IMAGING AND INTERVENTION IN HEMATEMESIS

Presented by: Moderator:

Dr. Sindu P. Gowdar Dr. Jeevika M.U.

GASTRO INTESTINAL BLEEDING

• Gastro intestinal bleeding is potentially serious problem which poses both clinical and technical diagnostic challenge.

• Broadly classified as acute and chronic.

• Acute Gl bleeding is responsible for 10-20%of mortality in patients with massive GI hemorrhage.

• Although more than 75% of cases of bleeding cease with supportive measures, a significant percentage of patients require further intervention, which often involves the combined efforts of gastroenterologists, surgeons, and interventional radiologist.

PRESENTATION

The upper and lower Gl tracts are divided by the ligament of Trietz

UGIB

• Bleeding above the ligament of treitz.

• More common

• Hemetemesis, melena,

• Hemobilia

LGIB

• Bleeding below the ligament of treitz.

• Less common

• Hematochezia

• Symptoms are not characteristic.

DEFINITIONS

• HEMATEMESIS: VOMITING OF BLOOD OR COFFEE GROUND MATERIAL DUE TO UPPER Gl BLEEDING, I.E. BLEEDING ABOVE LIGAMENT OF TREITZ

• Malaena: is passage of dark, black, shining stools . The black color is due to degradation of blood. About 60 ml of blood is needed to produce malena.

• Hematochezia: is the passage of bright red blood as such or mixed with stools.

• Obscure GIB: recurrent acute/chronic bleeding for which no cause has been identified with negative results in routine endoscopy or CM studies.

• OCCULT BLEEDING- bleeding that is unseen or hidden. It presents as iron deficiency anaemia or shows positive for fecal occult blood.

DIFFERENCES

HEMOPTYSIS HAEMETEMESIS

Color Bright red Dark red or coffee color

Froth present Absent

Reaction alkaline Acidic

Associated with cough Nausea/ vomiting

CAUSES OF HEMATEMESIS

ESOPHAGO GASTRIC JUNCTION

1. Esophageal varices

2. Mallory Weiss tear

3. Hiatus hernia

4. Erosive esophagitis

5. Aorto-esophageal fistula

6. Esophageal CA

7. Leiomyosarcoma

STOMACH-DUODENUM

1. Peptic ulcer

2. Gastric CA

3. Hemorrhagic gastritis

4. ZES

5. gastric leiomyoma

OTHERS

1. visceral artery aneurysms

2. Artero-venous malformations

3. pancreatitis

4. Hemobilia

5. Mesenteric venous thrombosis.

6. Pseudoxanthoma elasticum

7. Dieulalafoy"s lesion

8. Osier weber rendu disease

CAUSES OF INTRAMURAL HEMORRHAGE

• Vasculitis - HSP

• Trauma

• Coagulation defects

• Diseases with coagulation defects

• ischemia

GIB IN INFANTS

• Peptic ulcer

• Varices

• Ulcerated meckel’siverticulum

GIB IN CHILDREN

• Meckel’ diverticulum

• Juvenile polkyp

• IBDs

INCIDENCE

• The most common causes of upper Gl bleeding are erosive gastritis (20% of cases) and duodenal ulcers (30% of cases).

• 30% of cases of upper Gl bleed may originate in the esophagus.

• Tumours account for only 3% of the cases.

• In about 10% of the cases, no diagnosis can be made.

ARTERIAL ANATOMY

The organs of the GIT receive arterial blood supply from three arteries:

• Coeliac trunk for foregut

• Superior mesenteric artery for midgut

• Inferior mesenteric artery for hindgut

ARTERIAL ANATOMY

The celiac axis

• Celiac artery is the artery of the foregut- it supplies the GIT from the lower 1/3rd of the esophagus to the middle of the second part of the duodenum, (upper 2/3rd of esophagus is supplied by small direct branches arising thoracic aorta and inferior thyroid artery).

• It arises from the anterior wall of the abdominal aorta at the level of T12 - LI.

• Surrounded by celiac plexus and lies behind the lesser sac of the peritoneum.

• Has three terminal branches - left gastric, splenic and hepatic arteries.

BRANCHES OF COELIAC TRUNK

CT angiogram showing normal coeliac trunk and its branches

VARIANT ANATOMY-COMMON VARIANTS

• A replaced hepatic artery arising from mesenteric artery

• A replaced / accessory left hepatic artery arising from the left gastric artery

• The gastro duodenal artery arising from the left or right hepatic artery

VENOUS ANATOMY

• Venous blood from the greater part of the GIT and its accessory organs drains to the liver by the portal venous system.

• The proximal tributaries drain directly into the portal vein.

• Veins forming the distal tributaries correspond to the branches of the celiac, superior and inferior mesenteric arteries.

PORTAL VEIN

• Drains blood from the lower l/3rd of the esophagus to halfway down the anal canal; also from the spleen, pancreas and the gall bladder.

• Portal vein - liver sinusoids - hepatic veins - IVC.

• PV is 2 inches ( 5 cm ) long, formed behind the neck of pancreas by the splenic vein and the superior mesenteric vein.

• It ascends to the right behind the first part of duodenum and enters the lesser omentum.

• Turns upwards in front of the opening of the lesser sac to the porta hepatis where it divides into right and left terminal branches.

TRIBUTARIES:

• Splenic vein - lies below splenic artery, receives short gastric, left gastroepiploic, inferior mesenteric and pancreatic veins.

• IMV - joins splenic vein behind the body of the pancreas.

• SMV - lies on the right side of the SMA; receives jejunal, ileal, ileocolic, right colic, middle colic, inferior pancreaticoduodenal and right gastroepiploic veins.

• Left gastric vein - opens directly into the portal vein.

• Right gastric vein - opens directly into PV.

• Cystic veins - either drain gall bladder directly into the liver or join the portal vein.

PORTOSYSTEMIC ANASTOMOSIS

• Lower l/3rd of the esophagus - esophageal branches of the LGV anastomose with esophageal veins draining middle l/3rd of esophagus into the azygous veins (systemic tributaries).

• Halfway down the anal canal, superior rectal veins anastomose with middle and inferior rectal veins, tributaries of internal iliac and internal pudendal veins.

• Paraumbilical veins - connect the left branch of the PV with superficial veins of the anterior abdominal wall. Paraumbilical veins travel in the falciform ligament and accompany the ligamentum teres.

• Veins of the ascending colon, descending colon, duodenum, pancreas and liver (PV tributaries) anastomose with renal, lumbar and phrenic veins (systemic tributaries).

IMAGING MODALITIES

• Barium studies

• Endoscopy

• CT angiography

- Arteriography (hepatic and pancreatic arteriography)DSA

DIAGNOSTIC

THERAPEUTIC

• Venography

• Radio nucleotide studies

• Endosonography

INTRODUCTION

• Endoscopy plays the primary role in the initial investigation of GI bleeding. However, there remains a large group of patients with negative or failed endoscopy, in whom additional techniques are required to identify the source of bleeding.

• In the past, catheter angiography and radionuclide red cell labeling techniques were the preferred 'next step1 modalities used to aid in identifying a bleeding source within the gastrointestinal tract. However, these techniques are time-consuming and of limited sensitivity and specificity. In addition, catheter angiography is a relatively invasive procedure.

• In recent years, computerized tomography (CT) has undergone major technological advances in its speed, resolution, multiplanar techniques and angiographic abilities. In many centers CT has therefore become the 'next step' technique in identifying a bleeding source within the GIT following negative or failed endoscopy in the acute setting.

