ANNUAL REVIEWS
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Ann. Rev. Med. 1979. 30:41-59 Copyright @ 1979 by Annual Reviews Inc. All rights reserved
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
ANGIOGRAPHIC MANAGEMENT
.7305,
OF GASTROINTESTINAL BLEEDING! Saadoon Kadir, M.D.2 and Christos A. Athanasoulis, MD. Departments of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
Localization of gastrointestinal bleeding sites and the control of bleeding with vasopressin or transcatheter embolization are new applications of selective visceral angiography. In the majority of patients, gastrointestinal bleeding stops on conservative therapy and therefore the number of patients requiring diagnostic and therapeutic angiography is relatively small. How ever, when conservative measures fail, angiographic methods may be ap plied in order to prevent a major surgical intervention. In general, endoscopy should precede angiography, as endoscopic locali zation of the bleeding site can facilitate the angiographic procedure. On the other hand, barium studies are of little help in the evaluation of the acutely bleeding patient and may unnecessarily delay both angiography and endos copy. METHODS
Arteriography is performed via the femoral route using the techniques described by Seldinger (1) and Odman (2). The preceding endoscopy or clinical presentation determines the vessels to be selectively catheterized. For upper GI bleeding from the stomach we proceed directly to the selective catheterization of the left gastric artery and use the loop catheter technique (3). For duodenal bleeding a celiac arteriogram is performed first. For 'This work was supported in part by US Public Health Grants BRSG-05486i3 and lROl AM 19811-02. 2Present Address: Department of Radiology, Vanderbilt University Hospital, Nashville, Tennessee 37232. 41 0066-4219/79/0401-0041$01.00
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KADIR & ATHANASOULIS
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
colonic bleeding the superior mesenteric arteriogram is followed by an inferior mesenteric arteriogram. This sequence is reversed if clinical or endoscopic evidence suggests a left colonic source for the bleeding. The bleeding site is identified with the demonstration of contrast medium ex travasation on serial films. Once the bleeding site has been localized it can be treated with intraarterial or systemic infusion of vasopressin or transca theter vessel occlusion. VASOPRESSIN
Vasopressin, which was used as early as 1956 for the management of bleeding esophageal varices, has a dual action causing constriction of the smooth musculature of the bowel wall and blood vessels (4, 5). The choice of intravenous vs intraarterial vasopressin is determined by the location and type of bleeding. Our clinical experience shows that mucosal, variceal, and occasionally low grade colonic bleeding may respond to infusions of intravenous vasopressin. Otherwise the intraarterial route is used.
Once the bleeding site has been localized, vasopressin is infused for 20 minutes. A control arteriogram is then performed to evaluate the angio graphic results. If the bleeding has been controlled, the patient is managed according to the following infusion schedule: 0.2 V/min for 12-24 hr; 0.1 V/min for 12-24 hr; D5W or NS at 20--30 ml/hr to keep the catheter open. Meanwhile the patient is observed for signs of rebleeding (hematocrit, nasogastric aspirate, central venous pressure, and transfusion requirement). If bleeding has stopped the catheter is removed 6-12 hours later. If bleeding persists transcatheter occlusion is considered. Intraarterial vasopressin infusions are performed with a constant infusion
pump. If systemic vasopressin is used, the angiographic catheter is removed after completion of the diagnostic procedure. TRANSCATHETER OCCLUSION
The materials most commonly used for transcatheter occlusion of the bleed ing vessel are blood clot and Gelfoam.® Ivalon®, a compressible plastic foam of polyvinyl alcohol, and isobutyl-2-cyanoacrylate find occasional use in situations where a permanent occlusion is desirable. The latter is not yet available for general use. Detachable small balloons attached to angio graphic catheters have recently been introduced for the control of bleeding. The embolization procedure is preformed through the arteriography catheter. When superselective embolization becomes necessary a coaxial system using a 3-French, straight, Tellon® catheter is used. Gelfoam is cut
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
GASTROINTESTINAL BLEEDING
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into 2-mm square pieces. Prior to the embolization it is soaked in saline and, with a tuberculin syringe, the Gelfoam is loaded into the catheter and fu l shed occlude a bleeding vessel depends upon its size and location. For visceral arteries usually 2-5 plugs are sufficient. A similar technique is used for blood clot and Ivalon. For the delivery of isobutyl-2-cyanoacrylate, a coaxial system is used. A 3-French, straight, Teflon catheter is introduced through the arteriography catheter. Care must be taken to use nonionic solutions (5% dextrose) to fu l sh upon contact with an ionic surface, which thus leads to the incorporation of the catheter in the polymer. ESOPHAGEAL BLEEDING
Bleeding from the lower esophagus can be demonstrated by selective left gastric arteriography. This includes bleeding from Mallory-Weiss tears, esophageal tumors, reflux (Figure 1). Selective infusion of vasopressin in the left gastric artery is successful in controlling the bleeding in most cases. GASTRIC BLEEDING
Bleeding from peptic ulcers, which can often be massive, is best demon strated by a left gastric arteriogram. Intraarterial infusion of vasopressin can successfully stop the bleeding in 65-70% of patients (6, 7). In those patients where intraarterial vasopressin fails to control the bleeding, tran scatheter embolization is considered (Figure 2). Mucosal hemorrhage due to gastritis or superficial ulcerations can be controlled in 84% of patients with intraarterial vasopressin. Recurrent bleeding is observed in 16% (8). DUODENAL BLEEDING
Bleeding from a duodenal ulcer is demonstrated on a celiac arteriogram. As vasopressin infusions are unsuccessful in controlling duodenal hemorrhage in about 50% of these patients, transcatheter occlusion appears to be the angiographic method of choice for controlling the hemorrhage (Figure 3). The ineffectiveness of intraarterial vasopressin in controlling peptic ulcer bleeding in the duodenum and stomach is due to the presence of chronic infal mmatory constrictive response to vasopressin. Furthermore the dual blood supply to the duodenum may be responsible for the vasopressin failures.
