Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review

Abstract

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.

Keywords: Gastrointestinal bleeding; Non-variceal upper gastrointestinal bleeding; Rare causes; Upper endoscopy; Upper gastrointestinal bleeding; Vascular causes.

Figure 1

Non-variceal upper gastrointestinal bleeding due to primary aorto-gastric fistula. A and B: Retroflexed endoscopic view showing gastric bulging mass partially covered by blood clots, originating from the fundus and extending to the posterior wall of the proximal body; C: Three-dimensional computed tomography angiography showing ruptured thoracoabdominal aortic aneurysm (black asterisk), retained by a periaortic hematoma (white asterisk); D: Endovascular stent graft aortic repair. CA: Celiac artery; RRA: Right renal artery; SA: Splenic artery; LRA: Left renal artery; SMA: Superior mesenteric artery.

Figure 2

Non-variceal upper gastrointestinal bleeding due rupture of a superior mesenteric artery pseudoaneurysm into the duodenum. A and B: Upper endoscopy showing a bulging, focally ulcerated, lesion in the second-third part of the duodenum, with a suspected small fistulous orifice on its surface (arrow); C and D: Contrast-enhanced computed tomography axial scan in the arterial phase (C) and its maximum intensity projection oblique-coronal reconstruction (D) showing a large lesion (dotted area, C and D) arising from the second-third part of the duodenum, with peripheral vascularity and a pseudoaneurysm (long arrow, C and D) arising from branches of the superior mesenteric artery (short arrow, B); E: Superselective superior mesenteric artery angiography showing a pseudoaneurysm (red dotted circle) fed by the inferior pancreaticoduodenal artery; F: Successful endovascular embolization by the use of cohesive glue (Onyx-18^®, Medtronic, Dublin, Ireland) with disappearance of the pseudoaneurysm and visibility of the Onyx-18^® cast (red dotted circle).

Figure 3

Non-variceal upper gastrointestinal bleeding due to gastric submucosal arterial collaterals secondary to splenic artery thrombosis. A: Retroflexed endoscopic view of the gastric fundus showing varicose-shaped submucosal vessels with a small erosion (circle), in the absence of active bleeding; B and C: Pre-operative axial computed tomography arterial phase showing an arterial cluster at the gastric fundus (B: arrow) arising from splenic artery collateral vessels due to splenic artery complete thrombosis (C: arrow); D-F: Successful endoscopic mechanical hemostasis attempt, with intraprocedural spurting active bleeding following first endoclip application (D and E); G: Operative angiography with selective arterial embolization using microspheres; H: Post-operative axial computed tomography arterial phase showing gastric vascular lesion exclusion (red arrow) and splenic infarction (yellow arrow).

Figure 4

Non-variceal upper gastrointestinal bleeding due to Dieulafoy’s lesion. A: Retroflexed endoscopic view of the gastric fundus showing a minute mucosal defect, surrounded by normal-appearing mucosa, without active bleeding; B: Active bleeding following provocative water-jet endoscopic irrigation; C: Successful endoscopic mechanical hemostasis.

Figure 5

Non-variceal upper gastrointestinal bleeding due to Cameron lesion. Retroflexed endoscopic view of the gastric fundus showing a fibrin covered linear erosion (arrow) at the end of a large hiatal ernia.

Figure 6

Non-variceal upper gastrointestinal bleeding due to hemosuccus pancreaticus. A and B: Contrast-enhanced computed tomography axial scan in the arterial phase (A) and its maximum intensity projection axial reconstruction (B) showing a large pancreaticoduodenal artery pseudoaneurysm (arrow, A and B); C: Successful endovascular coil embolization (arrow).

Figure 7

Non-variceal upper gastrointestinal bleeding due to hemobilia. A and B: Contrast-enhanced computed tomography axial scan in the arterial phase (A) and its maximum intensity projection oblique-sagittal reconstruction (B) showing a pseudoaneurysm in the lumen of the metallic biliary stent (long arrow, A), arising from the hepatic artery (short arrow, B); C: Delayed phase celiac angiography showing a pseudoaneurysm (black asterisk) into the lumen of a metallic biliary stent (white arrow); D: The pseudoaneurysm of the proper hepatic artery was reached with a 2.7 Fr microcatheter (white arrow) coaxially through a 5 Fr catheter (black arrow) positioned into the celiac trunk; E: Successful coil embolization of both the proper hepatic artery (black arrow) and the gastroduodenal artery (white arrow), in order to avoid recanalization.