How to manage a gastroduodenal artery bleed?

Management of Gastroduodenal Artery Bleed

For gastroduodenal artery (GDA) bleeding, catheter angiography with embolization is the definitive treatment after failed or high-risk endoscopic therapy, with prophylactic embolization warranted in high-risk patients even after successful initial endoscopic hemostasis.

Initial Resuscitation and Stabilization

• Establish two large-bore peripheral IVs or central venous access immediately 1
• Target mean arterial pressure >65 mmHg while avoiding fluid overload 2
• Maintain restrictive transfusion strategy with hemoglobin threshold of 7 g/dL, targeting 7-9 g/dL 2
• Consider tracheal intubation for active hematemesis or inability to protect airway 2
• Correct coagulopathy targeting INR <1.5, platelets >50,000/µL, and fibrinogen >120 mg/dL only if needed 1, 2

Immediate Diagnostic Approach

• Perform urgent upper endoscopy (EGD) as soon as hemodynamic stabilization is achieved to identify the bleeding source 1, 3
• The GDA runs adjacent to the posterior duodenal wall, with proximal contact approximately 27mm from the pylorus and distal contact 15mm from the pylorus 4
• Critical anatomical consideration: The GDA's extraluminal course projects blood flow toward the gastroscope tip during endoscopy, requiring hemostatic measures to be applied aboral (distal) from the visible bleeding site 4

Endoscopic Management Limitations

• Endoscopic therapy for GDA bleeding has high rebleeding rates due to the large vessel caliber and anatomical factors 5, 6
• GDA pseudoaneurysms (particularly post-surgical) often fail endoscopic management and require immediate angiographic intervention 6
• Place endoscopic clips adjacent to the bleeding site during initial endoscopy to guide subsequent embolization if needed 1

Definitive Treatment: Catheter Angiography with Embolization

When to Proceed to Angiography

• Immediate angiography is indicated when endoscopy fails to achieve initial hemostasis or identifies but cannot treat the bleeding source 1
• Immediate angiography for recurrent bleeding after initially successful endoscopy when repeat endoscopy is unsuccessful or not recommended 1
• Prophylactic angiography should be performed after successful endoscopic hemostasis in high-risk patients with duodenal ulcers to prevent rebleeding 7

Angiographic Technique

• Interrogate both celiac and superior mesenteric arteries with high-volume contrast (20 mL at 5 mL/sec) and long imaging time (30-40 seconds) until portal system opacification 1
• Perform superselective embolization in a distal-to-proximal fashion to reduce "back door" rebleeding through collaterals 1
• "Sandwich" coiling of the GDA is effective, involving coil placement both proximal and distal to the bleeding site 5
• Alternative embolization materials include microcoils (most common), glue, gelatine particles, or plugs 1, 5
• If contrast extravasation is not visualized but documented at endoscopy or CTA, perform prophylactic embolization of the suspected vessel 1

Outcomes and Efficacy

• Technical success rate for GDA embolization reaches 95-98% 1, 7
• Clinical success (prevention of rebleeding) occurs in 67-87% of cases 1, 5, 7
• Prophylactic TAE after successful endoscopic hemostasis reduces rebleeding to 11% in high-risk patients 7
• Major complication rates are 4-10%, including access site issues, kidney damage, nontarget embolization, and bowel ischemia 1, 7
• Surgery is required in only 0.9-3% of patients when prophylactic embolization is employed 5, 7

Role of CT Angiography

• CTA can be performed when endoscopy identifies bleeding but cannot identify the source, or when emergency gastroenterology coverage is unavailable 1
• CTA helps localize the bleeding site before catheter angiography in hemodynamically stable patients 1

Surgical Intervention

• Reserve surgery for patients with failed angiographic embolization or when angiography is not available 6
• Surgical mortality remains high in critically ill patients with GDA bleeding, making embolization the preferred approach 5

Critical Pitfalls to Avoid

• Do not rely solely on endoscopic therapy for posterior duodenal wall ulcers given the high risk of GDA erosion and rebleeding 4, 7
• Do not delay angiography in patients with GDA pseudoaneurysms (especially post-gastrectomy, bypass surgery, or pancreatectomy), as mortality approaches 90% without definitive treatment 6
• Do not over-resuscitate with fluids or blood products, as this can increase portal pressure and worsen bleeding 2, 3
• Recognize that patients with GDA pseudoaneurysms can be asymptomatic for years before presenting with catastrophic bleeding 6