Steven B. Oglevie, MD • Douglas C. Smith, MD • S. Steve Mera, MD
Bleeding Marginal Ulcers: Angiographic Evaluation' The authors reviewed angiograms of patients who had previously undergone gastrojejunostomy and who were suffering from gastrointestinal bleeding. In five patients the site of bleeding was a surgically or endoscopically proved marginal ulcer. Only two of these ulcers were supplied by jejunal branches of the superior mesenteric artery; three of the five were supplied by gastric branches of the celiac artery. Thus, in angiography of patients with bleeding from marginal ulcers, the celiac, as well as the superior mesenteric, artery may need to be investigated. Index terms: Gastrointestinal tract, angiography, 741.1241, 741.1245, 951.714, 955.714 • Gastrointestinal tract, hemorrhage, 741.458 • Jejunum, hemorrhage, 741.458 • Stomach, hemorrhage, 72.458 Radiology 1990; 174:943-944
ASTROJEJUNOSTOMY is commonly performed for the treatment G of both peptic ulcer disease and duodenal obstruction. The common causes of postoperative upper gastrointestinal bleeding associated with this procedure include gastric pouch ulceration, marginal ulceration, gastritis from reflux of alkaline bile, slipped anastomotic sutures, and postoperative coagulation defects. Marginal ulcers are a specific type of peptic ulceration involving the jejunal mucosa near the site of a gastrojejunal anastomosis (1,2). Marginal ulceration has been reported in up to 8% of patients who have undergone gastrojejunostomy (3-5). Conventional teaching indicates that bleeding marginal ulcers are supplied by a proximal jejunal branch of the superior mesenteric artery. This is supported by the series of Rosenbaum et al, in which all five patients undergoing angiography for bleeding marginal ulcers showed extravasation of contrast material from proximal jejunal vessels (3). Herein we review our experience with angiography in patients with endoscopically or surgically proved bleeding marginal ulcers.
CASE REPORTS
1 From the Department of Radiation Sciences, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354. Received September 28, 1989; revision requested October 31; revision received November 21; accepted December 4. Address reprint requests to S.B.O. RSNA, 1990
We reviewed all angiograms obtained at our institution during 1974-1988 because of gastrointestinal bleeding. Extravasation of contrast material from marginal ulcers was found in five patients who had undergone gastrojejunostomy. Completed charts and angiograms were reviewed in all five. In only two of the five patients did bleeding occur, as traditionally described, from the jejunal branches of the superior mesenteric artery. Both were men, and they were 45 and 50 years of age. The interval between the gastrojejunostomy procedure and onset of bleeding was 5 days and 3 weeks, respectively, in these two patients. In both cases the bleeding was treated successfully with infusion of vasopressin into the superior mesenteric artery; however, one of these
patients died 2 months later of nonhemorrhagic complications. Branches of the celiac artery were responsible for bleeding in the other three cases (right gastroepiploic, short gastric, and left gastric arteries). There were two men and one woman, ranging in age from 52 to 75 years. The interval between surgery and bleeding ranged from 4 days to 6 years. The bleeding was treated successfully with embolization in one patient and failed to respond to selective vasopressin infusion in the other two. Case 1.—A 75-year-old woman with a long history of recurrent peptic ulcer disease underwent a Billroth II gastrojejunostomy and vagotomy. Six years later she presented with massive hematemesis. Gastroscopy failed to identify the source of bleeding. Celiac angiography showed extravasation of contrast material from the right gastroepiploic artery into the preanastomotic portion of the gastric remnant (Fig 1). Vasopressin infusion was attempted but did not control the bleeding. At surgery, a 1.5-cm ulcer involving the jejunal mucosa near the gastrojejunal anastomosis was seen. This ulcer penetrated the entire jejunal wall and eroded into the adjacent right gastroepiploic artery, which was actively bleeding. A subtotal gastrectomy with a Billroth I gastroduodenostomy was performed, and the patient had a rapid, uneventful recovery. Case 2.—A 52-year-old man had alcoholic cirrhosis, portal hypertension with esophageal varices, and carcinoma of the pancreas. A gastrojejunostomy was performed as part of a Whipple procedure. His postoperative course was complicated by a subphrenic abscess and recurrent upper gastrointestinal hemorrhage 3 weeks after the procedure. Endoscopy demonstrated an actively bleeding marginal ulcer just beyond the site of gastrojejunal anastomosis. Subsequent celiac angiography showed extravasation of contrast material from a short gastric branch of the proximal splenic artery (Fig 2). Because of inability to catheterize this tiny branch, the splenic artery adjacent to this branch was embolized with steel coils and gelatin sponge. He immediately stopped bleeding. However, he developed a severe Klebsiella bronchopneumonia, progressive septic shock, and died. Autopsy confirmed several marginal ulcerations involving the jejunal mucosa adjacent to
943
Figure 1. Case 1. Celiac angiOgram demonstrates extravasation of contrast material (arrowheads) from the right gastroduodenal artery (arrows). The stomach is markedly distended with blood.
