Abstract
Purpose/background
Acute gastrointestinal bleeding (GIB) is an emergency with high mortality rates, which requires a quick localization and treatment of the bleeding site. In this article, we give a summary of the diagnostic and interventional treatment of acute GIB with an emphasis on radiological methods.
Methods
The MEDLINE database identified relevant studies up until January 2011. Furthermore, experiences drawn from a highly experienced department of diagnostic radiology (~60 transarterial embolizations [TAEs]/year) were taken into account.
Results
Clinical risk scores are useful tools to triage patients for appropriate treatment. High-risk patients should undergo emergency endoscopy within 24 h. If endoscopical control of the bleeding cannot be achieved, a computed tomography angiography (CTA) should be done. If active bleeding (or if an active bleeding site) is found, in most cases, TAE should be performed prior to surgery because of the equal mortality rates with lower complication rates. If the site of bleeding is not identified and the patient is stable, a “watch-and-wait” strategy can be pursued. Especially for intermittent bleeding, scintigraphy with tagged red blood cells can be useful.
Conclusion
Managing obscure acute GIB remains a challenge. The best patient care is achieved with a multidisciplinary team of endoscopists, experienced surgeons, and interventional radiologists. If emergency endoscopy fails, a CTA has to be done, which is more sensitive than conventional angiography. Based on CTA findings, a decision must be made between TAE and surgical intervention.
Similar content being viewed by others
References
Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1997;92:419–24.
Sanders DS, Perry MJ, Jones SG, McFarlane E, Johnson AG, Gleeson DC, Lobo AJ. Effectiveness of an upper-gastrointestinal haemorrhage unit: a prospective analysis of 900 consecutive cases using the Rockall score as a method of risk standardisation. Eur J Gastroenterol Hepatol. 2004;16:487–94.
Yoon W, Jeong YY, Shin SS, Lim HS, Song SG, Jang NG, Kim JK, Kang HK. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology. 2006;239:160–7.
Manning-Dimmitt LL, Dimmitt SG, Wilson GR. Diagnosis of gastrointestinal bleeding in adults. Am Fam Physician. 2005;71:1339–46.
Ríos A, Montoya MJ, Rodríguez JM, Serrano A, Molina J, Ramírez P, Parrilla P. Severe acute lower gastrointestinal bleeding: risk factors for morbidity and mortality. Langenbecks Arch Surg. 2007;392:165–71.
van Leerdam ME, Vreeburg EM, Rauws EA, Geraedts AA, Tijssen JG, Reitsma JB, Tytgat GN. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterol. 2003;98:1494–9.
Sos TA, Lee JG, Wixson D, Sniderman KW. Intermittent bleeding from minute to minute in acute massive gastrointestinal hemorrhage: arteriographic demonstration. AJR Am J Roentgenol. 1978;131:1015–7.
Arber N, Tiomny E, Hallak A, Santo M, Moshkowitz M, Konikoff FM, Shumla V, Rozen P, Gilat T, Rattan J. An eight year experience with upper gastrointestinal bleeding: diagnosis, treatment and prognosis. J Med. 1994;25:261–9.
Barkun A, Sabbah S, Enns R, Armstrong D, Gregor J, Fedorak RN, Rahme E, Toubouti Y, Martel M, Chiba N, Fallone CA; RUGBE Investigators. The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting. Am J Gastroenterol. 2004;99:1238–46.
Strate LL, Ayanian JZ, Kotler G, Syngal S. Risk factors for mortality in lower intestinal bleeding. Clin Gastroenterol Hepatol. 2008;6:1004–10.
Hoedema RE, Luchtefeld MA. The management of lower gastrointestinal hemorrhage. Dis Colon Rectum. 2005;48(11):2010–24.
Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996;38:316–21.
Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000;356:1318–21.
Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med. 2008;359(9):928–37.
Romagnuolo J, Barkun AN, Enns R, Armstrong D, Gregor J. Simple clinical predictors may obviate urgent endoscopy in selected patients with nonvariceal upper gastrointestinal tract bleeding. Arch Intern Med. 2007;167:265–70.
Spiegel BM, Vakil NB, Ofman JJ. Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review. Arch Intern Med. 2001;161:1393–404.
Zuckerman GR, Prakash C. Acute lower intestinal bleeding: part I: clinical presentation and diagnosis. Gastrointest Endosc. 1998;48(6):606–17.
