upper gastrointestinal bleeding

1. RADIOLOGY OF UPPER GI
BLEEDING
BY
SAFWAN MUKHTAR DAFI
MSC RADIOLOGY ( SPS/MRA/21/00010)
26/2/2024

2. OUTLINE
 DEFINATION
 AETIOLOGY
 IMAGING MODALITIES
.RADIOGRAPH
.BARIUM MEAL
.CT
.USS
.MRI
.ANGIOGRAPHY
.NUCLEAR MEDICINE
 IMAGING FEATURES
 CONCLUSION

3. INTRODUCTION/DEFINATION
 Upper gastrointestinal bleeding (UGIB) refers to bleeding from the
intraluminal gastrointestinal tract proximal to the ligament of Trietz.
 The upper gastrointestinal bleeding remains the most frequent emergency in
gastroenterology.
 It results in high morbidity and mortality, especially when massive and if not
properly and aggressively managed
 Imaging is playing a growing role in the management of acute GI bleeding by
localizing the source of bleeding, differentiating the underlying disease
processes, and aiding decisions to proceed to endovascular therapies to treat
many causes of GI bleeding.

4. AETIOLOGY
Esophageal
 Esophageal varices
 Ulcer
 Esophagitis
 Malignancy
 Mallory Weiss tear
Gastric
 Gastritis
 Ulcer
 Varices
 Malignancy
Duodenal
 Duodenitis
 Ulcer
 Varices
 Malignancy (rare)

5. Incidence/Aetiology
1. PUD 60%
2. Varices 20%
3. Esophagitis 10%
4. Gastritis 10%
5. Duodenitis 5%
6. MW tear 3% (much more common in young)
7. Esophageal ulcer 3%
8. Carcinoma 3%

6. Incidence in Kano
 Peptic ulcer disease(52.9%) or
erosions
 Esophageal varices (36.5%)
 Gastric cancer (3.5%)
 Esophageal cancer (1.2%)
 Probable cause of bleeding could
not be found in 3.5% of the
patients.
BM Tijjani, MM Borodo, AA
Samaila. Endoscopic
findings in patient with
Upper Gastrointestinal
Bleeding in Kano, North
Western Nigeria.
Nigerian
Health Practise 2009;
4(384)

7. Presentation of Upper GI bleeding
 Gastrointestinal hemorrhage has five clinical presentations:
1. Hematemesis
2. Malena
3. Hematochezia
4. Occult blood
Symptoms of blood loss such as
 dyspnea
 dizziness
 or shock

8. American College of Radiology (ACR)
appropriateness criteria
 The ACR has published appropriateness criteria for imaging nonvariceal
UGIB. Key recommendations include the following :
 When endoscopy identifies the presence and location of bleeding but bleeding
cannot be controlled endoscopically, catheter-based arteriography with
treatment is an appropriate next study; computed tomography angiography
(CTA) is comparable to angiography as a diagnostic next step.
 If endoscopy demonstrates a bleed but the endoscopist cannot identify the
bleeding source, angiography or CTA can be performed and both are
considered appropriate.

9.  In the event of an obscure UGIB, angiography and CTA have
been shown to be equivalent in identifying the bleeding source;
 When endoscopy is contraindicated, primary angiography, CTA,
and CT with IV contrast are considered appropriate

10. IMAGING MODALITIES
 PLAIN ABDOMINAL RADIOGRAPHY
 BARIUM MEAL
 COMPUTED TOMOGRAPHY
 MRI
 ANGIOGRAPHY
 ULTRASONOGRAPHY
 NUCLEAR IMAGING

11. Plain radiograph
 Plain radiographs of the abdomen are not usually helpful in the
diagnosis of acute upper gastrointestinal bleeding (UGIB).
 The pathophysiology of acute UGIB is often mucosal erosion
with subsequent hemorrhage, which is not detected with plain
radiographs.
 Occasionally, free air under the diaphragm is seen in cases of
perforated viscous, and this may be accompanied by UGIB.
 Other etiologies, such as upper GI masses (which usually result in
chronic, not acute, UGIB), aneurysms with calcifications, and
ascites suggestive of portal hypertension, may be seen on
radiographs

12. PLAIN RADIOGRAPHY
Chest Radiographs
 Esophageal varices may
occasionally be manifested on chest
radiographs by a retrocardiac
posterior mediastinal mass.
 This finding is caused either by
dilated esophageal or paraesophageal
veins or, less commonly, by dilated
azygos or hemiazygos veins.
 The most common findings in
esophageal cancer include
 -Mediastinal widening
 -A hilar or retrocardiac mass
 -Anterior tracheal bowing
 - A widened retrotracheal stripe
 -An air-fluid level in the esophagus

13. PLAIN CHEST RADIOGRAPH
 Advanced esophageal
carcinoma with
abnormal chest
radiograph. Lateral
radiograph shows
increased soft tissue
density in the
retrotracheal space with
slight anterior bowing of
the trachea (straight
arrow).
 Also note thickening of
the retrotracheal stripe
inferiorly (curved arrow)
due to direct invasion of
this area by tumor.

