A 73-year-old woman 24 hours after percutaneous trans‑hepatic cholangiography develops upper gastrointestinal bleeding with anemia and borderline hypotension; what is the most appropriate next step: CT scan, endoscopy, ultrasound, or angiography?

Management of Upper GI Bleeding Post-Percutaneous Trans-Hepatic Cholangiography

Endoscopy (Option B) is the most appropriate next step in this patient with upper gastrointestinal bleeding 24 hours after percutaneous trans-hepatic cholangiography.

Clinical Reasoning

This 73-year-old woman presents with upper GI bleeding in a post-procedural context with hemodynamic borderline stability (BP 105/62, HR 89) and significant anemia (Hb 103 g/L). The clinical scenario requires immediate diagnostic and therapeutic intervention.

Why Endoscopy is the Correct Choice

• Endoscopy serves as both diagnostic and therapeutic modality for upper GI bleeding and should be performed within 24 hours of presentation after appropriate resuscitation 1, 2.

• This is NOT a post-surgical scenario where endoscopy is contraindicated. The ACR Appropriateness Criteria specifically reserve imaging-first approaches (CT, angiography) for situations where endoscopy is contraindicated or has already been performed and failed 3.

• The patient is hemodynamically stable enough for endoscopy (systolic BP >100 mmHg, HR <90), making this the standard first-line approach rather than proceeding directly to imaging 1.

Why Other Options Are Inappropriate at This Stage

CT Scan (Option A):

• CT angiography is reserved for scenarios where endoscopy has already been performed and either failed to identify the source or could not control bleeding 3.
• The ACR guidelines clearly state that CTA becomes appropriate only after endoscopy demonstrates bleeding without identifying the source, or when endoscopy is contraindicated 3.

Ultrasound (Option C):

• Ultrasound has no established role in acute upper GI bleeding evaluation 3.
• It cannot visualize active bleeding or identify most bleeding sources in the upper GI tract.

Angiography (Option D):

• Visceral arteriography is indicated when endoscopy identifies bleeding but cannot control it endoscopically, or when endoscopy fails to identify the bleeding source 3.
• Proceeding directly to angiography bypasses the diagnostic and therapeutic benefits of endoscopy.

Critical Management Considerations

Potential Bleeding Sources Post-PTC

The timing (24 hours post-procedure) raises concern for:

• Hemobilia (bleeding into the biliary tree from the hepatic puncture)
• Procedure-related mucosal injury
• Stress-related mucosal disease

Endoscopy can identify all these sources and provide immediate therapeutic intervention through cauterization, injection therapy, or clipping 1, 2.

Resuscitation Before Endoscopy

• Hemodynamic stabilization should precede endoscopy with IV fluid resuscitation and blood product transfusion as needed to maintain adequate perfusion 1.
• The patient's current vital signs suggest borderline stability requiring close monitoring during preparation for endoscopy.

If Endoscopy Fails

Should endoscopy be performed and fail to identify or control the bleeding source, the next appropriate steps would be:

• CT angiography or catheter-based arteriography are both rated as appropriate next studies (rated 8-9/9 by ACR) 3.
• CTA can detect bleeding rates as low as 0.3 mL/min with 79% sensitivity and 95% specificity 3.
• Angiography allows both diagnosis and therapeutic embolization if active bleeding is identified 3.

Common Pitfalls to Avoid

• Do not order barium studies in acute GI bleeding as they obscure active hemorrhage and interfere with subsequent endoscopy and angiography 3, 4.
• Do not administer positive oral contrast before imaging if CT becomes necessary, as it renders the examination nondiagnostic 3.
• Do not delay endoscopy beyond 24 hours in patients with upper GI bleeding, as early endoscopy improves outcomes 1.