Current concepts in angiographic management of gastrointestinal bleeding

CURRENT CONCEPTS IN ANGIOGRAPHIC MANAGEMENT OF GASTROINTESTINAL BLEEDING SAADOON KADIR, M.D. CALVIN B. ERNST, M.D.

0011-3840/83/06-281-343-$9.95 C 1 ~ , Year Book Medical Publishers, Inc.

TABLE OF CONTENTS FOREWORD

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SELF-ASSESSMENT

QUESTIONS

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284

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . .

287

CURRENT TRENDS IN DIAGNOSIS AND THERAPY . . . . . . . . . . .

287

METHODS OF DIAGNOSIS OF GASTROINTESTINAL BLEEDING . . . . . .

288

TREATMENT WITH VASOCONSTRICTORS

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299

FAILURE OF TRANSCATHETER THERAPY . . . . . . . . . . . . . .

307

COMPLICATIONS

308

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PATIENT CARE DURING VASOCONSTRICTOR THERAPY . . . . . . . .

310

APPROACH TO UPPER GASTROINTESTINAL BLEEDING

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313

APPROACH TO LOWER GASTROINTESTINAL BLEEDING

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321

POSTOPERATIVE BLEEDING . . . . . . . . . . . . . . . . . . . .

330

BLEEDING IN PATIENTS WITH PORTAL HYPERTENSION . . . . . . . .

331

CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . .

336

ACKNOWLEDGMENT . . . . . . . . . . . . . . . . . . . . . . .

337

SELF-AssESSMENT ANSWERS . . . . . . . . . . . . . . . . . . .

343

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FOREWORD

In the last twenty years, the clinical m a n a g e m e n t of bleeding from the gastrointestinal tract was first radically altered by the development of mesenteric angiography, so that the formerly, sometimes unnecessary, but always reprehensible, blind resection of major portions of the gastrointestinal tract could be abandoned. The radiologists, able with greater and greater facility to pass catheters into specific distal arterial branches, then began to assume a therapeutic role with infusion of vasoconstrictors and to allow the patient himself to clot the bleeding vessel, or injection of an occluding mass as an embolus to plug up the of_ fending vessel. Drs. Ernst and Kadir have given us a clear and lucid presentation of the various clinical problems involved in bleeding from the gastrointestinal tract and the role and technique of radiographic management. MARK M. RAVITCH, M.D. EDITOR-IN-CHIEF

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SELF-ASSESSMENT QUESTIONS 1. In duodenal ulcer bleeding the nasogastric aspirate will be negative in: a. All patients. b. None of the patients. c. In 20% of the patients. 2. Radionuclide studies for the detection of gastrointestinal bleeding are indicated in: a. All acute bleeders. b. Acute, low grade bleeders. c. Mild and intermittent bleeders. 3. Barium studies are indicated for the diagnosis of gastrointestinal bleeding in: a. Patients with acute GI bleeding. b. Massively bleeding patients. c. Chronic and i n t e r m i t t e n t GI bleeders. 4. Arteriography can: a. Localize and treat patients with arterial and mucosal GI bleeding. b. Treat patients with arterial or mucosal bleeding. c. Localize a site of arterial or mucosal bleeding. 5. Intravenous vasopressin is an effective method for the treatm e n t of: a. Arterial bleeding. b. Mucosal or variceal bleeding. c. Bleeding from solid organs. 6. Arteriography will most likely show a source of GI bleeding: a. If bleeding is less t h a n 4 U/24 hours. b. If nasogastric aspirate clears upon irrigation. c. If a continuous fluid and blood requirement is present to m a i n t a i n hemodynamic stability. 7. The maximal safe infusion rate for vasopressin is: a. 0.2 units/minute. b. 0.4 units/minute. c. 0.6 units/minute. 8. The most effective angiographic method to treat bleeding from Mallory-Weiss tears is: a. Selective embolization. b. Intra-arterial vasopressin. c. Intravenous vasopressin. 9. The angiographic t r e a t m e n t of choice for documented duodenal ulcer bleeding is: a. Intravenous vasopressin. 284

b. Intra-arterial vasopressin. c. Selective embolization. 10. Massive colorectal bleeding is mostly due to: a. Diverticular disease. b. Diverticular disease and occasionally angiodysplasia. c. Diverticular disease and occasionally due to angiodysplasia or carcinoma. 11. Angiodysplasia of the colon: a. Is a disease of patients 55 years and older. b. When demonstrated on arteriography it is the most likely etiology of gastrointestinal bleeding. c. Can be an incidental finding. Answers are listed at the end of the article.

285

) is an asociate professor of Radiology at the Johns Hopkins University School of Medicine. Dr. Kadir was born in Srinagar, Pakistan and received his M.D. from the University of Freiburg/Br., Federal Republic of Germany. His radiology and vascular radiology training was at the Massachusetts General Hospital.

is Professor of Surgery at the Johns Hopkins University School of Medicine and Chairman of the Section of Surgical Sciences at Baltimore City Hospitals. Dr. Ernst received his medical degree from the University of Michigan and completed his surgical internship at Ohio State University Hospitals and then returned to the University of Michigan for his residency training. He is a general vascular surgeon whose clinical and investigative interests have focused on vascular surgery and angiography.

286

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INTRODUCTION

OVER THE PAST 29 YEARS, since the description of the percutaneous catheterization technique by Seldinger, angiography has changed from a solely diagnostic modality to include sophisticated techniques of "interventional" radiology. 1 Because arteriography is available in most hospitals for diagnosis and treatment of gastrointestinal bleeding, proper understanding of its exact role in evaluation and management of such patients is necessary to ensure safe and appropriate utilization. Numerous reports deal with the diagnostic accuracy and therapeutic success or failure of arteriography in the management of gastrointestinal bleeding and detail differences in approach, indications and criteria of patient selection. 2-7 The purpose of this monograph is to outline the indications for angiographic management of gastrointestinal bleeding, to review the diagnostic accuracy and therapeutic results of gastrointestinal arteriography, and to present the different therapeutic techniques available to the cardiovascular radiologist for the management of gastrointestinal bleeding. CURRENT TRENDS IN DIAGNOSIS AND THERAPY

The number of patients with upper gastrointestinal bleeding due to gastroduodenal ulcer disease or hemorrhagic gastritis requiring angiographic diagnosis and transcatheter therapy has decreased as a result of improvements in medical management and effective prophylaxis against stress ulceration, s Advances in techniques for ablation of esophageal varices through an endoscope, endoscopic laser photocoagulation, neutralization of gastric acidity, electrocoagulation, and the effective utilization of intravenous infusions of vasopressin for the management of bleeding gastroesophageal varices and certain other forms of gastrointestinal hemorrhage have further reduced the number of patients requiring angiographic therapy. 9-12 Despite these advances in management, the overall mortality rate for gastrointestinal bleeding has remained between 8 and 10% over the past two decades. 13 The use of intravenous vasopressin without an endoscopically or arteriographically established diagnosis must be discouraged, since not all types of gastrointestinal bleeding respond to intravenous vasopressin therapy. With indiscriminate and inappropriate use of vasopressin, valuable time will be lost before definitive therapy--either surgical or angiographic--is initiated. Similarly, celiotomy without prior endoscopic or arteriographic localization of the bleeding source should be reserved for the few patients with massive bleeding in whom a significant risk of exsanguination is present unless immediate operation is per287

formed. Here too, angiographic techniques are available, using occlusion balloons, for temporary control of major hemorrhage in preparation for operation. 14 Not all patients with gastrointestinal bleeding will ultimately require surgical management, since bleeding from some benign conditions may never recur. Under these circumstances, use of angiographic transcatheter therapy should be considered before embarking upon a surgical procedure. Arteriography is an invasive procedure, b u t the risks associated with arteriography for gastrointestinal bleeding are outweighed by the advantages. In experienced hands and with proper application, arteriography has a small incidence of complications. It is important also to bear in mind the complications that m a y occur if the study is not performed. 15 In addition, any serious complication, fatal or nonfatal, occurring within 24 to 48 hours of a diagnostic or therapeutic angiographic procedure must be evaluated in the light of the patient's preangiographic condition. In one report based upon an analysis of 1,600 consecutive patients, the incidence and nature of serious complications (fatal and nonfatal) among patients undergoing arteriography and among those in whom arteriography was planned but not performed was quite similar. 15 Major complications occur in 0.7 to 1.73% of patients undergoing transfemoral diagnostic arteriography. 16-19 These complications are for the most part localized to the arterial puncture site and include hematomas, infection, false aneurysms and arterial thrombosis. 17-21 Fatal complications have been reported in less than 0.1% of patients. 16' 17, 19, 22, 23 Minor complications occur in about 5% of patients. The majority of these represent puncture site hematomas (Table 1). 15' 16, 19 METHODS OF DIAGNOSIS OF GASTROINTESTINAL BLEEDING NASOGASTRIC TUBE

In all patients with suspected upper gastrointestinal bleeding, a nasogastric tube should be inserted to determine if the bleedT A B L E I.--COMPLICATIONS OF DIAGNOSTICARTERIOGRAPHY

288

TYPE OF COMPLICATIONS

INCIDENCE

L a r g e h e m a t o m a s ( p u n c t u r e site) I6' 17, 19, 28 F a l s e a n e u r y s m ( a n e u r y s m a s p u r i u m ) 17' 19 Visceral a r t e r y occlusion TM ThromboemboliclS, 19 Death17, 19

-< 1.5% -< 0.03% 2.0% < 0.7% 0.03-0.06%

ing source is proximal to the ligament of Treitz (upper GI bleeding). This also serves to monitor the bleeding, to evaluate its intensity and to determine the response to therapy. Presence of blood clots, making aspiration of the gastroduodenal contents difficult or impossible, requires use of a large bore Ewald tube. Since the nasogastric aspirate in up to 20% of patients with bleeding duodenal ulcers m a y not return blood, 24 a negative aspirate does not exclude a source of hemorrhage between the pylorus and ligament of Treitz. Very rarely bleeding even from the stomach will not be detected. 25 In some patients with apparent lower GI bleeding (obviously not of those patients with bright red blood per rectum), a diagnostic nasogastric tube serves to identify those who have an upper GI source and accelerated passage of the blood down the GI tract so t h a t they present clinically as lower GI bleeders. ENDOSCOPY

