Interventional Radiology Approach to Nonvariceal … · Nonvariceal Nonvariceal GI Bleeding • •...

Interventional Radiology Approach to Interventional Radiology Approach to NonvaricealNonvariceal GI Hemorrhage GI Hemorrhage

January 9, 2009January 9, 2009

Kurt Kurt HusumHusum

OverviewOverview

•• BackgroundBackground•• AnatomyAnatomy•• PathologyPathology•• Radiological WorkupRadiological Workup•• Selected CasesSelected Cases

NonvaricealNonvariceal GI BleedingGI Bleeding

•• Upper GI vs. Lower GI bleedingUpper GI vs. Lower GI bleeding–– UGI bleedingUGI bleeding

•• 55--8x more common than LGIB (gastritis, ulcers)8x more common than LGIB (gastritis, ulcers)•• endoscopy initial diagnostic evaluation in endoscopy initial diagnostic evaluation in

stable ptsstable pts–– can identify bleeding source 95% of timecan identify bleeding source 95% of time–– TxTx electrocauteryelectrocautery, , sclerotherapysclerotherapy, banding, banding

•• angiography reserved when endoscopy angiography reserved when endoscopy impossible or inconclusive; unstable ptsimpossible or inconclusive; unstable pts

Acute Lower GI BleedingAcute Lower GI Bleeding

•• 300,000 admissions/year in US300,000 admissions/year in US•• 80% colonic in origin80% colonic in origin•• endoscopy often difficult/impossibleendoscopy often difficult/impossible•• radiology provides important role in radiology provides important role in

management of acute LGIB for management of acute LGIB for diagnosis and treatmentdiagnosis and treatment

Clinical Information for GI bleedingClinical Information for GI bleeding

•• what orifice blood is coming fromwhat orifice blood is coming from•• hemodyamichemodyamic stabilitystability•• resuscitative measures already takenresuscitative measures already taken•• NGT, Foley in placeNGT, Foley in place•• endoscopyendoscopy•• coagulopathiescoagulopathies/ corrective measures/ corrective measures•• hxhx GI surgeryGI surgery•• treatment plan following localizationtreatment plan following localization

Vascular AnatomyVascular Anatomy•• Celiac AxisCeliac Axis

–– liver, spleen, stomach, duodenumliver, spleen, stomach, duodenum–– arises at T12arises at T12--L1 L1 interspaceinterspace–– 11stst branch is left gastric arterybranch is left gastric artery

•• supplies gastric supplies gastric fundusfundus and GE junction, and GE junction, anastomosesanastomoses with right and short with right and short gastricsgastrics

–– 22ndnd branch is branch is splenicsplenic arteryartery–– 33rdrd branch is common hepatic arterybranch is common hepatic artery–– dorsal pancreatic artery may arise from dorsal pancreatic artery may arise from

celiac, hepatic, or celiac, hepatic, or splenicsplenic arteries in 10%arteries in 10%–– inferior inferior phrenicphrenic arteries in proximityarteries in proximity

Vascular anatomy Vascular anatomy concon’’tt

•• Celiac artery Celiac artery concon’’tt–– conventional branching in 70%conventional branching in 70%–– any of celiac branches can arise directly any of celiac branches can arise directly

from aorta, or with exception of the left from aorta, or with exception of the left gastric from the SMAgastric from the SMA

AnatomyAnatomy•• Celiac AxisCeliac Axis

commoncommonhepatichepatic

GDAGDA

splenicsplenic

left gastricleft gastric

right gastroepiploic

Vascular Anatomy Vascular Anatomy concon’’tt•• Superior Mesenteric ArterySuperior Mesenteric Artery

–– duodenum, small bowel, colon to duodenum, small bowel, colon to splenicsplenic flexureflexure

