RadioGraphics
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Quicktime Video
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Hastings, G. S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Hastings, G. S.
Related Collections
Right arrow Gastrointestinal Radiology
Right arrow Vascular and/or Interventional Radiology
(Radiographics. 2000;20:1160-1168.)
© RSNA, 2000

PLENARY SESSION

Angiographic Localization and Transcatheter Treatment of Gastrointestinal Bleeding1

Geoffrey S. Hastings, MD

1 From the Department of Diagnostic Imaging, Division of Interventional Radiology, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201-1595. From the Plenary Session, Friday Imaging Symposium: Algorithmic Controversies, at the 1999 RSNA scientific assembly. Received February 24, 2000; revision requested March 27 and received April 12; accepted April 14. Address correspondence to the author (e-mail: ghastings@rad1.ummc.umaryland.edu).

Index Terms: Angiography, comparative studies, 70.124 • Gastrointestinal tract, angiography, 70.124 • Gastrointestinal tract, hemorrhage, 95.71 • Gastrointestinal tract, radionuclide studies, 70.12178

Introduction

Most gastrointestinal hemorrhage stops spontaneously, but in approximately 25% of cases, imaging and directed treatment are required because bleeding is massive or recurrent (1). A site-specific diagnosis is extremely important in these patients because it can help determine whether a localized, minimally invasive procedure or a large, blind resection (eg, subtotal colectomy) is performed. This, in turn, has a profound influence on morbidity and mortality (2).

Gastrointestinal bleeding is typically intermittent and must be "caught in the act" to be localized; thus, proper timing is both critical and difficult. Diagnostic imaging and transcatheter treatment exist in the context of nonradiologic modalities such as clinical assessment, diagnostic and therapeutic endoscopy, and surgery. All of these diagnostic tests vary in their capacity to help detect hemorrhage over time, localize the hemorrhage precisely, and determine the causative lesion. The rate and pattern of the patient's bleeding are crucial in deciding which tests to use as well as their timing and sequence. Such decision making is an essential component of any comparison between the two complementary modalities of arteriography and scintigraphy.

In this article, the current status of angiographic diagnosis of gastrointestinal hemorrhage is addressed, and the use of angiography is compared with that of scintigraphy in this setting. In addition, transcatheter treatment of gastrointestinal hemorrhage is discussed.

Arteriography versus Scintigraphy in Gastrointestinal Hemorrhage

The use of arteriography can be compared with that of scintigraphy in gastrointestinal bleeding with respect to sensitivity, accuracy, and patient outcome. Canine studies have shown that sulfur colloid scanning can help detect bleeding at rates as low as 0.05–0.1 mL/min (3). Studies of transfusion requirements have shown that red blood cell scanning can help detect bleeding rates as low as 0.2–0.4 mL/min (4). Screen-film arteriography can demonstrate bleeding at rates as low as 0.5 mL/min in a canine model (5), but in vitro studies suggest that digital subtraction arteriography is five to nine times more sensitive than screen-film arteriography in detecting hemorrhage (6). Thus, there is no clear "winner" in terms of theoretic limits of detection, so clinical sensitivity becomes a more important issue.

Early scintigraphic studies from the late 1970s and early 1980s demonstrated sensitivities greater than 90% for gastrointestinal bleeding (7–10); later studies from the 1990s demonstrated sensitivities in the 20%–60% range (11–14). Because patients with a negative scan and no rebleed were excluded from the denominator in the earlier studies, sensitivities are hard to compare; the percentage of positive scans provides an easier comparison. More disturbing was the fact that only 41%–54% of positive scans in the later studies helped correctly identify the bleeding site, leading to incorrect surgical procedures in 42% of patients in one series (12). One recent study showed an 88% accuracy in localization of the bleeding site, probably due to frequent image acquisition (every 5–10 minutes) (15). Dynamic scanning is performed with even more frequent image acquisition (every 10–15 seconds), further improving the accuracy of localization. The clinical sensitivity of arteriography varies widely, ranging from 22% to 87%, with typical values of about 60%; however, localization accuracy is essentially 100% (16–19) (Table 1). A less widely recognized use of arteriography involves the patient whose diagnosis remains occult despite his or her having undergone all the other conventional tests. Two studies performed a decade apart showed that arteriography allowed a correct diagnosis in 44% and 45% of such patients, respectively (20,21).


