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Bleeding following endoscopic sphincterotomy: angiographic management by transcatheter embolization
0016·5107/89/3504-0300$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1989 by the American Society for Gastrointestinal Endoscopy
Bleeding following endoscopic sphincterotomy: angiographic management by transcatheter embolization Mohsin Saeed, MD, Saadoon Kadir, MD Stephen L. Kaufman, MD, Robert R. Murray, MD Francis Milligan, MD, Peter B. Cotton, MD Durham, North Carolina and Baltimore, Maryland
Transcatheter embolization is a well-established and effective method for the control of bleeding from the upper gastrointestinal tract and often represents the preferred alternative to more invasive surgical management. The applications of this technique for the management of bleeding following endoscopic sphincterotomy have not been reported previously. Of five patients referred for arteriography with life-threatening postsphincterotomy bleeding, active bleeding from branches of the gastroduodenal artery was demonstrated in four. Embolization of this vessel with Gelfoam controlled the bleeding in all three .patients in whom it was attempted. Arterial stenosis and spasm precluded such treatment in one patient. The fifth patient was not bleeding at the time of arteriography. There were no complications from these procedures. Our experience shows that postsphincterotomy bleeding can be safely and effectively controlled by transcatheter embolization, thereby avoiding surgery which is associated with significant morbidity and mortality in this setting. (Gastrointest Endosc 1989;35:300-303)
Bleeding is one of the most common and potentially serious complications of endoscopic sphincterotomy. It is reported in 2 to 9% of patients undergoing endoscopic sphincterotomy (ES) and represents a serious management problem.l-3 Medical treatment with intravenous infusion of vasoconstrictive agents or periampullary injection of epinephrine and sclerosing agents while successful in stopping bleeding of lesser severity is usually not successful or not possible in severe arterial bleeding. Thus, surgery has been the treatment of choice after failure of medical management. Surgical therapy is associated with a high morbidity and mortality since many patients are critically ill. 3,4 Arteriography has been used extensively for the diagnosis of gastrointestinal bleeding and transcatheter embolization has provided an effective means for control of bleeding from pyloroduodenal ulcers, vasReceived March 8, 1988. For revision April 26, 1988. Accepted July 5,1988. From the Departments of Radiology and Medicine, Duke University Medical Center, Durham, North Carolina and the Department of Medicine and Russell H. Morgan Department of Radiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland. Reprint requests: Saadoon Kadir, MD, Department of Radiology, Duke University Medical Center, Box 3808, Durham, North Carolina 27710.
300
cular malformations, tumors, and many other causeS.5-7 Successful management of postendoscopic sphincterotomy bleeding by transcatheter embolization has not been reported. On the contrary, some published opinions are skeptical about the potential efficacy of this method of treatment. 3 We present our experience with interventional radiological management of postendocopic sphincterotomy bleeding in five patients. MATERIALS AND METHODS
Between 1985 and 1987, five patients with persistent, severe bleeding after ES were referred for arteriography. Their ages ranged from 26 to 86 years, with a mean of 59.2 years. In four patients ES was performed for the management of common bile duct stones. Three had had a prior cholecystectomy for calculi and one had sclerosing cholangitis. The fifth patient was a liver transplant recipient who had an intrahepatic abscess. In this patient ES was performed to facilitate placement of a nasobiliary drain. All four patients with bleeding following ES for common duct stones came to angiography within a few hours of the procedure. In each case, brisk bleeding was observed endoscopically immediately after the sphincterotomy. Clinically, this was manifested by hematemesis and systemic hypotension necessitating blood transfusion. In the fifth patient bleeding occurred 2 days after ES, manifested by hemateGASTROINTESTINAL ENDOSCOPY
mesis and melena with hypotension. Initial management of this latter patient consisted of fluid replacement and blood transfusions, followed by endoscopic injection of epinephrine around the papilla of Vater. Failure of such treatment prompted angiography 3 days later. RESULTS
Arteriography demonstrated active bleeding from the gastroduodenal artery (GDA) branches in four patients (cases 1 to 4, Table 1). In three patients, the bleeding was controlled by embolization with Gelfoam. In each case, a catheter was selectively placed in the GDA, and its branches were occluded with sequential delivery of small (2 to 3 mm) Gelfoam pledgets through the catheter. The GDA itself was then occluded using larger Gelfoam pledgets in two patients and steel coils in one patient (Figs. 1 and 2). In the fourth patient, embolization was not possible because severe celiac artery obstruction by a diaphragmatic crux and spasm due to severe hypotension precluded selective catheter placement. This patient was referred for surgical management. In the fifth patient (case 5, Table 1), the bleeding had stopped by the time the patient underwent arteriography. This patient developed cholangitis due to obstruction by blood clots in the biliary ducts which was relieved by placement of a percutaneous biliary drain. Bleeding did not recur in this patient.