Endoscopy should be performed in almost all patients with acute or chronic gastrointestinal bleeding. For accessible lesions it is one of the best methods of detection, capable of identifying a bleeding source in over 90% of patients. 26-2s Endoscopy also helps to identify patients whose bleeding does not require, or will not respond to, angiographic management, such as those bleeding from esophageal varices, oropharyngeal lesions and anorectal disease. In addition, endoscopy provides a road map for selective arteriography and transcatheter therapy. Before considering arteriography, endoscopy should be performed on all patients unless: (1) There is brisk or massive bleeding which would make endoscopic localization difficult or impossible, resulting in delay in initiating therapy, inviting excessive blood loss or exsanguination. (2) It is contraindicated by concurrent medical problems such as delirium tremens, unstable angina or cardiac arrhythmias, or gastrointestinal perforation. (3) Endoscopy is not immediately available (within 60 minutes of time of request). In upper gastrointestinal bleeding, endoscopy is extremely valuable and whenever possible should be performed before arteriography. A negative endoscopic examination aids in guiding the arteriographic search for the bleeding source. Identification of nonbleeding esophageal varices, or a normal stomach, will exclude these as sources of bleeding in the vast majority of patients and will allow the vascular radiologist to focus on the duodenum or proximal small intestine. Even in patients with previously documented bleeding gastroesophageal varices, gastroduodenal ulcer disease, or other bleeding sources, endoscopy should be repeated if the previous study was performed several 289

months earlier, because in a large number of p a t i e n t s recurrent bleeding m a y be from a different source. 7' 2s, 2~ In patients with lower gastrointestinal bleeding, endoscopy is less helpful since such bleeding most often originates proximal to the sigmoid colon and visualization requires colonoscopy. In addition, reflux of blood from a rectal source m a y mislead the examiner into suspecting bleeding from the sigmoid or descending colon. Nevertheless, rectosigmoidoscopy should be performed because it m a y document sources of bleeding t h a t do not require arteriography or transcatheter therapy. An important aspect of the examination is careful inspection of the perianal area for ulcers, fissures and hemorrhoids. Recognition of such bleeding not only precludes an angiographic procedure which often incorporates an exhaustive and unfruitful search with attendant risk to the patient, b u t also saves the referring physician considerable embarrassment. RADIONUCLIDE STUDIES

Use of radionuclide studies for detection of gastrointestinal bleeding is not new. Almost thirty years ago, injection of chromium labelled red blood cells was used for detection of blood loss but such studies did not permit localization of the bleeding source. 3~ Recent reports of newer radionuclide imaging techniques indicate that these m a y now be able to document or localize bleeding in a significant number of p a t i e n t s Y -33 Nevertheless, the exact role of this diagnostic modality in the m a n a g e m e n t of an actively bleeding patient remains undefined. Enthusiasm for radionuclide evaluation m u s t be viewed in the context of several practical considerations. The time required to prepare the tracer and image the patient is longer than that required for arteriography, and such preparations m a y delay initiation of appropriate treatment. Further, arteriography performed during active arterial bleeding m a y provide prompt diagnosis and immediate therapy. However, if arteriography is unavailable on an emergency basis, radionuclide studies m a y be used in an attempt to localize a bleeding site, especially in patients with lower gastrointestinal bleeding. Thus, it would seem appropriate that radionuclide studies be performed in the actively bleeding patient after arteriography and only if arteriography does not document a bleeding source. The advantage of radionuclide evaluation lies in its ability to detect minimal and intermittent bleeding; and therefore, its greatest potential will be for detection of mild or occult gastrointestinal bleeding. Currently, two radionuclide techniques are in use: intravenous injection of technetium 99m sulfur colloid and intravenous injection of technetium 99m or indium 111 labelled erythrocytes. 290

The technetium 99m sulfur colloid technique is similar to arteriography and, under experimental conditions, this method has been reported to detect bleeding as small as 0.05 to 0.1 ml per minute. ~2 After intravenous injection, in patients with normal liver function, the sulfur colloid is picked up by the reticuloendothelial system and cleared from the blood within 12 to 15 minutes. In diffuse liver disease, the clearance of the tracer m a y be prolonged. If there is active bleeding, sulfur colloid will extravasate and will collect at the bleeding site. As background radioactivity decreases, radioactivity of the extravasated tracer increases, localizing the bleeding point. 34 The chance of detecting a bleeding site with this method is theoretically better than with arteriography because the intra-arterial time of the radionuclide is between 12 and 15 minutes versus only 8 to 10 seconds for arteriographic contrast medium. Localization of the extravasated tracer m a y change with intestinal activity permitting it to be distinguished from background reticuloendothelial activity in the liver, spleen and spine. 32 However, this distinguishing shift m a y also be responsible for a n u m b e r of incorrect interpretations. The other technique requires in vitro labelling of erythrocytes with either technetium 99m or indium 111 followed by intravenous injection. With this technique, the circulating labelled erythrocytes will be extravasated during bleeding. The longer half-life of indium 111 facilitates extending duration of imaging up to 24 hours or more. ~5 Focal accumulation of activity is interpreted as a bleeding site. Although both radionuclide techniques have strong proponents, preliminary data favor the technetium 99m sulfur colloid method for detection and localization of colorectal bleeding. 32 An alternative technique which m a y be helpful in some patients with bleeding gastric ulcers is imaging after oral ingestion of technetium 99m sulfur colloid. Accumulation of the radionuclide in an ulcer crater permits its detection (Fig 1). Technetium 99m pertechnetate scans are the method of choice for detection of bleeding from a Meckel's diverticulum (Fig 2). ~ This method detects the heterotopic gastric mucosa found in approximately 50% of Meckel's diverticula. The sensitivity of this technique is approximately 75%. 37 The overall sensitivity of detection of technetium labelled erythrocytes for identification of gastrointestinal bleeding was 62% in one study. 33 In the same study, 16% of gastroduodenal, 33% of small bowel, and 15% of colonic bleeding points were incorrectly localized. In 6 additional patients, in whom the scan was negative, arteriography documented active bleeding in one and angiodysplasia in five. The inaccuracy of localization of the technetium labelled RBC was, in our opinion, probably due to propulsion of the extravasated radionuclide by bowel peristalsis. 291

a

1-5

3hr

" ........................

=,m,m

Fig 1.--Detection of bleeding gastric ulcer using 99mTechnetium sulfur colloid.

Left, anterior abdominal image obtained 1-5 minutes after oral ingestion of technetium sulfur colloid documents presence of the tracer in the stomach and proximal small intestine (arrowheads). Arrow denotes focal area of minimally increased activity along lesser curvature of stomach. Right, image obtained at 3 hours documents passage of the tracer into the colon with persistent focal activity along the lesser curvature of the stomach (arrowhead). Endoscopy confirmed a gastric ulcer. Fig 2.--Detection of gastric mucosa using 99mTechnetium pertechnetate. Increased tracer activity is seen in the stomach and in the Meckel's diverticulum containing heterotopic gastric mucosa (arrow) suggesting that the diverticulum demonstrated may be the source of bleeding.

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This shortcoming is more likely to occur in patients who have received or are receiving vasopressin. Even though the overall sensitivity of radionuclide scanning is similar to that of arteriography, a significant n u m b e r of errors in localization have been recognized. 3~ Incorrect localization of GI bleeding by arteriography is unlikely, unless an anomalous vascular supply exists or the patient has two bleeding sources. Therefore, at the present stage of development, radionuclide localization of a bleeding gastrointestinal lesion with labelled erythrocytes does not substitute for arteriography and is not accurate enough to function as a surgical road map. The majority of scans that become positive do so between 1 and 24 hours. 33 That a large number of patients with both positive and negative scans do not require surgical m a n a g e m e n t confirms our impression that in most patients bleeding that is identified by radionuclide techniques can be controlled successfully by aggressive nonoperative management. Radionuclide localization techniques, in the current stage of development, should play a secondary role to arteriography. In patients with negative arteriograms they may be indicated to detect intermittent or occult gastrointestinal bleeding. If experience should prove radionuclide studies to be as accurate as some of the initial reports suggest, then indications for emergency arteriography will change. Nevertheless, arteriography will be required for initial evaluation and m a n a g e m e n t of patients with massive gastrointestinal bleeding when conservative measures fail. Radionuclide studies m a y be of value in patients with recurrent diverticular bleeding of the colon to determine what portion of the colon is to be resected. They m a y also obviate the need for repeat arteriography for intermittent or recurrent colonic bleeding. Whether radionuclide detection techniques can serve as a guide for angiographic transcatheter therapy without preliminary arteriographic confirmation of a bleeding source is as yet undetermined. Radionuclide studies m a y assume a role similar to endoscopy as initial diagnostic procedures for localization of bleeding during conservative therapy of patients with occult and mild gastrointestinal bleeding. B A R I U M STUDIES

Barium studies have no place in the m a n a g e m e n t of acute gastrointestinal bleeding. They should not be performed before arteriography because the barium m a y obscure the extravasation of the contrast medium. In addition, technically adequate barium studies m a y be difficult or impossible to obtain on critically ill or uncooperative patients. 27 ' 38 Highly sensitive double contrast techniques m a y be able to document one or several le293

sions but cannot determine w h e t h e r or not the lesion identified is the source of hemorrhage. An incorrect diagnosis is made in up to 24% of patients with acute gastrointestinal bleeding in whom barium studies have been used. 39 Among patients with chronic or low grade, intermittent bleeding, barium studies and endoscopy should precede arteriography. If such evaluation is not fruitful, subsequent arteriography m a y provide a diagnosis by documenting a vascular malformation or a vascular neoplasm. ARTERIOGRAPHY

Indications

Arteriographic techniques serve to: (1) localize the site of acute, massive gastrointestinal bleeding; (2) identify the source of chronic or intermittent gastrointestinal bleeding; and (3) treat acute bleeding by infusion of vasopressin or by transcatheter occlusion of bleeding vessels. In the majority of patients, upper or lower gastrointestinal bleeding will stop with nonoperative m a n a g e m e n t which includes bedrest, sedation, blood and fluid replacement, and correction of coagulation defects. 3s Only a relatively small number of patients, those in whom svch m a n a g e m e n t fails, require emergency arteriography. Elective arteriography may be required in patients with variceal bleeding to provide a preoperative guide to help determine the type of portosystemic shunt to be constructed. Elective arteriography is also helpful in management of some types of chronic or intermittent bleeding due to colonic angiodysplasia or arteriovenous malformations. In some patients, after endoscopic identification of a bleeding source, angiographic techniques m a y be required as initial therapy and serve as adjuncts to improve the patient's condition before definitive operation. Such may be the case in patients with bleeding gastric or duodenal ulcers or those bleeding from esophageal varices. In general, arteriography is likely to document an active bleeding source if: (1) Continuous blood and fluid are required to maintain hemodynamic stability (continued bleeding); (2) bleeding is massive, i.e., blood requirements exceed 4 units per day; or (3) nasogastric aspirate remains bloody or blood tinged in spite of repeated irrigation. (Blood tinged aspirate must be differentiated from coloring of the aspirate by old blood clot.) The large number of negative (53%) and indeterminate (17%) surgical explorations in some series confirms the difficulties of operative localization of an occult chronic bleeding source which m a y be due to angiodysplasia, arteriovenous malformations or other etiology. 4~ Operative endoscopy may be helpful in some instances of acute or chronic gastrointestinal bleeding, but such 294

endoscopy m a y be misleading because identification of blood within a bowel segment does not localize bleeding to that particular area. 41 Peristalsis m a y propel blood in both directions. During m a n a g e m e n t of acute gastrointestinal bleeding, correct decisions must be made to avoid inordinate delays in diagnostic evaluation or therapy. If avoiding ~'invasive" tests requires delaying arteriography for several hours, either in anticipation that the bleeding will stop, or until the radionuclide study or endoscopy has been performed, one m a y jeopardize the patient. One must keep in mind that immediately after arteriographic demonstration of a bleeding source, transcatheter embolotherapy or pharmacotherapy is available and, in a significant number of patients it m a y be the only t r e a t m e n t required. In patients requiring operation, arteriographic localization of the bleeding source facilitates performance of the operative procedure. There is no doubt that arteriography is an r procedure. As such, it requires a skilled operator in order to be an effective diagnostic and therapeutic tool. In skilled hands, serious complications are infrequent. Previous reports have adequately documented arteriographic techniques and approaches in patients with gastrointestinal bleeding and only a brief discussion will be presented. 1~ 25, 42-44

