Optimizing the Diagnostic Yield and Clinical Impact of Computed Tomography Enterography for Patients With Obscure Gastrointestinal Bleeds

Introduction: Computed tomography enterography (CTE) and capsule endoscopy (CE) are commonly performed to investigate obscure gastrointestinal bleeds (OGIB). CE is suggested as the first-line investigation of OGIB as it has been shown to have a superior diagnostic yield. However, CTE is more available and less expensive compared to CE. Despite evidence that CTE may be more accurate for identifying some lesions such as masses and strictures, patient selection to optimize the clinical impact of CTE has not been previously examined. This study sought to determine the diagnostic yield of CTE in OGIB, investigate characteristics associated with positive CTE, and examine clinical outcomes in patients with a positive CTE. Methods: We performed a retrospective cohort study on patients who underwent CTE from The Ottawa Hospital between 2005- 2015. Patient demographics, clinical presentation, prior investigations, post-CTE interventions and treatment outcomes were collected by chart review. All variables were selected a priori from literature review. Results: CTE was diagnostic in 52 (19%) of 274 OGIB cases. Patients with a positive CTE (mean age 65 years, range 25-88 years, 50% female) had an average presenting Hb of 87 g/L, ferritin 66 μL and iron 8 μmol/L. 40 (77%) of the diagnostic findings included intestinal wall thickening (40%), angiodysplasias (27%), bowel mass (17%), and/or stricture (6%). 27 patients (52%) presented with at least one of the following symptoms in addition to OGIB: nausea, abdominal pain, fatigue and weight loss. 13/52 (25%) patients had specific interventions done to address lesions found on the CTE. 5 patients underwent endoscopic hemostasis, 3 patients underwent bowel resection, 1 patient required vessel embolization, and 3 were treated for inflammatory bowel disease. These patients were also more likely to re-bleed, have ongoing anemia and be re-hospitalized for gastrointestinal bleeding. Conclusion: CTE may be diagnostic in 1 in 5 cases of OGIB, potentially avoiding the need for CE in these cases. The diagnostic yield may be even greater for patients who present with abdominal and/or constitutional symptoms. Patients who required specific interventions after a diagnostic CTE had a greater propensity for re-bleeding, suggesting that early interventions after positive CTE findings patients may result in better outcomes. Further research is needed to delineate the patient population most likely to benefit from CTE evaluation prior to or instead of CE for OGIB.

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