In the three patients who underwent embolotherapy, bleeding from the sphincterotomy site did not recur. The patient with a liver transplant (case 4, Table 1) continued to have slow diffuse gastrointestinal blood loss due to profound thrombocytopenia. Repeat endoscopy did not show any focal bleeding. This patient died 3 weeks later of overwhelming sepsis. There were no complications from embolization in any patient. Specifically, there was no evidence of duodenal ischemia resulting from occlusion of the GDA. DISCUSSION
The most common indications for ES are the management of common bile duct calculi and strictures. In experienced hands, this is an effective form of treatment and carries a low morbidity and mortality. 1, 2 However, clinically significant bleeding after ES may occur in up to 5% of patients, and the overall incidence of bleeding including occult bleeding is reported in as many as 9% of patients. 3 Control of hemodynamically significant bleeding presents a major problem, and mortality associated with its surgical management can be as high as 50%.2 Thus, an effective alternative form of treatment is highly desirable, since a significant proportion of patients presenting for endoscopic sphincterotomy are poor operative candidates. Following the first description ofpercutaneous trans-
Table 1. Clinical presentation and results of interventional radiological management in patients with postsphincterotomy bleeding Case
Sex/age
Diagnosis
Bleeding
1
M/60
Immediate
2
M/88
Sclerosing cholangitis. Common duct calculi Common duct calculi
3
M/59
Liver transplant; hepatic abscess
Two days after ES
4
M/73
Common duct calculi
Immediate
5
F/26
Common duct calculi
Immediate
VOLUME 35, NO.4, 1989
Immediate
Timing of arteriogram Within hours; bleeding documented Within hours; bleeding documented Three days after onset of hemorrhage, after failure of medical management; bleeding doeumented Within hours; bleeding doeumented
Within hours; no bleeding found
Intervention
Outcome
Embolization of GDA with Gelfoam Embolization of GDA with Gelfoam Embolization of GDAwith Gelfoam and steel coils
Bleeding stopped; no recurrence
Unable to place catheter selectively in GDA; no embolization done Percutaneous biliary drainage to relieve obstruction from blood clots
Bleeding stopped; no recurrence Bleeding stopped; no recurrence from sphincterotomy site Immunosuppressed patient died of sepsis 3 weeks later Bleeding controlled surgically
Cholangitis resolved; no recurrence of bleeding
301
Figure 2. A, Late arterial phase from a common hepatic arteriogram shows extravasation of contrast medium (arrow). B, Common hepatic arteriogram after embolization with Gelfoam and coils (arrow).