BARIUM STUDIES• It can be used to diagnose the conditions causing bleeding & their extent of

involvement, rather than the proper site of bleeding.

DISADVANTAGES

• It is difficult to perform in acutely ill patients.

• It cannot evaluate the mucosal details in the presence of blood.

• It may render further investigations like- angiography impracticable.

• hence reseved for chronic or intermittent bleeding due to ulcers, tumor polyps or diverticulum

ADVANTAGES

• Barium studies help in detecting structural lesions such as carcinoma, polyps and diverticuli. Maybe helpful in cases of chronic or intermittent bleeding by revealing ulcers etc.

INDICATIONS

• Ulcers - gastric (stomach) or peptic (duodenum)

• Gastroesophageal reflux disease (GERD)

• inflammation (esophagitis, gastritis, or duodenitis) or infection

• Benign tumors (nonmalignant)

• Cancer

• Structural problems, such as diverticula, strictures, or polyps (growths)

• Hiatal Hernia - upward movement of the stomach, either into or alongside the esophagus

• Dysphagia (difficulty swallowing)

• Motility disorders (difficulty moving foods through the pharynx or esophagus)

CONTRAINDICATIONS

• Bowel or esophagus perforation

• Bowel obstruction or severe constipation

• Pregnancy

• Severe swallowing difficulty such that aspiration (entry of substances into the lungs) of barium is likely

BARIUM STUDIES

• BARIUM STUDY-

Characteristic serpeginous filling defects esp.. On prone films.

Uphill varices

• Uphill esophageal varices in a patient who had cirrhosis secondary to alcohol abuse

Downhill esophageal varices on barium swallow examination.

ENDOSCOPY

• Primary investigation of choice is flexible upper GI endoscopy.

• It can influence the mortality by predicting the risk of rebreeding and by allowing the timely

• Implementation of endoscopic therapy to prevent it.

• It is best when done within 12hrs of bleeding

SIGNS OF ACTIVE BLEEDING

• Active arterial bleeding

• Adherent clot

• presence of visible vessel

INDICATIONS

• Esophageal varices - injection sclerotherapy treatment of choice.

• Commonly used sclerosing agents are ethanolamine oleate, 3% sodium tetradecylsulphate, polidocanol and dehydrated alcohol.

• Gastric varices

• Bleeding peptic ulcers ( gastric and duodenal)- involves Identification of the bleeding ulcer Assessment of the rebleeding risk (visible vessels, active arterial bleeding at the time of endoscopy ) Endoscopic hemostasis for ulcers with a high risk of rebleed (thermal methods - lasers, heater probes and diathermy and injection methods - simple tamponade and administration of vasoconstrictors and sclerosants.)

MASSIVE UPPER GASTROINTESTINAL BLEEDING.

VIDEOCAPSULE

• Videocapsule has traditionally been used to detect occult and obscure GI bleeding, but it is not accepted as an early diagnostic tool for acute life-threatening GI hemorrhage.

• Videocapsule is inappropriate in the acute setting, particularly in the emergency department at night.

• However, its use during or as close as possible to the active bleeding event may show a bleeding source in as many as 92% of patients after negative results from a standard endoscopic evaluation

ADVANTAGES OVER ARTERIOGRAPHY:

• Widely available, easy to arrange, relatively non invasive, allows biopsies to be obtained, provides a definite diagnosis, can be used to coagulate appropriate lesions and often identifies the cause for bleeding although the bleeding has temporarily stopped.

• Arteriography should not normally be undertaken without a previous endoscopy having been performed and is used only when endoscopy is unsuccessful in locating the source of bleeding or when therapeutic embolisation is indicated.

HOWEVER, ARTERIOGRAPHY CAN

• Precisely localise a bleeding site in regions inaccessible or relatively inaccessible to endoscopy eg.liver, pancreas, jejunum, ileum..

• In a case of active bleeding, good arteriography is almost certain to localise the site, irrespective of its anatomical location.

• Transcatheter embolisation can be applied to a much wider range of lesions than endoscopic coagulation.

• Endoscopy should be performed as soon as possible after initial assessment and stabilisation of the patient; preferably within 12 hours of admission.

CATHETER ANGIOGRAPHY

• Visceral arteriography has traditionally been used to diagnose active bleeding.

• Catheter angiography has the advantage of delivering a high iodine concentration with selective injection into a bleeding artery.

• However, contrast resolution is poor and movement or peristalsis makes interpretation difficult.

• What is more, the technique is time-consuming and invasive, and it requires more specialized expertise than does standard arteriography.

• The cause of the bleeding is often not determined, and variant vascular anatomy may lead to false-negative findings.

• GI bleeding can also have venous sources such as gastric or esophageal varices in the setting of portal hypertension.

The principle indications for arteriography of the GI tract are

• Diagnosis and/or treatment of Gl bleeding.

• Localization, pre operative assessment and/or treatment of Gl tumours (including hepatic and pancreatic lesions.)

• Investigation of suspected mesenteric ischaemia.

• Diagnosis of classical polyarteritis nodosa.

• Evaluation of the anatomy and flow dynamics of the portal system in portal hypertension.

ANGIOGRAPHY PROCEDURE

• Engage a catheter to the vessel of interest by searching the anterior aortic wall at the expected site of origin ie. T12 , L1 – L2 , L3 – L4 levels

• Visceral hook , sidewinder and cobra shape catheter are used for the coeliac and SMA arteriogram

• Reverse curve catheter used for inferior mesentric arteriography

• Straight (eg. Cobra) or long reverse curve catheter is used for selective injection of the SMA branches

• Coaxial microcatheters are used for superselective catheterisaton for intervention purposes

BASIC STRAIGHT ANGIOGRAPHIC CATHETERS

REVERSE CURVE ANGIOGRAPHY CATHETERS

HIGH FLOW CATHETERS

APPEARANCE OF BLEEDING ON ANGIOGRAPHY

• During arterial phase of selective angiogram –localized pooling of contrast material

• Later becomes increasingly obvious and persists after all the IV contrast is washed out

• Very brisk bleed shows opacification of the mucosa of GIT.

• Small amount of extravasation seen as localized flecks

• Lumen of GIT filled with blood clots , extravasated contrast appears tubular –venous structure – pseudo vein appearance

PSEUDO VEIN APPEARANCE

Selective left gastric arteriography ,

THE PSEUDOVEIN APPEARANCE

FUNDAL GASTRITIS

BLEEDING DUODENAL ULCER CONFUSED

WITH TRANSVERSE COLON BLEED

MULTIDETECTOR CT

• Multidetector CT is readily available in the emergency departments of most hospitals.

• CT angiography is a rapid and easy-to-perform diagnostic method for fast and accurate detection and localization of acute GI bleeding.

• High-speed narrow-collimation multidetector CT allows large volume coverage, produces images with decreased motion and respiratory artifacts, and can be accurately timed to acquire data during the arterial or venous phase.

• Multidetector CT allows arterial phase scanning of the whole abdomen, and contrast material extravasation can be revealed in the small bowel, which is an anatomic region not readily amenable to conventional endoscopy.

• However, contrast-enhanced multidetector CT has limited utility in cases of intermittent hemorrhageand involves intravenous contrast material and a relatively high radiation dose.

