eMedicine Specialties > Radiology > Vascular/Interventional

Gastrointestinal Bleeding, Lower: Follow-up

Author: Atif Rana, MBBS, Assistant Professor, Department of Radiology, Shifa College of Medicine, Islamabad, Pakistan
Contributor Information and Disclosures

Updated: Apr 13, 2009

Intervention

Transcatheter therapy for GI bleeding

Two transcatheter methods for the treatment of GI bleeding include vasopressin infusion and embolization. Superselective embolization has become more accepted in recent years.

Vasopressin infusion

Vasopressin infusion causes vasoconstriction of the small arteries, arterioles, and capillaries, and it has been used for both upper and lower GI bleeds. The rate of successful control of bleeding has been reported to be 70-90%. The repeat bleeding rate is reported to be 17-27%.

The infusion is started with the catheter in the main trunk of the mesenteric artery that is cause of bleeding. The initial rate is 0.2 U/min. A follow-up angiogram is obtained after about 30 minutes. In cases of active hemorrhage, the rate is increased to 0.4 U/min. Higher rates are not recommended because the potential complications from vasoconstriction can exceed the benefits. The infusion is tapered at 6- to 12-hour intervals and then stopped if no further bleeding ensues.

Complications of vasopressin infusion include myocardial ischemia, arrhythmia, hypertension, bowel ischemia, peripheral vascular ischemia, and antidiuretic effects. Because of significant rebleeding, variable success, the need for ICU monitoring, and the aforementioned adverse effects of the infusion, renewed interest in embolization therapy has developed over the last few years. In fact, embolization has now become the preferred transcatheter therapy. Embolization also achieves immediate control of the bleeding, and ICU monitoring to the degree required with vasopressin infusion is avoided.

Embolization

The aim of embolization is to decrease the arterial inflow so that the pressure at the bleeding site is decreased and hemostasis occurs. The important issue is to avoid devascularization of the tissues, which leads to ischemia and infarction. Although upper GI bleeds have been managed with embolization for years, enthusiasm for the use of this technique with lower GI bleeds was limited. The lack of rich collaterals in the colon and small bowel, unlike the stomach and duodenum, was thought to jeopardize the integrity of bowel after embolization. Because of the previously mentioned issues related to vasopressin use, interest in this technique was renewed, and embolization has now become the preferred transcatheter therapy.

Lower gastrointestinal bleeding. Postembolization...

Lower gastrointestinal bleeding. Postembolization selective angiogram. No further extravasation of contrast material is seen. Polyvinyl alcohol particles were used.

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Lower gastrointestinal bleeding. Postembolization...

Lower gastrointestinal bleeding. Postembolization selective angiogram. No further extravasation of contrast material is seen. Polyvinyl alcohol particles were used.


Lower gastrointestinal bleeding. Postembolization...

Lower gastrointestinal bleeding. Postembolization arteriogram shows no further bleeding. Microcoils and polyvinyl alcohol were used.

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Lower gastrointestinal bleeding. Postembolization...

Lower gastrointestinal bleeding. Postembolization arteriogram shows no further bleeding. Microcoils and polyvinyl alcohol were used.


In 1974, Bookstein first described transcatheter embolization by using an autologous clot.18 Since that time, various investigators have described small series of transcatheter embolization for lower GI bleeds, with varying success. The potential complication of bowel ischemia and infarction initially limited use of this technique. Earlier groups had described postembolization bowel infarction rates ranging from 0% to 23%. However, some authors claim that the high rate of significant ischemia may have been related to proximal embolization sites in relation to the marginal artery, as lack of large vascular collaterals in large bowel may jeopardize significant areas of colon.

With this issue in mind, further studies with superselective catheterization techniques and embolization were performed. Polyvinyl alcohol (PVA, Contour, Medi-tech Inc. Natick, Mass) particles and Gelfoam (Upjohn, Kalamazoo, Mich) have been used, although most of the studies have used microcoils (platinum coils), either alone or in conjunction with Gelfoam or PVA.

Evangelista et al described superselective embolization in 17 patients.19 They used coils (n = 12), coils with PVA (n = 4), PVA alone (n = 2), and Gelfoam with coils (n = 1). They reported an 88% success rate. Two patients developed transient signs of bowel ischemia, but none developed infarction, perforation, or stricture. These authors argue against the use of PVA as sole embolization agent. The reasoning is that the small particles may reach intramural circulation and thus occlude the submucosal plexus beyond the level of collateralization, leading to significant bowel ischemia. Another advantage of coils is that they are visible and, therefore, more controllable.