Figure 1. A, Common hepatic arteriogram shows contrast medium extravasation from a branch of the superior pancreaticoduodenal artery (arrow). B, Repeat arteriogram after embolization with Gelfoam shows occlusion of this vessel and no contrast medium extravasation. 302
catheter embolization by Rosch et al.i! in 1972, this technique has been successfully used to control bleeding from many causes. 5 - 7 It is now an established method for the management of pyloroduodenal bleeding due to peptic ulcer disease, complications of pancreatic pseudocysts, and postoperative bleeding. 7 ,9,10 However, there is no documentation in the literature of the efficacy of this procedure for control of postsphincterotomy bleeding. Incision of an aberrant retroduodenal artery passing anterior to the distal segment of the common bile duct has been implicated as the cause of a major bleed in many patients. l l Surgical treatment has been advocated because of the presumed ineffectiveness of embolization to control bleeding from both sides of the sphincterotomy and several collateral vessels supplying the duodenum.:J However, our experience indicates that the bleeding occurs from a smaller branch usually at some distance from the retroduodenal artery. Furthermore, our results in three patients confirm that Gelfoam embolization of the GDA and its branches can control major GASTROINTESTINAL ENDOSCOPY
hemorrhage from the sphincterotomy site. None of the patients developed duodenal ischemia as a result of this treatment. In patients with bleeding after ES, arteriography should be performed if brisk, arterial bleeding necessitates termination of the procedure or results in hemodynamic instability and multiple blood transfusions. The timing of arteriography is critical. The patients should be studied while there is clinical evidence of active bleeding so that the bleeding site can be localized and embolization performed. Continued attempts at conservative medical management in patients with persistent arterial bleeding increases the morbidity associated with subsequent therapy.3 The duodenum has an extensive vascular network and a dual blood supply from both the celiac artery via the GDA and its anterior and posterior pancreaticoduodenal branches, and the inferior pancreaticoduodenal artery arising from the superior mesenteric artery. In addition, it receives several branches from the pancreatic and splenic arteries. Since the major blood supply is from the GDA, this vessel is embolized, although additional vessels can be treated as well. Gelfoam particles 2 to 3 mm in size are delivered into the distal GDA to occlude the smaller branches. Frequent injections of contrast material are used to monitor changes in the flow pattern to prevent reflux of embolic material into the hepatic or other circulations. Whenever necessary, selective catheter placement into the pancreaticoduodenal arteries is used for more precise placement of embolic particles. Subsequently, the GDA itself is embolized using larger Gelfoam pledgets. The placement of smaller particles distally to occlude the smaller branches is important to reduce the collateral perfusion pressure to the site of bleeding. In patients with normal or near normal coagulation parameters, the reduction in arterial pressure in the smaller branches permits the hemostatic mechanisms to become effective despite the presence of multiple sources of blood supply to the duodenum. Since large embolic materials (2- to 3-mm pledgets) are used, the capillary bed is preserved and duodenal necrosis does not occur. Although Gelfoam itself is a resorbable material, it allows permanent occlusion to develop once thrombosis has occurred. While some authors find embolic occlusion of the GDA combined with vasopressin infusion in the SMA effective for the control of duodenal hemorrhage,12,13 this method of treatment cannot be recommended because it increases the risk of duodenal infarction. Vasoconstrictor therapy in combination with embolic
VOLUME 35, NO.4, 1989
treatment may severely restrict collateral flow, resulting in infarction also of organs as richly vascularized as the duodenum or stomach. 14 ,15 Such combined treatment is especially hazardous if there is vascular compromise from prior surgery or severe atherosclerosis. 5 Previous experience shows that intra-arterial or intravenous vasoconstrictive therapy does not provide effective control of bleeding from an arterial source. 10,12 This is due to the multiplicity of vascular supply and the poorer constrictive response of larger arteries to vasoconstrictive agents. Furthermore, vasopressin infusion may be associated with severe side effects especially if prolonged infusions are necessary. Therefore, embolotherapy has provided a safe and expedient method for the control of pyloroduodenal bleeding and should be considered for life-threatening bleeding following endoscopic sphincterotomy when local hemostatic efforts have failed or were not possible.