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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Figure 1 Distal esophageal bleeding due to reflux esophagitis. (A) The left gastric artery arises from the left hepatic artery. Contrast extravasation is seen from the esophageal branches (arrow). (B) Late arterial phase shows further extravasation (arrows). (C) Following intraarterial infusion of vasopressin the bleeding stopped.
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Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
GASTROINTESTINAL BLEEDING
Figure 2 Gastric stress ulcer bleeding. (A) Left gastric arteriogram shows contl"lllit extravasa tion. (B) After transcatheter embolization with Geifoam, bleeding that could not be controlled by intraarterial vasopressin stopped.
KADIR & ATHANASOULIS
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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Figure 3 Bleeding from a duodenal ulcer. (A) Common hepatic arteriogram demonstrates extravasation of contrast medium (arrow). (B) Control arteriogram following 20-min infusion of O.3-U/min vasopressin in the common hepatic artery. The extravasation persists. (C) Pre-embolization gastroduodenal ateriogram using a coaxial system shows persistent bleeding (arrow). (D) After transcatheter occlusion with Gelfoam, the arterial branches to the bleeding ulcer have been occluded (arrow). No further contrast medium extravasation is seen.
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Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
PORTAL HYPERTENSION
Bleeding from varices is difficult to demonstrate by mesenteric arteriogra phy because by the time the contrast medium reaches the veins, it is diluted. The diagnosis is made by endoscopy. However, in a patient with upper gastrointestinal bleeding and portal hypertension with varices demon strated by endoscopy and angiography, the source of bleeding may be a peptic ulcer or gastritis (9). Selective arteriography is able to determine the site of bleeding and delineate the portal venous anatomy if a shunt proce dure is considered. For variceal bleeding, once other sources of bleeding have been excluded, intravenous vasopressin is infused. This decreases por tal venous pressure by 35-50%, thereby decompressing the varices and facilitating thrombosis (9). Recent clinical and laboratory experience shows that both superior mesenteric artery and intravenous vasopressin in equiva lent dose rates reduce portal venous pressure to a comparable degree ( 10). Definitive therapy for variceal bleeding is a portosystemic shunt. As a temporizing maneuver to prepare the patient for definitive treatment, trans hepatic obliteration can be used. After percutaneous transhepatic catheter ization of the coronary vein, the varices are embolized with Gelfoam or isobutyl-2-cyanoacrylate (Figure 4). Before removing the transhepatic cath eter the intrahepatic tract is embolized with Gelfoam. This reduces the incidence of complications, such as hemoperitoneum and peritoneal irrita tion. In experienced hands this procedure is relatively safe and offers an attractive alternative to emergency surgery that has a high mortality. SMALL BOWEL
Common sources of bleeding from the small bowel are tumors, vascular malformations, ulcerations, and occasionally diverticula (Figure 5) (9). Selective arteriography may localize the bleeding, which can then be con trolled effectively with intraarterial vasopressin. COLONORECTAL BLEEDING
Massive colonic bleeding is most commonly due to diverticular bleeding or ulcerative colitis (9). Since up to 75% of the bleeding diverticula are located in the right hemicolon, the superior mesenteric arteriogram is performed first (Figure 6) (11). If no contrast extravasation is demonstrated or prior endoscopy shows a left-sided lesion, an inferior mesenteric arteriogram is performed first. If no bleeding is demonstrated, celiac arteriography should be done to exclude a hitherto unrecognized source of bleeding.