• The sensitivity of CT for diagnosing the source of GI bleeding has been shown to be higher in patients with active hemorrhage (91%–92%) than in those with obscure GI bleeding (45%–47%)

CT ANGIOGRAPHY

• Recent advances in CT technology allowing thinner collimation, faster scanning times, greater anatomic coverage, and better multiplanar reformatted(MPR) images have greatly expanded the diagnostic role of CT angiography for various pathologic processes.

• The CT angiographic diagnosis of active gastrointestinal bleeding is made when hyperattenuating extravasated contrast material is seen within the bowel lumen .

• The extravasated contrast material may demonstrate linear, jetlike, swirled, ellipsoid, or pooled configurations or may fill the entire bowel lumen, resulting in a hyperattenuating loop.

• In many cases, acute GI bleeding occurs intermittently or ceases spontaneously, presenting a major diagnostic and treatment dilemma.

• Even massive acute GI bleeding can be intermittent from minute to minute, and failure to demonstrate active bleeding may therefore not prove cessation of bleeding in all cases.

• Delayed follow-up examinations may then localize the bleeding.

• Therefore, to maximize detection capabilities, it is crucial that CT angiography should begin as soon as possible while the patient is actively bleeding.

• Multidetector CT angiography should be performed without prior oral administration of water or contrast material. Active contrast material extravasation within the bowel lumen is obscured by oral contrast material, leading to false-negative results.

• Intraluminal water may be helpful in finding the cause of acute GI bleeding, but it might also lead to dilution of extravasated contrast agent, leading to false-negative results.

CT PROTOCOL

• Images are acquired with the following parameters: • section thickness, 5 mm for the unenhanced phase and 1.25 mm for the arterial and portal-

venous phases; • 120 kVp; • rotation time, 0.7 seconds; • auto milliamperage.

• Images acquired with a 5-mm section thickness are reconstructed for the portal phase.

• Administer a dose of 1.5 mL/kg body weight of high-iodine-concentration contrast medium (350 mg/mL) at a rate of 4 mL/sec, with an upper limit of 150 mL.

• Venous access is in an antecubital vein with an 18-gauge needle.

• The scan delay time for arterial phase images is obtained by using bolus tracking with a circular region of interest positioned in the abdominal aorta and a predefined 90-HU bolus-trigger threshold to the start of scanning.

• The coverage from the diaphragm to the ischial tuberosities includes the rectum in all cases.

Patient Category

Those who:

Fail to respond medical and endoscopic management

Are unstable and massively hemorrhaging patients

Have transfusion requirement of > 500ml /8hrs

Main aim is

• To locate the site and transcatheter control of bleeding , to either obviate surgery or stabilize patient preoperatively

• TIME- patient should be actively bleeding at the time of angiography critical rate of bleeding 0.5 ml/min.

• Pretherepeutic considerations –

Previous IV vasopressin

Previous surgery

Previous endoscopic inj. of sclerosants or vasoconstrictors

DETECTION AND PITFALLS IN LOCALIZATION OF BLEEDING

• The diagnosis of acute GI bleeding is made when extravasated contrast material with a focal area of high attenuation (>90 HU) is seen within the bowel lumen during the arterial phase and increases during the portal-venous phase.

• The extravasation of contrast material may demonstrate a linear, jetlike, swirled, ellipsoid, or pooled configuration, or may fill the entire bowel lumen, resulting in a hyperattenuating loop.

• Suture material, clips, foreign bodies, orally administered pharmaceuticals, and coprolith in the diverticulum may be mistaken for acute GI bleeding.

• To avoid these pitfalls, an unenhanced scan must be performed before intravenous contrast material injection. False-positive multidetector CT results due to cone beam artifacts with hyperattenuating areas at the interface between normal bowel fluid content and air can also be obtained.

Copyright ©Radiological Society of North America, 2006

61-year-old man with melena for 5 days

Active duodenal bleeding in a 75-year-old woman with a duodenal ulcer

Acute duodenal bleeding after endoscopic sphincterotomy of the ampulla of Vater.

Duodenal hematoma due to increased output in voluminous duodenopancreaticarcades in a 73-year-old man with severe celiac trunk compression by the arcuate ligament of the diaphragm.

MERITS

• it can detect bleeding rate as low as 0.5ml/min.

• It has better spatiaJ resolution and localization.

• It can be used in active bleeding.

• Therapeutic measures can be combined with diagnostic approach.

DEMERITS

• Preliminary endoscopy for upper Gl & Scintigraphy for lower Gl should be performed before the investigation.

• Cannot be used in intermittent and low bleeding states.• Invasive• Can lead to allergic reactions and nephrotoxicity. • Radiation dose is high.

TYPES OF ANGIO

• When bleeding is from a larger artery such as in peptic ulcer/ diverticular disease-selective angiogram is done.

• Bleeding from minor source or multiple capillary sites(erosive gastritis/stress ulcers) - super selective angiogram is done.

Acute GIB is frequently intermittent-

• Proper timing is crucial for successful localization of hemorrhagic site & subsequent therapy.

Selective celiac artery angiography shows the celiac artery aneurysm.

DIGITAL SUBTRACTION ANGIOGRAPHY (DSA)

• Modern DSA systems are based on digital fluoroscopy/fluorography systems, which are equipped with special software and display facilities.

• Digital subtraction angiography (DSA) was developed to improve vessel contrast.

• This is a technique that uses a computer to subtract two images, obtained before and after contrast media is injected into the vessels of interest.

• The anatomical structures that are the same in the two images can be removed and the resulting image shows the vessels only.

• The image before the contrast agent is administered is called the mask image.

• Once the contrast is administered, a sequence of images are taken by a television camera in analog form, which is then digitalised by computer.

• The DSA processor has two separate image memories, one for the mask and the other for the images with contrast medium.

• These two image memories are subtracted from one another arithmetically, and the result goes to an image processing and display unit.

DIGITAL SUBTRACTION ANGIOGRAPHY (DSA)

TYPES-

• DIAGNOSTIC

• THERAPEUTIC

• Trans catheter treatment for GI bleeding

vasoconstrictive infusion therapy

therapeutic embolisation.

• Intraarterial digital subtraction angiography is an essential component of a properly equipped GI vascular unit.

DIAGNOSTIC

Advantages of DSA:

• Significantly smaller volumes of contrast medium used.

• Displays subtle differences in density of CM such as maybe found in tumoursor sites of GI bleeding.

• Speedy, allows review and image manipulation in therapeutic interventional procedures.

DISADVANTAGES OF DSA

1. Mis-registration .

2. Poor resolution compared to conventional angiography.

3. User dependent success rate.

4. Risk of emboli may reaching to healthy tissue.

5. Not suitable for everyone.

6. Interpretation of some gastrointestinal DSA studies will become extremely difficult even if there is slightest degree of motion artifact.

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PROCEDURE

• Gaining arterial access.

• Selective arterial catheterization.

• Image acquisition.

• Closure of arterial access.

• Post processing

• Hard copy

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During angiography, patients may be sedated to reduce anxiety.

Their heart rate and rhythm, breathing, and oxygen saturation are monitored throughout the procedure.

Patient clean & draped .

A local anesthetic is usually used in the area where the catheter is to be inserted, most commonly the femoral artery.

First, a small incision given, medicut is inserted into the artery. fluoroscopy is used to guide the needle to the proper position .

The needle is then removed after placing guide wire in the artery and vascular sheath is inserted over the guide wire . The catheter is then inserted along the guide wire through the sheath.

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When the catheter is in the correct position, the wire is pulled out and dye is injected through the catheter.

