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Upper Gastrointestinal Bleeding Imaging

  • Author: Manish K Varma, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR  more...
 
Updated: Nov 05, 2015
 

Overview

Upper gastrointestinal bleeding (UGIB) is defined as hemorrhage that emanates proximal to the ligament of Treitz. It is a common and potentially life-threatening condition. More than 350,000 hospital admissions are attributable to UGIB, which has an overall mortality rate of 10%. Although more than 75% of cases of bleeding cease with supportive measures, a significant percentage of patients require further intervention, which often involves the combined efforts of gastroenterologists, surgeons, and interventional radiologists.[1, 2, 3, 4]

See the images below.

Case 1. Celiac arteriogram obtained in a patient w Case 1. Celiac arteriogram obtained in a patient with duodenal ulcer bleeding that was documented endoscopically reveals standard celiac anatomy. No obvious hemorrhage from the gastroduodenal artery is seen.
Bleeding from duodenal leiomyoma. Gastroduodenal a Bleeding from duodenal leiomyoma. Gastroduodenal arteriogram showing a duodenal mass with active contrast extravasation (arrow).
Duodenal resected specimen showing a submucosal ma Duodenal resected specimen showing a submucosal mass with a central ulceration (arrow) (same patient as previous image).

For more information on this topic, see Upper Gastrointestinal Bleeding.

The first decision point in managing GI bleeding is defining the site and cause of bleeding: is it an upper GI or a lower GI hemorrhage?[5, 6]

Clinically, UGIB often causes hematemesis (vomiting of blood) or melena (passage of stools rendered black and tarry by the presence of altered blood). The color of the vomitus depends on its contact time with the hydrochloric acid of the stomach. If vomiting occurs early after the onset of bleeding, it appears red; with delayed vomiting, it is dark red, brown, or black. Coffee-ground emesis results from precipitation of blood clots in the vomitus. Hematochezia (red blood per rectum) usually indicates bleeding distal to the ligament of Treitz. Occasionally, rapid bleeding from an upper GI source may result in hematochezia.

The rate and extent of hemorrhage, coupled with the patient's comorbidities, determine the clinical presentation of UGIB. Endoscopy is a critical early intervention that can be used to establish the source of bleeding, and it also offers therapeutic options. If bleeding cannot be controlled by means of endoscopy, further interventions with catheter-directed embolotherapy or surgery may be warranted.[7]

Preferred examination

Upper endoscopy is the initial procedure of choice for the evaluation of acute upper gastrointestinal bleeding. Early endoscopy allows estimation of the rate of recurrent bleeding and enables various therapeutic options. It is also helpful in diagnosing and treating variceal bleeding. Recent studies have shown that early endoscopy is associated with lower healthcare costs and improved medical outcomes, compared with other procedures. However, upper GI endoscopic findings are nondiagnostic in about 10% of cases.[8, 9, 10, 11]

If endoscopy has failed to reveal a bleeding source or if the bleeding cannot be controlled, angiography is used for diagnosis and therapy. Angiography has been shown to depict the source with bleeding rates as low as 0.5 mL/min. If no active bleeding is identified angiographically in a patient with documented recurrent bleeding by endoscopy, prophylactic embolization of the left gastric artery or the gastroduodenal artery may be performed to control gastric or pyloroduodenal bleeding, respectively.

With advances in both endoscopic and angiographic techniques, surgical options are often limited in acute UGIB because of its morbidity and mortality rates. In the setting of recurrent variceal bleeding that is refractory to endoscopic control, the use of transjugular intrahepatic portosystemic shunts (TIPS) is preferred in the management of patients with a Child class B condition and in some with a Child class C condition. Currently, upper GI barium examinations have no role in the diagnosis of acute UGIB.

Limitations of techniques

Endoscopy is often the first-line diagnostic examination and treatment option for upper gastrointestinal bleeding. However, findings can be nondiagnostic in about 10% of cases. For example, in the setting of massive UGIB, endoscopy may not be helpful because intraluminal blood cannot be adequately cleared. Angiography is limited by the rate of bleeding, which usually must be at least 0.5 mL/min before it is detected. Its accuracy in the detection of acute UGIB is 90%, and it is helpful in assessing occult UGIB.

