Mesenteric Angiography Research Articles

Artificial Intelligence for Identification of Images with Active Bleeding in Mesenteric and Celiac Arteries Angiography

PurposeThe purpose of this study is to evaluate the efficacy of an artificial intelligence (AI) model designed to identify active bleeding in digital subtraction angiography images for upper gastrointestinal bleeding.MethodsAngiographic images were retrospectively collected from mesenteric and celiac artery embolization procedures performed between 2018 and 2022. This dataset included images showing both active bleeding and non-bleeding phases from the same patients. The images were labeled as normal versus images that contain active bleeding. A convolutional neural network was trained and validated to automatically classify the images. Algorithm performance was tested in terms of area under the curve, accuracy, sensitivity, specificity, F1 score, positive and negative predictive value.ResultsThe dataset included 587 pre-labeled images from 142 patients. Of these, 302 were labeled as normal angiogram and 285 as containing active bleeding. The model’s performance on the validation cohort was area under the curve 85.0 ± 10.9% (standard deviation) and average classification accuracy 77.43 ± 4.9%. For Youden’s index cutoff, sensitivity and specificity were 85.4 ± 9.4% and 81.2 ± 8.6%, respectively.ConclusionIn this study, we explored the application of AI in mesenteric and celiac artery angiography for detecting active bleeding. The results of this study show the potential of an AI-based algorithm to accurately classify images with active bleeding. Further studies using a larger dataset are needed to improve accuracy and allow segmentation of the bleeding.Graphical abstract

Long-term value in open and endovascular repair of chronic mesenteric ischemia

ObjectiveGuidelines recommend open revascularization (OR) over endovascular revascularization (ER) for the treatment of chronic mesenteric ischemia (CMI) for younger, healthier patients. However, little is known about the long-term costs of these recommendations with respect to patients' overall life expectancy. This study investigated whether 5-year value differs between these treatment modalities. MethodsPatient data were extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payor database containing demographics, diagnoses, treatments, and charges. The database was queried for patients with an International Classification of Diseases, ninth revision, code for CMI, with the specific exclusion of acute ischemia cases. A propensity score match was performed using the Charlson Comorbidity Index, age, sex, race, renal status, and pulmonary disease for the final cohort of patients. Multiple linear regression and mixed effects linear regression were used to determine factors associated with 5-year value, calculated as life-years/$100k in charges. Charges were gathered from the index admission and subsequent admissions for acute or CMI, mesenteric angiography, or follow-up reintervention. Kaplan-Meier estimation was performed for survival and reintervention-free survival. ResultsFrom 2000 to 2014, 875 patients underwent intervention for CMI. Of those meeting inclusion criteria, 209 (28.1%) underwent OR and 535 (71.9%) ER. After propensity score matching (n = 209 in each group), the ER group showed higher value at 5 years after the procedure (8.04 ± 11.42 life-years/$100k charges vs 4.89 ± 5.28 life-years/$100k charges; P < .01). More patients underwent reintervention in the ER group (37 patients vs 17 patients; P < .01), with 55 reinterventions in the ER group and 19 in the OR group (P < .01). Multiple linear regression analysis showed that age, congestive heart failure, dysrhythmia, cancer, and days spent in the intensive care unit were negatively associated with value at 5 years, whereas ER was positively associated. Survival was 59.6 ± 3.76% vs 62.3% ± 3.49% at 5 years (P = .91), and reintervention-free survival was 43.7 ± 3.86% vs 58.1 ± 3.53% (P = .04), for ER and OR respectively. ConclusionsDespite increased reinterventions and lower reintervention-free survival, the value for patients with CMI was higher in those who underwent ER in the largest propensity score-matched cohort to date looking at long-term value. Factors negatively associated with value were OR, age, days in intensive care, congestive heart failure, dysrhythmia, and cancer. In patients with amenable anatomy, ER is validated as the first-choice treatment for CMI based on the superior procedural value.