View this table:
[in this window]
[in a new window]

  		TABLE 1. Results of Selected Scintigraphic and Arteriographic Studies of the Diagnosis of Gastrointestinal Hemorrhage
 
Still, with such widely varying numbers and no good prospective comparison of the two techniques, neither arteriography nor scintigraphy is clearly superior in terms of clinical sensitivity or theoretic limits of detection. Thus, additional work has focused on two questions: (a) what clinical or imaging findings are predictive of a positive angiogram, and (b) what can be done to increase the yield of positive findings when an angiogram is negative?

As for the first question, two factors have been studied: hemodynamic instability and positive scintigraphic findings. Hemodynamic instability is very helpful in predicting a positive angiogram, with one study finding a perfect correlation (r = 1) between systolic blood pressure of less than 100 mm Hg and a positive arteriogram (22). The results for scintigrams that demonstrate bleeding are more mixed. The yield of positive angiographic findings after a positive scintigram is 44%–54% (11,14,19). In one series, the yield of positive angiographic findings after a negative scintigram was 44% (14). Another study showed that a positive scintigram increased the likelihood of a positive angiogram from 22% to 53% (19). What is not addressed by these studies is the potential downside of waiting for a nuclear medicine study; that is, how many potentially positive arteriograms became negative because the patient stopped bleeding during the delay caused by the nuclear medicine scan? To answer this question would require a large prospective study. In deciding which examination to use first, we are left with this rule of thumb: Hemodynamically unstable patients should immediately undergo angiography, whereas hemodynamically stable patients should first undergo nuclear medicine imaging.

Several techniques have been used to improve the sensitivity of arteriography in gastrointestinal bleeding. Pharmacoangiographic techniques that make use of heparin, vasodilators, and thrombolytic agents may increase the yield of diagnostic arteriographic findings by up to 33% (17,23,24). Hybrid angioscintigraphy, wherein sulfur colloid is injected into a mesenteric vessel and monitored with a gamma camera, has proved helpful in other series (25). Findings at carbon dioxide arteriography may be positive when those at conventional arteriography are negative, probably because the lower viscosity of carbon dioxide allows it to extravasate more easily through a smaller hole in the vessel (26–28). Computed tomography (CT) performed either after arteriography (29) or with intraarterial contrast material has been helpful in still other series (30). A recent study based on a porcine model suggests that CT performed with rapid bolus intravenous administration of contrast material, CT can help detect hemorrhage at a rate of less than 0.1 mL/min (31).

Ultimately, a comparison of arteriography and scintigraphy comes down to the issue of patient outcome. As mentioned previously, incorrect identification of the bleeding site at scintigraphy has been problematic, sometimes leading to incorrect surgical procedures (11–14). On the other hand, arteriography as a strictly diagnostic modality has been clearly associated with improved patient outcome in several series, one of which showed a mortality of 50% without arteriography versus 14% with arteriography prior to surgery (17). Another series showed that a positive arteriogram allowed segmental resection with an associated mortality of 8.6%, whereas a negative arteriogram resulted in subtotal colectomy with an associated mortality of 37% (2).

Transcatheter Therapy for Gastrointestinal Hemorrhage

Probably the most important benefit of arteriography is the opportunity it affords for minimally invasive intervention such as vasopressin infusion, embolization, transjugular intrahepatic portosystemic shunt placement, and "tagging" for surgery. The technical aspects, safety, and efficacy of these techniques vary according to the cause of hemorrhage and the involved anatomic region. The use of transjugular intrahepatic portosystemic shunt placement for treatment of portal hypertensive hemorrhage is beyond the scope of this article. Vasopressin, infused at a first-order intraarterial level at a rate of 0.2–0.4 U/min for arteriolocapillary hemorrhage, is the best-studied agent. It is more useful in the lower than in the upper gastrointestinal tract due to differences in collateral networks (32). Embolization has been performed with a variety of agents selectively in the upper gastrointestinal tract and superselectively in the lower gastrointestinal tract. Tagging with coils or with a catheter left in place for infusion of methylene blue stain at surgery can be helpful when lesion resection is required (33,34). The results of selected studies are summarized in Table 2.