A positive angiographic finding of bleeding is needed to initiate embolization, except in cases in which bleeding has been localized before—for example, in the left gastric artery (LGA) or gastroduodenal artery. In these situations, prophylactic embolization is helpful. Prophylactic embolization of the LGA without prior documented bleeding is advocated because almost 90% of patients with this condition survive if the bleeding is controlled. The left gastric artery is involved in 85% of cases of UGIB.

For patient education information, see the Esophagus, Stomach, and Intestine Center, as well as Gastrointestinal Bleeding.

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Radiography

Plain radiographs of the abdomen are not usually helpful in the diagnosis of acute upper gastrointestinal bleeding (UGIB). The pathophysiology of acute UGIB is often mucosal erosion with subsequent hemorrhage, which is not detected with plain radiographs. Occasionally, free air under the diaphragm is seen in cases of perforated viscous, and this may be accompanied by UGIB. Other etiologies, such as upper GI masses (which usually result in chronic, not acute, UGIB), aneurysms with calcifications, and ascites suggestive of portal hypertension, may be seen on radiographs.[12]

The radiographic findings, as outlined above, are usually nonspecific. Calcifications associated with aneurysms, in the aorta or branch vessels, are reliable but rare findings regarding a source of upper gastrointestinal bleeding.

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Computed Tomography

Usually, abdominal CT is not used in the evaluation of acute upper gastrointestinal bleeding from arterial sources, although it has been helpful in some series. However, in the detection of UGIB from pseudoaneurysms of the mesenteric vessels, branches of the celiac axis, or aortoenteric fistulas, it is the study of choice. In addition, in the evaluation of masses of the upper GI system or liver tumors that may be contributing to hemobilia, CT is an excellent modality. Occasionally, hemorrhage into the peritoneum can be detected on CT scans.[13, 14]

See the images below.

Case 4. CT scan obtained in a 45-year-old man with Case 4. CT scan obtained in a 45-year-old man with acute hematemesis reveals a left upper quadrant acute mesenteric and lesser sac hemorrhage.
Case 4. CT image caudal to previous image reveals Case 4. CT image caudal to previous image reveals acute hemorrhage.
Case 4. Image obtained with a selective common hep Case 4. Image obtained with a selective common hepatic artery injection reveals a pseudoaneurysm in the right gastric artery, which arises from the proper hepatic artery. The pseudoaneurysm has the appearance of a double density that overlaps the origin of the gastroduodenal artery in this projection.
Case 4. Image in a left anterior oblique projectio Case 4. Image in a left anterior oblique projection compared with the orientation of the diagnostic angiogram depicts selective embolization of the pseudoaneurysm of the right gastric artery with coils. The patient had no further bleeding.

In the setting of portal hypertension, the presence of varices and the patency of the portal and splenic veins can be evaluated prior to a transjugular intrahepatic portosystemic shunt (TIPS) procedure or splenic artery embolization.

Degree of confidence

CT is currently not the study of choice in the evaluation of acute upper gastrointestinal bleeding. If occult bleeding from masses or aneurysms is suspected, CT may be helpful. However, small pseudoaneurysms, small bowel tumors, and small biliary tumors can easily be missed by CT. In the catastrophic situation of aortoenteric fistula, CT may be helpful in detecting an early leak.

False positives and negatives

The usual drawbacks of upper abdominal CT for the evaluation of subtle lesions also apply to the use of this modality in the evaluation of upper gastrointestinal bleeding. These include underopacification of bowel loops, suboptimal visualization of the biliary system and small visceral aneurysms, and difficulty in evaluating the esophagus.

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Magnetic Resonance Imaging

MRI has a limited role in the evaluation of acute upper gastrointestinal bleeding (UGIB) from arterial sources. In the setting of aneurysms and pseudoaneurysm, magnetic resonance angiography may be helpful in depicting the vascular abnormalities. With magnetic resonance cholangiography, the depiction of subtle biliary abnormalities may be helpful in cases of hemobilia. MRI is comparable to CT in the evaluation of masses that cause UGIB.

Similar to CT, MRI has no real role in the assessment of acute upper gastrointestinal bleeding. It may be helpful in depicting small visceral pseudoaneurysms or masses, but a normal MRI finding is often only a starting point for further investigation.

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Ultrasonography

Ultrasonography has no role in the setting of acute upper gastrointestinal bleeding (UGIB). It may be helpful in establishing portal vein patency prior to transjugular intrahepatic portosystemic shunt (TIPS) placement in patients with variceal bleeding. Cross-sectional CT or MRI is used to detect occult sources of UGIB.