Images are acquired during contrast injection. Injections can be made directly into the artery of interest (selective arteriography)

Complications from an arteriogram are very rare, but there is some risk. Most problems that occur can be detected at the time of the procedure or immediately after the procedure. The artery may be injured at the puncture site or along the artery where the catheter is passed.

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SELDINGER TECHNIQUE ( STEP-BY-STEP)

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COMPLICATIONS

• 0.16% major complication rate.

• Local complications: hematoma, vessel laceration, dissection, pseudoaneurysm, AV fistula.

• Systemic complications: contrast reactions, fever, sepsis, dehydration, death.

• CNS complication: aggravation of preexisting complaints, neurological deficit.

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POSTPROCEDURAL CARE

• After the catheter is removed compression is applied to the puncture site.• The patient is asked for bed rest for a minimum of 4 hours• During rest patient is monitored and vital sign like peripheral pulse like distal

to Puncture are regularly checked.• The extremity is also checked for warmth, color, numbness to ensure

circulation has not been disrupted.• Oral fluid is given and analgesics are given if required.

TO REDUCE MOTION ARTIFACTS

Bowel movements are abolished by-

• 40 mg of hyoscine butyl bromide ( buscopan ) increased by 20 mg increments when required during the study - injected directly into the visceral arteries via the angiographic catheter.

• Glucagon in 1 mg aliquots may be necessary.

Respiratory movements is abolished by

• Asking the patient to hold breath.

• Using 'mask technique' - several images are taken(usually at one frame /s ) before the injection of CM to obtain frames at different stages of the respiratory cycle,which can be used as appropriate masks for the subsequent images obtained after CM injection.

RADIATION PROTECTION

• Radiation protection devices used

• Leaded glasses pulled into place

• Minimal fluoro use

• Collimation

• Wear badges and ring monitors

SELECTIVE ANGIO:

• It is usually desirable to perform selective arteriography of individual arteries or their branches. ( exceptions are in the case of suspected mesenteric ischaemia, suspected aortoduodenal fistula).

• It is a good practice to study all three visceral vessels in every patient with GI bleeding even if a likely source is found early in the investigation, as additional relevant ( or unrelated ) lesion may be identified.

Hepatic arteriographyIndications - investigation and treatment of hepatobiliary bleeding and assessment and management of primary and secondary liver tumours.

Pancreatic angiographyIndications-• Preoperative assessment of tumours and cysts to define their relationship to vascular structures

; potential resectability (to exclude tumour encasement of major contiguous vessels, particularly the splenic vein.)

• The assessment of other vascular complications of pancreatic disease when non invasive methods do not provide diagnosis or when intervention is required.

• As part of investigation of hemobilia.• Localisation of pancreatic endocrine tumours ( eg. Islet cell tumour).

THERAPEUTIC DSA

SAME PROTOCOL AS OF DIAGNOSTIC + STENTS, EMBOLIC MATERIALS, BALLOON CATHETERS and DRUGS-VASOCONSTRICTIVE

• PHARMACOLOGICAL INJECTION when subselective catheterisation not possible

• EMBOLOTHERAPY when subselective catheterisation is possible

VASOCONSTRICTIVE INFUSION THERAPY

Vasopressin - It is an octapeptide produced in neuroepiphysis.

Mechanism of action

• Constricts mesenteric arterioles

• Causes contraction of smooth muscles of the gastrointestinal tract and vascular bed

• It is not antagonised by adrenergic blocking agents

• Antidiuretic

PHARMACOLOGIC INFUSION

Intravenous therapy

• 1000-2000 U/L infused for 48hrs.

Intra arterial vasopressin therapy

• Most commonly performed method.

• Selective delivery is usually preferred-by precisely localizing bleeding artery.

ADVANTAGES OF VASOPRESSIN

• Causes significant and sustained reduction in splanchnic blood flow

• Direct and immediate action

• Dose can be modified , controlled and reversible ischaemia can be attained.

PROCEDURE

• Vasopressin diluted in saline or 5 % dextrose and water

• Infused at a constant rate 0.2 units / min for 20 min.s

• Repeat arteriogram

• If no further bleed– continue infusion at 0.2 units/min

• Bleed persists– increase to 0.4 units /min x 20 min

• Repeat arteriogram

Angiogram obtained after first 20 min –

to look for---

1. Moderate reduction in the caliber of infused vessel with preservation of good forward flow in capillary and venous phases

2. There is still filling of branches in the area of the bleeding point

3. No further extravasation

• If these criteria are met – apply a pressure dressing around the catheter entrY site –careful monitoring

• No clinical e/o bleed – continue initial infusion rate for 12 – 24 hrs then reduced by 50 % for 24hrs– stop infusion but keep catheter in place , maintain it patent for another 12 hrs – no bleed – remove catheter.

• Pain should not occur during infusion after the first 15 -30 min ( contraction of bowel and increased peristalsis )

• Pain persisting longer– stop infusion –reexamine patient

• Cause of pain – ischaemia , catheter tip wedging into a small mesentric arterial branch or catheter slipped into abdominal aorta

USES

• Successful in controlling bleeding from superficial gastric lesions. Diverticula & angiodysplasias are quite responsive.

• Infusion decreases the hemorrhage & stabilizes the patient condition so that resection can be planned later.

• It is less effective in controlling bleeding from duodenum..

COMPLICATIONS OF VASOPRESSIN:

MAJOR

1.Myocardial ischaemia

2.Malignant arrhythmias

3.Mesentric infarction or thrombus

4.Limb ischaemia

MINOR

1. elevated BP

2. acrocyanosis

3. electrolyte and fluid imbalance

It is also ineffective at sites where elecrocoagulation & heat probe has been tried.

VASOPRESSIN THERAPY

EMBOLOTHERAPY

Occlusion of arteries by insertion of blood clots, Gelfoam, coils, balloons, etc., with an angiographic catheter; used for control of inoperable hemorrhage or preoperative management of highly vascular neoplasms.

TYPES

Temporary treatment -• Widely used for transient lesions -ulcers, erosions. Diverticulas, spontaneous leaks, etc.. • Materials used eg. Gel foam in powder/solution, autologous blood clot.

Permanent embolisation-• Used to control immediate bleeding and definative therapy for underlining pathology.• Used for -tumors, AVM, large areas of angiodysplasia, varices, etc..• Materials-polyvinyl alcohol l(lvalon), platinum or GWC coils, balloon, polymers etc..

ARTERIAL EMBOLIZATION

• To stop / prevent bleeding

• To destroy tissue eg. Neoplasms

• To occlude vascular abnormalities eg. AV malformations, Varicoceles

PROXIMAL / DISTAL EMBOLIZATION

• Proximal – to stop flow through a vessel when remaining collaterals do not compromise the result

• eg. Pseudoaneurysms , traumatic extravasation

• Distal – at arteriolar or capillary level to detroy tissue or stop flow through a vessel when remaining collaterals could lead to recurrence of the problem

• eg. Bronchial artery bleeding , AV malformation

EQUIPMENT AND TECHNIQUE

• Diagnostic catheter

• Guide wire

• Micro catheter

• Micro and macro coils ( 0,018 - 0,035 inch) and other

• embolization material

• Medications

• ECG monitoring

TECHNIQUE

• Femoral artery access, usually

• Brachial artery access -occasionally

• Abdominal aortography (Pigtail catheter), or direct selective angiography-(Sidewinder 1 or Cobra shaped 5 Fr catheters-usually)-important flushing during intervention with non-heparinized saline and stable position.

