Intravenous Contrast Extravasation Research Articles

Adverse Clinical Events at the Injection Site Are Exceedingly Rare After Reported Radiopharmaceutical Extravasation in Patients Undergoing 99mTc-MDP Whole-Body Bone Scintigraphy: A 12-Year Experience.

The deleterious effects of high-dose radiation on normal tissue are sometimes extrapolated to diagnostic (SPECT and PET) radiopharmaceutical extravasation (RPE). It has been hypothesized that diagnostic RPE can have gradually evolving local tissue injury and a potentially increased risk of local dermatologic or oncologic diseases over a longer period. However, data on clinical adverse events after diagnostic RPE are limited. Therefore, our primary aim was to study the occurrence of short-term and long-term clinical adverse events in patients who underwent 99mTc-methylene diphosphonate (99mTc-MDP) whole-body bone scintigraphy (WBBS) with reported RPE. Methods: The records of 99mTc-MDP WBBS performed from June 2010 to January 2022 were retrospectively examined for RPE documented in the scan reports. The clinical records of patients with a documented RPE were extensively reviewed for any related short-term adverse events (within 2 wk of the WBBS: local symptoms and care sought for local dermatologic or musculoskeletal issues) and long-term adverse events (until the last follow-up: local deleterious effects and related consults for dermatology, plastic surgery, oncology, or orthopedics). Results: Retrospective review of the records of 31,679 99mTc-MDP WBBS studies showed RPE documented in 118 (0.37%). Medical records were not retrievable for 22 patients, yielding a final cohort of 96 patients with reported RPE. The median follow-up was 18.9 mo (interquartile range, 7.8-45.7 mo). Short-term events were noted in 4 patients, of whom one was asymptomatic. Of the 3 symptomatic patients, 2 experienced mild discomfort at the injection site, and 1 had tender swelling. Three of the 4 events were in patients who had a prior intravenous contrast extravasation for contrast-enhanced CT performed earlier during the day and a 99mTc-MDP injection later at the same site, likely leading to RPE. None of the long-term local events had any plausible link with the RPE event. Conclusion: Reported RPE was rare, and 3 patients (0.009%) had short-term local symptoms, all of which were likely related to the prior higher-volume intravenous contrast extravasation. The smaller-volume diagnostic radiopharmaceutical injections for WBBS are highly unlikely to cause local symptoms on their own. No patient had any long-term adverse event with a plausible link to the RPE.

Diagnostic value of CT contrast extravasation for major arterial injury after pelvic fracture: A meta-analysis

PurposeWe conducted a meta-analysis to determine diagnostic performance of CT intravenous contrast extravasation (CE) as a sign of angiographic bleeding and need for angioembolization after pelvic fractures. Materials and methodsA systematic literature search combining the concepts of contrast extravasation, pelvic trauma, and CT yielded 206 potentially eligible studies. 23 studies provided accuracy data or sufficient descriptive data to allow 2x2 contingency table construction and provided 3855 patients for meta-analysis. Methodologic quality was assessed using the QUADAS-2 tool. Sensitivity and specificity were synthesized using bivariate mixed-effects logistic regression. Heterogeneity was assessed using the I2-statistic. Sources of heterogeneity explored included generation of scanner (64 row CT versus lower detector row) and use of multiphasic versus single phase scanning protocols. ResultsOverall sensitivity and specificity were 80% (95% CI: 66–90%, I2 = 92.65%) and 93% (CI: 90–96, I2 = 89.34%), respectively. Subgroup analysis showed pooled sensitivity and specificity of 94% and 89% for 64- row CT compared to 69% and 95% with older generation scanners. CE had pooled sensitivity and specificity of 95% and 92% with the use of multiphasic protocols, compared to 74% and 94% with single-phase protocols. ConclusionThe pooled sensitivity and specificity of 64-row CT was 94 and 89%. 64 row CT improves sensitivity of CE, which was 69% using lower detector row scanners. High specificity (92%) can be maintained by incorporating multiphasic scan protocols.

Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage-Management, Risk Factors and Outcomes.

Spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH) is associated with high mortality in the literature, but studies on the subject are lacking. The objective of this study was to identify early predictors of the need for angiographic or surgical intervention (ASI) in patients with SRRSH and define risk factors for mortality. We conducted a retrospective cohort study at a tertiary academic hospital. All patients with computed tomography-identified SRRSH between 2012 to 2017 were included. Exclusion criteria were age below 18years, possible mechanical cause of SRRSH, aortic aneurysm rupture or dissection, and traumatic or iatrogenic sources of SRRSH. The primary outcome was the incidence of ASI and/or mortality. Of 100 patients included (median age 70years, 52% males), 33% were transferred from another hospital, 82% patients were on therapeutic anticoagulation, and 90% had serious comorbidities. Overall mortality was 22%, but SRRSH-related mortality was only 6%. Sixteen patients underwent angiographic intervention (n = 10), surgical intervention (n = 5), or both (n = 1). Flank pain (OR 4.15, 95% CI 1.21-14.16, p = 0.023) and intravenous contrast extravasation (OR 3.89, 95% CI 1.23-12.27, p = 0.020) were independent predictors of ASI. Transfer from another hospital (OR 3.72, 95% CI 1.30-10.70, p = 0.015), age above 70years (OR 4.24, 95% CI 1.25-14.32, p = 0.020), and systolic blood pressure below 110mmHg at the time of diagnosis (OR 4.59, 95% CI 1.19-17.68, p = 0.027) were independent predictors of mortality. SRRSH is associated with high mortality but is typically not the direct cause. Most SRRSHs are self-limited and require no intervention. Pattern identification of ASI is hard.

Index of Suspicion: Colonic Extravasation of Intravenous Contrast After Cardiac Catheterization

Index of Suspicion: Colonic Extravasation of Intravenous Contrast After Cardiac Catheterization

339 Comparison of Intravenous Contrast Extravasation Rates from Peripheral IVs Placed by Registered Nurses Using Ultrasound Guidance Versus Standard Methods

Placement of ultrasound-guided peripheral IVs (USGIV) is common practice in many emergency departments; many of these are used for administration of IV contrast for computed tomography (CT) examinations. A single prior study found the contrast extravasation (CE) rate amongst USGIVs placed by physicians to be greater than those placed using standard methods (3.6 vs 0.3%). Many emergency departments (EDs) have registered nurses (RNs) who have been trained in the placement of USGIVs, but whether these perform as well as those placed by physicians is unknown. The primary outcome of this study is comparison of the CE events between USGIVs placed by RNs and those placed using standard technique. Secondary outcomes include assessment of the associations between IV characteristics (location, size, length) and patient factors and CE in patients with USGIVs. This was a retrospective chart review, performed at an urban tertiary care facility with an annual ED volume of 65,000. Our ED has a nursing-lead program that trains RNs to place USGIVs (2.5in 18g or 1.75in 20g). All USGIVs placed by RNs are logged for quality-assurance purposes. We queried our electronic patient safety incident reporting system for all CE events (mandatory reporting is required by our hospital system) between May 2014, and February 2017, during which time the USGIV program was operational. The medical record for each extravasation event was reviewed, and data on patient and IV characteristics were recorded. During the study period, 1,500 USGIVs were placed by 27 RNs. Contrast was administered 29,508 times, 291 via USGIVs. Overall, there were 74 CEs in peripheral IVs (0.25%), of which 12 (4.1%) occurred with USGIVs, and 62 (0.21%) occurred in the 29,217 patients with standard IVs (relative risk 19.4, 95% CI 10.6-35.6; absolute risk difference 3.9%, 95% CI 1.6-6.2%). There were no significant differences between groups in terms of proportion of females (72% of CEs, n=9 and 42 in the USGIV and standard IV groups, respectively), history of ESRD, IVDA, or BMI, or the number of CT angiograms (67% (n=48) of total CEs, 6 in USGIV group and 42 in standard IV group). In the USGIV group, 6 were located in the forearm, 5 in the upper arm, and 1 in the antecubital fossa (AC); there were five 18g and seven 20g IVs in this group. In the standard group, IV location was 28 AC, 24 forearm, 5 upper arm, 4 wrist/hand, and 1 shoulder; there were forty-nine 20g, five 18g, seven 22g, and one 24g IVs. We found that the overall risk of CE with USGIVs placed by RNs to be low (4.1%), but significantly greater compared to IVs placed using standard technique (0.21%). These results are similar to a previously published study, in which USGIVs were placed by physicians. While further study is needed to delineate what, if any, operator characteristics are associated with CEs, our results suggest that USGIVs placed by RNs trained in the procedure perform as well those placed by physicians. Extravasation events are relatively rare, and the small number of CEs in the USGIV group (n=12) did not allow for meaningful comparisons of IV characteristics between the two groups. Larger data sets, likely drawn from multiple institutions (given the relative paucity of extravasations via USGIVs) are needed to ascertain whether IV gauge, location, or catheter length have an affect on contrast extravasation.