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Nuclear Imaging

Tagged-RBC and sulfur colloid studies are not generally used for the evaluation of upper gastrointestinal bleeding (UGIB). The diagnosis of UGIB is usually established with clinical parameters and endoscopic means. Nuclear medicine studies are usually reserved for the investigation of lower gastrointestinal bleeding in areas that cannot be reached with endoscopy because of anatomical or technical reasons (ie, brisk bleeding).[13, 15]

In addition, significant artifacts associated with nuclear medicine bleeding scanning can be present in the upper abdomen; these are caused by cardiac and vascular activity and breathing motion. Blood from UGIB often pools in the cecum, and the exact site of bleeding is often difficult to ascertain.

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Angiography

Angiography is often the next step if medical management or endoscopy fails to control upper gastrointestinal bleeding (UGIB). Angiography is minimally invasive; it often allows precise localization of bleeding; and it enables the use of therapeutic options, which include embolization or vasopressin infusion. A hemorrhage rate of 0.5-1.0 mL/min is required before it can be visualized with angiography. The detection of bleeding may be enhanced with carbon dioxide as an arterial contrast agent because of the low viscosity of the gas.[16, 17, 18, 19, 20]

Endoscopic evaluation is critical in providing information for subsequent angiography.[21] For example, if variceal bleeding is suspected instead of arterial bleeding, endoscopy can be used to guide subsequent therapy in favor of a transjugular intrahepatic portosystemic shunt (TIPS) procedure.[22] In cases such as hemorrhagic gastritis (shown in the images below), which is an important cause of UGIB caused by physiologic stress, the endoscopic diagnosis can guide subsequent vasopressin infusion. If a mass or recurrent bleeding from a suspected ulcer in the duodenum is present, the gastroduodenal artery can be embolized.

See the images below.

Case 2. Selective left gastric arteriogram obtaine Case 2. Selective left gastric arteriogram obtained in a patient with cirrhosis, recent upper GI bleeding, and esophageal ulcers, with diffuse hemorrhagic gastritis as demonstrated at recent endoscopy.
Case 2. Because the patient was known to have diff Case 2. Because the patient was known to have diffuse hemorrhagic gastritis, as assessed with endoscopy, vasopressin infusion was begun at 0.2 U/min. Follow-up angiogram reveals a decrease in vascularity to the stomach. Vasopressin was continued overnight, with the patient in the ICU. The patient weaned from the medication over the following 24 hours without a recurrence of bleeding.

Angiographic evaluation of UGIB is usually performed via common femoral artery access achieved with the Seldinger technique. A catheter is directed into the celiac artery and superior mesenteric artery for angiography. Prior diagnostic examinations such as endoscopy or CT can be used to guide subsequent catheterization.

Acute arterial bleeding is seen as the extravasation of contrast medium of arterial opacity at the bleeding site. The extravasating contrast agent frequently flows toward the dependent part of the viscous, creating the pseudovein appearance. If the bleeding is demonstrated on the celiac or superior mesenteric angiogram, a more selective injection of the extravasating artery (superselective catheterization) is performed for confirmation of the bleeding and embolization. If contrast agent extravasation is not seen with the selective injections, superselective catheterization of the gastroduodenal, left gastric, and splenic arteries is performed.

Angiography is insensitive in the detection of venous bleeding, such as variceal hemorrhage from portal hypertension. Clinical suspicion and endoscopic findings are helpful in evaluating variceal bleeds. However, angiography can be helpful in the detection of as much as 50% of occult UGIB.

See the images below.

Bleeding from duodenal leiomyoma. Gastroduodenal a Bleeding from duodenal leiomyoma. Gastroduodenal arteriogram showing a duodenal mass with active contrast extravasation (arrow).
Duodenal resected specimen showing a submucosal ma Duodenal resected specimen showing a submucosal mass with a central ulceration (arrow) (same patient as previous image).
Hemosuccus pancreaticus in patient with upper GI h Hemosuccus pancreaticus in patient with upper GI hemorrhage. Splenic artery aneurysm with bleeding into the pancreatic duct (arrow).
Variceal bleeding in a patient with hepatocellular Variceal bleeding in a patient with hepatocellular carcinoma invading the portal vein. Threads and streaks sign (arrow) indicating portal vein invasion by hepatoma.
Portal venous phase of a superior mesenteric angio Portal venous phase of a superior mesenteric angiogram showing portal vein occlusion and gastroesophageal varices (arrow) (same patient as previous image).

