Gastrointestinal hemorrhage

Case contributed by Melbourne Uni Radiology Masters

Presentation

Anemia and hypotension.

Patient Data

Age: 89-year-old
Gender: Female
CT

CT Abdomen Pelvis (GIT bleed protocol)

Intraluminal contrast extravasation within the first part of the duodenum. This is confirmed on PV  phase study with contrast extending through the duodenum into the jejunum. The bleeding vessel arises from the celiac trunk (likely gastroduodenal artery).

The stomach and small bowel is distended, the density of the intraluminal contents consistent with blood. The wall of the proximal duodenum is markedly thickened.

The liver, gallbladder, spleen, pancreas, kidneys and adrenals are unremarkable.

Colonic diverticular disease.

There is a small volume of intraperitoneal free fluid (HU 10). No evidence of intraperitoneal hemorrhage. No free gas to suggest perforation.

Dependent atelectasis in the lungs bilaterally. Small/moderate sized right pleural effusion. Cardiomegaly and reflux of contrast into the hepatic veins suggesting a degree of right heart failure. Fluid within the subcutaneous tissues noted.

No destructive osseous lesion. Heavily calcified vasculature.Conclusion

Large volume of contrast extravasation consistent with active bleeding within the first part of the duodenum. The bleeding vessel arises from the celiac trunk, likely gastroduodenal artery.

No free gas to suggest perforation.

Findings have been discussed with the treating team and the patient will undergo embolization.

DSA (angiography)

Angiography and embolization

Celiac angiography demonstrated high-grade active arterial bleeding arising from a branch of the gastroduodenal artery. Generalized small caliber vessels with areas of vasospasm.

A replaced right hepatic artery arising from the SMA.

Eventually a microcatheter was able to be manipulated to the site of bleeding and the GDA was coiled to a point just distal to the bifurcation with the left hepatic artery.

Some mild ongoing active bleeding was noted arising from the vessels arising from the SMA and replaced right hepatic. Due to small vessel caliber and vasospasm in the was difficult to completely approximate the inflow from this however the main feeder from the right hepatic was embolized as possible to reduce flow.

The patient stabilized during the procedure with these techniques. Hemostasis was achieved with a 5-French exoseal

Comment: Successful embolization of the main bleeding point arising from the GDA.

There may be some possible mild ongoing blood loss from collateral flow which was partially embolized, in combination however this is expected to secure the bleeding point.

Case Discussion

CTA and DSA of the gastroduodenal territory reveal a bleeding GDA artery which was subsequently embolized.

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Case information

rID: 39087
Published: 25th Aug 2015
Last edited: 14th Aug 2019
Tag: rmh
Inclusion in quiz mode: Included