REFERENCES 1. Cotton PB, Williams CB. Practical gastrointestinal endoscopy. Blackwell Scientific Publications, 1982. 2. Cotton PB. Complications of ERCP and its therapeutic applications. In: Taylor MB, ed. Gastrointestinal emergencies. Baltimore, Williams & Wilkins, 1988. 3. Goodall RJR. Bleeding after endoscopic sphincterotomy. Ann R Coli Surg EngI1985;67:87-8. 4. Seifert E, Gail K, Weismueller J. Langzeitresultate nach endoskopischer sphinkterotomie. Follow-up studie aus 25 zentren in der Bundesrepublik. Dtsch Moo Wochenschr 1982;107:6104. 5. Goldman ML, Land WC, Bradley EL, Anderson J. Transcatheter therapeutic embolization in the management of massive upper gastrointestinal bleeding. Radiology 1976;120:513-21. 6. Jander HP, Russinovich NAE. Transcatheter gelfoams embolization in abdominal, retroperitoneal and pelvic hemorrhage. Radiology 1980;136:337-44. 7. Athanasoulis CA, Waltman AC, Novelline RA, Krudy AG, Sniderman KW. Angiography: its contribution to emergency management of GI bleeders. Radiol Clin North Am 1976;14:265-80. 8. Rosch J, Dotter CT, Brown MJ. Selective arterial embolization. Radiology 1972;102:303. 9. Mandel SR, Jacques PF, Sanofsky S, Mauro MA. Nonoperative management of peripancreatic arterial aneurysms. Ann Surg 1987;205:126-8. 10. Kadir S, Ernst CB. Angiographic management of gastrointestinal bleeding. Curr Probl Surg 1983;20:287-343. 11. Geenen JE, LoGuidice JA. Endoscopic sphincterotomy for disease of the biliary tract. Adv Surg 1980;14:31-51. 12. Waltman AC, Greenfield AJ, Novelline RA, Athanasoulis CA. Pyloroduodenal bleeding and intraarterial vasopressin: clinical results. AJR 1979;133:643-6. 13. Granmayeh M, Wallace S, Schwarten D. Transcatheter occlusion of the gastroduodenal artery. Radiology 1979;131:59-64. 14. Alves M, Vinod P, et al. Gastric infarction: a complication of selective vasopressin infusion. Dig Dis 1979;24:409. 15. Prochaska JM, Flye MW, Johnsrude IS. Gastric artery embolization for control of gastric bleeding: a complication. Radiology 1973;107:521.
303
Bleeding following endoscopic sphincterotomy: angiographic management by transcatheter embolization Mohsin Saeed, MD, Saadoon Kadir, MD Stephen L. Kaufman, MD, Robert R. Murray, MD Francis Milligan, MD, Peter B. Cotton, MD Durham, North Carolina and Baltimore, Maryland
Transcatheter embolization is a well-established and effective method for the control of bleeding from the upper gastrointestinal tract and often represents the preferred alternative to more invasive surgical management. The applications of this technique for the management of bleeding following endoscopic sphincterotomy have not been reported previously. Of five patients referred for arteriography with life-threatening postsphincterotomy bleeding, active bleeding from branches of the gastroduodenal artery was demonstrated in four. Embolization of this vessel with Gelfoam controlled the bleeding in all three .patients in whom it was attempted. Arterial stenosis and spasm precluded such treatment in one patient. The fifth patient was not bleeding at the time of arteriography. There were no complications from these procedures. Our experience shows that postsphincterotomy bleeding can be safely and effectively controlled by transcatheter embolization, thereby avoiding surgery which is associated with significant morbidity and mortality in this setting. (Gastrointest Endosc 1989;35:300-303)
Bleeding is one of the most common and potentially serious complications of endoscopic sphincterotomy. It is reported in 2 to 9% of patients undergoing endoscopic sphincterotomy (ES) and represents a serious management problem.l-3 Medical treatment with intravenous infusion of vasoconstrictive agents or periampullary injection of epinephrine and sclerosing agents while successful in stopping bleeding of lesser severity is usually not successful or not possible in severe arterial bleeding. Thus, surgery has been the treatment of choice after failure of medical management. Surgical therapy is associated with a high morbidity and mortality since many patients are critically ill. 3,4 Arteriography has been used extensively for the diagnosis of gastrointestinal bleeding and transcatheter embolization has provided an effective means for control of bleeding from pyloroduodenal ulcers, vasReceived March 8, 1988. For revision April 26, 1988. Accepted July 5,1988. From the Departments of Radiology and Medicine, Duke University Medical Center, Durham, North Carolina and the Department of Medicine and Russell H. Morgan Department of Radiology, The Johns Hopkins Medical Institutions, Baltimore, Maryland. Reprint requests: Saadoon Kadir, MD, Department of Radiology, Duke University Medical Center, Box 3808, Durham, North Carolina 27710.