Long-term Value in Open and Endovascular Repair of Chronic Mesenteric Ischemia

Guidelines recommend open surgical (OR) over endovascular revascularization (ER) for the treatment of chronic mesenteric ischemia (CMI) for younger patients. However, little is known about the long-term costs of these recommendations with respect to patients' overall life expectancy. This study investigated whether 5-year value differs between these treatment modalities. Patient data was extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payer database containing demographics, diagnoses, treatments, and charges. The database was queried for patients with an International Classification of Diseases code for CMI over a 15-year period, with specific exclusion of acute ischemia cases. Propensity match was performed using Charlson Comorbidity Index, age, sex, race, renal status, and pulmonary disease for a final cohort of patients. Multiple linear regression was utilized to determine factors associated with 5-year value, calculated as life-years/$100K in charges adjusted for inflation. Charges were gathered from the index admission and any subsequent admissions over a 5-year period for mesenteric ischemia, mesenteric angiography, or follow-up reintervention. From 2000 to 2014, 744 patients underwent intervention for CMI. Of these, 209 (28.1%) underwent OR and 535 (71.9%) ER. After propensity matching (n = 209 each group), ER group had higher value at 5 years postprocedure (6.63 ± 8.51 vs 4.52 ± 5.12 life-years/$100K charges; P < .01). All-cause mortality was 53.6% and 68.4% at 5 years (P < .01) for OR and ER, respectively. Reintervention was more common in the ER group (37 vs 17 reinterventions; P = .01). Multiple linear regression analysis found congestive heart failure, dysrhythmia, and cancer were negatively associated with value at 5 years while ER was positively associated (Table). Despite increased reinterventions, value in patients with CMI was higher in those undergoing ER in the largest propensity score matched dataset to date looking at value. Factors negatively associated with 5-year value were OR, congestive heart failure, dysrhythmia, and cancer. In patients with amenable anatomy, ER should be considered over OR based on the superior procedural value. Further research should prospectively examine comorbid conditions, presentation and patient reported outcomes to further validate whether ER is appropriate as the primary treatment modality for CMI.Table IMultiple linear regression for value at 5 yearsβ Coefficient95% confidence intervalP valueER2.040.74-3.35<.01Congestive heart failure(2.35)(4.09-0.62)<.01Dysrhythmia(3.13)(4.83-1.43)<.01Cancer(4.18)(7.69-0.67).02( ) Indicates a negative value. Open table in a new tab

Inferior vena cava diameter on CT angiography predicts mesenteric angiography positive for extravasation in colonic diverticular bleeding.

Transcatheter arterial embolization (TAE) for colonic diverticular bleeding (CDB), an established procedure for hemostasis, is sometimes complicated by spontaneous hemostasis and unclear bleeding site on angiography despite active arterial bleeding on preoperative computed tomography angiography (CTA). Therefore, to investigate and increase the feasibility of TAE, this retrospective study evaluates the clinical and radiological features related to positive extravasation on angiography. Sixty CDB patients with extravasation on CTA underwent TAE between January 2011 and February 2021 and were divided into extravasation-positive (P-group; n = 25) and -negative groups (N-group; n = 35) based on the superior or inferior mesenteric angiography. Patient characteristics, laboratory findings, the diameter of the inferior vena cava (IVCD), the diameter of superior and inferior mesenteric veins, and technical outcomes were evaluated. TAE was successful in 24 patients in the P-group (96%) and 14 in the N-group (40%) (p < 0.001). Univariate analysis revealed "usage of anticoagulant" (p < 0.05) and "larger IVCD (p < 0.05) on preoperative CTA" to be significant predictors of positive extravasation. In the multivariate analysis, IVCD remained significant with an adjusted odds ratio of 1.17. The IVCD cutoff value was 13.6mm (area under the curve = 0.72, sensitivity = 84.0%, specificity = 54.3%). There were no significant differences in other parameters. Measurement of IVCD in CDB with the cutoff value of 13.6mm can be a simple and useful indicator to predict the detectability of extravasation following TAE procedures.

S2599 Gastroduodenal Artery Aneurysm: When Endoscopy Is Not the Answer

Introduction: Gastroduodenal artery aneurysms (GDAAs) are rare with high mortality rate. We present a patient with massive gastrointestinal (GI) bleeding found to have gastroduodenal artery pseudoaneurysm. Case Description/Methods: A 75-year-old woman with hypertension, diabetes, sleep apnea, and prior stroke presented with fatigue, nausea, and decreased appetite. Vital signs and physical exam were normal. Hemoglobin (Hgb) was 13.2 grams per deciliter (g/dl). Nine days later, she developed abdominal pain and melena. Vital signs and physical exam were normal, Hgb was 11.8 g/dl, and computed tomography angiography (CTA) was normal. Esophagogastroduodenoscopy (EGD) showed duodenal ulcer with visible vessel, treated with epinephrine injection (epi) and hemoclips. Melena recurred eleven days later. Repeat EGD showed duodenal bleeding with poor visibility, prompting transfer to our hospital. EGD at our facility showed hemi-circumferential deep ulcer and arterial spurting in the distal duodenal bulb, treated with epi and hemoclips resulting in initial hemostasis but then continued bleeding (Figure 1A). She developed pulseless electrical activity arrest but was resuscitated. Mesenteric angiogram showed a 0.8 × 0.8 centimeter distal gastroduodenal artery pseudoaneurysm with extravasation requiring embolization with 2-4 millimeter interlock coils (Figure 1B). There was no further bleeding and she was discharged. Discussion: GDAAs account for 1.5% of visceral arterial aneurysms, which include true aneurysms and pseudoaneurysms (PAs). True aneurysms arise from vessel wall abnormalities such as degenerative or atherosclerotic processes, fibromuscular dysplasia, or collagen vascular diseases. PAs arise from vascular insults such as trauma, iatrogenic injury, or inflammation. The risk of GDAA PA rupture is as high as 75%. GDAAs may be asymptomatic or present as GI bleeding, abdominal pain, gastric outlet obstruction, or a pulsatile abdominal mass. CTA is the initial imaging of choice given high sensitivity, availability, and promptness. Mesenteric angiography is the diagnostic gold standard and allows for therapeutic intervention with endovascular embolization, which has superior outcomes compared to open surgical ligation. Follow-up imaging is necessary to look for aneurysm reperfusion, seen in 9-15% of cases. GDAA rupture is a difficult yet crucial diagnosis to make given mortality rate up to 21%.Figure 1.: A, Duodenal ulcer with actively spurting visible vessel. B, Mesenteric angiogram shows gastroduodenal artery pseudoaneurysm with extravasation of contrast (black arrow).

