Is chest angiography indicated for a patient presenting with hematemesis (vomiting blood)?

Chest Angiography for Hematemesis (Vomiting Blood)

Chest angiography is not the first-line diagnostic approach for patients presenting with hematemesis (vomiting blood), but may be indicated in specific circumstances when endoscopy is not feasible or has failed to identify the bleeding source. 1

Initial Diagnostic Approach

• Esophagogastroduodenoscopy (EGD) should be the initial procedure of choice for hematemesis as it has both diagnostic and therapeutic capabilities 2
• For hemodynamically stable patients without active bleeding, early elective endoscopy (ideally the morning after admission) is appropriate 2
• For unstable patients or those with evidence of ongoing bleeding, emergency endoscopy should be performed within 24 hours 2
• During EGD, the source of bleeding should be identified and appropriate endoscopic therapy applied if active bleeding, non-bleeding visible vessel, or adherent clot is found 2

When to Consider CT Angiography (CTA)

• CTA can be considered if there is no in-house emergency gastroenterology coverage or the patient is not suitable for EGD 1
• CTA should be performed instead of other imaging modalities in patients with brisk ongoing bleeding and hemodynamic instability 1
• CTA can detect bleeding rates as low as 0.3 mL/min, making it more sensitive than conventional angiography (which requires 0.5-1.0 mL/min) 1
• In hemodynamically stable cases where active upper GI bleeding remains indeterminate, CTA may be used as an alternative diagnostic modality 1

Indications for Conventional Angiography

• If endoscopy visualizes but is unable to treat a source of bleeding, catheter angiography (CA) should be performed with intent to embolize 1
• Patients who are hemodynamically unstable with severe unremitting bleeding should undergo resuscitation and angiography as soon as possible 1
• In select cases, such as hepatic pseudoaneurysm, angiography may be the preferred first-line treatment 1
• Angiography has a specificity of 100% but a sensitivity of only 30-47% for detecting GI bleeding sources 1

Special Considerations

• Before performing catheter angiography, the patient's renal and coagulation status should be optimized 1
• If the bleeding site has been previously localized, angiography should initially target the bleeding vessel 1
• Both the celiac and superior mesenteric arteries should be interrogated to evaluate all potential bleeding sources and collateral vessels 1
• Technical success rate for angiographic treatment has been reported up to 95%, with a clinical success rate of 67% 1
• Complications of angiography occur in up to 10% of cases, including access site issues, kidney damage, and non-target embolization 1

Clinical Pathway for Hematemesis

1. Initial assessment of hemodynamic status and resuscitation if unstable 2
2. Risk stratification based on age, comorbidities, presence of shock 2
3. Upper endoscopy (EGD) as first-line diagnostic and therapeutic procedure 2
4. If endoscopy fails or is not feasible:
   • Consider CTA for patients with ongoing bleeding 1
   • Consider conventional angiography with potential for therapeutic embolization in cases of active bleeding 1

Common Pitfalls to Avoid

• Attributing all hematemesis to common causes without adequate evaluation, as rare but life-threatening conditions like aortoesophageal fistula can present with hematemesis 3
• Delaying endoscopic evaluation in patients with significant bleeding, as early intervention improves outcomes 2
• Relying solely on imaging without direct visualization through endoscopy when feasible 2
• Failing to recognize that most upper GI bleeding (88%) stops spontaneously, and only 6% of patients require therapeutic endoscopic intervention 4