Acute Lower Gastrointestinal Bleeding

Abstract

The annual incidence of lower gastrointestinal bleeding (LGIB) is ∼20.5 in 100,000 in the general Western population and results in 1 to 2% of hospital emergencies. When medical management and endoscopic therapy are inadequate in cases of acute LGIB, endovascular intervention can be lifesaving. In these emergent situations it is important for the interventional radiologist to be well versed in the multidisciplinary preangiographic work-up, the angiographic presentations of LGIB, and the endovascular therapeutic options. We describe a case of LGIB managed with endovascular embolization and detail the angiographic techniques used, followed by a detailed discussion of the various treatment approaches to LGIB.

Keywords

embolization - GI bleeding - emergent

• References

• 1 Barnert J, Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 2009; 6 (11) 637-646
• 2 d'Othée BJ, Surapaneni P, Rabkin D, Nasser I, Clouse M. Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol 2006; 29 (1) 49-58
• 3 Koh DC, Luchtefeld MA, Kim DG , et al. Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding. Colorectal Dis 2009; 11 (1) 53-59
• 4 Zuckerman GR, Prakash C. Acute lower intestinal bleeding: part I: clinical presentation and diagnosis. Gastrointest Endosc 1998; 48 (6) 606-617
• 5 Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1997; 92 (3) 419-424
• 6 Strate LL. Lower GI bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am 2005; 34 (4) 643-664
• 7 Stark ME, Gostout CJ, Balm RK. Clinical features and endoscopic management of Dieulafoy's disease. Gastrointest Endosc 1992; 38 (5) 545-550
• 8 Lee YT, Walmsley RS, Leong RW, Sung JJ. Dieulafoy's lesion. Gastrointest Endosc 2003; 58 (2) 236-243
• 9 Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol 2010; 105 (12) 2636-2641 ; quiz 2642
• 10 Billingham RP. The conundrum of lower gastrointestinal bleeding. Surg Clin North Am 1997; 77 (1) 241-252
• 11 Green BT, Rockey DC, Portwood G , et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized trial. Am J Gastroenterol 2005; 100 (11) 2395-2402
• 12 Valera JM, Pino RQ, Poniachik J , et al. Endoscopic band ligation of bleeding Dieulafoy lesions: the best therapeutic strategy. Endoscopy 2006; 38 (2) 193-194
• 13 Ahn DW, Lee SH, Park YS , et al. Hemostatic efficacy and clinical outcome of endoscopic treatment of Dieulafoy's lesions: comparison of endoscopic hemoclip placement and endoscopic band ligation. Gastrointest Endosc 2012; 75 (1) 32-38
• 14 Gunderman R, Leef J, Ong K, Reba R, Metz C. Scintigraphic screening prior to visceral arteriography in acute lower gastrointestinal bleeding. J Nucl Med 1998; 39 (6) 1081-1083
• 15 Millward SF. ACR appropriateness criteria on treatment of acute nonvariceal gastrointestinal tract bleeding. J Am Coll Radiol 2008; 5 (4) 550-554
• 16 Ng DA, Opelka FG, Beck DE , et al. Predictive value of technetium Tc 99m-labeled red blood cell scintigraphy for positive angiogram in massive lower gastrointestinal hemorrhage. Dis Colon Rectum 1997; 40 (4) 471-477
• 17 Martí M, Artigas JM, Garzón G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology 2012; 262 (1) 109-116
• 18 American College of Radiology (ACR) Committee on Drugs and Contrast Media. ACR Manual on Contrast Media: Version 7, 2010. Available at: xray.ufl.edu/files/2008/06/FullManualACRContrastVersion7.pdf
• 19 Schenker MP, Duszak Jr R, Soulen MC , et al. Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival. J Vasc Interv Radiol 2001; 12 (11) 1263-1271
• 20 Aina R, Oliva VL, Therasse E , et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001; 12 (2) 195-200
• 21 Maleux G, Roeflaer F, Heye S , et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009; 104 (8) 2042-2046
• 22 Kim JH, Shin JH, Yoon HK , et al. Angiographically negative acute arterial upper and lower gastrointestinal bleeding: incidence, predictive factors, and clinical outcomes. Korean J Radiol 2009; 10 (4) 384-390
• 23 Kim CY, Suhocki PV, Miller Jr MJ, Khan M, Janus G, Smith TP. Provocative mesenteric angiography for lower gastrointestinal hemorrhage: results from a single-institution study. J Vasc Interv Radiol 2010; 21 (4) 477-483
• 24 Krämer SC, Görich J, Rilinger N , et al. Embolization for gastrointestinal hemorrhages. Eur Radiol 2000; 10 (5) 802-805
• 25 Suh SW, Choi YS, Kim H, Kim BG. Small bowel ischemia after angiographic embolization for angiodysplasia of lower gastrointestinal tract: the case for conservative management. Clin Res Hepatol Gastroenterol 2011; 35 (12) 819-822
