UPPER GI BLEEDING

DR GOWTHAMI
Assistant Professor
Radiodiagnosis
 CLASSIFICATION
• Based on anatomic locationclassified into two main
categories: upper and lower GI bleed.
• Upper GI bleed (UGIB), -bleeding originating
anywhere from the mouth to the ligament of Treitz,
75% of cases .
• Lower GI bleed (LGIB) -bleeding originating below
the ligament of Treitz to the anus..
• Small-bowel bleeding -no bleeding site has been
identified.
• Obscure GI bleeding is used when no bleeding
source is found after the entire GI tract has
been examined with advanced techniques.
• The American College of Gastroenterology
recommended that the term “obscure” GI
bleeding be replaced by small bowel bleeding
as the majority of cases of “obscure” GI bleeds
are due to bleeding in the small bowel
 The ligament of Treitz, also known as the suspensory ligament of the
duodenum, is a double fold of peritoneum suspending the duodenojejunal
flexure from the retroperitoneum.
 Common causes of GI bleeding
• Upper gastrointestinal bleeding (Zurkiya and
Walker)
• Esophageal, gastric and duodenal ulcers
• Mallory Weiss tears
• Esophagitis, gastritis, duodenitis, pancreatitis
• Neoplasms
• Vascular malformations
• Varices
• Angiodysplasia,
• Post Endoscopic Retrograde
Cholangiopancreatography-papillotomy,
• Small bowel bleeding (ACG guidelines
2015)
• Inflammatory bowel disease
• Angioectasia
• Dieulafoy’s lesion
• Neoplasia
• Meckel’s diverticulum
• NSAID ulcers
• Polyposis syndromes
• Lower gastrointestinal bleeding (Strate and Gralnek-
2016)
• Diverticulosis
• Angioectasia
• Post-polypectomy bleeding
• Ischemic colitis
• Colorectal polyps/neoplasms
• Dieulafoy’s lesion
• Inflammatory bowel disease
• Anorectal conditions, i.e., solitary rectal ulcer, radiation
proctitis and rectal varices
 Upper GI BLEED
• Peptic ulcer disease (can be secondary to
excess gastric acid, H. pylori infection, NSAID
overuse, or physiologic stress)
• Esophagitis
• Gastritis and Duodenitis
• Varices
• Portal hypertensive gastropathy (PHG)
• Angiodysplasia
• Dieulafoy lesion (bleeding dilated vessel that erodes
through the gastrointestinal epithelium but has no
primary ulceration; can be at any location along the
GI tract
• Gastric antral valvular ectasia (GAVE; also known as
watermelon stomach)
• Mallory-Weiss tears
• Cameron lesions (bleeding ulcers occurring at the
site of a hiatal hernia
• Aortoenteric fistulas
• Post-surgical bleeds (post-anastomotic
bleeding, post-polypectomy bleeding, post-
sphincterotomy bleeding)
• Upper GI tumors
• Hemobilia (bleeding from the biliary tract)
• Hemosuccus pancreaticus (bleeding from the
pancreatic duct)
• Foreign body ingestion
 Role of imaging
• Clinical differentiation of GI bleed as UGIB
versus LGIB is the first step in diagnostic
workup.
• Overt UGIB work up starts with an upper
endoscopy.
• Imaging therefore plays a key role in all these
patients with both overt and occult GI
bleeding that are hemodynamically stable.
 Radiologic imaging modalities
* Computed tomography angiography (CTA),
*Catheter angiography (CA).
*Technetium 99m scintigraphy.
not good for upper GI Bleed.choice of
modality for hemodyanamically stable lower
GIB
 CT ANGIOGRAPHY
• first radiologic imaging option for most stable
patients presenting with GI bleeding..
• It has potential for use in the first-line evaluation
of acute LGIB and the evaluation of UGIB after
failed or nondiagnostic endoscopy
• CTA has a bleeding detection threshold (0.3–0.5
mL/min) similar to scintigraphy with tagged red
blood cells (0.1–0.5 mL/min), which is usually not
performed in an emergency setting, and superior
to angiography (1.0 mL/min), which is usually
performed only for therapeutic purposes
 Advantages:

