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Management of Acute Lower

Gastrointestinal Bleeding
Ethan J. Speir, BS, R. Mitchell Ermentrout, MD, and Jonathan G. Martin, MD

Acute lower gastrointestinal bleeding (LGIB), defined as hemorrhage into the gastro-
intestinal tract distal to the ligament of Treitz, is a major cause of morbidity and mortality
among adults. Overall, mortality rates are estimated between 2.4% and 3.9%. The most
common etiology for LGIB is diverticulosis, implicated in approximately 30% of cases,
with other causes including hemorrhoids, ischemic colitis, and postpolypectomy
bleeding. Transcatheter visceral angiography has begun to play an increasingly
important role in both the diagnosis and treatment of LGIB. Historically, transcatheter
visceral angiography has been used to direct vasopressin infusion with embolization
reserved for treatment of upper gastrointestinal bleeding. However, advances in micro-
catheter technology and embolotherapy have enabled super-selective embolization to
emerge as the treatment of choice for many cases of LGIB.
Tech Vasc Interventional Rad ]:]]]-]]] C 2017 Elsevier Inc. All rights reserved.

KEYWORDS Acute lower gastrointestinal bleeding, hemorrhage, embolization

Clinical Evaluation/Indication 2 modalities are given equal appropriateness ratings by


