Radiology · Year 4 · from Radiology

Case 2: Gastrointestinal Bleeding - Angiography and Embolization

Patient Demographics

  • Age: 74 years
  • Sex: Male

Chief Complaint

Bright red blood per rectum with hemodynamic instability

Presenting Symptoms

The patient presented to the emergency department with multiple episodes of large-volume bright red blood per rectum that began 3 hours prior to arrival. He reports passing approximately 1 liter of blood with clots. He feels lightheaded and nearly syncopized at home. Medical history includes hypertension, atrial fibrillation on apixaban, and osteoarthritis for which he takes daily NSAIDs.

Physical Exam Findings

  • Vital Signs: BP 88/54 mmHg, HR 118 bpm, RR 22/min, Temp 36.4C
  • General: Pale, diaphoretic, anxious
  • Cardiovascular: Tachycardic, irregular rhythm
  • Abdomen: Soft, mildly tender in left lower quadrant, no peritoneal signs
  • Rectal Exam: Gross blood, no masses
  • Laboratory:
  • Hemoglobin: 7.2 g/dL (baseline 12.8 g/dL per records)
  • Platelets: 198,000/uL
  • INR: 1.4 (on apixaban)
  • Creatinine: 1.4 mg/dL

Imaging Findings and Interpretation

Initial Resuscitation:

  • 2 large-bore IVs, crystalloid resuscitation
  • Massive transfusion protocol activated
  • Type and crossmatch for 6 units PRBCs
  • Reversal agent for apixaban (andexanet alfa) considered

CT Angiography Abdomen/Pelvis:

Arterial Phase:

  • Active Extravasation: Focal area of contrast extravasation into the sigmoid colon lumen
  • Extravasation appears to arise from a branch of the inferior mesenteric artery (sigmoid branch)
  • Blush increases on delayed phase - confirms active bleeding

Source Identification:

  • Multiple diverticula throughout the sigmoid colon
  • Bleeding appears to originate from the mouth of a diverticulum
  • Sentinel clot: Highest-attenuation clot adjacent to extravasation site

Colonoscopy vs. Angiography Decision: Given hemodynamic instability and localized bleeding source on CTA, decision made to proceed directly to angiography for potential embolization rather than colonoscopy.

Interventional Radiology Procedure

Mesenteric Angiography and Embolization:

Diagnostic Angiography:

  • Right common femoral artery access
  • Flush aortogram: IMA identified
  • Selective IMA arteriogram: Identifies sigmoid branches
  • Superselective sigmoid artery catheterization
  • Active extravasation confirmed: Contrast blush into colonic lumen from branch of sigmoid artery, correlating with CTA findings

Embolization:

  • Microcatheter advanced to the bleeding branch
  • Embolization with microcoils (2mm x 4cm)
  • Completion angiogram: No residual extravasation
  • Preserved flow to adjacent bowel segments

Post-Procedure Findings:

  • Hemorrhage controlled
  • Hemodynamic stabilization achieved
  • No immediate complications

Diagnosis

Acute lower gastrointestinal bleeding secondary to diverticular hemorrhage; treated with angiographic embolization

Management

  1. Post-Embolization Care:
  • ICU admission for monitoring
  • Serial abdominal exams for ischemia
  • Serial hemoglobin checks
  • Transfusion to maintain Hgb >7 g/dL
  1. Post-Procedure Course:
  • No further bleeding episodes
  • Hemoglobin stabilized at 8.8 g/dL
  • Resumed oral intake day 2
  • No evidence of bowel ischemia
  1. Medication Management:
  • NSAIDs permanently discontinued
  • Anticoagulation: Discussed risks/benefits; restarted apixaban at reduced dose after 7 days given high stroke risk (CHA2DS2-VASc score 5)
  1. Outpatient Follow-up:
  • Colonoscopy in 4-6 weeks (after healing) to evaluate for other pathology
  • PPI therapy added for gastroprotection
  • Discussed high-fiber diet for diverticular disease

Radiological Image

Image Description: Selective mesenteric arteriogram demonstrating active gastrointestinal hemorrhage. Contrast extravasation (blush) is visible extending from a branch of the mesenteric artery into the bowel lumen, confirming the site of active bleeding amenable to transcatheter embolization.

Source: Wikimedia Commons - "Angiography showing gastrointestinal bleeding" URL: https://commons.wikimedia.org/wiki/File:Angiography.jpg License: Creative Commons Attribution-Share Alike 3.0 Unported

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