Gastrointestinal Bleeding (Acute)
Pathway Home
Population Covered By The Guidance
This pathway provides guidance on the investigation of adult patients with acute gastrointestinal bleeding, with emphasis on endoscopy and non-invasive imaging modalities.
Last reviewed: May 2016
Date of next review: August 2023
Published: May 2017
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
SYMBOL | RRL | EFFECTIVE DOSE RANGE |
![]() |
None | 0 |
![]() |
Minimal | < 1 millisieverts |
![]() |
Low | 1-5 mSv |
![]() |
Medium | 5-10 mSv |
![]() |
High | >10 mSv |
Images
Teaching Points
Teaching Points
- Usually, endoscopy is the first line modality to evaluate, localise and treat patients with suspected upper GI haemorrhage.
- Usually, catheter angiography is the first line modality to evaluate, localise and treat haemodynamically unstable patients with suspected lower GI haemorrhage and unprepared bowel.
- Triphasic CT Angiogram is a rapid, non-invasive investigation that can accurately localise the site and aetiology of bleeding in patients with active bleeding.
- RBC Scintigraphy is recommended for intermittent bleeding as it allows repeated imaging over a 24 hour period.
References
References
Date of literature search: May 2016
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Moss A, Tuffaha H, Malik A. Lower GI bleeding: a review of current management, controversies and advances. Int J Colorectal Dis. 2016;31(2):175-88. (Review article) View the reference
- Strate L, Gralnek I. ACG clinical guideline: Management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol. 2016;111(4):459-74. (College guidelines) View the reference
- Hwang J, Fisher D, Ben Menachem T, Chandrasekhara V, Chathadi K, Decker GA, et al. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc. 2012;75(6):1132-8. (Clinical practice guidelines) View the reference
- Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol. 2007;62(10):938-49. (Level III evidence) View the reference
- Kim BSM, Li B, Engel A, Samra J, Clarke S, Norton I, et al. Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World J Gastrointest Pathophysiol. 2014;5(4):467-78. (Review article) View the reference
- Laine L, Jensen D. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345-60; quiz 61. (College guidelines) View the reference
- Barkun A, Bardou M, Kuipers E, Sung J, Hunt R, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101-13. (International consensus guidelines) View the reference
- Darcy MD CB, Feig BW, Fidelman N, Hara AK, Kapoor BS, Knuttien MG, Lambert DL, Minocha J, Rochon PJ, Shaw CM, Ray CE Jr, Lorenz JM. Expert Panel on Interventional Radiology. ACR Appropriateness Criteria® radiologic management of lower gastrointestinal tract bleeding. J Am Coll Radiol. 2014:8. (College guidelines)
- Kim J, Kim Y, Lee K, Lee Y, Park J. Diagnostic performance of CT angiography in patients visiting emergency department with overt gastrointestinal bleeding. Korean J Radiol. 2015;16(3):541-9. (Level III evidence) View the reference
- Foley PT, Ganeshan A, Anthony S, Uberoi R. Multi-detector CT angiography for lower gastrointestinal bleeding: Can it select patients for endovascular intervention? J Med Imaging Radiat Oncol. 2010;54(1):9-16. (Level IV evidence) View the reference
- Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding. J Med Imaging Radiat Oncol. 2008;52(4):333-8. (Level II evidence) View the reference
- Khan S, et al. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database Syst Rev. 2006:CD000553-CD. (Level I evidence) View the reference
- Deltenre P, Trépo E, Rudler M, Monescillo A, Fraga M, Denys A, et al. Early transjugular intrahepatic portosystemic shunt in cirrhotic patients with acute variceal bleeding: a systematic review and meta-analysis of controlled trials Eur J Gastroenterol Hepatol. 2015;27(9):e1-e9. (Level I evidence) View the reference
- Huang L, Yu Q-S, Zhang Q, Liu J-D, Wang Z. Transjugular intrahepatic portosystemic shunt versus surgical shunting in the management of portal hypertension. Chin Med J (Engl). 2015;128(6):826-34. (Level I evidence) View the reference
- Kennedy D, Laing C, Tseng L, Rosenblum D, Tamarkin S. Detection of active gastrointestinal hemorrhage with CT angiography: a 4(1/2)-year retrospective review J Vasc Interv Radiol. 2010;21(6):848-55. (Level III evidence) View the reference
- Lee S, Welman CJ, Ramsay D. Investigation of acute lower gastrointestinal bleeding with 16- and 64-slice multidetector CT J Med Imaging Radiat Oncol. 2009;53(1):56-63. (Level IV evidence) View the reference
- Kuhle W, Sheiman R. Detection of active colonic hemorrhage with use of helical CT: findings in a swine model. Radiology. 2003;228(3):743-52. (Animal study) View the reference
- García Blázquez V, Vicente Bártulos A, Olavarria Delgado A, Plana MN, van der Winden D, Zamora J. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol. 2013;23(5):1181-90. (Level II evidence) View the reference
