Unmasking lower gastrointestinal bleeding under administration of norepinephrine

Figure 1 Urgent colonoscopy in case 3. A: Revealed diverticular bleeding in the sigmoid colon; B: The endoscopic procedure was performed with three hemoclips; no further signs of bleeding; C: Injection therapy was used; D: Diverticular bleeding of the right colon was detected in case 4.

Figure 2 Final colonoscopy in case 1, which revealed a spurt of bleeding at the right colon during norepinephrine treatment of hemorrhagic shock. A: The bleeding site was clip-marked before the patient was transferred for angiographic treatment; B: Superselective view of the right colic artery after norepinephrine application and coiling (the cumulative dose of norepinephrine was 20 µg).

Figure 3 Angiographic procedure in case 4. A: The ileocolic artery after application of 10 µg of norepinephrine is shown; no sign of extravasation; B: Selective view of the superior mesenteric artery, showing bleeding next to the hemoclip after repeated administration of a cumulative dose of 20 µg of norepinephrine; C: Arterial vasospasm was observed during an ongoing extravasation in the cecum; D: Following extensive embolization, no further bleeding was seen after a cumulative dose of 30 µg of norepinephrine.