the gastrojejunal anastomosis. Case 3.—A 68-year-old man underwent a Billroth II gastrojejunostomy for peptic
ulcer disease. Four days later he developed upper gastrointestinal bleeding. Celiac angiography showed extravasation from a branch of the left gastric artery near the gastrojejunal anastomosis (Fig 3). The bleeding was initially controlled with a selective vasopressin infusion but recurred from the same arterial branch 1 week later. Repeat vasopressin infusion was unsuccessful, and the patient was taken to surgery, where multiple bleeding marginal ulcers were confirmed. Partial dehiscence of the anastomosis was also noted, and the gastrojejunostomy site was resected and revised. Pathologic evaluation of the resected gastrojejunostomy site confirmed ulceration of the proximal jejunal mucosa and partial dehiscence of the anastomosis. Despite the resolution of his bleeding, he developed peritonitis with gram-negative sepsis and died.
DISCUSSION
In this series, bleeding from documented marginal ulcers was controlled with nonsurgical treatment in three of five cases. The less invasive nature of transcatheter vasoconstrictor or embolization therapy makes it particularly attractive in patients with incurable carcinoma or previous abdominal surgery. Although the total number of patients in this study is small, it is interesting to note that the bleeding was easily controlled with selective vasopressin infusion in
944 • Radiology
Figure 2. Case 2. Splenic angiogram shows extravasation of contrast material (arrow) from a proximal short gastric branch.
both patients with bleeding jejunal branches from the superior mesenteric artery. In only one of the three cases in which bleeding was demonstrated from a gastric branch was hemostasis achieved with nonsurgical treatment (embolization). Although hemostasis was achieved with transcatheter treatment in three cases and at surgery in the other two, only two of our five patients survived their hospitalization. However, it should be noted that three of five had incurable carcinomas and that all the deaths were related to nonhemorrhagic postoperative complications. Because gastrojejunostomy marginal ulcers specifically erode the jejunal mucosa, it seems intuitive that bleeding caused by these lesions would be supplied by jejunal branches of the superior mesenteric artery. However, our series illustrates that a bleeding marginal ulcer will not invariably be identified on a superior mesenteric angiogram. Indeed, in three of our five cases the bleeding vessel was a branch of the celiac artery. There are three possible explanations for this finding. A marginal ulcer in the jejunal mucosa can erode deeply enough to cause bleeding in an adjacent gastric vessel, as seen in case 1. Additionally, proximal jejunal branches occasionally arise from celiac sources, such as the dorsal pancreatic artery. Finally, it is possible that as the gastrojejunal anastomosis ma-
Figure 3. Case 3. Left gastric angiogram demonstrates extravasation of contrast material (arrows) at the gastrojejunal anastomo sis. Reflux of contrast material into the splenic artery (arrowheads) is incidentally noted.
tures, vascular ingrowth at that site produces interdigitation of gastric and jejunal branches. In these three situations, ulceration of jejunal mucosa could result in bleeding from branches of the celiac artery. Thus, even if endoscopy reveals a bleeding gastrojejunostomy marginal ulcer, branches of the celiac, as well as the superior mesenteric, artery may need to be investigated during angiography. Celiac angiography will, of course, also allow for the investigation of the common gastric and duodenal sources of bleeding in patients who have undergone gastroenterostomy (5). n References 1.
2.
3.
4.
5.
Friel JP. Dorland's illustrated medical dictionary. 25th ed. Philadelphia: Saunders, 1974; 1669. Eisenberg RL. Gastrointestinal radiology: a pattern approach. 2nd ed. Philadelphia: Lippincott, 1990; 196-200. Rosenbaum A, Siegelman SS, Sprayregen S. The bleeding marginal ulcer: catheterization diagnosis and therapy. AJR 1975; 125:812-815. Burhenne HJ. The postoperative stomach. In: Taveras JM, Ferrucci JT, eds. Radiology: diagnosis, imaging, intervention. Philadelphia: Lippincott, 1988; 1-11. Hietala SO, Ghahremani GG, Crampton AR, Wirell M. Arteriographic evaluation of postsurgical stomach. Gastrointest Radiol 1985; 10:31-37.
