Diagnostic and interventional angiography in acute gastrointestinal hemorrhage

Transcatheter Embolization for Treatment of Acute Lower Gastrointestinal Bleeding

Treatment of lower gastrointestinal bleeding was attempted in 13 patients by selective embolization of branches of the mesenteric arteries with Gelfoam. Bleeding was adequately controlled in 11 patients with active bleeding during the examination. One patient improved after embolization but bleeding recurred within 24 hours and in another patient the catheterization was unsuccessful. Five patients with diverticular hemorrhage were embolized in the right colic artery four times, and once in the middle colic artery. Three patients had embolization of the ileocolic artery because of hemorrhage from cecal angiodysplasia, post appendectomy, and leukemia infiltration. Three patients had the superior hemorrhoidal artery embolized because of bleeding from unspecific proctitis, infiltration of the rectum from a carcinoma of the bladder, and transendoscopic polypectomy. One patient was septic and bled from jejunal ulcers. Ischemic changes with infarction of the large bowel developed in two patients and were treated by partial semi-elective colectomy, three and four days after embolization. Four other patients developed pain and fever after embolization. Transcatheter embolization of branches of mesenteric arteries is an effective way to control acute lower gastrointestinal bleeding, but still has a significant rate of complications that must be seriously weighed against the advantages of operation.

Early angiographic embolization is more effective than delayed angiographic embolization in patients with duodenal ulcer bleeding

BACKGROUND AND AIM

Though angiographic embolization (AE) is a type of effective treatment modality for duodenal ulcer bleeding, the optimum time at which to perform the procedure, early or delayed, is unknown. The authors compared the prognosis of early AE (EAE) and delayed AE (DAE) in patients with duodenal ulcer bleeding.

METHODS

A total of 54 patients with duodenal ulcer bleeding were evaluated with first-look endoscopy followed by AE. The patients were divided into two groups, the EAE group and DAE group, according to endoscopic attempts to stop the bleeding during the first-look endoscopy.

RESULTS

The success rate of AE, rebleeding rate, and number of patients who underwent surgery was not significantly different between the EAE group and DAE group (91.3% vs 93.5%, 21.7% vs 29.0% and 4.3% vs 16.1%, respectively; P > 0.05). With respect to death and intensive care unit (ICU) care rate, multivariate analysis showed more favorable results in the EAE group (0% vs 22.6%, P = 0.016 and 4.3% vs 57.4%, P = 0.003, respectively). Multivariate analysis also showed that prolonged prothrombin time (PT) > 1.2 international normalized ratio and the endoscopic attempt were independent factors associated with ICU care.

CONCLUSION

When the AE was performed early with correction for prolonged PT, the patients with duodenal ulcer bleeding had a more favorable prognosis.

Therapeutic management options for patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is one of the most challenging disorders faced by gastroenterologists because of its evasive nature and difficulty in identifying the exact source of bleeding. Recent technological advances such as video capsule endoscopy and small bowel deep enteroscopy have revolutionized the diagnosis and management of patients with OGIB. In this paper, we review the various diagnostic and therapeutic options available for the management of patients with OGIB.

Arterial interventions in gastrointestinal bleeding

The diagnosis and management of gastrointestinal (GI) bleeding are complicated. A multitude of pathologic processes results in GI bleeding, and often, the bleeding is intermittent in nature. Of the available diagnostic tools, angiography has been the gold standard. Management of patients requires a multidisciplinary approach involving gastroenterologists, interventional radiologists, and surgeons. Therapeutic arterial interventions include pharmacologic control with the use of intraarterial vasopressin, embolization with temporary and permanent embolizing materials, and catheter-induced vasospasm.

Detection of active gastrointestinal hemorrhage with CT angiography: a 4(1/2)-year retrospective review

PURPOSE

To retrospectively evaluate the performance of computed tomography (CT) angiography in the detection and localization of clinically active gastrointestinal (GI) hemorrhage of an unknown source.

MATERIALS AND METHODS

Eighty-six CT angiograms were obtained in 74 patients with the clinical diagnosis of acute GI hemorrhage of an unknown source. Results of CT angiography were recorded, and the patients' electronic medical records were reviewed for documentation of subsequent interventional procedures performed within 24 hours of the reference CT angiogram to diagnose or control ongoing GI hemorrhage. Surgical, endoscopic, and final pathologic reports, if available, were reviewed.