Frattaroli FM, Casciani E, Spoletini D, Polettini E, Nunziale A, Bertini L, Vestri A, Gualdi G, Pappalardo G. Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding. World J Surg. 2009;33:2209–17.
Jensen DM, Machicado GA. Colonoscopy for diagnosis and treatment of severe lower gastrointestinal bleeding. Routine outcomes and cost analysis. Gastrointest Endosc Clin N Am. 1997;7(3):477–98.
Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg. 1998;64(8):723–8.
Jensen DM, Machicado GA, Jutabha R, Kovacs TOG. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. 2000;342(2):78–82.
Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg. 1998;64(8):723–8.
Rossini FP, Ferrari A, Spandre M, Cavallero M, Gemme C, Loverci C, Bertone A, Pinna Pintor M. Emergency colonoscopy. World J Surg. 1989;13:190–2.
Czymek R, Kempf A, Roblick UJ, Bader FG, Habermann J, Kujath P, Bruch HP, Fischer F. Surgical treatment concepts for acute lower gastrointestinal bleeding. J Gastrointest Surg. 2008;12(12):2212–20.
Triantafyllou K. Can we improve the diagnostic yield of small bowel video-capsule endoscopy? World J Gastrointest Endosc. 2010;2(5):143–6.
Leighton JA. The role of endoscopic imaging of the small bowel in clinical practice. Am J Gastroenterol. 2011;106(1):27–36. (quiz 37. Epub 2010 Oct 26).
Bunker SR, Lull RJ, Tanasescu DE, Redwine MD, Rigby J, Brown JM, Brachman MB, McAuley RJ, Ramanna K, Landry A, Waxman AD. Scintigraphy of gastrointestinal hemorrhage: superiority of 99mTc red blood cells over 99mTc sulfur colloid. AJR Am J Roentgenol. 1984;143:543–8.
Zuckier LS. Acute gastrointestinal bleeding. Semin Nucl Med. 2003;33(4):297–311.
Graça BM, Freire PA, Brito JB, Ilharco JM, Carvalheiro VM, Caseiro-Alves F. Gastroenterologic and radiologic approach to obscure gastrointestinal bleeding: how, why, and when? Radiographics. 2010;30(1):235–52.
Ohri SK, Desa LA, Lee H, Patel T, Jackson J, Lavender JP, Spencer J. Value of scintigraphic localization of obscure gastrointestinal bleeding. J R Coll Surg Edinb. 1992;37:328–32.
Gupta S, Luna E, Kingsley S, Prince M, Herrera N. Detection of gastrointestinal bleeding by radionuclide scintigraphy. Am J Gastroenterol. 1984;79(1):26–31.
Olds GD, Cooper GS, Chak A, Sivak MV Jr, Chitale AA, Wong RC. The yield of bleeding scans in acute lower gastrointestinal hemorrhage. J Clin Gastroenterol. 2005;39(4):273–7.
Yoon W, Jeong YY, Kim JK. Acute gastrointestinal bleeding: contrast-enhanced MDCT. Abdom Imaging. 2006;31:1–8.
Jaeckle T, Stuber G, Hoffmann MHK, Freund W, Schmitz BL, Aschoff AJ. Acute gastrointestinal bleeding: value of MDCT. Abdom Imaging. 2008;33:285–93.
Sabharwal R, Vladica P, Chou R, Law WP. Helical CT in the diagnosis of acute lower gastrointestinal haemorrhage. Eur J Radiol. 2006;58:273–9.
Scheffel H, Pfammatter T, Wildi S, Bauerfeind P, Marincek B, Alkadhi H. Acute gastrointestinal bleeding: detection of source and etiology with multi-detector-row CT. Eur Radiol. 2007;17(6):1555–65. (Epub 2006 Dec 15).
Duchesne J, Jacome T, Serou M, Tighe D, Gonzales A, Hunt JP, Marr AB, Weintraub SL. CT-angiography for the detection of a lower gastrointestinal bleeding source. Am Surg. 2005;71:392–7.
Stunell H, Buckley O, Lyburn ID, McGann G, Farrell M, Torreggiani WC. The role of computerized tomography in the evaluation of gastrointestinal bleeding following negative or failed endoscopy: a review of current status. J Postgrad Med. 2008;54(2):126–34.
Foley PT, Ganeshan A, Anthony S, Uberoi R. Multi-detector CT angiography for lower gastrointestinal bleeding: can it select patients for endovascular intervention? J Med Imaging Radiat Oncol. 2010;54:9–16.
Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol. 2003;13:114–7.
Laing CJ, Tobias T, Rosenblum DI, Banker WL, Tseng L, Tamarkin SW. Acute gastrointestinal bleeding: emerging role of multidetector CT angiography and review of current imaging techniques. Radiographics. 2007;27(4):1055–70.
Sivit CJ, Peclet MH, Taylor GA. Life-threatening intraperitoneal bleeding: demonstration with CT. Radiology. 1989;171:430.
Kuhle WG, Sheiman RG. Detection of active colonic hemorrhage with use of helical CT: findings in a swine model. Radiology. 2003;228(3):743–52.
Nusbaum M, Baum S, Blakemore WS. Clinical experience with the diagnosis and management of gastrointestinal hemorrhage by selective mesenteric catheterization. Ann Surg. 1969;170(3):506–14.
Tew K, Davies RP, Jadun CK, Kew J. MDCT of acute lower gastrointestinal bleeding. AJR Am J Roentgenol. 2004;182:427–30.
Napoli A, Fleischmann D, Chan FP, Catalano C, Hellinger JC, Passariello R, Rubin GD. Computed tomography angiography: state-of-the-art imaging using multidetector-row technology. J Comput Assist Tomogr. 2004;28(Suppl 1):S32–45.
Yoon W, Jeong YY, Shin SS, Lim HS, Song SG, Jang NG, Kim JK, Kang HK. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology. 2006;239:160–7.
Abbas SM, Bissett IP, Holden A, Woodfield JC, Parry BR, Duncan D. Clinical variables associated with positive angiographic localization of lower gastrointestinal bleeding. ANZ J Surg. 2005;75(11):953–7.
Schenker MP, Duszak R Jr, Soulen MC, Smith KP, Baum RA, Cope C, Freiman DB, Roberts DA, Shlansky-Goldberg RD. Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival. J Vasc Interv Radiol. 2001;12(11):1263–71.
Rösch J, Dotter CT, Brown MJ. Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology. 1972;102:303–6.
Bookstein JJ, Naderi MJ, Walter JF. Transcatheter embolization for lower gastrointestinal bleeding. Radiology. 1978;127:345–9.
van Vugt R, Bosscha K, van Munster IP, de Jager CP, Rutten MJ. Embolization as treatment of choice for bleeding peptic ulcers in high-risk patients. Dig Surg. 2009;26(1):37–42. (Epub 2009 Jan 21).
Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010;33(6)1088–100. (Epub 2010 Mar 16).
Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg. 2008;143(5):457–61.
Defreyne L, Vanlangenhove P, De Vos M, Pattyn P, Van Maele G, Decruyenaere J, Troisi R, Kunnen M. Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology. 2001;218(3):739–48.
Langner I, Langner S, Partecke LI, Glitsch A, Kraft M, Bernstorff W, Hosten N. Acute upper gastrointestinal hemorrhage: is a radiological interventional approach an alternative to emergency surgery? Emerg Radiol. 2008;15(6):413–9. (Epub 2008 May 30).
Ripoll C, Bañares R, Beceiro I, Menchén P, Catalina MV, Echenagusia A, Turegano F. Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. J Vasc Interv Radiol. 2004;15(5):447–50.
Funaki B, Kostelic JK, Lorenz J, Ha TV, Yip DL, Rosenblum JD, Leef JA, Straus C, Zaleski GX. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol. 2001;177(4):829–36.
Golzarian J, Sapoval MR, Kundu S, Hunter DW, Brountzos EN, Geschwind JF, Murphy TP, Spies JB, Wallace MJ, de Baere T, Cardella JF; Society of Interventional Radiology (SIR); Cardiovascular and Interventional Radiological Society of Europe (CIRSE); Canadian Interventional Radiology Association (CIRA). Guidelines for Peripheral and Visceral Vascular Embolization Training: joint writing groups of the Standards of Practice Committees for the Society of Interventional Radiology (SIR), Cardiovascular and Interventional Radiological Society of Europe (CIRSE), and Canadian Interventional Radiology Association (CIRA). J Vasc Interv Radiol. 2010;21:436–441.
Encarnacion CE, Kadir S, Beam CA, Payne CS. Gastrointestinal bleeding: treatment with gastrointestinal arterial embolization. Radiology. 1992;183:505–8.
Aina R, Oliva VL, Therasse E, Perreault P, Bui BT, Dufresne MP, Soulez G. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol. 2001;12:195–200.
