1. Uncontrollable GI Bleed
Mamoun A. Rahman

2. Case 1 RT. 57 yrs-old lady BGhx: -Rectal cancer
-Pre-operative adjuvant chemotherapy: 5FU based
-low anterior resection
Medications:
- Losec 20 mg Od

3. Presentation C/O: Lower abdominal pain for 3-4 days Admitted
Next morning: PR bleeding, bright red
Weak and anxious
O/E:
- Pale
- Pulse: 98
- BP: 106/64
- Abdomen: stoma; soft, non tender.
- DRE: clotted blood, nil active bleeding

4. Lab results Hb: 10.1 ALP: 141 PCV: 0.30 GGT: 151 WBC: 6.8 Bil: 3
Urea: 4.7
Cr: 95
Na: 137
K: 4.3

5. Few hours later Had another episode of PR bleed Hb: 8.3 PCV: 0.24
Received 2 unit of RCC
Patient “stabilized”
PR bleeding continuing
- pulse: 109
CT angiography

6. On arrival in X-Ray Anxious Tachypnoeic Cold and clammy Pulse: 125
BP: 70/50
Unstable

7. Resuscitation by surgical team
Trendelenburg position
3 IV lines
Received Hartmann’s solution and Gelofusin
Tranfusion with 2 units O –ve blood
ICU informed
Urgent angiography

8. Angiography & embolization
Bleeding in the pelvis
Ruptured aneurysm
branch of internal iliac artery
Anterior branch of IIA embolized

9. Post embolization Transferred to ICU Pulse: 144 BP: 140/65
Chest: course crepitations
Received Frusemide 40 mg
Remained stable, melaena only

10. Case 2 TY 52 yrs-old lady Background history: - Recurrent cholangitis
- ERCP and stent

11. C/O - Epigastric pain O/E - Jaundiced Lab results
- Fever
- Pale stool
- Dark urine
O/E
- Jaundiced
- Temp: 41
- Tender RUQ
Lab results
- Cholestatic picture Hb
11.6
HCT
36.1
WBC
4.7
Neut
3.78 Ur
13.1 Cr
138 Na
135 K
4.4 Cl
110 PT
11.6
INR
1.1
Bil
113.9
ALT
131
ALP
270
GGT
278
Amylase 10
CRP
352

12. USS
Cotracted, thick-walled GB, multiple stones
CBD: 14 mm, stones

13. ERCP performed
Sphincterotomy and CBD clearance
Bleeding from sphincter site
Adrenalin injected
Continued to ooze

14. Post ERCP Haematemesis Melaena Dizzy Pulse: 90 BP: 139/67 Hb:9.7
INR: 1.2
CT Angiogram:
- ?Arterial haemorrhage at ampulla

15. Embolization
Bleeding from branches of GDA and Superior pancreaticodudenal artery
Embolization performed with coil and gel foam
SMA angiogram: normal

16. Day 1 Post Embolization Seen by team as a consult Vitals stable
Hb: 6.6
INR: 1.37
Transfused 4 units of RCCs and 1 unit FFP
IV fluids and Abx continued
Repeat ERCP:
- No further bleeding. Stent inserted

17. Post repeat ERCP Remained asymptomatic No further GI bleeding
Discharged with planned ERCP and Cholecystectomy in 6 weeks’ time

18. Superselective embolization of lower GI hemorrhage

19. Etiologies of Lower GI bleeding
Most common in the elderly
Variety of causes :
- Diverticular disease (10% to 20% risk)
- Neoplasia ( Ca colon causes 5% of
major bleeding) Boley et al, Am J Surg 1979
- Angiodysplasia (right colon, <10% risk)

20. Evaluation Recurrent minor bleeding: colonoscopy
Severe but intermittent, stable patient: Tc-99M RBC scanning
Hemodynamically unstable patient: angiography
Helical CT: 80% accurate in some series
Ernst et al, Eur Radiol 2003

21. History Rosch and Bookstein, early 1970s
Ischemic complications was13% to 33%
Throughout the 1980s it was a taboo
Dissatisfaction with vasoconstriction methods led renew interest in embolization in 1990s

22. Coaxial Microcatheters
Range in size from 2.5 to 3 F
5-French catheter may be used to select a first-order vessel
microcatheter can be advanced through this catheter more distally

23. Superselective Catheterization
Distal arteries, close to bleeding points
Embolic material is deployed
It limits the segment of bowel at risk for ischemia

24. Choice of embolic Gel foam Polyvinyl alcohol particles Microcoils
some combination

25. Published experience
Guy et al, 1992, reported 10 superselective embolization procedures in nine patients. All procedures were successful
Gordon et al, 1997: 17 cases of microcatheter embolization using microcoils, gel foam, and polyvinyl alcohol particles. Success rate was 76%. No bowel ischaemia

26. Published experience
>100 successful embolization have been reported 1997 – 2002
Clinical success ranged from 44% to 91%
Ischemic complications ranged from 0% to 6%
Funaki et al, AJR, 2001
Bandi et al, J Vasc Interv Radiol, 2001

27. Published experience
Tan et al, patients underwent angiography for GI bleeding.
32 ( 12%) had superselective embolization for lower GI hemorrhage
In 31 patients (97%) technical success was achieved
7 had re-bleed
1 had bowel ischaemia

28. Limitations of embolization
Colonic bleeding is multifactorial
- Diverticular bleed vs. Angiodysplasia
Patients who are not actively bleeding
Difficult vascular anatomy or severe atherosclerotic disease
“Symptomatic treatment”

29. Summary
Minimally invasive techniques have replaced surgical resection as the initial therapies of choice
Superselective embolization and endoscopic treatment appear complementary

30. Thank you