ACR Criteria, CTA is preferred at our institution as this
Initial management of a patient presenting with acute modality has greater accuracy in localizing the source of
lower gastrointestinal bleeding (LGIB) should focus on the hemorrhage2 in addition to providing valuable ancil-
securing intravenous access and initiating fluid resuscita- lary data regarding patient anatomy and underlying
tion with crystalloids or blood products if necessary. Any pathology. Furthermore, recent data from within our
underlying coagulopathy or thrombocytopenia should be institution indicates that positive findings on CTA are
promptly corrected. corroborated on transcatheter visceral angiography (TVA)
Further evaluation of the patient’s clinical status will significantly more often compared to RBC scintigraphy.
direct management. A valuable method for categorizing For patients presenting with LGIB and hemodynamic
patient status is described in the American College of instability, defined as systolic blood pressure ≤90 mmHg,
Radiology (ACR) Appropriateness Criteria.1 Based upon or who require more than 5 units of blood, ACR Criteria
these criteria, patients presenting with hematochezia or indicates that the most appropriate intervention is TVA.
melena who are hemodynamically stable should first Even in these patients, however, we will perform a pre-
undergo colonoscopy. However, endoscopic evaluation procedural CTA if it can be completed without delay of
may be limited by either inadequate bowel preparation or TVA.
due to active bleeding, which can obscure visualization of
colonic mucosa. In these patients, noninvasive radio-
graphic studies such as computed tomography angiogra-
phy (CTA) and 99mTechnetium-labeled red blood cell
(RBC) scintigraphy can be performed. Although these Contraindications
There are no absolute contraindications for TVA, partic-
ularly when a patient is presenting with life-threatening
Department of Radiology and Imaging Sciences, Emory University LGIB. For patients with a history of severe contrast allergy,
Hospital, Emory University School of Medicine, Atlanta, GA.
pre-treatment with corticosteroids can be considered, and
Address reprint requests to Ethan J. Speir, Department of Radiology and
Imaging Sciences, Emory University Hospital, Emory University intubation for airway protection should be considered.
School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322. E-mail: Alternatively, carbon dioxide (CO2) may be used as a
ethan.speir@emory.edu contrast agent.3
1089-2516/14/$ - see front matter & 2017 Elsevier Inc. All rights reserved. 1
http://dx.doi.org/10.1053/j.tvir.2017.10.005
2 E.J. Speir et al.
Equipment Needed (tPA).9 At our institution, however, this approach is
typically reserved for patients with obscure LGIB who
The choice of equipment used for super-selection
have repeatedly negative TVAs.
of mesenteric arteries will often depend on product
availability, patient anatomy, and physician preference.
A wide range of guide and microcatheter systems are used
at our institution. Recognizing and Treating
Available embolic agents for super-selective emboliza- Complications
tion (SSE) include Gelfoam (Pharmacia and Upjohn Co,
Complications from TVA include those associated with
Kalamazoo, MI), particles, microcoils, n-butyl cyanoacry-
arteriography and include bleeding, hematoma, or
late (NBCA) glue (Codman Neuro, Warren NJ), and
pseudoaneurysm at the at the access site. Although
ethylene vinyl alcohol copolymer (Onyx) (ev3, Plymouth,
nontarget embolization may occur, a more common
MN). In the absence of robust clinical trials comparing the
complication of SSE is bowel ischemia. This occurs
relative efficacy of embolic agents, operator preference
more often in the lower gastrointestinal tract due to the
often dictates which agent is used. Microcoils are the most
lack of extensive collateral networks seen in the upper
commonly used embolic agent at our intuition. However,
tract. Minor ischemia manifesting as abdominal pain
there are particular clinical situations in which other
with or without increase in serum lactic acid levels is
embolics may be preferred. If bleeding is nonfocal or if
not uncommon. Major ischemia requiring surgical
the microcatheter cannot be advanced directly adjacent to
resection occurs in 1.3%-5% of patients.10,11 Risk of
the bleed, flow-directed polyvinyl alcohol of a minimum
ischemia is directly proportional to the extent of
size of 300 μm may be used.4 For patients with uncorrect-
vascular territory embolized with animal models show-
able coagulopathy, the use of a liquid casting agent such as
ing a substantially increased risk when ≥4 vasa recta
NBCA or Onyx may be considered as these agents do not
are embolized.12,13
require thrombus formation in order to create vessel
occlusion.5,6
Clinical Follow-Up
Overcoming Technical In addition to monitoring for access site complications,
Challenges clinical observation should focus on hemodynamic
Distinguishing a true source of hemorrhage on TVA may be status and serial hemoglobin and hematocrit levels to
difficult especially when patient motion or peristaltic bowel determine if there is continued resolution of bleeding.
activity results in misleading artifacts on digital subtraction Stool character is a less reliable predictor of persistent
angiography. Reviewing suspicious findings on nonsub- bleeding as continued passage of blood may represent
tracted imaging may alleviate uncertainty in this setting. residua of earlier bleeding. Routine monitoring of
Additionally, administration of 1 mg intravenous glucagon serum lactic acid is not necessary following emboliza-
prior to TVA will often successfully arrest bowel peristalsis. tion but is appropriate if the patient develops severe
Occasionally, extravasation seen during evaluation of a and progressive abdominal pain. Temporary abdominal
parent vessel may not be able to be reproduced after pain or a transient rise in lactic acid warrants further
further selection is performed. This may be due to evaluation if either fails to resolve. Cross-sectional
temporary vasospasm of the bleeding vessel. If vasospasm imaging or endoscopy may be necessary to assess for
is suspected, an aliquot of 100-200 μg of nitroglycerine bowel infarction.
can be injected intra-arterially.
Given the intermittent nature of LGIB, a frequent
challenge encountered during TVA is inability to corrob- Expected Outcomes
orate positive findings observed on preprocedural imag- TVA with SSE is highly effective in treating acute LGIB
ing. For example, given the high sensitivity of RBC with technical success rates as high as 96.4%-100%.14,15
scintigraphy along with its prolonged acquisition time, Clinical success rates are somewhat lower, ranging from
PPV for this modality has been reported to be as low as 63.0%-91.2%, often due to rebleeding following emboli-
24%.7 In the setting of nonrevealing TVA, one may zation.15,16 Notably, thrombocytopenia prior to SSE is
consider the use of CO2 contrast. The extremely low strongly associated with clinical failure.17
viscosity of CO2 allows for easy delivery through even the
smallest diameter microcatheters and, as some have
argued, may even confer a higher sensitivity for active
LGIB.3 Alternatively, use of cone-beam CT with accom-
Case 1
panying vessel-tracking software, if available, may improve A 91-year-old man with a history of bladder cancer,
detection of bleeding and expedite selection of the culprit prostate cancer, and diverticular bleeding presented from
vessel.8 Finally, one may consider provocative angiogra- an outside rehabilitation facility with hematochezia.
phy using systemic heparinization and selective injection Upon presentation, the patient had a blood pressure of
of a vasodilator along with tissue plasminogen activator 115/65 and required 3 units of packed RBCs within a 24-
Acute LGIB 3

A B

C D

Figure 1 : (A) Axial abdominal CTA obtained during the arterial phase demonstrating pooling of contrast in the
mid-portion of the sigmoid colon (arrow) consistent with active bleeding. (B) DSA of the IMA without definite
evidence of active extravasation. (C) Super-selective DSA demonstrating active extravasation from distal branches
of the IMA supplying the rectosigmoid region (circle). (D) Super-selective embolization performed with a single
microcoil (arrow) placed as proximal to the source of bleeding as possible with resulting hemostasis.