–– arises at L1 1arises at L1 1--20 mm below celiac20 mm below celiac–– 11stst branch usually inferior branch usually inferior

pancreaticoduodenalpancreaticoduodenal arteryartery–– 22ndnd branch middle colic branch middle colic –– jejunaljejunal and and ilealileal branchesbranches–– right colic right colic –– ileocolicileocolic–– appendicealappendiceal ((ileocolicileocolic or distal SMA)or distal SMA)

AnatomyAnatomy•• Superior Mesenteric ArterySuperior Mesenteric Artery

middle colic

jejunal branches

ileal branchesright colic

ileocolic

Vascular Anatomy Vascular Anatomy concon’’tt•• Inferior Mesenteric ArteryInferior Mesenteric Artery

–– left and sigmoid colon, proximal rectumleft and sigmoid colon, proximal rectum–– arises left side of distal AA at L3arises left side of distal AA at L3–– 11stst branch is left colicbranch is left colic–– sigmoid branchessigmoid branches–– superior rectal is terminal branchsuperior rectal is terminal branch

•• Internal Iliac ArteriesInternal Iliac Arteries–– middle and inferior rectal arteries arise off middle and inferior rectal arteries arise off

anterior divisionanterior division

AnatomyAnatomy•• Inferior Mesenteric ArteryInferior Mesenteric Artery

left colic

sigmoidbranchessuperior

rectal

Vascular Collateral PathwaysVascular Collateral Pathways•• Celiac to SMACeliac to SMA

–– Arc of BuehlerArc of Buehler–– pancreaticoduodenalpancreaticoduodenal arcadesarcades

•• SMA to IMASMA to IMA–– middle colic to left colicmiddle colic to left colic–– Arc of Arc of RiolanRiolan–– marginal artery of Drummondmarginal artery of Drummond

•• IMA to Internal IliacIMA to Internal Iliac–– via superior via superior hemorrhoidalhemorrhoidal

•• Rectal arcadesRectal arcades

Vascular Anatomy Vascular Anatomy concon’’tt

•• StomachStomach–– fundusfundus primarily via left gastricprimarily via left gastric–– short and posterior short and posterior gastricsgastrics–– body by body by gastroepiploicgastroepiploic artery along artery along

greater curvaturegreater curvature–– lesser curvature by left and right lesser curvature by left and right gastricsgastrics–– antrumantrum and pylorus supplied by right and pylorus supplied by right

gastroepiploicgastroepiploic, right gastric, and , right gastric, and pancreaticoduodenalpancreaticoduodenal arteriesarteries

Vascular Anatomy Vascular Anatomy concon’’tt

•• DuodenumDuodenum–– 11stst and 2and 2ndnd portions from GDA and its portions from GDA and its

branch the superior branch the superior pancreaticoduodenalpancreaticoduodenal arteryartery

–– 33rdrd and 4and 4thth portions from SMA and its portions from SMA and its branch the inferior branch the inferior pancreaticoduodenalpancreaticoduodenal arteryartery

Etiologies of Acute UGIBEtiologies of Acute UGIB•• gastritisgastritis•• PUDPUD•• GastoesophagealGastoesophageal varicesvarices•• MalloryMallory--Weiss tearWeiss tear•• iatrogeniciatrogenic•• AVM / AVM / angiodysplasiaangiodysplasia•• tumortumor•• aneurysm / PSAaneurysm / PSA

Potential ABR Written QuestionPotential ABR Written Question

•• What is a What is a DieulafoyDieulafoy lesion?lesion?

a) iatrogenic injurya) iatrogenic injuryb) congenital malformationb) congenital malformationc) acquired / degenerativec) acquired / degeneratived) related to severe burnsd) related to severe burns

DieulafoyDieulafoy LesionLesion

•• 1898 Paul Georges 1898 Paul Georges DieulafoyDieulafoy–– Rare (<5%) cause of gastric bleedingRare (<5%) cause of gastric bleeding–– CongenitalCongenital

•• Single large tortuous arteriole in Single large tortuous arteriole in submucosasubmucosa, , around 10x normal diameteraround 10x normal diameter