• Superselective angiography with microcatheters-coaxially

• Delivery of coils-injection technique or with ”coil pusher”- be aware of risk for over or undersizing of the coils

• Particulate embolic material-mixed with 50% contrast and injected under continuous fluoroscopy

• Catheter is placed close to the site of extravasation and embolic material injected through the catheter to block the artery

• This fails in area with dual blood supply– thus embolize both sides of an arcade

• eg. Superior and inferior pancreaticoduodenal arterial arcade in duodenum

• Left and right gastric arteries at lesser curvature of the stomach

• Right and left gastroepiploic arterial communications at the greater curvature of the stomach

EMBOLIZATION MATERIALS AVAILABLE

→ TEMPORARY

eg. Absorbable gelatin foam ,clots pretreated with thrombin ,E aminocaproicacid used with double lumen balloon tipped catheters

Used in Transient lesions - erosion , ulceration , diverticula , traumatic tears

→ PERMANENT

eg. Polyvinylalcohol and metal coils

Used in - Tumors, AVmalformations , varices, angiodysplasia

POLYVINYL ALCOHOL ( PVA ) PARTICLES

• For occlusion of small size arteries and arterioles (50-2500micrometer)

• Induce an inflammatory reaction in the vessel wall

• Expand on contact with fluid

• Mixed with dye and injected under fluoroscopy guidance

BALLOON OCCLUSION CATHETER

ARTERIAL EMBOLOTHERAPY

• The goal of embolotherapy is to decrease the blood pressure at the site of the bleeding lesions and thereby allow a stable clot to form without causing tissue ischaemia or necrosis.

• Because GI hemorrhage is secondary to benign self limiting lesions, gelfoam, a temporary vasoocclusive agent is widely used.

• Recanalisation takes place within 1 to 3 weeks.

Gelfoam Slurry Preparation

• Permanent embolic agents are usually reserved for controlling hemorrhage resulting from invasion of the GI tract by primary or secondary malignancies.

RECENT ADVANCES

• The Occlusin 500 Artificial Embolization Device (OCL 500) is a microspherical embolization agent approved for the treatment of highly vascularized, unresectable tumors, e.g., hepatocellular carcinoma or renal cell carcinoma. After being injected into a vessel supplying the tumor, the microspheres form a platelet-rich clot interrupting its blood supply. One advantage of the biodegradable agent is that the microspheres degrade over time, allowing the vessel to re-canalize, thereby maintaining the option of using the same vessel in the future for further treatments.

• In the upper GI tract, because of the rich collateral blood supply, individual branches can be occluded with an almost negligilble risk of ischaemiccomplications.

• Major branches of the celiac artery such as the left gastric, hepatic, gastroduodenal or gastroepiploic arteries can be individually embolised.

• Embolisation can be used to control acute bleeding from Mallory Weiss tears, peptic ulcers, tumours, trauma, surgery, aneurysms, vascular malformations and iatrogenic bleeding due to recent biopsy or surgery.

Control of an acutely bleeding gastric ulcer by embolization.

Control of acute hemorrhage from a duodenal ulcer.

RISKS ASSOCIATED WITH EMBOLIZATION

• Spill over /embolic reflux /embolization of non target vessels –pancreatitis , gall bladder infarction , hepatic abscess , splenic infarction and abscess

• Infarction and necrosis of embolized tissue esp. small bowel and colon

Minimized by – superselective catheterization using balloon catheter

EMBOLOTHERAPY

-BLEEDING DUODENAL ULCER

• Factors suggesting VASOPRESSIN will be useful

Small vessel bleed

Diffuse bleed

Bleed from a vessel primarily supplied by one artery

• Factors in favour of EMBOLOTHERAPY

Single point source of bleeding

When vessel can be selectively catheterised

VENOGRAPHY

TYPES

• DIRECT VENOGRAPHY

• INDIRECT VENOGRAPHY

DIRECT VENOGRAPHY

• Most common means of opacification of venous system

• TECHNIQUE:

• Needle is directly placed in to the vein to be imaged n CM injected.

• ANTEGRADE METHOD: needle is inserted in to antecubital fossa vein to demontratebrachial, axilary, subclavian, brachiocephalic or SVC & in femoral vein for IVC.

• RETROGRADE METHOD: as in selective hepatic venography

INDIRECT VENOGRAPHY

TECHNIQUE:

• CM is injected in to arterial system of area being studied n delayed films are obtained to image venous return.

• It has got great advantage in examining portal venous system.

• It is possible to gain direct access to portal system.

• Direct approach is more invasive n requires greater technical expertise.

COMPLICATIONS

• PAIN : hypertonic contrast material (CM) cause pain due to irritation of vessel.

• Extravasation of CM : pain and necrosis.

• VASCULAR COMPLICATIONS:

• Dissection of vein being cannulated.

• SYSTEMIC COMPLICATIONS:

• Pulmonary embolism,

• Cardiac arrhythmias

• Air embolism.

GI HEMORRHAGE OF VENOUS ORIGIN

• Portal hypertension is an important cause of Gl bleeding.

• Angiographic techniques determine the cause of hypertension if this is not already known ( eg. Arterioportal fistula )

• To show the anatomy and flow dynamics of the portal venous system.

• To apply interventional techniques for the control of bleeding and creation of porto-systemic shunts.

• Angiographic diagnosis of variceal hemorrhage is based on the following two criteria :

• Visualisation of the varices during the venous phase of splenic angiography or on sup mesenteric or left gastric pharmacoangiograms after the administration of tolazine.

• Exclusion of arterial or capillary bleeding sites.

THERAPY FOR VARICEALHEMORRHAGE

1. Low dose peripheral intravenous infusion of vasopressin to

reduce portal pressure.

2. Endoscopic sclerotherapy.

3. Transjugular intrahepatic portosystemic shunt ( TIPSS )

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPSS)

TIPSS is often life saving in patients with acute variceal hemorrhage who have not responded to emergency endoscopic sclerotherapy.

Indications :

1. Patients awaiting liver transplantation.

2. Severe ascitis that is resistant to medical therapy.

3. Budd-Chiari syndrome.

4. Hepatorenal syndrome.

Disadvantage – high incidence of shunt stenosis on follow up.

• Three types of stents are commonly used -

• the Glanturco - Rosch Z stent

• the Palmaz stent

• the Wallstent.

The portosystemic gradient should be reduced to about 10 mm Hg.

• Complications of TIPSS: Early

• Death ( <5% of patients)

• Hemoperitoneum ( puncture of extrahepatic PV or capsular puncture).

• Biliovenous fistula. Delayed

• Stent stenosis (in 50% of cases).

• Worsening encephalopathy (in 30%).

Technique of insertion

• Preliminary arterial portography is necessary.

• Most common is the right internal jugular vein approach ; 8F sheath is introduced and the IVC and right or middle hepatic vein catheterised.

• Wedge hepatic venograms – performed at this stage demonstrate intrahepatic portal vein branches.

• Transhepatic puncture of PV branch ( ideally the right portal vein should be entered about 2 cm from its bifurcation ) – with a 16 G needle or a 5 F Teflon catheter.

• Balloon dilatation of the track and placement of metallic endoprosthesis.

CT Wedge portal venogram obtained as a part of TIPS procedure

Complications of TIPSS

Early 1. Death ( <5% of patients )

2. Hemoperitoneum ( puncture of extrahepatic PV or capsular puncture ).

3. Biliovenous fistula.

Delayed 1. Stent stenosis (in 50% of cases).

