Angiographic control of nonvariceal gastrointestinal bleeding in adults
- Jonathan B Kruskal, MD, PhD
Jonathan B Kruskal, MD, PhD
- Section Editor — Kidney Disease
- Professor of Radiology
- Harvard Medical School
- Felipe B Collares, MD
Felipe B Collares, MD
- Instructor in Radiology
- Harvard Medical School
In the overwhelming majority of patients with upper or lower gastrointestinal (GI) bleeding, the bleeding either resolves spontaneously or can be controlled endoscopically. However, some patients have persistent or recurrent bleeding. Persistent or recurrent bleeding occurs in 7 to 16 percent of patients with upper GI bleeding  and in up to 25 percent of patients with lower GI bleeding [2,3]. Such patients may require angiographic intervention to locate and/or to treat the source of bleeding. Arterial GI bleeding can be controlled by selective embolization of the bleeding artery with coils or particulate matter, selective arterial infusion of vasoconstrictive drugs, or by a combination of these techniques.
This topic will review the angiographic methods available to control upper and lower GI bleeding. The diagnosis of upper and lower GI bleeding, as well as the endoscopic and surgical methods used to control GI bleeding, are discussed separately. (See "Approach to acute upper gastrointestinal bleeding in adults" and "Approach to acute lower gastrointestinal bleeding in adults" and "Overview of the treatment of bleeding peptic ulcers" and "Colonic diverticular bleeding" and "Angiodysplasia of the gastrointestinal tract".)
Angiographic control of gastrointestinal (GI) bleeding is indicated for patients with upper or lower GI bleeding who fail to respond to medical and/or endoscopic therapy. In patients with upper GI bleeding, angiographic control of bleeding is generally considered if endoscopic attempts at therapy have failed . In patients with lower GI bleeding, angiographic control of bleeding is used as an alternative to surgery in hemodynamically unstable patients with severe bleeding or for patients with ongoing or recurrent bleeding following attempts to control the bleeding endoscopically [4,5]. (See "Overview of the treatment of bleeding peptic ulcers", section on 'Interventional angiography' and "Colonic diverticular bleeding", section on 'Angiography'.)
In most cases, angiographic control of gastrointestinal (GI) bleeding requires that the site of bleeding first be identified. This can be done with endoscopy, nuclear scintigraphy (tagged red blood cell scan), computed tomographic angiography, or standard angiography. These diagnostic tests are discussed in detail elsewhere. (See "Approach to acute lower gastrointestinal bleeding in adults", section on 'Diagnostic studies' and "Approach to acute upper gastrointestinal bleeding in adults", section on 'Upper endoscopy'.)
Prior to attempting angiographic bleeding control, the bleeding vessel(s) are identified angiographically. Optimally, prior to undergoing angiography, patients should have a serum creatinine less than 1.5 mg/dL with an estimated glomerular filtration rate greater than 60 mL/min/1.73 m2, an international normalized ratio (INR) less than 1.5, and a platelet count greater than 50,000/mm3 . If needed, fresh frozen plasma or platelets should be transfused prior to or during the procedure.
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- LESION LOCALIZATION
- ANGIOGRAPHIC THERAPIES
- - Indications
- - Agents
- - Technique
- - Complications
- Intra-arterial vasopressin
- - Technique
- - Complications
- Choice of therapy
- Management of rebleeding
- Efficacy of embolization
- Efficacy of intra-arterial vasopressin
- SUMMARY AND RECOMMENDATIONS