•• 95% gastric 95% gastric fundusfundus; can occur anywhere in GI ; can occur anywhere in GI tracttract

•• Hemorrhage from erosion in overlying mucosa Hemorrhage from erosion in overlying mucosa likely from pulsationlikely from pulsation

–– Treatment with endoscopyTreatment with endoscopy

http://www.gcgeorge.net/2008/07/18/

Etiologies of Acute LGIBEtiologies of Acute LGIB

•• Large Bowel OriginLarge Bowel Origin–– diverticulosisdiverticulosis–– angiodysplasiaangiodysplasia / AVM/ AVM–– colon Cacolon Ca–– polypspolyps–– IBD, other IBD, other colitidescolitides–– rectal disease rectal disease –– vasculitidesvasculitides–– aortoentericaortoenteric fistulafistula

Etiologies of Acute LGIBEtiologies of Acute LGIB

•• Small Bowel OriginSmall Bowel Origin–– AVMAVM–– leiomyomaleiomyoma–– ulcersulcers–– small bowel small bowel varicesvarices–– IBDIBD–– diverticulosisdiverticulosis–– tumorstumors–– MeckelMeckel’’ss diverticulumdiverticulum

Potential ABR Written QuestionPotential ABR Written Question

•• Angiography performed in a patient Angiography performed in a patient with chronic intermittent lower GI bleed with chronic intermittent lower GI bleed demonstrates the following:demonstrates the following:

Angiodysplasia

Hastings, G. S. Radiographics 2000;20:1160-1168

Nuclear Nuclear ScintigraphyScintigraphy

•• stable patient with intermittent stable patient with intermittent hemorrhage, bleeding scan initially hemorrhage, bleeding scan initially performed prior to angiographyperformed prior to angiography

•• both both 99m99mTc RBC and Tc RBC and 99m99mTc colloid usedTc colloid used•• can detect bleeding rates as low as 0.1 can detect bleeding rates as low as 0.1

ml/minml/min•• most centers will proceed to most centers will proceed to angioangio if if

bleeding scan positivebleeding scan positive•• scans not usually helpful in UGIBscans not usually helpful in UGIB

Nuclear Nuclear ScintigraphyScintigraphy

•• most LGIB intermittent, thus chances most LGIB intermittent, thus chances of detecting site of hemorrhage of detecting site of hemorrhage enhanced by radiopharmaceutical with enhanced by radiopharmaceutical with long T1/2 long T1/2

•• scans best for acute LGIB; chronic low scans best for acute LGIB; chronic low volume blood loss rarely benefitvolume blood loss rarely benefit

•• agent of choice agent of choice 99m99mTc RBCTc RBC–– sensitivity upwards of 90%sensitivity upwards of 90%

99m 99m TcTc RBC RBC ScintigraphyScintigraphy

•• In Vitro ProcedureIn Vitro Procedure–– 11--3 ml 3 ml anticoagulatedanticoagulated blood added to vial blood added to vial

with stannous chloridewith stannous chloride–– sodium hypochlorite added to oxidize sodium hypochlorite added to oxidize

extracellular tinextracellular tin–– mixture of citric acid, sodium citrate, and mixture of citric acid, sodium citrate, and

dextrose addeddextrose added–– then then 99m99mTc Tc pertechnetatepertechnetate indroducedindroduced; after ; after

20 minutes cells re20 minutes cells re--injectedinjected•• labellinglabelling efficiency > 95%efficiency > 95%

99m99mTc RBC Tc RBC scintigraphyscintigraphy

•• ImagingImaging–– initial rapid perfusion sequence 2initial rapid perfusion sequence 2--3 3

second abdominal and pelvic images over second abdominal and pelvic images over 3030--60 seconds60 seconds

–– static images then obtained at 5 minute static images then obtained at 5 minute intervals for 60 minutes, thereafter images intervals for 60 minutes, thereafter images taken at 15taken at 15--60 minute intervals60 minute intervals