Arteriographic Methods In most patients, the percutaneous femoral artery route (Seldinger technique) is used. In patients who have severe iliofemoral artery occlusive disease or other contraindications such as recent inguinal operation, groin infection or previous aortobifemoral bypass graft, the axillary artery approach m a y become necessary. In addition, the axillary approach m a y be desirable in patients in whom the femoral artery route does not permit subselective catheterization. 45 A disposable, 2.5-inch long arterial puncture needle or catheter needle with a minimum inner diameter of 0.039-inch at the tip is inserted into the femoral artery percutaneously. This is exchanged for a 6.5 French Cobra or a 6 French sidewinder catheter over a 0.038-inch flexible tip J-guidewire. Catheterization is performed of the artery supplying the source of bleeding which was localized by preceding endoscopy or suspected on the basis of the clinical presentation. For bleeding from the distal esophagus, the left gastric artery or the celiac artery is catheterized. If the bleeding source is in the stomach, the left gastric artery is catheterized. This is accomplished by using either a sidewinder or a Cobra catheter in the loop configuration. 46 In 150 patients with gastric bleeding the bleeding site was documented on a left gastric arteriogram in 92.6% of patients. 47 In the remainder of the patients the bleeding site was in the 295

distribution of the right gastric artery in 2.0%, short gastric arteries in 2.7% and the gastroepiploic arteries in 2.7%. In the same series, the left gastric artery was a branch of the abdominal aorta, either directly or as a splenogastric trunk in 11.3% of patients. Celiac arteriograms may not document gastric bleeding either because of this relatively high occurrence of variant left gastric arterial anatomy or because the catheter tip is placed beyond the left gastric artery during performance of the celiac arteriogram.43, 47~ Pyloroduodenal bleeding is best identified by selective catheterization of the gastroduodenal artery. A Cobra shaped catheter is used for catheterization of the gastroduodenal artery. The catheter is placed in the celiac artery orifice and can usually be torqued into the common hepatic and further into the gastroduodenal artery. If selective catheterization is not possible, a celiac arteriogram may identify the bleeding. Failure to opacify the gastroduodenal artery on celiac arteriography may be due to alterations in flow patterns related to catheter induced vasospasm and necessitates selective catheterization of the inferior pancreaticoduodenal artery which is a branch of the superior mesenteric artery. 4s Alternatively, the hepatic artery, which gives off the gastroduodenal, may be a branch of the superior mesenteric artery, as in 14% of patients, and catheterization of the superior mesenteric artery will be required. 4~ In this situation, the loop catheter technique using a Cobra shaped catheter is used. 46 Bleeding from the small intestine, or ascending and transverse colon is studied by superior mesenteric arteriography. Occasionally, aberrant vascular supply to the proximal jejunum may be from the celiac artery branches. Therefore, a celiac arteriogram is performed if the bleeding source is not identified by the mesenteric arteriogram. Bleeding from the descending and sigmoid colon is evaluated by inferior mesenteric arteriography. Among patients with atherosclerotic occlusion of the inferior mesenteric artery, a superior mesenteric arteriogram is performed. Anorectal bleeding should be evaluated by inferior mesenteric and internal iliac arteriography. Both the superior and inferior mesenteric arteries can be catheterized with either the sidewinder or the Cobra catheters. Bleeding aortoenteric fistulas are the only type of gastrointestinal bleeding not requiring selective arteriography. A pigtail catheter (5 or 6 French) is inserted into the abdominal aorta and is placed with its tip at the 12th thoracic vertebral body. A biplane aortogram is performed using an alternating filming technique in the anterior/posterior and horizontal planes. For selective catheterization reinforced wall, preshaped, tapered 6 or 7 French catheters are used. These catheters can be 296

used both for diagnostic arteriography and for transcatheter therapy. Radiographs are obtained for 2 5 - 3 0 seconds after the contrast injection has begun.

Optimal Timing for Arteriography Arteriographic documentation of a bleeding site requires active bleeding at the time of the study. Gastrointestinal bleeding is usually intermittent so that failure to see extravasated contrast material in the lumen of the bowel provides little information unless an arteriovenous malformation, angiodysplasia, or a vascular tumor is documented. On the other hand, mere identification of such lesions does not imply that these are the sources of bleeding (see section on lower GI bleeding). Experimental studies have documented that under optimal conditions bleeding at a rate of 0.5 ml/min or more can be detected by arteriography. %50 Clinical experience suggests that in most instances a rate of bleeding greater than 0.5 ml/min is necessary in order to be documented by arteriography. Transfusion requirements correlate with severity of bleeding, and bleeding that requires greater than 2,000 ml of blood within 24 hours to maintain hemodynamic stability is more likely to be detected than are lesser rates of bleeding. Patients with acute gastrointestinal bleeding should not be rushed for arteriography upon admission to the hospital without first undergoing resuscitation and stabilization of hemodynamics. If bleeding persists, one should proceed to arteriography. An inordinate period of waiting in the presence of continued bleeding is just as undesirable as precipitous and p r e m a t u r e arteriography because: (1) replacement of large volumes of blood m a y lead to coagulation defects which m a y render intravenous or intra-arterial vasoconstrictive therapy ineffective; (2) continued hemodynamic instability increases the risks of both angiographic therapy and operation; and (3) the risk of hepatitis increases with the number of transfusions. Furthermore, transfusion of large volumes of blood products m a y place an unnecessary burden upon the hospital blood b a n k 4 7 a n d increase the cost of such therapy.

Accuracy of Arteriographic Diagnosis Reports of the overall accuracy of diagnostic arteriography for detection of gastrointestinal bleeding vary between 60 and 86%, which reflect experience of the vascular radiologist as well as patient selection. 3-7' ~1, 52 With upper gastrointestinal bleeding, accuracy is greater than with lower gastrointestinal bleeding. Among individuals having melena without hematemesis, the accuracy was 48%. 53 By comparison, ~'blind" celiotomy m a y be successful in localizing such bleeding in only 30% of patients. 4~ Some factors responsible for a nondiagnostic arteriographic study are listed in Table 2. The accuracy of diagnostic arteriog297

TABLE 2.--FACTORSRESPONSIBLEFOR NONDIAGNOSTIC ARTERIOGRAPHY 1. Inappropriate patient selection a. Patient not bleeding b. Diffuse bleeding 2. Venous bleeding (variceal, hemorrhoidal) 3. Faulty technique a. Inappropriate catheter technique (nonselective position) b. Inappropriate filming technique (too slow, too fast) c. Inappropriate contrast volume d. Inappropriate patient positioning

raphy for detection of a source of gastrointestinal bleeding depends upon several factors including timing of the study, type of study, and the type of bleeding and associated diseases.

Timing of the Study A critical rate of bleeding is necessary to permit detection by arteriography. Clinically, this is greater than 0.5 ml/min. Thus, arteriography should only be performed if there is continued evidence of bleeding. Mere presence of blood in the nasogastric aspirate or identified in the rectum on endoscopic evaluation simply serves to document that bleeding has occurred, but bleeding may not be continuing. It bears emphasis that hematemesis and hematochezia may occur, even though the active bleeding has stopped, as the gut empties itself of irritating blood. Timing of the arteriogram, therefore, is crucial if maximum information and benefit are to be obtained. Often arteriography is requested soon after hemodynamic stabilization, when the bleeding is decreasing. To proceed with arteriography at this point, when hemodynamic and clinical parameters document decreasing or cessation of bleeding or when the nasogastric aspirate is clearing, is an exercise in futility. Instead, it may be appropriate to attempt a radionuclide study in such patients. Timing of the arteriogram is made on clinical grounds by estimating whether or not the bleeding continues. Once blood volume has been restored, following initial resuscitative efforts, if the patient requires approximately 500 ml of blood every 8 hours (a bleeding rate of about 1 ml/min) to maintain hemodynamic stability, then such bleeding will probably be identified on properly performed arteriographic studies. As has been pointed out by numerous investigators, the indication for operation and arteriography is that the patient may be bleeding to death. Continued hemorrhage requiring 500 ml of blood replacement every 8 hours qualifies as bleeding to death and such bleeding is detectable by arteriographic methods. 298

Type of Study In most cases selective arteriography of the appropriate vessel will be required. Familiarity with variant a n a t o m y and anomalous sources of vascular supply are necessary. Aortography is not indicated in the diagnosis of gastrointestinal bleeding except when an aortoenteric fistula is suspected. The experience and expertise of the vascular radiologist, quality of the radiographic technique, and appropriate patient positioning are essential for making a correct diagnosis.