14. PLAIN RADIOGRAPHY…
 PUDx
 Pneumoperitoneum can be
seen in perforated gastric
ulcer cases
 May show distended
stomach in the setting of
gastric outlet obstruction
Plain abdominal radiographs
 Gastric carcinomas are
occasionally seen as
abnormalities in the gastric
contour or as soft-tissue masses
indenting the gastric contour.
 Rarely, mucin-producing
carcinomas may show areas of
punctate calcification

15. PLAIN RADIOGRAPHY…
 Close-up view from an
abdominal radiograph
shows a large cluster of
punctate or sandlike
calcifications in the
region of the stomach.

17. BARIUM MEAL FINDINGS
PEPTIC
ULCER
DISEASE
 Gastric ulcers are most prevalent in the
distal stomach and along the lesser
curvature.
 They are more common on the posterior
wall of the stomach than the anterior wall
and least common in the fundus.
 Benign greater curvature ulcers are found
in the distal half of the stomach and are
most often associated with NSAID use.
 Benign ulcers are much less common in
the fundus and along the proximal half of
the greater curvature.

18. Fluoroscopic findings:
 Features of ulceration include:
 Pocket of barium filling the ulcer crater
 85% round; 15% linear
 10-15% of ulcers are multiple
 Edematous collar of swollen mucosa should be distinguished from the
rolled edges of a malignant ulcer
 Radiating folds of mucosa away from the ulcer

19. Small posterior wall ulcer (asterisk)
demonstrated en face. Radiating mucosal folds
extend to the edge of the crater.

20. BARIUM MEAL…
 Most duodenal ulcers are depicted as
round or ovoid pools of barium
 About 5% may be linear, and most are
smaller than 1cm in diameter.
 Giant duodenal ulcers, defined as those
>2 cm in diameter, have an increased
risk of perforation, obstruction, and
bleeding.
 A giant ulcer may replace the whole of
the duodenal cap, and, when smooth
margined, such ulcers may be mistaken
for a normal cap.
 Multiple ulcers occur in about 15% of
patients
 The duodenal bulb is often
deformed by edema and spasm
associated with the ulcer or by
scarring from a previous ulcer.
 Postbulbar duodenal ulcers are
more likely to be associated with
upper bleeding than those in the
duodenal bulb.

21. BARIUM MEAL – DUODENAL ULCER
 A large ulcer is seen at the
apex of the duodenal bulb

22. BARIUM MEAL
ACUTE
GASTRITIS
 Acute gastritis includes hemorrhagic or erosive
 Barium meal show erosion which appear as
punctate or linear barium collections surrounded
by radiolucent halos of edematous mucosa
 Gastritis caused by aspirin and NSAIDs may
appear as linear or serpiginous erosions in the
body or near the greater curvature, because these
are dependent portions of the stomach where the
medication settles while dissolving
 Erosions may be subtle; the primary finding may
be thickening of the antral folds

23. BARIUM MEAL - EROSIVE GASTRITIS
 Distinctive linear and
serpiginous erosions are
clustered in the body of
the stomach near the
greater curvature as a
result of NSAID ingestion..

24. BARIUM MEAL – EROSIVE GASTRITIS DUE TO ASPIRIN
USE
 Coned-down image of
the gastric antrum from
air-contrast phase of
double-contrast upper
GI series shows
numerous 1-3 mm
punctate, ovoid, or
linear barium
collections surrounded
by 5 mm radiolucent
halos

25. BARIUM MEAL - REFLUX OESOPHAGITIS
 Reflux esophagitis with
a granular mucosa.
There is a finely
nodular or granular
appearance of the
mucosa extending
proximally from the
gastroesophageal
junction as a continuous
area of disease.

26. BARIUM MEAL…
ESOPHAGEAL VARIX
 Esophageal varices are dilated submucosal
veins.
 In the lower oesophagus they occur chiefly as
a consequence of portal hypertension in
cirrhosis of the liver.
 Varices appear
1. en face as beaded or serpiginous translucent
filling defects and
2. in profile as lines of nodular or scalloped
filling defects

27. BARIUM SWALLOW- OESOPH. VARICES
 Esophagogram
demonstrates multiple
serpentine filling
defects in the
esophagus resulting
from varices secondary
to portal hypertension.