KADIR & ATHANASOULIS
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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Figure 4 Transhepatic obliteration of gastroesophageal varices for endoscopy-proven vari ceal bleeding. (A) Contrast injection in the splenic vein: There is fugal flow into the inferior mesenteric vein and opacification of short gastric varices and right gastric vein (arrow). (B) Catheterization of the short gastric varices using a coaxial system. (C) Selective contrast injection into the coronary varices. (0) Splenic venogram following embolization of the short gastric and coronary varices. The bleeding stopped and the patient was discharged.
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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KADIR & ATHANASOULIS
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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Figure 5 Bleeding from a jejunal diverticulum. (A) Superior mesenteric arteriogram shows extravasation of contrast medium from a branch of the first jejunal artery (arrow). (B) Selective contrast injection into the first jejunal artery redemonstrates the bleeding site. (C) H.e bleeding stopped temporarily following intraarterial infusion of vasopressin. At surgery the bleeding jejunal diverticulum was resected. (0) Upper gastrointestinal barium examination performed several days prior to the surgery shows a large proximal jejunal diverticulum (arrows ) .
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Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
GASTROINTESTINAL BLEEDING
Figure 6 Bleeding from a right colon diverticulum. (A) Early arterial phase of a superior mesenteric arteriogram demonstrates extravasation of contrast in the ascending colon. (B) Late arterial phase from the same arteriogram shows further extravasation. (C) Intravenous vasopressin failed to control the bleeding. (D) The bleeding stopped following infusion of O.2-U/min vasopressin via the superior mesenteric artery.
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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Intraarterial vasopressin can successfully control acute colonorectal bleeding in up to 90% of patients. Recurrent bleeding is observed in around 25% of patients generally within the first 24 hours (12). However, localiza tion of the bleeding site helps to modify the operative procedure, thus lowering operative mortality. Lower intestinal bleeding can also be due to mesenteric varices that may develop after abdominal surgery or as a result of mesenteric vein obstruc tion caused by pancreatic carcinoma, mesenteric panniculitis, carcinoid, and portal hypertension (Figure 7). Although these can be demonstrated on the venous phase of the superior mesenteric arteriogram, for better visuali zation transhepatic portography may be used. Here the management is primarily surgical but intravenous vasopressin can decompress the varices and thus lead to temporary cessation of the bleeding.
Figure 7 Lower intestinal bleeding in a patient with carcinoid of the mesentery. (A) Arterial phase of the superior mesenteric arteriogram: There is a typical fixed, stellate configuration of the arteries with encasement and occlusion of several branches. (B) Superior mesenteric arteriogram: Close-up view in the right posterior oblique projection shows the arterial occlu sions and encasement in greater detail. (C) There is a similar stellate configuration of the veins and occlusion of the superior mesenteric vein with visualization of multiple dilated collaterals.
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
COLONIC ARTERIOVENOUS MALFORMATIONS
Arteriovenous malformations of the colon may cause acute rectal bleeding. The diagnosis is made by selective arteriography of the superior and inferior mesenteric arteries. If the arteriovenous malformation is located in the sigmoid colon or rectum, bilateraI'internal iliac arteriograms are also per formed. As these arteriovenous malformations do not respond to intraar terial vasopressin, the angiographic treatment is transcatheter occlusion (Figure 8).
Figure 8 Acute lower intestinal bleeding from a sigmoid arteriovenous malformation in a 21-year-old female. (A) The inferior mesenteric arteriogram demonstrates a large arteriove nous malformation. (B) After embolization with Gelfoam through a coaxial system, the bleeding stopped but recurred 21h months later.