2. Worsening encephalopathy ( in 30%).

Main portal venogram performed via a TIPSS in a patient who had showed Doppler US evidence of shunt stenosis

Demonstration of portal hypertension and esophageal varices in a patient with upper GI tract hemorrhage.

SCINTIGRAPHY

• It is the investigation of choice in intermittent bleeding or when bleeding has stopped. Used as a screening modality especially in LGIB. Two approaches are used

IV administration of radiolabeled particles or solutions

• Cleared from vascular spaces

• Those which extravasate in to bowel are not available for normal clearance. Ex:sulfur colloid

heat damaged RBCs DTPA.

All the above can be labelled with technetium.

• Use of intravascular markers-

• circulating RBCs and serum albumin

• these are not cleared from blood stream until Rn decays.

• extended period of imaging.

NUCLEAR SCINTIGRAPHY

• Most sensitive

• Noninvasive

• Detecting active GI hemorrhage

• Easy to perform

• No patient preparation

• Monitor the patient over a prolonged period of time

• Detect intermittent bleeding

TECHNIQUES OF SCINTIGRAPHY

TWO TECHNIQUES -

1. RAPIDLY EXTRACTED FROM CIRCULATION-

Tc-99m SULPHUR colloid

2. REMAINS IN CIRCULATION FOR LONG TIME-Tc 99m LABELLED RBC

(invivo and modified invitro Tc99m-RBC)

ADVANTAGES

• Highly sensitive(can detect bleeding as low as 0.05ml /min.

• Quick, repeatable

• Non invasive

• Low radiation dose

• No danger of nephrotoxicity /allergy.

• Used as a screening procedure for LGIB

• It can be used to evaluate the success of interventional therapy.

PRINCIPAL STUDIES

1. 99mTc sulphur colloid scan-

• It is cleared from the blood by RES.

• it is composed of small particles measuring l-2microns

• Tl/2- 2.5-3min.

• It can detect bleeding at the rates of 0.l ml/min.

• The scan be repeated .

• Bleeding in the hepatic and splenic flexure is difficult to detect because of the overlapping of activities.

TC 99M SULPHUR COLLOID SCAN

TechniqueI.V administration of 10-15 mci 99mTc-SC

Early images-pelvis and midabdomen- multiple images at short intervals ( 1 /1-2 min )

At active bleeding sites- fraction of isotope extravasates , eliminated from circulation

After 12-15 min. the tracer is cleared from the circulation creating a contrast between bleeding site and surrounding

•Early images : reveal extravasation

• Later images : aboral progression of the isotope

SULPHUR COLLOID SCINTIGRAPHY

Advantages:

• Exquisitely sensitive-can detect bleeding as low as 0.05 to 0.1 ml /min

• Takes 30 min.

• Reveal bleeding in the venous system

• Prognosis of positive angiography

SCINTIGRAPHY-SULPHUR COLLOID

Limitations:• Patient must be actively bleeding

• Bleeding near the liver and spleen – obscured by activity of these organs

• False positive foci of activity due to ectopic / accessory spleen , abnormal focus of bone marrow and uterine leiomyomas etc.

TC LABELLED RBCS

• These extravasate during bleeding.

• Images can be obtained up to two hours after initial injection.

• Useful in evaluating intermittent breeding.

• Identification of bleeding site - in this technique, normal vasculature can be visualized

• False positive findings can be due to the presence of free technetium in renal collecting system and bladder, or its excretion through Gl mucosa and subsequent progression in to the distal portion.

• Hence exact site of the bleed cannot be Identified.

• Vascular tumors appear as areas of hyperemia.

TECHNETIUM 99M-LABELLED RBC SCANS

Technique:• In-vitro RBC labelling method –

• > 95% labelling efficiency –very little unbound pertechnate is available for uptake by gastric mucosa , kidney and bladder

• Continuous dynamic imaging

• Large field of view camera

• 15 min dynamic imaging sequence of 60 images / 15 sec until a bleeding site is identified.

CRITERIA-FOR POSITIVE STUDY

• Hot spot -focus of radio-labeled RBC ’S that first appear outside the normal blood pool

• Abnormal activity increases over time

• Abnormal activity moves within the bowel antegrade or retrograde through bowel[ essential criteria]

SCINTIGRAPHY-LABELED RBC SCANS

Advantages:

• Continuous monitoring of entire GIT for several hours - intermittent bleeding

Limitations:

• Less sensitive than sulphur colloid technique

• Requires bleeding rate of 0.2 ml/min for detection within 10 min. and rate of 0.04 ml/min for detection within 55min.

• Minimum 5-10 ml of extravasated blood must be present for detection

• Bleeding noted only on delayed images diff. to interpret origin

BLEED IN GASTRIC MUCOSA

Copyright ©Radiological Society of North America, 2000

Rapid antegrade transit from a bleeding site at the hepatic flexure

0 – 30 sec

24 min

TC 99 M-DTPA

• Tc 99 m-DTPA ,heat damaged RBCs can be used in similar way.

• DTPA has advantage of late excretion(1 hr)through kidneys.

• It can be used to investigate bleeding in upper abdomen and investigation can be extended.

MECKEL'S SCAN

• A Nuclear Medicine Meckel's scan is performed to look for the presence of ectopic gastric mucosa in the large bowel. If this condition exists it can cause pain in the abdomen and blood in the stool.

• Nuclear Medicine scans are performed using very small amounts of radioactive material. The radioactive material is usually bound to other non-radioactive elements. These combined elements are called "radionuclides". The radionuclides emit energy called "photons".

MECKELS SCAN

• It is used to localise the ectopic gastric mucosa and not to localise the bleeding.

• Tc 99m pertechnitate is used.

• Images should be taken- starting from the injection up to one hour.

• Sensitivity is as high as 85%.

Meckel's diverticulum scintigraphyperformed on 2-y-old boy with intermittent bleeding (bright red blood) and no other accompanying symptom.

ENDOSCOPIC ULTRASONOGRAPHY

• Endoscopic Ultrasound (EUS) is a imaging modality that combine the endoscopic

view and the ultrasound picture.

• The method is superior in staging and diagnosing of gastrointestinal cancer and

benign diseases in esophagus, stomach, pancreas, and related organs.

• EUS have shown to be superior in assessment of the common bile duct in patients

suspected for common bile duct stones.

INDIVIDUAL CASES

ESOPHAGEAL VARICES

• Dilated submucosal veins due to increased collateral blood flow from portal venous system to azygos system

• Uphill varices

• Collateral blood flow from portal vein via azygos vein into SVC (usually lower esophagus drains via left gastric vein into portal vein)

• Most common cause is portal hypertension secondary to cirrhosis

• Varices in lower half of esophagus to the level of the carina (azygous vein)

• More common than downhill varices

• Causes

• Intrahepatic obstruction from cirrhosis

• Splenic vein thrombosis (usually gastric varices only)

• Obstruction of hepatic veins

• Portal vein thrombosis

• IVC obstruction below hepatic veins

• Marked splenomegaly / splenic hemangiomatosis (rare)

• Downhill varices• Collateral blood flow from SVC via azygos vein into IVC / portal venous system (upper

esophagus usually drains via azygos vein into SVC)• Varices in upper 1/3 of esophagus

• Usually extend down to the level of the carina (azygous vein)

• Less common than uphill varices

• Causes• Obstruction of superior vena cava distal to entry of azygos vein due to

• Lung cancer (most common)• Lymphoma

• Retrosternal goiter

• Thymoma• Mediastinal fibrosis

• Plain film• Lobulated masses in posterior mediastinum (visible in a small percentage of patients

with varices)

• Silhouetting of descending aorta

• Abnormal convex contour of azygoesophageal recess

• UGI (fluoroscopic guided esophagography)• Thickened and interrupted mucosal folds (earliest sign)

• Tortuous radiolucencies of variable size and location

• "Worm-eaten" smooth lobulated filling defects

• Characteristic serpeginous filling defects esp.. on prone films.