–– or continuous dynamic computer or continuous dynamic computer acquisition, results viewed in cine formatacquisition, results viewed in cine format

–– 6, 12, 24 hour delayed images obtainable6, 12, 24 hour delayed images obtainable

99m99mTc RBC Tc RBC scintigraphyscintigraphy

•• Imaging Imaging concon’’tt–– free technetium not bound to RBC free technetium not bound to RBC

excreted by kidneys and gastric mucosa excreted by kidneys and gastric mucosa and passes into bladder, small bowel, and passes into bladder, small bowel, coloncolon

99m 99m TcTc RBC RBC ScintigraphyScintigraphy

•• Positive Scan FindingsPositive Scan Findings–– initial focus of activity, which must initial focus of activity, which must

increase and change position over timeincrease and change position over time–– if activity remains in same location, if activity remains in same location,

consider static vascular abnormalityconsider static vascular abnormality–– blood is irritant to intestine, movement of blood is irritant to intestine, movement of

tracer activity often rapid and bidirectionaltracer activity often rapid and bidirectional–– earlier in study that bleeding is seen, more earlier in study that bleeding is seen, more

accurate is degree of localizationaccurate is degree of localization

Positive Positive 99m99mTc RBC ScanTc RBC Scan

http://brighamrad.harvard.edu/Cases/bwh/hcache/126/full.html

99m 99m TcTc Sulfur ColloidSulfur Colloid•• Uncommonly usedUncommonly used

–– inexpensive, easy prep, readily availableinexpensive, easy prep, readily available•• Colloid clears rapidly from Colloid clears rapidly from

intravascular space via RESintravascular space via RES–– good contrast between background and good contrast between background and

extravasatedextravasated isotopeisotope–– disadvantage as bleeding must be actively disadvantage as bleeding must be actively

occurring during short time colloid is occurring during short time colloid is intravascular ( t intravascular ( t ½½ 2.5 to 3.5 minutes)2.5 to 3.5 minutes)

–– liver and spleen activity can obscure liver and spleen activity can obscure flexuresflexures

99m99mTc Bleeding ScansTc Bleeding Scans

•• occasional confusion of bladder occasional confusion of bladder activity within activity within rectosigmoidrectosigmoid bleed can bleed can be resolved with be resolved with postvoidpostvoid or lateral or lateral pelvic imagespelvic images

•• interfering genital activity can also be interfering genital activity can also be confused for bleeding site; oblique or confused for bleeding site; oblique or lateral views helpfullateral views helpful

•• important to watch for free technetium important to watch for free technetium or or pertechnetatepertechnetate artifactsartifacts

99m99mTc RBC: Free Tc RBC: Free PertechnetatePertechnetate??

http://gamma.wustl.edu/gi007te177.html

Nuclear Medicine Nuclear Medicine MeckelMeckel’’ss ScanScan

•• MeckelMeckel’’ss DiverticulumDiverticulum–– congenital congenital diverticulumdiverticulum; vestigial remnant ; vestigial remnant

of of omphalomesentericomphalomesenteric ((vitellinevitelline) duct) duct–– 2% of population2% of population–– 96% lesions will remain asymptomatic96% lesions will remain asymptomatic

•• complications include hemorrhage, complications include hemorrhage, obstruction, obstruction, intussusceptionintussusception, , volvulusvolvulus

–– most common presentation is with most common presentation is with painless rectal bleedingpainless rectal bleeding

–– virtually all cases of bleeding virtually all cases of bleeding MeckelMeckel’’ss involve ectopic gastric mucosa +/involve ectopic gastric mucosa +/-- ulcerulcer

MeckelMeckel’’ss ScanScan

•• imaging based on visualization of imaging based on visualization of ectopic gastric mucosa via intravenous ectopic gastric mucosa via intravenous 99m 99m TcTc pertechnetatepertechnetate

•• dose administered, sequential anterior dose administered, sequential anterior abdominopelvicabdominopelvic images obtained for images obtained for 4545--60 minutes60 minutes