Type of Bleeding Bleeding m a y be of arterial, capillary or venous origin. Only arterial or capillary bleeding can be detected by selective arteriography. Venous bleeding is very difficult to demonstrate on the venous phase of an arteriogram. Consequently, in endoscopically diagnosed variceal or hemorrhoidal bleeding among patients with portal hypertension, emergency diagnostic arteriography is not indicated except to provide information for portosystemic shunt procedures. TREATMENT WITH VASOCONSTRICTORS

Vasopressin is a purified preparation of the antidiuretic hormone from the posterior pituitary. It acts by constricting smooth muscle of arterioles and venules. 54 Smooth muscle of large- and medium-sized arteries is less responsive. Adrenergic blockade or sympathetic denervation have no effect on the vasoconstrictive action of vasopressin. Vasopressin also constricts smooth muscle of the bowel wall, thus producing a twofold effect in the intestines. This is most pronounced in the colon. Vasopressin m a y be used either as an intravenous or an intra-arterial infusion. In the dog, the optimal infusion rate for vasopressin has been found to be 0.3 U/kg/min, which is equivalent to 0.2 U/min in the adult human. 55'56 Maximal blood flow reduction is usually observed between 20 and 30 minutes after the infusion is begun. This maximal flow reduction is dose dependent; a higher dose effects a more rapid decline in blood flow. 55 After terminating the infusion, rebound hyperemia has been observed. Therefore, gradual tapering of vasopressin infusion is required to avoid rebleeding resulting from abrupt cessation of administration. Animal experiments have also documented that at an infusion rate of 0.2 U/min, coronary artery blood flow was reduced by 25% and at 0.4 U/rain it was reduced by 35%. 57 In another study, cardiac output fell by 26% at an infusion rate of 3.0 U/ kg/min (equivalent to an adult h u m a n infusion rate of 0.2 U/ min). 56 In addition, vasopressin also affects the cardiac function by effecting the autonomic innervation. 54 Thus, patients with 299

coronary insufficiency m a y experience angina even after small doses. The peripheral vasoconstrictor effects of vasopressin result in elevation of the systemic blood pressure and decreased peripheral pulses, especially in patients with occlusive arterial disease. In addition, there may be decreased skin perfusion with resultant acral cyanosis. Vasopressin infusion into the superior mesenteric artery abruptly reduces portal venous pressure by approximately 50%.~s Reduction in portal venous pressure is more gradual after intravenous infusion, but the effective reduction in portal venous pressure is similar. Blood flow to the left gastric artery decreases by 90% after selective intra-arterial injection, 60% after celiac artery infusion, and only 55% after intravenous infusion. 59 An autoregulatory escape phenomenon has been observed during celiac infusion in which blood flow returned to 90% of the baseline level. ~~ This may help to explain the failure of intravenous or celiac artery infusions to control gastric bleeding. During vasopressin infusion into the superior mesenteric artery, hepatic artery flow increases by 96.5%. After celiac artery infusion, hepatic blood flow decreases initially but later increases by 45 to 50%. 56' 61, 62 Success of vasopressin therapy for gastrointestinal bleeding is summarized in Table 3. Intravenous and intra-arterial vasopressin protocol appears in Table 4. Infusion rates above 0.4 U/min do not significantly increase therapeutic effects; on the contrary, they m a y be associated with significant morbidity and, therefore, should not be used.

INTRAVENOUS VASOPRESSIN INFUSION

Intravenous vasopressin infusion should be through a central venous line. Peripheral venous lines are not appropriate for vaT A B L E 3.--ANGIOGRAPHIC MANAGEMENT OF GASTROINTESTINAL BLEEDING: SUCCESS OF VASOPRESSIN THERAPY

TYPE OF BLEEDING

TYPE OF INFUSION

M a l l o r y - W e i s s t e a r s s3, 84 A c u t e h e m o r r h a g e g a s t r i t i s 93 G a s t r i c u l c e r 4t Pyloroduodena195, 14s S m a l l bowel 149 Colorecta151, 149, 1~o V a r i c e a l , g a s t r o e s o p h a g e a l 1~ 126, 14s, 1~1,152 ( Child A, B a n d C) P o s t o p e r a t i v e 123

intra-arterial intra-arterial intra-arterial intra-arterial intra-arterial intra-arterial intra-arterial intravenous intra-arterial

300

SUCCESS RATE (%) 77-88 84 65-70 33-62 71 83-100 55-98 79 82

RECURRENT BLEEDING(%} 15 7-16 -33 -14-25 13-51 ---

TABLE 4.--PROTOCOL FOR INTRAVENOUSOR INTRA-ARTERIALVASOPRESSIN THERAPY 1. Localize bleeding point by arteriography or endoscopy. 2. Start vasopressin infusion: 0.2 U/min for 20-30 minutes (via constant infusion pump). 3. Repeat arteriogram. 4. If bleeding has stopped, continue at this rate for 12-24 hours. 5. If bleeding continues, increase infusion to 0.4 U/min for 20-30 minutes and repeat arteriogram. 6. If bleeding has stopped, continue vasopressin as follows: 0.4 U/min for 6-12 hours, then 0.3 U/min for 6-12 hours, then 0.2 U/min for 6-12 hours, and finally 0.1 U/min for another 6-12 hours. 7. Thereafter, infuse 5% Dextrose or normal saline at 15-20 ml/hr for 4 - 6 hours to maintain catheter patency and observe for signs of recurrent bleeding: Nasogastric aspirate, central venous pressure, hematocrit and transfusion requirement. 8. If bleeding has ceased, remove catheter. If bleeding persists after infusion of 0.4 U/min consider embolization or operation.

sopressin infusion because of the potential for dermal vasoconstriction and subsequent skin necrosisS Intravenous infusion of vasopressin is the treatment of choice for bleeding esophageal varices in patients with portal hypertension. Occasionally, mucosal, capillary, and arteriolar bleeding as in acute hemorrhagic gastritis and certain forms of colonic bleeding may respond favorably to intravenous vasopressin infusion. 63 INTRA-ARTERIAL I N F U S I O N

In most patients with bleeding from an arterial or capillary source, selective arterial vasopressin infusion is much more effective than a nonselective infusion. Placement of the arterial infusion catheter into branch vessels of the superior or inferior mesenteric arteries must be avoided because resulting vasoconstriction might totally occlude the branch with subsequent bowel infarction.

TREATMENT W I T H TRANSCATHETER OCCLUSING A G E N T S (TABLE 5)

The choice of embolic material to be used for transcatheter occlusion of bleeding vessels is dictated by the goals of therapy (temporary or permanent occlusion), type of circulation to be treated (end arterial, collateral blood supply, main arteries) and the organ in question. For embolization of gastrointestinal bleeding, only large, particulate emboli can be used safely. Cap301

T A B L E 5 . - - E M B O L I C MATERIAL FOR TRANSCATHETER OCCLUSION IN THE MANAGEMENT OF GASTROINTESTINAL BLEEDING

MATERIAL

DURATION OF OCCLUSION

INTIMAL/MEDIAL INFLAMMATORY RESPONSE

Autologous blood clot Gelfoam Ivalon steel coils detachable balloons Isobutyl 2-cyanoacrylate ethanol

1 - 5 days 3 - 6 weeks permanent permanent permanent permanent permanent

none moderate none minimal none moderate moderate

illary occluding agents such as Avitene, Ivalon microspheres and Gelfoam powder are not safe because of their propensity to cause nutrient bed obstruction and increase the likelihood of tissue necrosis. Avitene when mixed with contrast medium to form a slurry is a particular offender and should be avoided. 65 Necrosis has also been reported after use of cyanoacrylate. 64 In most patients with gastrointestinal bleeding, Gelfoam sponge has provided satisfactory occlusion and it is the most commonly used embolic agent. Patients who fail to respond to intra-arterial vasoconstrictive therapy can be considered for embolotherapy. Transcatheter embolization is applicable and safe only for organs rich in collateral blood supply like the stomach, duodenum, rectum, and liver. The use of embolotherapy in patients having small bowel or colonic bleeding must be determined on an individual basis. Important considerations when using embolotherapy include the type of bleeding, the underlying disease, the possible success of surgical intervention and proximity of the embolotherapy catheter to the bleeding vessel. Thus, in a moribund, high operative-risk patient with severe gastrointestinal bleeding, indications for use of embolization may be liberal. Refractory colonic bleeding or postoperative bleeding can also be treated with transcatheter embolization, providing a satisfactory catheter position can be obtained. In such instances, a few (1-3) pieces of Gelfoam delivered through a subselectively placed or coaxial catheter are sufficient to occlude the bleeding vessel. In most patients embolization should be performed only when active bleeding is identified by arteriography so that the precise bleeding vessel may be occluded. Endoscopically confirmed duodenal ulcer bleeding m a y be an exception. We have successfully used embolotherapy in several patients with duodenal ulcer bleeding identified by endoscopy who were not bleeding at the time of arteriography and did not rebleed. 3o2

AUTOLOGOUS BLOOD CLOT The greatest advantages of autologous blood clot used as embolic material are availability, ease of preparation and cost. A major disadvantage and the reason t h a t autologous clot is used infrequently is t h a t lysis occurs within hours or days. 66 For this reason, use of autologous clot should be limited to situations in which other embolic material is unavailable. Clot preparation m a y be enhanced by using thrombin or aminocaproic acid, perm i t t i n g its use even in patients with impaired coagulation mechanisms. GELFOAM The most frequently used material for embolic occlusion of bleeding vessels is absorbable gelatine (Gelfoam, Upjohn Co., Kalamazoo, MI). It is available as a sponge or powder. Gelfoam powder with particle size between 40 and 60 microns is used when occlusion is required at the arteriolar-capillary level. Gelfoam sponge is easy to inject through standard angiographic catheters and is the material of choice for most embolizations where temporary occlusion is either desired or considered to be adequate. Gelfoam incites an intravascular inflammator~ reaction. The duration of occlusion is between 7 and 21 days. ~ Commercially available sterile Gelfoam sponge is cut into small pieces (approximately 3 mm • 3 mm) using sterile scissors or a scalpel blade. The Gelfoam pledgets are soaked in contrast medium and are loaded into a tuberculin syringe for injection through the selectively placed arterial catheter. IVALON Ivalon (Unipoint Industries, Highpoint, NC), a polyvinyl alcohol, is also available as sponge or in microsphere form. It is quite similar to Gelfoam in m a n y respects but is more difficult to handle. It causes permanent vascular occlusion, but does not induce intravascular inflammatory reaction. It is available in the compressed state and will re-expand upon contact with fluids. This particular property of Ivalon makes possible the embolic occlusion of larger arterial branches. For embolization, Ivalon sponge may be prepared in a similar fashion as Gelfoam. Alternatively, it is cut into 1 m m • 5 mm strips which are t h e n loaded into a K-50 extension tubing for embolization through the arterial catheter. 6s

303

COILS (Fig 3) The original coil used for embolotherapy was made of steel and had attached wool strands to induce thrombus formation. 69 This provided permanent vascular occlusion. Such coils could only be delivered through specially constructed angiographic catheters. On the newer ~mini" coils, Dacron has been substituted for wool and the coils have been designed for use through regular, tapered angiographic catheters. However, this advantage of easier delivery has been partially offset by the coil's inability to occlude, possibly because of the low thrombogenicity of the Dacron fibers. In combination with other embolic material such as Gelfoam, stainless steel coils with Dacron fibers provide permanent vascular occlusion. Recanalization is extremely rare but has been reported in association with the development of aneurysms.7O, 71 Fig 3.--Coils for intra-arterial insertion. A, original steel coils: wool (a), dacron (b), pediatric size coil (c). B, preloaded mini coils for use through regular anglographic catheters.