• of being able to accurately locate the source and the

entity of arterial or venous gastrointestinal bleeding and
• identify the underlying pathology that may be causing
the bleeding in order to guide subsequent management.
• very accurate at identifying the bleeding site , providing
information on vascular anatomy (anatomical variants,
vessel occlusions, etc.) and indicating the need for a
selective or super-selective angiographic procedure .
• It is also considered a second-line procedure in patients
with a previous endoscopy negative for GIB .
 Limitations :
• Intermittent bleeding represents a limitation for
CTA.
• However, even when CTA cannot identify the exact
site of the bleeding, it can still quickly recognise
the lesion causing the intra- or extraluminal
abnormalities that may be responsible for the
bleeding, such as ischemia, inflammatory bowel
disease, neoplasms and arteriovenous
malformations (AVMs)
 Technique
• The CTA protocol includes a
• Non contrast study : preliminary low radiation dose scan of the abdomen and
pelvis without an intravenous (IV) contrast medium. This is useful for recognising
any pre-existing hyperdense material in the lumen of the bowel (e.g., suture
material, clips, foreign bodies, orally administered drugs, coprolith, etc.) that can
be mistaken for an active focal haemorrhage .
• Arterial phase is obtained with the “bolus tracking” technique which allows the
scan to be synchronised with the transit of the contrast medium in the aortic arch
when the value of 100 Hounsfield units (HU) 15 -30 secs is reached and after
having placed a region of interest (ROI) in this location; this scanning phase is
extremely useful for documenting arterial extravasations of contrast medium and
the vascular anatomy of the anatomical district examined.
• Portal venous phase then, with a delay of 70 to 90 s from injection, is obtained,
which is useful for documenting the increase in arterial extravasation or
haemorrhage of venous aetiology
• late venous phase In some cases, and especially in patients with reduced cardiac
function, or with the finding of pathology in need of further investigation, a 5 min
from the start of the injection can also be considered.
 POST PROCESSING
• In all cases of GIB,post-processing appears to
be fundamental, i.e., carefully ex amining the
MIP reconstructions,because they can identify
unseen subtle bleeding in non-reconstructed
images or better highlight vascular
malformations with an anatomy similar to that
of an angiographicstudy.
 SIGNS OF HEMORRHAGE
• In patients with recent bleeding but who are not bleeding at the time of
CTA, only a hyperdense clot is found within the intestinal lumen, defined as
a “sentinel” clot (seen as an unchanging hyperdensity) is an indicator of the
site of previous active bleeding
• The critical sign of haemorrhage detected by CTA imaging is a “blush” of
contrast medium in the lumen of an intestinal loop, detectable as a focus of
high attenuation (about 90 HU)not present in the images acquired in the
basal phase or in the dual-energy virtual reconstructions; in the venous
phase, this also tends to change in size and morphology assuming a lower
position in the lumen of the intestinal loop or it can be moved by peristalsis,
taking on a more irregular shape
• Slow or delayed bleeds :in patients with low-flow bleeding, contrast
extravasation of arterial origin may be detectable in the venous phase
• Active bleeding :a changing appearance of the focus of extravasated
contrast with time between phases
• Based on clinical scenario (patient history, CTA, endoscopic
findings) the most suspected bleeding vessel is first studied.
• For suspected upper GIB, the celiac artery is commonly
interrogated first as a majority of upper GIB is caused by
gastroduodenal ulcers which are supplied by branches of the
celiac artery. If angiographically negative, selective left gastric and
the gastroduodenal artery evaluation is done.
• If the source of bleeding is thought to be in the small bowel or if
no evidence of bleeding is seen upon interrogation of the celiac
artery or its branches, the superior mesenteric artery (SMA) is
evaluated next.
• If these angiographic studies are all negative, then evaluation of
the inferior mesenteric artery (IMA) is considered.
 Portal hypertension