S2579 Colonic Varices: What Are the Therapeutic Options?

Introduction: Colonic varices are a rare case of lower gastrointestinal bleeding (LGIB) with an incidence of 0.07%. The most common sites of colonic varices are the rectum and cecum. Colonic varices are diagnosed on colonoscopy, mesenteric angiography, or computed tomography (CT) scans. Currently, there are no standardized treatments for treatment of colonic varices due to the heterogeneity in localization and vascular anatomy. We present a case of LGIB due to an ascending colon varix. Case Description/Methods: A 38 year-old-man with a history of decompensated alcoholic cirrhosis complicated by esophageal and gastric variceal bleed requiring balloon-occluded retrograde transvenous obliteration one month ago was transferred from an outside hospital (OSH) for liver transplant evaluation and hematochezia. He underwent a colonoscopy at the OSH which showed an ascending colon varix with white nipple sign. His vital signs were normal. His physical exam was benign except for scleral icterus with spider angiomas on his chest. His labs were pertinent for a hemoglobin of 8.0, hematocrit 24, platelet 50,000, alanine aminotransferase 50, total bilirubin 3.0, and international normalized ratio 2.0. The patient was treated with octreotide infusion and antibiotics for spontaneous bacterial peritonitis prophylaxis. A CT three phase abdominal imaging was revealed significant perisplenic and ascending colon varices with smaller varices supplying the descending colon. The case was reviewed with interventional radiology and hepatology and the patient underwent transjugular intrahepatic portosystemic shunt (TIPS) placement with coil and plug embolization of the splenic varix and gonadal varix feeding into the ascending colon varix. The patient did not have any further episodes of hematochezia and his hemoglobin stabilized. A few days later, the patient underwent an orthotic liver transplant. His post-operative clinical course was uncomplicated. Discussion: This is a rare case of a colonic varix resulting in a clinically significant LGIB. There is no standardization of therapy for ectopic varices due to the heterogeneity in vascular anatomy. Therapeutic options include endoscopic variceal band ligation, cyanoacrylate injections, surgery, TIPS and coil embolization. This case highlights the importance of a multi-disciplinary approach with gastroenterologists, hepatologist, interventional radiologists, and surgeons for the treatment of colonic varices.

S1906 A Rare Cause of Delayed Life-Threatening Hemorrhage in a Patient With Pancreas Transplant

Introduction: Complications of vascular anastomosis usually occur early after pancreas transplant (PTx) and carry a substantial risk of graft loss and mortality. Hemorrhage may result from arterial anastomosis failure, but more commonly from superior mesenteric or splenic vessel ligation. We present a challenging case of GI hemorrhage from a pseudoaneurysm (PA) in the implanted vascular Y graft 7 years after PTx. Case Description/Methods: A 45-year-old male 7 years post simultaneous pancreas-kidney transplant presented with painless rectal bleeding. EGD and Colonoscopy showed blood throughout the duodenum and colon, but the source could not be localized. Push enteroscopy showed blood extending into the proximal jejunum, and no active bleeding source could be identified. CT angiogram showed active extravasation into a small bowel loop near the PTx. Mesenteric angiography with IR revealed active extravasation into jejunum from a PA which had developed off the SMA Y graft anastomosis, eroding into the adjacent duodenal stump. Successful coil embolization was performed. 2 days later, he developed rectal bleeding requiring massive transfusion. Tagged RBC scan and CT angiography could not localize the bleeding source. Emergent mesenteric angiography showed contrast leakage into the anastomotic stump beyond the previously placed coil (Figure A). A covered stent was placed into the right external iliac artery arresting the bleeding into the SMA anastomotic stump (Figure B). Bleeding and shock resolved, and he was discharged with transplant surgery follow-up. Discussion: Pseudoaneurysms, AV fistulae, arterial dissection and stenosis represent rare vascular complications of PTx. PAs, if early, may be the result of surgical technique, infection, severe pancreatitis, or allograft biopsy. Arterial anastomotic PAs can be asymptomatic or present with symptoms signaling impending rupture such as abdominal pain, pulsatile mass, or endocrine failure. Endoscopic localization and management of bleeding from Y graft PAs are challenging due to altered anatomy and brisk bleeding. Multidisciplinary management is essential and often involves endovascular hemostasis with IR, possibly with surgical exploration. Stent placement is usually preferred over embolization due to the ability to deploy with precision while maintaining end-organ perfusion. Although guidelines are lacking, it would be reasonable to consider periodic Doppler US to screen for post-operative PAs for early detection and preventative endovascular treatment.Figure 1.: A. Pre-stent mesenteric angiogram with contrast leaking through coil into SMA anastomotic stump; B. Post stent mesenteric angiogram with no contrast leaking into the SMA anastomotic stump.