Angioembolization is necessary with any volume of contrast extravasation in blunt trauma.

Introduction:Reduction of nonessential angiogram and embolization for patients sustaining blunt abdominal and pelvic trauma would allow improved utilization and decreased morbidity related to nontherapeutic embolization. We hypothesized that the nature of intravenous contrast extravasation (IVCE) on computed tomography (CT) would be directly related to the finding of extravasation on angiogram and need for embolization.Methods:A 5-year retrospective evaluation of trauma patients with IVCE on CT. Demographics, hemodynamics, and IVCE location and maximal dimension/volume were examined for relationship to IVCE on angiography and need for embolization. Primary complications were defined as nephropathy and acute respiratory distress syndrome.Results:A total of 128 patients were identified with IVCE on CT. Ninety-seven (75.8%) also had IVCE identified on angiography requiring some form of embolization. The size of IVCE on CT was not related to IVCE on angiogram (P = 0.69). Location of IVCE was related to need for embolization, with spleen embolization (85.4%) being much more frequent than liver (51.5%, P = 0.006). Complication rate was 8.7% in all patients, and was not different between patients undergoing embolization and those who did not (P = 0.40).Conclusion:IVCE volume was not predictive of continued bleeding and need for embolization. However, splenic injuries with IVCE required embolization more frequently. In contrast, liver injuries were found to have infrequent on-going IVCE on angiography. Complications associated with angiogram with or without embolization are infrequent, and CT findings may not be predictive of ongoing bleeding. We do not recommend selective exclusion of patients from angiographic evaluation when a blush is present.

CT imaging signs of surgically proven bowel trauma

The objective of this study was to determine the incidence and interobserver agreement of individual CT findings as well as the bowel injury prediction score (BIPS) in surgically proven bowel injury after blunt abdominal trauma. This HIPAA-compliant retrospective study was IRB approved and consent was waived. All patients 14years or older who sustained surgically proven bowel injury after blunt abdominal trauma between 1/1/2004 and 6/30/2015 were included. Admission trauma MDCT scans were independently interpreted by two abdominal fellowship-trained radiologists who recorded the following CT findings: intraperitoneal fluid, mesenteric hematoma/fat stranding, bowel wall thickening/hematoma, active intravenous contrast extravasation, free intraperitoneal air, bowel wall discontinuity, and focal bowel hypoenhancement. Subsequently, the electronic medical records of the included patients, admission abdominal physical exam results, admission white blood cell count, and findings at exploratory laparotomy of the included patients were recorded. Thirty-three patients met the inclusion criteria. The incidence and interobserver agreement of the CT findings were as follows: intraperitoneal fluid 93.9%, kappa = 0.784 (good); mesenteric hematoma/fat stranding 84.8%, kappa = 0.718 (good); bowel wall thickening/hematoma 42.4%, kappa = 0.491 (moderate); active IV contrast extravasation 36.3%, kappa = 1.00 (perfect); free intraperitoneal air 21.2%, kappa = 0.904 (very good), bowel wall discontinuity 6.1%, kappa = 1.00 (perfect); and focal bowel hypoenhancement 6.1%, kappa = 0.468 (moderate). An absence of the specified CT findings was encountered in 9.1% with surgically proven bowel injuries (kappa = 1.00, perfect). In our study, 9/16 patients or 56.3% had a bowel injury prediction score (BIPS) of 2 or more as defined by McNutt et al. (J Trauma Acute Care Surg 78(1):105-111, 2014). The presence of intraperitoneal fluid and mesenteric hematoma/fat stranding are the most common CT findings in bowel injuries proven at laparotomy. A small percentage of patients have no abnormal CT findings. This grading system did not prove to be useful in our study likely due to our inherently small patient population; however, the use of BIPS deserves further investigation as it may help in identifying blunt bowel and mesenteric injury patients with often subtle or nonspecific CT findings.