A r

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The coils are preloaded in color coded cartridges. Such "mini" coils are available in three different sizes: l a r g e - 8 mm, med i u m - 5 mm, and s m a l l - 3 mm coils. The diameter in millimeters refers to the size of the coil after extrusion from the cartridge. DETACHABLE BALLOONS (Fig 4) Detachable silicone balloons also provide p e r m a n e n t vascular occlusion. 72 The greatest advantages of this technique lie in the flow directability of the balloon and the possibility for prelimin a r y test occlusion to assess its adequacy. The balloons, like the coils, provide proximal main arterial branch occlusion. Since bleeding from the gastrointestinal tract is usually at the small artery or arteriolar-capillary level, a proximal vessel occlusion provides little benefit, except for the t r e a t m e n t of arteriovenous communications or aneurysms. In appropriate cases, detachable balloons provide a safe and efficacious method of embolization. The detachable silicone balloons are available in two sizes. The smaller, 1 m m balloon has an outer diameter of 1 m m in the uninflated state. The balloon diameter after maximal inflation is 4 mm. This balloon can be inserted either through thinwalled 5 French, nontapered polyethylene catheters or specially constructed nontapered 6.5 or 7.3 French reinforced wall preshaped polyethylene angiographic catheters. ~3 This balloon is used to occlude vessels t h a t have an opacified lumen diameter of 4 m m or less. The larger, 2 m m balloon has an outer diameter of 2 m m in Fig 4.--Detachable silicone balloons.

llllltlltLlZlr II MET !Cl/

305

the uninflated state. The balloon diameter after maximal inflation is 9 mm. Thus, it can be used to occlude vessels that have an opacified lumen diameter of less t h a n 9 mm. This balloon is inserted through a thin-walled, nontapered 9 French polyethylene catheter which can be custom shaped for selective catheter placement at the time of the embolization. These balloons are attached to a 150-cm long Bismuth impregnated radiopaque Polyurethrane catheter with a self-sealing valve. The catheter with the balloon at its tip is threaded into the artery through a specially constructed coiling chamber. When proper placement has been confirmed, the balloon is disengaged while the self-sealing valve maintains its expansion. Silicone balloons are inflated with iso-osmotic contrast medium (equal parts of iodipamide meglumine and sterile water). For most embolizations in the GI tract, detachable silicone balloons are of adequate diameter. However, for vessels with lumen larger than 9 mm, a detachable latex balloon, which can be inflated to 12 mm, can be used. TM The latex balloon is inflated with liquid silicone, which hardens after balloon placement. As with other embolization materials, the use of these balloons requires selective catheterization of the artery that is to be embolized. Use of balloons in conjunction with other arteriolar level occluding embolic materials, similar to that used with coils, can be an effective means of controlling some forms of gastrointestinal bleeding. However, cost ($300 per silicone balloon) limits their use to lesions in which conventional embolic material cannot be used safely. TISSUE ADHESIVES The most commonly used polymer for embolotherapy is Isobutyl 2-cyanoacrylate (Ethicon, Summerville, NJ). It is used in liquid form and polymerizes immediately upon contact with circulating free ions, providing permanent vascular occlusion. Only a small portion of the Isobutyl 2-cyanoacrylate cast comes in contact with the vessel intima. 75 Histologic studies document only mild histocytic reaction in the vessel intima. 7~' 7~ Nonetheless, tissue glues have not yet been approved for general use, they are difficult to use, and tissue necrosis has been reported after embolization with Isobutyl 2-cyanoacrylate. 64 ETHANOL Absolute ethanol is a potent, permanent vascular occluding agent. In the gastrointestinal tract it has been used effectively to obliterate gastroesophageal varices. The mechanism of action 3o6

depends upon the rate at which ethanol is injected and m a y be due to arterial spasm, endothelial or perivascular necrosis and sludging of erythrocytes.77

FAILURE OF TRANSCATHETER THERAPY (Fig 5) Vasopressin infusion therapy is not suited for all types of bleeding. Some of the reasons for failure of vasopressin therapy to control gastrointestinal bleeding appear in Table 6. The most likely cause for failure to control bleeding from gastric or duodenal peptic ulcers is that such bleeding m a y result from erosion of a large arterial branch that does not respond to the vasoconstrictor. In addition, presence of chronic inflammatory reaction at the ulcer base m a y prevent vasoconstriction as well. Bleeding from some solid organs such as liver and kidney responds poorly to vasoconstrictive therapy. Intra-arterial infusion into the splenic artery, on the other hand, m a y have profound vasoconstrictive effects and m a y effectively control bleeding from the spleen or short gastric arteries. Careful consideration of these factors prior to attempting vasopressin therapy m a y decrease the failure rate by providing appropriate patient selecFig 5.--Left gastric artery aneurysm with gastric bleeding uncontrolled by intravenous vasopressin. Patient receMved 0.4 U/min intravenously without prior arteriography. A hemiparesis and the failure to control the bleeding prompted arteriography. The celiac arteriogram shows a left gastric artery aneurysm. There is vasoconstriction of the gastric, intrasplenic and duodenal branches (vasopressin effect). Angiography undertaken first would have precluded vasopressin therapy,

307

TABLE 6.--FACTORS RESPONSIBLEFOR FAILUREOF VASOPRESSIN THERAPY 1. Inappropriate patient selection a. Brisk arterial bleeding (visceral artery aneurysms, trauma, arterial erosions) b. Arteriovenous malformations c. Bleeding from solid organs (liver, pancreas) d. Chronic inflammatory or postoperative lesions (peptic ulcers, pancreatitis) 2. Inappropriate catheter position a. Nonselective infusion b. Dual blood supply (duodenum, colonic flexures) c. Catheter dislodgement 3. Inappropriate infusion technique a. Intermittent or short infusion b. Abrupt termination of infusion c. Bolus injection of vasopressin 4. Inappropriate clotting mechanisms a. Patients receiving anticoagulants (coumarin derivatives, heparin) b. Multiple blood transfusion requirement due to inappropriately long delay in instituting vasopressin c. Thrombocytopenia (less than 60,000) d. Abnormal PT and PTT due to other causes

tion. In addition, abortive attempts in patients not likely to respond to vasopressin will be avoided and undue delay of alternative treatment will be prevented. Similarly, success of embolotherapy requires a carefully selected and skillfully performed technique guided by critical evaluation of the etiology of bleeding and underlying problems. Proper patient selection will not only enhance the chances of success, but will also decrease the incidence of complications and chance of failure. COMPLICATIONS

In the majority of patients, diagnostic arteriography for gastrointestinal bleeding is safe and without significant morbidity, 7s even though patients are mostly elderly, and often very ill. Death directly attributable to diagnostic or therapeutic arteriography for gastrointestinal bleeding is rare despite the concerns expressed by some. 33 COMPLICATIONS OF VASOPRESSIN INFUSIONS

When used properly, there are few serious complications associated with intra-arterial or intravenous vasopressin. Death directly attributable to such therapy has not been reported in series evaluating large numbers of patients undergoing vasopressin therapy.~7 Major complications requiring discontinua3O8

tion of vasopressin infusion were observed in 8.3% of patients in one series, t7 Some of the complications of both intravenous and intra-arterial infusions are listed in Table 7. Differences in the incidences and severity of complications during intra-arterial and intravenous vasopressin infusion are not significant. 79 Some of these complications are due to the indwelling arterial catheter itself, whereas others result from the pharmacologic properties of vasopressin. 7s-s~ Water retention and hyponatremia leading to cerebral edema, with alterations in mental status, have been reported in a few patients. Administration of a diuretic and discontinuation of vasopressin infusion have proven successful in managing this complication. Cardiac complications are more common among patients with pre-existing ischemic heart disease than in those without a history of cardiac disease. Infusion rates greater than 0.4 U/min are particularly prone to precipitate cardiac complications. Occasionally, in susceptible individuals, angina and arrhythmias m a y occur during lower infusion rates (0.2 U/min), during left TABLE 7.--COMPLICATIONSOF VASOPRESSINTHERAPY* TYPE OF COMPLICATION

Cardiac

MINOR (%)

MAJOR(%)

11

4

9

0.5

47

1.0

Arrhythmias Bradycardia Acute congestive failure Angina Myocardial infarction Hypertension

Systemic Peripheral Vascular Pulmonary edema Acral vasoconstriction Leg gangrene

Renal~Metabolic Hyponatremia Cerebral edema Oliguria Hematuria

0.8

Visceral Mesenteric ischemia Mesenteric infarction

Infusion Site~Catheter Related

5

Thromboembolism False aneurysm Infection Phlebitis *Adapted from Athanasoulis C.A. 47

309

gastric artery infusion or even during intravenous infusion. In most patients with cardiac complications, upon stopping the infusion, angina will subside and the arrhythmias will be reversed. Disability or death occurs very infrequently. COMPLICATIONS OF E M B O L O T H E R A P Y

(Table 8)

Complications of embolotherapy include tissue ischemia with necrosis, and inadvertent embolization of other vessels as a result of reflux of embolic material from the t r e a t m e n t site. Most complications of embolotherapy can be avoided by appropriate selection of embolic material and by using appropriate embolization techniques. Most complications of embolotherapy result from "overkill," due to occlusion of more vessels than required by using excess or inappropriate embolic materials. For example, small caliber branch vessels of the superior mesenteric artery m a y be occluded with one or two plugs of Gelfoam. If more embolic material is used, it will reflux into and occlude other branches. Resultant stricture of the gut following mural ischemia has been reported after small intestine and colonic embolization, sl Capillary occluding agents such as Ivalon microspheres and Gelfoam powder should not be used for embolization of mesenteric arterial branches because these agents m a y cause intestinal necrosis. Vasopressin should not be infused immediately after embolotherapy. Use of vasopressin under such circumstances m a y further decrease the collateral blood supply to the embolized organ and precipitate necrosis. Similarly, postoperative embolotherapy should be cautiously undertaken because the collateral blood supply to the organ m a y have been compromised by the operation, and lacking collateral protection, tissue may be infarcted. PATIENT CARE DURING VASOCONSTRICTOR THERAPY

