In Reply to: Re: Case 797_09 -- Upper GI hemorrhage posted by Scott Trerotola on July 21, 1997 at 21:04:28:
I don't think I would have used coils initially, especially with what seemed to be a good result after your first embolization. I don't think you need to use a permanent agent for such a bleed in general, either--my first response would have been to use gelfoam. I think the real problem here is the coagulopathy. I was recently faced with a similar case in which there was bleeding in the region of the gastric fundus in a patient with coagulopathy. The bleeding was too brisk to be approached endoscopically. There was obvious extravasation from the left gastric artery which we embolized with gelfoam; after the embolization, a celiac arteriogram showed, to our dismay, bleeding from splenic artery branches to the stomach; we were able to catheterize two of these with microcatheters and (because the positions seemed a bit tenuous) I did place microcoils with a pusher. On the final injection, yet another splenic branch showed minimal extravasation (same region in the stomach) but it was not amenable to catheterization. Interestingly, the patient stabilized clinically; since we saw minimal extravasation at the end, repeat endoscopy was performed and at this time it proved easy to see the site and "finish it off" endoscopically. Again, I think the problem here was the coagulopathy more than the type of agent used or the underlying pathology (the patient was anticoagulated for a heart valve and there was great reluctance to reverse this).
With regard to other collaterals, I think the splenic artery (short gastrics, posterior gastric branches if present) would be more important than the GDA/gastroepiploic(gastrooemntal) pathway, but I don't think I would do anything more than a celiac arteriogram after what seemed to be successful LGA embolization unless I saw suspicious findings on the less selective injection.