Degree of confidence

The degree of confidence in the angiographic diagnosis of upper gastrointestinal bleeding is high. Arteriography can be used to accurately identify 90% of acute UGIB. It is also useful in depicting occult bleeding in 50% of patients. However, a bleeding rate of 0.5-1.0 mL/min is required for the angiographic depiction of hemorrhage. Venous bleeding (eg, from variceal bleeding) is difficult to detect with angiography.

False positives and negatives

Bowel motion, prior barium examinations, and abnormal staining from inflammation or breathing artifact can hinder angiographic depiction of bleeding. Multiple superselective injections may be required for a confident diagnosis. A bleeding rate of 0.5-1.0 mL/min is required to visualize angiographic hemorrhage; otherwise, a false-negative angiogram results. Alternatively, if the bleeding has stopped at the time of study, the clinical parameters may be helpful in this distinction. Venous hemorrhage from portal hypertension might be another cause of false-negative findings.

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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, Radiological Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Michael AJ Sawyer, MD Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Medical Director, Lawton Bariatrics

Michael AJ Sawyer, MD is a member of the following medical societies: American Society for Metabolic and Bariatric Surgery, Society for Surgery of the Alimentary Tract, Society of Laparoendoscopic Surgeons, American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Anthony W Allen, MD Chief of Interventional Radiology, Brooke Army Medical Center; Associate Professor of Radiology, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Anthony W Allen, MD is a member of the following medical societies: American College of Radiology

Disclosure: Received consulting fee from Teleflex Medical for consulting.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Chief Editor

Kyung J Cho, MD, FACR, FSIR William Martel Professor of Radiology, Interventional Radiology, University of Michigan Health System, Frankel Cardiovascular Center

Kyung J Cho, MD, FACR, FSIR 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, Radiological Society of North America

Disclosure: Nothing to disclose.

Additional Contributors

Robert A Koenigsberg, MSc, DO, 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, MSc, DO, FAOCR is a member of the following medical societies: American Osteopathic Association, American Society of Neuroradiology, Radiological Society of North America, Society of NeuroInterventional Surgery

Disclosure: Nothing to disclose.

References
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  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. 2008 May. 92(3):491-509, xi. [Medline].

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  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. 2008 Aug 28. 14(32):5046-50. [Medline].

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  10. 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. 1999 Dec. 50(6):755-61. [Medline].

  11. 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. 1995 Apr 1. 310(6983):853-6. [Medline].

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  13. 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. 2008 Jul 3. [Medline].

  14. Soto JA, Park SH, Fletcher JG, Fidler JL. Gastrointestinal hemorrhage: evaluation with MDCT. Abdom Imaging. 2015 Jun. 40 (5):993-1009. [Medline].

  15. Haghighatafshar M, Gheisari F, Ghaedian T. Importance of Heparin Provocation and SPECT/CT in Detecting Obscure Gastrointestinal Bleeding on 99mTc-RBC Scintigraphy: A Case Report. Medicine (Baltimore). 2015 Aug. 94 (34):e1325. [Medline].

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

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  19. Artigas JM, Martí M, Soto JA, Esteban H, Pinilla I, Guillén E. Multidetector CT angiography for acute gastrointestinal bleeding: technique and findings. Radiographics. 2013 Sep-Oct. 33(5):1453-70. [Medline].

  20. Artigas JM, Martí M, Soto JA, Esteban H, Pinilla I, Guillén E. Multidetector CT angiography for acute gastrointestinal bleeding: technique and findings. Radiographics. 2013 Sep-Oct. 33 (5):1453-70. [Medline].

  21. Nakamura S, Matsumoto T, Sugimori H, Esaki M, Kitazono T, Hashizume M. Emergency endoscopy for acute gastrointestinal bleeding: Prognostic value of endoscopic hemostasis and the AIMS65 score in Japanese patients. Dig Endosc. 2013 Oct 29. [Medline].

  22. Saad WE, Wagner CC, Lippert A, Al-Osaimi A, Davies MG, Matsumoto AH, et al. Protective Value of TIPS Against the Development of Hydrothorax/Ascites and Upper Gastrointestinal Bleeding after Balloon-Occluded Retrograde Transvenous Obliteration (BRTO). Am J Gastroenterol. 2013 Oct. 108(10):1612-9. [Medline].

