Surgical evacuation of the hematoma is necessary when there is compression of neurological structures or if the hematoma is causing local ischemia. Gann Hematoma is generally defined as a collection of blood outside of blood vessels. The procedure started with intravenous unfractionated heparin in prophylactic doses of 100 IU/kg/d and continued with subcutaneous low-molecular-weight heparin (enoxaparin) in doses of 2,850 IU anticoagulation factor Xa every 12 hours. Both CT and MRI are painless, however, MRI can be more bothersome to some Physical therapy helps you recover faster from accident-related injuries and decreased joint movements due to joint conditions such as osteoarthritis and rheumatoid arthritis. , Schweizer W, Wagner HE. , Baker KG. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. A Comparison of Perceived and Observed Practice Behaviors, Rehabilitation for COVID-19 Lung Transplant, A Systematic Appraisal of Conflicts of Interest and Researcher Allegiance in Clinical Studies of Dry Needling for Musculoskeletal Pain Disorders, Receive exclusive offers and updates from Oxford Academic, Copyright 2023 American Physical Therapy Association. View. , Pfaffenberger S, Groschl M, et al. Angiography showing a ruptured superficial branch of the superior gluteal artery (arrow). Ultrasound therapy helps because micro vibrations enhance the absorption. DA A rubber donut may be used to decrease the pain of sitting on a swollen buttock. This risk is increased in the elderly and pts on anticoagulation. SJ Sharafuddin MJ, Andresen KJ, Sun S, Lang E, Stecker MS, Wibbenmeyer LA. FAQ; Legal; Newsletter. Internal echoes and fat globules were found . The only code I can find for this tx is an i&d which is inaccuarate. Assessment and Treatment of Carpal Tunnel Syndrome is never complete without a High Resolution Ultrasound Examination. Egger If possible, discontinuation of anticoagulants is the first step in management and may be sufficient to allow for hemostasis to occur and resolution of the muscular hematoma. Bilateral gluteal tendinitis; Gluteal tendinitis of right hip; Right gluteal . Please always consult with a professional and certified healthcare provider to discuss if a treatment is right for you. The gluteal hematoma was suspected clinically, confirmed by ultrasound and the arterial injury was diagnosed by CT angiography that revealed a large right gluteal hematoma with a focal contrast leakage forming a pseudoaneurysm within the hematoma. Therapeutic US can be pulsed or continuous. Arteriole flexibility had decreased significantly in our case, making the arterioles prone to rupture with external forces and when subjected to aggressive massage therapy such as deep tissue massage therapy, the blood vessel ruptured. Warden Dohan A, Sapoval M, Chousterman BG, di Primio M, Guerot E, Pellerin O. Spontaneous soft-tissue hemorrhage in anticoagulated patients: safety and efficacy of embolization. Spontaneous extraperitoneal hemorrhage with hemodynamic collapse in patients undergoing anticoagulation: management with selective arterial embolization. , Tighe MK, DeCosse JJ, Dannenberg AJ. Ultrasound therapy was administered once a day, 5 times per week for 4 weeks, for a total of 20 sessions. After this period, hematoma has most likely turned to thick gelatinous mass and this is the best time to try to remove it. ^/xck<2F{m! Timely identification and management of a Morel-Lavalle lesion is crucial because distracting injuries in the polytraumatized patient can result in a missed or delayed diagnosis. A subcutaneous hematoma occurs when a ruptured blood vessel leaks blood into the surrounding fatty tissue. They have been reported to be metabolically active on FDG-PETref. ; In children: Ultrasound over the bone that has not fully developed may cause fractures or other problems with the part of the bones that are responsible for growth. See additional information. , van der Windt DA, de Winter AF. MRI (or magnetic resonance imaging) scan is a radiology technique which uses magnetism, radio waves, and a computer to produce images of body structures. right buttock at the site of the BMP. % However, while this was the low hanging fruit, he also had evidence on exam of sciatica (pinched S1 nerve in his back). <>>> Berna Dr Berna-Serna provided writing, and Dr Berna-Serna and Mr Berna-Mestre provided data collection. Unenhanced CT of abdominal and pelvic hemorrhage. The clinical presentations of the cases displayed high variability, and included: hematoma with buttock pain, sciatic nerve discomfort and gluteal compartment