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Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
ANGIODYSPLASIA
In patients 55 years and older, intermittent low grade, and occasionally massive, lower GI bleeding may be due to angiodysplasia of the right colon or cecum. The characteristic angiographic appearance of angiodysplasia is (Figure 9): (a) early draining vein; (b) persistent and dense opacification of the vein; (c) vascular tuft on the antimesenteric border; and (d) on occasion contrast extravasation. The lesions are submucosal and can on occasion be identified by the experienced colonoscopist. Surgical exploration and barium examination are usually negative. However, a barium examination is essential to exclude coexisting lesions, which have been observed in 22% of patients ( 13). The treatment of choice for angiodysplasia is a right hemicolectomy. More recently, electrocoagulation has been used with success. POSTOPERATIVE BLEEDING
Angiography has made an important contribution to the diagnosis and therapy of postoperative bleeding (14). Such bleeding can occur in the immediate postoperative period as a result of a slipped ligature or inade quate ligation of bleeding vessels, or it may be seen several days later following mucosal sloughing. Selective arteriography of the major visceral artery supplying the oper ated area will demonstrate the source of bleeding. Treatment includes in travenous or intraarterial infusion of vasopressin or transcatheter occlusion (Figure 10). Occasionally the bleeding may be only indirectly related to the surgery as in stress ulcer bleeding. Here the appropriate vessel is catheter ized and treated with vasopressin infusions. COMPLICATIONS
Complications of angiographic management of gastrointestinal bleeding are similar to those observed in patients undergoing diagnostic arteriography (15). Vasopressin can be infused for several days without any serious side effects. However, its use under general anesthesia and with ganglion block ers should be cautious (5). Anginal pains have been observed in patients with ischemic heart disease. Abdominal cramps, nausea, and vomiting are seen occasionally. Water and electrolyte imbalance with a temporary de crease in urine output, which is a result of the antidiuretic hormone effect of vasopressin, can be managed with diuretics. Following aberrant vasopressin infusion, premature ventricular con tractions, bradycardia, hematuria, and peripheral vasoconstriction have
KADIR & ATHANASOULIS
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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Figure 9 Angiodysplasia of the cecum. (A) Superior mesenteric arteriogram with magnifica tion demonstrates a vascular tuft (arrow) and an early draining vein (arrowheads). (B) Late arterial phase: persistent, dense opacification of the vein. (C) A typical angiodysplasia lesion as visualized under the dissecting microscope. (0) Histological section (lOx magnification) through a typical lesion shows multiple dilated submucosal vascular spaces (black). (E) 40x magnification of a section from the specimen in D. The dilated vascular space is separated from the colonic lumen by a single layer of cells (arrow).
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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been observed (16). During intravenous vasopressin therapy, care must be taken to use a central venous line and thus avoid dermal vasoconstriction and necrosis. Complications can arise during the use of particulate embolic material or tissue adhesives. Embolization or occlusion of distant or neighboring circu lations may result in infarction, pain, or abscess formation. This is usually a result of improper technique and can be avoided by the use of balloon occlusion techniques and/or superselective embolization. CONCLUSION
Selective arteriography is a valuable method for the localization of sources of acute and chronic gastrointestinal bleeding. With intraarterial and in travenous infusions of vasopressin and transcatheter embolization the bleeding can be controlled in the majority of patients. In those patients in whom arteriography has failed to control the bleeding, localization of the source of bleeding facilitates the surgical procedure.
Figure 10 Postoperative cecostomy bleeding. (A) Superior mesenteric arteriogram demon strates the bleeding site in the cecum. (B) The bleeding stopped following intraarterial infusion of vasopressin at 0.2 U/min.
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Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
Literature Cited
1. Selding, S. L. 1953. Catheter replace ment of needle in percutaneous arterio graphy: A new technique. Acta Radiol 39:368-76 O 2. dman, P. 1956. Percutaneous selective angiography of the main branches of the aorta. Acta Radiol 45:1-14 3. Waltman, A. C., Courey, W. R., Athanasoulis, C. A., et a1. 1973. Tech nique for left gastric artery catheteriza tion. Radiology 109:732-34 4. Kehne, J. H., Hughes, F. A., Gomperte, N. L. 1956. The use of surgical pituitrin in the control of esophageal vanx bleed ing. Surgery 39:917-25 5. Goodman, L. S., Gilman, A. 1970. The Pharmacological Basis of Therapeutics. New York: MacMillan 4th ed. 6. Athanasoulis, C. A., Waltman, A. C.,
13.
terial infusions of vasopressin for the control of upper gastrointestinal hemor rhage. In Gastrointestinal Emergencies, ed. H. R. Clearfield, V. P. Dinoso, Jr., pp. 37-47. New York: Grune & Strat ton 7. Baum, S. 1974. Hematemesis and melena. Part II. Angiography. In Gas troenterology, ed. H. L. Bockus, pp. 827-46. Philadelphia: Saunders 8. Athanasoulis, C. A., Baum, S., Walt man, A. C., et al. 1974. Control of acute gastric mucosal hemorrhage: Intraar terial infusion of posterior pituitary ex tract. N. Engl J. Med. 290:597-603 9. Hedberg, S., Welch, C. E. 1973. Gas-
plasia of the colon: A cause of rectal bleeding. Cardiovasc. Radiol 1:3-13 14. Kadir, S., Athanasoulis, C. A. 1978. Angiographic diagnosis and manage ment of postoperative bleeding. Crit. Rev. Med. Imaging. In press 15. Meany, T. F. 1973. Percutaneous Fem oral Angiography: Complications and Legal Implications of Radiographic Special Procedures, ed. T. F., Meany, R. J. Alfidi, pp. 15-35. St. Louis: Mosby 16. Kadir, S, Athanasoulis, C. A. 1978. Catheter dislodgement: A cause for the failure of intraarterial vasopressin to control gastrointestinal hemorrhage. Cardiovasc. Radiol 1:187-91
Novelline, R. A., et al. 1976. Intraar
10.
II.