300
cular malformations, tumors, and many other causeS.5-7 Successful management of postendoscopic sphincterotomy bleeding by transcatheter embolization has not been reported. On the contrary, some published opinions are skeptical about the potential efficacy of this method of treatment. 3 We present our experience with interventional radiological management of postendocopic sphincterotomy bleeding in five patients. MATERIALS AND METHODS
Between 1985 and 1987, five patients with persistent, severe bleeding after ES were referred for arteriography. Their ages ranged from 26 to 86 years, with a mean of 59.2 years. In four patients ES was performed for the management of common bile duct stones. Three had had a prior cholecystectomy for calculi and one had sclerosing cholangitis. The fifth patient was a liver transplant recipient who had an intrahepatic abscess. In this patient ES was performed to facilitate placement of a nasobiliary drain. All four patients with bleeding following ES for common duct stones came to angiography within a few hours of the procedure. In each case, brisk bleeding was observed endoscopically immediately after the sphincterotomy. Clinically, this was manifested by hematemesis and systemic hypotension necessitating blood transfusion. In the fifth patient bleeding occurred 2 days after ES, manifested by hemateGASTROINTESTINAL ENDOSCOPY
mesis and melena with hypotension. Initial management of this latter patient consisted of fluid replacement and blood transfusions, followed by endoscopic injection of epinephrine around the papilla of Vater. Failure of such treatment prompted angiography 3 days later. RESULTS
Arteriography demonstrated active bleeding from the gastroduodenal artery (GDA) branches in four patients (cases 1 to 4, Table 1). In three patients, the bleeding was controlled by embolization with Gelfoam. In each case, a catheter was selectively placed in the GDA, and its branches were occluded with sequential delivery of small (2 to 3 mm) Gelfoam pledgets through the catheter. The GDA itself was then occluded using larger Gelfoam pledgets in two patients and steel coils in one patient (Figs. 1 and 2). In the fourth patient, embolization was not possible because severe celiac artery obstruction by a diaphragmatic crux and spasm due to severe hypotension precluded selective catheter placement. This patient was referred for surgical management. In the fifth patient (case 5, Table 1), the bleeding had stopped by the time the patient underwent arteriography. This patient developed cholangitis due to obstruction by blood clots in the biliary ducts which was relieved by placement of a percutaneous biliary drain. Bleeding did not recur in this patient.
In the three patients who underwent embolotherapy, bleeding from the sphincterotomy site did not recur. The patient with a liver transplant (case 4, Table 1) continued to have slow diffuse gastrointestinal blood loss due to profound thrombocytopenia. Repeat endoscopy did not show any focal bleeding. This patient died 3 weeks later of overwhelming sepsis. There were no complications from embolization in any patient. Specifically, there was no evidence of duodenal ischemia resulting from occlusion of the GDA. DISCUSSION
The most common indications for ES are the management of common bile duct calculi and strictures. In experienced hands, this is an effective form of treatment and carries a low morbidity and mortality. 1, 2 However, clinically significant bleeding after ES may occur in up to 5% of patients, and the overall incidence of bleeding including occult bleeding is reported in as many as 9% of patients. 3 Control of hemodynamically significant bleeding presents a major problem, and mortality associated with its surgical management can be as high as 50%.2 Thus, an effective alternative form of treatment is highly desirable, since a significant proportion of patients presenting for endoscopic sphincterotomy are poor operative candidates. Following the first description ofpercutaneous trans-
Table 1. Clinical presentation and results of interventional radiological management in patients with postsphincterotomy bleeding Case