RESULTS

Twenty-two of the 86 CT angiograms (26%) were positive for active hemorrhage, with findings confirmed in 19 of the 22 cases (86%). Thirteen cases were confirmed with angiography, five cases were confirmed with surgery, and one case was confirmed with autopsy. Sixty-four of the 86 CT angiograms were negative, and 59 (92%) of the CT angiograms required no further intervention. These patients were discharged without incident. There were no cases in which CT angiography was negative and subsequent angiography within 24 hours was positive. The overall sensitivity, specificity, accuracy, and positive and negative predictive value of CT angiography in the detection of active GI hemorrhage within this study population were 79%, 95%, 91%, 86%, and 92%, respectively.

CONCLUSIONS

CT angiography provides valuable information that can be used to determine the appropriateness of catheter angiography and guide mesenteric catheterization if a bleeding source is localized. The authors' experience with this study cohort supports its use before angiography in those patients with acute GI bleeding of an unknown source who are being considered for catheter-directed intervention.

Short- and long-term results of transcatheter embolization for massive arterial hemorrhage from gastroduodenal ulcers not controlled by endoscopic hemostasis

BACKGROUND AND AIM

Severe bleeding from gastrointestinal ulcers is a life-threatening event that is difficult to manage when endoscopic treatment fails. Transcatheter embolization has been suggested as an alternative treatment in this situation. The present study reports on the efficacy and long-term outcomes of transcatheter embolization after failed endoscopic treatments were assessed in high operative- risk patients.

METHODS

A retrospective review of 60 consecutive emergency embolization procedures in hemodynamically unstable patients (41 men, 19 women; mean [+/-SD] age 69.4+/-15 years) was conducted. Patients were referred for selective angiography between 1999 and 2008 after failed endoscopic treatment of massive bleeding from gastrointestinal ulcers. Mean follow-up was 22 months.

RESULTS

Embolization was feasible and successful in 57 patients. Sandwich coiling of the gastroduodenal artery was used in 34 patients, and superselective occlusion of the terminal feeding artery (with glue, coils or gelatin particles) was used in 23 patients. Early rebleeding occurred in 16 patients and was managed with endoscopy (n=8), reembolization (n=3) or surgery (n=5). No major embolization-related complications occurred. Sixteen patients died within 30 days after embolization (including three who died from rebleeding) and 11 died thereafter. No late bleeding recurrences were reported.

CONCLUSIONS

Selective angiographic embolization is safe and effective for controlling life-threatening bleeding from gastroduodenal ulcers. The procedure usually obviates the need for emergency surgery in these high-risk patients. Survival depends chiefly on underlying conditions.

Evaluation of dual-phase multi-detector-row CT for detection of intestinal bleeding using an experimental bowel model

To evaluate dual-phase multi-detector-row computed tomography (MDCT) in the detection of intestinal bleeding using an experimental bowel model and varying bleeding velocities. The model consisted of a high pressure injector tube with a single perforation (1 mm) placed in 10-m-long small bowel of a pig. The bowel was filled with water/contrast solution of 30-40 HU and was incorporated in a phantom model containing vegetable oil to simulate mesenteric fat. Intestinal bleeding in different locations and bleeding velocities varying from zero to 1 ml/min (0.05 ml/min increments, constant bleeding duration of 20 s) was simulated. Nineteen complete datasets in arterial and portal-venous phase using increasing bleeding velocities, and seven negative controls were measured using a 64 MDCT (3-mm slice thickness, 1.5-mm reconstruction increment). Three radiologists blinded to the experimental settings evaluated the datasets in a random order. The likelihood for intestinal bleeding was assessed using a 5-point scale with subsequent ROC analysis. The sensitivity to detect bleeding was 0.44 for a bleeding velocity of 0.10-0.50 ml/min and 0.97 for 0.55-1.00 ml/min. The specificity was 1.00. The area under the curve was calculated to be 0.73, 0.88 and 0.89 for reader 1, 2 and 3, respectively. Dual-phase MDCT provides high sensitivity and specificity in the detection of intestinal bleeding with bleeding velocities of 0.5-1.0 ml/min. Therefore, MDCT should be considered as a primary diagnostic technique in the management of patients with suspected intestinal bleeding.

