eMedicine Specialties > Radiology > Vascular/Interventional

Gastrointestinal Bleeding, Upper: Follow-up

Author: Manish K Varma, MD, Chief of Interventional Radiology, Department of Radiology, Tripler Army Medical Center
Coauthor(s): Anthony W Allen, MD, Chief, Interventional Radiology, Brooke Army Medical Center; Associate Professor of Radiology, Uniformed Services University of the Health Sciences; Michael AJ Sawyer, MD, Director, Videoendoscopic Surgical Institute of Oklahoma, Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Lawton, Oklahoma
Contributor Information and Disclosures

Updated: Sep 10, 2008

Intervention

Selective arterial embolization is effective in arresting arterial bleeding from peptic ulcer disease, Dieulafoy disease, Mallory-Weiss tear, hemobilia, and hemosuccus pancreaticus. Intra-arterial vasopressin infusion is an ineffective treatment for bleeding from ulcer disease, but it is effective in controlling bleeding from hemorrhagic gastritis. Vasopressin is infused intravenously for control of variceal bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) placement is an effective means of controlling variceal bleeding unresponsive to endoscopic sclerotherapy or banding. When gastroesophageal varices continue to fill after placement of a TIPS in the patient with massive variceal bleeding, variceal embolization is performed.20,21,22

The angiographic appearance of an acute upper gastrointestinal bleeding is extravasation of contrast medium during the arterial phase, which runs toward the dependent part of the viscus and may persist as an opaque pooling of contrast medium during the capillary and venous phase. Carbon dioxide is more frequently used as an arterial contrast agent for the diagnosis of both upper and lower GI hemorrhage.

In general, active extravasation should be demonstrated prior to embolotherapy in a case of upper GI arterial bleeding. The bleeding from Mallory-Weiss tears is usually self-limiting, and if no bleeding is seen during angiography, embolotherapy is not initiated. Vasopressin infusion into the left gastric artery is used for treatment of hemorrhagic gastritis with a good success rate; embolization is ineffective because the bleeding is capillary or mucosal in nature. Endoscopic therapy is the first and safest choice of treatment, but the presence of multiple bleeding sites precludes the use of endoscopic therapy in hemorrhagic gastritis.

Vasopressin causes constriction of the arterioles and capillaries. It is infused at a rate of 0.2 U/min once the catheter is placed in the appropriate vessel. After 20 minutes of the infusion, a repeat angiogram is obtained to check for recurrent bleeding or the degree of vasoconstriction. If hemostasis is not achieved, the infusion rate is increased to 0.4 U/min. The maximal dose is 0.6 U/min, because higher rates lead to myocardial or intestinal ischemia. The optimal result is cessation of hemorrhage with pruning, but patent, vessels extending to the area of interest. The infusion is continued for 24 hours and adjusted as necessary. The initial success rate for gastric bleeding is approximately 70%, but recurrent bleeding frequently occurs. Vasopressin infusion is contraindicated in patients with coronary artery disease.

Embolotherapy with Gelfoam pledgets, polyvinyl alcohol, or (less often) coils, can be used to effectively control UGIB. If a 3F coaxial catheter can be placed in the bleeding artery at or close to the site of extravasation, microcoils (platinum coils) may be used. Placing a coil proximal to the bleeding site may result in recurrent bleeding via collaterals. Because of the rich collateral circulation in this region, ischemia is rarely a problem in the absence of prior GI surgery. However, combined therapy with vasopressin infusion and embolization should be avoided because of the potential risk of ischemia to the embolized viscus.

The duodenum has a dual blood supply from the branches of the celiac and superior mesenteric arteries. Thus, after embolization of the branches of the gastroduodenal artery, a superior mesenteric arteriogram should be obtained to evaluate reconstitution of the bleeding artery. Occasionally, both branches from the celiac and superior mesenteric arteries may have to be embolized to control bleeding from the duodenum. Concurrent correction of any underlying coagulopathy is important to aid in thrombosis.

Gomes et al reported an 88% success rate with embolization, compared with a 52% success rate with vasopressin. Major complications occurred in 12.5% of patients treated with embolization and in 8.7% of patients treated with vasopressin.23

In esophageal variceal bleeding that is refractory to banding or sclerosis, TIPS placement is the procedure of choice in patients with a Child class B condition and in some with a Child class C condition. Subsequent embolization of large varices during the procedure is controversial. As a rule, if large varices fill despite the presence of a satisfactory portosystemic gradient (<12 mm Hg) after a TIPS procedure, selective embolization is performed. In variceal bleeding secondary to hepatoma, embolization of the hepatic feeding vessel may be effective in controlling hemorrhage.