syndrome. A comprehensive secondary examination can be an effective way to identify less obvious injuries, and radiography is a good initial screening tool. Disc herniation is usually the cause of sciatica. Ice, elevation, and rest may be helpful. Dec 2012. He underwent the Regenexx-PL disc procedure for his irritated low . neous and deep fat of the gluteal region in-clude fibrous tumors, cellulitis (Fig. Furthermore, pain from spinal root compression caused by a hematoma in the lumbar or gluteal regions must merit consideration. A gluteal contusion is a bruise to the muscle area. Bursitis of the hip results when the fluid-filled sac (bursa) near the hip becomes inflamed due to localized soft tissue trauma or strain. When the gluteal muscles are inflamed, movement of the hip joint causes pain. The exam was notable for a large hypoechoic fluid collection deep to the subcutaneous tissue and superior to the gluteal musculature (Figures 1 and 2). Teixeira, Pedro Augusto Gondim. Citation, DOI & article data. Ultrasound is the most widely available and the most frequently used electrophysical agent in physical therapy.11 Ultrasound is used in the management of a wide range of musculoskeletal disorders.12 The effects of US for patients with musculoskeletal disorders, which occur through a variety of biological and physical mechanisms, include muscle relaxation, reduced swelling, and pain relief.12,13 Most knowledge of the effects of US on living tissue has been gained through in vitro studies and animal models, but relatively little in vivo evidence that these effects actually occur has been published.12,14 Ultrasound can induce thermal and nonthermal physical effects in tissues.13 In a review of the purported effects of therapeutic US, Speed12 concluded that the thermal effects of US may include increased blood flow, reduction of pain, reduction of muscle spasm, increased tissue extensibility, and a mild inflammatory response. Is there any numbness or tingling or pain that radiates down the leg? Usually seen as well-defined small nodules that often contain calcification. Spontaneous muscular hematomas similarly require an interdisciplinary approach to achieve the best outcomes. Percutaneous thrombin injection under contrast-enhanced ultrasound guidance to control active extravasation not associated with pseudoaneurysm. Endovascular embolization was selected in all cases, either alone or with the evacuation of the hematoma, with complete procedural success. "Spontaneous" hematoma of the rectus abdominis muscle: critical review of 50 cases with emphasis on early diagnosis and treatment. Pulsed US was used because this nonthermal option is thought to involves less risk of bleeding than thermal US (continuous wattage) mode. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. We believe that conservative management of RSH, especially in cases of large RSH, requires close coordination of the surgeon, radiologist, hematologist, and physical therapist. However, with no defecation after 20 hours, the pain suddenly worsened and pressure in the left buttock increased significantly. University of Washington: Musculoskeletal radiology. Unable to process the form. MRI T2-weighted magnetic resonance images showing irregular bleeding in the gluteal muscle (arrow). A dedicated probe cover or an exam glove can be used to cover the probe. or emphysema. A radiology-based musculoskeletal ultrasound was performed on the right upper gluteal region. Severe hematoma of the buttock following a gluteal compartment syndrome due to a vascular injury. Affiliation 1 . This condition usually appears after a bout of coughing. These muscles obtain their vascular supply from the inferior epigastric arteries and the circumflex iliac arteries. Computed tomographic (CT) scan showing hematoma (arrows, top image); CT scan showing slight asymmetry of the rectus muscle (arrow, bottom image). IMG2882. Ultrasound. View Frank Gaillard's current disclosures, see full revision history and disclosures, the appearance depends on the temporal evolution of the granuloma, T2 hyperintense if the reaction is inflammatory, T2 hypointense if the reaction is fibrous. Contusions occur when a direct blow or repeated blows by a blunt object strike part of the body, crushing underlying muscle fibers and connective tissue without breaking the skin. Other muscles, nerves, and bursae in the gluteal region that may cause, Hip rotator muscles: Piriformis, obturator, quadratus, and gemellus muscles, Most commonly, gluteal injuries are due to local. Right gluteal region ultrasound