Acute Gastrointestinal Bleeding: Emerging Role of Multidetector CT Angiography and Review of Current Imaging Techniques

Acute gastrointestinal bleeding is a common cause of hospitalization, morbidity, and mortality in the United States. The evaluation and treatment of acute gastrointestinal bleeding are complex and often require a multispecialty approach involving gastroenterologists, surgeons, internists, emergency physicians, and radiologists. The multitude of pathologic processes that can result in gastrointestinal bleeding, the length of the gastrointestinal tract, and the often intermittent nature of gastrointestinal bleeding further complicate patient evaluation. In addition, there are multiple imaging modalities and therapeutic interventions that are currently being used in the evaluation and treatment of acute gastrointestinal hemorrhage, each with its own strengths and weaknesses. Initial experience indicates that multidetector computed tomographic angiography is a promising first-line modality for the time-efficient, sensitive, and accurate diagnosis or exclusion of active gastrointestinal hemorrhage and may have a profound impact on the evaluation and subsequent treatment of patients who present with acute gastrointestinal bleeding.

Outcome of acute nonvariceal gastrointestinal haemorrhage after nontherapeutic arteriography compared with embolization

In acute nonvariceal gastrointestinal (GI) bleeding, immediate arteriographic haemostasis is presently assumed to be a therapeutic advantage. This study assesses whether the risk of a delayed haemostasis, caused by arteriographic findings precluding embolization, might influence patient outcome. We performed a 5.5-year retrospective database search to find all patients referred for arteriography to arrest acute nonvariceal GI bleeding with embolization. The embolized and nonembolized patients were compared for differences in baseline characteristics and bleeding parameters. In both groups the outcome of all endoscopic or surgical interventions after catheterization was included in the follow-up. Clinical success (at 30 days, after all therapy) and in-hospital mortality in the embolized and nonembolized group were compared. We retrieved 63 nonembolized bleedings in 58 patients and 49 embolized bleedings in 49 patients. In the nonembolized group, transfusion need and haemodynamic instability were significantly less severe. Forty-two of 63 (66%) nonembolized bleedings persisted requiring haemostasis by surgery (n=23), endoscopy (n=13) or supportive transfusions. Thirteen of 49 (27%) embolized bleedings recurred and were managed by surgery (n=7), endoscopy (n=3) or transfusion. Overall clinical success rate was 88.9% (56 of 63) in the nonembolized and 87.8% (43 of 49) in the embolized group. Mortality rate was 17.2% (10 of 58) in the nonembolized vs 30.6% (15 of 49) in the embolized patients (P=0.115). Whether or not arteriographic findings afforded the opportunity to embolize, outcome of acute nonvariceal GI bleeding did not differ significantly; however, patients undergoing embolization were more critically bleeding and ill.

Morphologic and histopathologic changes in the bowel after super-selective transcatheter embolization for focal lower gastrointestinal hemorrhage

PURPOSE

To evaluate the safety of superselective arterial embolization therapy in the lower gastrointestinal tract. The sequelae on normal enteric tissue in lower gastrointestinal arterial embolization were retrospectively reviewed.

MATERIAL AND METHODS

To control hemorrhage and tumor blood supply, 14 patients were treated by superselective transcatheter embolization at different levels of the colonic and small intestine vessels via the superior and inferior mesenteric arteries using microcoils and/or gelatin sponge. Normal enteric tissues in the embolized areas were analyzed for the occurrence of ischemic changes by clinical follow-up, colonoscopy, and surgery.

RESULTS

Normal bowel function was preserved in 13 patients. In 1 patient treated with numerous gelatin sponge particles delivered from the proximal arcade of the superior mesenteric artery, significant muscular fibrosis occurred.

CONCLUSION

Superselective arterial embolization for lower gastrointestinal hemorrhage can be safely performed by minimizing the amount of embolic materials and delivering them as distally as possible.

Angiography for acute lower gastrointestinal hemorrhage: efficacy of cut film compared with digital subtraction techniques

PURPOSE

To find out if digital subtraction angiography (DSA) has a different diagnostic power than conventional cut-film angiography in investigating acute lower gastrointestinal (GI) hemorrhage.

