The use of catheter-based techniques to treat upper gastrointestinal hemorrhage has evolved considerably over the past few decades. At present, the state-of-the-art interventional suites provide optimal imaging. Coupled with advanced catheter technology, the two may be used to manage and treat the patient with acute upper gastrointestinal hemorrhage. This article summarizes these techniques and, when possible, compares them with other methods such as surgery and endoscopy. The specific role of transcatheter embolotherapy is highlighted, alongside an additional discussion on pharmacologic infusion of vasopressin.
The use of catheter-based techniques to treat upper gastrointestinal hemorrhage has evolved considerably over the past few decades. At present, the state-of-the-art interventional suites provide optimal imaging. Coupled with advanced catheter technology, the two may be used to manage and treat the patient with acute upper gastrointestinal hemorrhage. This article summarizes these techniques and, when possible, compares them with other methods such as surgery and endoscopy. The specific role of transcatheter embolotherapy is highlighted, alongside an additional discussion on pharmacologic infusion of vasopressin.
Upper gastrointestinal hemorrhage is a potentially life-threatening condition that requires immediate medical attention. Interventional radiology plays an active role in the management of patients presenting with upper gastrointestinal hemorrhage. A thorough knowledge of the patients’ clinical history, surgical history, medications, and other medical conditions are essential to plan appropriate therapy. Upper gastrointestinal hemorrhage (nonvariceal) maybe categorized broadly as that arising from (1) direct hemorrhage from an artery and (2) from transpapillary hemorrhage. The former would include direct bleeding from gastric or duodenal mucosal lesions, posttraumatic hemorrhage, vascular malformations, and neoplastic causes. By contrast, transpapillary hemorrhage is bleeding associated with endoscopic procedures, hemobilia, and bleeding from the pancreatic duct. The common causes of nonvariceal upper gastrointestinal hemorrhage are summarized in Box 1 .
Direct Hemorrhage
Ulceration (gastric and duodenal)
Mallory-Weiss tear
Gastritis/esophagitis
Angiodysplasia
Dieulafoy lesion
Postanastomotic (marginal) ulcer
Arterioenteric fistula (aneurysms and pseudoaneurysms)
Tumors (particularly large primary leiomyosarcomas and pancreatic neuroendocrine tumors)
Duodenal diverticular disease
Transpapillary Hemorrhage
Endoscopic sphincterotomy
Hemobilia (trauma, hepatic abscesses, iatrogenic injury to the biliary system during surgery, hepatic surgery, liver biopsy, biliary drainage procedures, tumors)
Transpancreatic duct (postpancreatitis pseudoaneurysm, tumors)
In general, treatment of the nonvariceal upper gastrointestinal hemorrhage involves (1) mechanical blockage of an artery through embolotherapy or (2) pharmacologic vasoconstriction using infused drugs such as vasopressin.
Embolotherapy for treatment of upper gastrointestinal hemorrhage was first introduced by Rosch in 1972. Given the added risks of critically ill patients undergoing major surgical procedures, transcatheter management has become the preferred treatment when endoscopic intervention fails. Surgery is now commonly reserved for those patients who have failed endoscopic and radiologic treatments. Management of a patient with upper gastrointestinal hemorrhage requires a multidisciplinary team approach, involving the endoscopist, surgeon, intensive care unit (ICU) team, and emergency department personnel.
The goal of the physician is to examine, stabilize, and treat the patient with upper gastrointestinal (GI) bleeding. Once stabilized, patients are generally admitted to the ICU for hemodynamic monitoring and further workup. If the patient cannot be stabilized medically, the gastroenterologist, interventional radiologist, and surgeon are consulted. The location and severity of GI bleeding dictates therapy.
Upper GI bleeding
If the patient is stable, upper GI endoscopy is generally performed based on the patient’s history. If the patient is not a surgical candidate, due to underlying medical conditions such as chronic obstructive pulmonary disease or severe cardiac disease, the radiologist is frequently asked to perform arteriography and transcatheter embolotherapy in the upper GI tract. The precise site of bleeding can usually be determined by angiography. A site of contrast extravasation on the images obtained during the arteriogram determines the next course of action. A thorough understanding of anatomy is essential to avoid complications.