View this table:
[in this window]
[in a new window]

  		TABLE 2. Results of Selected Studies of Transcatheter Control of Gastrointestinal Hemorrhage
 
Arterial hemorrhage in the upper gastrointestinal tract is most often due to gastritis, Mallory-Weiss tear (Fig 1), or peptic ulcer disease. It most often manifests as hematemesis, but 10% of rectal bleeding has an upper gastrointestinal source (32). Endoscopy is not only the most reliable means of distinguishing upper from lower gastrointestinal hemorrhage; it can also often help identify and treat upper gastrointestinal sources. As a result, upper gastrointestinal hemorrhage is currently less commonly seen at arteriography than is lower gastrointestinal bleeding, and the lesions tend to be unusual ones such as biliary and pancreatic lesions (Fig 2), tumors, aortoenteric fistulas, and the like. In the upper gastrointestinal tract (except when it is interrupted by surgery), there is a rich network of collateral vessels; consequently, ischemic complications are very rare, but backbleeding can be problematic (Fig 3). Thus, embolization is more effective than vasopressin infusion and is generally bast performed selectively rather than superselectively (32).



View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1.   Hemorrhage from a Mallory-Weiss tear. Angiogram demonstrates hemorrhage caused by a Mallory-Weiss tear appearing as a small focus of extravasated contrast material (arrow).

 


View larger version (107K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2.   Stent-related upper gastrointestinal bleeding. Angiogram shows brisk hemorrhage from the main trunk of the right hepatic artery due to erosion from an endoscopically placed stent (Wallstent; Schneider, Minneapolis, Minn). Note the presence of extravasated contrast material in the common duct and duodenum (arrows).

 


View larger version (140K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3a.   Arterial pseudoaneurysm in the upper gastrointestinal tract. Angiograms demonstrate a pseudoaneurysm in the pancreaticoduodenal artery (arrow) supplied by the celiac (a) and superior mesenteric (b) arteries. As with many upper gastrointestinal lesions, more than one source of blood supply must be taken into account before initiation of transcatheter therapy. In this case, embolization of the superior and inferior pancreaticoduodenal arteries would be necessary to "trap" the pseudoaneurysm and prevent backbleeding.

 


View larger version (149K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3b.   Arterial pseudoaneurysm in the upper gastrointestinal tract. Angiograms demonstrate a pseudoaneurysm in the pancreaticoduodenal artery (arrow) supplied by the celiac (a) and superior mesenteric (b) arteries. As with many upper gastrointestinal lesions, more than one source of blood supply must be taken into account before initiation of transcatheter therapy. In this case, embolization of the superior and inferior pancreaticoduodenal arteries would be necessary to "trap" the pseudoaneurysm and prevent backbleeding.

 
Bleeding from the small bowel is less common than bleeding from the upper gastrointestinal tract or colon, and the underlying cause is more difficult to diagnose (46). Many referring surgeons prefer to resect the offending segment, and tagging with placement of either a microcatheter for infusion of methylene blue stain (Fig 4) or of a microcoil can help identify the segment and thus limit the extent of resection (33,34).



View larger version (129K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 4.   Preoperative tagging with microcatheter placement. Angiogram demonstrates hemorrhage from a jejunal diverticulum (arrow). Note the characteristic appearance of the jejunal folds. In this case, the referring surgeon preferred to resect the affected segment, so a microcatheter was placed in the responsible jejunal branch to allow tagging with injection of methylene blue stain in the operating room. At surgery, a 15-cm segment of diverticular jejunum was found and resected.

 
Colonic bleeding is most commonly due to diverticulosis (Fig 5) or angiodysplasia (Fig 6) (32). Collateral pathways are not as extensive in the lower gastrointestinal tract as in the upper gastrointestinal tract. Therefore, vasopressin is more effective in the former than in the latter, helping control 80%–90% of lower gastrointestinal hemorrhage, with a recurrence rate of approximately 20% (35,36). However, problems such as coronary and peripheral ischemia, water retention, hyponatremia, catheter dislodgement, and peripheral embolization can develop in up to 40% of patients (37). Early reports antedating the widespread availability of microcatheters for superselective embolization for lower gastrointestinal bleeding showed a 0%–15% rate of bowel infarction (38–42), but an aggregate of more recent studies in which superselective microcatheter techniques were used have shown no bowel infarcts and a 91% success rate in controlling bleeding, with a 12% recurrence rate (43–45). This procedure can be quite technically demanding. Spasm can cause problems, although vasodilator infusion or the use of flow-directed catheters can be helpful (47). Precise identification of the origin and course of the bleeding branch can also be difficult, but rotational arteriography (see movie at same URL as above) has proved helpful in clarifying tortuous anatomy (48).



