upper and lower gi bleeding cta and invasive angiogram and lo… · •upper gi tract >>>...
TRANSCRIPT
![Page 1: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/1.jpg)
Upper and Lower GI bleeding CTA and invasive angiogram
Nakarin Inmutto, MD
Chiang Mai University, Thailand
![Page 2: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/2.jpg)
Introduction
• Acute gastrointestinal (GI) bleeding is common .
• Need rapid diagnosis and treatment.
• Bleeding can occur anywhere throughout the GI tract.
• Upper GI tract >>> lower GI tract. (75% vs 25%)
• Hematemesis, coffee ground emesis, melena
• 80%–85% of cases of GI bleeding resolve spontaneously
![Page 3: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/3.jpg)
GI bleeding
![Page 4: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/4.jpg)
GI bleeding
Stability
![Page 5: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/5.jpg)
GI bleeding
Stability
Source of bleeding Upper VS Lower
![Page 6: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/6.jpg)
Common cause of bleeding
Upper GI bleeding
• Esophageal varices
• Gastritis or duodenitis
• Peptic ulcer
• Arteriovenous malformation
Lower GI bleeding
• Diverticular disease
• Colitis and IBD
• Neoplasia
• Coagulopathic hemorrhage
• Angiodysplasia
![Page 7: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/7.jpg)
Current nomenclature
• Upper GI bleeding (UGIB) = bleeding originating proximal to the Treitz ligament.
• Lower GI bleeding (LGIB) = bleeding originating from the colon or rectum.
• Suspected small-bowel bleeding = upper and lower GI tracts have been evaluated (typically with endoscopy) and no bleeding site has been identified.
CT for Evaluation of Acute Gastrointestinal Bleeding; RadioGraphics 2018; 38:1089–1107
![Page 8: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/8.jpg)
CT angiography: Role
• Rapid localizing the source of bleeding
• Differentiating the underlying disease
• Aiding decisions to proceed to endovascular therapies
![Page 9: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/9.jpg)
Diagnostic modalities in acute GI bleeding
Wortman JR, LandmanW, Fulwadhva UP, Viscomi SG, Sodickson AD. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90: 20170076
![Page 10: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/10.jpg)
CT angiography: Role
• Positive result
• Sensitivity 85%, Specificity 92%
• Negative result
• Unlikely to need emergent surgical or angiographic intervention
• Discharge from hospital without intervention
![Page 11: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/11.jpg)
CT technique
• Oral contrast is not administered
• Non-contrast, arterial and venous phase
• The scan range diaphragm to below the inferior pubic rami
• Contrast injection, 100–125 ml , 4–5 ml/ sec
• Reconstruction; 5-mm thickness for non-contrast images and 1.25 mm for arterial and venous phase images.
• Multiplanar reformation images in the sagittal and coronal planes
• Maximum intensity projection images in the sagittal and coronal planes
![Page 12: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/12.jpg)
Renal dysfunction?
• Jacovides , et al.
• JAMA Surg 2015;150(7):650–656.
• Catheter angiogram vs underwent CTA before catheter angiogram
• Received a greater cumulative iv contrast load (130cc – 220cc).
• Additional contrast load was not associated with greater renal dysfunction.
![Page 13: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/13.jpg)
CT findings
• Contrast extravasation
• Non-contrast images; not present
• Arterial phase; intraluminal focus of high attenuation
• Portal venous phase; change in appearance and generally moves distally within the bowel lumen.
![Page 14: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/14.jpg)
Upper GI bleeding
![Page 15: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/15.jpg)
Upper GI bleeding
• Many common causes of bleeding in the esophagus and upper GI cannot be optimally evaluated with CT
CT for Evaluation of Acute Gastrointestinal Bleeding; RadioGraphics 2018; 38:1089–1107
![Page 16: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/16.jpg)
Wortman JR, LandmanW, Fulwadhva UP, Viscomi SG, Sodickson AD. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90: 20170076
![Page 17: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/17.jpg)
Case 1
![Page 18: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/18.jpg)
Case 1
• A 78-year-old woman with UGIH
• S/P EGD (large DU) → adrenaline injection, glue injection and clip
• New episode of massive UGIH
![Page 19: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/19.jpg)
Case 1
• A 78-year-old woman with UGIH
• S/P EGD and clip
• New episode of massive UGIH
![Page 20: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/20.jpg)
![Page 21: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/21.jpg)
Question
![Page 22: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/22.jpg)
Bleeding from vessel?
• Common hepatic artery
• Gastroduodenal artery
• Gastroepiploic artery
• Left gastric artery
![Page 23: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/23.jpg)
![Page 24: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/24.jpg)
![Page 25: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/25.jpg)
Case 2
![Page 26: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/26.jpg)
Case 2
• A 74-year-old female
• Known case of HT, DLP, gout
• She developed UGIH for 2 days ago.
• The last EGD revealed duodenitis and antral gastritis
• Without evidence of bleeding point.