S2895 A Rare Case of Inferior Pancreaticoduodenal Artery Pseudoaneurysm Rupture Following Endoscopic Retrograde Cholangiopancreatography

Introduction: Hemorrhage is a known potential complication of endoscopic retrograde cholangiopancreatography (ERCP), often occurring at the site of sphincterotomy. Less commonly, intra- and retroperitoneal hemorrhage can occur secondary to splenic, hepatic, or vascular injury. Here we present a rare case of inferior pancreaticoduodenal artery (IPDA) pseudoaneurysm (PSA) rupture following ERCP in a patient with a large diaphragmatic hernia. Case Description/Methods: The patient is a 68 year old man with a history of hypertension, chronic kidney disease, and splenectomy. He presented with jaundice, fatigue, and labs notable for hypoglycemia, acidemia, acute kidney injury, normal transaminase levels, alkaline phosphatase (129 IU/L), total bilirubin (4.2 mg/dL), direct bilirubin (2.5 mg/dL), and lipase (157 IU/L). Computed tomography (CT) with contrast revealed choledocholithiasis with a 1.2 cm stone in the head of the pancreas associated with pneumobilia, intra- and extrahepatic ductal dilation, and pancreatic ductal dilation. A large left diaphragmatic hernia with protrusion of nonobstructed loops of large and small bowel into the left hemithorax was also noted. He underwent ERCP with biliary sphincterotomy and removal of one stone. One large stone remained. A plastic stent was placed in the common bile duct with plans to repeat ERCP in 4-6 weeks with cholangioscopy and electrohydrolic lithotripsy. Following ERCP, the patient developed acutely worsening anemia without overt evidence of lumenal gastrointestinal bleeding. CT angiography revealed active extravasation and a PSA within an intra-abdominal hematoma (18.4 x 8.5 cm). The patient then underwent mesenteric angiography which showed one multilobulated (2 x 1.8 cm) and one smaller PSA arising from an IPDA branch. Coil embolization of the dominant PSA was performed, achieving hemostasis. (Figure, Table) Discussion: Visceral artery aneurysm (VAA) rupture is an exceedingly rare complication of ERCP with IPDA pseudoaneurysms accounting for just 2% of VAA. Although there is a known association of VAA with pancreatitis, the mechanism for PSA formation following ERCP is unclear. It is thought to be associated with sphincterotomy with rupture caused by direct mechanical injury related to pancreaticobiliary manipulation. Mortality related to VAA rupture and hemorrhage can be as high as 19%. A high index of suspicion and early detection followed by angioembolization are critical for reducing mortality.Figure 1.: (A) CT with contrast showing choledocholithiasis with a 1.2 cm stone in the head of the pancreas. (B) CT angiography showing active extravasation and a pseudoaneurysm (PSA) within an intra-abdominal hematoma (18.4 x 8.5 cm). (C) Mesenteric angiography which showed one multilobulated (2 x 1.8 cm) and one smaller PSA arising from an inferior pancreaticoduodenal artery branch. Table 1 - Summary of currently available case reports of inferior pancreaticoduodenal artery (IPDA) pseudoaneurysm (PSA) development following endoscopic retrograde cholangiopancreatography (ERCP) Age/Sex Comorbidities ERCP Indication Interventions Symptom Diagnosis Treatment Al-Jeroudi et al 2001 76 F None Palliation of pancreatic carcinoma Precut sphincterotomy, biliary stent Abdominal pain IPDA PSA Embolization Rim et al 2021 27 M Sickle cell disease Choledocholithiasis Sphincterotomy, stone extraction, biliary stent, pancreatic duct stent Abdominal pain, acute anemia IPDA PSA rupture Embolization Current Case 68 M Hypertension, chronic kidney disease, diaphragmatic hernia Choledocholithiasis Sphincterotomy, stone extraction, biliary stent Abdominal pain, acute anemia IPDA PSA rupture Embolization

S2004 Colonic Varices as a Complication of Pancreatic Adenocarcinoma: A Case Report and Literature Review