Pemetrexed long-term maintenance treatment leading to multiple finger amputation; cardiovascular complications after energy drink consumption; compartment syndrome due to extravasation of intravenous contrast; blue-gray mucocutaneous discoloration with ezogabine.

The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), discuss methods of prevention, and promote reporting of ADRs to the US Food and Drug Administration's (FDA's) MedWatch program (800-FDA-1088). If you have reported an interesting, preventable ADR to MedWatch, please consider sharing the account with our readers. Write to Dr. Mancano at ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044 (phone: 215-707-4936; e-mail: mmancano@temple.edu). Your report will be published anonymously unless otherwise requested. This feature is provided by the Institute for Safe Medication Practices (ISMP) in cooperation with the FDA's Med Watch program and Temple University School of Pharmacy. ISMP is an FDA Med Watch partner.

Intravenous Contrast Extravasation During CT: A National Data Registry and Practice Quality Improvement Initiative

PurposeEstablish 3 performance benchmarks for intravenous contrast extravasation during CT examinations: extravasation frequency, distribution of extravasation volumes, and severity of injury. Evaluate the effectiveness of implementing practice quality improvement (PQI) methodology in improving performance for these 3 benchmarks. MethodsThe Society of Abdominal Radiology and ACR developed a registry collecting data for contrast extravasation events. The project includes a PQI initiative allowing for process improvement. ResultsAs of December 2013, a total of 58 radiology practices have participated in this project, and 32 practices have completed the 2-cycle PQI. There were a total of 454,497 contrast-enhanced CT exams and 1,085 extravasation events. The average extravasation rate is 0.24%. The median extravasation rate is 0.21%. Most extravasations (82.9%) were between 10 mL and 99 mL. The majority of injuries, 94.6%, are mild in severity, with 4.7% having moderate and 0.8% having severe injuries.Data from practices that completed the PQI process showed a change in the average extravasation rate from 0.28% in the first 6 months to 0.23% in the second 6 months, and the median extravasation rate dropped from 0.25% to 0.16%, neither statistically significant. The distribution of extravasation volumes and the severity of injury did not change between the first and second measurement periods. ConclusionsNational performance benchmarks for contrast extravasation rate, distribution of volumes of extravasate, and distribution of severity of injury are established through this multi-institutional practice registry. The application of PQI failed to have a statistically significant positive impact on any of the 3 benchmarks.

Image Diagnosis: Spontaneous Hematoma from Scurvy

A 58-year-old alcoholic man presented with pain, swelling, and bruising of his right leg. He had no history of trauma or injury. His medical history was significant for frequent spontane ous hematomas in his legs (Figure 1), the first and most dramatic of which was a large thigh hematoma occurring 4 years earlier. This area became infected, developing necrotizing fasciitis that required emergency surgery. On physical examination, he had hyperplastic gums and no teeth. He had no body hair below his head. The calf of his right leg was enlarged and tender, with more swelling medially than laterally. Dependent bruising was noted in the popliteal fossa initially as his leg was elevated; several days later, when he started ambulating, bruising became apparent around his ankle. His initial blood alcohol level was 0.28%, and his Aspartate Aminotransferase and Alanine Aminotransferase levels were 90 and 61 international units/microliter, respectively. His platelet count and coagulation studies were normal. His body mass index was 30 kg/m 2 . Color flow Doppler ultrasound of his right leg was performed, and no deep venous thrombosis was identified. Imaging of his leg by a contrast-enhanced computerized tomography scan (Figure 2) showed a large hematoma in the right calf (white arrows), measuring 7.5 x 3.5 x 12.6 cm (anterior-posterior, transverse, and caudal-cranial dimensions, respectively). Extravasation of intravenous contrast was seen, indicating active bleeding (black arrowhead). There were no aneurysms or other vascular malformations in or near the hematoma. This patient drank a 1.75-liter bottle of vodka daily and smoked cigarettes. He ate mostly precooked hash brown potatoes, pasta, and occasional canned tuna. He did not eat fresh vegetables and rarely ate fruit.