View larger version (113K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 5a.   Colonic diverticular hemorrhage. (a) Angiogram demonstrates a small focus of extravasated contrast material near the hepatic flexure on the superior mesenteric artery "run" (arrow). A catheter was advanced into the right colic artery, and a rotational arteriogram was obtained to localize the origin and course of the responsible arterial branch (see movie at http://radiographics.rsnajnls.org/cgi/content/full/20/4/1160/DC1/index.htm). (b) Optimal oblique view helps pinpoint the location of the extravasation (arrow). (c) Angiogram shows the microcatheter positioned in the bleeding branch. (d) Angiogram demonstrates cessation of hemorrhage following embolization. (Reprinted, with permission, from reference 45.)

 


View larger version (94K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 5b.   Colonic diverticular hemorrhage. (a) Angiogram demonstrates a small focus of extravasated contrast material near the hepatic flexure on the superior mesenteric artery "run" (arrow). A catheter was advanced into the right colic artery, and a rotational arteriogram was obtained to localize the origin and course of the responsible arterial branch (see movie at http://radiographics.rsnajnls.org/cgi/content/full/20/4/1160/DC1/index.htm). (b) Optimal oblique view helps pinpoint the location of the extravasation (arrow). (c) Angiogram shows the microcatheter positioned in the bleeding branch. (d) Angiogram demonstrates cessation of hemorrhage following embolization. (Reprinted, with permission, from reference 45.)

 


View larger version (80K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 5c.   Colonic diverticular hemorrhage. (a) Angiogram demonstrates a small focus of extravasated contrast material near the hepatic flexure on the superior mesenteric artery "run" (arrow). A catheter was advanced into the right colic artery, and a rotational arteriogram was obtained to localize the origin and course of the responsible arterial branch (see movie at http://radiographics.rsnajnls.org/cgi/content/full/20/4/1160/DC1/index.htm). (b) Optimal oblique view helps pinpoint the location of the extravasation (arrow). (c) Angiogram shows the microcatheter positioned in the bleeding branch. (d) Angiogram demonstrates cessation of hemorrhage following embolization. (Reprinted, with permission, from reference 45.)

 


View larger version (97K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 5d.   Colonic diverticular hemorrhage. (a) Angiogram demonstrates a small focus of extravasated contrast material near the hepatic flexure on the superior mesenteric artery "run" (arrow). A catheter was advanced into the right colic artery, and a rotational arteriogram was obtained to localize the origin and course of the responsible arterial branch (see movie at http://radiographics.rsnajnls.org/cgi/content/full/20/4/1160/DC1/index.htm). (b) Optimal oblique view helps pinpoint the location of the extravasation (arrow). (c) Angiogram shows the microcatheter positioned in the bleeding branch. (d) Angiogram demonstrates cessation of hemorrhage following embolization. (Reprinted, with permission, from reference 45.)

 


View larger version (133K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 6a.   Hemorrhage due to angiodysplasia. (a) Early angiogram shows an abnormal tuft of vessels (arrow). (b) On a subsequent angiogram, the tuft is again seen (white arrow), along with characteristic early and prominent filling of the accompanying mesenteric vein (black arrow). Although such a lesion often responds to vasopressin infusion, this particular lesion was resected. (c) Angiogram of the resected specimen demonstrates the lesion, which is indicated by the needles.

 


View larger version (124K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 6b.   Hemorrhage due to angiodysplasia. (a) Early angiogram shows an abnormal tuft of vessels (arrow). (b) On a subsequent angiogram, the tuft is again seen (white arrow), along with characteristic early and prominent filling of the accompanying mesenteric vein (black arrow). Although such a lesion often responds to vasopressin infusion, this particular lesion was resected. (c) Angiogram of the resected specimen demonstrates the lesion, which is indicated by the needles.

 


View larger version (150K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 6c.   Hemorrhage due to angiodysplasia. (a) Early angiogram shows an abnormal tuft of vessels (arrow). (b) On a subsequent angiogram, the tuft is again seen (white arrow), along with characteristic early and prominent filling of the accompanying mesenteric vein (black arrow). Although such a lesion often responds to vasopressin infusion, this particular lesion was resected. (c) Angiogram of the resected specimen demonstrates the lesion, which is indicated by the needles.