Sex/age
Diagnosis
Bleeding
1
M/60
Immediate
2
M/88
Sclerosing cholangitis. Common duct calculi Common duct calculi
3
M/59
Liver transplant; hepatic abscess
Two days after ES
4
M/73
Common duct calculi
Immediate
5
F/26
Common duct calculi
Immediate
VOLUME 35, NO.4, 1989
Immediate
Timing of arteriogram Within hours; bleeding documented Within hours; bleeding documented Three days after onset of hemorrhage, after failure of medical management; bleeding doeumented Within hours; bleeding doeumented
Within hours; no bleeding found
Intervention
Outcome
Embolization of GDA with Gelfoam Embolization of GDA with Gelfoam Embolization of GDAwith Gelfoam and steel coils
Bleeding stopped; no recurrence
Unable to place catheter selectively in GDA; no embolization done Percutaneous biliary drainage to relieve obstruction from blood clots
Bleeding stopped; no recurrence Bleeding stopped; no recurrence from sphincterotomy site Immunosuppressed patient died of sepsis 3 weeks later Bleeding controlled surgically
Cholangitis resolved; no recurrence of bleeding
301
Figure 2. A, Late arterial phase from a common hepatic arteriogram shows extravasation of contrast medium (arrow). B, Common hepatic arteriogram after embolization with Gelfoam and coils (arrow).
Figure 1. A, Common hepatic arteriogram shows contrast medium extravasation from a branch of the superior pancreaticoduodenal artery (arrow). B, Repeat arteriogram after embolization with Gelfoam shows occlusion of this vessel and no contrast medium extravasation. 302
catheter embolization by Rosch et al.i! in 1972, this technique has been successfully used to control bleeding from many causes. 5 - 7 It is now an established method for the management of pyloroduodenal bleeding due to peptic ulcer disease, complications of pancreatic pseudocysts, and postoperative bleeding. 7 ,9,10 However, there is no documentation in the literature of the efficacy of this procedure for control of postsphincterotomy bleeding. Incision of an aberrant retroduodenal artery passing anterior to the distal segment of the common bile duct has been implicated as the cause of a major bleed in many patients. l l Surgical treatment has been advocated because of the presumed ineffectiveness of embolization to control bleeding from both sides of the sphincterotomy and several collateral vessels supplying the duodenum.:J However, our experience indicates that the bleeding occurs from a smaller branch usually at some distance from the retroduodenal artery. Furthermore, our results in three patients confirm that Gelfoam embolization of the GDA and its branches can control major GASTROINTESTINAL ENDOSCOPY
hemorrhage from the sphincterotomy site. None of the patients developed duodenal ischemia as a result of this treatment. In patients with bleeding after ES, arteriography should be performed if brisk, arterial bleeding necessitates termination of the procedure or results in hemodynamic instability and multiple blood transfusions. The timing of arteriography is critical. The patients should be studied while there is clinical evidence of active bleeding so that the bleeding site can be localized and embolization performed. Continued attempts at conservative medical management in patients with persistent arterial bleeding increases the morbidity associated with subsequent therapy.3 The duodenum has an extensive vascular network and a dual blood supply from both the celiac artery via the GDA and its anterior and posterior pancreaticoduodenal branches, and the inferior pancreaticoduodenal artery arising from the superior mesenteric artery. In addition, it receives several branches from the pancreatic and splenic arteries. Since the major blood supply is from the GDA, this vessel is embolized, although additional vessels can be treated as well. Gelfoam particles 2 to 3 mm in size are delivered into the distal GDA to occlude the smaller branches. Frequent injections of contrast material are used to monitor changes in the flow pattern to prevent reflux of embolic material into the hepatic or other circulations. Whenever necessary, selective catheter placement into