March 1990 • Part 2
Bleeding Marginal Ulcers: Angiographic Evaluation' The authors reviewed angiograms of patients who had previously undergone gastrojejunostomy and who were suffering from gastrointestinal bleeding. In five patients the site of bleeding was a surgically or endoscopically proved marginal ulcer. Only two of these ulcers were supplied by jejunal branches of the superior mesenteric artery; three of the five were supplied by gastric branches of the celiac artery. Thus, in angiography of patients with bleeding from marginal ulcers, the celiac, as well as the superior mesenteric, artery may need to be investigated. Index terms: Gastrointestinal tract, angiography, 741.1241, 741.1245, 951.714, 955.714 • Gastrointestinal tract, hemorrhage, 741.458 • Jejunum, hemorrhage, 741.458 • Stomach, hemorrhage, 72.458 Radiology 1990; 174:943-944
ASTROJEJUNOSTOMY is commonly performed for the treatment G of both peptic ulcer disease and duodenal obstruction. The common causes of postoperative upper gastrointestinal bleeding associated with this procedure include gastric pouch ulceration, marginal ulceration, gastritis from reflux of alkaline bile, slipped anastomotic sutures, and postoperative coagulation defects. Marginal ulcers are a specific type of peptic ulceration involving the jejunal mucosa near the site of a gastrojejunal anastomosis (1,2). Marginal ulceration has been reported in up to 8% of patients who have undergone gastrojejunostomy (3-5). Conventional teaching indicates that bleeding marginal ulcers are supplied by a proximal jejunal branch of the superior mesenteric artery. This is supported by the series of Rosenbaum et al, in which all five patients undergoing angiography for bleeding marginal ulcers showed extravasation of contrast material from proximal jejunal vessels (3). Herein we review our experience with angiography in patients with endoscopically or surgically proved bleeding marginal ulcers.
CASE REPORTS
1 From the Department of Radiation Sciences, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354. Received September 28, 1989; revision requested October 31; revision received November 21; accepted December 4. Address reprint requests to S.B.O. RSNA, 1990
We reviewed all angiograms obtained at our institution during 1974-1988 because of gastrointestinal bleeding. Extravasation of contrast material from marginal ulcers was found in five patients who had undergone gastrojejunostomy. Completed charts and angiograms were reviewed in all five. In only two of the five patients did bleeding occur, as traditionally described, from the jejunal branches of the superior mesenteric artery. Both were men, and they were 45 and 50 years of age. The interval between the gastrojejunostomy procedure and onset of bleeding was 5 days and 3 weeks, respectively, in these two patients. In both cases the bleeding was treated successfully with infusion of vasopressin into the superior mesenteric artery; however, one of these
patients died 2 months later of nonhemorrhagic complications. Branches of the celiac artery were responsible for bleeding in the other three cases (right gastroepiploic, short gastric, and left gastric arteries). There were two men and one woman, ranging in age from 52 to 75 years. The interval between surgery and bleeding ranged from 4 days to 6 years. The bleeding was treated successfully with embolization in one patient and failed to respond to selective vasopressin infusion in the other two. Case 1.—A 75-year-old woman with a long history of recurrent peptic ulcer disease underwent a Billroth II gastrojejunostomy and vagotomy. Six years later she presented with massive hematemesis. Gastroscopy failed to identify the source of bleeding. Celiac angiography showed extravasation of contrast material from the right gastroepiploic artery into the preanastomotic portion of the gastric remnant (Fig 1). Vasopressin infusion was attempted but did not control the bleeding. At surgery, a 1.5-cm ulcer involving the jejunal mucosa near the gastrojejunal anastomosis was seen. This ulcer penetrated the entire jejunal wall and eroded into the adjacent right gastroepiploic artery, which was actively bleeding. A subtotal gastrectomy with a Billroth I gastroduodenostomy was performed, and the patient had a rapid, uneventful recovery. Case 2.—A 52-year-old man had alcoholic cirrhosis, portal hypertension with esophageal varices, and carcinoma of the pancreas. A gastrojejunostomy was performed as part of a Whipple procedure. His postoperative course was complicated by a subphrenic abscess and recurrent upper gastrointestinal hemorrhage 3 weeks after the procedure. Endoscopy demonstrated an actively bleeding marginal ulcer just beyond the site of gastrojejunal anastomosis. Subsequent celiac angiography showed extravasation of contrast material from a short gastric branch of the proximal splenic artery (Fig 2). Because of inability to catheterize this tiny branch, the splenic artery adjacent to this branch was embolized with steel coils and gelatin sponge. He immediately stopped bleeding. However, he developed a severe Klebsiella bronchopneumonia, progressive septic shock, and died. Autopsy confirmed several marginal ulcerations involving the jejunal mucosa adjacent to
943
Figure 1. Case 1. Celiac angiOgram demonstrates extravasation of contrast material (arrowheads) from the right gastroduodenal artery (arrows). The stomach is markedly distended with blood.