A shrunken liver with nodular surface is highly suggestive of liver cirrhosis. Hepatic hydrothorax
and splenomegaly are manifestations of portal hypertension. b Elevated portal pressure may
also drive the recannulation of periumbilical veins and cause paraumbilical varices. c and d
Dilated paraesophageal and paragastric veins can also be seen in portal hypertension,
representing esophageal and gastric varices respectively
Portal hypertensive gastropathy

• Refers to mucosal hyperemia and dilated submucosal vessels in the

stomach of patients with chronic portal hypertension..
• Mild PHG in a 47-year-old man. CECT shows multifocal hypoattenuating
mucosa (arrows) in the fundus and body of the greater curvature on (a)
arterial phase, which returns to normal attenuation on (b) portal and
(c) delayedphase images. Gastric endoscopy (d, e) shows a mosaic or
snakeskin-like appearance in the fundus and body.
 Esophageal varices

Figure 12. Esophageal and paraesophageal varices in a 63-year-old man with decompensated cirrhosis,
portal hypertension, and anemia. Axial portal venous phase CT image shows submucosal esophageal
varices (white arrow) and paraesophageal varices (blue arrows). Also noted is a large amount of ascites (*)
and small bilateral pleural effusions (arrowheads).
Figure 9. Gastric ulcer causing active bleeding in an 80-year-old woman receiving enoxaparin and warfarin for chronic atrial
fibrillation and aortic valve replacement who underwent recent spinal fusion surgery. Axial (main image) and coronal (inset) portal
venous phase CT images show contrast extravasation along the lesser curvature of the stomach (arrow in both images).

Guglielmo FF. Published Online: October 01, 2021

https://doi.org/10.1148/rg.2021210043
 Esophagitis due to GERD

Figure 11. Esophagitis with possible active bleeding in a 62-year-old man with esophagitis, gastroesophageal reflux disease, and peptic ulcer disease who
presented with chest pain and hematemesis. Axial arterial phase CT image shows diffuse esophageal wall thickening, fluid distending the esophagus,
paraesophageal fluid (arrow), and a tiny focus of high attenuation in the posterior esophageal lumen that is concerning for active bleeding (arrowhead).
However, contrast extravasation could not be confirmed on this single-phase CT image. At endoscopy (not shown), a bleeding deep mucosal tear was
found in the esophagus, with an associated clot.
Caustic Oesophagitis
Mallory weis tear
Esophaseal diverticula
Figure 14. Esophageal carcinoma with adjacent lymphadenopathy in a 48-year-old man who presented with
dysphagia, weight loss, and occult GI bleeding. Axial portal venous phase CT image shows moderate
asymmetric distal esophageal wall thickening consistent with the biopsy-confirmed poorly differentiated
adenocarcinoma (arrow), with adjacent lymphadenopathy (arrowhead). Figure E2 is an endoscopic image in
this patient that shows the esophageal mass, with an area of hemorrhage.

Guglielmo FF. Published Online: October 01, 2021

https://doi.org/10.1148/rg.2021210043
 Gastric ulcer

Upper gastrointestinal bleed secondary to gastric/duodenal ulcers. Fifty-four-year-old male with history of
gastric ulcers which were treated by clipping through endoscopy. Despite endoscopic intervention, the
patient presented with dropping hematocrit requiring transfusion. A: Noncontrast; B and C: contrast
enhanced computed tomography imaging demonstrates active extravasation at the level of the gastric
antrum with blood product filling the stomach; D and E: Active extravasation was found at the
gastroduodenal artery (not shown) which was embolized with coils and gelfoam.
 GASTRIC ULCER

Red arrow indicates the site of contrast pooling

in the antrum of the stomach in a gastric ulcer.
This on seen on this portal venous phase
image.
 DUODENAL ULCER

