ED docs overusing CT imaging for gastrointestinal bleeding, study finds
Emergency department providers appear to be overusing CT for gastrointestinal issues, according to new research published Friday in JAMA Network Open.
Bleeding in the digestive tract is a costly and life-threatening concern often seen in EDs—currently the leading cause of gastrointestinal-related hospitalizations in the U.S. CT angiography, using injected contrast to create images of blood vessels, is a common tool for assessing GI bleeding and recommended by medical societies in certain scenarios.
However, despite its high accuracy, CTA can come with tradeoffs including requiring radiologists to review a high number of images looking for findings that can be subtle, increasing case complexity and workloads. New data from a single hospital show that use of the exam rose substantially between 2017 and 2023, all while the number of scans positive for GI bleeding dropped.
“This trend highlights the need to balance the diagnostic benefit of CTA with interpretation time, radiation exposure and operational strain,” Marc D. Succi, MD, a board-certified emergency radiologist with Massachusetts General Hospital, and co-authors concluded in their Aug. 29 research paper. “These findings support a need for evidence-based ordering criteria and decision-support tools to help guide CTA use in the ED evaluation of gastrointestinal bleeding.”
The retrospective study included all adult patients who underwent a CTA exam for suspected GI bleeding at a 1,011-bed urban academic medical center with a 66-bed ED seeing 110,000 visits annually. Altogether, the investigation included 954 patients, with the percentage of individuals testing positive for this concern increasing from 0.09% in 2017 up to 0.65% by the end of the study period. This represents a nearly tenfold increase in the number of GI bleeding-related scans over a seven-year period.
Over the same time, the proportion of CTAs positive for GI bleeding fell from 20% (or 6/30) down to 6.3% (or 18/288) seven years later in 2023. Further analysis showed scans ordered in more recent years were less likely to test positive for gastrointestinal bleeding. Same for imaging of individuals with active cancer, while older patient age was tied to higher odds of a positive exam.
In a corresponding editorial, gastroenterology experts called the study’s findings “timely and thought-provoking,” raising “fundamental questions about the balance between diagnostic access and appropriateness in contemporary emergency medicine.” They note that the uptick in unnecessary CTA orders likely stems from a variety of factors including malpractice concerns, imperatives to “act decisively in crowded EDs,” and subtle patient symptoms (such as anemia without overt bleeding).
“Overuse of imaging is not a benign phenomenon,” Jose Ignacio Vargas, MD, and Alberto Espino, M, both with the Pontifical Catholic University of Chile, Santiago, wrote Friday. “In addition to exposing patients to radiation and contrast media, excessive CTA orders strain radiologic services, increase interpretation burden, and may contribute to ED throughput delays. In a broader sense, it risks undermining the value-based care framework by diluting the clinical utility of a high-yield diagnostic tool.”
To address this problem, they recommend strategies including:
- CDS: Implementing clinical decision-support tools at the point of imaging exam order entry to guide providers to use evidence-based criteria for CTA selection.
- Risk scores: Employing gastrointestinal bleeding-specific screening tools, such as Glasgow-Blatchford or Oakland scores, to identify patients with a low probability of active bleeding. This would allow for observation or alternative diagnostic approaches, Vargas and Espino note.
- Collaboration: Fostering multidisciplinary collaboration across radiology, emergency medicine and gastroenterology, which they see as “crucial for developing consensus protocols tailored to local resources and expertise.”
“Crucially, the goal is not to limit access to lifesaving diagnostics but to ensure that access is thoughtful and targeted,” the two editorialists emphasized. “In certain high-acuity settings, rapid CTA remains indispensable for guiding endoscopic or interventional therapy. However, a patient presenting with vague symptoms and stable vitals may benefit more from initial clinical observation, serial hemoglobin checks, or alternate imaging modalities, depending on the suspected source.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.