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Provocative Angiography: Final Test for Occult Gastrointestinal Bleeds

July 30, 2009
Written by: , Filed in: Emergency Radiology
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Almost 15,000 patients each year have lower gastrointestinal bleeding that cannot be diagnosed despite aggressive workup, because standard modes of imaging and endoscopy show normal results.

Using pharmacological agents during standard angiography to induce a prohemorrhagic state is termed provocative angiography and is best used when conventional angiography is non-diagnostic, and significant bleeding would otherwise necessitate emergency surgery.

Provocative angiography involves a full diagnostic angiogram followed by administration of intra-arterial procoagulant agents to identify an occult bleeding source in patients who have normal test results after lower gastrointestinal bleeding.

Agents used include intravenous heparin, intra-arterial papaverine, and intra-arterial tissue plasminogen activator.

A positive test is seen in 29% to 80% of cases, and is usually followed by selective coil embolization of the bleeding vessel.

This case report shows that provocative angiography can be a useful adjunct in patients that have several episodes of undiagnosed bleeding.

Case Report
The authors describe a case of a 62-year-old man who had been bleeding through the rectum for 12 hours and had lower abdominal pain. This patient had been admitted 12 times during the previous 7 years for similar bleeding episodes and had undergone extensive testing.

The patient had been diagnosed with diverticular disease in the descending and sigmoid colon, based on colonoscopy and barium enema.

Some of the patient’s tests had shown negative results, but 7 months prior to the current admission, the patient had undergone successful coil embolization of bleeding secondary to angiodysplasia in the colon at the ileocolic artery.

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On the current occasion, after a negative angiogram, the patient underwent provocative mesenteric angiography with intravenous heparin, intra-arterial papaverine, and intra-arterial tissue plasminogen activator.

The testing failed to induce bleeding in the superior mesenteric artery, the branch of the ileocolic artery that had previously been repaired, or the inferior mesenteric artery.

On a repeat of the angiography after the tissue plasminogen activator, active bleeding was found in the mid-descending colon, which originated in an ascending branch of the left colic artery.

Embolization was successful in stopping the bleeding, and the patient had not returned for treatment in the 10 months since the procedure.

Discussion/Conclusions
Provocative angiography has been reported since 1982, with few large series. No standard protocol exists, so the method is currently operator-dependent.

Full involvement of the surgical team must be present prior to initiating this if embolization is not effective or cannot be performed.

Provocative angiography can be a useful adjunct in patients that have several episodes of undiagnosed bleeding.

Reference:
Johnston, C., Tuite, D., et al. Use of provocative angiography to localize site in recurrent gastrointestinal bleeding. Cardiovasc Intervent Radiol. 2007 Sep-Oct;30(5):1042-6.

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