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MDCT of Small-Bowel Disease: Value of 3D Imaging

¹ Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, Korea.
² Present address: Department of Radiology, Soonchunhyang University Hospital, Seoul, Korea.

Received November 12, 2004; accepted after revision June 13, 2005.

 
Address correspondence to A. Y. Kim (aykim{at}amc.seoul.kr).

Abstract

Top Abstract Introduction MDCT Protocol Clinical Applications of MDCT Summary References

 
OBJECTIVE. Our objective is to show the various clinical applications of MDCT enterography for evaluating small-bowel disease, with a focus on the added value of 3D imaging.

CONCLUSION. MDCT and refined 3D imaging processes can offer a full examination of the small bowel as well as powerful information about the bowel and its surrounding structures.

Keywords: abdominal imaging • CT • MDCT • small bowel

Introduction

Top Abstract Introduction MDCT Protocol Clinical Applications of MDCT Summary References

 
In the evaluation of patients with suspected small-bowel disease, an accurate radiologic examination is important both for recognizing possible small-bowel disease and to help reliably document normal morphology. Small-bowel follow-through and enteroclysis are widely used for small-bowel imaging; however, these examinations provide only indirect information about the bowel wall and surrounding structures and are prone to problems caused by overlapping bowel loops.

To overcome the limitations of previous techniques, CT enteroclysis, a technique combining the advantages of enteroclysis and CT, has been extensively investigated [1, 2]. Although CT enteroclysis profits from excellent distention of the entire small bowel and precise evaluation of the extent of extraluminal disease, it has the major drawbacks of invasiveness and high radiation exposure. Recently, the role of wireless capsule endoscopy to assess small-bowel disease has been reported. The value of this technique is well documented for diagnosing obscure gastrointestinal bleeding and early Crohn's disease [3, 4]. However, problems with this technique include capsule obstruction by bowel strictures and battery failure in prolonged transit (battery life is approximately 7 hours). The technique may provide false-negative results if there is rapid peristalsis at a lesion site or if there is bowel angulation at a lesion that impairs the camera view [5, 6].

Currently, the availability of MDCT and the continuous refinement of the 3D imaging process have greatly expanded the utility of CT for evaluating patients with small-bowel disease. MDCT is now readily available and has advantages over classic helical CT in the imaging of the mesenteric vasculature and of the small bowel. We will show various clinical applications of MDCT enterography for evaluating small-bowel diseases, focusing on the added value of 3D imaging. In addition, the technical limitations and potential pitfalls in the interpretation of 3D imaging will be discussed.

MDCT Protocol

Top Abstract Introduction MDCT Protocol Clinical Applications of MDCT Summary References

 
MDCT scans were obtained with a 16-MDCT scanner (Somatom Sensation 16, Siemens Medical Solutions) using the following scanning parameters: collimation, 16 x 0.75 mm; table feed/rotation, 12 mm; slice width, 0.75 mm; volume pitch, 16; 120 kVp; and 165 mAs. Images were reconstructed at 1-mm intervals with a B30 soft-tissue algorithm.

At the beginning of the contrast-enhanced CT scan, 150 mL of nonionic iodinated contrast material (Ultravist 370 [iopromide], Schering) was injected IV through a 20-gauge cannula at 3 mL/s using an automated power injector. The delay between the start of contrast administration and the start of helical scanning was approximately 10 seconds to achieve the arterial phase (using the CARE bolus-triggering program [Siemens Medical Solutions]) and 72 seconds for the delayed phase. Images were obtained from the dome of the liver to the lower margin of the symphysis pubis during a single breath-hold.