Loffroy R, Guiu B, Mezzetta L, Minello A, Michiels C, Jouve JL, Cheynel N, Rat P, Cercueil JP, Krausé D. Short- and long-term results of transcatheter embolization for massive arterial hemorrhage from gastroduodenal ulcers not controlled by endoscopic hemostasis. Can J Gastroenterol. 2009;23:115–20.
Khanna A, Ognibene SJ, Koniaris LG. Embolization as first-line therapy for diverticulosis-related massive lower gastrointestinal bleeding: evidence from a meta-analysis. J Gastrointest Surg. 2005;9(3):343–52.
Defreyne L, Vanlangenhove P, De Vos M, Pattyn P, Van Maele G, Decruyenaere J, Troisi R, Kunnen M. Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology. 2001;218(3):739–48.
Loffroy R, Guiu B, D’Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009;7:515–23.
Lang EK. Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology. 1992;182:703–7.
Drooz AT, Lewis CA, Allen TE, Citron SJ, Cole PE, Freeman NJ, Husted JW, Malloy PC, Martin LG, Van Moore A, Neithamer CD, Roberts AC, Sacks D, Sanchez O, Venbrux AC, Bakal CW; Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for percutaneous transcatheter embolization. J Vasc Interv Radiol. 2003;14:S237–42.
Bloomfeld RS, Smith TP, Schneider AM, Rockey DC. Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin. Am J Gastroenterol. 2000;95(10):2807–12.
Strate LL. Lower GI bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am. 2005;34:643–64.
Loffroy R, Guiu B. Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers. World J Gastroenterol. 2009;15(47):5889–97.
Weldon DT, Burke SJ, Sun S, Mimura H, Golzarian J. Interventional management of lower gastrointestinal bleeding. Eur Radiol. 2008;18:857–67.
Blanc T, Cortes A, Goere D, Sibert A, Pessaux P, Belghiti J, Sauvanet A. Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated? Am J Surg. 2007;194(1):3–9.
Czymek R, Grossmann A, Roblick U, Jungbluth T, Fischer F, Bruch HP. Surgical intervention in acute upper gastrointestinal bleeding. Chirurg. 2010;81(10):922–9.
Vreeburg EM, Snel P, de Bruijne JW, Bartelsman JFWM, Rauws EAJ, Tytgat GNJ. Acute upper gastrointestinal bleeding in the Amsterdam area: incidence, diagnosis, and clinical outcome. Am J Gastroenterol. 1997;92:236–43.
Langner I, Langner S, Partecke LI, Glitsch A, Kraft M, Bernstorff W, Hosten N. Acute upper gastrointestinal hemorrhage: is a radiological interventional approach an alternative to emergency surgery? Emerg Radiol. 2008;15(6):413–9. (Epub 2008 May 30).
Das A, Wong RC. Prediction of outcome in acute lower gastrointestinal hemorrhage: role of artificial neural network. Eur J Gastroenterol Hepatol. 2007;19(12):1064–9. Review.
Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol. 1998;93:1202–8.
McGuire HH Jr. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg. 1994;220:653–6.
Stabile BE, Stamos MJ. Surgical management of gastrointestinal bleeding. Gastroenterol Clin North Am. 2000;29:189–222.
Leitman IM, Paull DE, Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg. 1989;209:175–80.
Farner R, Lichliter W, Kuhn J, Fisher T. Total colectomy versus limited colonic resection for acute lower gastrointestinal bleeding. Am J Surg. 1999;178:587–91.
Vernava AM 3rd, Moore BA, Longo WE, Johnson FE. Lower gastrointestinal bleeding. Dis Colon Rectum. 1997;40:846–58.
Cohn SM, Moller BA, Zieg PM, Milner KA, Angood PB. Angiography for preoperative evaluation in patients with lower gastrointestinal bleeding: are the benefits worth the risks? Arch Surg. 1998;133:50–5.
Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med. 1994;331:717–27.
Walsh RM, Anain P, Geisinger M, Vogt D, Mayes J, Grundfest-Broniatowski S, Henderson JM. Role of angiography and embolization for massive gastroduodenal hemorrhage. J Gastrointest Surg. 1999;3:61–5.
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Friebe, B., Wieners, G. Radiographic techniques for the localization and treatment of gastrointestinal bleeding of obscure origin. Eur J Trauma Emerg Surg 37, 353–363 (2011). https://doi.org/10.1007/s00068-011-0128-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00068-011-0128-z