 
Conclusions

A site-specific diagnosis is critical in patients with massive or recurrent gastrointestinal hemorrhage, but making such a diagnosis can be quite challenging due to the intermittent nature of gastrointestinal bleeding. Hemodynamic instability despite resuscitation is the best indicator of active bleeding. Diagnostic tests vary in their capacity to help detect hemorrhage over time and to allow precise localization. Arteriography has the advantage of allowing precise localization and minimally invasive transcatheter treatment but requires active hemorrhage at the moment that contrast material is injected. It is best suited to hemodynamically unstable patients in whom the likelihood of bleeding at the precise time of study is highest. Tc-99m–labeled red blood cell scanning can often help overcome the timing problems associated with arteriography but may lead to less precise (and sometimes misleading) localization and an inability to treat the patient. Scintigraphy is best suited to hemodynamically stable patients who may not be bleeding at the time the study is initiated but may begin bleeding while scanning is underway.

With timely response and appropriate patterns of referral and patient transport, a cooperative team can exploit the best qualities of each modality. Hemodynamically unstable patients should immediately undergo arteriography, whereas hemodynamically unstable patients should first undergo nuclear medicine imaging. The intensivist who diligently resuscitates a patient to achieve complete stability for transfer to arteriography or the nuclear medicine imager who sends a patient with a positive scan back to the intensive care unit instead of directly to the interventional radiology suite misses the window of opportunity for diagnosis. The opportunity for making a positive diagnosis and allowing minimally invasive treatment is squandered when an interventional radiology team does not respond promptly to a hemodynamically unstable patient with gastrointestinal bleeding. Such opportunities typically do not last long, nor do they resurface at a more convenient time. Conversely, arteriography in hemodynamically stable patients with low-volume hemorrhage is likely to be fruitless and is best reserved for cases in which all other standard work-up has failed to localize or characterize the source of bleeding. A logical progression of diagnosis that proceeds at a pace that is compatible with the patient's hemodynamic status will yield the best outcome.

Footnotes

Editor's note.—Supplemental material (see the editorial by Honeyman and Olmsted in this issue [pp 905–906 ]) for this article in the form of a movie mode display image is available at http://radiographics.rsnajnls.org/cgi/content/full/20/4/1160/DC1/index.htm.