MATERIALS AND METHODS

Retrospective analysis of two cohorts of patients investigated by angiography for acute lower GI hemorrhage was performed. One group of patients treated at one center ("hospital H") underwent conventional angiography. The other patients, treated at another center ("hospital G"), were investigated exclusively by DSA. The groups were compared for demographic characteristics, etiology, and bleeding parameters. The diagnostic power of both angiographic modalities was compared and statistically analyzed.

RESULTS

Fifty-five lower GI hemorrhages investigated by conventional cut-film angiography and 53 cases studied by DSA were included. Both study groups had statistically similar demographic and bleeding characteristics. Overall sensitivity, specificity, and positive and negative predictive values of cut-film angiography for localizing the lower GI bleeding were 62%, 73%, 86%, and 42%, whereas, for DSA, the respective values were 60%, 100%, 100%, and 24% (Z-test P values were.78,.02,.03, and.16).

CONCLUSIONS

DSA is as sensitive as conventional cut-film angiography for localizing acute lower GI bleeding. If a lesion is found, the chance that it will be the bleeding source is higher with DSA than with conventional angiography.

Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival

PURPOSE

To identify clinical and technical factors influencing the outcome of transcatheter embolotherapy for nonvariceal upper gastrointestinal (GI) hemorrhage and to quantify the impact of successful intervention on patient survival.

MATERIALS AND METHODS

A retrospective review was performed of all patients (n = 163) who underwent arterial embolization for acute upper GI hemorrhage at a university hospital over an 11.5-year period. Clinical success was defined as target area devascularization that resulted in the clinical cessation of bleeding and stabilization of hemoglobin level. The clinical condition of each patient at intervention was defined by history, laboratory examination, and two composite indicator variables. With use of logistic regression, the dependent variable, clinical success, was modeled on two categories of clinical and technical variables. A final model regressed patient survival on clinical success and other clinical variables.

RESULTS

None of the procedural variables analyzed had a significant influence on clinical success. Several clinical variables did impact clinical success, including multiorgan system failure (OR, 0.36; P =.030), coagulopathy (OR, 0.36; P =.026), and bleeding subsequent to trauma (OR, 7.1; P =.040) or invasive procedures (OR, 6.5; P =.009). Regardless of their clinical condition at intervention, patients who underwent clinically successful embolization were 13.3 times more likely to survive than those who had an unsuccessful procedure (CI, 4.54-39.2; P =.000). Nevertheless, patients with multiorgan system failure were 17.5 times more likely to die, independent of the outcome of the procedure (CI, 0.014-0.229; P =.000).

CONCLUSION

Arresting nonvariceal upper GI hemorrhage with transcatheter embolotherapy has a large positive effect on patient survival, independent of clinical condition or demonstrable extravasation at intervention. Aggressive treatment with transcatheter embolotherapy is advisable in patients with acute nonvariceal upper GI hemorrhage.

Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage

PURPOSE

To determine technical and clinical results of embolization of endoscopically unmanageable nonvariceal gastrointestinal hemorrhage (GIH).

MATERIALS AND METHODS

Results of 40 embolizations in 91 patients who underwent arteriography for acute nonvariceal GIH were retrospectively studied. GIH was upper, lower, or transpapillar (hemobilia, pancreatic duct bleeding). Clinical parameters and embolization data were assessed for clinical success and in-hospital survival.

RESULTS

Technical success (bleeding target devascularization) was achieved in all patients except one with upper GIH (39 [98%] of 40 patients). No bowel complications occurred. One partial liver lobe and one partial spleen infarction were noted. Five (13%) of 39 patients bled again within 3 days; all had upper GIH (P =.049). Clinical success (no rebleeding after 30 days) was achieved in 32 (82%) of 39 patients. Clinical success occurred in 13 (68%) of 19 patients with upper GIH, in 10 (91%) of 11 with lower GIH, and in all with transpapillar GIH (P =.084). Mortality rate was 28% (11 of 40 patients), equally spread over upper, lower, and transpapillar GIH (P =.87). Blood loss (hemoglobin level < 80 g/L, P =.041), use of packed cells (P =.049) and fresh frozen plasma (P =.006); shock (P =.047); and corticosteroid use (P =.036) were related to rebleeding. Shock (P =.039) and use of fresh frozen plasma (P =.003) before embolization and rebleeding (P =.012), coagulopathy (P =.007), and need for surgery (P =.03) after embolization were strongly correlated with mortality.

CONCLUSION

Embolization is an effective first approach with lower and transpapillar GIH after endoscopy; it was less effective with upper GIH.