• 26 Kuo WT, Lee DE, Saad WE, Patel N, Sahler LG, Waldman DL. Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2003; 14 (12) 1503-1509
• 27 Kickuth R, Rattunde H, Gschossmann J, Inderbitzin D, Ludwig K, Triller J. Acute lower gastrointestinal hemorrhage: minimally invasive management with microcatheter embolization. J Vasc Interv Radiol 2008; 19 (9) 1289-1296 , e2
• 28 Kwak HS, Han YM, Lee ST. The clinical outcomes of transcatheter microcoil embolization in patients with active lower gastrointestinal bleeding in the small bowel. Korean J Radiol 2009; 10 (4) 391-397
• 29 Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001; 12 (12) 1399-1405
• 30 Funaki B, Kostelic JK, Lorenz J , et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol 2001; 177 (4) 829-836
• 31 Han YM, Lee JM, Jin KY, Lee SY, Kim CS. Embolization of superior mesenteric artery branches in dogs. Ischemic bowel changes depend on location of vessel occlusion and embolic materials. Invest Radiol 1999; 34 (10) 629-635
• 32 Frodsham A, Berkmen T, Ananian C, Fung A. Initial experience using N-butyl cyanoacrylate for embolization of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2009; 20 (10) 1312-1319
• 33 Darcy M. Treatment of lower gastrointestinal bleeding: vasopressin infusion versus embolization. J Vasc Interv Radiol 2003; 14 (5) 535-543
• 34 DeBarros J, Rosas L, Cohen J, Vignati P, Sardella W, Hallisey M. The changing paradigm for the treatment of colonic hemorrhage: superselective angiographic embolization. Dis Colon Rectum 2002; 45 (6) 802-808
• 35 Defreyne L, Vanlangenhove P, De Vos M , et al. Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology 2001; 218 (3) 739-748
• 36 Guy GE, Shetty PC, Sharma RP, Burke MW, Burke TH. Acute lower gastrointestinal hemorrhage: treatment by superselective embolization with polyvinyl alcohol particles. AJR Am J Roentgenol 1992; 159 (3) 521-526
• 37 Kusano S, Murata K, Ohuchi H, Motohashi O, Atari H. Low-dose particulate polyvinyl alcohol embolization in massive small artery intestinal hemorrhage. Experimental and clinical results. Invest Radiol 1987; 22 (5) 388-392
• 38 Fidelman N, Freed RC, Nakakura EK, Rosenberg J, Bloom AI. Arterial embolization for the management of gastrointestinal hemorrhage from metastatic renal cell carcinoma. J Vasc Interv Radiol 2010; 21 (5) 741-744
• 39 Kurihara N, Kikuchi K, Tanabe M , et al. Partial resection of the second portion of the duodenum for gastrointestinal stromal tumor after effective transarterial embolization. Int J Clin Oncol 2005; 10 (6) 433-437
• 40 Mensel B, Kühn JP, Kraft M , et al. Selective microcoil embolization of arterial gastrointestinal bleeding in the acute situation: outcome, complications, and factors affecting treatment success. Eur J Gastroenterol Hepatol 2012; 24 (2) 155-163
• 41 Khanna A, Ognibene SJ, Koniaris LG. Embolization as first-line therapy for diverticulosis-related massive lower gastrointestinal bleeding: evidence from a meta-analysis. J Gastrointest Surg 2005; 9 (3) 343-352
• 42 Peck DJ, McLoughlin RF, Hughson MN, Rankin RN. Percutaneous embolotherapy of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 1998; 9 (5) 747-751
• 43 Cynamon J, Atar E, Steiner A , et al. Catheter-induced vasospasm in the treatment of acute lower gastrointestinal bleeding. J Vasc Interv Radiol 2003; 14 (2 Pt 1) 211-216
• 44 Peura DA, Lanza FL, Gostout CJ, Foutch PG. The American College of Gastroenterology Bleeding Registry: preliminary findings. Am J Gastroenterol 1997; 92 (6) 924-928
• 45 Al Qahtani AR, Satin R, Stern J, Gordon PH. Investigative modalities for massive lower gastrointestinal bleeding. World J Surg 2002; 26 (5) 620-625
• 46 Setya V, Singer JA, Minken SL. Subtotal colectomy as a last resort for unrelenting, unlocalized, lower gastrointestinal hemorrhage: experience with 12 cases. Am Surg 1992; 58 (5) 295-299
• 47 Pennoyer WP, Vignati PV, Cohen JL. Management of angiogram positive lower gastrointestinal hemorrhage: long term follow-up of non-operative treatments. Int J Colorectal Dis 1996; 11 (6) 279-282
• 48 Griner D, Adams A, Kotwall CA, Clancy TV, Hope WW. After-hours urgent and emergent surgery in the elderly: outcomes and prognostic factors. Am Surg 2011; 77 (8) 1021-1024
• 49 Kurian A, Suryadevara S, Ramaraju D , et al. In-hospital and 6-month mortality rates after open elective vs open emergent colectomy in patients older than 80 years. Dis Colon Rectum 2011; 54 (4) 467-471