 
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Case 1. Celiac arteriogram obtained in a patient with duodenal ulcer bleeding that was documented endoscopically reveals standard celiac anatomy. No obvious hemorrhage from the gastroduodenal artery is seen.
Case 1. Image depicts selective catheterization of gastroduodenal artery (GDA). Attenuation of the GDA is secondary to recent hemorrhage and vasospasm.
Case 1. Image obtained in a patient with recurrent duodenal ulcer bleeding depicts selective embolization of the gastroduodenal artery with coils. When prophylactic embolization is performed in duodenal bleeding, one may embolize the proximal gastroepiploic artery with coils to protect the stomach, and then embolize the branches of the gastroduodenal artery with either Ivalon or Gelfoam.
Case 1. Arterial-phase image obtained with selective injection of the superior mesenteric artery shows no contribution of the inferior pancreaticoduodenal arcade to the duodenal ulcer; thus, no embolization was performed. Injecting the appropriate collaterals in upper GI bleeding is important to prevent further hemorrhage.
Case 1. Late-arterial phase superior mesenteric angiogram shows no contribution of the superior mesenteric artery to the duodenal ulcer hemorrhage.
Case 2. Selective left gastric arteriogram obtained in a patient with cirrhosis, recent upper GI bleeding, and esophageal ulcers, with diffuse hemorrhagic gastritis as demonstrated at recent endoscopy.
Case 2. Because the patient was known to have diffuse hemorrhagic gastritis, as assessed with endoscopy, vasopressin infusion was begun at 0.2 U/min. Follow-up angiogram reveals a decrease in vascularity to the stomach. Vasopressin was continued overnight, with the patient in the ICU. The patient weaned from the medication over the following 24 hours without a recurrence of bleeding.
Case 3. Selective celiac arteriogram reveals active bleeding in the stomach from a branch of the left gastric artery along the greater curvature of the stomach.
Case 3. Image obtained with a selective injection of the feeding vessel of the left gastric artery shows extravasation of contrast material into the dependent portion of the stomach; this finding is the pseudovein sign.
Case 3. Image depicts superselective angiography and embolization of branch vessel of the left gastric artery with a platinum coil using a 3F microcatheter. A persistent pseudovein sign is shown.
Case 3. Image obtained with a selective gastroduodenal artery injection with filling of the right gastroepiploic artery shows that small branches fill the bleeding vessel along the greater curvature of the stomach.
Case 3. Embolization of the right gastroepiploic artery with Gelfoam and a single embolization coil.
Case 3. Image obtained with a final superior mesenteric arterial injection to evaluate the collateral contribution to bleeding.
Case 4. CT scan obtained in a 45-year-old man with acute hematemesis reveals a left upper quadrant acute mesenteric and lesser sac hemorrhage.
Case 4. CT image caudal to previous image reveals acute hemorrhage.
Case 4. Image obtained with a selective common hepatic artery injection reveals a pseudoaneurysm in the right gastric artery, which arises from the proper hepatic artery. The pseudoaneurysm has the appearance of a double density that overlaps the origin of the gastroduodenal artery in this projection.
Case 4. Image in a left anterior oblique projection compared with the orientation of the diagnostic angiogram depicts selective embolization of the pseudoaneurysm of the right gastric artery with coils. The patient had no further bleeding.
Case 5. Portal venogram obtained in a patient with gastric variceal bleeding before the placement of a transjugular intrahepatic portosystemic shunt shows large gastric varices.
Case 5. Venogram obtained after the placement of a 12-mm transjugular intrahepatic portosystemic shunt and selective coil embolization of gastric varices.
Bleeding from duodenal leiomyoma. Gastroduodenal arteriogram showing a duodenal mass with active contrast extravasation (arrow).
Duodenal resected specimen showing a submucosal mass with a central ulceration (arrow) (same patient as previous image).
Gastroduodenal arteriogram with a pancreatic pseudoaneurysm (arrow).
Control of upper GI hemorrhage by coil occlusion of the pancreatic artery pseudoaneurysm (arrow) (same patient as previous image).
Hemosuccus pancreaticus in patient with upper GI hemorrhage. Splenic artery aneurysm with bleeding into the pancreatic duct (arrow).
Variceal bleeding in a patient with hepatocellular carcinoma invading the portal vein. Threads and streaks sign (arrow) indicating portal vein invasion by hepatoma.
Portal venous phase of a superior mesenteric angiogram showing portal vein occlusion and gastroesophageal varices (arrow) (same patient as previous image).
 
 
 
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