hour time period. Given the patients hemodynamic It was then used to select the inferior mesenteric
stability, he first underwent colonoscopy, which revealed artery (IMA). Arteriography was performed through the
fresh blood along the mucosa of the sigmoid colon along Mickelson catheter in the IMA with an injection rate of
with multiple diverticula. However, no site of active 3 mL/s without definite evidence of active extravasation
hemorrhage was able to be identified. A CTA was (Fig 1B).
subsequently performed showing pooling of contrast in Given the focally positive CTA findings, targeted inves-
the midportion of the sigmoid colon on arterial phase tigation for a bleeding source was performed with micro-
consistent with acute bleeding (Fig. 1A). The patient was catheter evaluation. A 2.4 Fr angled Renegade STC-18
brought to interventional radiology for TVA with possible (Boston Scientific, Marlborough, MA) microcatheter was
embolization. advanced over a 0.016′′ Fathom (Boston Scientific, Marl-
Under ultrasound guidance, the right common femoral borough, MA) microwire into branches of the IMA. Super-
artery was accessed using a micropuncture needle. selective arteriography was performed demonstrating
A 0.018′′ Nitinol wire was advanced through the needle active extravasation from distal branches supplying the
into the artery and the needle was exchanged for a 5 Fr. rectosigmoid region (Fig. 1C). Further selection of these
transitional catheter. The wire and inner dilator were branches was performed with a 1.9 Fr. Echelon (Med-
removed and a 0.035′′ Bentson wire was advanced into tronic, Irvine, CA) microcatheter and a 0.018′′ double
the artery. The transitional catheter was exchanged for a angle GT (Terumo, Tokyo, Japan) microwire. Super-
5 Fr. Pinnacle (Terumo, Tokyo, Japan) vascular introducer selective coil embolization of a sixth order branch was
sheath, and the sheath was attached to a heparinized, then performed with a single 2 mm × 4 cm Concerto
pressurized bag of saline. A 5 Fr Mickelson (Cook Medical (Covidien, Dublin, Ireland) microcoil placed as proximate
Inc, Bloomington, IN) catheter was advanced over to the source of bleeding as possible (Fig. 1D). Postembo-
the Bentson wire and formed in the abdominal aorta. lization arteriography of this vessel demonstrated
4 E.J. Speir et al.

A B

C D

Figure 2 : (A) RBC scintigraphy with intense radiotracer uptake within the cecal lumen (arrow) consistent with
active large bowel gastrointestinal bleed in this region. (B) DSA of the superior mesenteric artery (SMA) showing a
focal area of blush in the right colon (arrow). (C) DSA of branches of the ileocolic artery following super-selection
redemonstrating of the area of extravasation (arrow). (D) Postembolization DSA shows an NBCA cast filling the
culprit ileocolic branch (arrow) with resultant resolution of active hemorrahage (circle).