Introduction: Colonic varices are a rare subtype of ectopic varices with unknown prevalence rates, likely due to under-diagnosis. They form due to venous anomalies, portal hypertension, splenic or portal vein (PV) thrombosis and mesenteric vein obstruction. We present a rare case of isolated colonic varices related to pancreatic cancer. Case Description/Methods: A 64-year-old male with pancreatic cancer presented with hematochezia. Endoscopic evaluation at an outside facility showed fresh blood in the colon and terminal ileum. His hemoglobin dropped from 13 to 6 mg/dL and a tagged RBC scan identified extravasation in the right lower quadrant, localizing to the ileum. He was transferred to our hospital for a retrograde single balloon enteroscopy, which noted isolated ascending colon and hepatic flexure varices (felt to be the source of bleeding) and normal ileum. A CT angiogram revealed the pancreas mass encased the celiac axis, superior mesenteric artery, and portal confluence with occlusion of the superior mesenteric vein (SMV) and extensive collateral vessels in the hepatic flexure/ascending colon. Interventional radiology and surgical oncology were consulted for management. Given extensive vasculature involvement, no interventions were possible, and patient was medically managed. Discussion: Pancreatic cancer is a cause of left sided portal hypertension through occlusion of either the splenic vein or a non-splenic vein branch of the PV. Isolated colonic varices secondary to pancreatic cancer are rarely described. The gold standard for diagnosis is CT or selective mesenteric angiography. Often, they are diagnosed by colonoscopy for lower GI bleed evaluation but can be missed due to flattening with insufflation or blood precluding visualization. Treatment options are limited and mostly based on recommendations from case reports as there are no guidelines. For uncomplicated cases, conservative management with laxatives and iron supplementation is reasonable. For SMV occlusion, stenting of the SMV can reduce PH (table 1). In active bleeding, options include embolization, endoscopic therapy (sclerotherapy, cyanoacrylate injection, argon plasma coagulation, and band ligation), or transjugular intrahepatic portosystemic shunt (TIPS). However, if significant bleeding, laparoscopic ligation or colectomy may be indicated. Management of colonic varices due to pancreatic malignancy remains controversial and may require a multidisciplinary approach.

S1949 An Unusual Case of Chronic Pancreatitis Presenting With Recurrent Obscure Gastrointestinal Bleeding

Introduction: Chronic pancreatitis (CP) is a sequela of repeated pancreatic injury resulting in loss of exocrine and endocrine function of the pancreas. In most cases, CP presents with chronic abdominal pain and patients usually have either clinical and radiological features of CP, with gastrointestinal bleeding (GIB) as a very rare occurrence. Herein is a presentation of recurrent obscure GIB caused by chronic pancreatitis. Case Description/Methods: A 48-year-old male with a prior history of PUD and recurrent GIB episodes for several years presents with dark red bleeding per rectum for two days. Of note, the patient had undergone several endoscopies and the most recent endoscopies done six months prior were all unremarkable. He denied hematemesis, NSAIDs, or anticoagulant use. Denied liver or pancreatic disease but endorsed a prior history of moderate alcohol intake. Physical examination was unremarkable except for tachycardia and epigastric tenderness. He was mildly anemic with leukocytosis. The abdominal and pelvic CT scan was unremarkable. EGD revealed a small gastric oozing site (Figure) suspected to be an AVM or dieulafoy's lesion and clipped. He continued to have a frank bloody stool and developed hemorrhagic shock requiring multiple transfusions and vasopressors. Findings on two additional EGDs were unremarkable. He had mesenteric angiography performed with ligation of the gastroduodenal artery empirically. Despite the intervention, he continued to bleed. Abdominal CTA (Figure) noted active extravasation in the 2nd segment of the duodenum. Explorative laparotomy revealed an edematous head and uncinate portion of the pancreas with venous engorgement. There was erosion into the duodenum with acute hemorrhage (Figure). A duodenotomy and Roux-en-y (duodenojejunostomy and jejunojejunostomy) were performed. On account of the above findings, a tissue biopsy was not obtained. Following surgery, he remained hemodynamically stable and got discharged. Discussion: Massive obscure GIB due to complications of pancreatitis rarely does occur. A few cases reported are due to complications resulting from hemosuccus pancreaticus, pseudoaneurysm from a vascular supply, or erosion into adjacent viscus in the setting of known pancreatitis. Our patient represents an unusual presentation in which his recurrent obscure massive GI bleeding was the initial presentation of CP. We present this case to broaden our knowledge that obscure GI bleeding can be a complication of CP and the only manifestation of the disease.Figure 1.: The image on the left shows an EGD with the gastric oozing site with clips, and the middle image shows CTA with extravasation in the second segment of the duodenum. The image on the right shows the posterior aspect of the head of the pancreas, the uncinate, and venous engorgement.

S1718 Delayed Gastrointestinal Hemorrhage From Visceral Artery Pseudoaneurysm in Necrotizing Pancreatitis After LAMS Removal

