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Localizing obscure gastrointestinal bleeding can be a clinical challenge, despite the availability of various endoscopic, imaging, and visceral angiographic techniques. We reviewed the management of patients presenting with obscure gastrointestinal bleeding during the period from 2005 to 2011. Four patients had preoperative localization of the bleeding site with superselective mesenteric angiography, which was confirmed by the use of intraoperative methylene blue injection. This novel technique allowed us to identify the abnormal pathology, and, consequently, resection of the implicated segment of small bowel was performed without any postoperative complications. Final histology showed that 2 patients had arteriovenous malformations: one had a benign hemangioma of the small bowel, and the other had chronic ischemic ulceration in the ileum. Superselective mesenteric angiography combined with intraoperative localization with methylene blue is an important and innovative technique in the management of patients with unclear sources of gastrointestinal bleeding and allows for effective hemorrhage control with a focused and therefore limited bowel resection.

Objective: The objective of our study was to review the final diagnosis and outcome in patients undergoing visceral angiography for gastrointestinal hemorrhage in whom a diagnosis of inflammatory bowel disease (IBD) had been suspected on the basis of angiographic findings., Materials and Methods: A retrospective review was performed of all visceral angiography referrals over a 10-year period. During that time, 522 visceral angiograms were obtained for the investigation of acute or chronic gastrointestinal bleeding. IBD was reported as a possible or probable diagnosis based on the angiographic findings in 43 patients (8.2%) (male-to-female ratio, 23:20; age range, 11-79 years; mean age, 48.6 years)., Results: Active IBD was confirmed in 25 (58%) of these 43 individuals (male-to-female ratio, 15:10; mean age, 46.5 years), representing 4.8% of all patients referred for the investigation of gastrointestinal bleeding. In 14 of these individuals, a diagnosis of IBD had not been suspected previously. A diagnosis other than IBD was found to be the cause of the angiographic findings in seven subjects. In the 32 patients in whom a cause for the angiographic findings was identified, IBD was the diagnosis in 25 (78%)., Conclusion: In a group of patients referred for angiography to investigate acute or chronic gastrointestinal bleeding, IBD can be expected to be the cause in approximately 5%. Radiologists should be aware of the angiographic abnormalities seen in patients with IBD and be prepared to consider this diagnosis even if the results of other previous investigations have been reported as normal.

The case of a patient with Crohn's disease and who presented 4 days after a percutaneous liver biopsy with haematochezia suggestive of an exacerbation of his inflammatory bowel disease is described. Subsequent abdominal ultrasonography revealed free fluid in the peritoneal cavity and around the gallbladder. Haemobilia was suspected. Selective hepatic arteriography demonstrated a fistula between the hepatic artery and the portal venous system, with the presence of a hepatic artery pseudoaneurysm. Bleeding was stopped by arterial embolisation using titanium microcoils. Haemobilia is a very rare complication of percutaneous liver biopsy, but it should not be overlooked as a potential late-onset cause of rectal bleeding following this procedure. Selective hepatic arterial embolisation is an effective and safe treatment for this serious complication.

Aim: Haemosuccus pancreaticus is bleeding into the pancreatic duct from a peripancreatic artery. This condition most commonly follows pseudoaneurysm formation secondary to acute or chronic pancreatitis. It is a rare disorder, challenging in both diagnosis and therapy. We present an eight-year experience of managing these patients using endovascular embolization as the primary therapy., Materials and Methods: We retrospectively reviewed the imaging, laboratory results and clinical notes of the five patients who presented to this institution between 1991-1999 with gastrointestinal bleeding subsequently found to be haemosuccus pancreaticus., Results: There were four men and one women aged 38-75 years. All had a history of gastrointestinal haemorrhage and had acute (n=1) or chronic pancreatitis with a complicating pseudoaneurysm. All underwent embolization as the primary therapy for the pseudoaneurysm. There was immediate technical success in all cases without major complication. No patient required operative surgery for the pseudoaneurysm. Follow-up ranged from 18 months to 7 years. One patient died four years after embolization due to hepatic failure but the other four remain well without further gastrointestinal bleeding., Conclusion: Endovascular embolization is an effective and safe treatment for haemosuccus pancreaticus.

Aim: Porto-portal varices are commonly seen in patients with segmental extra-hepatic portal hypertension and develop to provide a collateral circulation around an area of portal venous obstruction. It is not well recognized that such communications may also develop across surgical anastomoses and be the source of gastrointestinal haemorrhage. The possible mode of development of such communications has not been previously discussed., Materials and Methods: Over a 3-year period between 1995 and 1998, porto-portal varices were demonstrated across surgical anastomoses in four patients who were referred for the investigation of acute (two), acute-on-chronic (one) and chronic gastrointestinal bleeding (one). Their medical notes and the findings at angiography were reviewed., Results: Three patients had segmental portal hypertension due to extra-hepatic portal vein (one) or superior mesenteric vein (two) stenosis/occlusion. One patient had mild portal hypertension due to hepatic fibrosis secondary to congenital biliary atresia. At angiography all patients were shown to have varices crossing previous surgical anastomoses. These varices were presumed to be the cause of bleeding in three of the four patients; the site of bleeding in the fourth individual was not determined., Conclusions: Trans-anastomotic porto-portal varices are rare. They develop in the presence of extra-hepatic portal hypertension and presumably arise within peri-anastomotic inflammatory tissue. Such varices may be difficult to manage and their prognosis is poor when bleeding occurs., (Copyright 2000 The Royal College of Radiologists.)

This report describes a 44 year old man with a severe gastrointestinal haemorrhage from oesophageal varices. Bleeding could not be controlled with conservative therapy and sclerotherapy. He was successfully treated with a radiologically guided transjugular intrahepatic stent shunt at a time when his condition was too poor to attempt an open surgical procedure.

Gastric antral vascular ectasia ('watermelon stomach') is a rare cause of chronic gastrointestinal bleeding and various medical and surgical treatments have been described. We report a patient in whom an oestrogen-progesterone preparation successfully controlled recurrent blood loss.