Special considerations in the management of lower GI bleed by interventional radiology

Abstract

Despite the rapid development of diagnostic and therapeutic modalities and techniques to manage LGIB patients from interventional radiology's standpoint, a successful localization of the bleeding site that leads to an effective embolotherapy remains a significant technical challenge. The interventional radiologist's decisions when managing patients with LGIB may significantly impact the clinical outcomes; therefore, management should be made based on careful and thorough considerations of factors such as etiology, locations, patient's comorbidities, and potential post-procedure complications, among others. The purpose of this paper is to review the management of LGIB by interventional radiology, focusing on a few challenging and common clinical situations that require special consideration by interventional radiologists.

Keywords: Angiography; Anticoagulation related lower gastrointestinal bleeding; Embolization; Lower gastrointestinal bleeding.

Fig. 1

(A-E), 49 years old male has anticoagulation related lower GI bleeding. A. SMA arteriogram showed significant tissue stain/contrast extravasation, indicating active bleeding at the proximal jejunum (arrow). B. Sub-selective jejunal branch of SMA showed significant tissue stain, consistent with findings of angiodysplasia. C. Status post sub-selective micro-coils and Gel-foam slurry embolization of the jejunal branch of SMA with minimal residual tissue stain (arrow). D. CT angiogram one day post first embolization: active contrast extravasation again noted at proximal jejunum (arrow). E. Repeat mesenteric angiography: active bleeding localized from different segmental jejunal artery (arrow). F. Successful trans-catheter embolization with micro-coils (arrow) with no further bleeding and complications.

Fig. 2

(A–J), 72 years old female, s/p LVAD, with anticoagulation related LGIB. A, nuclear scintigraphy: Bleeding at distal ileum (arrow); B-D Mesenteric angiography: no active bleeding localized. Prophylactic trans-catheter embolization of two branches of ileal artery with coils was done (arrows); E, s/p prophylactic coil embolization 1 week after. nuclear scintigraphy showed again bleeding at distal ileum (arrow); F–H, Mesenteric angiography again showed no signs of active bleeding. Additional prophylactic trans-catheter embolization of more branches of ileal artery with coils was performed (arrows); I, despite repeat prophylactic embolization, contrast enhanced CT scan showed no signs of bowel ischemia or infarction; J, abdominal scout picture showed left ventricular assisted device (arrow).