Vascular anatomy of the upper GI tract
The celiac axis arises from the ventral surface of the aorta at the level between the lower half of the T12 vertebral body and the T12-L1 disk space. The celiac axis generally has the following 3 major branches: (1) the left gastric artery; (2) the common hepatic artery; and (3) the splenic artery. There are several important variants in arterial anatomy, and “textbook anatomy” is frequently not found. As mentioned, knowledge of arterial anatomy is essential so that serious complications can be avoided during embolization procedures.
The arterial variants commonly found in the upper GI tract include the following:
- 1.
The splenic artery may arise as a separate trunk from the aorta
- 2.
The left gastric artery may arise directly from the aorta rather than from the celiac axis
- 3.
Hepatic arterial blood supply is frequently variable.
The right and left hepatic arterial blood supply normally arises from the proper hepatic artery. The proper hepatic artery is a short trunk that is found just distal to the point where the gastroduodenal artery (GDA) arises from the common hepatic artery. The left hepatic arterial blood supply may arise from the left gastric artery rather than from the proper hepatic artery; this is known as a “replaced” left hepatic artery. Similarly, the right hepatic artery may originate from the proximal aspect of the superior mesenteric artery (SMA); this is known as a “replaced” right hepatic artery. When a portion of the right or left hepatic arterial blood supply arises from the proper hepatic artery and the remainder arises from either the left gastric artery (in the case of left hepatic blood supply) or from the SMA (in the case of right hepatic arterial blood supply), the terms “accessory replaced” are used. Thus, a patient with left hepatic arterial blood supply arising in part from the proper hepatic artery (eg, a vessel supplying the medial segment of the left lobe) and from the left gastric artery (eg, supplying the lateral segment of the left lobe) has a so-called accessory replaced left hepatic artery arising from the left gastric artery. Similarly, an accessory replaced right hepatic arterial blood supply may be seen. In the latter case, a portion of right hepatic arterial blood supply arises from the SMA and the remainder from the proper hepatic artery. The vessel arising from the SMA is an accessory replaced right hepatic artery. It is important to recognize right and left hepatic artery anatomic variants and to be aware that such variants are common. There are numerous other variants including a “replaced common hepatic artery” to the SMA, and so forth.
The gastroesophageal junction is supplied primarily by small vessels arising from the left gastric artery. The fundus and a portion of the body of the stomach are also supplied by the left gastric arterial branches. Important arterial anastomoses exist between the left gastric artery and the spleen (ie, short gastric arteries). Terminal branches of the left gastric artery anastomose with the right gastric artery, forming an arcade along the lesser curvature of the stomach.
The right gastric artery generally arises at the bifurcation of the proper hepatic and gastroduodenal arteries. Variant anatomy may also be found at this location; for example, the right gastric artery may arise from the common hepatic artery. The right gastric artery is generally small in caliber and may not be visualized during routine celiac arteriography.
The GDA supplies a portion of the stomach, the duodenum, and the pancreas. A rich anastomotic arcade is found between the pancreaticoduodenal blood supply arising from the GDA and the SMA via the inferior pancreaticoduodenal artery. The inferior pancreaticoduodenal artery arises from the proximal SMA and forms an anastomosis with the posterior and anterior pancreaticoduodenal arteries, the latter arising from the GDA. The terminal branch of the GDA is the right gastroepiploic artery. Similar to the right gastric/left gastric arterial arcade, the right gastroepiploic artery has a rich anastomotic network (arcade) with the left gastroepiploic artery along the greater curvature of the stomach. The left gastroepiploic artery is the terminal branch of the splenic artery.
