ugi radiology final

8/9/2019 Ugi Radiology Final

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UPPER GIUPPER GI

BLEEDINGBLEEDINGDR. SUBASH K.C.DR. SUBASH K.C.

RESIDENT,RADIODIAGNOSISRESIDENT,RADIODIAGNOSIS


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UPPER GI BLEEDUPPER GI BLEED

Etiology of Upper BleedsEtiology of Upper Bleeds Duodenal Ulcer-30%Duodenal Ulcer-30% Gastric Ulcer-20%Gastric Ulcer-20% Varices-10%Varices-10% Gastritis and duodenitis-5-10%Gastritis and duodenitis-5-10% Esophagitis-5%Esophagitis-5% Mallory Weiss Tear-3%Mallory Weiss Tear-3% GI Malignancy-1%GI Malignancy-1% Dieulafoy LesionDieulafoy Lesion AV Malformation-angiodysplasiaAV Malformation-angiodysplasia


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COMMON CAUSES OFCOMMON CAUSES OF

UPPER GI BLEEDINGUPPER GI BLEEDING

PEPTIC ULCERATIONPEPTIC ULCERATION

EROSIVE GASTRITISEROSIVE GASTRITIS

VARICESVARICES OESOPHAGOGASTRIC MUCOSALOESOPHAGOGASTRIC MUCOSAL

TEARSTEARS


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LESS COMMON CAUSES OFLESS COMMON CAUSES OF

UGIHUGIH Neoplasms of esophagus, stomach andNeoplasms of esophagus, stomach andduodenumduodenum

Aortoenteric fistulaAortoenteric fistula

PancreatitisPancreatitis

HaemobiliaHaemobilia

Arterovenous malformationArterovenous malformation Splanchnic arterial aneurysmsSplanchnic arterial aneurysms

Mesenteric venous thrombosisMesenteric venous thrombosis

Rarely primary blood dyscrasias, vasculitis,Rarely primary blood dyscrasias, vasculitis,connective tissue disorders and uremiaconnective tissue disorders and uremia


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RADIOLOGICAL EVALUATIONRADIOLOGICAL EVALUATION

BARIUM STUDYBARIUM STUDY

ULTRASOUND AND DOPPLER STUDYULTRASOUND AND DOPPLER STUDY

C T IMAGINGC T IMAGING MR IMAGINGMR IMAGING

ANGIOGRAPHYANGIOGRAPHY

PORTOGRAPHYPORTOGRAPHY


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BARIUM STUDYBARIUM STUDY

BARIUM SWALLOW :BARIUM SWALLOW :

Esophageal varices appear asEsophageal varices appear asbeaded or serpiginousbeaded or serpiginous

translucenttranslucent filling defectsfilling defects


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BARIUM STUDIESBARIUM STUDIES No role in management of acute UGIB becauseNo role in management of acute UGIB because

1.1. Mucosal details are difficult to evaluate in presence of bloodMucosal details are difficult to evaluate in presence of blood

clots in stomachclots in stomach

2.2. Difficult to perform in acutely ill patientsDifficult to perform in acutely ill patients

3.3. May render further investigations like angiography difficultMay render further investigations like angiography difficult

4.4. Inconclusive and provide no clue about detected lesion as aInconclusive and provide no clue about detected lesion as a

cause of bleedcause of bleed


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ULTRASONOGRAPHYULTRASONOGRAPHY Features of portal hypertensionFeatures of portal hypertension

SplenomegalySplenomegaly AscitesAscites

Features of Liver CirrhosisFeatures of Liver Cirrhosis

Coarsened liver echo textureCoarsened liver echo texture

Nodular liver surfaceNodular liver surfaceReduced liver size (shrunken liver)Reduced liver size (shrunken liver)

Features of portal vein thrombosisFeatures of portal vein thrombosis

Absence of colour filling due toAbsence of colour filling due toanechoic thrombusanechoic thrombus..


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ULTRASONOGRAPHYULTRASONOGRAPHY

No role in the setting of acuteNo role in the setting of acute

upper gastrointestinal bleeding.upper gastrointestinal bleeding. It may be helpful in establishingIt may be helpful in establishing

portal vein patency prior toportal vein patency prior to

transjugular intrahepatictransjugular intrahepaticportosystemic shunt (TIPS)portosystemic shunt (TIPS)

placement in patients with varicealplacement in patients with variceal

bleedingbleeding..