Balloon-occluded retrograde transvenous obliteration (BRTO) through the left renal-inferior phrenic vein from a femoral vein approach is an effective method of treatment for gastric variceal bleeding that cannot be treated by endoscopic method.

Medicolegal Pitfalls

  • Potential medical/legal pitfalls include a delay in the diagnosis and treatment of upper gastrointestinal bleeding and the failure to adequately and completely counsel a patient about the potential complications of various treatment modalities.24
  • To prevent these potential problems, having a well-established system in place to evaluate GI bleeding and cooperation among the specialists involved is important in the care of this multidisciplinary problem.
 


More on Gastrointestinal Bleeding, Upper

Overview: Gastrointestinal Bleeding, Upper
Imaging: Gastrointestinal Bleeding, Upper
Follow-up: Gastrointestinal Bleeding, Upper
Multimedia: Gastrointestinal Bleeding, Upper
References
Further Reading
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References

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  2. Kandarpa K, Aruny JE. Acute gastrointestinal bleeding. In: Handbook of Interventional Radiologic Procedures. 2nd ed. 1996: 130-8.

  3. Reuter SR, Redman HC, Cho KC. Gastrointestinal bleeding. In: Gastrointestinal Angiography. 1986: 282-338.

  4. Richter JM, Isselbacher KJ. Gastrointestinal bleeding. In: Harrison's Principles of Internal Medicine. 12th ed. 1991: 261-4.

  5. Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin North Am. May 2008;92(3):491-509, xi. [Medline].

  6. Eisen GM, Dominitz JA, Faigel DO. An annotated algorithmic approach to upper gastrointestinal bleeding. Gastrointest Endosc. Jun 2001;53(7):1-6. [Medline].

  7. Tammaro L, Di Paolo MC, Zullo A, Hassan C, Morini S, Caliendo S, et al. Endoscopic findings in patients with upper gastrointestinal bleeding clinically classified into three risk groups prior to endoscopy. World J Gastroenterol. Aug 28 2008;14(32):5046-50. [Medline].

  8. Venbrux AC. Upper gastrointestinal bleeding: diagnostic evaluation and management. In: SCVIR Syllabus: Thoracic and Visceral Vascular Interventions. 1996: 235-46.

  9. Rockall TA, Logan RF, Devlin HB. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage. BMJ. Jul 22 1995;311(6999):222-6. [Medline].

  10. Yavorski RT, Wong RK, Maydonovitch C. Analysis of 3,294 cases of upper gastrointestinal bleeding in military medical facilities. Am J Gastroenterol. Apr 1995;90(4):568-73. [Medline].

  11. da Silveira EB, Lam E, Martel M, Bensoussan K, Barkun AN. The importance of process issues as predictors of time to endoscopy in patients with acute upper-GI bleeding using the RUGBE data. Gastrointest Endosc. Sep 2006;64(3):299-309. [Medline].

  12. Spiegel BM, Vakil NB, Ofman JJ. Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review. Arch Intern Med. Jun 11 2001;161(11):1393-404. [Medline].

  13. Lee JG, Turnipseed S, Romano PS, Vigil H, Azari R, Melnikoff N, et al. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc. Dec 1999;50(6):755-61. [Medline].

  14. Axon AT, Bell GD, Jones RH, Quine MA, McCloy RF. Guidelines on appropriate indications for upper gastrointestinal endoscopy. Working Party of the Joint Committee of the Royal College of Physicians of London, Royal College of Surgeons of England, Royal College of Anaesthetists, Association of Surgeons, the British Society of Gastroenterology, and the Thoracic Society of Great Britain. BMJ. Apr 1 1995;310(6983):853-6. [Medline].

  15. Lefkovitz Z, Cappell MS, Kaplan M. Radiology in the diagnosis and therapy of gastrointestinal bleeding. Gastroenterol Clin North Am. Jun 2000;29(2):489-512. [Medline].

  16. Schillaci O, Spanu A, Tagliabue L, Filippi L, Danieli R, Palumbo B, et al. SPECT/CT with a hybrid imaging system in the study of lower gastrointestinal bleeding with technetium-99m red blood cells. Q J Nucl Med Mol Imaging. Jul 3 2008;[Medline].

