Role of interventional radiology in the management of acute gastrointestinal bleeding

Abstract

Acute gastrointestinal bleeding (GIB) can lead to significant morbidity and mortality without appropriate treatment. There are numerous causes of acute GIB including but not limited to infection, vascular anomalies, inflammatory diseases, trauma, and malignancy. The diagnostic and therapeutic approach of GIB depends on its location, severity, and etiology. The role of interventional radiology becomes vital in patients whose GIB remains resistant to medical and endoscopic treatment. Radiology offers diagnostic imaging studies and endovascular therapeutic interventions that can be performed promptly and effectively with successful outcomes. Computed tomography angiography and nuclear scintigraphy can localize the source of bleeding and provide essential information for the interventional radiologist to guide therapeutic management with endovascular angiography and transcatheter embolization. This review article provides insight into the essential role of Interventional Radiology in the management of acute GIB.

Keywords: Angiography; Embolization; Interventional radiology; Lower gastrointestinal bleeding; Therapeutic management; Upper gastrointestinal bleeding.

Figure 1

Upper gastrointestinal bleed secondary to gastric/duodenal ulcers. Fifty-four-year-old male with history of gastric ulcers which were treated by clipping through endoscopy. Despite endoscopic intervention, the patient presented with dropping hematocrit requiring transfusion. A: Noncontrast; B and C: contrast enhanced computed tomography imaging demonstrates active extravasation at the level of the gastric antrum with blood product filling the stomach; D and E: Active extravasation was found at the gastroduodenal artery (not shown) which was embolized with coils and gelfoam.

Figure 2

Lower gastrointestinal bleeding secondary to angiodysplasia. Sixty-one-year-old female with multiple bloody stools prior to admission and negative colonoscopy. A: Tc-99m red blood cell study demonstrates active bleeding in the region of the cecum; B and C: Selective catheterization of the distal ileocolic artery demonstrates a small focus of hemorrhage consistent with an area of angiodysplasia; D and E: Coil embolization was performed with two 3 mm coils. Post embolization images demonstrates resolved bleeding.

Figure 3

Lower gastrointestinal bleed secondary to diverticulitis. Sixty-eight-year-old male with history of esophageal carcinoma with acute diverticulitis with drifting hematocrit. A: Tc-99m labeled red blood cell study demonstrates bleeding at the hepatic flexure of the colon; B: Selective catheter angiography at the middle colic artery demonstrates active extravasation into a diverticulum present at the hepatic flexure the colon; C: Coil embolization of the right lateral aspect of the middle colic artery, across a small perforating vessel associated with a diverticular hemorrhage.

Figure 4

Sixty-six-year-old male with ongoing gastrointestinal hemorrhage requiring multiple transfusions over the last 72 h. EGD performed revealed ulcers in the first and second portion of the duodenum. A: Technetium-99m tagged RBC scan demonstrates brisk hemorrhage arising from the proximal small bowel/duodenum; B and C: Digitally subtracted images reveal active extravasation in the second portion of the duodenum from the inferior pancreaticoduodenal artery corresponding to area of hemorrhage on tagged RBC scan; D: Successful and uncomplicated coil embolization of the inferior pancreaticoduodenal artery with cessation of active hemorrhage. EGD: Esophagoduodenoscopy; RBC: Red blood cell.

Figure 5

Seventy-two-year-old female with worsening abdominal pain and acute gastrointestinal hemorrhage. Upper gastrointestinal endoscopy reveals multiple large bleeding ulcers in the duodenum. A and B: Selective catheter angiography of the gastroduodenal and pancreaticoduodenal arteries demonstrates active extravasation; C: A combination of gelfoam slurry and coils were used to embolize branches of the pancreaticoduodenal and gastroduodenal artery; D: Representative post embolization image demonstrates no further evidence of active extravasation or bleeding.

Figure 6

Lower gastrointestinal bleed from acute diverticulitis. Seventy-three-year-old male patient with bloody diarrhea, severely hypotensive (blood pressure 70/40) requiring 10 units of packed red blood cells. A and B: Contrast enhanced computed tomography abdomen demonstrates acute diverticulitis at the hepatic flexure, with active hemorrhage; C: Visceral angiography demonstrates the region of active bleeding in the ascending colon at the hepatic flexure; D: Successful distal Gelfoam and coil embolization of the supplying right colic artery branches.

Figure 7

Lower gastrointestinal bleed secondary to supratherapeutic international normalized ratio. Seventy-six-year-old female with supratherapeutic INR (3.5) with painless hematochezia. A: Tc-99m labeled RBC study demonstrates brisk gastrointestinal bleeding localized to the sigmoid colon; B and C: Catheter angiography demonstrates active extravasation from a tertiary branch of the inferior mesenteric artery supplying the distal sigmoid colon which was subsequently embolized; D: With coils and no evidence of continued bleeding. RBC: Red blood cell.