• CT

• Thickened esophageal wall and lobulated outer contour

• Scalloped esophageal luminal masses

• Right- / left-sided soft-tissue masses = paraesophageal varices

• Marked enhancement following dynamic CT

• Complications

• Bleeding in 28% within 3 years

• Exsanguination in 10-15%

• DDx

• Early

• Other forms of chronic esophagitis

• Late

• Varicoid carcinoma of esophagus

• Wall more rigid and less likely to change in varicoid carcinoma

• Nodular filling defects in varicoid ca

ANGIOGRAPHY

• Diagnosis of variceal bleeding is based on -

• Visualisation of varices in venous phases of splenic/SMA or LGA angiography. Exclusion

of arterial/capillary bleeding sites.

GASTRIC VARICES

• Gastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage.

• They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis.

• Gastric varices may also be found in patients with thrombosis of the splenic vein, into which the short gastric veins which drain the fundus of the stomach flow.

• The latter may be a complication of acute pancreatitis, pancreatic cancer, or other abdominal tumours.

• BARIUM STUDY-

Characteristic serpeginous filling defects esp.. On prone films.

Uphill varices

• Uphill esophageal varices in a patient who had cirrhosis secondary to alcohol abuse

40 year old man with alcoholic cirrhosis and esophageal varices who had several bleeding episodes.

MANAGEMENT OF VARICES

1. Immediate treatment-

• IV metoclopramide

• Minnesota tube

2. Sclerotherapy-

• Agents- ethanolamine oleate, sod tetradecyl sulphate(3%), polidocanol,& dehydrated alcohol.

• Technique-not more than 2 sessions of inj given/week.

• Unless otherwise contraindicated, proponolol should be used to prevent recurrence.

Complications-

• ulcerative necrosis, perforation, chest pain, pleural effusion, dysphagia, strictures, etc..

3. Endoscopic ligation therapy

• ANGIOGRAPHIC THERAPY-

• ls based on visualisation of varices in venous phases. By exclusion of arterial & capillary bleeding sites.

• Vasopressin infusion.

• Trans hepatic embolisation of gastroesophageal varices

• TIPSS

MALLORY WEISS TEAR

• A Mallory-Weiss tear is a longitudinal mucosal laceration observed in the distal esophagus or across the gastroesophageal junction.

• It occurs in the setting of retching or vomiting, frequently after excessive alcohol consumption; they also may occur as a complication of endoscopy.

• Some degree of hematemesis is invariably present and is an indication for upper endoscopy.

• Initially bleeding is brisk but stops spontaneously in 85-90% cases.

• Similar linear mucosal lacerations occurring elsewhere in the esophagus as a result of forceful swallowing of an impacted foreign body or food bolus may pose a diagnostic dilemma.

MALLORY WEISS TEAR

• A mucosal laceration without transmural perforation is likely to be radiographically occult.

• Unless bleeding persists, the treatment of a Mallory-Weiss tear, like that of other mucosal lacerations, is supportive.

• Endoscopy is best for diagnosis.

• Air-contrast esophagogram shows longitudinal tears at the esophagogastric junction.

• Mallory-Weiss tear is difficult to diagnose with esophagography, but when identified, it manifests as a 1-4-cm longitudinal collection of barium in the distal esophagus

• DD- Boarhaave's syndrome.

MALLORY WEISS TEAR

MALLORY-WEISS TEAR.

• Mallory-Weiss tear is difficult to diagnose with esophagography, but when identified, it manifests as a 1–4-cm longitudinal collection of barium in the distal esophagus

Hemorrhage from a Mallory-Weiss tear

MALLORY WEISS TEAR

Selective Left gastric arteriograph

Patient with bleeding from Mallory Weiss esophageal tear

FEATURES OF BENIGN ULCER

1. Ulcer crater-collection of barium on dependent surface which usually projects beyond anticipated wall of stomach

2. Hampton’s line-1 mm thin straight line at neck of ulcer in profile view which represents the thin rim of undermined gastric mucosa

3. Ulcer collar-smooth, thick, lucent band at neck of ulcer in profile view representing thicker rim of edematous gastric wall

4. Ulcer mound-smooth, sharply delineated tissue mass surrounding a benign ulcer

5. Ring shadow-thin rim of contrast which represents an ulcer on the non-dependent surface of an air-contrast study

6. Thickened folds radiating directly to the base of the ulcer en face

HAMPTON'S LINE

Benign. lesser curvature gastric

ulcer. Red arrows point to Hampton's

Line, a thin, straight line at neck of

ulcer in profile view which represents

the thin rim of undermined gastric mucosa.

Ulcer collar

• This image from an upper gastrointestinal series shows a small lesser-curve ulcer with regular radiating mucosal folds.

• Histologic evaluation revealed no evidence of malignancy

MALIGNANT ULCER

Radiographic signs of malignant ulcer• Ulcer projects within the anticipated wall of the stomach

• Ulcer is eccentrically located within the ulcer mound

• Irregularly shaped ulcer crater

• Nodular ulcer mound

• Abrupt transition between normal and abnormal mucosa several cms away from the ulcer crater

• Rigidity, lack of distensibility and lack of changeability

• Associated large mass

• Carman meniscus sign

MALIGNANT ULCER

• Carmen meniscus sign-a relatively shallow gastric ulcerating malignancy projecting as an ulcer which is always convex inwards to the lumen and which does not project beyond the wall = Kirklin meniscus complex

• The Carman meniscus sign is created by a large, flat ulcer with heaped-up edges. The edges of the ulcer trap a lenticular barium collection that is convex relative to the lumen when the edges are folded upon themselves during compression. These findings are indicative of a malignant gastric ulcer.

• Extravasations in to the lumen of stomach with neovascutarity within the tumor itself.

Carman meniscus sign and gastric adenocarcinoma.

MALIGNANT ULCER

• Vasopressin is not effective.

Embolisation therapy-

• When super selective catheterization is possible- permanent agents like EVALON is used.

• In sub selective catheterization-temporary agents are used-GELFOAM.

AIMS-

• to reduce tumor size before resection.

• To control acute bleeding

• To achieve stabilization of patient.

ENDOSCOPIC TREATMENT

Injection therapy-

• Using vasoconstrictors or sclerosing agents into the bleeding artery or close to it.

• Concentrated alcohol, prolidocanol with or without epinephrine.

• Complications-

• perforation,

• fatal gastro duodenal necrosis (Clostridia infection).

A 62 year old man with metastatic renal cell carcinoma presenting with severe GI bleeding from malignant ulcer in second portion of duodenum.

Hourglass deformity caused by fibrosis.

Gastric ulceration with coarse irregular mucosal folds. Histologic evaluation revealed an adenocarcinoma.

GASTRIC MUCOSAL HEMORRHAGE

• Ulcerations secondary to

Stress , drug / alcohol , idiopathic.

