Angiographic Localization of Unknown Acute Gastrointestinal Bleeding Sites

Abstract

The radiographic demonstration of gastrointestinal bleeding sites through the use of arteriography has been described by Baum and others (1–5, 14, 15). Despite their convincing results, this method of examination has not gained its deserved place in the work-up of acute gastrointestinal bleeders. In the past year we had the opportunity to examine four patients in whose diagnoses and management this procedure proved extremely helpful. The case histories and a discussion of this mode of identifying the site of gastrointestinal bleeding are presented below. Case I: A. E., a 69-year old white male, had undergone total cystectomy and ileal loop urinary diversion nine years previously. His present admission to the hospital was because of fever, chills, and hematuria. Intravenous urography showed no function of the left kidney. The patient stated that he noted several dark bowel movements and had an episode of rectal bleeding after taking castor oil. On admission the hemoglobin level was found to be 10.1 g. Guaiac stools were 4+. The findings on x-ray studies, including a barium enema examination, upper gastrointestinal scries, and a small bowel series were all normal. Two days after admission the patient's condition necessitated transfusion of 3 units of blood because of the falling hematocrit. All bleeding and clotting time tests were normal. Despite the transfusion, the hemoglobin levels continued to fall. A nasogastric tube yielded red-brown liquid as well as small blood clots. Because of continuous bleeding and fall in blood pressure an exploratory laparotomy was decided upon. At the time of surgery no site of bleeding could be found. A pyloroplasty was performed. The left kidney was removed and found to contain a large abscess. The gallbladder was removed because of stones. The patient was returned to the recovery room, but shortly afterward started to vomit bright red blood. Multiple transfusions failed to maintain his blood pressure. The patient was, therefore, returned to the operating room and again no site of bleeding could be determined. A subtotal gastrectomy and gastrojejunostomy were performed. Despite the surgery he continued to vomit blood and pass tarry stools. During the next two days, he received more than 40 units of blood but continued to bleed. At this time it was decided to perform celiac and superior mesenteric arteriography. Figure 1 shows the injection into the celiac artery, and the point of extravasation of contrast medium is noted in the second part of the duodenum. The patient was promptly returned to the operating room, and this time a small bleeding point in the second part of the duodenum was found and tied. A second small bleeding point was also noted in the remaining stomach. Following this procedure the bleeding was arrested. Shortly after surgery pulmonary edema developed. The patient was digitalized and did reasonably well until cardiac arrest occurred on the third postoperative day.