References

  1. Welch CE, Hedberg S. Gastrointestinal hemorrhage. I. General considerations of diagnosis and therapy. Adv Surg 1973; 7:95-148.
  2. Browder W, Cerise EJ, Litwin MS. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 1986; 204:530-536.[Medline]
  3. Alavi A, Dann RW, Baum S, Biery DN. Scintigraphic detection of acute gastrointestinal bleeding. Radiology 1977; 124:753-756.[Abstract]
  4. Smith R, Copely DJ, Bolen FH. 99m Tc RBC scintigraphy: correlation of gastrointestinal bleeding rates with scintigraphic findings. AJR Am J Roentgenol 1987; 148:869-874.[Abstract/Free Full Text]
  5. Nusbaum M, Baum S. Radiographic demonstration of unknown sites of gastrointestinal bleeding. Surg Forum 1963; 14:374-375.[Medline]
  6. Kruger K, Heindel W, Dolken W, Landwehr P, Lackner K. Angiographic detection of gastrointestinal bleeding: an experimental comparison of conventional screen-film angiography and digital subtraction angiography. Invest Radiol 1996; 31:451-457.[Medline]
  7. Alavi A. Detection of gastrointestinal bleeding with 99m Tc-sulfur colloid. Semin Nucl Med 1982; 12:126-138.[Medline]
  8. Bunker SR, Lull RJ, Tanasescu DE, et al. Scintigraphy of gastrointestinal hemorrhage: superiority of 99m Tc red blood cells over 99m Tc sulfur colloid. AJR Am J Roentgenol 1984; 143:543-548.[Abstract/Free Full Text]
  9. McKusick KA, Froelich J, Callahan RJ, Winzelberg GG, Strauss HW. 99m Tc red blood cells for detection of gastrointestinal bleeding: experience with 80 patients. AJR Am J Roentgenol 1981; 137:1113-1118.[Abstract/Free Full Text]
  10. Winzelberg GG, McKusick KA, Froelich JW, Callahan RJ, Strauss HW. Detection of gastrointestinal bleeding with 99m Tc-labeled red blood cells. Semin Nucl Med 1982; 12:139-146.[Medline]
  11. Bentley DE, Richardson JD. The role of tagged red blood cell imaging in the localization of gastrointestinal hemorrhage. Arch Surg 1991; 126:821-824.[Abstract]
  12. Hunter JM, Pezim ME. Limited value of technetium 99m-labeled red blood cell scintigraphy in localization of lower gastrointestinal bleeding. Am J Surg 1990; 159:504-506.[Medline]
  13. Ryan P, Styles CB, Chmiel R. Identification of the site of severe colon bleeding by technetium-labeled red-cell scan. Dis Colon Rectum 1992; 35:219-222.[Medline]
  14. Voeller GR, Bunch G, Britt LG. Use of technetium-labeled red blood cell scintigraphy in the detection and management of gastrointestinal hemorrhage. Surgery 1991; 110:799-804.[Medline]
  15. Gutierrez C, Mariano M, Vander Laan T, Wang A, Faddis DM, Stain SC. The use of technetium-labeled erythrocyte scintigraphy in the evaluation and treatment of lower gastrointestinal hemorrhage. Am Surg 1998; 64:989-992.[Medline]
  16. Casarella WJ, Galloway SJ, Taxin RN, Follett DA, Pollock EJ, Seaman WB. "Lower" gastrointestinal tract hemorrhage: new concepts based on arteriography. AJR Am J Roentgenol 1974; 121:357-368.[Abstract]
  17. Uden P, Jiborn H, Jonsson K. Influence of selective mesenteric arteriography on the outcome of emergency surgery for massive, lower gastrointestinal hemorrhage: a 15-year experience. Dis Colon Rectum 1986; 29:561-566.[Medline]
  18. Koval G, Benner KG, Rosch J, Kozak BE. Aggressive angiographic diagnosis in acute lower gastrointestinal hemorrhage. Dig Dis Sci 1987; 32:248-253.[Medline]
  19. Gunderman R, Leef J, Ong K, Reba R, Metz C. Scintigraphic screening prior to visceral arteriography in acute lower gastrointestinal bleeding. J Nucl Med 1998; 39:1081-1083.[Abstract/Free Full Text]
  20. Sheedy FP, II, Fulton RE, Atwell DT. Angiographic evaluation of patients with chronic gastrointestinal bleeding. AJR Am J Roentgenol 1975; 123:338-347.
  21. Rollins ES, Picus D, Hicks ME, Darcy MD, Bower BL, Kleinhoffer MA. Angiography is useful in detecting the source of chronic gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol 1991; 156:385-388.[Abstract/Free Full Text]
  22. Nicholson AA, Ettles DF, Hartley JE, et al. Transcatheter coil embolotherapy: a safe and effective option for major colonic hemorrhage. Gut 1998; 43:79-84.[Abstract/Free Full Text]
  23. Rosch J, Keller FS, Wawrukiewicz AS, Krippaehne WW, Dotter CT. Pharmacoangiography in the diagnosis of recurrent massive lower gastrointestinal bleeding. Radiology 1982; 145:615-619.[Abstract/Free Full Text]
  24. Glickerman DJ, Kowdley KV, Rosch J. Urokinase in gastrointestinal tract bleeding. Radiology 1988; 168:375-376.[Abstract/Free Full Text]
  25. St George JK, Pollack JS. Acute gastrointestinal hemorrhage detected by selective scintigraphic angiography. J Nucl Med 1991; 32:1601-1604.[Abstract/Free Full Text]