Introduction: Delayed bleeding from visceral artery pseudoaneurysm (PA) formation is an uncommon complication of lumen-apposing metal stent (LAMS) placement. Risk factors for gastrointestinal bleeding (GIB) in patients with LAMS remain largely undefined. We report a case of delayed GIB due to rupture of a splenic artery PA 16 months after LAMS removal. Case Description/Methods: A 34-year-old female with a history of severe necrotizing pancreatitis presented to our hospital with massive hematemesis. 23 months prior to presentation, she underwent uncomplicated placement of a 15x10 mm LAMS and 2 7 Fr x 4 cm double pigtail plastic stents for drainage of walled-off pancreatic necrosis. She was briefly lost to follow-up and returned for LAMS removal 5 months later. Contrast was injected into the residual cyst cavity and contrast filling was noted of what appeared to be a splenic vessel without active bleeding (Figure A). CT angiogram showed no PA but proximity of the splenic hilar vasculature to the LAMS (Figure B). The LAMS was successfully removed 2 months later without complication. On presentation, she was tachycardic but normotensive. Laboratory studies were notable for hemoglobin 8.8 g/dL (baseline 14 g/dL). Upper endoscopy showed brisk bleeding in the proximal gastric body near the area of prior LAMS. Her bleeding was refractory to endoscopic hemostatic maneuvers, and she underwent emergent mesenteric angiography. Angiography revealed active arterial extravasation arising from the inferior segmental branch of the splenic artery ( Figure C) which was successfully embolized with no further bleeding. Discussion: Visceral artery PA development after LAMS placement is thought to occur due to friction of the inner flange against regional vasculature surrounding the necrotic cavity as it collapses. Close anatomical proximity of LAMS to regional vasculature increases the risk of PA development. In our case, the LAMS was placed near the rich vascular supply of the splenic hilum. Most reported bleeding events related to LAMS have occurred within 8 weeks of placement. Our case is notable for the prolonged delay between LAMS removal and bleeding presentation. Adherent scar tissue between the gastric wall and vasculature could potentially cause delayed PA development after LAMS removal. This case reinforces that high clinical suspicion for PA bleeding is necessary for patients who have previously undergone distant LAMS removal who present with massive GIB.Figure 1.: (A) Fluoroscopic image of contrast injection into residual cyst cavity demonstrating opacification of likely splenic vasculature; (B) Coronal images demonstrating the proximity of the LAMS to the vasculature of the splenic hilum (yellow arrow); (C) Super-selective angiography demonstrating active extravasation into the lateral aspect of the stomach from a pseudoaneurysm (White arrow) involving an inferior segmental branch of the splenic artery.

Abstract No. 344 Selective vs. superselective mesenteric angiography in identifying sources of acute lower gastrointestinal bleeding

To assess the diagnostic accuracy of selective mesenteric angiography compared with superselective mesenteric angiography in identifying sources of acute lower gastrointestinal bleeding (LGIB) following an initial computed tomography (CT) demonstrating active arterial bleeding. Secondary evaluations included technical success rate, clinical success rate, and complications of transcatheter embolization for the treatment of LGIB.

Role of clinical data and multidetector computed tomography findings in acute superior mesenteric artery embolism.

BACKGROUNDSuperior mesenteric artery embolism (SMAE) has acute onset and fast progression, which seriously threatens the life of patients. Multidetector computed tomography (MDCT) is one of the most important diagnostic methods for SMAE, which plays an important role in the diagnosis and prognosis of SMAE.AIMTo evaluate the value of combined clinical data and MDCT findings in the diagnosis of acute SMAE and predict the risk factors for SMAE-related death.METHODSData from 53 SMAE patients who received abdominal MDCT multi-phase enhancement and superior mesenteric artery digital subtraction angiography examinations were collected. Univariate cox regression and multivariate cox model were used to analyze the correlation between death risk and clinical and computed tomography features in SMAE patients.RESULTSUnivariate Cox regression model showed that intestinal wall thinning, intestinal wall pneumatosis, blood lactate > 2.1 mmol/L and blood pH < 7.35 increased the risk of death in patients with SMAE. After adjusting for age, sex, embolic involvement length and embolic distribution region, multivariate Cox regression model I showed that blood lactate > 2.1 mmol/L (HR = 5.26, 95%CI: 1.04-26.69, P = 0.045) and intestinal wall thinning (HR = 9.40, 95%CI: 1.05-83.46, P = 0.044) were significantly increases the risk of death in patients with SMAE.CONCLUSIONFor patients with SAME, increased blood lactate and intestinal wall thinning are the risk factors for death; hence, close monitoring may reduce the mortality rate. Clinical observation combined with MDCT signs can significantly improve SMAE diagnosis.

Angiographic Diagnosis of a Meckel's Diverticulum in a 26-month-old Boy.