To evaluate mesenteric ischemia and gastrointestinal bleeding, three-phase CT (unenhanced, arterial, and delayed phase) was performed without oral contrast material. However, the weighted CT dose index and the dose-length product accrued from one dynamic phase CT were 9.32 mGy and 526-529 mGy, respectively. Therefore, in patients with suspected small-bowel obstruction, inflammatory bowel disease, or neoplasm, a single CT scan or a two-phase CT scan (delayed phase or unenhanced phase or both) was obtained.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —56-year-old man with acute mesenteric ischemia. Emboli or thrombi are not definitively shown on axial arterial phase CT image.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —56-year-old man with acute mesenteric ischemia. Oblique coronal plane of volume-rendered image shows large embolus (thick arrow) and extensive vascular occlusion (arrowheads) along superior mesenteric artery and its branches, with multifocal renal infarction (thin arrows). Because this patient suffered from longstanding severe heart failure, mesenteric ischemia was conservatively managed with anticoagulant drugs.

Real-time interactive 3D imaging was created by using multiplanar reconstruction, volume rendering, maximum or minimal intensity projection or both, and surface shaded display techniques using a commercially available workstation (Leonardo, Siemens Medical Solutions). Postimaging processing was performed by one experienced abdominal radiologist and took approximately 15 minutes.

Clinical Applications of MDCT

Top Abstract Introduction MDCT Protocol Clinical Applications of MDCT Summary References

 
Mesenteric Ischemia
Thromboembolic occlusion is the most common cause of acute mesenteric ischemia, with the emboli mainly originating from the heart. The critical roles of CT are to detect ischemic changes in the affected bowel loops and mesentery and to determine the cause of ischemia. Bowel distention, bowel-wall thickening, mesenteric edema, and ascites are common CT findings in patients with mesenteric ischemia; however, these findings are nonspecific. CT findings such as splanchnic vascular occlusion, intramural gas, lack of bowel-wall enhancement, and multiorgan infarctions have been proposed as specific findings that suggest acute mesenteric ischemia. These findings are readily evident using MDCT (Figs. 1A, 1B, 2A, and 2B). Thickened small-bowel loops may show an absence of enhancement or, in some cases, delayed and persistent enhancement when compared with unaffected loops [7-9].

View larger version (180K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —43-year-old man with acute mesenteric ischemia. MDCT volume-rendered image of arterial phase clearly shows no evidence of arterial emboli.

View larger version (187K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —43-year-old man with acute mesenteric ischemia. Volume-rendered delayed phase image shows extensive thrombosis of superior mesenteric vein (arrowheads) and its tributaries with adjacent infarcted bowel segment (thin arrows). Development of periportal collateral vessels (thick arrow) is also noted. Patient underwent segmental resection of ileal bowel loops because of transmural infarction.

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —36-year-old man with chronic mesenteric ischemia. Thick-slab volume-rendered image of contrast-enhanced MDCT dramatically shows small pseudoaneurysm (arrow) in proximal origin portion of superior mesenteric artery.

View larger version (168K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —36-year-old man with chronic mesenteric ischemia. On multiplanar reconstruction image, extensive thrombosis (arrowheads) is well shown yet is not evident on thick-slab volume-rendered image (A). These findings were consistently depicted on follow-up CT scans for 1 year without interval change (not shown).

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —55-year-old man with intermittent abdominal pain. Initial contrast-enhanced CT scan shows partial opacification of tributary of superior mesenteric vein (arrow), mimicking mesenteric venous occlusion.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —55-year-old man with intermittent abdominal pain. Axial CT image of delayed phase reveals full opacification of this mesenteric venous structure (arrow), indicating pseudoocclusion by systemic hypotension.

View larger version (174K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —56-year-old man with asymptomatic atherosclerotic plaque. On combined image of maximal intensity projection and surface shaded display, focal vascular narrowing of proximal superior mesenteric artery is observed because of small defect (arrow), suggesting atherosclerotic plaque. Similar multiple focal defects (arrowheads) are also seen along abdominal aorta, indicating underlying chronic atherosclerotic vascular disorder.