•• positive scan shows focal increased positive scan shows focal increased activity in RLQ or activity in RLQ or midabdomenmidabdomen

MeckelMeckel’’ss ScanScan

•• sensitivity and specificity around 90%sensitivity and specificity around 90%•• sensitivity can be increased bysensitivity can be increased by

–– cimetidinecimetidine to block release of to block release of pertechnetatepertechnetate from gastric mucosafrom gastric mucosa

–– pentagastrinpentagastrin to enhance mucosal uptake to enhance mucosal uptake of of pertechnetatepertechnetate

–– glucagon to decrease small bowel activityglucagon to decrease small bowel activity

Positive Positive 99m99mTc Tc PertechnetatePertechnetate ScanScan

http://jnm.snmjournals.org/cgi/content-nw/full/49/5/776/FIG4

Mesenteric AngiographyMesenteric Angiography

•• positive in only around 50% of casespositive in only around 50% of cases•• should begin with selective injection of should begin with selective injection of

most likely source vessel supplying most likely source vessel supplying site of bleedingsite of bleeding–– celiac for upper GI sourceceliac for upper GI source–– SMA for small bowel and right colonSMA for small bowel and right colon–– IMA for sigmoid and rectumIMA for sigmoid and rectum


•• bleeding not identified on first bleeding not identified on first injection, next most likely artery should injection, next most likely artery should be selectedbe selected

•• celiac injection should be included for celiac injection should be included for LGIB when SMA or IMA injections are LGIB when SMA or IMA injections are negative as middle colic artery is negative as middle colic artery is replaced to dorsal pancreatic artery in replaced to dorsal pancreatic artery in 11--2% of patients2% of patients

•• occasional internal iliac artery occasional internal iliac artery injections needed with occluded IMAinjections needed with occluded IMA


•• filming should be rapid 3filming should be rapid 3--6 frames per 6 frames per second during arterial phase, then second during arterial phase, then slower during portal venous phaseslower during portal venous phase

•• visualization of portal venous phase visualization of portal venous phase mandatory as bleeding can be due to mandatory as bleeding can be due to varicesvarices or venous thrombosisor venous thrombosis

•• IV glucagon can help decrease artifact IV glucagon can help decrease artifact from bowel gas / peristalsisfrom bowel gas / peristalsis


•• Positive Angiographic findingsPositive Angiographic findings–– extravasationextravasation of contrast into bowel lumenof contrast into bowel lumen–– ““pseudoveinpseudovein signsign”” of contrast within of contrast within

gastric gastric rugaerugae–– extravasationextravasation should appear during should appear during

arterial phase, persist during venous arterial phase, persist during venous phase, and change over timephase, and change over time

–– additional signs of vascular abnormalities additional signs of vascular abnormalities include caliber changes, tumor include caliber changes, tumor vascularityvascularity, , aneurysms / PSA, AV shunting etc.aneurysms / PSA, AV shunting etc.

Mesenteric AngiographyMesenteric Angiography•• Digital images should be inspected in Digital images should be inspected in

both subtracted and both subtracted and unsubtractedunsubtracted modesmodes

•• False positive examsFalse positive exams–– barium in prebarium in pre--existing existing diverticuladiverticula, bowel , bowel

gas, densely enhancing veins, hyperemic gas, densely enhancing veins, hyperemic bowel mucosa, adrenal blushbowel mucosa, adrenal blush

•• False negative examsFalse negative exams–– injection of inadequate volumes of injection of inadequate volumes of

contrast, failure to include all vascular bed contrast, failure to include all vascular bed in FOV, wrong artery selectedin FOV, wrong artery selected

Endovascular InterventionEndovascular Intervention

•• Vasopressin Infusion (historical)Vasopressin Infusion (historical)–– pituitary hormone causing smooth muscle pituitary hormone causing smooth muscle

constriction and water retentionconstriction and water retention–– could control bleeding when injected into could control bleeding when injected into

proximal SMA, IMAproximal SMA, IMA•• Best for diffuse mucosal hemorrhage or Best for diffuse mucosal hemorrhage or

bleeding from small caliber arteriesbleeding from small caliber arteries•• Usually started with 0.2 U/min, increased up to Usually started with 0.2 U/min, increased up to

