Indications

• Clinical evidence of arterial GI hemorrhage

  • • Hematemesis, melena, hematochezia, hemobilia

    • Hypotension, tachycardia, transfusion requirement, pressor requirement despite conservative (and sometimes endoscopic therapy)

• Imaging evidence of arterial GI hemorrhage

  • • CTA

    • Endoscopy

    • Tagged RBC scan

Contraindications

• Absolute: None, when intervention anticipated to be life-saving

• Relative:

  • • Uncorrectable bleeding diathesis

    • Contrast allergy (premedicate, as time allows)

    • Renal impairment

    • Prior surgery altering vascular anatomy (increases risk of gut ischemia)

Imaging Review

• CTA (3-phase: noncon, arterial, delay) required for most angio/embos, unless a source has already been localized by another method.

• Tagged RBC scan (scintigraphy) is more sensitive (90%) but takes hours and poor at localizing bleed to a vascular territory. Therefore, not a good test when there is active bleeding clinically.

Tips for Workup

• Upper GI bleed:

  • • What did endoscopy show? CTA, if source not yet identified?

    • Duodenal ulcers bleeding from the GDA are the most common, and we will often be asked to “embolize GDA empirically” even if it looks normal angiographically.

• Lower GI bleed:

  • • What did CTA show? Endoscopy not 1^st line due to lack of colon prep

    • Diverticulitis is most common

• Is coagulopathy being reversed?

• Is the patient unstable to the point of requiring anesthesia? NPO?

• Consent: Risk of non-target embolization, ischemic bowel, contrast nephropathy, inability to localize bleed, access site complications