hemostasis. A right common femoral angiogram was was brought to interventional radiology for TVA with
obtained through the sheath to evaluate the location of possible embolization.
the arterial access site. An Angio-Seal (Terumo, Tokyo, Under ultrasound guidance, the right common femoral
Japan) device was deployed at the arteriotomy resulting in artery was accessed using a micropuncture needle. This
immediate hemostasis. was upsized to a 5 Fr Pinnacle (Terumo, Tokyo, Japan)
vascular introducer sheath using the method described in
the preceding case. Through the sheath, a 5 Fr Sim-1
Glidecath (Terumo, Tokyo, Japan) was advanced over a
Case 2 Bentson wire into the abdominal aorta. The reverse curve
A 62-year-old man with a remote history of upper gastro- was subsequently formed using a Tevdek (Teleflex,
intestinal bleeding due to hemorrhagic gastritis presented Gurnee, IL) suture for traction, and the celiac artery
to the emergency department following 2 episodes of was engaged. Arteriography was performed showing
bright red blood per rectum. His blood pressure remained normal anatomy without evidence of extravasation. Next,
stable at 120/80 following initiation of crystalloids and he the superior mesenteric artery was selected and arteriog-
did not require blood transfusion. Despite his history, raphy performed. Active bleeding was identified with a
LGIB was presumed given bright red blood per rectumin focal area of blush in the right colon supplied by ileocolic
the setting of hemodynamic stability. As such, a RBC arterial branches (Fig. 2B). Based on these findings, an
scintigraphy study was performed at the request of the Echelon 14 (Medtronic, Irvine, CA) microcatheter was
emergency medicine physician prior to interventional advanced over a 0.014′′ Transend (Stryker Neurovascu-
radiology consultation. The study demonstrated radio- lar, Fremont, CA) microwire into the ileocolic artery. This
tracer uptake within the cecum consistent with active was then used to super-select branches of the ileocolic
bleeding (Fig. 2A). Based upon these findings, the patient artery (Fig. 2C).
Acute LGIB 5
Once the culprit vessel was catheterized, there was 6. Jae HJ, Chung JW, Jung AY, et al: Transcatheter arterial embolization
difficulty advancing the microcatheter across the origin of nonvariceal upper gastrointestinal bleeding with N-butyl cyanoa-
of the bleed. Due to the proximal microcatheter position- crylate. Korean J Radiol 1:48-56, 2007
7. Yi WS, Garg G, Sava JA: Localization and definitive control of lower
ing, combined with a desire to embolize across the gastrointestinal bleeding with angiography and embolization. Am
bleeding origin and operator familiarity with the ability Surg 4:375-380, 2013
to advance glue farther in to the target vessel, glue 8. Ierardi AM, Urbano J, De Marchi G, et al: New advances in lower
embolization was performed with approximately gastrointestinal bleeding management with embolotherapy. Br J
0.25 mL of NBCA glue diluted 1:3 in Lipiodol (Guerbert, Radiol 1061:20150934, 2016
9. Kim CY, Suhocki PV, Miller MJ Jr., et al: Provocative mesenteric
Villepinte, France). This mixture ratio was chosen based
angiography for lower gastrointestinal hemorrhage: Results from a
upon evidence describing NBCA polymerization times.18 single-institution study. J Vasc Interv Radiol 4:477-483, 2010
To prevent catheter adhesion, care was taken to gently pull 10. Kickuth R, Rattunde H, Gschossmann J, et al: Acute lower gastro-
back the catheter during injection and, once the NBCA had intestinal hemorrhage: Minimally invasive management with micro-
infiltrated the appropriate vascular distribution, the cath- catheter embolization. J Vasc Interv Radiol 9 2008 1289-96.e2
11. Lipof T, Sardella WV, Bartus CM, et al: The efficacy and durability of
eter was quickly removed. Postembolization angiography
super-selective embolization in the treatment of lower gastrointes-
was performed demonstrating adequate hemostasis tinal bleeding. Dis Colon Rectum 3:301-305, 2008
(Fig. 2D). Angiography of the right common femoral 12. Ikoma A, Kawai N, Sato M, et al: Ischemic effects of transcatheter
arterial access site was performed through the vascular arterial embolization with N-butyl cyanoacrylate-lipiodol on the
sheath to document access site. Finally, the arteriotomy colon in a Swine model. Cardiovasc Intervent Radiol 5:1009-1015,
was closed using a VASCADE (Cardiva Medical, Inc, Santa 2010
13. Jae HJ, Chung JW, Kim HC, et al: Experimental study on acute
Clara, CA) closure device.
ischemic small bowel changes induced by superselective emboliza-
tion of superior mesenteric artery branches with N-butyl cyanoa-
References crylate. J Vasc Interv Radiol 5:755-763, 2008
1. Darcy MD, Cash BD, Feig, BW, et al: American College of Radiology 14. Hur S, Jae HJ, Lee M, et al: Safety and efficacy of transcatheter
ACR Appropriateness Criteria® Radiologic Management of Lower arterial embolization for lower gastrointestinal bleeding: A single-
Gastrointestinal Tract Bleeding. Available from: https://acsearch.acr. center experience with 112 patients. J Vasc Interv Radiol 1:10-19,
org/docs/69457/Narrative/. 2014
2. Feuerstein JD, Ketwaroo G, Tewani SK, et al: Localizing acute lower 15. Koh DC, Luchtefeld MA, Kim DG, et al: Efficacy of transarterial
gastrointestinal hemorrhage: CT angiography versus tagged RBC embolization as definitive treatment in lower gastrointestinal bleed-
scintigraphy. AJR Am J Roentgenol 3:578-584, 2016 ing. Colorectal Dis 1:53-59, 2009
3. Back MR, Caridi JG, Hawkins IF Jr, et al: Angiography with carbon 16. Tan KK, Wong D, Sim R: Superselective embolization for lower
dioxide (CO2). Surg Clin North Am 4:575-591, 1998 gastrointestinal hemorrhage: An institutional review over 7 years.
4. Urbano J, Manuel Cabrera J, Franco A, et al: Selective arterial World J Surg 12:2707-2715, 2008
embolization with ethylene-vinyl alcohol copolymer for control of 17. Chan DK, Soong J, Koh F, et al: Predictors for outcomes after super-
massive lower gastrointestinal bleeding: Feasibility and initial expe- selective mesenteric embolization for lower gastrointestinal tract
rience. J Vasc Interv Radiol 6:839-846, 2014 bleeding. ANZ J Surg 6:459-463, 2016
5. Guimaraes M, Wooster M: Onyx (ethylene-vinyl alcohol copolymer) 18. Pollak JSWhite RI Jr: The use of cyanoacrylate adhesives in
in peripheral applications. Semin Intervent Radiol 3:350-356, 2011 peripheral embolization. J Vasc Interv Radiol 8:907-913, 2001