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6 —31-year-old woman with acute onset of mid upper abdominal pain and intestinal obstruction after blunt trauma. On volume-rendered image after ingestion of diluted water-soluble oral contrast medium, abrupt luminal narrowing (thin arrows) with distended proximal bowel loops is clearly identified in duodenum (D). Adjacent perienteric hematoma (H) is also shown with segmental duodenal wall thickening and perienteric infiltration (arrowheads) indicating posttraumatic change. Opacification of distal bowel loops also suggests incomplete bowel obstruction (thick arrow). S = stomach.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —33-year-old man with acute postoperative small-bowel obstruction. Linear alignment of stricture sites (arrowheads) is shown on posterior view of thick-slab volume-rendered image obtained after digital removal of bone structures. These multifocal strictures, located along an imaginary perpendicular line, suggest presence of postoperative adhesive band that was confirmed at surgery.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —Small-bowel obstruction in 46-year-old man who underwent segmental resection of ileum. Thick-slab volume-rendered image obtained after ingestion of diluted water-soluble oral contrast medium shows metallic surgical clips (arrows) and adjacent collapsed bowel loops (arrowheads), indicating transition point of small intestinal obstruction.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —67-year-old woman with complete small-bowel obstruction. On thick-slab volume-rendered image of contrast-enhanced MDCT after ingestion of water-soluble oral contrast medium, complete bowel obstruction (O) at proximal jejunum is shown with masslike, multiconcentric bowel-wall thickening (arrows). In conjunction with hepatic metastases (arrowheads) and mesenteric lymphadenopathy, this masslike wall thickening indicates intussusception by intestinal metastasis. Sonography-guided biopsy of mesenteric node revealed distant metastasis from lung cancer.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —27-year-old man with acute intestinal obstruction. Thick-slab volume-rendered image obtained after ingestion of diluted water-soluble oral contrast medium shows markedly dilated small-bowel loops (S) with diffuse fold thickening, but passage of oral contrast medium is not interrupted or delayed through large intestine (L). No definite pathologic obstruction site is shown.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —27-year-old man with acute intestinal obstruction. Thin-slice volume-rendered image shows suspicious multifocal stenotic segments (arrows) along small intestine. Tentative diagnosis based on CT scan was low-grade small-bowel obstruction of unknown cause due to nonspecific findings. However, cause of small-bowel obstruction proved to be persimmon bezoar that was extracted just before CT. No abnormal small-intestine findings were detected on small-bowel follow-through examination 3 months later (not shown).

Using MDCT to diagnose mesenteric ischemia does have some limitations. First, inadequate or nonopacified blood in the mesenteric vessels, which can be caused by hypovolemia or spasm, can lead to a falsepositive diagnosis (Figs. 4A and 4B). Second, although calcified atherosclerotic plaques in the mesenteric vessels, seen on MDCT, are common features in patients with chronic mesenteric ischemia, these plaques often can be observed at the origin of the mesenteric arteries in older individuals lacking clinical symptoms. On the other hand, the small intestine can appear normal in patients with chronic mesenteric ischemia (Fig. 5). Therefore, careful clinical correlation with the CT findings is essential in the evaluation of patients with suspected mesenteric ischemia.

Small-Bowel Obstruction
The small bowel is involved in 60-80% of cases of intestinal obstruction. Because of the possibility of strangulation, misdiagnosis or delayed diagnosis can result in lethal or life-threatening complications such as ischemia and perforation. Therefore, in patients with suspected small-bowel obstruction, the role of imaging is to determine the presence or absence of an obstruction; to identify the site, severity, and cause of an existing obstruction; and to detect the possible presence of strangulation [13-15].

Diagnosis of bowel obstruction depends on the identification of a transition zone with dilated proximal bowel loops. However, depiction of a definite transition zone is sometimes difficult because of overlapping dilated bowel loops when viewing only axial images. Similarly, it is often difficult to differentiate obstruction from adynamic ileus. In these situations, the easily accessible 3D imaging of MDCT may help to verify the site, level, and cause of the obstruction [16] (Fig. 6). In particular, 3D imaging can be helpful in evaluating indeterminate cases on the axial plane, such as volvulus or internal hernia. The additional use of positive oral contrast material can help to distinguish complete from incomplete bowel obstruction.

