QuickTime and a

TIFF (Uncompressed) decompressor

are needed to see this picture.

GASTROINTESTINAL BLEEDING:
Interventional Radiology Procedures
and Indications for Operation

Amanda A. Muoz, MD
PGY-1
Trauma Conference
December 18, 2006

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

Quiz

This picture
includes:
a.) Amanda
b.) Cindy
c.) Bea
d.) Stephanie

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

GIB: Indications for IR

Failure of endoscopic management (20%)

Non-diagnostic endoscopy (10%-40%)
Poor surgical candidates

1. Selective mesenteric angiography

2. Provocative angiography
GOALS: definitive treatment or reduction in
surgical morbidity

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

GIB: IR Rx Options

Intra-arterial vasopressin
Arteriolar constriction and bowel wall contraction
Long half-life
Success rates 60-100% LGIB, complications 1020%, rebleed 50%
Only controls 15-30% of pyloroduodenal sources
Transcatheter embolization
- Gelatin sponge, microcoils, polyvinyl alcohol, balloon
- 73 -100% success rate, particularly in the UGI tract

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

UGIB: IR Rx

UGI lesions amenable to IR:

Dieulafoy lesions
Hemobilia: embolization of affected liver
segment
PUD: GDA
Gastroduodenal AVMs
Atherosclerotic and false aneurysms
Varices (shunt planning in a non-transplant
candidate)

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

LGIB: IR Rx

LGI lesions amenable to IR eval or

embolization:
Diverticular disease
Malignancy
Inflammatory bowel disease
Acute colitis
AV malformations

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

Quiz

This picture
includes:
a.) Amanda
b.) Cindy
c.) Bea
d.) Stephanie

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

GIB: IR Rx

Vasopressin Infusion
Limited by atherosclerotic disease
Coagulopathy
Catheter must be maintained in proper position for
the length of the infusion
2% rate of catheter dislodgement causing
recurrent bleeding (Darcy, J Vasc Intervent Radiol,
2003)

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

GIB: IR Rx

Success affected by vessel

tortuosity, arterial spasm,
collateral flow
Risk factors for rehemorrhage
after embolization:
- intra-abdominal malignancy
- Transfusion requirement >
10U prior to angio
- source other than GDA
(Keeling, Am Surg 2006)
Diverticular bleeding may have
the best results compared to
other causes (Khanna, J
Gastrointest Surg 2005)

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

IR Complications

Vasopressin therapy (0-20%):

Ischemia (myocardial, peripheral), hypotension,
Dysrhythmias, mesenteric thrombosis,
intestinal infarction, puncture site, infusion
into other site, SBP
Embolization (1-15%):
Ischemia, infarction, puncture site

10

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

Quiz

This picture
includes:
a.) Amanda
b.) Cindy
c.) Bea
d.) Stephanie

11

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

GIB: Indications for OR

Uncontrolled hemorrhage or hemodynamic

instability
Persistent bleeding despite medical therapy
and endoscopic intervention
>4U/24h, persistent for > 72h, rebleeding w/in 1
week

Perforation
Obstruction
Need to rule out malignancy

12

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

UGIB: Indications for OR

Ulcer disease: high risk endoscopic

findings
Visible GDA
Clot in base of ulcer
Giant ulcers

SB diverticula, vascular malformations,

13

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

UGIB: Non-operative mgmt

Mallory-Weiss tears
Acute hemorrhagic gastritis
Dieulafoy lesion
Delayed repair if stable:
Paraesophageal or esophageal hiatal
hernia

14

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

LGIB: Indications for OR

Diverticular disease: unlocalized,

uncontrolled, recurrent
Ischemic colitis w/ peritonitis: sigmoid or
L hemicolectomy
AEF
Meckels

15

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

Quiz

This picture
includes:
a.) Amanda
b.) Cindy
c.) Bea
d.) Stephanie

16

QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.

References

Darcy, M. Treatment of lower gastrointestinal bleeding: vasopressin vs. embolization. J Vasc

Interv Radiol. 2003: 14, 535-543.
Fiser, SM. The Absite Review.
Keeling WB et al. Risk factors for recurrent hemorrhage after sucessful mesenteric arterial
embolization. Am Surg. 2006 Sep;72(9):802-6
Khanna A, Ognibene SJ, Koniaris LJ. Embolization as first-line therapy for diverticulosis-related
massive lower gastrointestinal bleeding: evidence from a meta-analysis. J Gastrointest
Surg. 2005 Mar;9(3):343-52.
Kim, LT, Heldmann M, Turnage RH. Acute gastrointestinal hemorrhage. In Greenfield Surgery:
Scientific principles and practice. Chapter 67, LW&W, Philadelphia, 2006.
Harold KL and Schlinkert RT. Upper gastrointestinal bleeding. In ACS Surgery Principles and
Practice.
Lefkovitz, Z. Radiology in the daignosis and therapy of gastrointestinal bleeding. Gastrointest
Clin N Am. June 2000 (2): 489.
Mulholland, MW. Gastroduodenal Ulceration. In Greenfields Surgery: Scientific Principles and
Practice. Chapter 46, Lippincott, Williams & Wilkins, Philadelphia, 2006.
Rosen MJ and Ponsky JL. Lower gastrointestinal bleeding. In ACS Surgery Principles and
Practice.

17