depicted a heterogenous solid mass without areas of liquid consistency. Most traumatic gluteus injuries resolve on their own with time and conservative therapy, but recovery time may be measured in weeks and not days. , Sakamoto I, Kohzaki S, et al. Blood test: hemoglobin, 93 g/L; red blood cell count, 2.82 10 12 /L; platelet count, 112 10 9 /L; and hemagglutination: thrombin time, 18.6 second; fibrinogen, 1.665 g/L. Gluteal injection site granulomas are a very common finding on CT and plain radiographs. When you are standing on one foot and holding the other . For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Rectus sheath hematoma (RSH) is an uncommon and often misdiagnosed condition.1 The most frequent location is infraumbilical.2,3 The causes of RSH described in the literature include anticoagulant therapy, hematological disorders, trauma, physical exercise, coughing, sneezing, pregnancy, and hypertension.110 The most frequent predisposing factor is anticoagulant therapy, and the most important precipitating factor is coughing.2,10 Rectus sheath hematoma can be suspected in women above 60 years of age who have the clinical triad of acute abdominal pain, an abdominal mass, and anemic syndrome. The health care professional may check for, Has there been any issue with the ability to urinate or have a bowel movement? Messages 242 Location Dallas, GA Best answers 0. [9], Arterial embolization is sometimes proposed as a treatment option for the management of spontaneous muscular hemorrhages and has the advantage of being less invasive than surgical evacuation while maintaining a clinical success rate of 57to 69%. A history of trauma is common in the presence of traumatic muscular hematomas but may not become clinically relevant for several days, especially when the patient has distracting injuries. Management of muscular hematomas requires the careful collaboration of all members of the healthcare team and a well-rounded interprofessional approach that considers the patient's unique history and needs to achieve the best outcomes. Treatments include applying an ice pack and pressure to the area by hand. - Nearby surgery. They occur as a result of subcutaneous (i.e. JD A low back MRI revealed a large herniated disc (his back hurt some, but most of his attention was on the butt pain). MRI (magnetic resonance imaging) is a procedure that uses strong magnetic fields and radiofrequency How would you code this cpt?? Ultrasound Reimbursement Rates are approximate and based on the National Average of the Medicare Physician Fee Schedule. 2), and at the 12th (Fig. , Onundarson PT, Carstensen EL, et al. Clinical improvement is usually rapid in patients with type I or II RSH.2,10 Spontaneous resolution of RSH, especially in large hematomas (type III), however, takes place over several months.2 Surgical intervention would be indicated primarily in cases in which hemodynamic stability is not achieved. Prosch H, Mirzaei S, Oschatz E et-al. On physical examination, a tender mass (12 8 cm) of soft consistency over the infraumbilical right abdomen was detected. Consider active arterial hemorrhage in a large or expanding traumatic hematoma. Is the patient able to walk, and if so, is there a limp? The thigh, hip, and pelvic region are the most commonly affected locations. My doc did needle aspiration w/ ultrasonic guidance of a hematoma on pt.'s gastrocnemius. Patients who develop a spontaneous muscular hematoma should be evaluated by a healthcare professional who can carefully weigh the risks and benefits of all treatment options. Case: Occasionally, a large, deep, consolidated hematoma is hard to evacuate without an incision, yet there are concerns about possible complications of surgical removal. Terms of Use. Following a bout of coughing, she experienced sudden abdominal pain. B Monitoring of coagulation parameters took place every 6 to 8 hours, and the INR returned to normal 8 hours after intervention began. D Andexanet alfa is a drug approved for use to reverse apixaban and rivaroxaban in cases of serious hemorrhage, typically reserved for pts undergoing operative intervention due to cost. Take care. Moving the hip may cause pain in the buttock due to muscle inflammation and damage. MRI costs more than CT, while CT is a quicker and more comfortable test for the patient. Y Gluteal muscle and tendon strains occur because of overuse injuries, usually of the hip joint. 