All patients with intra-arterial catheters for vasopressin infusion should be admitted to an intensive care unit. Continuous electrocardiographic monitoring is mandatory for all patients reTABLE 8.--COMPLICATIONS OF EMBOLOTHERAPY 1. Local a. infarction/necrosis b. infection c. incorporation of catheter in polymer (cyanoacrylate) 2. Remote a. i n a d v e r t e n t reflux of emboli b. coagulopathy due to extensive tissue necrosis 310

ceiving vasopressin because vasopressin induced cardiac arrhythmias occur in about 3% of patients, necessitating discontinuation of vasopressin. 47 Electrocardiographic monitoring also identifies early evidence of myocardial ischemia. Urine output, daily serum electrolytes, and assessment of the patient's mental status permit early detection of fluid retention as a result of antidiuretic effects of vasopressin. CARE OF PUNCTURE SITE At regular intervals, the arterial puncture site in the groin must be examined for bleeding and the peripheral pulses must be evaluated. Use of the Doppler instrument for m e a s u r e m e n t of ankle blood pressures provides objective data concerning pulses distal to the arterial puncture. Such data help detect thromboembolic complications and identify excessive peripheral vasoconstriction by cessation of Doppler flow signals or significant decreases in ankle blood pressures. This is of particular importance in patients with known peripheral arterial occlusive disease. Clinically, excessive peripheral vasoconstriction m a y be manifested by acrocyanosis and decrease in skin temperature. CARE OF THE INDWELLING ARTERIAL CATHETER Vasopressin must be infused by a constant infusion pump. The minimal flow rate to maintain catheter and arterial patency must be determined and concentrations of vasopressin adjusted accordingly. For most catheters, a flow rate of 15-20 ml/hr is adequate to maintain patency. The volume of fluid infused must be included in the patient's daily fluid requirements, and usually amounts to 500 ml/day. A disposable three-way stopcock is attached to the catheter hub to provide access for portable arteriography to check catheter position without disconnecting the catheter from the infusion pump. This is helpful in case of rebleeding. This sideport should not be used for injection of drugs or fluids other than those required for intra-arterial vasoconstrictive therapy. The patient's leg should be restrained and unnecessary motion, such as bending during nursing care, must be avoided since this m a y lead to dislodgement of the catheter from the selected intra-arterial position, s2 A method for securing the catheter is shown in Figure 6. The catheter must be sutured or taped firmly to the skin at the puncture site. A topical antibiotic is applied and the puncture site is covered with a loose gauze or elastic bandage. Application of a totally occlusive pressure dressing or sand bags should be discouraged since this may provide a false sense of security, because significant bleeding m a y occur around the catheter before such bleeding is detected. The arterial puncture 311

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312

site itself rarely needs to be exposed. Should a dressing change become necessary, care must be used to avoid traction on the catheter. Such traction is one of the frequent causes of catheter dislodgement from a selective arterial position. APPROACH TO UPPER GASTROINTESTINAL BLEEDING

If a bleeding source has been identified by endoscopy, the appropriate vessel is catheterized (left gastric artery for gastric bleeding and gastroduodenal artery for pyloroduodenal bleeding). Preliminary endoscopic localization shortens the arteriographic procedure since an arteriographic search for the bleeding vessel is avoided. If endoscopy proves unsuccessful, and either esophagogastric or duodenal source of bleeding is likely, Fig 7.--Algorithm showing approach to diagnosis and management of upper gastrointestinal bleeding. UPPER GASTROINTESTINAL BLEEDING

I

NO PSPIRATE

t

ENDOSCOPY~

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BLEEDING SITE LOCALIZED i

D~GNOSI~"~"~BLEED1NGSTOPPED

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BLEEDING SITE LOCALIZED

BARIUM STUDIES ?REPEAT ELECTIVE PANENDOSCOPY

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T

TRANSHEPATIC OCCLUSION OPERATION GASTRODUODENAL ULCER

TRANSCATHETER MANAGEMENT

$

/

ENBOLIZATION

SUCCESSFUL

OPERATION?

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SUCCESSFUL UNSUCCESSFUL OPERATION

UNSUCCESSFUL

OPERATION 313

a celiac arteriogram is obtained first. If the bleeding site is suspected to be in the distal duodenum or proximal jejunum, a superior mesenteric arteriogram is performed first. Figure 7 is an algorithm for diagnosis and therapy in upper gastrointestinal bleeding. ESOPHAGOGASTRIC JUNCTION BLEEDING (Figs 8 and 9) Nonvariceal bleeding from the esophagogastric junction is most often due to a Mallory-Weiss tear which may affect 7-14% of patients with upper gastrointestinal bleeding, s3, sa The majority of Mallory-Weiss tears occur in male patients, 40% are related to excessive alcohol consumption, and 20% to aspirin ingestion, s5 A history of retching and vomiting may be obtained in m a n y of these patients. In one series, 72% of the patients had a hiatal hernia while 83% had additional mucosal lesions including varices, esophagitis and gastritis, s5 Seventy-seven percent of the time, Mallory-Weiss tears are single and are located in the stomach. Other causes for gastroesophageal junction bleeding include ulcerations, hiatal hernia, esophagitis and trauma.3S, 63.85 In up to 88% of such patients, the bleeding can be controlled effectively by intra-arterial infusion of vasopressin. Fig 8.--Bleeding from Mallory-Weiss tear treated with intra-arterial vasopressin in a 40-year-old alcoholic with hematemesis. A, left gastric arteriogram shows accumulation of extravasated contrast medium in gastric folds (arrowheads). B, after intra-arterial infusion of vasopressin the bleeding stopped.

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Fig 9.--Bleeding Mallory-Weiss tear treated by transcatheter embolization. A, left gastric arteriogram shows contrast extravasation at the gastroesophageal junction (arrowhead)9 The bleeding site is supplied by esophageal and cardia branches arising from the proximal left hepatic artery. The left hepatic artery is a branch of the left gastric artery (curved arrow). B, postembolization arteriogram shows occlusion of branches to the gastroesophageal junction and of the left hepatic artery. Liver enzymes remained normal.

315

In patients in whom the bleeding does not stop after intra-arterial vasopressin therapy and in those patients who have recurrent bleeding after successful vasopressin therapy (15% of patients), the bleeding artery may be occluded by embolotherapy. Some reports indicate that embolization may be more effective than vasopressin infusion for the t r e a t m e n t of bleeding MalloryWeiss tears (See Table 3). 82' s6 GASTRIC BLEEDING (Figs 10 and 11) Acute hemorrhagic gastritis is the cause of massive bleeding in 17 to 27% of patients, s7-89 According to some authors, it m a y be the responsible lesion in up to 43% of hospital admissions for upper gastrointestinal bleeding. 9~ It m a y occur without determinabte precipitating events in 21% of c a s e s 9~ or m a y occur in the critically ill following operations, burns, or trauma. A history of ingestion of toxic agents m a y be obtained in 79% of patients: 9~ Such toxins include alcohol in 39%, salicylates in 24%, other medication in 16%. Since the introduction of Cimetidine and antacid prophylaxis in high risk patients, a reduction in the incidence of acute hemorrhagic gastritis has been reported. 91 Hemorrhagic gastritis can be successfull~ treated in up to 85% of patients by nonoperative management, o In one study evaluating 210 patients with acute hemorrhagic gastritis, 99 patients Fig 10.--Acute hemorrhagic gastritis. A, left gastric arteriogram shows diffuse mucosal hyperemia with superficial erosions (arrowheads). B, after intra-arterial infusion of vasopressin the bleeding stopped.

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Fig 11 .--Bleeding gastric ulcer successfully managed by vasopressin infusion into the left gastric artery. A, early arterial phase from a left gastric arteriogram shows no definite contrast extravasation. B, later frame shows extravasated contrast medium (arrow). C, arteriogram after 20 minutes infusion of vasopressin into the left gastric artery shows excellent vasoconstriction with cessation of the bleeding.

or 46.6% did not require blood transfusions during treatment. 9~ In only 33 patients, or 20.4%, did the transfusion requirement exceed 4 units. Of the 184 patients managed by conservative measures only 13 (7%) died. Surgical treatment, which usually requires subtotal gastrectomy, is successful in controlling the bleeding in the majority of patients b u t m a y be associated with a mortality rate as high as 55%. 92 Selective intra-arterial vasopressin administration, which is the angiographic t r e a t m e n t of choice, is successful in stopping the bleeding in up to 84% of patients. 9a Less severe forms of acute hemorrhagic gastritis m a y respond to intravenous vasopressin infusion. However, a prolonged trial of intravenous infusion is not recommended without prior arteriographic or endoscopic confirmation or without exclusion of another bleeding source. Embolotherapy is rarely indicated for acute hemorrhagic gastritis and is reserved for patients who do not respond to vasoconstrictor therapy and who are poor risks for operation. Approximately 10% of acute upper gastrointestinal bleeding results from gastric ulcers, as' 90 If massive, such bleeding is easily documented by arteriography. In patients with intermittent, nonmassive bleeding, however, angiographic identification and localizaton of the bleeding site m a y be challenging and is often unsuccessful. Gastric distention with air m a y be used to enhance definition of a bleeding source. In anterior wall lesions, however, this m a y obscure the bleeding site unless the bleeding is brisk. In such patients, extravasation of contrast medium between gastric folds is easier to recognize in a collapsed, nondistended stomach. 317

The definitive t r e a t m e n t for bleeding gastric ulcer is operation. In selected patients, transcatheter embolotherapy m a y be used as a temporary measure to prepare the patient adequately for operation. It must be recognized, however, that embolotherapy does not affect the underlying pathophysiology of gastric ulcer or its natural history. Selective intra-arterial vasopressin m a y control bleeding in up to 70% of patients with gastric ulcers.lO, 44 If the arterial branch feeding the bleeding site can be selectively catheterized, the angiographic t r e a t m e n t of choice is transcatheter embolization rather than drug infusion. PYLORODUODENAL BLEEDING (Figs 12-14) Peptic ulcer is the most common source of pyloroduodenal bleeding. In one series duodenal ulcer was responsible for acute upper gastrointestinal bleeding in 17.5% of patients, 9~ and m a y account for such bleeding in up to 25% of such individuals. Other causes include arteriovenous malformations, vascular neoplasms or visceral arterial aneurysms. 2~' 94 In the majority of patients, pyloroduodenal bleeding is clinically manifest as upper gastrointestinal bleeding with hematemesis or recovery of blood in the nasogastric tube aspirate. However, in about 10% of patients, pyloroduodenal bleeding m a y present only as lower gastrointestinal bleeding with melena, and in up to 20% of patients with duodenal ulcer bleeding the nasogastric aspirate m a y be negative. 24 Fig 12.--Embolotherapy for bleeding duodenal ulcer identified by endoscopy. A, late arterial phase of gastroduodenal arteriogram shows hyperemic ulcer base (arrowhead) without active bleeding. B, arteriograrn after selective embolization of gastroduodenal artery branches in region of ulcer (arrowheads). Bleeding recurred several hours later. {3, arteriogram after embolization of entire gastroduodenal artery with Gelfoam and coils (arrow). Bleeding was controlled. A

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Fig 13.--Duodenal bleeding due to metastatic renal cell carcinoma in 16-year-old patient. A, common hepatic arteriogram shows a hypervascular duodenal mass (arrows). Surgical clips are from a radical right nephrectomy. B, arteriogram after embolization with Gelfoam and coils. The bleeding was controlled effectively. Note dnsplacement of left ureter by retroperitoneal metastasis (arrow).