the gastrojejunal anastomosis. Case 3.—A 68-year-old man underwent a Billroth II gastrojejunostomy for peptic
ulcer disease. Four days later he developed upper gastrointestinal bleeding. Celiac angiography showed extravasation from a branch of the left gastric artery near the gastrojejunal anastomosis (Fig 3). The bleeding was initially controlled with a selective vasopressin infusion but recurred from the same arterial branch 1 week later. Repeat vasopressin infusion was unsuccessful, and the patient was taken to surgery, where multiple bleeding marginal ulcers were confirmed. Partial dehiscence of the anastomosis was also noted, and the gastrojejunostomy site was resected and revised. Pathologic evaluation of the resected gastrojejunostomy site confirmed ulceration of the proximal jejunal mucosa and partial dehiscence of the anastomosis. Despite the resolution of his bleeding, he developed peritonitis with gram-negative sepsis and died.
DISCUSSION
In this series, bleeding from documented marginal ulcers was controlled with nonsurgical treatment in three of five cases. The less invasive nature of transcatheter vasoconstrictor or embolization therapy makes it particularly attractive in patients with incurable carcinoma or previous abdominal surgery. Although the total number of patients in this study is small, it is interesting to note that the bleeding was easily controlled with selective vasopressin infusion in
944 • Radiology
Figure 2. Case 2. Splenic angiogram shows extravasation of contrast material (arrow) from a proximal short gastric branch.
both patients with bleeding jejunal branches from the superior mesenteric artery. In only one of the three cases in which bleeding was demonstrated from a gastric branch was hemostasis achieved with nonsurgical treatment (embolization). Although hemostasis was achieved with transcatheter treatment in three cases and at surgery in the other two, only two of our five patients survived their hospitalization. However, it should be noted that three of five had incurable carcinomas and that all the deaths were related to nonhemorrhagic postoperative complications. Because gastrojejunostomy marginal ulcers specifically erode the jejunal mucosa, it seems intuitive that bleeding caused by these lesions would be supplied by jejunal branches of the superior mesenteric artery. However, our series illustrates that a bleeding marginal ulcer will not invariably be identified on a superior mesenteric angiogram. Indeed, in three of our five cases the bleeding vessel was a branch of the celiac artery. There are three possible explanations for this finding. A marginal ulcer in the jejunal mucosa can erode deeply enough to cause bleeding in an adjacent gastric vessel, as seen in case 1. Additionally, proximal jejunal branches occasionally arise from celiac sources, such as the dorsal pancreatic artery. Finally, it is possible that as the gastrojejunal anastomosis ma-
Figure 3. Case 3. Left gastric angiogram demonstrates extravasation of contrast material (arrows) at the gastrojejunal anastomo sis. Reflux of contrast material into the splenic artery (arrowheads) is incidentally noted.
tures, vascular ingrowth at that site produces interdigitation of gastric and jejunal branches. In these three situations, ulceration of jejunal mucosa could result in bleeding from branches of the celiac artery. Thus, even if endoscopy reveals a bleeding gastrojejunostomy marginal ulcer, branches of the celiac, as well as the superior mesenteric, artery may need to be investigated during angiography. Celiac angiography will, of course, also allow for the investigation of the common gastric and duodenal sources of bleeding in patients who have undergone gastroenterostomy (5). n References 1.
2.
3.
4.
5.
Friel JP. Dorland's illustrated medical dictionary. 25th ed. Philadelphia: Saunders, 1974; 1669. Eisenberg RL. Gastrointestinal radiology: a pattern approach. 2nd ed. Philadelphia: Lippincott, 1990; 196-200. Rosenbaum A, Siegelman SS, Sprayregen S. The bleeding marginal ulcer: catheterization diagnosis and therapy. AJR 1975; 125:812-815. Burhenne HJ. The postoperative stomach. In: Taveras JM, Ferrucci JT, eds. Radiology: diagnosis, imaging, intervention. Philadelphia: Lippincott, 1988; 1-11. Hietala SO, Ghahremani GG, Crampton AR, Wirell M. Arteriographic evaluation of postsurgical stomach. Gastrointest Radiol 1985; 10:31-37.
March 1990 • Part 2