  26. Textor HJ, Wilhelm K, Strunk H, Schuller H, Schild HH. The diagnosis of intra-abdominal hemorrhages with CO2 as the contrast medium. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 1997; 166:51-53.[Medline]
  27. Sandhu C, Buckenham TM, Belli AM. Using CO2-enhanced arteriography to investigate acute gastrointestinal hemorrhage. AJR Am J Roentgenol 1999; 173:1399-1401.[Abstract/Free Full Text]
  28. Garbagnati F, Spreafico C, Marchiano A, et al. Carbon dioxide digital subtraction angiography in oncological-interventional radiology. Tumori 1995; 81:52-55[Italian].[Medline]
  29. Singer AA. Value of CT in localizing site of gastrointestinal hemorrhage following negative angiography. Abdom Imaging 1995; 20:31-32.[Medline]
  30. Ettorre GC, Francioso G, Garribba AP, Fracella MR, Greco A, Farchi G. Helical CT angiography in gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol 1997; 168:727-731.[Abstract/Free Full Text]
  31. Kuhle WG, Shieman RG. The sensitivity of helical CT in detecting active colonic hemorrhage (abstr). J Vasc Interv Radiol 2000; 11(suppl):208.
  32. Shapiro MJ. The role of the radiologist in the management of gastrointestinal bleeding. Gastroenterol Clin North Am 1994; 23:123-181.[Medline]
  33. Lau WY, Yuen WK, Chu KW, Poon GP, Li AK. Obscure bleeding in the gastrointestinal tract originating in the small intestine. Surg Gynecol Obstet 1992; 174:119-124.[Medline]
  34. Zuckerman DA, Gaz RD. Catheter-guided intraoperative localization of a jejunal angiodysplasia using the Tracker-18 coaxial catheter system: case report. Cardiovasc Intervent Radiol 1991; 14:358-359.[Medline]
  35. Athanasoulis CA, Baum S, Rosch J, et al. Mesenteric arterial infusions of vasopressin for hemorrhage from colonic diverticulosis. Am J Surg 1975; 129:212-216.[Medline]
  36. Baum S, Rosch J, Dotter CT, et al. Selective mesenteric arterial infusions in the management of massive diverticular hemorrhage. N Engl J Med 1973; 288:1269-1272.
  37. Sherman LM, Shenoy SS, Cerra FB. Selective intra-arterial vasopressin: clinical efficacy and complications. Ann Surg 1979; 189:298-302.[Medline]
  38. Chuang VP, Wallace S, Zornoza J, Davis LJ. Transcatheter arterial occlusion in the management of rectosigmoidal bleeding. Radiology 1979; 133:605-609.[Abstract]
  39. Jander HP, Russinovich NA. Transcatheter gelfoam embolization in abdominal, retroperitoneal, and pelvic hemorrhage. Radiology 1980; 136:337-344.[Abstract/Free Full Text]
  40. Walker WJ, Goldin AR, Shaff ME, Allibone GW. Per catheter control of hemorrhage from the superior and inferior mesenteric arteries. Clin Radiol 1980; 31:71-80.[Medline]
  41. Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB, II, Healy JF. Postembolic colonic infarction. Radiology 1982; 142:47-51.[Abstract/Free Full Text]
  42. Uflacker R. Transcatheter embolization for treatment of acute lower gastrointestinal bleeding. Acta Radiol 1987; 28:425-430.[Medline]
  43. Guy GE, Shetty PC, Sharma RP, Burke MW, Burke TH. Acute lower gastrointestinal hemorrhage: treatment by superselective embolization with polyvinyl alcohol particles. AJR Am J Roentgenol 1992; 159:521-526.[Abstract/Free Full Text]
  44. Ledermann HP, Schoch E, Jost R, Decurtins M, Zollikofer CL. Superselective coil embolization in acute gastrointestinal hemorrhage: personal experience in 10 patients and review of the literature. J Vasc Interv Radiol 1998; 9:753-760.[Medline]
  45. Gordon RL, Ahl KL, Kerlan RK, et al. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg 1997; 174:24-28.[Medline]
  46. Briley CA, Jr, Jackson DC, Johnsrude IS, Mills SR. Acute gastrointestinal hemorrhage of small-bowel origin. Radiology 1980; 136:317-319.[Abstract/Free Full Text]
  47. Murphy KJ, Becker CD, Szopinski KT, Piotin M, Rufenacht DA. Embolization of colonic hemorrhage with use of a flow-assisted catheter. J Vasc Interv Radiol 1999; 10:1239-1242.[Medline]
  48. Hastings GS. Rotational angiography clarifies tortuous anatomy and aids in super-selective embolization of colonic diverticular hemorrhage; Available at: http://www.scvir.org..



This article has been cited by other articles:


Home page
 J. Nucl. Med. Technol.Home page
G. M. Currie
Cost-Effectiveness Analysis of Subtraction Scintigraphy in Patients with Acute Lower Gastrointestinal Tract Hemorrhage
J. Nucl. Med. Technol., September 1, 2007; 35(3): 140 - 147.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Quicktime Video
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Hastings, G. S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Hastings, G. S.
Related Collections
Right arrow Gastrointestinal Radiology
Right arrow Vascular and/or Interventional Radiology

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
RADIOGRAPHICS RADIOLOGY RSNA JOURNALS ONLINE