A 26-month-old boy presented with recurrent hematochezia. Abdominal examination was normal. Laboratory findings showed hemoglobin of 7.5 g/dL. Abdominal ultrasound (US) for intussusception revealed a short (0.3 cm) segment of wall thickening in the distal ileum and Meckel’s scan was negative. The patient underwent two additional Meckel’s scans, tagged red blood cell scan, CT-angiography, upper endoscopy and colonoscopy, and video capsule endoscopy, but had normal results. Superior mesenteric angiography was performed revealing an area of abnormal vasculature in the terminal ileum (Fig. 1). Subsequently, exploratory laparotomy showed an obvious Meckel’s diverticulum (MD), and Meckel’s diverticulectomy was performed (Fig. 2).FIGURE 1.: Meckel's Diverticulectomy.FIGURE 2.: Meckel’s Diverticulectomy. A) Gross specimen of MD removed from patient and (B) histological examination of MD with the presence of ectopic gastric mucosa.MD is the most common congenital malformation of the gastrointestinal tract, occurring in approximately 2% of the population (1). The gold standard in diagnosing a MD is a Meckel’s scan which detects the accumulation of a radioisotope, Technetium-99m. However, false negatives do occur and this is likely due to insufficient gastric mucosa in the MD (2). The literature on typical angiographic findings for diagnosis of MD are limited to a few individual cases (3–6). Our patient exhibited multiple abnormal corkscrew-like arteries of the ileocolic artery. Angiography can detect MD in the absence of acute bleeding through visualization of the vitelline artery (7). ACKNOWLEDGMENTS A.P. was involved in conception and design, acquisition of data, drafting the work, final approval of the version to be published. M.R.A., P.M., T.R.B., and C.M.S. were involved in conception and design, critical revision of work, final approval of version to be published. L.A. was involved in conception and design, acquisition of data, critical revision of work, final approval of version to be published.

A common celiacomesenteric trunk is a rare anatomic variant in dogs.

With the increasing use of CT and MRI for diagnostic imaging and planning of interventional procedures, it is important for veterinary radiologists to be familiar with variations in normal vascular anatomy and not mistake them for pathology. The arterial blood supply to the cranial abdominal viscera is provided by the celiac and the cranial mesenteric arteries. A common celiacomesenteric trunk (CMT) has been reported as a rare anatomical variant in dogs. The goals of this retrospective, observational, cross-sectional prevalence study were to determine the prevalence of a CMT in dogs with non-abdominal disease and compare it to the prevalence in dogs with portosystemic shunts (PSS). Magnetic resonance imaging studies of the thoracolumbar and lumbosacral spine in dogs that included the origin of the celiac and cranial mesenteric arteries and dual-phase CT angiography studies of the abdomen in dogs with portosystemic shunts were retrospectively reviewed by a veterinary student and a board-certified veterinary radiologist. The prevalence of a CMT was determined as the proportion of dogs diagnosed with this vascular anomaly in the MRI and CT group, respectively. Fisher's exact test was used to determine any association of a CMT with the concurrent presence of a PSS, sex, and breed size. A CMT was identified in seven of 606 (1.2%) MRI studies and in none of 47 abdominal CT studies. There was no association between the presence of a CMT and PSS (P=1.000), sex (P=.4694), or breed size (P=1.000). A CMT is a rare incidental finding in dogs.

Acute necrotizing pancreatitis as a manifestation of Behcet’s Disease: A case report and review of the literature

BackgroundBehçet’s disease (BD) is a chronic, relapsing, multisystemic vasculitis with varying frequency of gastrointestinal manifestations. Pancreatitis is a rare manifestation of BD. Case presentationA 31-year-old man diagnosed with Behçet’s disease with a fiveyear history of recurrent orogenital ulcers, ocular involvement and pseudofolliculitis presented with severe epigastric pain radiating to back that worsens after meals and weight loss (10 kg in 3 months). He denied history of abdominal trauma, drug abuse or alcohol consumption. He was found to be hypertensive. Laboratory investigations revealed presence of leukocytosis, thrombocytosis, high inflammatory markers, low serum albumin, impaired renal functions, hyperglycemia and elevated serum amylase. Post contrast triphasic computed tomography scan showed a picture of necrotizing hemorrhagic pancreatitis. Bile and pancreatic ducts were normal. CT mesenteric angiography showed no evidence of aortic, celiac or superior mesenteric artery aneurysms, also splenic artery and veins were patent with no evidence of occlusion. After exclusion of other causes of acute pancreatitis, the condition has been attributed to BD. High dose of oral corticosteroids was started (60 mg/day) in addition to proper hydration, antihypertensive medications, intravenous antibiotics and insulin to control elevated blood sugar. Cystogastrostomy through endoscopic ultrasound was done to relieve the patient’s pain. Unfortunately, three months after the onset of pain, the patient developed systemic inflammatory response syndrome and passed away. ConclusionAlthough acute pancreatitis is a rare gastrointestinal manifestation of BD, it is a possibly fatal one.

1228 Massive Gastrointestinal Bleeding Secondary to Bleeding Jejunal Diverticulum

Abstract Usually, the Jejunal diverticula appeared multiple and vary in size. These false diverticula lack the muscular coat of the normal intestinal walls, and most patients presented with it were asymptomatic. Although 10% of all patients develop complications such as perforation, obstruction, or bleeding, which then requires surgical intervention, but bleeding is relatively rare among these complications. A case of 74 years old lady was referred to our hospital because of persistent hematemesis and fresh melena. Her previous and recent upper gastrointestinal endoscopy both revealed only gastric erosions without any active bleeding. Also, previous, and recent colonoscopy was done but not completed due to the presents of fresh blood and blood clots along the colon, which led to improper visualization. Her selective mesenteric angiography was done together with upper and lower endoscopy, but none of them revealed the source of bleeding. Emergency exploratory laparotomy was undertaken, and a prominent single jejunal diverticulum with a prominent vessel entering it was noted, and no bleeding from other sites detected. Enterotomy was performed, and enteroscopy confirmed ulceration at the jejunal diverticulum site. Resection of the portion containing the diverticulum and primary anastomosis was done, and this cured the patient. The histopathological examination of the specimen showed an ulcerative lesion with an exposed vessel suggestive of the source of bleeding. Although jejunal diverticula incidence is rare, it is important to look for such lesions in patients with intestinal bleeding. Keywords: jejunal diverticulum, small intestine, intestinal bleeding.