Vascular anatomy of the upper GI tract
The celiac axis arises from the ventral surface of the aorta at the level between the lower half of the T12 vertebral body and the T12-L1 disk space. The celiac axis generally has the following 3 major branches: (1) the left gastric artery; (2) the common hepatic artery; and (3) the splenic artery. There are several important variants in arterial anatomy, and “textbook anatomy” is frequently not found. As mentioned, knowledge of arterial anatomy is essential so that serious complications can be avoided during embolization procedures.
The arterial variants commonly found in the upper GI tract include the following:
- 1.
The splenic artery may arise as a separate trunk from the aorta
- 2.
The left gastric artery may arise directly from the aorta rather than from the celiac axis
- 3.
Hepatic arterial blood supply is frequently variable.
The right and left hepatic arterial blood supply normally arises from the proper hepatic artery. The proper hepatic artery is a short trunk that is found just distal to the point where the gastroduodenal artery (GDA) arises from the common hepatic artery. The left hepatic arterial blood supply may arise from the left gastric artery rather than from the proper hepatic artery; this is known as a “replaced” left hepatic artery. Similarly, the right hepatic artery may originate from the proximal aspect of the superior mesenteric artery (SMA); this is known as a “replaced” right hepatic artery. When a portion of the right or left hepatic arterial blood supply arises from the proper hepatic artery and the remainder arises from either the left gastric artery (in the case of left hepatic blood supply) or from the SMA (in the case of right hepatic arterial blood supply), the terms “accessory replaced” are used. Thus, a patient with left hepatic arterial blood supply arising in part from the proper hepatic artery (eg, a vessel supplying the medial segment of the left lobe) and from the left gastric artery (eg, supplying the lateral segment of the left lobe) has a so-called accessory replaced left hepatic artery arising from the left gastric artery. Similarly, an accessory replaced right hepatic arterial blood supply may be seen. In the latter case, a portion of right hepatic arterial blood supply arises from the SMA and the remainder from the proper hepatic artery. The vessel arising from the SMA is an accessory replaced right hepatic artery. It is important to recognize right and left hepatic artery anatomic variants and to be aware that such variants are common. There are numerous other variants including a “replaced common hepatic artery” to the SMA, and so forth.
The gastroesophageal junction is supplied primarily by small vessels arising from the left gastric artery. The fundus and a portion of the body of the stomach are also supplied by the left gastric arterial branches. Important arterial anastomoses exist between the left gastric artery and the spleen (ie, short gastric arteries). Terminal branches of the left gastric artery anastomose with the right gastric artery, forming an arcade along the lesser curvature of the stomach.
The right gastric artery generally arises at the bifurcation of the proper hepatic and gastroduodenal arteries. Variant anatomy may also be found at this location; for example, the right gastric artery may arise from the common hepatic artery. The right gastric artery is generally small in caliber and may not be visualized during routine celiac arteriography.
The GDA supplies a portion of the stomach, the duodenum, and the pancreas. A rich anastomotic arcade is found between the pancreaticoduodenal blood supply arising from the GDA and the SMA via the inferior pancreaticoduodenal artery. The inferior pancreaticoduodenal artery arises from the proximal SMA and forms an anastomosis with the posterior and anterior pancreaticoduodenal arteries, the latter arising from the GDA. The terminal branch of the GDA is the right gastroepiploic artery. Similar to the right gastric/left gastric arterial arcade, the right gastroepiploic artery has a rich anastomotic network (arcade) with the left gastroepiploic artery along the greater curvature of the stomach. The left gastroepiploic artery is the terminal branch of the splenic artery.
Related posts:
Differential Diagnosis of Upper Gastrointestinal Bleeding Proximal to the Ligament of Trietz
Pathology of Diseases that Cause Upper Gastrointestinal Tract Bleeding
Epidemiology and Demographics of Upper Gastrointestinal Bleeding: Prevalence, Incidence, and Mortality
Pharmacologic Therapy for Nonvariceal Upper Gastrointestinal Bleeding
Management of Nonvariceal Upper Gastrointestinal Bleeding
New Diagnostic Imaging Technologies in Nonvariceal Upper Gastrointestinal Bleeding
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