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Lower Gastrointestinal Hemorrhage
Andrew Kolarich, MD; Yvonne Tsitsiou; Christos Georgiades, MD, PhD, FSIR, FCIRSE
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          TERMINOLOGY

          • Definitions

            • Lower gastrointestinal (LGI) hemorrhage
              • Territory supplied by superior mesenteric artery (SMA) and inferior mesenteric artery (IMA)
                • Middle and inferior rectal arteries are supplied by internal iliac artery
                • Internal iliac artery must be investigated in cases of distal rectal/anal hemorrhage and SMA or IMA source is not found
              • Boundary between upper GI (UGI) and LGI is celiac artery-SMA watershed zone
                • Near ligament of Treitz
              • Some hemorrhages supplied by both celiac and SMA (commonly 2nd and 3rd portion of duodenum); both celiac and superior mesenteric arteriograms are necessary if hemorrhage is in that location, before and after embolization
            • Epidemiology
              • ~ 375,000 patients receive treatment for arterial GI hemorrhage in USA annually
                • ~ 20% have LGI source
              • Prior to introduction of endoscopic/endovascular treatments, mortality was 25%; it is now ~ 5%
            • Causes of LGI hemorrhage
              • Most common cause of LGI arterial hemorrhage is colonic diverticulosis (~ 28%)
              • Secondary causes of LGI hemorrhage
                • Erosive disease (~ 17%)
                • Angiodysplasia (~ 15%)
                • Infection/ischemia (~ 14%)
                • Cancer (~ 13%): Incidence is age related
                • Other (~ 8%)

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Equipment Preparation

                    • Procedure Steps

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Expected Outcome

                          • Things to Do

                            • Things to Avoid

                              OUTCOMES

                              • Problems

                                • Complications

                                  • Expected Outcome

                                    Selected References

                                    1. Dariushnia SR et al: Society of Interventional Radiology quality improvement standards for percutaneous transcatheter embolization. J Vasc Interv Radiol. 32(3):476.e1-33, 2021
                                    2. Greco L et al: Surgical options and approaches for lower gastrointestinal bleeding: when do we operate and what do we do? Clin Colon Rectal Surg. 33(1):10-15, 2020
                                    3. Mujtaba S et al: Diagnosis and management of non-variceal gastrointestinal hemorrhage: a review of current guidelines and future perspectives. J Clin Med. 9(2), 2020
                                    4. Vora P et al: Thirty-year incidence and mortality trends in upper and lower gastrointestinal bleeding in Finland. JAMA Netw Open. 3(10):e2020172, 2020
                                    5. Feuerstein JD et al: Localizing acute lower gastrointestinal hemorrhage: CT angiography versus tagged RBC scintigraphy. AJR Am J Roentgenol. 1-7, 2016
                                    6. Zahid A et al: Making decisions using radiology in lower GI hemorrhage. Int J Surg. 31:100-3, 2016
                                    7. Chan V et al: Outcome following a negative CT angiogram for gastrointestinal hemorrhage. Cardiovasc Intervent Radiol. 38(2):329-35, 2015
                                    8. Jacovides CL et al: Arteriography for lower gastrointestinal hemorrhage: role of preceding abdominal computed tomographic angiogram in diagnosis and localization. JAMA Surg. 150(7):650-6, 2015
                                    Related Anatomy
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                                    Related Differential Diagnoses
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                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Terminology

                                      • Preprocedure

                                        • Procedure

                                          • Post Procedure

                                            TERMINOLOGY

                                            • Definitions

                                              • Lower gastrointestinal (LGI) hemorrhage
                                                • Territory supplied by superior mesenteric artery (SMA) and inferior mesenteric artery (IMA)
                                                  • Middle and inferior rectal arteries are supplied by internal iliac artery
                                                  • Internal iliac artery must be investigated in cases of distal rectal/anal hemorrhage and SMA or IMA source is not found
                                                • Boundary between upper GI (UGI) and LGI is celiac artery-SMA watershed zone
                                                  • Near ligament of Treitz
                                                • Some hemorrhages supplied by both celiac and SMA (commonly 2nd and 3rd portion of duodenum); both celiac and superior mesenteric arteriograms are necessary if hemorrhage is in that location, before and after embolization
                                              • Epidemiology
                                                • ~ 375,000 patients receive treatment for arterial GI hemorrhage in USA annually
                                                  • ~ 20% have LGI source
                                                • Prior to introduction of endoscopic/endovascular treatments, mortality was 25%; it is now ~ 5%
                                              • Causes of LGI hemorrhage
                                                • Most common cause of LGI arterial hemorrhage is colonic diverticulosis (~ 28%)
                                                • Secondary causes of LGI hemorrhage
                                                  • Erosive disease (~ 17%)
                                                  • Angiodysplasia (~ 15%)
                                                  • Infection/ischemia (~ 14%)
                                                  • Cancer (~ 13%): Incidence is age related
                                                  • Other (~ 8%)

                                            PREPROCEDURE

                                            • Indications

                                              • Contraindications

                                                • Preprocedure Imaging

                                                  • Getting Started

                                                    PROCEDURE

                                                    • Equipment Preparation

                                                      • Procedure Steps

                                                        • Alternative Procedures/Therapies

                                                          POST PROCEDURE

                                                          • Expected Outcome

                                                            • Things to Do

                                                              • Things to Avoid

                                                                OUTCOMES

                                                                • Problems

                                                                  • Complications

                                                                    • Expected Outcome

                                                                      Selected References

                                                                      1. Dariushnia SR et al: Society of Interventional Radiology quality improvement standards for percutaneous transcatheter embolization. J Vasc Interv Radiol. 32(3):476.e1-33, 2021
                                                                      2. Greco L et al: Surgical options and approaches for lower gastrointestinal bleeding: when do we operate and what do we do? Clin Colon Rectal Surg. 33(1):10-15, 2020
                                                                      3. Mujtaba S et al: Diagnosis and management of non-variceal gastrointestinal hemorrhage: a review of current guidelines and future perspectives. J Clin Med. 9(2), 2020
                                                                      4. Vora P et al: Thirty-year incidence and mortality trends in upper and lower gastrointestinal bleeding in Finland. JAMA Netw Open. 3(10):e2020172, 2020
                                                                      5. Feuerstein JD et al: Localizing acute lower gastrointestinal hemorrhage: CT angiography versus tagged RBC scintigraphy. AJR Am J Roentgenol. 1-7, 2016
                                                                      6. Zahid A et al: Making decisions using radiology in lower GI hemorrhage. Int J Surg. 31:100-3, 2016
                                                                      7. Chan V et al: Outcome following a negative CT angiogram for gastrointestinal hemorrhage. Cardiovasc Intervent Radiol. 38(2):329-35, 2015
                                                                      8. Jacovides CL et al: Arteriography for lower gastrointestinal hemorrhage: role of preceding abdominal computed tomographic angiogram in diagnosis and localization. JAMA Surg. 150(7):650-6, 2015