28. BARIUM MEAL
 Gastric varices.
Tortuous folds and
submucosal filling
defects are seen in the
gastric fundus,
resembling the
appearance of a bunch
of grapes

29. BARIUM STUDY…
OESOPHAGEAL
CANCER
 Radiological manifestations of
 oesophageal carcinoma on barium
 swallow include
1. Stricture (i.e. circumferential or
eccentric mass)
2. Mucosal irregularities (i.e.
ulcerated surface)
3. Polyploid mass with irregular
outline protruding into lumen
4. Tracheo-oesophageal fistula – due to
tumour invasion anteriorly into
trachea

30. BARIUM STUDY
 Carcinoma of the
oesophagus- stricture,
effaced mucosa,
shouldering

31. BARIUM STUDIES
GASTRIC CANCER
 On barium studies, gastric carcinomas may be
 Polypoidal
 ulcerative, or
 infiltrating lesions.
 Polypoid carcinomas are lobulated masses that protrude
into the lumen. They may contain 1 or more areas of
ulceration

32. Computed Tomography findings:
 Usually, abdominal CT is not used in the evaluation of acute
upper gastrointestinal bleeding from arterial sources, although it
has been helpful in some series.
 However, in the detection of UGIB from pseudoaneurysms of the
mesenteric vessels, branches of the celiac axis, or aortoenteric
fistulas, it is the study of choice.
 In addition, in the evaluation of masses of the upper GI system or
liver tumors that may be contributing to hemobilia, CT is an
excellent modality.
 Occasionally, hemorrhage into the peritoneum can be detected on
CT scans.

33.  In the catastrophic situation of aortoenteric fistula, CT may be
helpful in detecting an early leak.
 The usual drawbacks of upper abdominal CT for the evaluation of
subtle lesions also apply to the use of this modality in the
evaluation of upper gastrointestinal bleeding. These include
underopacification of bowel loops, suboptimal visualization of
the biliary system and small visceral aneurysms, and difficulty in
evaluating the esophagus.

34. COMPUTED TOMOGRAPHY
 On CT angiography (CTA), the critical imaging finding
of GI bleeding is active extravasation of IV contrast into
the bowel lumen.
 This can be diagnosed with CTA when an intraluminal
focus of high attenuation (>90 HU) is seen on arterial
phase images (“contrast blush”) that is not present on
non-contrast images.
 On portal venous phase images, this extravasation should
change in appearance and generally moves distally
within the bowel lumen..

35. GASTRIC BLEEDING ULCER

36. CT SCAN…
 Esophageal varices may be
recognized on CT by a thickened,
lobulated esophageal wall containing
round, tubular, or serpentine
structures that have homogeneous
attenuation and enhance with contrast
material to the same degree as
adjacent vessels
Esophageal varices. An enhanced axial (top) and coronal
reconstruction CT scan of the upper abdomen shows markedly
tortuous and dilated varices surrounding the lower esophagus.
The liver (L) is small and nodular from cirrhosis and the spleen (S) is
enlarged from portal hypertension.

37. CT SCAN
GASTRIC CANCER
CT scans may show the following:
 Polypoidal mass with or without
ulceration
 Focal wall thickening with mucosal
irregularity or ulceration
 Wall thickening with the absence of
normal mucosal folds (infiltrative lesions)
 Mucinous carcinomas, may contain
calcification
Axial, contrast-enhanced CT shows circumferential gastric
wall thickening of the antrum due to submucosal extension
of a tumor, causing a linitis plastica appearance

38. CT SCAN
 Axial, contrast-
enhanced CT shows an
ulcerative gastric
carcinoma arising from
the posterior gastric
body

39. ANGIOGRAPHY
 Angiography should be performed
in patients with upper
gastrointestinal hemorrhage if
1. endoscopy is inconclusive or
2. in anticipation of transcatheter
intervention.
1. Angiography is minimally invasive;
it often allows precise localization
of bleeding; and it enables the use of
therapeutic options, which include
embolization or vasopressin
infusion.
 Angiography can locate the
bleeding site and effect
transcatheter control to
obviate surgery or stabilize
the patient before surgery
 A critical rate of bleeding of
approximately 0.5 mL/min
is necessary to enable
detection by angiography.

40.  Acute arterial bleeding is seen as the extravasation of contrast medium of
arterial opacity at the bleeding site.
 The extravasating contrast agent frequently flows toward the dependent part of
the viscous, creating the pseudovein appearance.
 If the bleeding is demonstrated on the celiac or superior mesenteric angiogram,
a more selective injection of the extravasating artery (superselective
catheterization) is performed for confirmation of the bleeding and
embolization.
 If contrast agent extravasation is not seen with the selective injections,
superselective catheterization of the gastroduodenal, left gastric, and splenic
arteries is performed.