12.
trointestinal hemorrhage I: General considerations of diagnosis and therapy. Adv. Surgery 7:95-148 Athanasoulis, C. A., Waltman, A. C., Novelline, R. A., et a1. 1976. Angiogra phy: Its contribution to emergency management of gastrointestinal hemor rhage. Radiol. Clin. North Am 14: 265-80 Casarella, W. J., Kanter, I. E., Seaman, W. B. 1972. Right sided colonic di verticula as a cause of acute rectal hem orrhage. N. Engl J. Med. 286:450-53 Athanasoulis, C. A., Baum, S, ROsch, J. 1975. Mesenteric arterial infusion of vasopressin for hemorrhage from co lonic diverticulosis. Am. J. Surg. 129:212-16 Athanasoulis, C. A., Galdabini, J. J., Waltman, A. C., et al. 1978. Angiodys
Further
Quick links to online content
Ann. Rev. Med. 1979. 30:41-59 Copyright @ 1979 by Annual Reviews Inc. All rights reserved
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
ANGIOGRAPHIC MANAGEMENT
.7305,
OF GASTROINTESTINAL BLEEDING! Saadoon Kadir, M.D.2 and Christos A. Athanasoulis, MD. Departments of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
Localization of gastrointestinal bleeding sites and the control of bleeding with vasopressin or transcatheter embolization are new applications of selective visceral angiography. In the majority of patients, gastrointestinal bleeding stops on conservative therapy and therefore the number of patients requiring diagnostic and therapeutic angiography is relatively small. How ever, when conservative measures fail, angiographic methods may be ap plied in order to prevent a major surgical intervention. In general, endoscopy should precede angiography, as endoscopic locali zation of the bleeding site can facilitate the angiographic procedure. On the other hand, barium studies are of little help in the evaluation of the acutely bleeding patient and may unnecessarily delay both angiography and endos copy. METHODS
Arteriography is performed via the femoral route using the techniques described by Seldinger (1) and Odman (2). The preceding endoscopy or clinical presentation determines the vessels to be selectively catheterized. For upper GI bleeding from the stomach we proceed directly to the selective catheterization of the left gastric artery and use the loop catheter technique (3). For duodenal bleeding a celiac arteriogram is performed first. For 'This work was supported in part by US Public Health Grants BRSG-05486i3 and lROl AM 19811-02. 2Present Address: Department of Radiology, Vanderbilt University Hospital, Nashville, Tennessee 37232. 41 0066-4219/79/0401-0041$01.00
42
KADIR & ATHANASOULIS
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
colonic bleeding the superior mesenteric arteriogram is followed by an inferior mesenteric arteriogram. This sequence is reversed if clinical or endoscopic evidence suggests a left colonic source for the bleeding. The bleeding site is identified with the demonstration of contrast medium ex travasation on serial films. Once the bleeding site has been localized it can be treated with intraarterial or systemic infusion of vasopressin or transca theter vessel occlusion. VASOPRESSIN
Vasopressin, which was used as early as 1956 for the management of bleeding esophageal varices, has a dual action causing constriction of the smooth musculature of the bowel wall and blood vessels (4, 5). The choice of intravenous vs intraarterial vasopressin is determined by the location and type of bleeding. Our clinical experience shows that mucosal, variceal, and occasionally low grade colonic bleeding may respond to infusions of intravenous vasopressin. Otherwise the intraarterial route is used.