![Page 27: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/27.jpg)
3613131
• A 74-year-old female
• Known case of HT, DLP, gout
• UGIH for 2 days ago
• The last EGD revealed
• Duodenitis and antral gastritis
• No evidence of bleeding point
![Page 28: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/28.jpg)
Question
![Page 29: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/29.jpg)
Point of bleeding
• A
• B
• A + B
• None
A B
![Page 30: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/30.jpg)
A B
![Page 31: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/31.jpg)
![Page 32: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/32.jpg)
![Page 33: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/33.jpg)
![Page 34: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/34.jpg)
Case 3
![Page 35: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/35.jpg)
Case 3
• A 56-year-old man
• CA pancreas S/P chemoradiation therapy and gastrojejunostomy
• He develop UGIH
• Suspected gastric ulcer
• EGD → no lesion, then CTA
![Page 36: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/36.jpg)
![Page 37: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/37.jpg)
![Page 38: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/38.jpg)
![Page 39: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/39.jpg)
![Page 40: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/40.jpg)
![Page 41: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/41.jpg)
Conclusion for Upper GI bleed
• Search site of bleeding
• Pre-treatment for endoscopy or endovascular
![Page 42: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/42.jpg)
Lower GI bleeding
![Page 43: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/43.jpg)
Oakland K, et al. Gut 2019;68:776–789.
![Page 44: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/44.jpg)
Oakland K, et al. Gut 2019;68:776–789.
![Page 45: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/45.jpg)
Case 4
![Page 46: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/46.jpg)
Case 4
• An 80-year-old woman with simple falling and traumatic closed fracture right superior pubic rami.
• Pulmonary embolism S/P enoxaparin.
• Then, she developed lower GI bleeding.
![Page 47: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/47.jpg)
![Page 48: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/48.jpg)
Case 5
![Page 49: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/49.jpg)
Case 5
• A 49-year-old man
• Present with lower GI bleeding.
![Page 50: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/50.jpg)
Diffuse thickening of bowel walls of entire colon down to the rectum
![Page 51: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/51.jpg)
![Page 52: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/52.jpg)
Case 6
![Page 53: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/53.jpg)
Question
![Page 54: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/54.jpg)
Bleeding site?
• A
• B
• C
• D
A B
C D
![Page 55: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/55.jpg)
![Page 56: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/56.jpg)
![Page 57: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/57.jpg)
![Page 58: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/58.jpg)
![Page 59: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/59.jpg)
CT angiography: Role
![Page 60: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/60.jpg)
Case 7
![Page 61: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/61.jpg)
Case 7
• A 75-year-old man, known case of ESRD, with LGIH S/P EGD and colonoscopy. No bleeding point.
• Today he developed hematochezia with hypotension.
• Suspected active bleeding.
![Page 62: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/62.jpg)
![Page 63: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/63.jpg)
![Page 64: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/64.jpg)
Case 8
![Page 65: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/65.jpg)
Case 8
• A 74-year-old female
• Known case factor VIII inhibitor
• Massive LGIH.
• Her EGD and colonoscope; WNL
![Page 66: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/66.jpg)
![Page 67: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/67.jpg)
![Page 68: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/68.jpg)
Case 9
![Page 69: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/69.jpg)
Case 9
• Case 40-year-old woman
• Underlying SLE with lupus nephritis, febrile neutropenia with sepsis and DIC
• Presents with LGIH
![Page 70: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/70.jpg)
![Page 71: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/71.jpg)
![Page 72: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/72.jpg)
Case 10
![Page 73: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/73.jpg)
Case 10
• A 60-year-old female
• Known case ESRD
• Ruptured infrarenal abdominal aortic aneurysm S/P open repair with aortic bifurcated graft
• Presents with abdominal pain and LGIH
![Page 74: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/74.jpg)
![Page 75: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/75.jpg)
![Page 76: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/76.jpg)
![Page 77: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/77.jpg)
Case 11
![Page 78: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/78.jpg)
Case 11
• A 59-year-old man
• LGIH S/P colonoscopy + clip, point of bleeding about 10 cm from anal verge
• PE shows blood pressure 70/50 mmHg, HR 80/min.
• Suspected rebleed
![Page 79: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/79.jpg)
![Page 80: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/80.jpg)
![Page 81: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/81.jpg)
Pre-treatment Post-treatment
![Page 82: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/82.jpg)
What should you do?
• Done, I completed embolization.
• SMA angiography
• Iliac angiography
• Femoral angiography
![Page 83: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/83.jpg)
Rt-iliac a. Lt-iliac a.
![Page 84: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/84.jpg)
• 1 week later
• Re-bleeding of lower GI (fresh blood about 2L.)
![Page 85: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/85.jpg)
![Page 86: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/86.jpg)
![Page 87: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/87.jpg)
Conclusion
• Difference guideline in Acute massive GI bleeding
• CT is a good tool
• Rapid
• Identify point of bleeding
![Page 88: Upper and Lower GI bleeding CTA and invasive angiogram and Lo… · •Upper GI tract >>> lower GI tract. (75% vs 25%) •Hematemesis, coffee ground emesis, melena ... Conclusion](https://reader036.vdocuments.us/reader036/viewer/2022062605/5fcd344e369b3f6ea2356d57/html5/thumbnails/88.jpg)
Thank you