In Reply to: Re: Case 0599_01 -- Embolization of Lower GI Bleed- Where is Safe? posted by Grant Price on May 05, 1999 at 10:33:53:
In this particular case, I can't tell exactly where the source of hemorrhage is on the posted images. Before excluding the possibility of intervention, I would recommend doing subselective areteriography (using a microcatheter) to clearly delineate the site of bleeing. If there is a clear cut, and accessable point source, the decisin of how to occlude it depends on technical considerations - how close can you get the catheter tip to it. I would occlude it with 1-2 microcoils if I could get in the terminal branch that i s bleeding and do the embo without compromising side branches. If I can get the catheter just to the distal arcade level, I might occlude the arcade on both sides of the bleeding branch. If I couldn't advance the catheter into the bleeding branch, but it was large and had high flow, I might try to float 1-2 gelfoam pledgets from a more central catheter position - I would err on the side of conservatism in this latter strategy.
In any case, in a setting where the hemorrhage is from an underlying inflammatory condition, the embolization is unlikely to be curative - but it might buy time to allow medical treatment to work or to turn an emergent ex-lap into a diagnostic laparoscopy.
I would not hesitate to embolize small bowel lesions if precise subselective catheter position is possible. I don't think that the risk of bowel perforation is higher in the small bowel than in the colon; in the institutions where I have practiced, surveillance colonoscopy following bowel embolization is not routinely done. Patients are followed for ischemic complications using physical examination.