A later retrospective study involved the use of PVA. Bandi et al reported their experience with 39 procedures in 35 patients.20 They performed embolization in only those patients in whom they could successfully catheterize the arteria recta leading to the bleeding point. They used only PVA (150-500 µm) in 28 of these procedures. Twenty-five patients underwent objective follow-up with colonoscopy (n = 12), surgery (n = 9), or both (n = 4). Mucosal ischemia was demonstrated in 6 (24%) of these patients, but they remained asymptomatic without clinical sequela. No clinically significant bowel ischemia was seen.

An advantage of angiography over coloscopy or scintigraphy is that no special preparation is needed. Arterial access is obtained in a standard fashion from the right side of the groin, and a sheath is placed. A 5F diagnostic catheter can then be advanced through this site. Glucagon (0.5-1.0 mg) is intravenously administered to decrease the bowel peristalsis.

The superior mesenteric artery (SMA) is usually selected first, because about 60% of angiographically detected lower GI bleeds are reported to be from the right side of the colon. The inferior mesenteric artery (IMA) is then evaluated. Both these territories may require multiple injections for complete coverage. Because a middle colic artery origin from the celiac axis or splenic artery and other rare anomalous vascular patterns have been described, celiac arteriography is performed if no source is found with injections in the SMA and the IMA. This technique also aids in excluding the upper GI tract as a possible source of bleeding.

Embolization is performed by a 3F microcatheter coaxially placed through the diagnostic 5F catheter. This catheter is usually advanced over a 0.018-in guidewire. The microcatheter should be advanced as far as possible, to the level of arteria recta, so that large areas of colon are not at risk for ischemia from embolization. As mentioned earlier, microcoils are the most commonly used agents, although PVA and Gelfoam, alone or with coils, are also used. PVA sizes reported in literature range from 150-500 µm. PVA particles are suspended in contrast material and delivered through the microcatheter under fluoroscopic guidance.

Summary

Most patients with a lower GI hemorrhage stop bleeding with conservative management. Colonoscopy after a rapid purge is now considered the procedure of choice for the evaluation of acute lower GI bleeds. In the case of a hemodynamically unstable patient, angiography may be the best option because it can be performed in a relatively short period and because it also provides a means for immediate treatment. Patients in stable condition can undergo scintigraphy to guide and increase the yield of angiography.

 


More on Gastrointestinal Bleeding, Lower

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Multimedia: Gastrointestinal Bleeding, Lower
References
Further Reading
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Further Reading

Clinical guidelines
ASGE guideline: the role of endoscopy in the patient with lower-GI bleeding.
American Society for Gastrointestinal Endoscopy - Medical Specialty Society.  2005 Nov.  5 pages.  NGC:004584

Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.].  2008 Sep.  57 pages.  NGC:006730

Clinical trials

 Diagnostic Evaluation of Obscure Gastrointestinal Bleeding

Related eMedicine topics

 Lower Gastrointestinal Bleeding (gastroenterology)

Lower Gastrointestinal Bleeding: Surgical Perspective

Diverticular Disease (emergency medicine)

Pediatrics, Gastrointestinal Bleeding

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Keywords

lower gastrointestinal bleeding, GI bleeding, lower GI bleeding, gastrointestinal hemorrhage, GI hemorrhage

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Contributor Information and Disclosures

Author

Atif Rana, MBBS, Assistant Professor, Department of Radiology, Shifa College of Medicine, Islamabad, Pakistan
Atif Rana, MBBS is a member of the following medical societies: Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Anthony Watkinson, MD, Professor of Interventional Radiology, The Peninsula Medical School; Consultant and Senior Lecturer, Department of Radiology, The Royal Devon and Exeter Hospital, UK
Anthony Watkinson, MD is a member of the following medical societies: Radiological Society of North America, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Douglas M Coldwell, MD, PhD,, Principal, Coldwell Associates. Interventional Radiologist, Jane Phillips Medical Center, Bartlesville, OK
Douglas M Coldwell, MD, PhD, is a member of the following medical societies: American Association for Cancer Research, American College of Radiology, American Heart Association, American Physical Society, American Roentgen Ray Society, Society of Cardiovascular and Interventional Radiology, Southwest Oncology Group, and Special Operations Medical Association
Disclosure: Sirtex, Inc. Consulting fee Speaking and teaching

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Kyung J Cho, MD, FACR, William Martel Professor of Radiology, Interventional Radiology Fellowship Director, University of Michigan Health System
Kyung J Cho, MD, FACR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

 
 
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