Upper and Lower GI bleeding CTA and invasive angiogram

Nakarin Inmutto, MD

Chiang Mai University, Thailand

Introduction

• Acute gastrointestinal (GI) bleeding is common .

• Need rapid diagnosis and treatment.

• Bleeding can occur anywhere throughout the GI tract.

• Upper GI tract >>> lower GI tract. (75% vs 25%)

• Hematemesis, coffee ground emesis, melena

• 80%–85% of cases of GI bleeding resolve spontaneously

GI bleeding

GI bleeding

Stability

GI bleeding

Stability

Source of bleeding Upper VS Lower

Common cause of bleeding

Upper GI bleeding

• Esophageal varices

• Gastritis or duodenitis

• Peptic ulcer

• Arteriovenous malformation

Lower GI bleeding

• Diverticular disease

• Colitis and IBD

• Neoplasia

• Coagulopathic hemorrhage

• Angiodysplasia

Current nomenclature

• Upper GI bleeding (UGIB) = bleeding originating proximal to the Treitz ligament.

• Lower GI bleeding (LGIB) = bleeding originating from the colon or rectum.

• Suspected small-bowel bleeding = upper and lower GI tracts have been evaluated (typically with endoscopy) and no bleeding site has been identified.

CT for Evaluation of Acute Gastrointestinal Bleeding; RadioGraphics 2018; 38:1089–1107

CT angiography: Role

• Rapid localizing the source of bleeding

• Differentiating the underlying disease

• Aiding decisions to proceed to endovascular therapies

Diagnostic modalities in acute GI bleeding

Wortman JR, LandmanW, Fulwadhva UP, Viscomi SG, Sodickson AD. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90: 20170076

CT angiography: Role

• Positive result

• Sensitivity 85%, Specificity 92%

• Negative result

• Unlikely to need emergent surgical or angiographic intervention

• Discharge from hospital without intervention

CT technique

• Oral contrast is not administered

• Non-contrast, arterial and venous phase

• The scan range diaphragm to below the inferior pubic rami

• Contrast injection, 100–125 ml , 4–5 ml/ sec

• Reconstruction; 5-mm thickness for non-contrast images and 1.25 mm for arterial and venous phase images.

• Multiplanar reformation images in the sagittal and coronal planes

• Maximum intensity projection images in the sagittal and coronal planes

Renal dysfunction?

• Jacovides , et al.

• JAMA Surg 2015;150(7):650–656.

• Catheter angiogram vs underwent CTA before catheter angiogram

• Received a greater cumulative iv contrast load (130cc – 220cc).

• Additional contrast load was not associated with greater renal dysfunction.

CT findings

• Contrast extravasation

• Non-contrast images; not present

• Arterial phase; intraluminal focus of high attenuation

• Portal venous phase; change in appearance and generally moves distally within the bowel lumen.

Upper GI bleeding

Upper GI bleeding

• Many common causes of bleeding in the esophagus and upper GI cannot be optimally evaluated with CT

CT for Evaluation of Acute Gastrointestinal Bleeding; RadioGraphics 2018; 38:1089–1107

Wortman JR, LandmanW, Fulwadhva UP, Viscomi SG, Sodickson AD. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90: 20170076

Case 1

Case 1

• A 78-year-old woman with UGIH

• S/P EGD (large DU) → adrenaline injection, glue injection and clip

• New episode of massive UGIH

Case 1

• A 78-year-old woman with UGIH

• S/P EGD and clip

• New episode of massive UGIH

Question

Bleeding from vessel?

• Common hepatic artery

• Gastroduodenal artery

• Gastroepiploic artery

• Left gastric artery

Case 2

Case 2

• A 74-year-old female

• Known case of HT, DLP, gout

• She developed UGIH for 2 days ago.

• The last EGD revealed duodenitis and antral gastritis

• Without evidence of bleeding point.

3613131

• A 74-year-old female

• Known case of HT, DLP, gout

• UGIH for 2 days ago

• The last EGD revealed

• Duodenitis and antral gastritis

• No evidence of bleeding point

Question

Point of bleeding

• A

• B

• A + B

• None

A B

A B

Case 3

Case 3

• A 56-year-old man

• CA pancreas S/P chemoradiation therapy and gastrojejunostomy

• He develop UGIH

• Suspected gastric ulcer

• EGD → no lesion, then CTA

Conclusion for Upper GI bleed

• Search site of bleeding

• Pre-treatment for endoscopy or endovascular

Lower GI bleeding

Oakland K, et al. Gut 2019;68:776–789.

Oakland K, et al. Gut 2019;68:776–789.

Case 4

Case 4

• An 80-year-old woman with simple falling and traumatic closed fracture right superior pubic rami.

• Pulmonary embolism S/P enoxaparin.

• Then, she developed lower GI bleeding.

Case 5

Case 5

• A 49-year-old man

• Present with lower GI bleeding.

Diffuse thickening of bowel walls of entire colon down to the rectum

Case 6

Question

Bleeding site?

• A

• B

• C

• D

A B

C D

CT angiography: Role

Case 7

Case 7

• A 75-year-old man, known case of ESRD, with LGIH S/P EGD and colonoscopy. No bleeding point.

• Today he developed hematochezia with hypotension.

• Suspected active bleeding.

Case 8

Case 8

• A 74-year-old female

• Known case factor VIII inhibitor

• Massive LGIH.

• Her EGD and colonoscope; WNL

Case 9

Case 9

• Case 40-year-old woman

• Underlying SLE with lupus nephritis, febrile neutropenia with sepsis and DIC

• Presents with LGIH

Case 10

Case 10

• A 60-year-old female

• Known case ESRD

• Ruptured infrarenal abdominal aortic aneurysm S/P open repair with aortic bifurcated graft

• Presents with abdominal pain and LGIH

Case 11

Case 11

• A 59-year-old man

• LGIH S/P colonoscopy + clip, point of bleeding about 10 cm from anal verge

• PE shows blood pressure 70/50 mmHg, HR 80/min.

• Suspected rebleed

Pre-treatment Post-treatment

What should you do?

• Done, I completed embolization.

• SMA angiography

• Iliac angiography

• Femoral angiography

Rt-iliac a. Lt-iliac a.

• 1 week later

• Re-bleeding of lower GI (fresh blood about 2L.)

Conclusion

• Difference guideline in Acute massive GI bleeding

• CT is a good tool

• Rapid

• Identify point of bleeding

Thank you