Gastrointestinal Haemorrhage

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Gastrointestinal tract (GIT) or digestive tract is the pathway by which food enters the body and solid wastes are expelled. The gastrointestinal tract includes the mouth, pharynx (throat), esophagus (food pipe), stomach, small & large intestine and anus.  

Gastrointestinal haemorrhage (GIH) is bleeding that occurs from the gastrointestinal tract. It can be a slow ooze of small amount of blood, or a sudden massive loss of blood requiring urgent treatment. This section concentrates on the latter, and aims to elucidate about Interventional radiological treatment options for the same.  

Commons causes are ulcers, tumours, abnormal blood vessels (eg. angiodysplasia), diverticulitis, blood clotting disorders, or after trauma or surgery. 

Symptoms depend on the site of the bleeding point in the digestive tract and also on the rate of bleeding.  

Bleeding from the upper digestive tract (esophagus, stomach and small intestine) can cause blood in vomit. 

It can also cause dark, tarry, maroon coloured stool due to blood that has been altered during passage through the digestive tract. Bleeding from the lower digestive tract (large bowel and rectum) usually causes bright red rectal bleeding. 

GIH is usually initially investigated with ENDOSCOPY by a Gastroenterologist, where a camera on a flexible tube will be inserted into the digestive tract via the mouth or anus. This may allow the bleeding point to be located and treated. 

If endoscopy fails to locate the source of bleeding, CT angiography is usually the next line of investigation. In CT angiography, CT scan is done after injecting contrast (x-ray) dye from arm veins. It is very sensitive investigation, and can detect bleeding at very small rates (0.5 ml/min). However, there needs to be active bleeding at the time of the scan, to allow detection of the bleeding point. This can cause problems with timing the scan, as GIH is often intermittent. Therefore, CT angiography may need to be repeated to allow the detection of GIH. 

It may be possible to treat GIH at endoscopy itself. Surgical treatment, by removing the segment of bowel suspected to be involved, or by oversewing bleeding ulcers, tend to be used as last resorts. Mesenteric angiography and embolisation is an Interventional Radiological technique very commonly used to treat GIH. 

• This is a procedure performed by Interventional Radiologists to diagnose and treat GIH. 
• The procedure is performed in a dedicated angiographic suite, which has specialised X-ray equipment. 
• Through a groin or wrist artery catheters (fine plastic tubes) are placed into the 3 main arteries arising from the aorta that supply blood to the bowel. Contrast is injected through the catheter to either detect the bleeding point or to confirm what was seen on a prior CT angiogram.  
• When the bleeding point is detected, micro-catheter is advanced close to it. The arteries supplying the bleeding point are then occluded (embolised). 
• This is usually done by deploying small metallic coils of a few millimetres in diameter through the catheter, although alternatively, other embolic agents (eg. Glue, PVA) may be used. 
• The time taken for the radiologist to find and occlude all the arteries supplying the bleeding point can be variable, due to anatomical differences and rate and site of bleed. 

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Once the procedure is completed, catheter is removed and the puncture site in the artery is then closed. If there is a risk of further bleeding, the Interventional Radiologist may elect to leave the sheath in the groin, to allow the procedure to be repeated later if need arises. 

A period of close observation for 24- 48 hours in an I CU will usually follow this procedure. 

Further tests and/or treatment may be needed once the acute situation settles, depending on the cause of bleeding. 

This is a safe and widely-performed procedure, and complications are rare. 

• Bowel injury or gangrene due to loss of blood supply after embolisation – this very rarely happens, as the bowel usually gets its blood supply by numerous arterial branches, not all of which will be embolised. 
• Puncture site hematoma is also very rare. 

• Variceal haemorrhage (VH) is a specific type of GIH that occurs due to bleeding from engorged and dilated veins that drain blood from the bowel, usually the oesophagus(food pipe) and stomach. It most commonly occurs in advanced cirrhosis (scarring of the liver), but can also arise due to other, less common conditions. 
• Endoscopy is often used to diagnose and treat VH. 
• Transjugular intrahepatic porto-systemic shunt (TIPSS) is an Interventional Radiological technique used to treat VH. The technique creates an artificial communication between the hepatic portal vein (which drains blood from the engorged veins causing VH), and the hepatic veins, which drain blood into the heart. 
• This relieves the pressure and stops bleeding. The bleeding varices can also be embolised at this time.