Diagnosis of Acute Active Gastrointestinal Bleeding by Multi-phase Contrast-enhanced Computed Tomography: A Clinical Case Analysis
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摘要:
急性胃肠道出血（AGIB）临床较为常见并且需要快速诊断和采取有效治疗措施。多期增强CT可以快速诊断胃肠道活动性出血的位置和原因等关键信息，指导后续治疗的选择，使其成为评估AGIB的潜在一线工具。本文报告4例AGIB的病例，临床表现主要为呕血、黑便、活动后心慌、乏力、血压下降、意识不清、昏迷等，部分患者伴腹胀、腹痛、头晕、胸闷；实验室检查结果提示贫血和便潜血阳性。多期增强CT检查后准确定位消化道活动性出血灶。4例患者中有2例患者经治疗后症状明显好转，1例患者因病情危重转入上级医院治疗后因多器官衰竭死亡，1例患者合并淋巴瘤及多器官衰竭，后因失血性休克死亡。本文对多期增强CT在AGIB临床诊断中的价值进行讨论并文献综述，旨在总结AGIB多期增强CT的影像学特点，为AGIB的及时诊断提供可靠依据。
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关键词:
- CT /
- 急性活动性胃肠道出血 /
- 诊断
Abstract:Acute gastrointestinal bleeding (AGIB) is a common and serious condition that requires prompt diagnosis and effective treatment. Multi-phase contrast-enhanced computed tomography (CT) can rapidly identify the location and cause of active gastrointestinal bleeding, providing crucial information for subsequent treatment decisions, and has become a potential first-line tool for evaluating AGIB. In this report, we describe four cases of AGIB with clinical presentations of hematemesis and melena, accompanied by symptoms such as post-exertional palpitations, weakness, hypotension, confusion, and coma. Some patients also had abdominal distension, pain, dizziness, and chest tightness. The laboratory results showed anemia and positive fecal occult blood tests. Multi-phase contrast-enhanced CT allowed for the accurate localization of the active bleeding sites in the digestive tract. Among the four patients, two showed significant symptom improvement after treatment, one was transferred to a higher-level hospital due to critical illness and died from multiple organ failure, and one patient died from hemorrhagic shock due to lymphoma and multiple organ failure. This article discusses the value of multi-phase contrast-enhanced CT for the clinical diagnosis of AGIB and provides a literature review to summarize the imaging characteristics of AGIB on multi-phase contrast-enhanced CT to provide reliable evidence for the timely diagnosis of AGIB.
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Keywords:
- CT /
- acute gastrointestinal bleeding /
- diagnosis
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图 1 患者女性，38岁，十二指肠活动性出血
（a）、（c）、（d）分别显示增强CT动脉期、静脉期和平衡期横断面图像；（b）为动脉期冠状MIP图像，可见十二指肠降部肠腔见不规则环形高密度影，并见造影剂喷射样向外渗出，平衡期可见造影剂渗出范围逐渐扩大（箭号），诊断为十二指肠活动性出血；（e）为DSA检查显示十二指肠上动脉局部不规则瘤样改变。
Figure 1. Female patient, 38 years of age, with active bleeding in the duodenal area
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图 2 患者男性，42岁，近段空肠活动性出血
（a）显示增强CT动脉期可见近段空肠肠腔内有活动性出血点及造影剂外溢；（b）显示静脉期空肠近段外溢的造影剂外渗范围进一步扩大；（c）为冠状面MIP图像显示空肠动脉分支见局限性瘤样改变；（d）为DSA检查显示空肠肠腔内局限性造影剂外溢聚集，造影剂弥散至肠管内呈铸形改变。
Figure 2. Male patient, 42 years of age, with active bleeding in the proximal jejunum
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图 3 患者男性，75岁，胃窦部活动性出血
（a）显示增强CT动脉期胃窦部小弯侧可见一类圆形瘤样突起；（b）为动脉期MIP图像显示胃十二指肠动脉可见一类圆形瘤样改变；（c）和（d）为静脉期和平衡期图像，显示病灶密度逐渐减低，并可见胃窦部胃壁明显水肿伴不均匀增厚；（e）为DSA检查显示胃十二指肠动脉局部见类圆形造影剂聚集，形成瘤样改变。
Figure 3. Male patient, 75 years of age, with active bleeding in the gastric antrum
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图 4 患者男性，25岁，回盲部肠壁活动性出血
（a）显示增强CT动脉期可见回盲部肠腔内见多发局灶性出血点；（b）为动脉期冠状面MIP图像，回盲部可见杂乱血管团影，局部见团状造影剂聚集；（c）和（d）为静脉期及平衡期图像，回盲部肠腔内外溢的造影剂范围逐渐扩大。
Figure 4. Male patient, 25 years of age, with active bleeding in the ileocecal region of the intestinal wall
表 1 AGIB增强CT特征性表现
Table 1 Characteristic enhanced computed tomography features of acute gastrointestinal bleeding (AGIB)
主要征象 CT表现 活动性出血 肠腔内造影剂外渗，表明有活动性出血 血管异常 病变血管呈瘤样突起或形成畸形的血管结构，表示有动脉瘤或畸形血管 局灶性肠壁增厚 局部的肠壁水肿增厚和强化，表示有炎症 肠壁缺血坏死 肠壁或相邻软组织中缺乏造影剂强化，表示有缺血或梗死 肠腔外液体 肠腔外液体积聚，表示有穿孔或破裂。 
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