Incidence of intravenous contrast extravasation: increased risk for patients with deep brachial catheter placement from the emergency department

Deep brachial intravenous catheter (IV) placement can be performed in emergency department patients with difficult vascular access, but the safety of deep brachial IV for iodinated contrast administration has not been assessed. This study compares the relative risk for extravasation of deep brachial IV compared with antecubital IV during power injected computed tomography (CT) examinations. A departmental practice quality improvement was performed to assess the rate of IV extravasation for all CT examinations during a 1 year period. De-identified data was analyzed with a waiver of informed consent to identify the rate and relative risk of iodinated contrast extravasation by catheter type. A total of 10,750 injections were performed, with 82 extravasation events (0.8 %). There were 51 extravasations of antecubital IV from approximately 8,599 placed (0.6 %). For 123 deep brachial IV placed, there were eight extravasations (6.5 %). The relative risk of a deep brachial IV extravasation was 9.4 compared to 0.4 for antecubital placement. Deep brachial IV demonstrated a markedly higher rate of contrast extravasation than antecubital IV. For power injected iodinated contrast administration, it is recommended to avoid the use of deep brachial IV whenever possible.

“Blush” on trauma computed tomography

Intravenous contrast extravasation (IVCE) on a trauma computed tomography has been quoted as a reason for intervention (angiographic embolization or operation). The new-generation computed tomographic (CT) scanners identify IVCE with increasing frequency. We hypothesized that most IVCEs do not require an intervention. This study was a retrospective evaluation of trauma patients with IVCE on abdomen or pelvis CT scan (January 2005-December 2009). Along with demographic and hemodynamic variables, the following characteristics of IVCE were examined as potential risk factors for intervention: maximal dimension, small (≤ 1.5 cm) versus large (>1.5 cm), contained versus free, and single versus multiple and location. Sixty-nine patients with 81 IVCEs were identified: 48 IVCEs occurred in intra-abdominal solid organs, 18 IVCEs in the pelvic retroperitoneal space, and 15 IVCEs in the soft tissues or other locations. Thirty patients (43.5%) were managed without an intervention, and 39 patients (56.5%) required either an immediate (30 patients) or a delayed (9 patients) intervention. Multivariate analysis identified three independent predictors of an intervention: an admission systolic blood pressure of 100 mm Hg or lower, a large ICVE, and an Abbreviated Injury Score of the abdomen of 3 or higher. If all three independent predictors were present, 100% of patients received an intervention. Nearly half of IVCEs on CT scan did not require an intervention. A hypotension at admission, a severe abdominal trauma, and a blush diameter of 1.5 cm or greater predicted the need for intervention. Therapeutic study, level IV; prognostic study, level III.

Study of patients with intravenous contrast extravasation on CT studies, with radiology staff and ward staff cannulations

Intravenous (IV) contrast extravasation is an adverse outcome of computed tomography (CT) studies. This study evaluates for any differences in rates of extravasation between radiology (radiographer) staff and ward medical staff cannulations, and secondarily by cannula size and study type. A prospective study of 26,854 studies in adults between September 2004 and April 2008 accumulated 119 extravasations. Patients were divided into two groups, those cannulated by radiology staff and those cannulated by non-radiology staff. Patients with extravasations were followed for treatment outcomes. Statistical analysis between our groups was undertaken. The total extravasation rate was 0.44%. The extravasation rate for those patients cannulated by radiology staff was 0.34% (n= 11,470 cannulations) and those cannulated by non-radiology staff was 0.52% (n = 15,384 cannulations). This was not statistically significantly different. The site where most extravasations occurred was at the elbow (71.4%). The injection rate where most extravasations occurred was in the 1-2 mL/s range (42%). No patient required surgical intervention or had any significant morbidity. Radiology radiographer staff can provide safe administration of IV contrast in CT scanning with low rates of extravasation. Extravasation may occur with high or low injection rates and when small or large size cannulas are used.

Pre-existing oral contrast from lanthanum carbonate: a confounding factor in CT mesenteric angiography

A 69-year-old male was referred from the renal unit to radiology for investigation of bleeding per rectum. A CT mesenteric angiogram was performed. However, it was noted on the pre-contrast images that the large bowel contained positive oral contrast media. The procedure was abandoned as it would have been difficult to see extravasation of intravenous contrast from a bleeding point in the large bowel. The initial belief was that either the patient had been given oral contrast by ward staff on the assumption that it would be needed, or had had a recent radiological study requiring contrast, which was still present. Neither was the case; it emerged that the patient was taking Fosrenol (Shire Pharmaceuticals, Wayne, PA), a lanthanum carbonate medication used in the treatment of hyperphosphataemia. Lanthanum is densely radio-opaque and appears as positive bowel contrast on CT and plain radiography studies. When considering radiological studies specifically requiring the absence of oral contrast, it is important to be aware of the patient's drug history to avoid non-diagnostic scans with the associated radiation exposure.