0.4 U/min; once bleeding stopped, continuous 0.4 U/min; once bleeding stopped, continuous infusion, ICU monitoring, taper 24infusion, ICU monitoring, taper 24--48 hrs48 hrs

–– complications including arrhythmias, complications including arrhythmias, coronary and digital ischemiacoronary and digital ischemia

Endovascular InterventionEndovascular Intervention

•• TranscatheterTranscatheter EmbolizationEmbolization–– now used almost exclusively due to rapid now used almost exclusively due to rapid

and definitive resultsand definitive results–– basic objective is to decrease arterial basic objective is to decrease arterial

pressure and flow to point that pressure and flow to point that hemostasishemostasis can occur, without creating symptomatic can occur, without creating symptomatic ischemiaischemia

–– steel or platinum steel or platinum microcoilsmicrocoils, large , large particles, particles, gelfoamgelfoam pledgetspledgets

Common Embolic AgentsCommon Embolic Agents

Boston Scientific VortX® coil

Boston Scientific Contour® PVA particles

Amaral, J. G. et al. Am. J. Roentgenol. 2006;187:W644-W649

TranscatheterTranscatheter EmbolizationEmbolization•• General rule is identification of General rule is identification of

bleeding source prior to bleeding source prior to embolizationembolization–– ExceptionsExceptions

•• empiric left gastric artery empiric left gastric artery embolizationembolization in in patients with endoscopic evidence of patients with endoscopic evidence of fundalfundal or or GE junction lesionsGE junction lesions

•• empiric GDA empiric GDA embolizationembolization in patients with in patients with endoscopic evidence of duodenal lesionsendoscopic evidence of duodenal lesions

–– Bowel should only be Bowel should only be embolizedembolized superselectivelysuperselectively due to risk of ischemiadue to risk of ischemia

•• ideally just proximal to terminal arcade or ideally just proximal to terminal arcade or immediately adjacent to mucosal surface immediately adjacent to mucosal surface

TranscatheterTranscatheter EmbolizationEmbolization

•• technically successful in >90% of technically successful in >90% of cases; cases; rebleedingrebleeding occurs around 20%occurs around 20%

•• pts should be evaluated for pts should be evaluated for development of ischemiadevelopment of ischemia–– delayed ischemic colonic strictures have delayed ischemic colonic strictures have

been reportedbeen reported•• may pass may pass melanoticmelanotic stools long after stools long after

bleeding has stoppedbleeding has stopped

TranscatheterTranscatheter EmbolizationEmbolization

•• Causes of failed Causes of failed embolizationembolization–– failure to recognize collateral supplyfailure to recognize collateral supply–– incomplete occlusionincomplete occlusion–– failure to recognize spasm failure to recognize spasm –– failure to recognize/correct failure to recognize/correct coagulopathycoagulopathy

•• ComplicationsComplications–– non target non target embolizationembolization–– ischemiaischemia–– aneurysm ruptureaneurysm rupture

Provocative AngiographyProvocative Angiography

•• Around 5% of patients will multiple Around 5% of patients will multiple admissions / transfusions for LGIB, admissions / transfusions for LGIB, however repeat radiologic and however repeat radiologic and endoscopic exams are negativeendoscopic exams are negative

•• Adding pharmacologic agents Adding pharmacologic agents (anticoagulants, vasodilators, (anticoagulants, vasodilators, fibrinolyticsfibrinolytics) during standard ) during standard angiographic examinations to induce a angiographic examinations to induce a prohemorrhagicprohemorrhagic state state


