Provocative Angiography

  • Mayur B. Patel
  • Charles Y. Kim
  • Michael J. Miller


Determination of the site and etiology of lower gastrointestinal (GI) bleeding may lead to frustration for internists, gastroenterologists, surgeons, diagnostic, and interventional radiologists. The intermittent nature, variable severity, and changes in patient hemodynamic status can result in multiple rounds of diagnostic imaging without an answer. This is especially true in the setting of negative upper endoscopy and limited lower endoscopy due to the amount of blood within the colon. Despite significant blood loss, traditional diagnostic examinations such as tagged red cell scans may be negative or positive without definitive localization of the responsible site. Mesenteric angiography is the definitive imaging tool for localization of the bleeding site. This can, however, lend to confusion when multiple vascular lesions are identified without visible bleeding. With the addition of super-selective microcatheter embolization, angiography has become both diagnostic and therapeutic, and in many institutions, the first-line intervention for the management of lower GI bleeding. The main limitations of angiographic detection are the temporal relation of the arteriogram to the intermittent nature of the bleed, as well as the volume of bleeding. To help improve the sensitivity of angiography, practices have combined catheter-based delivery of pharmacologic agents with intermittent angiography in hopes of increasing the yield of angiography without compromising safety or efficacy. Now, known as provocative angiography, this technique has been applied to assess fore-, mid-, and hindgut bleeding that is refractory to traditional diagnostic and therapeutic modalities.


Methylene Blue Bleeding Site Fibrinolytic Agent Intermittent Nature Mesenteric Angiography 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Rösch J, Keller FS, Wawrukiewicz AS, Krippaehne WW and Dotter CT. Pharmaco-angiography in the diagnosis of recurrent massive lower gastrointestinal bleeding. Radiology 1982 Dec;145(3):615–619.PubMedGoogle Scholar
  2. 2.
    Koval G, Benner KG, Rösch J and Kozak BE. Aggressive angiographic diagnosis in acute lower gastrointestinal hemorrhage. Dig Dis Sci 1987 Mar;32(3):248–253.CrossRefPubMedGoogle Scholar
  3. 3.
    Glickerman DJ, Kowdley KV and Rosch J. Urokinase in gastrointestinal tract bleeding. Radiology 1988 Aug;168(2):375–376.PubMedGoogle Scholar
  4. 4.
    Mernagh JR, O’Donovan N, Somers S, Gill G and Sridhar S. Use of heparin in the investigation of obscure gastrointestinal bleeding. Can Assoc Radiol J 2001 Aug;52(4):232–235.PubMedGoogle Scholar
  5. 5.
    Malden ES, Hicks ME, Royal HD, Aliperti G, Allen BT and Picus D. Recurrent gastrointestinal bleeding: use of thrombolysis with anticoagulation in diagnosis. Radiology 1998 Apr;207(1):147–151.PubMedGoogle Scholar
  6. 6.
    Bloomfeld RS, Smith TP, Schneider AM and Rockey DC. Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin. Am J Gastroenterol 2000 Oct;95(10):2807–2812.CrossRefPubMedGoogle Scholar
  7. 7.
    Ryan JM, Key SM, Dumbleton SA and Smith TP. Nonlocalized lower gastrointestinal bleeding: provocative bleeding studies with intraarterial tPA, heparin, and tolazoline. J Vasc Interv Radiol 2001 Nov;12(11):1273–1277.CrossRefPubMedGoogle Scholar
  8. 8.
    Widlus DM and Salis AI. Reteplase provocative visceral arteriography. J Clin Gastroenterol 2007 Oct;41(9):830–833.CrossRefPubMedGoogle Scholar
  9. 9.
    Glickerman DJ, Kowdley KV and Rosch J. Urokinase in gastrointestinal tract bleeding. Radiology 1988 Aug;168(2):375–376.PubMedGoogle Scholar
  10. 10.
    Shetzline MA, Suhocki P, Dash R and Rockey DC. Provocative angiography in obscure gastrointestinal bleeding. South Med J 2000 Dec;93(12):1205–1208.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Mayur B. Patel
    • 1
  • Charles Y. Kim
    • 2
  • Michael J. Miller
    • 2
  1. 1.General Surgery Residency Training ProgramDuke University Medical CenterDurhamUSA
  2. 2.Department of RadiologyDuke University Medical CenterDurhamUSA

Personalised recommendations