Surgical management of gastrointestinal bleeding

Severe gastrointestinal bleeding has historically been a clinical problem primarily under the purview of the general surgeon. Diagnostic advances made as the result of newer technologies, such as fiberoptic and video endoscopy, selective visceral arteriography, and nuclear scintigraphy, have permitted more accurate and targeted operations. More importantly, they have led to safe, effective nonoperative therapeutic interventions that have obviated the need for surgery in many patients. Today, most gastrointestinal bleeding episodes are initially managed by endoscopic or angiographic control measures. Such interventions are often definitive in obtaining hemostasis. Even temporary cessation or attenuation of massive bleeding in an unstable patient permits a safer, more controlled operative procedure by allowing an adequate period of preoperative resuscitation. Despite the less frequent need for surgical intervention, traditional operative approaches, such as suture ligation, lesion or organ excision, vagotomy, portasystemic anastomosis, and devascularization procedures, continue to be life-saving in many instances. The proliferation of laparoscopic surgery has fostered the application of minimally invasive techniques to highly selected patients with gastrointestinal bleeding. Intraoperative endoscopy has greatly facilitated the accuracy of laparoscopic surgery by endoscopic localization of bleeding lesions requiring excision. It is anticipated that the evolving technologies pertinent to the diagnosis and management of gastrointestinal bleeding will continue to promote collaboration and cooperation between gastroenterologists, radiologists, and surgeons.

Imaging and radiological interventional techniques for gastrointestinal bleeding in children

Causes of pediatric gastrointestinal (GI) bleeding in children are numerous. The role of radiology in defining associated pathology, pinpointing the bleeding site, and intervening to control hemorrhage is discussed here. Barium studies, computed tomography (CT), and magnetic resonance imaging (MRI) each may play a role in identifying the underlying pathology associated with the bleeding. The exact source of bleeding may be localized by means of nuclear scintigraphy as well as selective angiography. In cases of life-threatening or persistent hemorrhage, once a bleeding source is identified, the interventional radiologist may offer percutaneous transcatheter therapy with selective intraarterial vasopressin infusion or embolotherapy.

Embolization of the vasa recta in acute lower gastrointestinal hemorrhage: A report of five cases

PURPOSE

To present our preliminary experience in embolization of the vasa recta in acute gastrointestinal hemorrhage.

METHODS

In four of five patients with acute gastrointestinal hemorrhage superselective embolization of the vasa recta was performed. In one patient in whom superselective catheterization of the bleeding vas rectum was technically impossible, the origin of this vessel was embolized at the level of the terminal arcade. The following embolization materials were used: microcoils and polyvinyl alcohol particles (355-500 microm), n = 2; microcoils only, n = 2; Gelfoam particles, n = 1.

RESULTS

Bleeding was found in two patients in the small bowel (jejunum and ileum) and in three patients in the colon. Immediate hemostasis was achieved in all patients. No signs of ischemia or infarction were observed after intervention.

CONCLUSIONS

Superselective embolization of the vasa recta proved efficient and safe in our small patient group. Advantages of this technique are reduction of the embolized area to a minimum and direct control of hemostasis.

Superselective coil embolization in acute gastrointestinal hemorrhage: personal experience in 10 patients and review of the literature

PURPOSE

To evaluate the safety and efficiency of microcoil embolization in upper and lower gastrointestinal hemorrhage.

PATIENTS AND METHODS

Superselective microcoil embolization was performed in 10 patients (upper gastrointestinal bleeding, n = 3; lower gastrointestinal bleeding, n = 7) who had acute gastrointestinal hemorrhage. Embolization was performed as peripherally as possible with use of coaxial catheter systems. Embolization materials included microcoils (2-4 mm) alone (n = 5), microcoils and polyvinyl alcohol particles (355-500 microm) (n = 4), and microcoils and gelatin sponge particles (n = 1).

RESULTS

Immediate hemostasis was achieved in eight patients. In two patients with dual blood supply of the bleeding site, significant reduction of hemorrhage resulted. In these two patients, it was technically impossible to place the coaxial catheter distally enough to allow safe embolization of both feeding vessels. No clinical signs of ischemia or infarction were observed after intervention.