41. ANGIOGRAPHY
 Bleeding gastric ulcer
(arrow) supplied by the
right gastroepiploic
artery. No contribution
from the left gastric
artery was seen on
selective
catheterization.

42. ULTRASONOGRAPHY
 Useful for evaluation of cirrhosis and
portal hypertension such as
 Decreased hepatic size,
 Nodularity of the liver surface
 Marked coarsening of the hepatic
architecture
 Ascites
 Signs of portal hypertension are seen.
 Also useful for evaluating gastric
carcinoma
Longitudinal scan of the left lobe shows
multiple nodules producing multiple echogenic
masses

43.  US of the gastrohepatic
ligament shows multiple
dilated vessels within
the ligament-an
appearance virtually
diagnostic of varices.

44. Magnetic Resonance Imaging
 MRI has a limited role in the evaluation of acute upper gastrointestinal bleeding
(UGIB) from arterial sources.
 In the setting of aneurysms and pseudoaneurysm, magnetic resonance angiography
(MRA) may be helpful in depicting the vascular abnormalities.
 With magnetic resonance cholangiography, the depiction of subtle biliary abnormalities
may be helpful in cases of hemobilia.
 MRI is comparable to CT in the evaluation of masses that cause UGIB.
 Similar to CT, MRI has no real role in the assessment of acute upper gastrointestinal
bleeding. It may be helpful in depicting small visceral pseudoaneurysms or masses, but
a normal MRI finding is often only a starting point for further investigation.

45. NUCLEAR MEDICINE
 Radionuclide imaging for GI bleeding is generally performed with technetium-
99m tagged red blood cells (RBCs), with initial injection of radiotracer and
subsequent gamma camera imaging.
 GI bleeding can be diagnosed when radiotracer activity is visualized outside of
normal areas of blood pool, which either focally intensifies or moves over time
in an antegrade or retrograde fashion.
 Scintigraphy can assess for bleeding over a prolonged period of time and can
detect both arterial and venous hemorrhage
 Nuclear scintigraphy is the most sensitive modality in detecting occult GI
bleeding.

46.  Advantages of radionnuclinde imaging are that it enables continuous
monitoring of the entire gastrointestinal tract for up to 24 hours.
 The ability to perform continuous imaging increases the likelihood of
detection of intermittent bleeding over other techniques that are limited a single
time point or periodic sampling.
 GIBS does not require any patient preparation, can be performed with
standard nuclear medicine instrumentation, and is well tolerated even in
patients who are acutely ill

48. ENDOVASCULAR MANAGEMENT
INDICATIONS:
 Non-diagnostic endoscopic results or remains refractory to medical and
endoscopic treatment
 Non-invasive radiologic imaging options include computed tomography
angiography (CTA) and nuclear scintigraphy.
 Preference of patient.

49. PROCEDURE
 Access for endovascular angiography is gained via the common femoral artery
 The aim of endovascular angiography is to identify bleeding vessel(s) and use
selective catheterization to prepare for embolization
 For suspected upper GIB, the celiac artery is commonly interrogated first . If
angiographically negative, selective left gastric and the gastroduodenal artery
evaluation is done.

50. ADVANTAGES
 Both a diagnostic and therapeutic tool.
 Can be performed emergently without any bowel preparation.
 Effective and safe alternative to surgical intervention

51. TRANSCATHETER ARTERIAL EMBOLIZATION
 Transcatheter arterial embolization (TAE) is effective for controlling acute GIB
 TAE is a viable option and temporizing measure in circumstances where endoscopic and/or
surgical approach is not ideal.
 The goal of TAE is super-selective embolization of bleeding vessels to reduce arterial perfusion
pressure while maintaining adequate collateral blood flow to minimize the risk of bowel infarction[

52. Transjugular intrahepatic portosystemic
shunt (TIPS or TIPSS)
 TIPS is a treatment for portal hypertension in which
direct communication is formed between a hepatic
vein and a branch of the portal vein,
 It allows some proportion of portal flow to bypass
the liver.
 The target portosystemic gradient after TIPS formation
is <12 mmHg.
27/02/2024 52

53. CONCLUSION
Imaging is playing a growing role in the management of acute GI
bleeding by localizing the source of bleeding, differentiating the
underlying disease processes, and aiding decisions to proceed to
endovascular therapies to treat many causes of GI bleeding.

54. THANK YOU