Figure 2. Active bleeding in the proximal duodenum, which was caused by two bleeding
duodenal ulcers that were identified with endoscopy (not shown), in a 71-year-old man who
presented with melena, hypotension, and shock. Axial noncontrast (A), arterial phase (B), and
portal venous phase (C) CTA images show contrast extravasation in the proximal duodenum,
which
G appears in the arterial phase (arrow in B) and changes in size, attenuation, and shape in
the portal venous phase (arrow in C). The bleeding duodenal ulcers noted at endoscopy were
not visualized on CT images.
Figure 10. Duodenal ulcer with active bleeding in a 54-year-old man with anemia who presented with syncope and large-
volume melena. Axial arterial phase (main image), noncontrast (top inset), and venous phase (bottom inset) CTA images show
mild stranding adjacent to the proximal duodenum (arrow in top inset). On the arterial phase image there is discontinuous
duodenal mucosal enhancement (arrow in main image), which is consistent with an ulcer crater, with associated duodenal wall
thickening and adjacent stranding. There are foci of arterial enhancement (arrowhead in main image) that are not present on
the noncontrast image and change in size, attenuation, and shape in the venous phase (arrowhead in bottom inset), which are
consistent with active bleeding.
Figure 15.
Gastric carcinoma in an 80-year-old man with weight loss and anemia. Axial arterial phase (main
image) and portal venous phase (inset) CTA images show a large polypoid mass in the stomach (arrows), with
adjacent contrast extravasation in the arterial phase (arrowhead in main image), which changes in size,
attenuation, and shape in the portal venous phase (arrowhead, inset image). Figure E3 is an endoscopic
image in this patient that shows a large gastric mass with an area of hemorrhage. Endoscopic biopsy results
confirmed moderately differentiated adenocarcinoma.

Guglielmo FF. Published Online: October 01, 2021

https://doi.org/10.1148/rg.2021210043
 Gastric GIST

Figure 16. Gastric GIST with active bleeding in a 35-year-old woman with a history of paraganglioma who presented with abdominal pain, hypotension,
tachycardia, and severe anemia. Axial portal venous phase (main image and top inset) and 7-minute delayed phase (bottom inset) CT images show a
homogeneously enhancing lobulated partially exophytic and endophytic mass in the lesser curvature of the stomach (arrow in all images). There are foci of
contrast extravasation in the portal venous phase (arrowhead in top inset) that increase in size and change in attenuation and shape in the delayed phase
(arrowheads in bottom inset), which are consistent with active bleeding. Figure E4 is an endoscopic image in this patient that shows the endophytic portion
of the mass, with
Guglielmo FF.anPublished
area of hemorrhage.
Online: October 01, 2021
https://doi.org/10.1148/rg.2021210043
GIST
GASTRIC DIEULAFOY LESION
Figure 17. Active bleeding from a Dieulafoy lesion in the proximal stomach in a 62-year-old man with a history of massive hematemesis. Coronal arterial
phase (main image), noncontrast (left inset), and portal venous phase (right inset) CTA images show a small hyperenhancing Dieulafoy lesion in the
proximal stomach (arrowhead in main image) with a contiguous focus of contrast extravasation in the arterial phase (arrow in main image), which changes
in size, attenuation, and shape in the portal venous phase (arrow in right inset).

Guglielmo FF. Published Online: October 01, 2021

https://doi.org/10.1148/rg.2021210043
VASCULAR LESION OF AORTA
 AORTIC ANEURYSM WITH AORTO DUODENALFISTULA

Figure 3. Aortic aneurysm with an aortoduodenal fistula and active bleeding in a 77-year-old man with a
history of melena and anemia. Axial arterial phase (A) and late venous phase (B) CTA images show contrast
extravasation in the distal duodenum in the arterial phase (arrow in A), which changes in size, attenuation,
and shape in the late venous phase (arrows in B). Also noted is an abdominal aortic aneurysm containing
 POST OP CONDITIONS

Figure 18. Roux-en-Y gastric bypass with active bleeding in a 49-year-old woman with a history of melena. Axial arterial phase
(A) and portal venous phase (B) CTA images show contrast extravasation in the arterial phase at the gastrojejunostomy site
(arrow in A), which changes in size, attenuation, and shape in the portal venous phase (arrow in B). There are multiple adjacent
surgical clips related to Roux-en-Y gastric bypass surgery (arrowheads). The active bleeding was caused by a marginal ulcer
adjacent to the gastrojejunostomy site, which was noted at upper endoscopy.
 POST OP STATUS