CONCLUSION

Microcoil embolization is a safe and efficient procedure for controlling acute lower gastrointestinal bleeding if performed in a superselective catheter position. In upper gastrointestinal bleeding, microcoil embolization is an established treatment and can be performed more proximally.

Lower gastrointestinal bleeding

BACKGROUND

Lower gastrointestinal bleeding can be a confusing clinical conundrum, the satisfactory evaluation and management of which requires a disciplined and orderly approach. Diagnosis and management has evolved with the development of new technology such as selective mesenteric angiography and colonoscopy.

PURPOSE

This study was undertaken to review the available data in the literature and to determine the current optimum method of evaluation and management of lower gastrointestinal hemorrhage most likely to result in a successful outcome.

METHODS

Data available on the topic of lower gastrointestinal bleeding in the English literature were obtained via MEDLINE search and were reviewed and analyzed.

RESULTS

The colonic origin of lower gastrointestinal hemorrhage in order of decreasing incidence is diverticulosis, inflammatory bowel disease, including ischemic and infectious colitis, colonic neoplasia, benign anorectal disease, and arteriovenous malformations. Approximately 10 to 15 percent of all cases of rectal bleeding are attributable to a cause that is proximal to the ligament of Treitz. Small intestinal sources such as arteriovenous malformations, diverticula, and neoplasia account for between 3 and 5 percent of all cases. Colonoscopy successfully identified an origin in severe hematochezia in 74 to 82 percent of cases. Mesenteric angiography has a sensitivity of 42 to 86 percent. The best method of management depends on whether hemorrhage persists, the severity of continued hemorrhage, the cumulative transfusion requirement, and the specific origin of bleeding.

CONCLUSION

Lower gastrointestinal hemorrhage is a complex clinical problem that requires disciplined and sophisticated evaluation for successful management. Diverticulosis is the most common cause. Colonoscopy is the diagnostic procedure of choice both for its accuracy in localization and its therapeutic capability. Selective mesenteric angiography should be reserved for those patients in whom colonoscopy is not practical. Precise identification of the bleeding source is crucial for a successful outcome. Specific directed therapy, such as segmental colonic resection for bleeding diverticulosis, is associated with the highest success rate and the lowest morbidity. A complete review of lower gastrointestinal bleeding is contained herein.

Angiographic detection of gastrointestinal bleeding. An experimental comparison of conventional screen-film angiography and digital subtraction angiography

RATIONALE AND OBJECTIVES

The authors experimentally assess and compare the detection limit of gastrointestinal bleeding in digital subtraction angiography (DSA) and conventional screen-film angiography.

MATERIALS AND METHODS

Arterial blood flow was simulated using a tube model in which bleeding was imitated by exudation of liquid containing contrast material. Gut peristalsis was imitated using silicone tubes filled with air and liquid. Images were acquired by DSA and conventional screen-film angiography. The iodine concentration was increased in increments from 1 mg I/mL, with and without simulated peristalsis, and with both free and circumscribed extravasation of contrast material.

RESULTS

The detection limit for free extravasation in DSA was 1 mg I/mL without peristalsis and 60 mg I/mL with peristalsis. The corresponding figures for circumscribed extravasation were 1 mg I/mL and 34 mg I/mL. The detection limit for free extravasation in screen-film angiography was 172 mg I/mL both with and without simulated peristalsis. Circumscribed extravasation was detected at 9 mg I/mL without peristalsis and 7 mg I/mL with peristalsis.

CONCLUSION

Digital subtraction angiography is the more sensitive angiographic technique for detection of gastrointestinal bleeding and is superior to conventional screen-film angiography, provided that it is performed with adequate parasym-pathicolysis and suspended respiration. Only when these requirements cannot be achieved is screen-film angiography advantageous.

Synchronous embolization of the gastroduodenal artery and the inferior pancreaticoduodenal artery in patients with massive duodenal hemorrhage

PURPOSE

To assess the efficacy and safety of synchronous embolization of the gastroduodenal artery (GDA) and inferior pancreaticoduodenal artery (IPDA) in patients with massive duodenal hemorrhage.

PATIENTS AND METHODS

All cases of synchronous embolization of the GDA and IPDA at the authors' hospital between 1980 and 1989 were retrospectively reviewed.

