For a 52-year-old male with a history of GI bleed and epigastric pain, is CT abdomen and pelvis with contrast or CTA abdomen and pelvis a better initial study?

CT Abdomen/Pelvis with IV Contrast vs CTA for Epigastric Pain with History of GI Bleed

For a 52-year-old male with history of GI bleed presenting with epigastric pain without active bleeding, CT abdomen and pelvis with IV contrast is the better initial imaging study compared to CTA abdomen/pelvis. 1

Rationale for CT Abdomen/Pelvis with IV Contrast

The American College of Radiology (ACR) Appropriateness Criteria specifically addresses this clinical scenario and recommends:

• CT abdomen and pelvis with IV contrast is usually appropriate as initial imaging for epigastric pain, particularly when there is concern for gastric pathology 1
• The examination should be performed with IV contrast to assess for nodular wall thickening and soft tissue attenuation of wall thickening 1
• Neutral oral contrast (water or dilute barium suspension) is recommended to help delineate the intraluminal space 1

When to Consider CTA Instead

CTA abdomen/pelvis would be more appropriate in specific scenarios:

• When there is active, ongoing bleeding (not present in this case) 1
• When endoscopy has confirmed bleeding without identifying a clear source 1
• When a multiphase examination is needed to evaluate suspected acute GI bleeding 1

Key Differences Between the Two Studies

1. CT with IV contrast:

   • Single-phase examination (typically portal venous phase)
   • Optimized for evaluating gastric wall abnormalities, masses, inflammation
   • Better for detecting structural causes of epigastric pain without active bleeding

2. CTA:

   • Multiphase examination (includes arterial phase)
   • Optimized for detecting active extravasation of contrast
   • Better for localizing active bleeding sites

Clinical Approach Algorithm

1. For epigastric pain with history of GI bleed but no active bleeding:

   • Start with CT abdomen/pelvis with IV contrast
   • Use neutral oral contrast
   • Include the pelvis to assess for distant metastases or other pathology 1, 2

2. If active bleeding develops or is suspected:

   • Consider CTA abdomen/pelvis without and with IV contrast
   • This allows for detection of bleeding at rates as low as 0.3 mL/min 1

3. If CT findings are inconclusive:

   • Proceed to endoscopy (gold standard for evaluation of gastric pathology) 2

Important Considerations

• CT with IV contrast will help identify potential causes of epigastric pain including gastric wall thickening, ulcers, masses, or inflammation 1
• Including the pelvis in the examination is important to assess for distant metastases and provide complete evaluation 1, 2
• A dedicated CT with IV contrast is particularly valuable if there is concern for gastric pathology that may have caused previous bleeding 2

Pitfalls to Avoid

• Performing CT without IV contrast will significantly limit evaluation of gastric wall abnormalities 1
• Performing CTA when there is no active bleeding may expose the patient to unnecessary radiation from multiphase imaging 1
• Limiting the scan to abdomen only (without pelvis) may miss important findings 2

In summary, for this 52-year-old male with history of GI bleed presenting with epigastric pain but no active bleeding, CT abdomen and pelvis with IV contrast is the most appropriate initial imaging study according to current ACR guidelines.