Strangulating obstruction is more common in closed-loop obstruction than in simple obstruction. In the assessment of strangulation, various CT findings such as thickening and increased attenuation of the affected bowel wall, serrated beaklike narrowing at the site of obstruction, target or halo sign, pneumatosis intestinalis, and gas in the portal veins have been reported to be suggestive of strangulation. Among these features, poor or absent enhancement of the bowel wall, a "serrated beak" sign, and an unusual course of mesenteric vasculature or whirl sign are more specific findings that have statistical significance [17]. Findings of haziness or obliteration of the mesenteric vessels, localized mesenteric fluid, and hemorrhage are seen in the mesentery attached to the ischemic bowel loops. These CT features can be observed using 3D imaging with MDCT. Advanced 3D imaging processing, such as slab volume rendering using MDCT, is more flexible than 2D multiplanar reconstruction and also makes it possible to display unlimited planes with markedly reduced artifacts (Figs. 7, 8, 9).

View larger version (172K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —35-year-old woman with relapsed active Crohn's disease. Thin-slab volume-rendered image provides excellent topographic information regarding perienteric abscess and fistulous tract formation (arrows) resulting from relapsed ileocecal Crohn's disease (IC). Deformed terminal ileum and cecum show strongly enhanced bowel walls, suggesting active inflammation.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —35-year-old woman with relapsed active Crohn's disease. Multiplanar reconstruction image using a minimal intensity projection clearly shows multidirectional fistulous tracts (arrowheads) and active abscesses (a).

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —38-year-old man with longstanding Crohn's disease. Thick-slab volume-rendered image obtained after ingestion of diluted water-soluble oral contrast medium shows segmental bowel aggregation and multifocal strictures (dotted circle). Eccentric bowel-wall thickening with perienteric infiltration (arrows) is also seen along mesenteric border.

View larger version (155K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —38-year-old man with longstanding Crohn's disease. Thick-slab volume-rendered image with a surface shaded display shows longitudinal linear ulcerations along mesenteric border (arrows) of multifocal small intestines and pseudosacculations (arrowheads).

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —43-year-old woman with malignant gastrointestinal stromal tumor arising from jejunum. Coronal thick-slab volume-rendered image shows well-demarcated, exophytic growing mass (arrows) with large central ulceration originating from jejunum (J).

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —43-year-old woman with malignant gastrointestinal stromal tumor arising from jejunum. Thick-slab volume-rendered image mimicking maximum intensity projection shows tumor-supplying mesenteric branches (thin arrows) of superior mesenteric artery and enlarged draining veins (arrowheads) from mass (thick arrows).

Inflammatory Bowel Disease
For a long time, small-bowel series and enteroclysis have had a primary role in the diagnosis and management of patients with suspected inflammatory bowel disease of the small intestine. However, these imaging techniques do not offer any important information about extraluminal extension of the disease or changes in surrounding structures. CT can overcome this limitation, but its effectiveness is limited because it lacks both the ability to depict fine mucosal change of the affected bowel and to depict and localize a potential fistulous tract or bowel perforation. In some complex cases, such as Crohn's disease, the exact evaluation of the disease extent or stricture segment may be difficult to identify if only axial images are reviewed [18].

In evaluating bowel inflammation complicated by fistula or abscess, as seen in Crohn's disease or tuberculosis, 3D imaging may be helpful in understanding the full extent of disease (Figs. 11A and 11B). Three-dimensional volume rendering of MDCT performed with positive oral contrast material can improve visualization of the presence and site of both the stricture and the fistula (Figs. 12A and 12B). This valuable information from 3D CT may significantly improve the observer's confidence in interpreting the imaging and the clinician's or surgeon's understanding of the extent of the disease.

Among the limitations of using MDCT to diagnose inflammatory bowel disease are that to obtain proper 3D information, optimal distention of the entire small intestine is essential. Although positive oral contrast material is valuable for diagnosing bowel obstruction, perforation, and fistulization, evaluation for bowel-wall enhancement after injection of IV contrast material can be limited because of the partial volume averaging effect. From this point of view, the use of negative oral contrast material, such as water or methylcellulose, can be considered in early active change of inflammatory bowel disease.