RESULTS

Bleeding was successfully controlled acutely in all six patients who underwent synchronous embolization. Clinical evidence of recurrent hemorrhage was found in two patients, but repeat angiography showed no extravasation of contrast material. Three patients died within 30 days of embolotherapy. In one patient who also received an infusion of vasopressin, postmortem evidence of pancreatic necrosis was found.

CONCLUSION

Synchronous embolization of the GDA and IPDA can be an effective treatment for continuing duodenal hemorrhage after failed endoscopic therapy in patients considered a poor surgical risk. The procedure should be undertaken only as a lifesaving measure due to the risk of pancreatic and duodenal necrosis.

Embolotherapy of massive duodenal hemorrhage

Eleven patients with massive duodenal hemorrhage were treated by emergent embolization. Bleeding originated from duodenal ulcer in three patients, from duodenal tumor in one, from ruptured pancreaticoduodenal artery pseudoaneurysm in three, and from ruptured gastroduodenal artery pseudoaneurysm in four. Complete hemostasis was obtained immediately after embolotherapy in all cases. Three of these patients died during the hospitalization period, one of whom from duodenal infarction and pancreas necrosis induced by embolization. In three patients with duodenal ulcer, complete hemostasis was obtained only by the gastroduodenal artery embolization with Gelfoam particles. Seven patients with pseudoaneurysms of the gastroduodenal artery or its branches required not only blockage of blood flow from the celiac artery but also the superior mesenteric artery for complete hemostasis. Therefore, in patients presenting with duodenal hemorrhage, the possibility of dual blood supply to the duodenum should be considered. Emergent embolization represents a useful alternative to surgery for massive duodenal hemorrhage, but it carries a risk of complications in patients with previous gastroduodenal surgery or significant visceral atherosclerosis.

Emergent embolotherapy of small intestine hemorrhage

The efficacy of emergent embolotherapy was evaluated in six patients suffering hemorrhage from the small intestine. Hemorrhage was from the jejunum in four patients, from the ileum in one, and from Meckel's diverticulum in one. Superselective embolization of the arcade of the small intestine artery branch was performed in all patients with a coaxial catheter. Embolic materials used were Gelfoam particles alone or Gelfoam particles plus coils in earlier cases and microcoils in recent cases. Complete hemostasis was immediately achieved in all patients, but one patient died of disseminated intravascular coagulation. After stabilization of the patient's condition by hemostasis, elective surgery was performed on three patients suffering small intestine ulcer. Histopathologically, no bowel infarction was noted but mild mucosal inflammation with submucosal edema was found in the jejunum of two patients. We recommend embolization for life-threatening small intestine hemorrhage, preferentially in situations where the blood vessel involved can be super-selectively occluded at the nearest level of the arcade of the vasa recta, lest the vasa recta should be occluded.

Aggressive angiographic diagnosis in acute lower gastrointestinal hemorrhage

To assess the value of recently developed aggressive pharmacologic angiographic techniques for the diagnosis of acute lower gastrointestinal hemorrhage, we reviewed our experience with 63 consecutive patients referred for angiography. Hemorrhage was severe as indicated by a mean blood transfusion requirement of 9.4 units. Extravasation of contrast (46%), or an obvious vascular abnormality suggestive of a bleeding site (32%), was identified in 78% of patients. Extravasation was seen more frequently in patients with greater than or equal to 3 units of transfusion (66%) than in those with less than 3 units of transfusion (17%, P less than 0.001). After the introduction of pharmacologic techniques using heparin, tolazoline, streptokinase, and indwelling arterial catheters, the percentage of studies with extravasation of contrast increased from 32 to 65% (P less than 0.01). Application of aggressive angiographic techniques increases the diagnostic yield of angiography in acute severe lower gastrointestinal hemorrhage while exposing the patient to modest increased procedure-related risks which can be accepted in selected patients.

Transcatheter control of postpolypectomy hemorrhage

Intraarterial vasopressin infusion of the inferior mesenteric artery was used in the treatment of 2 patients with massive hemorrhage following colonoscopic polypectomy. Both patients had multiple medical problems and were considered to be very-high-risk candidates for emergency surgery. Arteriography readily demonstrated the site of bleeding, and vasopressin infusion effectively controlled the hemorrhage in both patients without complication. Angiographic management allowed elective colonic resection 1 month later in 1 patient and prevented surgery in the other who has not bled again in the 6 months following the procedure. The role of arteriography in the management of postpolypectomy hemorrhage is discussed.