3 0 obj If the gluteal injury is due to overuse, or an abnormal gait (pattern of walking), physical therapy may be considered to prevent further injury and inflammation. G At the time the article was last revised Daniel J Bell had no recorded disclosures. [4][10], The differential diagnosis of spontaneous muscular hematoma is largely dependent on the location of the bleed. Treatment of a fracture depends on the type and location of the injury. An injury to a ligament is called a sprain, and an injury to muscle or tendon is called a strain. We reasoned that applying pulsed US would produce nonthermal effects through an increase in acoustic microstreaming12 and an acceleration of fibrinolysis,18,19 which might accelerate the reabsorption of RSH. In uncertain situations, imaging is frequently performed to . A . Acute changes in bowel or bladder function are associated with potential, Inspection or looking at the buttock area might reveal. Intact gluteal muscle. Should the gluteal injury be due to a direct blow or fall, resulting in a contusion, treatment aims to decrease the inflammation in the area. This cavity is surrounded by fibrous tissue and reactive inflammatory cells (lymphocytes, foamy histiocytes, and giant cells). , Rukshin V, Tsang V, et al. Your comment will be reviewed and published at the journal's discretion. A frequency of 1 MHz was used because the RSH was situated at a depth of more than 2 cm because of abundant subcutaneous fat. They see their family doctors who prescribe anti-inflammatory drugs and maybe some PT, but when the pain doesnt get better, theres often a reluctance to really dig deeper. The gluteal region of the body (the buttocks) consists of three major muscles: gluteus maximus, gluteus medius, and gluteus minimus. To observe the changes in condition, we had not prescribed the pain medication. It is important to have good footwear, be aware of surroundings, especially when the weather is rainy, snowy, or icy. All authors provided concept/idea/project design and consultation (including review of manuscript before submission). Is the patient taking blood thinners? This case report suggests that clinicians should consider the status of the vascular system (potential blood vessel brittleness) when selecting therapeutic massage techniques for patients. Check for errors and try again. Abdominal wall hematomas must be a consideration in all causes of pain in either the right or left iliac fossa. After the first 5 sessions of US therapy, the abdominal discomfort ceased and a progressive diminution of the abdominal mass was observed. The overlying skin might feel warm. We applied this intervention as a result of information from a physical therapist in our hospital. due to the enclosed space and noise the machine makes. Blood transfusion is performed in all type III hematomas. Palatucci V, Lombardi G, Lombardi L, Giglio F, Giordano F, Lombardi D. Spontaneous muscle haematomas: management of 10 cases. Tough Journeys: When Cancer Strikes People Living With Dementia, Sea Spray Can Waft Polluted Coastal Water Inland, Cats, Dogs 'Part of the Family' for Most American Pet Owners: Poll, Dozens of Medical Groups Launch Effort to Battle Health Misinformation. Presentation of spontaneous muscular hematomas are more variable and most commonly present with localized or diffuse pain in the flank or abdomen. Oral anticoagulant therapy was stopped. Acute gluteal compartment syndrome: superior gluteal artery rupture following a low energy injury. Dystrophic calcification can eventually occur. Examining the hip may uncover pain with tenderness over the joint line or the greater trochanter. For example, stopping anticoagulation therapy may be suitable for the management of a patient's spontaneous muscular hematoma but is not reasonable from the perspective of his or her other medical comorbidities. , Chen X, Francis CW, et al. Home Blog Severe Buttocks Pain After a Fall: A Patients Story. Ultrasound therapy was initiated on an outpatient basis 9 days after the diagnosis of RSH. The provisional diagnosis was injury of the SGA with hematoma and pressure on the sciatic nerve. The intervention, including the use of US therapy, may have enabled a rapid resolution of the hematoma. While patients with traumatic muscular hematomas have a very favorable outcome, the mortality of spontaneous muscular hematomas ranges from 4 to 20%. Ultrasound therapy is often used in sports medicine and physical therapy. We believe that US therapy should not be administered when the hematoma is recent because of the risk of new bleeding. We struck up a conversation about his severe buttock pain after a fall. Ultrasonographic findings after intervention revealed a small, elongated anechoic image. It must be applied when the hematoma is organized (when US imaging shows a predominantly hipoechoic mass) and the coagulation parameters are within the correct range (INR=23.5). Common entities that arise in the subcutaneous and deep fat of the gluteal region include fibrous tumors, cellulitis (Figs. IH'm_Cx\M~D dFI4GQ': ( Ws283b`m?hf#LN0 Lf4;?a~w?,9JWW7xSO2@#Zhy}iNZ''7fG_;X>od\L56t{{p27eN8I7=5s b9thSCi$c=p%4= Bz~We[PaesAkvz?