Study Raises Concerns Over Rising Use of CT for Gastrointestinal Bleeding in the ED

New research published in JAMA Network Open suggests that emergency departments may be overusing CT angiography (CTA) for evaluating suspected gastrointestinal (GI) bleeding, raising questions about diagnostic appropriateness and resource strain.

GI bleeding is a major cause of hospitalization in the U.S. and is frequently encountered in emergency settings. CTA, which uses injected contrast to visualize blood vessels, is a highly accurate tool and is recommended by medical societies in certain scenarios. However, its widespread use comes with tradeoffs, including heavy interpretation workloads for radiologists, radiation exposure, and operational strain.

A retrospective study from Massachusetts General Hospital analyzed CTA use for suspected GI bleeding between 2017 and 2023. The hospital, a 1,011-bed academic center with a 66-bed emergency department handling 110,000 visits annually, provided data on 954 adult patients.

The findings revealed that while CTA use increased nearly tenfold during the seven-year period, the yield of positive scans declined sharply. In 2017, 20 percent of exams (6 of 30) confirmed GI bleeding. By 2023, that figure had dropped to just 6.3 percent (18 of 288). Further analysis showed that newer CTA orders were less likely to detect bleeding, with particularly low yields among patients with active cancer. Older age, however, was associated with higher odds of a positive result.

“This trend highlights the need to balance the diagnostic benefit of CTA with interpretation time, radiation exposure and operational strain,” wrote senior author Marc D. Succi, MD, an emergency radiologist at MGH. “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.”

In a corresponding editorial, gastroenterologists Jose Ignacio Vargas, MD, and Alberto Espino, M, of the Pontifical Catholic University of Chile, described the study as both “timely and thought-provoking.” They argued that the results highlight a central dilemma in modern emergency medicine: ensuring rapid access to diagnostics while preserving appropriateness.

They cautioned that “overuse of imaging is not a benign phenomenon.” In addition to unnecessary radiation and contrast exposure, excessive CTA orders “strain radiologic services, increase interpretation burden, and may contribute to ED throughput delays.” They warned that inappropriate use could ultimately undermine value-based care by diluting the utility of what should be a high-yield test.

The editorialists suggested several strategies to address overuse:

• Clinical decision support (CDS): Embedding tools at the point of order entry to guide providers with evidence-based criteria.

• Risk scores: Applying bleeding-specific tools such as the Glasgow-Blatchford or Oakland scores to triage patients and identify those who may be safely observed or evaluated with alternate methods.

• Collaboration: Promoting multidisciplinary protocols across radiology, gastroenterology, and emergency medicine tailored to local resources.

“Crucially, the goal is not to limit access to lifesaving diagnostics but to ensure that access is thoughtful and targeted,” Vargas and Espino wrote. They stressed that while CTA remains indispensable for critically ill patients requiring urgent intervention, individuals presenting with vague symptoms and stable vital signs may benefit more from initial observation, lab monitoring, or alternative imaging.

The study and commentary together call for a more targeted, evidence-based approach to CTA ordering, ensuring that this powerful diagnostic tool is deployed where it can deliver the most clinical value.