Successful transcatheter Gelfoam embolization of a bleeding cecal vascular ectasia.

A 64-year-old white female had persistent lower gastrointestinal hemorrhage and hepatitis. Since 1970, three episodes of bleeding had occurred; on the latest episode, she required multiple blood transfusions. Proctoscopy as well as stomach and small bowel barium studies were normal; a barium enema demonstrated sigmoid diverticula. She was admitted to a local hospital with transfusional hepatitis; several days later, lower gastrointestinal bleeding recurred, requiring 23 units of blood over the next 5 days. On transfer to our hospital, the patient was passing bright red blood per rectum; the hematocrit was 34.1 . She was jaundiced and had mild hepatomegaly, but no ascites. Total bilirubin was 15.3 mg/100 ml; alkaline phosphatase, 190 mU/mi; SGOT, 545 mU/mi; serum albumin/globulin, 2.8/1.9; and normal prothrombin time and partial thromboplastin time. Angiography was performed on the first hospital day. Supenor mesenteric arteriography demonstrated extravasation of contrast medium from a small branch of the ileocolic artery into the cecum, evidence of active bleeding at this site (fig. 1A). The typical angiographic pattern of a vascular ectasia was identified. After a 20 mm infusion of vasopressin into the superior mesenteric artery at 0.2 U/mm, repeat superior mesentenic arteriography demonstrated cessation of bleeding. However, the typical pattern of the vascular ectasia remained. No further evidence of bleeding was noted clinically.and 36 hr later the infusion rate was decreased to 0.1 U/mm; 3 hr later, the patient rebled. In view of the hepatitis, the patient was considered to be a poor surgical risk, at least for several weeks. For this reason, although continuous vasopressin infusion temporarily controlled the bleeding, a more permanent form of hemostasis was chosen at this time. Repeat superior mesenteric arteriography again demonstrated the bleeding cecal vascular ectasia. The catheter was advanced under fluoroscopic control to within 2.5 cm of the lesion, and multiple small pledgets of Gelfoam (absorbable gelatin sponge) soaked in saline were slowly injected through the catheter. Several control injections were recorded on 105 mm spot films during this procedure to be certain of the location of the emboli. Superior mesenteric arteriography after embolization demonstrated occlusion of the artery to the ectasia, with no opacification of the ectasia (fig. 1B). The cecum remained vascularized via collaterals from the right colic artery. No angiographic evidence of bleeding was noted. Clinically. the patient’s hemorrhage stopped. Liver function tests improved and hematocrit remained stable. A localized resection of the terminal ileum and cecum was performed 47 days after embolization. The arteries to the specimen were injected with a barium gel prior to fixation. Radiographs of the injected specimen (fig. 24) demonstrated a vascular pattern identical to the postembolization arteniogram. Microscopic examination of the resected specimen demonstrated partial recanalization of a small mesenteric artery (fig. 2B) and multiple thrombosed small mural arteries. The Gelfoam was not identified, but macrophages were seen in some sections. The vascular ectasia was not identified.