Provocative mesenteric angiography for localizing ambiguous gastrointestinal hemorrhage

Objectives: Five percent of patients with recurrent gastrointestinal (GI) hemorrhage have indeterminate origin by radiological and endoscopic examinations. To improve diagnostic accuracy and therapeutic embolization, the technique of provocative mesenteric angiography (PMA) has been developed. It involves the addition of pharmacologic agents to standard angiographic protocols to induce bleeding. Material and Methods: This is an institutional review board-approved, retrospective study of 20 patients who underwent PMA between 2014 and 2019. All patients had clinical evidence of GI hemorrhage without a definite source. PMA consisted of anticoagulation with 5000 units of heparin and selective transcatheter injection of up to 600 μg of nitroglycerine, followed by slow infusion of up to 24 mg of tissue plasminogen activator into the arterial distribution of the highest suspicion mesenteric artery. Results: Among the 20 patients who underwent PMA, 11/20 (55%) resulted in angiographically visible extravasation. Of these 11 patients, nine patients underwent successful embolization with coil or glue and were discharged upon achieving hemodynamic stability. Two patients spontaneously stopped bleeding. In our series, PMA resulted in the successful treatment of 9/20 (45%) patients with recurrent hemorrhage. No procedure-associated complications were reported with these 20 patients during the procedure and their course of hospitalization. Conclusion: In our experience, PMA is an effective and safe approach in localizing and treating the source of GI bleeding in about half of patients with an otherwise unidentifiable source.

Video Capsule Endoscopy In Comparison To Radiological Examination In Detection Of Small Bowel Lesions

Abstract BACKGROUND Small bowel obscured its lesions as secrets which were difficult to diagnose before video capsule endoscopy as a new modality for investigation. Aim of the study Evaluation of video capsule endoscopy in comparison to radiological examination in detection of small bowel lesions. Patients and methods Fifty patients were recruited from Kafrawy Video Capsule Endoscopy Unit of Internal Medicine Department and endoscopy unit of Ain Shams University Hospital. The study included patients with occult or overt GIT bleeding, patients with unexplained microcytic iron deficiency anemia, patients with chronic diarrhea and abdominal pain, with normal upper GI endoscopy and colonoscopy. Exclusion of any patient younger than 18 years old, has intestinal stricture, achalasia, or dysphagia. All patients were studied biochemically with CBC and radiological by CT pelvis and abdomen with IV and oral positive contrast some of them were radiologically examined with CTE or CT mesenteric angiography. All patients were endoscopically examined by OGD, colonoscopy, VCE, and some of them were examined also with enteroscope. Results The study revealed that the detection rate of SB lesions with VCE was 84%. In the current study, (44%) of cases had AVMs, (72.73) % of them were above the age of forty five, and (27.27) % were below the age of forty five. All patients who were investigated with CT mesenteric angiography revealed negative results. In this study (20) % of patients had SB masses and polyps, (70) % of them were at age of forty five or more and only (30) % of them were below the age of forty five. All patients underwent CT pelvis and abdomen with IV and oral positive contrast, and we found that all patients had a negative results regarding the SB lesions. In comparison between CTE and VCE in detection of SB vascular lesions CTE did not detect SB vacular lesions. On the other hand, VCE detected the AVMs in the cases with negative CTE results. In this study one patient (2)% was diagnosed with hookworm infection. All patient underwent for OGD. We found that (20)% of patients had a significant gastric or duodenal lesions (proximal to the papilla) by VCE but missed by upper GI endoscopy. In our study the concomitant of VCE and enteroscope increase the detection of SB vascular lesions than isolated use of VCE only. Conclusion VCE has a high detection rate of SB lesions (84)%. CTE has a low significance in detection of SB vascular lesions and CT mesenteric angiography sensitivity relatively low. AVMs more common with increasing the age. PHE and SB ectopic varicies, were found to be common causes of GIT bleeding in CLD patient. There is a significant rate of missed gastric and duodenal (proximal to the papilla) lesions that the cause of GIT bleeding and unexplained iron deficiency anemia in OGD examination that were detected by VCE.

Provocative Mesenteric Angiography: Outcomes and Standardized Protocol for Management of Recurrent Lower Gastrointestinal Hemorrhage

Provocative Mesenteric Angiography: Outcomes and Standardized Protocol for Management of Recurrent Lower Gastrointestinal Hemorrhage