the pancreaticoduodenal arteries is used for more precise placement of embolic particles. Subsequently, the GDA itself is embolized using larger Gelfoam pledgets. The placement of smaller particles distally to occlude the smaller branches is important to reduce the collateral perfusion pressure to the site of bleeding. In patients with normal or near normal coagulation parameters, the reduction in arterial pressure in the smaller branches permits the hemostatic mechanisms to become effective despite the presence of multiple sources of blood supply to the duodenum. Since large embolic materials (2- to 3-mm pledgets) are used, the capillary bed is preserved and duodenal necrosis does not occur. Although Gelfoam itself is a resorbable material, it allows permanent occlusion to develop once thrombosis has occurred. While some authors find embolic occlusion of the GDA combined with vasopressin infusion in the SMA effective for the control of duodenal hemorrhage,12,13 this method of treatment cannot be recommended because it increases the risk of duodenal infarction. Vasoconstrictor therapy in combination with embolic
VOLUME 35, NO.4, 1989
treatment may severely restrict collateral flow, resulting in infarction also of organs as richly vascularized as the duodenum or stomach. 14 ,15 Such combined treatment is especially hazardous if there is vascular compromise from prior surgery or severe atherosclerosis. 5 Previous experience shows that intra-arterial or intravenous vasoconstrictive therapy does not provide effective control of bleeding from an arterial source. 10,12 This is due to the multiplicity of vascular supply and the poorer constrictive response of larger arteries to vasoconstrictive agents. Furthermore, vasopressin infusion may be associated with severe side effects especially if prolonged infusions are necessary. Therefore, embolotherapy has provided a safe and expedient method for the control of pyloroduodenal bleeding and should be considered for life-threatening bleeding following endoscopic sphincterotomy when local hemostatic efforts have failed or were not possible.
REFERENCES 1. Cotton PB, Williams CB. Practical gastrointestinal endoscopy. Blackwell Scientific Publications, 1982. 2. Cotton PB. Complications of ERCP and its therapeutic applications. In: Taylor MB, ed. Gastrointestinal emergencies. Baltimore, Williams & Wilkins, 1988. 3. Goodall RJR. Bleeding after endoscopic sphincterotomy. Ann R Coli Surg EngI1985;67:87-8. 4. Seifert E, Gail K, Weismueller J. Langzeitresultate nach endoskopischer sphinkterotomie. Follow-up studie aus 25 zentren in der Bundesrepublik. Dtsch Moo Wochenschr 1982;107:6104. 5. Goldman ML, Land WC, Bradley EL, Anderson J. Transcatheter therapeutic embolization in the management of massive upper gastrointestinal bleeding. Radiology 1976;120:513-21. 6. Jander HP, Russinovich NAE. Transcatheter gelfoams embolization in abdominal, retroperitoneal and pelvic hemorrhage. Radiology 1980;136:337-44. 7. Athanasoulis CA, Waltman AC, Novelline RA, Krudy AG, Sniderman KW. Angiography: its contribution to emergency management of GI bleeders. Radiol Clin North Am 1976;14:265-80. 8. Rosch J, Dotter CT, Brown MJ. Selective arterial embolization. Radiology 1972;102:303. 9. Mandel SR, Jacques PF, Sanofsky S, Mauro MA. Nonoperative management of peripancreatic arterial aneurysms. Ann Surg 1987;205:126-8. 10. Kadir S, Ernst CB. Angiographic management of gastrointestinal bleeding. Curr Probl Surg 1983;20:287-343. 11. Geenen JE, LoGuidice JA. Endoscopic sphincterotomy for disease of the biliary tract. Adv Surg 1980;14:31-51. 12. Waltman AC, Greenfield AJ, Novelline RA, Athanasoulis CA. Pyloroduodenal bleeding and intraarterial vasopressin: clinical results. AJR 1979;133:643-6. 13. Granmayeh M, Wallace S, Schwarten D. Transcatheter occlusion of the gastroduodenal artery. Radiology 1979;131:59-64. 14. Alves M, Vinod P, et al. Gastric infarction: a complication of selective vasopressin infusion. Dig Dis 1979;24:409. 15. Prochaska JM, Flye MW, Johnsrude IS. Gastric artery embolization for control of gastric bleeding: a complication. Radiology 1973;107:521.
303