Definitive treatment for pyloroduodenal peptic ulcer is operative. The angiographic treatment of choice is transcatheter embolization, although bleeding originating from small arterial branches may respond to intra-arterial v a s o p r e s s i n S The success rate for intra-arterial vasopressin therapy is poor and has been reported to be as low as 31%, 95 Fig 14.--Duodenal arteriovenous malformation clinically manifest by melena..&, early arterial phase of common hepatic arteriogram shows a collection of abnormal vessels and hyperemia of the proximal duodenum (arrows). B, late arterial phase from the same arteriogram shows an early draining vein (arrow)9

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Arteriography may document active bleeding by identification of contrast medium extravasation. Even though active bleeding may not be documented by contrast extravasation, occasionally, the hyperemic base of the ulcer may be noted on arteriograms (Fig 12). Embolization of the gastroduodenal artery may be performed in either setting. However, endoscopic confirmation of a bleeding duodenal ulcer is necessary before proceeding with embolotherapy when only the hyperemic blush of the ulcer base is identified. Experience has proven that the entire gastroduodenal artery must be occluded for effective control of the bleeding. If smaller branches are occluded by subselective embolization, the incidence of recurrent bleeding is high. Fig 15.--Algorithm of approach to diagnosis and management of lower gastrointestinal bleeding.

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In patients with bright red rectal bleeding, the inferior mesenteric artery is catheterized first. If a bleeding source is not identified on the inferior mesenteric arteriogram, the superior mesenteric artery is catheterized. The entire colon should be evaluated, which may require studying the patient in several radiographic positions, particularly when evaluating the region of the splenic flexure, the sigmoid colon and the rectum. An algorithm for evaluation of a patient with lower GI bleeding appears in Figure 15. AORTOENTERIC FISTULA (Figs 16 and 17) Gastrointestinal bleeding from an aortoenteric fistula does not require selective arteriography for diagnosis, because the bleeding occurs from the aorta, not from intrinsic gut vessels. In fact, if only selective arteriography is performed, the lesion may be overlooked and valuable time may be lost. Biplane aortography is performed. The most common gastrointestinal site involved is the duodenum, which is affected in over 80% of cases. However, aortoenteric fistulae have been reported to involve all segments of the gastrointestinal tract including esophagus, stomach, jejunum, ileum, colon and appendix. 96-1~176 Fig 16.--Lower GI bleeding from aortoenteric fistula. Lower abdominal aortogram shows an aorto-iliac graft with a nipple-like outpouching (arrow) in the area of the fistulous tract.

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Active bleeding through a small fistulous tract into the duodenum from the proximal aortic graft anastomosis is identified occasionally. In a recent study evaluating 17 patients, actual bleeding from an aortoenteric fistula was not seen in any of the 7 patients who underwent aortography, l~ More often, an anterior nipple-like outpouching from the aortic anastomosis is observed, confirming the presence of a pseudoaneurysm. Indirect evidence of the fistula, by documenting a pseudoaneurysm between the aorta and the graft, m a y be the only objective finding, suggesting aortoenteric fistula as the cause of massive gastrointestinal bleeding. Occasionally, prone aortography may be successful in documenting this abnormality. SMALL INTESTINAL BLEEDING (Figs 18 and 19) The jejunum and ileum are the source of hemorrhage in approximately 5% of all acute gastrointestinal bleeders, but are the source in up to 30% of patients with acute, massive lower gastrointestinal bleeding. 102 ' 103 Usually, such bleeding is m a n l "fest as rectal bleeding. Causes include mucosal ulcers, tumors, diverticula, vascular malformations including aneurysms, anastomotic ulcers, the blind pouch syndrome, trauma, postoperative complications and inflammatory bowel disease (Table 9). 322

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Fig 18.--Superior mesenteric artery aneurysm causing hematemesis and melena A, 99mTechnetiumlabelled erythrocyte scan demonstrates a focal midline collection of activity which was interpreted as site of GI bleeding (arrow). Celiotomy performed at another hospital was unreveahng. B, superior mesenteric arteriogram after the patient was transferred to Johns Hopkins Hospital shows a large aneurysm of the inferior pancreatfcoduodenal artery.

Treatment is dictated by the etiology of the bleeding. For stress ulcer bleeding, intra-arterial infusion of vasopressin may be successful in controlling hemorrhage in about 75% of patients. Stress ulcer bleeding in uremic patients, however, may not respond to vasopressin therapy, l~ If the branch from which contrast extravasation is documented can be selectively catheterized," embolotherapy may prove successful,, especiallY~a in patients not responding to vasoconstrictlve therapy. The precise etiology of small bowel bleeding is often unclear, and operative intervention may be required after thorough radiologic evaluation. In such patients, arteriographic localization of the bleeding site, irrespective of etiology, can be invaluable in guiding surgical therapy. An example is the patient with an arterio-venous malformation. Subselective catheter placement preoperatively permits intraoperative injection of methylTABLE 9.--ETIOLOGY OF ACUTE SMALL INTESTINAL HEMORRHAGE9S, lol, 103, 106, lo8, 153

Tumor Diverticula Ulcers Vascular malformations Aortoenteric fistula Trauma

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Fig 19.--Intermittent bleeding from a jejunal arteriovenous malformation. A, early arterial phase from a superior mesenteric arteriogram shows an arteriovenous malformation (curved arrow) with early venous opacification (straight arrows). B, late arterial phase demonstrates two densely opacified jejunal veins (arrows). C, coaxial catheter placement for intraoperative methylene blue dye injection.

ene blue dye for localization of the bowel segment containing the arteriovenous malformation. 25' lo4, lo5 The dye does not stain the arteriovenous malformation itself b u t serves to identify the segment of bowel in which it resides. One to two hours before the operation, a subselective, coaxial catheter (3 French Teflon catheter) is placed through a standard 6.5 French cobra or sidewinder-shaped angiographic catheter in the mesenteric branch from which the arteriovenous malformation arises. The catheter is secured at the skin entry site by a suture and adhesive tape. Normal saline is infused at 15 ml/hr via a constant infusion pump to maintain catheter patency. After the bowel has been exposed, 1 ml of methylene blue dye diluted to 5 ml with normal saline, is injected through the coaxial catheter as the surgeon observes the bowel for staining, thus localizing the segment to be resected. Unless the exploration is done carefully, however, excessive 324

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Fig 20.--Bleeding left colonic diverticulum. A, superior mesenteric arteriogram shows contrast extravasation in the proximal descending colon (arrow). B, bleeding was successfully controlled by intra-arterial vasopressin.

manipulation of the bowel may lead to catheter dislodgement with subsequent failure to identify the bleeding source. 25 No complications have resulted either from the methylene blue dye or the catheter. A potential source of complications, though, is allergy to methylene blue dye. 325

COLORECTAL BLEEDING (Figs 20-22)

For colorectal bleeding, arteriography is helpful not only to identify the site of bleeding and determine the etiology, but to determine m a n a g e m e n t as well. The rectum, anal canal and perianal area should be examined carefully before proceeding to arteriography because rectal bleeding secondary to hemorrhoids, ulcers, and t r a u m a can be successfully treated directly. In fact, it is a major diagnostic and therapeutic error to proceed to arteriography without thorough examination of the rectum and anal canal. Massive colorectal bleeding is most frequently from diverticular disease of the colon which accounted for 70% of lower GI bleeding in one study. 1~ Less frequent causes of massive bleed-

Fig 21.--Right colonic bleeding from metastatic synovial cell sarcoma. A, superior mesenteric arteriogram shows a hypervascular metastasis (curved arrow) and contrast extravasation (arrowhead). B, later frame from the same arteriogram shows further contrast extravasation. C, after intra-arterial infusion of vasopressin the bleeding stopped.

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ing include carcinoma of the colon and colonic polyps. Rectal bleeding of lesser severity may be due to carcinoma of the left colon in up to 33% of patients and to diverticular disease or ulcerative colitis in 38% of patients. 1~ Other infrequent causes of massive colorectal bleeding include angiodysplasia, cecal or rectal ulcers, t r a u m a , carcinoid tumors, mesenteric panniculitis, visceral artery aneurysms and mesenteric varices. 107 - 110 Most colon tumors are not very vascular, but an occasional colonic tumor m a y mimic an arteriovenous malformation and m a y be the source of massive bleeding. Chronic, low grade, intermittent bleeding should be evaluated by colonoscopy and barium examination including both regular and air contrast studies. An air contrast barium enema, excellent for documenting lesions such as ulcerations and polyps, m a y overlook carcinoma. 111 Therefore, a regular b a r i u m enema should precede the air contrast study. If these examinations are unrewarding, arteriography may be indicated before diagnostic celiotomy because the source of bleeding m a y be difficult to identify at the time of operation, particularly if the bowel is full of blood. 41 If the patient has received vasopressin, a shift of the intraluminal contents from the site of the bleeding as a result of 327

vasopressin induced hyperperistalsis m a y further confound operative localization. Although diverticular disease involves the left colon more often than the right colon, clinical experience suggests that the bleeding diverticulum m a y be located in the ascending colon in up to 75% of patients. 112 If hemicolectomy is to be performed, preoperative arteriographic identification of the bleeding site is required. But is arteriography an adequate guide for hemicolectomy in patients with diverticular bleeding? In patients with known, diffuse colonic diverticular disease, it would be logical to assume that rebleeding could occur from any of the many diverticula. Under such circumstances, subtotal colectomy and ileoproctostomy m a y be the operation of choice and thereby obviate repeat arteriography. 41 In one series in which subtotal colectomy was not performed upon all patients, the perioperative morbidity was 58.8% and 35.3% of patients required two or more operations. 113 After angiographic identification, diverticular bleeding should be treated with intra-arterial vasopressin infusion. 114 Subsequent barium enema examination is important to determine if and what type of operation will be required. Intra-arterial infusion of vasopressin m a y control diverticular bleeding in up to 92% of patients. Recurrent bleeding following vasopressin therapy, however, has been observed in 23% of patients. ~1 In selected patients, and if selective catheter position in the bleeding vessel can be achieved, transcatheter embolization may be attempted. 115 ANGIODYSPLASIA (Figs 23 and 24) Chronic intermittent nonmassive bleeding and occasionally massive colonic bleeding m a y be due to angiodysplasia of the cecum or ascending colon. This disease most commonly occurs among patients 55 years of age or older. 116 If other sources of bleeding such as ulcers, diverticula, colitis or neoplasm have been excluded, a search for an angiodysplasia is warranted. According to some authors, angiodysplasia m a y be responsible for colonic bleeding in up to 50% of patients in the older age group.11o, 117 On the other hand, angiodysplasia may be an incidental finding in up to 15% of patients without a history of gastrointestinal bleeding. 11s The incidence of this lesion identified at autopsy has been reported to be 2%. 119 The typical arteriographic features of angiodysplasia are: (1) early venous opacification of the ileocolic vein; (2) persistent and dense opacification of the vein; and (3) one or more vascular tufts located towards the antimesenteric border of the cecum or ascending colon. Early venous opacification m a y also be observed in inflam328

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matory bowel disease, after selective intra-arterial injection of vasodilators, or following contrast injection if the catheter is wedging the artery injected, and occasionally in some carcinomas. Colonic wall hyperemia may also be observed after prolonged contact with intraluminal blood. Because of the high incidence of associated lesions (22%), deFig 2 4 . - - C e c a l carcinoma mimicking an arteriovenous malformation 9 A, superior mesenteric arteriogram shows a hypervascular lesion (curved arrow) with an early draining vein (arrowhead). B, magnification arteriogram shows multiple hypertrophied and tortuous vessels. C, operative specimen of cecal carcinoma.