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14 —37-year-old man with obscure gastrointestinal bleeding. In this patient, two attempts at RBC scans yielded negative results. This coronal maximum-intensity-projection image obtained from arterial phase of MDCT shows direct extravasation of contrast material into proximal jejunal loop (arrow). At surgery, bleeding focus was confirmed to be angiodysplasia of proximal jejunum.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15A —55-year-old man with obscure gastrointestinal bleeding. Axial CT image obtained from arterial phase MDCT shows highly enhanced, tortuous vascular structure (arrows) along bowel wall of distal ileum.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15B —55-year-old man with obscure gastrointestinal bleeding. Thick-slab volume-rendered image shows vascular structure of distal ileum (arrows) with hypertrophied supplying arteries (arrowheads). There is an early draining vein (not shown). From these confirmatory CT features, mass was diagnosed as arteriovenous malformation of distal ileum.

In addition, CT angiography can provide information regarding the vascular supply of the tumor and vascular invasion by the tumor (Figs. 13A and 13B). Therefore, in such patients, administration of a negative oral contrast material (such as water) seems preferable because of its preservation of the vascular information regarding the tumor, the affected bowel segment, and related vascular structures. However, if communication between the necrotic tumor and the adjacent bowel, fistula formation, or perforation is suspected, we prefer the use of a water-soluble positive oral contrast medium.

Obscure Gastrointestinal Bleeding
Compared with the stomach and the colon, the small intestine is an uncommon site for intestinal bleeding, and unless the bleeding is massive, it is often difficult to diagnose. Therefore, such patients may present with prolonged, chronic occult blood loss or recurrent episodes of melena without a specific diagnosis. Although various radiologic studies have been used, a bleeding site cannot be localized in approximately 5-20% of these patients who are therefore classified with obscure gastrointestinal bleeding [20]. Nevertheless, every effort should be made to determine the source of their gastrointestinal bleeding because adequate diagnosis is followed by an improved patient outcome and a decreased need for transfusion.

Although CT is still not comparable in sensitivity to scintigraphy using ^99mTc-labeled RBCs or to conventional angiography, it may be an alternative to more invasive procedures when routine workup fails to determine the cause of active intestinal bleeding [21, 22]. With advanced 3D imaging, MDCT (including CT angiography) may have a role in evaluating patients with obscure gastrointestinal bleeding because it can be performed rapidly and noninvasively. Obscure gastrointestinal bleeding, unexpected bleeding foci, unexpected tumors, and inflammatory bowel disease can all be easily observed on MDCT (Figs. 14, 15A, and 15B).

Summary

Top Abstract Introduction MDCT Protocol Clinical Applications of MDCT Summary References

 
MDCT and refined 3D imaging processes can offer a full examination of the small intestine and powerful information about the bowel and its surrounding structures. These are inherent advantages of CT over conventional enteroclysis. In most cases of small-bowel disease, various 3D technologies can help radiologists make an easy, rapid, and accurate diagnosis while avoiding unnecessary examinations. Therefore, knowledge and awareness of the valuable 3D CT features and each proper application technique of MDCT are essential to achieve the diagnostic goal of one-step imaging.

Acknowledgments
 
We thank Bonnie Hami, Department of Radiology, University Hospitals Health System, Cleveland, OH, for editorial assistance in preparing the manuscript.

References

Top Abstract Introduction MDCT Protocol Clinical Applications of MDCT Summary References

 