• Figure 1. Sentinel clot related to active bleeding at the pancreaticojejunostomy anastomosis in a 65-year-old
woman who presented with hematemesis and jaundice 12 days after she underwent the Whipple procedure
for pancreatic adenocarcinoma. Axial noncontrast (A), arterial phase (B), and portal venous phase (C) CTA
images show a sentinel clot in the stomach (white arrows) and contrast extravasation at the
pancreaticojejunostomy site, which appears during the arterial phase (blue arrow in B) and changes in size,
attenuation, and shape in the portal venous phase (blue arrow in C). There is a nasoenteric tube in place
Guglielmo FF. Published Online: October 01, 2021
(arrowhead in all images).
https://doi.org/10.1148/rg.2021210043
 Hemobilia
• Hemobilia is defined as hemorrhage within the biliary system.
• It is an infrequent form of upper gastrointestinal (GI) hemorrhage that occurs in the setting
of abnormal communication between the bile ducts and adjacent vasculature).
• Iatrogenic injury after hepato-biliary intervention is the most common cause. However, it may
also occur secondary to accidental trauma or a variety of neoplastic, infectious, and
inflammatory processes
• CT is the first-line diagnostic modality in evaluation of hemobilia, while catheter angiography
and endoscopy play vital and complementary roles in both diagnosis and treatment
Figure 8.Hepatic laceration and active hemorrhage in a 47-year-old woman after she was involved
vehicle crash. (a, b) Coronal (a) and axial (b) contrast-enhanced CT images demonstrate a gra
laceration in the central liver with active extravasation (arrow). (c) Axial contrast-enhanced C
demonstrates layering blood in the common bile duct (arrow). (d, e) Gray-scale US images dem
echogenic intraluminal blood within the dilated common bile duct (arrow in d) and a het-erogeneo
(arrow in e) within the hepatic parenchyma, corresponding to the hematoma seen on the CT image
hepatic arteriogram demonstrates active extravasation from a distal branch (arrow), which was suc
 Hemosuucus pancreatitis

A 47-year-old man with alcohol-related cirrhosis and chronic pancreatitis presented with
hematemesis. Upper endoscopy and colonoscopy demonstrated blood in the proximal small
bowel, without active bleeding. An image from final endoscopy performed in the intensive care
unit for massive hematemesis demonstrated active bleeding emanating from the ampulla of
Vater (Fig 1). Contrast-enhanced computed tomography angiography demonstrated focal
aneurysmal dilatation of the distal splenic artery and fistulous communication to the pancreatic
tail (Fig 2
). Splenic arteriography confirmed a distal splenic arterial fistula to the pancreatic duct (Fig 3).
Angiography performed after embolization (Fig 4) with detachable coils demonstrated no
active bleeding.
Considerations When Using Dual–Energy CT

• Dual-energy CT techniques can be helpful in patients with acute GI

bleeding.
• The ability to create virtual noncontrast reconstructions can eliminate
the need for true noncontrast images and reduce the total CT radiation
dose
• In addition, low kiloelectron voltage (virtual monoenergetic), iodine
density map, and color overlay images can increase the conspicuity of
iodinated contrast material, thus facilitating detection of active
extravasation .
• This can be particularly helpful when subtle bleeding is partially
obscured by adjacent hyperattenuating intraluminal hemorrhage .
• Metal suppression techniques can reduce beam hardening artifacts from
dense materials such as surgical clips or ballistic fragments and improve
detection of extravasated iodinated contrast material
 CATHETER ANGIOGRAPHY

Advantages:
• Ability to directly visualize and embolize a site of bleeding .
• No bowel preparation is required .
Disadvantage :
• Requirement of a higher rate of bleeding for visualization. Historically, the
minimum rate of bleeding required was 0.5–1 mL/min, though digital
subtraction angiography may be able to identify slower bleeds .
• It is an invasive modality and thus has complications.
• Non-targeted embolization and induction of bowel ischemia are two of the
most feared complications,.
• The use of microcatheters and deploying the embolic agent as selectively as
possible has decreased the incidence of these complications .
• Other complications include access site bleeding, hematoma or
pseudoaneurysm and arterial dissection or spasm. .
Duodenal ulcer
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