-$b7iGni%!P8WX_ _xH>4sge.2!c73zzjb!g<9.Al~([k$[!l1)e7"q)MV7|;h)#r)CYjK%oDhtEpBp}84KIN48XPG3OoNW(q'?7S>N7NAM19{Z>KPnk6-_ythwpk':lkU=l|!VUWi.-HE9ceu!^T5fO%yU]A7J4,Mb@]zPQ His story might be helpful to other patients with buttock pain after falling, as his case was one of a bright, shiny object which looked like the cause of his pain and a more subtle problem which turned out to be the cause. X-ray showed no fracture in the right hip or pelvis. ; During pregnancy: The effect of therapeutic ultrasound on a . Case 2. RP is an ex-military doctor who now makes a living in retirement performing life insurance physicals. Patient reviews and testimonials on this site should not be interpreted as a statement on the effectiveness of our treatments for anyone else. <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 7 0 R] /MediaBox[ 0 0 595.38 841.92] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Ultrasound at a frequency of 1 MHz is absorbed primarily by tissues at a depth of 3 to 5 cm; a frequency of 3 MHz is recommended for more superficial lesions at depths of 1 to 2 cm.17 To our knowledge, the use of US therapy in the management of RSH has not been reported in the literature. 2012;198 (2): W146-51. Severe Buttocks Pain After a Fall: A Patients Story. All symptoms related to buttock pain must be evaluated in terms of their intensity, duration, location, and aggravating or relieving factors. Traumatic hematomas are generally managed conservatively, especially in patients who are not currently receiving treatment with anticoagulants. . Full-text available. However, gluteus maximus hematoma secondary to blunt, low impact trauma has rarely been reported [2]. The gluteus medius tendon, . Dr is looking for a hematoma in the patients buttocks (Ultrasound). Learn about Regenexx procedures for hip conditions. He underwent the Regenexx-PL disc procedure for his irritated low back nerve and I saw him today, without his cane! Showing 1-25: ICD-10-CM Diagnosis Code M76.00 [convert to ICD-9-CM] Gluteal tendinitis, unspecified hip. Perhaps hes making up for all of those years in fatigues. Buttock 76857 Groin 76880 Perineum 76857 Lower Extremity 76880 Other Soft Tissue 76999 . Can Med Assoc J. Chronic hematomas (age range of >3 months) may appear as a mixture of low-intensity dark areas, resulting from the paramagnetic properties of iron . N Superior gluteal artery pseudoaneurysms are rare but should be considered as a differential diagnosis of gluteal swelling and pain, especially in patients with a history of trauma. MRI reveals an encapsulated expansive two-lobes mass located in the right gluteal region. . Fat necrosis occurs, which can liquefy. http://creativecommons.org/licenses/by-nc-nd/4.0/ For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Follow us on socials. Fall from height about 6 days ago. MedicineNet does not provide medical advice, diagnosis or treatment. Become a Gold Supporter and see no third-party ads. Sasson Z, Mangat I, Peckham KA. 81371987, 81171761) from the National Natural Science Foundation of China. On Day 11 post BMP, worsening pain and paresthesias prompted a Doppler ultrasound revealing a IMG2866. Buttock pain after running can be from muscle strain. US Duplex Scan Aorta, IVC, Iliac, Complete - IMG 8047 or IMG 196. Seroma: Anechoic fluid collection internal debris; minimal or no wall hyperemia. 294, used pulsed US to regain some ROM in young pt with a hematoma in the quadriceps. How do medical professionals diagnose a gluteal injury? Approximately 7085% people suffer lower back pain (LBP) at some point in their lives . Falls or direct blows to the buttock can cause bleeding, inflammation, and swelling. When I first examined him, I immediately noticed a large lump in the gluteal muscles of his buttocks. A rubber donut may be used to decrease the pain of sitting on a swollen buttock. Created with. 2 0 obj C. chembree Guru. Chronic lower back pain (CLBP) is one of the most common musculoskeletal disorders in modern society which seriously impacts the people's daily life . A pelvic CT with contrast revealed a 3.42.6 cm gluteal hematoma and a pseudoaneurysm of the right gluteal artery in the right piri-formis muscle immediately adjacent to the right PSIS (Figure 1A). Surgery is not commonly considered but may be an option when nonsurgical treatments have failed, and torn muscles need to be repaired. Copyright Regenexx 2023. 