Once the bleeding site has been localized, vasopressin is infused for 20 minutes. A control arteriogram is then performed to evaluate the angio graphic results. If the bleeding has been controlled, the patient is managed according to the following infusion schedule: 0.2 V/min for 12-24 hr; 0.1 V/min for 12-24 hr; D5W or NS at 20--30 ml/hr to keep the catheter open. Meanwhile the patient is observed for signs of rebleeding (hematocrit, nasogastric aspirate, central venous pressure, and transfusion requirement). If bleeding has stopped the catheter is removed 6-12 hours later. If bleeding persists transcatheter occlusion is considered. Intraarterial vasopressin infusions are performed with a constant infusion
pump. If systemic vasopressin is used, the angiographic catheter is removed after completion of the diagnostic procedure. TRANSCATHETER OCCLUSION
The materials most commonly used for transcatheter occlusion of the bleed ing vessel are blood clot and Gelfoam.® Ivalon®, a compressible plastic foam of polyvinyl alcohol, and isobutyl-2-cyanoacrylate find occasional use in situations where a permanent occlusion is desirable. The latter is not yet available for general use. Detachable small balloons attached to angio graphic catheters have recently been introduced for the control of bleeding. The embolization procedure is preformed through the arteriography catheter. When superselective embolization becomes necessary a coaxial system using a 3-French, straight, Tellon® catheter is used. Gelfoam is cut
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
GASTROINTESTINAL BLEEDING
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into 2-mm square pieces. Prior to the embolization it is soaked in saline and, with a tuberculin syringe, the Gelfoam is loaded into the catheter and fu l shed occlude a bleeding vessel depends upon its size and location. For visceral arteries usually 2-5 plugs are sufficient. A similar technique is used for blood clot and Ivalon. For the delivery of isobutyl-2-cyanoacrylate, a coaxial system is used. A 3-French, straight, Teflon catheter is introduced through the arteriography catheter. Care must be taken to use nonionic solutions (5% dextrose) to fu l sh upon contact with an ionic surface, which thus leads to the incorporation of the catheter in the polymer. ESOPHAGEAL BLEEDING
Bleeding from the lower esophagus can be demonstrated by selective left gastric arteriography. This includes bleeding from Mallory-Weiss tears, esophageal tumors, reflux (Figure 1). Selective infusion of vasopressin in the left gastric artery is successful in controlling the bleeding in most cases. GASTRIC BLEEDING
Bleeding from peptic ulcers, which can often be massive, is best demon strated by a left gastric arteriogram. Intraarterial infusion of vasopressin can successfully stop the bleeding in 65-70% of patients (6, 7). In those patients where intraarterial vasopressin fails to control the bleeding, tran scatheter embolization is considered (Figure 2). Mucosal hemorrhage due to gastritis or superficial ulcerations can be controlled in 84% of patients with intraarterial vasopressin. Recurrent bleeding is observed in 16% (8). DUODENAL BLEEDING
Bleeding from a duodenal ulcer is demonstrated on a celiac arteriogram. As vasopressin infusions are unsuccessful in controlling duodenal hemorrhage in about 50% of these patients, transcatheter occlusion appears to be the angiographic method of choice for controlling the hemorrhage (Figure 3). The ineffectiveness of intraarterial vasopressin in controlling peptic ulcer bleeding in the duodenum and stomach is due to the presence of chronic infal mmatory constrictive response to vasopressin. Furthermore the dual blood supply to the duodenum may be responsible for the vasopressin failures.
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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I
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Figure 1 Distal esophageal bleeding due to reflux esophagitis. (A) The left gastric artery arises from the left hepatic artery. Contrast extravasation is seen from the esophageal branches (arrow). (B) Late arterial phase shows further extravasation (arrows). (C) Following intraarterial infusion of vasopressin the bleeding stopped.
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Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
GASTROINTESTINAL BLEEDING
Figure 2 Gastric stress ulcer bleeding. (A) Left gastric arteriogram shows contl"lllit extravasa tion. (B) After transcatheter embolization with Geifoam, bleeding that could not be controlled by intraarterial vasopressin stopped.
KADIR & ATHANASOULIS
Annu. Rev. Med. 1979.30:41-59. Downloaded from www.annualreviews.org Access provided by New Mexico State University (NMSU) on 02/01/15. For personal use only.
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Figure 3 Bleeding from a duodenal ulcer. (A) Common hepatic arteriogram demonstrates extravasation of contrast medium (arrow). (B) Control arteriogram following 20-min infusion of O.3-U/min vasopressin in the common hepatic artery. The extravasation persists. (C) Pre-embolization gastroduodenal ateriogram using a coaxial system shows persistent bleeding (arrow). (D) After transcatheter occlusion with Gelfoam, the arterial branches to the bleeding ulcer have been occluded (arrow). No further contrast medium extravasation is seen.
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PORTAL HYPERTENSION
Bleeding from varices is difficult to demonstrate by mesenteric arteriogra phy because by the time the contrast medium reaches the veins, it is diluted. The diagnosis is made by endoscopy. However, in a patient with upper gastrointestinal bleeding and portal hypertension with varices demon strated by endoscopy and angiography, the source of bleeding may be a peptic ulcer or gastritis (9). Selective arteriography is able to determine the site of bleeding and delineate the portal venous anatomy if a shunt proce dure is considered. For variceal bleeding, once other sources of bleeding have been excluded, intravenous vasopressin is infused. This decreases por tal venous pressure by 35-50%, thereby decompressing the varices and facilitating thrombosis (9). Recent clinical and laboratory experience shows that both superior mesenteric artery and intravenous vasopressin in equiva lent dose rates reduce portal venous pressure to a comparable degree ( 10). Definitive therapy for variceal bleeding is a portosystemic shunt. As a temporizing maneuver to prepare the patient for definitive treatment, trans hepatic obliteration can be used. After percutaneous transhepatic catheter ization of the coronary vein, the varices are embolized with Gelfoam or isobutyl-2-cyanoacrylate (Figure 4). Before removing the transhepatic cath eter the intrahepatic tract is embolized with Gelfoam. This reduces the incidence of complications, such as hemoperitoneum and peritoneal irrita tion. In experienced hands this procedure is relatively safe and offers an attractive alternative to emergency surgery that has a high mortality. SMALL BOWEL
Common sources of bleeding from the small bowel are tumors, vascular malformations, ulcerations, and occasionally diverticula (Figure 5) (9). Selective arteriography may localize the bleeding, which can then be con trolled effectively with intraarterial vasopressin. COLONORECTAL BLEEDING
Massive colonic bleeding is most commonly due to diverticular bleeding or ulcerative colitis (9). Since up to 75% of the bleeding diverticula are located in the right hemicolon, the superior mesenteric arteriogram is performed first (Figure 6) (11). If no contrast extravasation is demonstrated or prior endoscopy shows a left-sided lesion, an inferior mesenteric arteriogram is performed first. If no bleeding is demonstrated, celiac arteriography should be done to exclude a hitherto unrecognized source of bleeding.