Hydrothorax Due to Extravasation of Intravenous Contrast after Power Injection through Right Subclavian Catheter

We report a case of hydrothorax after receiving intravenous (IV) contrast material by power injector through right subclavian central venous catheter (CVC) line. A 38-year-old woman presented to the local emergency department with hypotension after a pedestrian accident. After resuscitation, CVC was inserted into her right subclavian vein and fluid was administered well before computed tomography (CT) enhancement. Contrast-enhanced CT scan showed a large amount of extravasation of contrast material and fluid collection in the thoracic and pericardial cavities which was not shown in non-enhanced CT scan. During operation, vascular perforation was found in right subclavian vein. This case highlights that emergency physicians must keep in mind the possibility of vessel injury after CVC insertion and contrast material is preferably injected via peripheral IV access.

Hydrothorax due to extravasation of intravenous contrast through left subclavian catheter -A case report-

Central venous catheterization is associated with a large number of complications, such as pneumothorax, hydrothorax, hemothorax, phlebothrombosis, pericardial tamponade, air embolism, aberrant placement and line sepsis. There are many case reports of the extravasation of various central venous catheter fluids, including the intravenous fluids, total parenteral nutrition and chemotherapeutic agents into the pleural cavity and mediastinum. These have led to hydrothorax, hydromediastinum and pericardial effusions. We report a case of the extravasation of intravenous contrast into the pleural cavity after dynamic CT through a left subclavian catheter.

Extravasation of Intravenous Computed Tomography Scan Contrast in Blunt Abdominal and Pelvic Trauma

Intravenous contrast extravasation (CE) on computed tomography (CT) scan in blunt abdominal trauma is generally regarded as an indication for the need for invasive intervention (either angiography or laparotomy). More recently, improvements in CT scan technology have increased the sensitivity in detecting CE, and, thus, we postulate that not all patients with this finding require intervention. This study is a retrospective review of all patients who underwent a CT scan for blunt abdominal trauma between January 1999 and September 2003. Patterns of injury, associated injuries, management, and outcomes were examined for patients with CE. Seventy of 1,435 patients (4.8%) demonstrated CE. Mean age was 44 years and mean Injury Severity Score was 39. The location of CE was intra-abdominal in 25, pelvis/retroperitoneum in 39, and both areas in 3 patients. Six patients received supportive treatment for nonsurvivable head injury and were excluded from further analysis. Overall, 30 (47%) patients underwent immediate intervention (angiography or laparotomy) and 34 (53%) were managed nonoperatively. Of those who had initial nonoperative management, overall seven (20.5%) underwent intervention, with the remainder being managed without intervention. The success for nonoperative management was greater for those with pelvic/retroperitoneal CE (4 of 7: 57%) than for intra-abdominal extravasation (23 of 27: 85%). Although evidence of CE may suggest significant vascular injury, our data suggest that not all patients require invasive intervention. Further studies are needed to better define criteria for nonoperative management in patients with CE identified on their initial CT scan.

Extravasation of intravenous contrast into the mediastinum

Extravasation of intravenous contrast into the mediastinum

Contrast Blush on CT After Splenic Injury Does Not Mandate Surgery

The CT finding of intravenous contrast extravasation, known as contrast blush, from the perisplenic area suggests hemorrhage from that organ. These

Gastric ulcer bleeding: diagnosis by computed tomography

A case of CT demonstration of a bleeding gastric ulcer is presented, in a patient with confusing clinical manifestations. Abdominal CT was performed without oral contrast medium administration, and showed extravasation of intravenous contrast into a gastric lumen distended with material of mixed attenuation. It is postulated that if radiopaque oral contrast had been given, peptic ulcer bleeding would probably have been masked. CT demonstration of gastric ulcer bleeding, may be of value in cases of differential diagnostic dilemmas.