- Wu L-M, Xu J-R, Yin Y, Qu X-H. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis. World J Gastroenterol. 2010;16(31):3957-63. (Level II evidence) View the reference
- Awais M. Accuracy of 99mTechnetium-labeled RBC scintigraphy and MDCT with gastrointestinal bleed protocol for detection and localization of source of acute lower gastrointestinal bleeding. J Clin Gastroenterol. 2015. (Level II evidence) View the reference
- Jaskolka J, Binkhamis S, Prabhudesai V, Chawla T Acute gastrointestinal hemorrhage: radiologic diagnosis and management. Can Assoc Radiol J. 2013;64(2):90-100. (Review article) View the reference
- Ren J-Z, Zhang M-F, Rong A-M, Fang X-J, Zhang K, Huang G-H, et al. Lower gastrointestinal bleeding: role of 64-row computed tomographic angiography in diagnosis and therapeutic planning. World J Gastroenterol. 2015;21(13):4030-7. (Level II evidence) View the reference
- Grady E. Gastrointestinal bleeding scintigraphy in the early 21st century. J Nucl Med. 2016;57(2):252-9. (Review article) View the reference
- Jacovides C, Nadolski G, Allen S, Martin N, Holena D, Reilly P, et al. Arteriography for lower gastrointestinal hemorrhage: role of preceding abdominal computed tomographic angiogram in diagnosis and localization. JAMA surgery. 2015;150(7):650-6. (Level III evidence) View the reference
- Sun H, Jin Z, Li X, Qian J, Yu J, Zhu F, et al. Detection and localization of active gastrointestinal bleeding with multidetector row computed tomography angiography: a 5-year prospective study in one medical center. J Clin Gastroenterol. 2012;46(1):31-41. (Level III evidence) View the reference
- Tabibian J, Wong Kee Song LM, Enders F, Aguet J, Tabibian N. Technetium-labeled erythrocyte scintigraphy in acute gastrointestinal bleeding. Int J Colorectal Dis. 2013;28(8):1099-105. (Level III evidence) View the reference
- Currie G, Kiat H, Wheat J. Scintigraphic evaluation of acute lower gastrointestinal hemorrhage: current status and future directions. J Clin Gastroenterol. 2011;45(2):92-9. (Review article) View the reference
- Olds G, Cooper G, Chak A, Sivak M, Chitale A, Wong RCK. The yield of bleeding scans in acute lower gastrointestinal hemorrhage. J Clin Gastroenterol. 2005;39(4):273-7. (Level III evidence) View the reference
- Levy R, Barto W, Gani J. Retrospective study of the utility of nuclear scintigraphic-labelled red cell scanning for lower gastrointestinal bleeding. ANZ J Surg. 2003;73(4):205-9. (Level III evidence) View the reference
- Suzman MS, Talmor M, Jennis R, Binkert B, Barie PS. Accurate localization and surgical management of active lower gastrointestinal hemorrhage with technetium-labeled erythrocyte scintigraphy. Ann Surg. 1996;224(1):29-36. (Level III evidence) View the reference
- Loffroy R, Rao P, Ota S, De Lin M, Kwak B-K, Geschwind J-F. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010;33(6):1088-100. (Review article) View the reference
- Ali M. Treatment of nonvariceal gastrointestinal hemorrhage by transcatheter embolization. Radiol Res Pract. 2013(2013):604328-. (Level IV evidence) View the reference
- Hur S, Jae H, Lee M, Kim H-C, Chung J. Safety and efficacy of transcatheter arterial embolization for lower gastrointestinal bleeding: a single-center experience with 112 patients. J Vasc Interv Radiol. 2014;25(1):10-9. (Level IV evidence) View the reference
- Khanna A, Ognibene S, Koniaris L. Embolization as first-line therapy for diverticulosis-related massive lower gastrointestinal bleeding: evidence from a meta-analysis. J Gastrointest Surg. 2005;9(3):343-52. (Level II evidence) View the reference
- Walker TG, Salazar G, Waltman A. Angiographic evaluation and management of acute gastrointestinal hemorrhage. World J Gastroenterol. 2012;18(11):1191-201. (Review article) View the reference
- Frattaroli F, Casciani E, Spoletini D, Polettini E, Nunziale A, Bertini L, et al. Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding World J Surg. 2009;33(10):2209-17. (Level III evidence) View the reference
- Zurkiya O, Walker TG. Angiographic evaluation and management of nonvariceal gastrointestinal hemorrhage. Am J Roentgenol. 2015;205(4):753-63. (Review article) View the reference
- Tan K-K, Shore T, Strong D, Ahmad M, Waugh R, Young C. Factors predictive for a positive invasive mesenteric angiogram following a positive CT angiogram in patients with acute lower gastrointestinal haemorrhage. Int J Colorectal Dis. 2013;28(12):1715-9. (Level IV evidence) View the reference
Information for Consumers
Information for Consumers
Information from this website |
Information from the Royal Australian and New Zealand College of Radiologists’ website |
Consent to Procedure ot Treatment Radiation Risks of X-rays and Scans |
Iodine-Containing Contrast Medium Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
File Formats
Some documents for download on this website are in a Portable Document Format (PDF). To read these files you might need to download Adobe Acrobat Reader.