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Figure 4 Transhepatic obliteration of gastroesophageal varices for endoscopy-proven vari ceal bleeding. (A) Contrast injection in the splenic vein: There is fugal flow into the inferior mesenteric vein and opacification of short gastric varices and right gastric vein (arrow). (B) Catheterization of the short gastric varices using a coaxial system. (C) Selective contrast injection into the coronary varices. (0) Splenic venogram following embolization of the short gastric and coronary varices. The bleeding stopped and the patient was discharged.
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Figure 5 Bleeding from a jejunal diverticulum. (A) Superior mesenteric arteriogram shows extravasation of contrast medium from a branch of the first jejunal artery (arrow). (B) Selective contrast injection into the first jejunal artery redemonstrates the bleeding site. (C) H.e bleeding stopped temporarily following intraarterial infusion of vasopressin. At surgery the bleeding jejunal diverticulum was resected. (0) Upper gastrointestinal barium examination performed several days prior to the surgery shows a large proximal jejunal diverticulum (arrows ) .
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Figure 6 Bleeding from a right colon diverticulum. (A) Early arterial phase of a superior mesenteric arteriogram demonstrates extravasation of contrast in the ascending colon. (B) Late arterial phase from the same arteriogram shows further extravasation. (C) Intravenous vasopressin failed to control the bleeding. (D) The bleeding stopped following infusion of O.2-U/min vasopressin via the superior mesenteric artery.
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Intraarterial vasopressin can successfully control acute colonorectal bleeding in up to 90% of patients. Recurrent bleeding is observed in around 25% of patients generally within the first 24 hours (12). However, localiza tion of the bleeding site helps to modify the operative procedure, thus lowering operative mortality. Lower intestinal bleeding can also be due to mesenteric varices that may develop after abdominal surgery or as a result of mesenteric vein obstruc tion caused by pancreatic carcinoma, mesenteric panniculitis, carcinoid, and portal hypertension (Figure 7). Although these can be demonstrated on the venous phase of the superior mesenteric arteriogram, for better visuali zation transhepatic portography may be used. Here the management is primarily surgical but intravenous vasopressin can decompress the varices and thus lead to temporary cessation of the bleeding.
Figure 7 Lower intestinal bleeding in a patient with carcinoid of the mesentery. (A) Arterial phase of the superior mesenteric arteriogram: There is a typical fixed, stellate configuration of the arteries with encasement and occlusion of several branches. (B) Superior mesenteric arteriogram: Close-up view in the right posterior oblique projection shows the arterial occlu sions and encasement in greater detail. (C) There is a similar stellate configuration of the veins and occlusion of the superior mesenteric vein with visualization of multiple dilated collaterals.
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COLONIC ARTERIOVENOUS MALFORMATIONS
Arteriovenous malformations of the colon may cause acute rectal bleeding. The diagnosis is made by selective arteriography of the superior and inferior mesenteric arteries. If the arteriovenous malformation is located in the sigmoid colon or rectum, bilateraI'internal iliac arteriograms are also per formed. As these arteriovenous malformations do not respond to intraar terial vasopressin, the angiographic treatment is transcatheter occlusion (Figure 8).
Figure 8 Acute lower intestinal bleeding from a sigmoid arteriovenous malformation in a 21-year-old female. (A) The inferior mesenteric arteriogram demonstrates a large arteriove nous malformation. (B) After embolization with Gelfoam through a coaxial system, the bleeding stopped but recurred 21h months later.