•• 11stst described by described by RoschRosch in 1982in 1982–– 3 pts given 50 mg 3 pts given 50 mg tolazolinetolazoline, 10,000 U , 10,000 U

heparin, and combination of 50 mg heparin, and combination of 50 mg tolazolinetolazoline with 60,000 U streptokinasewith 60,000 U streptokinase

•• all three pts had successful provocationall three pts had successful provocation–– 11stst large series by large series by KovatKovat in 1987in 1987

•• increase in diagnostic yield for demonstration increase in diagnostic yield for demonstration of of extravasationextravasation at at angioangio from 32% to 65% in from 32% to 65% in patients who received heparin +/patients who received heparin +/-- tolazolinetolazoline and streptokinase and who had bled in and streptokinase and who had bled in previous 12 hrsprevious 12 hrs


•• Duke study in 2001 by Ryan et alDuke study in 2001 by Ryan et al–– involved 17 provocative angiograms in 16 involved 17 provocative angiograms in 16

patients using a protocol with patients using a protocol with tolazolinetolazoline, , heparin, and heparin, and tPAtPA

–– all pts had previous negative workupsall pts had previous negative workups–– identified site of bleeding in 37.5% of identified site of bleeding in 37.5% of

patients, and found 2 additional vascular patients, and found 2 additional vascular abnormalitiesabnormalities

–– no procedural complications reportedno procedural complications reported


•• Various studies have reported a Various studies have reported a success rate at provoking hemorrhage success rate at provoking hemorrhage of between 29of between 29--80%80%–– Reasons for variable successReasons for variable success

•• lack of standardized regimenlack of standardized regimen•• different combinations of drugs/dosingdifferent combinations of drugs/dosing•• different duration in time from active bleedingdifferent duration in time from active bleeding•• referral patternsreferral patterns•• operator experience operator experience


•• ContraindicationsContraindications–– similar to peripheral similar to peripheral thrombolysisthrombolysis

•• AbsoluteAbsolute–– TIA within 2 months, CVA within 6 monthsTIA within 2 months, CVA within 6 months–– intracranial neoplasmintracranial neoplasm–– craniotomy within 3 monthscraniotomy within 3 months–– mobile left heart thrombusmobile left heart thrombus

•• RelativeRelative–– recent major surgery, trauma, CPRrecent major surgery, trauma, CPR–– uncontrolled HTNuncontrolled HTN–– endocarditisendocarditis–– pregnancy and postpartum periodpregnancy and postpartum period–– severe severe cerebrovascularcerebrovascular diseasedisease


•• FutureFuture–– need for large scale studyneed for large scale study–– optimal protocol has not yet been optimal protocol has not yet been

establishedestablished

Case #1Case #1

•• 73 year old female on chronic NSAIDS 73 year old female on chronic NSAIDS with 6with 6--8 day history of nausea, black 8 day history of nausea, black emesis, emesis, melanoticmelanotic stools found down at stools found down at home and brought to EDhome and brought to ED–– BP 80/40, BP 80/40, HctHct 23, NG 23, NG lavagelavage ++–– endoscopy with large clot in duodenal endoscopy with large clot in duodenal

bulb and 2bulb and 2ndnd portion of duodenumportion of duodenum

Case #1Case #1

Case #2Case #2

•• 46 year old male presented to ED with 46 year old male presented to ED with nausea and nausea and syncopalsyncopal episode.episode.–– vitals stable, found to have vitals stable, found to have HgbHgb 5.7, 5.7, HctHct 1818–– admitted to MICU, transfusedadmitted to MICU, transfused–– large volume large volume hematemesishematemesis–– endoscopy with large duodenal ulcer in endoscopy with large duodenal ulcer in

bulb with adherent clot 4bulb with adherent clot 4--5 cm in diameter5 cm in diameter