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Shrunken liver with nodularShrunken liver with nodular

margin and ascitesmargin and ascites


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Presence of Porto systemicPresence of Porto systemic

collateralscollaterals

Porto systemic venous collaterals arePorto systemic venous collaterals are

indicative of PHTindicative of PHT

Collaterals are visualised as dilatedCollaterals are visualised as dilated

tortuous veinstortuous veins


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Porto SystemicPorto Systemic

CollateralsCollaterals


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ANGIOGRAPHYANGIOGRAPHY Valuable tool in patients with recurrent orValuable tool in patients with recurrent or

continued bleedingcontinued bleeding When endoscopic , radionuclide and bariumWhen endoscopic , radionuclide and barium

studies not helpfulstudies not helpful

Especially important in whom bleeding hasEspecially important in whom bleeding has

continued after blind laparotomycontinued after blind laparotomy

Diagnostic if bleeding exceeds .5ml/min(bloodDiagnostic if bleeding exceeds .5ml/min(blood

loss exceeds four units within 24 hours)loss exceeds four units within 24 hours)

If bleeding is intermittent and patient is stableIf bleeding is intermittent and patient is stableradionuclide studies useful for diagnosis as wellradionuclide studies useful for diagnosis as well

as a guide for angiographyas a guide for angiography


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Angiographic evaluation of UGIB isAngiographic evaluation of UGIB is

usually performed via commonusually performed via common

femoral artery access achieved withfemoral artery access achieved withthe Seldinger technique.the Seldinger technique.

A catheter is directed into the celiacA catheter is directed into the celiac

artery and superior mesentericartery and superior mesentericartery for angiography.artery for angiography.

Prior diagnostic examinations suchPrior diagnostic examinations such

as endoscopy or CT can be used toas endoscopy or CT can be used toguide subsequent catheterizationguide subsequent catheterization

It enables the use of therapeuticIt enables the use of therapeutic


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If the bleeding is demonstrated on theIf the bleeding is demonstrated on the

celiac or superior mesenteric angiogram,celiac or superior mesenteric angiogram,

a more selective injection of thea more selective injection of the

extravasating artery (superselectiveextravasating artery (superselective

catheterization) is performed forcatheterization) is performed for

confirmation of the bleeding andconfirmation of the bleeding andembolizationembolization

If contrast agent extravasation is notIf contrast agent extravasation is not

seen with the selective injections,seen with the selective injections,superselective catheterization of thesuperselective catheterization of the

gastroduodenal, left gastric, and splenicgastroduodenal, left gastric, and splenic

arteries is performed.arteries is performed.


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Angiography is insensitive in the detectionAngiography is insensitive in the detection

of venous bleeding, such as varicealof venous bleeding, such as variceal

hemorrhage from portal hypertension.hemorrhage from portal hypertension.

Clinical suspicion and endoscopic findingsClinical suspicion and endoscopic findingsare helpful in evaluating variceal bleeds.are helpful in evaluating variceal bleeds.

However, angiography can be helpful inHowever, angiography can be helpful in

the detection of as much as 50% of occultthe detection of as much as 50% of occult

UGIB.UGIB.


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ANGIOGRAPHIC FINDINGSANGIOGRAPHIC FINDINGS

IN UGIHIN UGIH

Extravasation of contrast ,seen asExtravasation of contrast ,seen as

puddling or staining that persistspuddling or staining that persists

beyond capillary or venous phasebeyond capillary or venous phase

Delayed films show opacified intestinalDelayed films show opacified intestinalfolds due to luminal extravasation offolds due to luminal extravasation of

contrast mediumcontrast medium

If lumen of gi tract is filled with clottedIf lumen of gi tract is filled with clottedblood, a pseudovein appearance isblood, a pseudovein appearance is

seenseen


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RADIONUCLIDE STUDIESRADIONUCLIDE STUDIES

Can localise GI bleed , with bleedingCan localise GI bleed , with bleeding

rates as low as .1ml/minrates as low as .1ml/min

Major indication is where bleedingMajor indication is where bleeding

has stopped or is intermittenthas stopped or is intermittent

Tc99m sulphur colloidTc99m sulphur colloid

Tc99m-labelled RBC (Tagged RBC)Tc99m-labelled RBC (Tagged RBC)Tc99m pertechnetate scanTc99m pertechnetate scan