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ANGIODYSPLASIA
In patients 55 years and older, intermittent low grade, and occasionally massive, lower GI bleeding may be due to angiodysplasia of the right colon or cecum. The characteristic angiographic appearance of angiodysplasia is (Figure 9): (a) early draining vein; (b) persistent and dense opacification of the vein; (c) vascular tuft on the antimesenteric border; and (d) on occasion contrast extravasation. The lesions are submucosal and can on occasion be identified by the experienced colonoscopist. Surgical exploration and barium examination are usually negative. However, a barium examination is essential to exclude coexisting lesions, which have been observed in 22% of patients ( 13). The treatment of choice for angiodysplasia is a right hemicolectomy. More recently, electrocoagulation has been used with success. POSTOPERATIVE BLEEDING
Angiography has made an important contribution to the diagnosis and therapy of postoperative bleeding (14). Such bleeding can occur in the immediate postoperative period as a result of a slipped ligature or inade quate ligation of bleeding vessels, or it may be seen several days later following mucosal sloughing. Selective arteriography of the major visceral artery supplying the oper ated area will demonstrate the source of bleeding. Treatment includes in travenous or intraarterial infusion of vasopressin or transcatheter occlusion (Figure 10). Occasionally the bleeding may be only indirectly related to the surgery as in stress ulcer bleeding. Here the appropriate vessel is catheter ized and treated with vasopressin infusions. COMPLICATIONS
Complications of angiographic management of gastrointestinal bleeding are similar to those observed in patients undergoing diagnostic arteriography (15). Vasopressin can be infused for several days without any serious side effects. However, its use under general anesthesia and with ganglion block ers should be cautious (5). Anginal pains have been observed in patients with ischemic heart disease. Abdominal cramps, nausea, and vomiting are seen occasionally. Water and electrolyte imbalance with a temporary de crease in urine output, which is a result of the antidiuretic hormone effect of vasopressin, can be managed with diuretics. Following aberrant vasopressin infusion, premature ventricular con tractions, bradycardia, hematuria, and peripheral vasoconstriction have
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Figure 9 Angiodysplasia of the cecum. (A) Superior mesenteric arteriogram with magnifica tion demonstrates a vascular tuft (arrow) and an early draining vein (arrowheads). (B) Late arterial phase: persistent, dense opacification of the vein. (C) A typical angiodysplasia lesion as visualized under the dissecting microscope. (0) Histological section (lOx magnification) through a typical lesion shows multiple dilated submucosal vascular spaces (black). (E) 40x magnification of a section from the specimen in D. The dilated vascular space is separated from the colonic lumen by a single layer of cells (arrow).
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been observed (16). During intravenous vasopressin therapy, care must be taken to use a central venous line and thus avoid dermal vasoconstriction and necrosis. Complications can arise during the use of particulate embolic material or tissue adhesives. Embolization or occlusion of distant or neighboring circu lations may result in infarction, pain, or abscess formation. This is usually a result of improper technique and can be avoided by the use of balloon occlusion techniques and/or superselective embolization. CONCLUSION
Selective arteriography is a valuable method for the localization of sources of acute and chronic gastrointestinal bleeding. With intraarterial and in travenous infusions of vasopressin and transcatheter embolization the bleeding can be controlled in the majority of patients. In those patients in whom arteriography has failed to control the bleeding, localization of the source of bleeding facilitates the surgical procedure.
Figure 10 Postoperative cecostomy bleeding. (A) Superior mesenteric arteriogram demon strates the bleeding site in the cecum. (B) The bleeding stopped following intraarterial infusion of vasopressin at 0.2 U/min.
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1. Selding, S. L. 1953. Catheter replace ment of needle in percutaneous arterio graphy: A new technique. Acta Radiol 39:368-76 O 2. dman, P. 1956. Percutaneous selective angiography of the main branches of the aorta. Acta Radiol 45:1-14 3. Waltman, A. C., Courey, W. R., Athanasoulis, C. A., et a1. 1973. Tech nique for left gastric artery catheteriza tion. Radiology 109:732-34 4. Kehne, J. H., Hughes, F. A., Gomperte, N. L. 1956. The use of surgical pituitrin in the control of esophageal vanx bleed ing. Surgery 39:917-25 5. Goodman, L. S., Gilman, A. 1970. The Pharmacological Basis of Therapeutics. New York: MacMillan 4th ed. 6. Athanasoulis, C. A., Waltman, A. C.,
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plasia of the colon: A cause of rectal bleeding. Cardiovasc. Radiol 1:3-13 14. Kadir, S., Athanasoulis, C. A. 1978. Angiographic diagnosis and manage ment of postoperative bleeding. Crit. Rev. Med. Imaging. In press 15. Meany, T. F. 1973. Percutaneous Fem oral Angiography: Complications and Legal Implications of Radiographic Special Procedures, ed. T. F., Meany, R. J. Alfidi, pp. 15-35. St. Louis: Mosby 16. Kadir, S, Athanasoulis, C. A. 1978. Catheter dislodgement: A cause for the failure of intraarterial vasopressin to control gastrointestinal hemorrhage. Cardiovasc. Radiol 1:187-91
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