1. Maglinte DD, Bender GN, Heitkamp DE, Lappas JC, Kelvin FM. Multidetector-row helical CT enteroclysis. Radiol Clin North Am 2003; 41:249 -262[CrossRef][Medline]
2. Horton KM, Fishman EK. The current status of multidetector row CT and 3D imaging of small bowel. Radiol Clin North Am2003; 41:199 -212[CrossRef][Medline]
3. Lewis BS, Swain P. Capsule endoscopy in the evaluation of patients with suspected small intestinal bleeding: results of a pilot study. Gastrointest Endosc 2002;56 : 349-353[CrossRef][Medline]
4. Voderholzer WA, Beinhoelzl J, Rogalla P, et al. Small bowel involvement in Crohn's disease: a prospective comparison of wireless capsule endoscopy and CT enteroclysis. Gut 2005;54 : 369-373[Abstract/Free Full Text]
5. Hartmann D, Schilling D, Bolz G, Riemann JF. Capsule endoscopy, technical impact, benefits and limitations. Langenbecks Arch Surg 2004; 389:225 -233[Medline]
6. Voderholzer WA, Ortner M, Rogalla P, Beinholzl J, Lochs H. Diagnostic yield of wireless capsule enteroscopy in comparison with CT enteroclysis. Endoscopy 2003;35 : 1009-1014[CrossRef][Medline]
7. Kim AY, Ha HK. Evaluation of suspected mesenteric ischemia: efficacy of radiologic studies. Radiol Clin North Am2003; 41:327 -342[CrossRef][Medline]
8. Rha SE, Ha HK, Lee SH, et al. CT and MRI findings of bowel ischemia from various primary causes. RadioGraphics2000; 20:29 -42[Abstract/Free Full Text]
9. Horton KM, Fishman EK. Volume-rendered 3D CT of the mesenteric vasculature: normal anatomy, anatomic variants, and pathologic conditions. RadioGraphics 2002;22 : 161-172[Abstract/Free Full Text]
10. Kaleya RN, Sammartano RJ, Boley SJ. Aggressive approach to mesenteric ischemia. Surg Clin North Am1992; 72:157 -181[Medline]
11. Grendel JH, Ockner RK. Mesenteric venous thrombosis. Gastroenterology 1982;82 : 358-372[Medline]
12. Trompeter M, Brazda T, Remy CT, et al. Nonocclusive mesenteric ischemia: etiology, diagnosis, and interventional therapy. Eur Radiol 2002; 12:1179 -1187[CrossRef][Medline]
13. Ha HK, Park CH, Kim SK, et al. CT analysis of intestinal obstruction due to adhesions: early detection of strangulation. J Comput Assist Tomogr 1993;17 : 386-389[Medline]
14. Maglinte DDT, Gage S, Harmon B, et al. Obstruction of the small intestine: accuracy and role of CT in diagnosis. Radiology 1993;186 : 61-64
15. Taourel PG, Fabre J-M, Pradel JA, Seneterre EJ, Megibow AJ, Bruel J-M. Value of CT in the diagnosis and management of patients with suspected acute small-bowel obstruction. AJR 1995;165 : 1187-1192[Abstract/Free Full Text]
16. Caoili EM, Paulson EK. CT of small-bowel obstruction: another perspective using multiplanar reformations. AJR2000; 174:993 -998[Free Full Text]
17. Ha HK, Kim JS, Lee MS, et al. Differentiation of simple and strangulated small-bowel obstructions: usefulness of known CT criteria. Radiology 1997;204 : 507-512[Abstract/Free Full Text]
18. Raptopoulos V, Schwartz RK, McNicholas MM, et al. Multiplanar helical CT enterography in patients with Crohn's disease. AJR 1997; 169:1545 -1550[Abstract/Free Full Text]
19. Buckley JA, Jones B, Fishman EK. Small bowel cancer: imaging features and staging. Radiol Clin North Am1997; 35:381 -402[Medline]
20. Lefkovitz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS. Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia. Med Clin North Am 2002;86 : 1357-1399[CrossRef][Medline]
21. Krestan CR, Pokieser P, Wenzl E, Leitha T. Localization of gastrointestinal bleeding with contrast-enhanced helical CT. AJR 2000; 174:265 -266[Free Full Text]
22. Miller FH, Hwang CM. An initial experience: using helical CT to detect obscure gastrointestinal bleeding. Clin Imaging2004; 28:245 -251[CrossRef][Medline]

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This Article Abstract Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hong, S. S. Articles by Ha, H. K. Search for Related Content PubMed PubMed Citation Articles by Hong, S. S. Articles by Ha, H. K. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?