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tection of an angiodysplasia during arteriography is an indication for thorough evaluation of the patient during remission from the bleeding episode. 117 Such evaluation must include barium studies and complete colonoscopy. Occasionally, bleeding from angiodysplasia can be massive. If massive bleeding is noted at the time of arteriography, embolotherapy or a trial infusion of vasopressin m a y be used for temporary control prior to operative intervention. 12~ 121 Preferred treatments for nonmassively bleeding angiodysplasia are electrocoagulation through the colonoscope, provided no other colonic lesions exist, or hemicolectomy. POSTOPERATIVE

BLEEDING

(Figs 25 a n d 26)

Postoperative bleeding, although uncommon, m a y occur despite a skillfully performed operative procedure. Bleeding m a y occur within several hours or several days following operation and m a y be due to either a slipped ligature, infection, or incomplete ligation or cauterization of vessels. In addition, bleeding may be from mucosal abrasions, or indwelling tubes or drains.25, 6~ Postoperative bleeding m a y also occur remote from the operative site and m a y be due to stress ulceration. Fig 25.--Postoperative bleeding after vagotomy. A, left gastric arteriogram demonstrates a left gastric/left hepatic arterial trunk. Contrast extravasation is seen from gastric branches of the left hepatic artery (arrow). B, embolization of the left gastric artery controlled the bleeding. The left hepatic artery has not been embolized (ar-

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Bleeding m a y also originate from the operative site several months or years later. 122 This is often due to development of mesenteric varices as a result of venous ligation or intra-abdominal vascular adhesions. Thus, in patients with a history of an abdominal operation, if an arterial source of bleeding is not found during arteriography, a search for focal mesenteric varices adjacent to the operative area should be made. However, these m a y be quite difficult to demonstrate by arteriography. In the diagnosis and m a n a g e m e n t of postoperative bleeding, arteriography has made a significant contribution. 63' 123 Such bleeding was controlled by transcatheter methods in 82% of patients reported in o n e study. 123

BLEEDING IN PATIENTS WITH PORTAL HYPERTENSION (Fig 27) Esophagogastric varices are the cause of massive bleeding in up to 17.5% of patients with upper gastrointestinal bleed331

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ing.9O, 124 However, despite endoscopic identification of varices, gastrointestinal bleeding may be from other sources in up to 60% of patients, usually from peptic ulcer disease or gastritis. 125 Repeat endoscopy is essential before starting intravenous vasopressin infusion even in patients with previously documented bleeding esophageal varices, particularly if several months have elapsed between bleeding episodes. Emergency arteriography is rarely required unless it serves to define portal venous anatomy for an emergency portosystemic shunt. Occasionally, arteriography may also be used to search for an arterial or capillary bleeding source such as gastritis or peptic ulcer when endoscopy has excluded variceal bleeding. Bleeding from esophagogastric varices is rarely demonstrable by arteriography. Nonoperative methods for control of bleeding from esophagogastric varices include: (1) transendoscopic sclerotherapy, (2) balloon tamponade, (3) intravenous vasopressin infusion and (4) percutaneous transhepatic embolic occlusion. Success of vasopressin therapy and the prognosis thereafter vary with the extent of the liver disease. In one study from this institution, among 39 patients intra-arterial vasopressin was successful in stopping the bleeding in 100% of patients in Child's class A, 62% in class B and only 33% in class C. 126 Patient survival was 100% in class A, 67% in class B and zero percent in class C. In another randomized prospective study, the bleeding was controlled in 56% of patients (-- 85% Child's class C), and the 30-day survival was 64%. 11 The 30-day survival increased to 79% in patients without coagulopathy. The initial treatment of choice for endoscopically confirmed 332

bleeding varices is intravenous infusion of vasopressin. Several studies document no significant differences in the effectiveness of control of variceal bleeding between intra-arterial and intravenous infusion. 11' 127 Because vasopressin infusion into the superior mesenteric artery decreases blood flow abruptly and about 15% to 20% more effectively than intravenous infusion, selective superior mesenteric arterial infusion m a y be attempted in selected patients in whom intravenous therapy has been unsuccessful. If vasopressin infusion proves unsuccessful in controlling variceal bleeding, transhepatic embolic occlusion of esophagogastric varices m a y be performed as a temporary maneuver to prepare the patient for elective operation. 12s In general, the results of transhepatic coronary vein embolization for bleeding esophageal varices are not encouraging for patients in Child's class C. 12~131 Although some authors have reported control of variceal bleeding in up to 94% of patients, l~s' 132, 133 the rate of recurrent bleeding is high (up to 44%) and this procedure finds few supporters. 32 Alternatively, in selected patients, transhepatic embolothera~( may be performed electively to prevent recurrent bleeding.l~ Complications of percutaneous transhepatic coronary vein occlusion include significant bleeding from the catheter tract in 3 7% patients, and inadvertent embolization into other circulations through existing or surgically created communications.12s, 133, r34 Portal vein thrombosis has been reported in 8 36% of patients undergoing emergency percutaneous transhepatic coronary vein occlusion. 12s' l~Z BLEEDING FROM LIVER AND PANCREAS

Bleeding from the liver and pancreas into a major duct of either organ m a y manifest itself as gastrointestinal bleeding. In addition, bleeding from liver or pancreas m a y be intra- or retroperitoneal. HEPATOBILIARY (Fig 28) Common causes of bleeding from the liver manifesting as hematobilia are blunt or penetrating abdominal trauma, including percutaneous needle biopsy and biliary drainage procedures, and rupture of intrahepatic arterial aneurysms. Intrahepatic hematomas have been reported in 7% of patients undergoing percutaneous liver biopsy. 135 In one series, severe hemorrhage was noted among 6.4% of patients undergoing percutaneous biliary drainage. 13~ In our experience, four intrahepatic arterial aneurysms have been identified in over 140 patients undergoing percutaneous biliary drainage catheter placement. 333

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Fig 28.--Bleeding from a cholecystostomy tube. A, arteriogram of the accessory right hepatic artery (arising off the superior mesenteric artery) shows a small aneurysm of a branch of the pancreaticoduodenal artery. B, arteriogram after selective embolization with Gelfoam and placement of a mini coil in the gastroduodenal artery. The bleeding was stopped. The coil (arrow) does not occlude the artery, indicating that a co~l alone would have been inadequate. C, cholecystogram performed a few days later showed no blood in the gallbladder. Tumor mass or adherent blood clot is seen in the common bile duct adjacent to the earlier bleeding site.

In patients with continuous intrahepatic bleeding, operative management consists of either hepatic artery ligation or blind hepatic resection because operative identification of such a bleeding site is challenging and often impossible. In addition, main hepatic artery ligation, because it may be far proximal to the bleeding site and therefore imprecise, may be followed by recurrent bleeding in a significant number of individuals. 137 Collateral arterial supply to the liver appears to be essential for prevention of hepatic necrosis following arterial ligation. Since such collateral blood supply is established over a relatively short period of time, hepatic artery ligation may be well tolerated by the patient. 13s' 139 The role of arteriography in hepatic bleeding is both for localization and for treatment. Intrahepatic lesions and those located posteriorly may be very difficult to detect at celiotomy. Preoperative arteriography not only serves as a guide for localization of the bleeding source but also for identification of variants in hepatic blood supply, which may be of importance to the surgeon. Intra-arterial vasopressin infusion is not only ineffective in controlling hepatic bleeding but, due to mesenteric vasoconstriction, a reflex increase in hepatic arterial flow occurs. The angiographic treatment of choice for intrahepatic bleeding is transcatheter embolization of large particulate material such as Gelfoam sponge, Ivalon strips, or detachable balloons. 14~ Small particulate material such as Gelfoam powder or Ivalon spheres penetrates to the capillary level, obstructs collateral flow and 334

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335

may result in tissue necrosis. Such agents should, therefore, be used only when treating lesions that have diffuse parenchymal involvement such as hepatomas or hemangiomas in which necrosis is desired. In treating hepatic arterial aneurysms or hepatic arteriovenous or arterioportal fistulae, large particulate embolic material is required. Lesions that have been treated successfully by transcatheter embolic occlusion include hemangiomas, hemangioendotheliomas, hepatic arterial aneurysms-both traumatic and mycotic, arterioportal fistulae and traumatic arteriobiliary fistulae. 14~ PANCREAS (Fig 29) Aneurysms of the pancreatic vessels may occur in up to 10% of patients with chronic pancreatitis. 14~ As many as 50% of these may rupture and give rise to intraluminal or extraluminal bleeding. Visceral arterial erosion as a sequela of pancreatitis may also occur and result in significant intraperitoneal or retroperitoneal hemorrhage. 146 Additional sources of bleeding in patients with pancreatitis are gastric varices that result from splenic vein thrombosis. 147 In these patients, arteriography not only helps establish a diagnosis but may also be used for emergency or elective management. 14s Bleeding from large visceral arteries such as the splenic requires operative intervention. Bleeding from small arteries such as the pancreatic and gastroduodenal may be managed successfully by transcatheter embolization. Pancreatic pseudocysts or abscesses which are often associated with pancreatitis may necessitate subsequent operative or percutaneous drainage procedure. CONCLUSION

Angiography remains an important primary method for the diagnosis and management of gastrointestinal bleeding. Approximately 20-25% of all patients with gastrointestinal bleeding are candidates for angiography. Although it is an invasive procedure, complications related to diagnostic or therapeutic angiography are infrequent. Safe and appropriate utilization of this procedure requires a good understanding of the indications and limitations of arteriography. Thus, correct decisions regarding timing of angiography are necessary to facilitate early diagnostic evaluation and prompt initiation of appropriate therapy. With appropriate indications and patient selection, a diagnostic accuracy close to 90% can be achieved by arteriography for all gastrointestinal bleeding problems. In addition, the greatest 336

a d v a n t a g e o f a r t e r i o g r a p h y l i e s i n t h e c a p a c i t y i t o f f e r s for t r e a t ing gastrointestinal bleeding immediately after establishing the site of bleeding even though angiotherapy may not be definitive and elective operation may ultimately be required, but under more favorable circumstances. In some patients with gastrointestinal bleeding, transcatheter therapy may be the only treatment required.

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SELF-ASSESSMENT ANSWERS 1. 2. 3. 4. 5. 6.

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343