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Hegde S, Sutphin PD, Zurkiya O, Kalva SP. Provocative mesenteric angiography for occult gastrointestinal bleeding: a systematic review. CVIR Endovasc 2023; 6:42. [PMID: 37589781 PMCID: PMC10435437 DOI: 10.1186/s42155-023-00386-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/28/2023] [Indexed: 08/18/2023] Open
Abstract
Occult gastrointestinal bleeding (GIB) is a challenge for physicians to diagnose and treat. A systematic literature search of the PubMed and Embase databases was conducted up to January 1, 2023. Eligible studies included primary research studies with patients undergoing provocative mesenteric angiography (PMA) for diagnosis or localization of occult GIB. Twenty-seven articles (230 patients) were included in the review. Most patients (64.8%) presented with lower GIB. The average positivity rate for provocative angiography was 48.7% (58% with heparin and 46.7% in thrombolytics). Embolization was performed in 46.4% of patients, and surgical management was performed in 37.5%. Complications were rare. PMA can be an important diagnostic and treatment tool but studies with high-level evidence and standardized protocols are needed to establish its safety and optimal use.
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Affiliation(s)
- Siddhi Hegde
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Patrick D Sutphin
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Omar Zurkiya
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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2
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Werner DJ, Wenzel N, Abusalim N, Kiesslich R, Baar T, Tresch A, Rey JW. Unmasking lower gastrointestinal bleeding under administration of norepinephrine. World J Radiol 2022; 14:375-383. [PMID: 36605886 PMCID: PMC9808013 DOI: 10.4329/wjr.v14.i12.375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/24/2022] [Accepted: 12/01/2022] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Bleeding in the gastrointestinal tract is common and transarterial embolization enables the clinician to control gastrointestinal bleeding. Contrast extravasation is a prerequisite for successful embolization. Provocative angiography is helpful in the detection of elusive bleeding.
AIM We performed a retrospective analysis of angiographic treatment in patients with lower gastrointestinal hemorrhage and initially negative angiographies, as well as the role of norepinephrine (NE) in unmasking bleeding.
METHODS We analyzed 41 patients with lower gastrointestinal bleeding after angiography who had undergone treatment over a period of 10 years. All patients had a positive shock index and needed intensive care.
RESULTS In three of four patients, angiography disclosed the site of bleeding when NE was used during the procedure for hemodynamic stabilization.
CONCLUSION We suggest that angiography performed after the administration of NE in unstable patients with gastrointestinal bleeding and an initially negative angiography has the potential to unmask bleeding sites for successful embolization. However, this statement must be confirmed in prospective studies.
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Affiliation(s)
- David John Werner
- Department of Radiology, Helios Dr. Horst-Schmidt-Clinic, Wiesbaden 65199, Hessen, Germany
- Radiologie Rhein-Nahe, Krankenhaus St. Marienwörth, Bad Kreuznach 55543, Rheinland-Pfalz, Germany
| | - Nicolai Wenzel
- Department of Radiology, Helios Dr. Horst-Schmidt-Clinic, Wiesbaden 65199, Hessen, Germany
| | - Nael Abusalim
- Department of Radiology, Helios Dr. Horst-Schmidt-Clinic, Wiesbaden 65199, Hessen, Germany
- Department of Diagnostic and Interventional Radiology, Medical Center Hanau, Hanau 63450, Hessen, Germany
| | - Ralf Kiesslich
- Department of Internal Medicine II, Helios Dr. Horst-Schmidt-Clinic, Wiesbaden 65199, Hessen, Germany
| | - Till Baar
- Institute for Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne 50923, Nordrhein-Westfalen, Germany
| | - Achim Tresch
- Institute for Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne 50923, Nordrhein-Westfalen, Germany
| | - Johannes Wilhelm Rey
- Department of Internal Medicine II, Helios Dr. Horst-Schmidt-Clinic, Wiesbaden 65199, Hessen, Germany
- Department of Gastroenterology and Endoscopy, Medical Center Osnabrueck, Osnabrueck 49076, Niedersachsen, Germany
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Raines DL, Adler DG. The Role of Provocative Testing and Localization of the Video Capsule Endoscope in the Management of Small Intestinal Bleeding. Gastrointest Endosc Clin N Am 2021; 31:317-330. [PMID: 33743928 DOI: 10.1016/j.giec.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The cause of small intestinal bleeding (SIB) may be elusive despite exhaustive testing. This article describes the current understanding of SIB regarding evaluation, with emphasis on the use of video capsule endoscopy (VCE) as a diagnostic procedure. This article addresses the utility of provocative testing in challenging cases and the performance of endoscopic procedures on active antithrombotic therapy. Specific recommendations accompany this article, including use of antithrombotic agents to stimulate bleeding when clearly indicated; performance of endoscopic procedures on active antithrombotic therapy; and progressive adoption of VCE and device-assisted enteroscopy in the inpatient setting.
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Affiliation(s)
| | - Douglas G Adler
- University of Utah School of Medicine, 30 North 1900 East 4R118, Salt Lake City, UT 84132, USA
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Kokoroskos N, Naar L, Peponis T, Martinez M, El Moheb M, El Hechi M, Alser O, Fuentes E, Velmahos G. Provocative Angiography, Followed by Therapeutic Interventions, in the Management of Hard-To-Diagnose Gastrointestinal Bleeding. World J Surg 2021; 44:2944-2949. [PMID: 32405731 DOI: 10.1007/s00268-020-05545-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite significant advances in imaging and endoscopic diagnostic techniques, adequate localization of gastrointestinal bleeding (GIB) can be challenging. Provocative angiography (PROVANGIO) has not been part of the standard diagnostic algorithms yet. We sought to examine the ability of PROVANGIO to identify the bleeding source when conventional radiography fails. METHODS Patients undergoing PROVANGIO for GIB during 2008-2014 were retrospectively included. Demographics and periprocedural patient characteristics were recorded. PROVANGIO was performed in a multidisciplinary setting, involving interventional radiology, surgery and anesthesiology teams, ready to intervene in case of uncontrolled bleeding. The procedure included conventional angiography of the celiac, superior and inferior mesenteric arteries (SMA, IMA) followed by a stepwise bleeding provocation with anticoagulating, vasodilating and/or thrombolytic agent administration, combined with angiography. RESULTS Twenty-three PROVANGIO were performed. Patients were predominantly male (15, 65.2%), and hematochezia was the most common presenting symptom (12, 52.2%). Patients with a positive PROVANGIO had lower Charlson comorbidity index (1 vs. 7, p = 0.009) and were less likely to have a prior history of GIB (14.3% vs. 87.5%, p = 0.001). PROVANGIO localized bleeding in 7 (30%) patients. In 6 out of 7 patients, the bleeding source was identified in the SMA and, in one case, in the IMA distribution. The bleeding was controlled angiographically in four cases, endoscopically in one case and surgically in the remaining two. No complications related to PROVANGIO were detected. CONCLUSIONS In our series, PROVANGIO safely identified the bleeding source, and provided that necessary safeguards are put into place, we recommend incorporating it in the diagnostic algorithms for GIB management.
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Affiliation(s)
- Nikolaos Kokoroskos
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
| | - Leon Naar
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Thomas Peponis
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Myriam Martinez
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Mohamad El Moheb
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Majed El Hechi
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Osaid Alser
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Eva Fuentes
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - George Velmahos
- Division of Trauma, Department of Surgery, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
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Kariya S, Nakatani M, Ono Y, Maruyama T, Ueno Y, Yoshida A, Komemushi A, Tanigawa N. Provocative angiography for lower gastrointestinal bleeding. Jpn J Radiol 2019; 38:248-255. [DOI: 10.1007/s11604-019-00909-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 12/02/2019] [Indexed: 12/16/2022]
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Loffroy R, Falvo N, Nakai M, Pescatori L, Midulla M, Chevallier O. When all else fails - Radiological management of severe gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101612. [PMID: 31785732 DOI: 10.1016/j.bpg.2019.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/15/2019] [Indexed: 02/08/2023]
Abstract
Although most cases of acute nonvariceal gastrointestinal bleeding (GIB) either spontaneously resolve or respond to medical management and endoscopic therapy, there are still a significant proportion of severe patients who require emergency angiography and endovascular treatment. Over the past three decades, transcatheter arterial embolization (TAE) has become the first-line therapy for the management of acute nonvariceal GIB that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer liquid embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the treatment of bleeding for a variety of indications. TAE is a safe and effective minimally invasive alternative to surgery, when endoscopic treatment fails to control acute bleeding from the gastrointestinal tract. In this article we review the current role of angiography and TAE in the management of acute nonvariceal GIB.
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Affiliation(s)
- Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France.
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Motoki Nakai
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Lorenzo Pescatori
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
| | - Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, François-Mitterrand University Hospital, Dijon, France
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Storace M, Martin JG, Shah J, Bercu Z. CTA As an Adjuvant Tool for Acute Intra-abdominal or Gastrointestinal Bleeding. Tech Vasc Interv Radiol 2017; 20:248-257. [DOI: 10.1053/j.tvir.2017.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Raines DL, Jex KT, Nicaud MJ, Adler DG. Pharmacologic provocation combined with endoscopy in refractory cases of GI bleeding. Gastrointest Endosc 2017; 85:112-120. [PMID: 27343413 DOI: 10.1016/j.gie.2016.06.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 06/02/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The source of GI bleeding may elude us despite exhaustive testing in some cases. Bleeding in these cases is often related to a vascular lesion that is discernible only when actively bleeding. The objective of this study was to determine the efficacy and safety of endoscopy combined with the administration of antiplatelet and/or anticoagulant agents to stimulate bleeding in order to define a source. METHODS A retrospective review of a database of device-assisted enteroscopy (DAE) procedures was completed to identify cases in which provocation with antiplatelet or anticoagulant agents was used as part of a GI bleeding evaluation. Procedures were divided into 3 groups based on the method of provocation: patients with a history of bleeding associated with an antiplatelet/anticoagulant (provocation-experienced); patients naïve to these medications (provocation-naïve); and cases of recurrent, overt GI bleeding in which a combination of clopidogrel and intravenous heparin was administered for provocation (Lousiana State University [LSU] protocol). RESULTS A review of 824 DAE procedures was completed to identify a total of 38 instances in which provocation was attempted in 27 patients. These cases were subdivided into 13 provocation-experienced procedures, 18 provocation-naïve procedures, and 7 LSU protocol procedures. The diagnostic yield of provocative testing per procedure was 53% in the provocation-experienced group, 27% in the provocation-naïve group, and 71% in the full protocol group. Provocative testing was revealing in 15 of 27 patients; angioectasias and Dieulafoy lesions were the most common pathologies. Provocative testing was not beneficial in 4 patients who were eventually diagnosed with bleeding caused by intestinal angioectasias (3) and an aorto-enteric fistula (1). There were no adverse events. CONCLUSIONS Provocative testing combined with endoscopy can be justified as an option in the diagnostic algorithm of complex cases of GI bleeding when intermittent bleeding related to a vascular lesion, such as an angioectasia or Dieulafoy, is suspected. However, this novel technique should be considered only after standard management has failed to define a bleeding source, and bleeding continues to recur. This is the first reported case series of provocative testing combined with endoscopy.
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Affiliation(s)
| | - Kellen T Jex
- LSU Health Sciences Center, New Orleans, Louisiana
| | | | - Douglas G Adler
- University of Utah School of Medicine, Salt Lake City, Utah, USA
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9
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Letter Reply Re: “Endoscopy-Guided Empiric Arterial Embolization for Angiographically Negative Upper Gastrointestinal Bleeding: Use it Without Fear!”. Cardiovasc Intervent Radiol 2013; 36:869. [DOI: 10.1007/s00270-013-0587-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Accepted: 02/12/2013] [Indexed: 11/25/2022]
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10
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Anil G, Tan AGS. Re: emergency gastroduodenal artery embolization by sandwich technique for angiographically obvious and oblivious, endotherapy failed bleeding duodenal ulcers. A reply. Clin Radiol 2012; 68:105. [PMID: 22878064 DOI: 10.1016/j.crad.2012.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 06/22/2012] [Accepted: 07/05/2012] [Indexed: 10/28/2022]
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Loffroy RF, Abualsaud BA, Lin MD, Rao PP. Recent advances in endovascular techniques for management of acute nonvariceal upper gastrointestinal bleeding. World J Gastrointest Surg 2011; 3:89-100. [PMID: 21860697 PMCID: PMC3158888 DOI: 10.4240/wjgs.v3.i7.89] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 07/09/2011] [Accepted: 07/15/2011] [Indexed: 02/06/2023] Open
Abstract
Over the past two decades, transcatheter arterial embolization has become the first-line therapy for the management of upper gastrointestinal bleeding that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the management of hemorrhage for a variety of indications, such as peptic ulcer bleeding, malignant disease, hemorrhagic Dieulafoy lesions and iatrogenic or trauma bleeding. Transcatheter interventions include the following: selective embolization of the feeding artery, sandwich coil occlusion of the gastroduodenal artery, blind or empiric embolization of the supposed bleeding vessel based on endoscopic findings and coil pseudoaneurysm or aneurysm embolization by three-dimensional sac packing with preservation of the parent artery. Transcatheter embolization is a fast, safe and effective, minimally invasive alternative to surgery when endoscopic treatment fails to control bleeding from the upper gastrointestinal tract. This article reviews the various transcatheter endovascular techniques and devices that are used in a variety of clinical scenarios for the management of hemorrhagic gastrointestinal emergencies.
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Affiliation(s)
- Romaric F Loffroy
- LE2I Laboratory, CNRS UMR 5158, Department of Vascular and Interventional Radiology, University of Dijon School of Medicine, Bocage Teaching Hospital, 2 Bd Maréchal de Lattre de Tassigny, BP 77908, 21079 Dijon, France
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Kim CY, Suhocki PV, Miller MJ, Khan M, Janus G, Smith TP. Provocative Mesenteric Angiography for Lower Gastrointestinal Hemorrhage: Results from a Single-institution Study. J Vasc Interv Radiol 2010; 21:477-83. [DOI: 10.1016/j.jvir.2009.11.021] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 10/26/2009] [Accepted: 11/30/2009] [Indexed: 12/21/2022] Open
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Johnston C, Tuite D, Pritchard R, Reynolds J, McEniff N, Ryan JM. Use of provocative angiography to localize site in recurrent gastrointestinal bleeding. Cardiovasc Intervent Radiol 2008; 30:1042-6. [PMID: 17587076 DOI: 10.1007/s00270-007-9107-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND While the source of most cases of lower gastrointestinal bleeding may be diagnosed with modern radiological and endoscopic techniques, approximately 5% of patients remain who have negative endoscopic and radiological investigations [1]. CLINICAL PROBLEM These patients require repeated hospital admissions and blood transfusions, and may proceed to exploratory laparotomy and intraoperative endoscopy. The personal and financial costs are significant. METHOD OF DIAGNOSIS AND DECISION MAKING The technique of adding pharmacologic agents (anticoagulants, vasodilators, fibrinolytics) during standard angiographic protocols to induce a prohemorrhagic state is termed provocative angiography. It is best employed when significant bleeding would otherwise necessitate emergency surgery. TREATMENT This practice frequently identifies a bleeding source (reported success rates range from 29 to 80%), which may then be treated at the same session. We report the case of a patient with chronic lower gastrointestinal hemorrhage with consistently negative endoscopic and radiological workup, who had an occult source of bleeding identified only after a provocative angiographic protocol was instituted, and who underwent succeeding therapeutic coil embolization of the bleeding vessel.
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Affiliation(s)
- Ciaran Johnston
- Department of Radiology, St. James' Hospital, Dublin 8, Ireland.
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Abstract
GOALS To present the results of a new protocol for provocative visceral arteriography. BACKGROUND Acute lower gastrointestinal hemorrhage (LGIB) usually stops spontaneously. In the absence of an identifiable source, if bleeding is recurrent, provocative visceral arteriography has been advocated for diagnosis. Prior studies using Streptokinase, Urokinase, or tissue plasminogen activator have reported a 33% to 37.5% rate of identifying the site of hemorrhage. STUDY We report a retrospective analysis of 9 patients in whom provocative visceral arteriography was performed using a new protocol with Reteplase as the fibrinolytic agent. All patients had recurrent, massive LGIB without definable source. Initial arteriography did not elicit a site of bleeding. Five units of Reteplase were administered over 1 minute into the inferior mesenteric artery, the superior mesenteric artery or both vessels sequentially. Arteriography was repeated after 5 to 10 minutes. RESULTS Colonic hemorrhage was induced in 89% of patients. There were no procedure-related complications. CONCLUSIONS Reteplase may prove safe and effective as a provocative agent, stimulating bleeding to allow localization, in patients with occult, recurrent, massive LGIB.
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Affiliation(s)
- David M Widlus
- Department of Radiology, Northwest Hospital Center, 5401 Old Court Road, Randallstown, MD 21133, USA.
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Burke SJ, Golzarian J, Weldon D, Sun S. Nonvariceal upper gastrointestinal bleeding. Eur Radiol 2006; 17:1714-26. [PMID: 17058080 DOI: 10.1007/s00330-006-0477-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Revised: 08/11/2006] [Accepted: 08/25/2006] [Indexed: 12/27/2022]
Abstract
Nonvariceal upper gastrointestinal bleeding (NUGB) remains a major medical problem even after advances in medical therapy with gastric acid suppression and cyclooxygenase (COX-2) inhibitors. Although the incidence of upper gastrointestinal bleeding presenting to the emergency room has slightly decreased, similar decreases in overall mortality and rebleeding rate have not been experienced over the last few decades. Many causes of upper gastrointestinal bleeding have been identified and will be reviewed. Endoscopic, radiographic and angiographic modalities continue to form the basis of the diagnosis of upper gastrointestinal bleeding with new research in the field of CT angiography to diagnose gastrointestinal bleeding. Endoscopic and angiographic treatment modalities will be highlighted, emphasizing a multi-modality treatment plan for upper gastrointestinal bleeding.
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Affiliation(s)
- Stephen J Burke
- Department of Radiology, University of Iowa, Iowa, IA 52242-1107, USA
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16
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Abstract
Modern transcatheter embolization has emerged as a viable option for the treatment of lower gastrointestinal (LGI) hemorrhage. Over the last decade, steady data has accumulated showing the safety and effectiveness of superselective microcoil embolization within the colon. In light of such results, the application of microcatheter-based skills has become more important in an algorithm for managing LGI bleeding. The purpose of this article is to discuss the modern embolization technique while also reviewing traditional and experimental transcatheter methods that may prove useful in the appropriate clinical settings. While recognizing that transcatheter therapy continues to evolve, the proposed indications for these current treatments are reviewed.
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Affiliation(s)
- William T Kuo
- Department of Diagnostic Radiology, Division of Vascular and Interventional Radiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642-8648, USA
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Duchesne J, Jacome T, Serou M, Tighe D, Gonzales A, Hunt J, Marr A, Weintraub S. CT-Angiography for the Detection of a Lower Gastrointestinal Bleeding Source. Am Surg 2005. [DOI: 10.1177/000313480507100505] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The evaluation of lower gastrointestinal bleeding (LGIB) often involves the collaborative efforts of the gastroenterologist, radiologist, and surgeon. Efforts to localize the acute LGIB have traditionally involved colonoscopy, technetium-labeled red blood cell (RBC) scintigraphy, angiography, or a combination of these modalities. The sensitivity of each method of diagnosis is limited, with the most common cause of a negative study the spontaneous cessation of hemorrhage. Other technical factors include vasospasm, lack of adequate contrast volume or exposure time, a venous bleeding source, and a large surface bleeding area. We report the use of multidetector computed tomography (MDCT), or CT-angiography (CT-A), in the initial evaluation of LGIB, and speculate on the incorporation of this technique into a diagnostic algorithm to treat LGIB. MDCT may offer a very sensitive means to evaluate the source of acute LGIB, while avoiding some of the morbidity and intense resource use of contrast angiography, and may provide unique morphologic information regarding the type of pathology. Screening with the more rapid and available MDCT, followed by either directed therapeutic angiography or surgical management, may represent a reasonable algorithm for the early evaluation and management of acute LGIB in which an active bleeding source is strongly suspected.
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Affiliation(s)
- J. Duchesne
- Departments of Surgery, LSU School of Medicine in New Orleans, New Orleans, Louisiana
| | - T. Jacome
- Departments of Surgery, LSU School of Medicine in New Orleans, New Orleans, Louisiana
| | - M. Serou
- Departments of Radiology, LSU School of Medicine in New Orleans, New Orleans, Louisiana
| | - D. Tighe
- Departments of Radiology, LSU School of Medicine in New Orleans, New Orleans, Louisiana
| | - A. Gonzales
- Departments of Radiology, LSU School of Medicine in New Orleans, New Orleans, Louisiana
| | - J.P. Hunt
- Departments of Surgery, LSU School of Medicine in New Orleans, New Orleans, Louisiana
| | - A.B. Marr
- Departments of Surgery, LSU School of Medicine in New Orleans, New Orleans, Louisiana
| | - S.L. Weintraub
- Departments of Surgery, LSU School of Medicine in New Orleans, New Orleans, Louisiana
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Wright CA, Petersen BT, Bridges CM, Alexander JA. Heparin provocation for identification and treatment of a gastric Dieulafoy's lesion. Gastrointest Endosc 2004; 59:728-30. [PMID: 15114325 DOI: 10.1016/s0016-5107(04)00161-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Curtis A Wright
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
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Defreyne L, Vanlangenhove P, De Vos M, Pattyn P, Van Maele G, Decruyenaere J, Troisi R, Kunnen M. Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology 2001; 218:739-48. [PMID: 11230648 DOI: 10.1148/radiology.218.3.r01mr05739] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- L Defreyne
- Departments of Radiology and Medical Imaging, University Hospital of Gent, De Pintelaan 185, B-9000 Gent, Belgium.
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Gallardo L, Górriz E, Dolores Pardo M, Reyes R. Uso del CO2 como medio de contraste angiográfico en el diagnóstico de hemorragia hepática aguda: a propósito de un caso. RADIOLOGIA 2001. [DOI: 10.1016/s0033-8338(01)78008-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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21
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Bloomfeld RS, Smith TP, Schneider AM, Rockey DC. Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin. Am J Gastroenterol 2000; 95:2807-12. [PMID: 11051352 DOI: 10.1111/j.1572-0241.2000.03191.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE A standard diagnostic evaluation including upper and/or lower endoscopy, tagged red blood cell scintigraphy, and visceral angiography identifies the source of GI bleeding in the majority of patients who present with acute GI hemorrhage. However, in a small group of patients the source of bleeding remains obscure; this form of GI hemorrhage is uncommon but represents a considerable diagnostic challenge. Some investigators have advocated provocation of bleeding with vasodilators, anticoagulants, and/or thrombolytics in association with tagged red blood cell scans or angiography. Unfortunately, the available literature on this topic is limited. Therefore, the purpose of this study is to report our experience with provocative GI bleeding studies. METHODS The radiology databases at Duke University Medical Center and the Durham Veterans Administration Medical Center were reviewed from 1994 to 1999. Any patient who received a vasodilator, anticoagulant, or thrombolytic to induce bleeding during a tagged red blood cell scan or visceral angiogram was included. RESULTS Seven provocative bleeding studies were performed on seven patients. All patients underwent a visceral angiogram with intra-arterial administration of tolazoline (a vasodilator), heparin (an anticoagulant), and/or urokinase (a thrombolytic). Of the seven provocative studies, only two induced angiographically identifiable bleeding. Both of these patients underwent surgical therapy. There were no complications attributed to the provocative bleeding studies. CONCLUSIONS These results suggest that provocative GI bleeding studies can be performed safely. However, because an active bleeding source was identified in only a small proportion of patients, we believe that further study is required to optimize patient selection and to clarify the cost-effectiveness of this approach in patients with GI hemorrhage of obscure origin.
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Affiliation(s)
- R S Bloomfeld
- Department of Medicine and Radiology, Duke University Medical Center, Durham, North Carolina, USA
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22
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Berkelhammer C, Radvany A, Lin A, Hopkins W, Principe J. Heparin provocation for endoscopic localization of recurrent obscure GI hemorrhage. Gastrointest Endosc 2000; 52:555-6. [PMID: 11023582 DOI: 10.1067/mge.2000.108929] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- C Berkelhammer
- Departments of Medicine, Pathology and Surgery, Christ Hospital, University of Illinois, Oak Lawn, Illinois, USA
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23
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Affiliation(s)
- G S Hastings
- Department of Diagnostic Imaging, Division of Interventional Radiology, University of Maryland School of Medicine, Baltimore 21201-1595, USA.
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24
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Zuckerman GR, Prakash C, Askin MP, Lewis BS. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology 2000; 118:201-21. [PMID: 10611170 DOI: 10.1016/s0016-5085(00)70430-6] [Citation(s) in RCA: 319] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics committee. The paper was approved by the committee on May 16, 1999, and by the AGA governing board on July 18, 1999.
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Affiliation(s)
- G R Zuckerman
- Division of Gastroenterology Washington University School of Medicine St. Louis, Missouri, USA
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25
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Pennoyer WP, Vignati PV, Cohen JL. Mesenteric angiography for lower gastrointestinal hemorrhage: are there predictors for a positive study? Dis Colon Rectum 1997; 40:1014-8. [PMID: 9293927 DOI: 10.1007/bf02050921] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Selective mesenteric angiography is an expensive, invasive, diagnostic, and therapeutic tool for lower gastrointestinal hemorrhage. Some institutions have required a positive nuclear medicine bleeding scan before angiography. We have attempted to determine if this is a valid screening test for mesenteric angiography. Are there any other factors to predict which patients are actively bleeding and who will benefit from angiography? METHODS All cases of mesenteric angiography for hemorrhage performed during a 12-year period were reviewed. RESULTS A total of 131 angiograms were performed during a 12-year period with 45 patients demonstrating active bleeding; 54 patients had a bleeding scan before angiography. A positive bleeding scan did not increase the percentage of positive angiograms. A history of prior gastrointestinal bleeding, transfusions, orthostatic hypotension, or tachycardia were not predictors for a positive angiogram. DISCUSSION This study could not identify any single useful predictor that will increase the likelihood of obtaining a positive angiogram. Nuclear medicine scans should not be used routinely as a screening test for angiography.
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Affiliation(s)
- W P Pennoyer
- Department of Surgery, Hartford Hospital, Connecticut, USA
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26
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Kerr A, Spector J, Mokrzycki M, Blau S, Simon R. Vasodilator provocation of occult urinary tract hemorrhage. THE JOURNAL OF TRAUMA 1996; 40:152-4. [PMID: 8576984 DOI: 10.1097/00005373-199601000-00033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This case demonstrates the use of vasodilators to reactivate an intermittent urinary tract hemorrhage. The site of bleeding was demonstrated and treated with subselective embolization.
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Affiliation(s)
- A Kerr
- Department of Radiology, Albert Einstein College of Medicine, Bronx, New York, USA
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27
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Shapiro MJ. THE ROLE OF THE RADIOLOGIST IN THE MANAGEMENT OF GASTROINTESTINAL BLEEDING. Gastroenterol Clin North Am 1994. [DOI: 10.1016/s0889-8553(21)00121-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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Reeves TQ, Osborne TM, List AR, Civil ID. Dieulafoy disease: localization with thrombolysis-assisted angiography. J Vasc Interv Radiol 1993; 4:119-21. [PMID: 8425088 DOI: 10.1016/s1051-0443(93)71833-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- T Q Reeves
- Department of Radiology, Auckland Hospital, New Zealand
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Keller FS, Barton RE, Routh WD, Gross GM. Gross hematuria in two patients with ureteral-ileal conduits and double-J stents. J Vasc Interv Radiol 1990; 1:69-77; discussion 77-9. [PMID: 2134038 DOI: 10.1016/s1051-0443(90)72505-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- F S Keller
- Department of Radiology, University of Alabama, Birmingham 35233
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Koval G, Benner KG, Rösch J, Kozak BE. Aggressive angiographic diagnosis in acute lower gastrointestinal hemorrhage. Dig Dis Sci 1987; 32:248-53. [PMID: 3493124 DOI: 10.1007/bf01297049] [Citation(s) in RCA: 90] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Wilson AR, Fuchs JC. Percutaneous transluminal angioplasty. The radiologist's contribution to the treatment of vascular disease. Surg Clin North Am 1984; 64:121-50. [PMID: 6230743 DOI: 10.1016/s0039-6109(16)43235-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Percutaneous transluminal angioplasty is a nonsurgical treatment for vascular disease. It is relatively safe and economical and may be an alternative, or an adjunct, to surgery, or may be helpful where no surgical alternative exists. Percutaneous transluminal angioplasty is applicable to nearly every system, except the carotid bifurcation plaque.
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