Angiographic appearance of bleeding stress ulcer:

massive extravasation in a normal stomach/duodenum

Angio –

gastritis: multiple areas of extravasation in a bed that is very hyperemic

Bleeding controlled by selective infusion of vasopressin into left gastric artery

GASTRIC ULCERBleeding from ulcer is due to erosion of ulcer into the lateral wall of the vessel.

Causes

• Stress

• Burns=Curling ulcer

• Cerebral disease=Cushing ulcer

• Uremia

• Steroid therapy

• Hyperparathyroidism (25% have ulcer disease)

Other facts

• Multiple in 2-8%

• Coexistent duodenal ulcer disease in 5-42%; duodenal:gastric ratio=3:1

• Multiple postbulbar duodenal ulcers should suggest Zollinger-Ellison

Location

• Lesser curvature aspect of body and antrum usually for benign ulcers

• Benign ulcers also occur on posterior wall; not usually anterior wall

• May be found in proximal half of stomach in geriatric patient

• Almost all lesser curvature gastric ulcers <1cm are benign

• Greater curvature benign ulcers are associated with considerable mass effect which erroneously leads to conclusion of malignancy

Early phase selective Gastroduodenal arteriogram

Late phase extravasation of contrast

Fundal gastritis and actively bleeding lesser curvature ulcer in a patient presenting with massive upper GI hemorrhage.

GREATER CURVATURE ULCER

Upper GI bleeding from a greater curvature ulcer. This patient has had previous surgery and the gastroduodenal artery was ligated.

PEPTIC ULCER• Most common cause of UGIB

• Ulcers bleed when a vessel in the ulcer base or edge erodes- MC an artery (true vessel/ plug of clot or pseudoaneurysm.

• In patients requiring resection - bleeding arterial diameter should be 7mm.

• Recurrence is most common in ulcers with a visible bleeding vessel.

ENDOSCOPY-

• Main aims -

• To identify ulcer

• Assessment of rebleeding

• in actively bleeding ulcer - rebleeding risk is 80-100%

• in non bleeding ulcer - rebleeding risk is 15-20%.

• Endoscopic treatment.

• Most common Site - posterior wall of the duodenal bulb

• Involves the gastroduodenal artery

• Complication –rebleeding when ulcer diameter is >1cm,visible vessel in the ulcer

• Treatment :

• Endoscopy- inject epinephrine around the ulcer

• Vasopressin inj.

• Embolotherapy – gelfoam / coils

• Life saving measure – synchronous embolization of gastroduodenal artery and inferior pancreaticoduodenal artery- ↑ necrosis

DUODENAL ULCER

DUODENAL ULCER HEMORRHAGIC GASTRITIS

GASTRITIS

• Diffuse mucosal inflammation and superficial ulcerations due to break own of mucosal barrier and back flow of acid

• Stress ,alcohol, NSAID

• Self limited

• Diffuse hyperemia noted on angiography

• No extravasation of contrast →intraarterial injection of vasopressin

• Active extravasation →embolotherapy

HAEMORRHAGIC GASTRITIS

Selective Left gastric arteriography

Arterial pseudoaneurysm in the upper gastrointestinal tract

Arterial pseudoaneurysm in the upper GI tract

HEMORRHAGIC/ EROSIVE GASTROPATHY

• NSAIDS, smoking, alcohol & stress related.

• Multiple site of extravasations seen within the lumen with diffuse hyperemia.

• Selective angiography followed by Intra-arterial vasopressin therapy is most commonly used.

• Gastric necrosis is rare.

Selective left gastric arteriogram in patient with diffuse mucosal bleeding in erosive gastritis demonstrated by endoscopy.

• The bleeding results from an abnormally large eroded submucosal artery commonly located in the proximal stomach

• Consists of a bleeding artery surrounded by normal or near normal mucosa.

• Most commonly found in the fundus of stomach, other sites are-duodenum, jejunum & colon.

• Common in male alcoholics.

• It has high tendency to recurrent massive hemorrhage.

• Treatment-with prolidocanol / bipolar electro coagulation is effective to certain extent but, surgery is ultimate treatment of choice.

DIEULAFOY LESION

A 77-year-old man known to have diabetes mellitus, parkinsonism, hypothyroidism, sick sinus syndrome and

advanced chronic obstructive pulmonary disease; presented with a 12-hour history of vomiting bright red blood. He gave a history of one-month dizziness, easy fatigability and black stools.

ACUTE DUODENAL BLEEDING IN A 39-YEAR-OLD MAN WITH ACUTE PANCREATITIS WHO PRESENTED WITH MASSIVE HEMATEMESIS.

DIFFUSE GASTRIC TELANGIECTASIA

(WATERMELON STOMACH)• Raised bright red longitudinal folds in the gastric antrum radiating from

pylorus are characteristic features (resemble longitudinal strips in a skin of watermelon) .

• Patient presents with chronic anemia.

• Endoscopic treatment is effective ,but recurrence rate is high.

• Antrectomy is required in almost all cases

Diffuse gastric telangiectasia or watermelon stomach

ZOLLINGER-ELLISON SYNDROME

• Zollinger-Ellison syndrome is caused by a gastrin-secreting islet cell neoplasm (gastrinoma) that

stimulates acid hypersecretion by parietal cells in the gastric fundus and upper body.

• These two sites subsequently become grossly hyperplastic, a phenomenon that accounts for

much of the fold thickening, to which inflammation adds more distally.

• Approximately 60% of gastrinomas are malignant, and these malignant neoplasms can be

associated with multiple endocrine neoplasia syndrome type I.

• Gastrinomas most commonly occur in the pancreas, with the duodenum and other sites being

less commonly affected.

• The continuous secretion of gastrin leads to increased gastric acid production, resulting in severe

peptic ulcer disease.

• Characteristic radiographic findings include

• multiple gastric and duodenal ulcers,

• with distal duodenal ulcers being highly suggestive of the disease,

• as well as gastric and duodenal fold thickening.

• Hypersecretion can also lead to barium dilution with poor coating.

• Zollinger-Ellison syndrome. Image from a single-contrast upper gastrointestinal study

A gastrinoma was found at surgery

HEMOBILIA

• Triad of GI bleed, biliary colic and jaundice suggests hemobilia.

• Most common causes are –hepatic injury, iatrogenic , hepatic artery aneurysms , liver abscess, GB vasculitis ,etc..

• Bleeding may originate from pancreatic duct due to erosion of pseudo aneurysm.

• Diagnosis is made by endoscopy / hepatic arteriography.

• Treatment-angiographic detection & embolisation.

In this case, small pseudoaneurysm of right hepatic artery arising from the superior mesenteric artery was the cause of hemobilia. ERCP could show a biliary leak in the hepatic bed, the existence of an arterobiliary fistula remained unvisualised by the imaging techniques.

GASTRIC & OESOPHAGIAL TUMORS

• Gastric & duodenal leiomyomas are common causes of bleeding.

• Tumor outline along with extravasation can be studied.

Glomus tumour of the stomach in a 33 year old woman

REFERENCES

• DIAGNOSTIC IMAGING ABDOMEN -FEDERLE

• SCINTIGRAPHY DETECTION OF ACUTE Gl BLEEDING - ALVI.A,DANN.RW.

• IMAGES FROM RSNA, AJR, BJR, emedicine.com.

• DIAGNOSTIC RADIOLOGY - GRAINGER & ALLISON.

• TEXT BOOK OF RADIOLOGY & IMAGING - DAVID SUTTON

THANK YOU