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Computed TomographyComputed Tomography


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Computed TomographyComputed Tomography In UGIB from pseudoaneurysms ofIn UGIB from pseudoaneurysms of

the mesenteric vessels, branches ofthe mesenteric vessels, branches ofthe celiac axis, or aortoentericthe celiac axis, or aortoenteric

fistulas, it is the study of choice.fistulas, it is the study of choice. GI or liver tumorsGI or liver tumors To evaluate the presence of varicesTo evaluate the presence of varices

and the patency of the portal andand the patency of the portal and

splenic veins prior to a transjugularsplenic veins prior to a transjugularintrahepatic portosystemicintrahepatic portosystemicshunt (TIPS) procedure or splenicshunt (TIPS) procedure or splenicartery embolization.artery embolization.


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Gastric varix protruding

into the gastric lumen


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Magnetic Resonance ImagingMagnetic Resonance Imaging


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Magnetic Resonance ImagingMagnetic Resonance Imaging may be helpful in cases of hemobilia.may be helpful in cases of hemobilia. comparable to CT in the evaluation ofcomparable to CT in the evaluation of

masses that cause UGIBmasses that cause UGIB


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INTERVENTIONALINTERVENTIONAL

RADIOLOGYRADIOLOGY

Angiographic infusionsAngiographic infusions

TIPS (Transjugular Intrahepatic TIPS (Transjugular Intrahepatic

Portosystemicshunt )Portosystemicshunt )

Transcatheter embolisationTranscatheter embolisation

i f i l


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Intervention of varicealIntervention of variceal

bleedbleed Angiographic vasopressin infusionAngiographic vasopressin infusion


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TIPSS


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Indications of TIPSIndications of TIPS

Control of active variceal bleedingControl of active variceal bleeding

refractory to sclerotherapy and bandingrefractory to sclerotherapy and banding

Intractable ascitesIntractable ascites

Alternative to shunt surgery in patientAlternative to shunt surgery in patientwho have high surgical riskwho have high surgical risk

Appropriate temporary measure beforeAppropriate temporary measure before

liver transplantationliver transplantation

TIPSS


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TIPSS

SPIRAL CT AFTER TIPSSSPIRAL CT AFTER TIPSS


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SPIRAL CT AFTER TIPSSSPIRAL CT AFTER TIPSS

PLACEMENTPLACEMENT


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MR ANGIO BEFORE TIPSSMR ANGIO BEFORE TIPSS


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COMPLICATIONS OF TIPSCOMPLICATIONS OF TIPS

INTRAPERITONEAL BLEEDINTRAPERITONEAL BLEED

SHUNT THROMBOSIS,HEMATOMASHUNT THROMBOSIS,HEMATOMA

COMPROMISE OF HEPATIC BLOOD SUPPLYCOMPROMISE OF HEPATIC BLOOD SUPPLY

BILIARY OBSTRUCTIONBILIARY OBSTRUCTION SHUNT STENOSISSHUNT STENOSIS

LIVER FAILURE PRECIPITATED ORLIVER FAILURE PRECIPITATED OR

ACCELARATEDACCELARATED HEPATIC ENCEPHALOPATHYHEPATIC ENCEPHALOPATHY

RANSCATHETER EMBOLISATIORANSCATHETER EMBOLISATIO


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RANSCATHETER EMBOLISATIORANSCATHETER EMBOLISATIO In lesions of stomach, colon and small bowelIn lesions of stomach, colon and small bowel

In treatment of bleeding pancreatic or hepaticIn treatment of bleeding pancreatic or hepaticartery pseudoaneurysmsartery pseudoaneurysms

Angiographic embolisation of tributary veinsAngiographic embolisation of tributary veins

feeding the esophageal varicesfeeding the esophageal varices

Minimal amount of embolic material needed eg.Minimal amount of embolic material needed eg.

Gelatin sponge, steel coils, polyvinyl alcohal etc.Gelatin sponge, steel coils, polyvinyl alcohal etc.

Control of bleeding immediateControl of bleeding immediate

Risk of visceral ischemia minimal if embolisationRisk of visceral ischemia minimal if embolisationis superselective and collaterals preservedis superselective and collaterals preserved


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ugi radiology final

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