Research Author, University of Chicago Medical Center, Chicago, Illinois.
Co-author, University of Wisconsin Hospital & Clinics, Madison, Wisconsin.
J Am Coll Radiol. 2017 May;14(5S):S177-S188. doi: 10.1016/j.jacr.2017.02.038.
Upper gastrointestinal bleeding (UGIB) remains a significant cause of morbidity and mortality with mortality rates as high as 14%. This document addresses the indications for imaging UGIB that is nonvariceal and unrelated to portal hypertension. The four variants are derived with respect to upper endoscopy. For the first three, it is presumed that upper endoscopy has been performed, with three potential initial outcomes: endoscopy reveals arterial bleeding source, endoscopy confirms UGIB without a clear source, and negative endoscopy. The fourth variant, "postsurgical and traumatic causes of UGIB; endoscopy contraindicated" is considered separately because upper endoscopy is not performed. When endoscopy identifies the presence and location of bleeding but bleeding cannot be controlled endoscopically, catheter-based arteriography with treatment is an appropriate next study. CT angiography (CTA) is comparable with angiography as a diagnostic next step. If endoscopy demonstrates a bleed but the endoscopist cannot identify the bleeding source, angiography or CTA can be typically performed and both are considered appropriate. In the event of an obscure UGIB, angiography and CTA have been shown to be equivalent in identifying the bleeding source; CT enterography may be an alternative to CTA to find an intermittent bleeding source. In the postoperative or traumatic setting when endoscopy is contraindicated, primary angiography, CTA, and CT with intravenous contrast are considered appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
上消化道出血 (UGIB) 仍然是发病率和死亡率的重要原因，死亡率高达 14%。本文件针对非静脉曲张性和与门静脉高压无关的 UGIB 的影像学检查指征。这四个变体是根据上内窥镜检查衍生而来的。对于前三个变体，假设已经进行了上内窥镜检查，有三种潜在的初始结果：内窥镜检查显示动脉出血源，内窥镜检查证实 UGIB 但无明确来源，以及阴性内窥镜检查。第四个变体，“UGIB 的术后和创伤原因；内镜检查禁忌”被单独考虑，因为没有进行上内窥镜检查。当内窥镜检查确定出血的存在和位置，但无法通过内镜控制出血时，基于导管的动脉造影术联合治疗是一种合适的下一步研究。CT 血管造影术 (CTA) 在诊断方面与血管造影术相当。如果内窥镜检查显示出血，但内窥镜医生无法确定出血源，通常可以进行血管造影术或 CTA，两者均被认为是合适的。在隐匿性 UGIB 的情况下，血管造影术和 CTA 已被证明在识别出血源方面具有同等效果；CT 肠造影术可能是替代 CTA 以寻找间歇性出血源的替代方法。在术后或创伤情况下，如果内镜检查禁忌，原发性血管造影术、CTA 和静脉造影 CT 被认为是合适的。美国放射学院适宜性标准是针对特定临床情况的循证指南，每年由多学科专家小组进行审查。指南的制定和修订包括对同行评议期刊的现有医学文献进行广泛分析，并应用成熟的方法（RAND/UCLA 适宜性方法和推荐评估、制定和评估分级或 GRADE）对特定临床情况下的影像学和治疗程序的适宜性进行评估。在缺乏证据或证据模棱两可的情况下，专家意见可以补充现有证据，以推荐影像学或治疗。