  17. Ettorre GC, Francioso G, Garribba AP. Helical CT angiography in gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol. Mar 1997;168(3):727-31. [Medline].

  18. Hawkins IF, Caridi JG, LeVeen RF. Use of carbon dioxide for the detection of gastrointestinal bleeding. In: Techniques in Vascular and Interventional Radiology. 2000: 130-8.

  19. Laing CJ, Tobias T, Rosenblum DI, Banker WL, Tseng L, Tamarkin SW. Acute gastrointestinal bleeding: emerging role of multidetector CT angiography and review of current imaging techniques. Radiographics. Jul-Aug 2007;27(4):1055-70. [Medline].

  20. Coldwell DM. Embolotherapy of miscellaneous lesions. In: Radiologic Interventions: Embolotherapy. 1997: 93-103.

  21. Patel TH, Cordts PR, Abcarian P. Will transcatheter embolotherapy replace surgery in the treatment of gastrointestinal bleeding?. Curr Surg. May 2001;58(3):323-7. [Medline].

  22. Weintraub JL, Haskal ZJ. Embolotherapy of upper gastrointestinal hemorrhage. In: Techniques in Vascular and Interventional Radiology. 2000: 162-70.

  23. Gomes AS, Lois JF, McCoy RD. Angiographic treatment of gastrointestinal hemorrhage: comparison of vasopressin infusion and embolization. AJR Am J Roentgenol. May 1986;146(5):1031-7. [Medline].

  24. Stuber T, Hoffmann MH, Stuber G, Klass O, Feuerlein S, Aschoff AJ. Pitfalls in detection of acute gastrointestinal bleeding with multi-detector row helical CT. Abdom Imaging. Jul 3 2008;[Medline].

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Further Reading

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. American Association for the Study of Liver Diseases - Private Nonprofit Research Organization
American College of Gastroenterology - Medical Specialty Society.  1997 (revised 2007 Sep).  17 pages.  NGC:005907

Preparation of patients for GI endoscopy.
American Society for Gastrointestinal Endoscopy - Medical Specialty Society.  2003 Apr.  5 pages.  NGC:003818

The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. American Association for the Study of Liver Diseases - Private Nonprofit Research Organization.  2005 Feb.  15 pages.  NGC:004222

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

ASGE guideline: the role of endoscopy in acute non-variceal upper-GI hemorrhage.
American Society for Gastrointestinal Endoscopy - Medical Specialty Society.  2004 Oct.  8 pages.  NGC:004062

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Keywords

upper gastrointestinal bleeding, upper GI bleeding, UGIB, gastrointestinal bleeding, GI bleeding, hematemesis, variceal bleeding, upper GI hemorrhage, lower GI bleeding, LGIB, hemorrhage

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Contributor Information and Disclosures

Author

Manish K Varma, MD, Chief of Interventional Radiology, Department of Radiology, Tripler Army Medical Center
Manish K Varma, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Coauthor(s)

Anthony W Allen, MD, Chief, Interventional Radiology, Brooke Army Medical Center; Associate Professor of Radiology, Uniformed Services University of the Health Sciences
Anthony W Allen, MD is a member of the following medical societies: American College of Radiology
Disclosure: Nothing to disclose.

Michael AJ Sawyer, MD, Director, Videoendoscopic Surgical Institute of Oklahoma, Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Lawton, Oklahoma
Michael AJ Sawyer, MD is a member of the following medical societies: American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Robert A Koenigsberg, DO, MSc, FAOCR, Professor, Director of Neuroradiology, Program Director, Diagnostic Radiology and Neuroradiology Training Programs, Department of Radiology, Hahnemann University Hospital, Drexel University College of Medicine
Robert A Koenigsberg, DO, MSc, FAOCR is a member of the following medical societies: American Osteopathic Association, American Society of Neuroradiology, Radiological Society of North America, and Society of NeuroInterventional Surgery
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

George Hartnell, MB, Professor of Radiology, Tufts University School of Medicine, Director of Cardiovascular and Interventional Radiology, Department of Radiology, Baystate Medical Center
George Hartnell, MB is a member of the following medical societies: American College of Cardiology, American College of Radiology, American Heart Association, Association of University Radiologists, British Institute of Radiology, British Medical Association, Massachusetts Medical Society, Radiological Society of North America, Royal College of Physicians, Royal College of Radiologists, and Society of Cardiovascular and Interventional Radiology
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
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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