Case #2Case #2

Case #2 Case #2 concon’’tt

•• Sent back to MICU, Sent back to MICU, HctHct stabilized over stabilized over next several daysnext several days–– 5 days later, presented with repeat episode 5 days later, presented with repeat episode

of large volume of large volume hematemesishematemesis

Case #3Case #3

•• 67 year old male previously healthy 67 year old male previously healthy with acute onset BRBPRwith acute onset BRBPR–– syncopalsyncopal event at urgent care centerevent at urgent care center–– transferred to regional medical center, transferred to regional medical center,

initial NM RBC scan negativeinitial NM RBC scan negative–– second RBC scan positive in ascending second RBC scan positive in ascending

colon; colon; angioangio negativenegative–– transferred to Duke for elective transferred to Duke for elective

colonoscopycolonoscopy–– over weekend , repeat RBC scan over weekend , repeat RBC scan

performedperformed


•• back to MICU; continued to have back to MICU; continued to have episodic BRBPRepisodic BRBPR

•• colonoscopy demonstrated extensive colonoscopy demonstrated extensive diverticulosisdiverticulosis with multiple polyps in with multiple polyps in cecumcecum and transverse colonand transverse colon

•• surgery consulted; decision made to surgery consulted; decision made to proceed with provocative arteriogramproceed with provocative arteriogram

ReferencesReferences•• Johnston, Johnston, CiaranCiaran et al. Use of Provocative Angiography to Localize Site in Recuret al. Use of Provocative Angiography to Localize Site in Recurrent Gastrointestinal Bleeding. rent Gastrointestinal Bleeding.

CardiovascCardiovasc InterventIntervent RadiolRadiol 2007 30: 10422007 30: 1042--10461046•• KandarpaKandarpa K and K and ArunyAruny JE. Handbook of Interventional Radiologic Procedures. Third EdiJE. Handbook of Interventional Radiologic Procedures. Third Edition. Philadelphia, tion. Philadelphia,

Lippincott, 218Lippincott, 218--226.226.•• Kaufman JA and Lee MJ. Vascular and Interventional Radiology: ThKaufman JA and Lee MJ. Vascular and Interventional Radiology: The Requisites. Philadelphia: Mosby, 2004. 286e Requisites. Philadelphia: Mosby, 2004. 286--

321.321.•• MettlerMettler FA and FA and GuiberteauGuiberteau MJ. Essentials of Nuclear Medicine Imaging. Fifth Edition. PhilMJ. Essentials of Nuclear Medicine Imaging. Fifth Edition. Philadelphia: Saunders, adelphia: Saunders,

2006. 2152006. 215--218.218.•• Miller M, Smith T. Angiographic Diagnosis and Endovascular ManagMiller M, Smith T. Angiographic Diagnosis and Endovascular Management of ement of NonvaricealNonvariceal Gastrointestinal Gastrointestinal

Hemorrhage. Gastroenterology Clinics. 2005 December. Hemorrhage. Gastroenterology Clinics. 2005 December. VolVol 34, Issue 4, 73534, Issue 4, 735--752752•• Ryan JM et al. Ryan JM et al. ““NonlocalizedNonlocalized lower gastrointestinal bleeding: provocative bleeding studies wlower gastrointestinal bleeding: provocative bleeding studies with ith intraarterialintraarterial tPAtPA, ,

heparin, and heparin, and tolazolinetolazoline. JVIR. 2001 Nov; 12 (11), 1273. JVIR. 2001 Nov; 12 (11), 1273--77•• SuhockiSuhocki PV. Provocative Angiography for Obscure Gastrointestinal BleediPV. Provocative Angiography for Obscure Gastrointestinal Bleeding. Techniques in Gastrointestinal ng. Techniques in Gastrointestinal

Endoscopy, 2003 Endoscopy, 2003 VolVol 5, No 3 (July). pp 1215, No 3 (July). pp 121--126126•• Tan K, Wong D, Tan K, Wong D, SimSim R. R. SuperselectiveSuperselective EmbolizationEmbolization for Lower Gastrointestinal Hemorrhage: An institutional for Lower Gastrointestinal Hemorrhage: An institutional

Review over 7 Years. World J Review over 7 Years. World J SurgSurg 2008 32: 27072008 32: 2707--27152715

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