554-610. February 2023; This seemed to be tender so I attempted to remove the blood under ultrasound guidance. Injection granuloma of the buttock. It is essential to inquire about a history of anticoagulant use when there is suspicion of a muscular hematoma, particularly in the geriatric population. {"url":"/signup-modal-props.json?lang=us"}, Gaillard F, Bell D, Sharma R, et al. studied blood vessel elasticity in 373 children and 393 adults and found that arterial compliance decreased with age. Ultrasound examination identified a hematoma within the muscle fibers of left gluteal maximus. [ 3, 14] The advantages of bedside ultrasonography include low cost, portability, patient comfort, speed of detection (usually < 1 min . A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries.A hematoma is benign and is initially in liquid form spread among the tissues including in sacs between tissues where it may coagulate and solidify before blood is . Become a Gold Supporter and see no third-party ads. Around the liquid fat, a calcified rim can form, resulting in an oil cyst. The purpose of this case report is to describe the management and outcomes of a patient with a large RSH secondary to oral anticoagulant therapy. . This can be associated with gluteal tendinopathy (inflammation and damage of the gluteus tendon that attach the gluteal muscles to the greater trochanter). A contusion may result from a direct blow to a muscle when players collide during sports. Robertson This is especially true for elderly patients and those who may have impaired balance. This case was chosen to illustrate multidisciplinary coordination in the management of a large RSH, which included US, and avoidance of surgical intervention and its possible complications. , Vidali M, Zucarotto D, Rodighiero D. Wegener Practitioners should carefully monitor for symptoms of blood loss such as tachycardia, hypotension, and pallor, which can result in anemia and, in more severe cases, organ failure. The purpose of this case report is to describe the intervention, including the use of US, in the management of a large rectus sheath hematoma (RSH) in a patient receiving anticoagulant therapy. See how to prevent strains, sprains, and tears with proper form, stretching, and more. the brain, legs, and lung, and lung infections or diseases like pneumonia Note that, generally, the INR will remain within the therapeutic target. , Lipsius M, Krakauer JS. . Falls are a common cause of a gluteal or buttock contusion. This leads to pain, making it difficult to sit on the buttocks, or stand and/or walk normally because of the decreased range of motion of the hip. 349 results found. Rectus sheath hematoma nearly always presents acutely with sudden onset of abdominal pain and may mimic a variety of abdominal pathologies, such as appendicitis, perforated ulcer, ovarian cyst torsion, intestinal obstruction, ectopic pregnancy, or tumor.2,4,6,7,21 Ultrasound and CT are the imaging methods of choice for the diagnosis of RSH.2,810 The intervention of choice is conservative.2,4,9,10 Surgical intervention is indicated primarily in those cases where hemodynamic stability is not achieved.5, Our patient had RSH with a clinical picture of abdominal pain, an abdominal mass, and anemic syndrome. These muscular hematomas may be traumatic or spontaneous. A CT scan is a low-risk procedure. Baker Discussion. The Morel-Lavalle lesion is a closed soft-tissue degloving injury commonly associated with high-energy trauma. After two to five days hot-cold . De Simone et al. All rights reserved. The outcomes suggest that US therapy accelerates the reabsorption of the hematoma and quickly relieves the abdominal pain. It is also important to consider the presence or absence of accompanying medical issues in order to precisely identify the cause and to help formulate the optimal treatment for pain in the buttocks. The term hematoma describes an area of blood that collects outside of the larger blood vessels. , Garcia-Medina V, Guirao J, Garcia-Medina J. Blum diagnose broken bones, tumors or lesions in areas of the body, blood clots in GJ Most commonly, myositis ossificans occurs within the quadriceps muscles, the brachialis muscle, and the gluteal muscles. Davis DD, Kane SM. JD Bern JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding.