Nonvariceal upper gastrointestinal bleeding: the usefulness of rotational angiography after endoscopic marking with a metallic clip

Abstract

Objective: We wanted to assess the usefulness of rotational angiography after endoscopic marking with a metallic clip in upper gastrointestinal bleeding patients with no extravasation of contrast medium on conventional angiography.

Materials and methods: In 16 patients (mean age, 59.4 years) with acute bleeding ulcers (13 gastric ulcers, 2 duodenal ulcers, 1 malignant ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. All patients had negative results from their angiographic studies. To localize the bleeding focus, rotational angiography and high pressure angiography as close as possible to the clip were used.

Results: Of the 16 patients, seven (44%) had positive results after high pressure angiography as close as possible to the clip and they underwent transcatheter arterial embolization (TAE) with microcoils. Nine patients without extravasation of contrast medium underwent TAE with microcoils as close as possible to the clip. The bleeding was stopped initially in all patients after treatment of the feeding artery. Two patients experienced a repeat episode of bleeding two days later. Of the two patients, one had subtle oozing from the ulcer margin and that patient underwent endoscopic treatment. One patient with malignant ulcer died due to disseminated intravascular coagulation one month after embolization. Complete clinical success was achieved in 14 of 16 (88%) patients. Delayed bleeding or major/minor complications were not noted.

Conclusion: Rotational angiography after marking with a metallic clip helps to localize accurately the bleeding focus and thus to embolize the vessel correctly.

Keywords: Angiography; Embolization; Gastrointestinal bleeding.

Fig. 1

82-year-old man who presented with gastric ulcer with massive bleeding. A. Endoscopy shows large ulcer with multiple bleeding foci (arrows). Note metallic clip was placed in fibrous edge of ulcer. B. Left gastric artery angiography does not show any bleeding focus. C. After rotational angiography, superselective angiography that was done as close as possible to clip shows active contrast extravasation (arrow). D. Angiography after embolization with N-butyl cyanoacrylate does not show any evidence of bleeding. E. One-week follow-up endoscopy does not show red spot or presence of bleeding lesion.

Fig. 2

72-year old man with gastric ulcer and massive bleeding. A. Endoscopy after placement of metallic clip in gastric ulcer shows small pseudoaneurysm adjacent to metallic clip (arrow). B. Left gastric artery angiography does not show any bleeding focus. C. After rotational angiography, superselective angiography as close as possible to clip shows presence of focal pseudoaneurysm (arrow). D. Angiography after performing embolization with microcoils does not show any evidence of bleeding. E. One-month follow-up endoscopy does not show pseudoaneurysm or gastric ulcer.