hemodynamically unstable patients or for those who cannot otherwise prepare for colonoscopy [1], however no firm guidelines exist to ensure they are ordered in the appropriate clinical context. Excessive use of CTAs can lead to avoidable contrast and radiation exposure and increased cost of care without enhancing management. Methods: We performed a retrospective analysis of all CTAs ordered for hospitalized patients in 2018 and 2019 at Albert Einstein Medical Center, a 548-bed tertiary care hospital in Philadelphia. For each patient, we looked for signs of hypotension, defined in our study as mean arterial pressure (MAP) < 70 at admission or just prior to the scan. We also evaluated the subsequent hospital course for each patient to determine what intervention, if any, was performed. Results: A total of 526 CTAs were ordered for GIB in a two-year period. Among these, 70% failed to show active bleeding. 473 (89.9%) CTAs were ordered for patients without documented hypotension while 10.1 % of patients had at least one MAP < 70. Among non-hypotensive patients, 30% of CTAs positively identified acute bleeding compared to 32% in hypotensive patients. Among non-hypotensive patients, 65% had no intervention, 24% underwent endoscopy and 9.5% underwent catheter embolization with interventional radiology. Among hypotensive patients, 52.8% had no intervention, 28% underwent endoscopy and 13.2% underwent embolization. Among the 17 hypotensive patients with positive scans, four underwent embolization, five underwent endoscopy and six had no intervention or required surgery. Conclusion: Most CTAs for GIB at our hospital were ordered in normotensive patients. Patients with bleeding identified on CTA were more than two times more likely to undergo endoscopy than embolization, suggesting most CTAs do not significantly alter management. Our data suggests that contrast and radiation exposure from these scans, along with additional cost of care, may be avoided. Additional research to establish appropriateness criteria for CTAs in GIB is warranted.Table 1.: Mortality in MDS patients with GI bleed (OR).