CC BY 4.0 · The Arab Journal of Interventional Radiology 2023; 07(02): 076-087
DOI: 10.1055/s-0043-1770915
Review Article

Acute Nonvariceal Gastrointestinal Bleeding: A Comprehensive Review and Approach for an Interventional Radiologist

1   Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
Aymen Al Hadidi
2   Department of Radiology, Al Nahdha Hospital, Muscat, Oman
Basit Salam
1   Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
1   Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
3   Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, Michigan, United States
› Author Affiliations


Gastrointestinal bleeding (GIB) is one of the most common leading life-threatening conditions requiring prompt diagnosis and rapid endoscopic and interventional radiology (IR) management. Endoscopy is the first line of management for upper GIB, while it has a limited role in lower GIB, especially in acute clinical settings, due to poor bowel preparation. Patients with failed and refractory endoscopic management necessitate emergent computed tomography angiography (CTA) evaluation. CTA is crucial in assessing underlying causes and planning transarterial embolization (TAE). It has been almost three decades since IR gained popularity by virtue of increased technical experience, availability of sophisticated hardware, and evolving techniques. Newer embolization agents and catheters, as well as the established role of CTA, have expanded and enhanced the role of IR in the management of GIB. TAE has been proven to be a safe, rapid, effective, and minimally invasive procedure alternative to surgery when endoscopic management fails to control GIB. We present a comprehensive approach for managing nonvariceal GIB, including CTA protocol, anatomical variants, visceral to visceral collateral pathways, and specific embolization techniques. This article will help readers get an insight into TAE that will help better management of patients with GIB.

Ethical Approval Statement

Institutional review board (Medical ethical committee) approval was exempted.

Publication History

Article published online:
04 September 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (

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  • References

  • 1 Lu Y, Loffroy R, Lau JY, Barkun A. Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding. Br J Surg 2014; 101 (01) e34-e50
  • 2 Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol 2010; 33 (06) 1088-1100
  • 3 van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2008; 22 (02) 209-224
  • 4 Zuccaro G. Epidemiology of lower gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2008; 22 (02) 225-232
  • 5 Wells ML, Hansel SL, Bruining DH. et al. CT for evaluation of acute gastrointestinal bleeding. Radiographics 2018; 38 (04) 1089-1107
  • 6 Shi ZX, Yang J, Liang HW, Cai ZH, Bai B. Emergency transcatheter arterial embolization for massive gastrointestinal arterial hemorrhage. Medicine (Baltimore) 2017; 96 (52) e9437
  • 7 Koh DC, Luchtefeld MA, Kim DG. et al. Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding. Colorectal Dis 2009; 11 (01) 53-59
  • 8 Kim J, Lee I. Role of surgery in gastrointestinal bleeding. Int J Gastrointest Interv 2018; 7: 136-141
  • 9 Darcy M. Acute gastrointestinal arterial bleeding. In: Kandarpa K, Machan L. eds. PA: Lippincott Williams & Wilkins; 2011: 233-239
  • 10 Sung JJ, Tsoi KK, Lai LH, Wu JC, Lau JY. Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis. Gut 2007; 56 (10) 1364-1373
  • 11 Marmo R, Rotondano G, Piscopo R, Bianco MA, D'Angella R, Cipolletta L. Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol 2007; 102 (02) 279-289 , quiz 469
  • 12 Gweon T, Kim J. Comprehensive review of outcomes of endoscopic treatment of gastrointestinal bleeding. Int J Gastrointest Interv 2018; 7: 123-130
  • 13 Brullet E, Calvet X, Campo R, Rue M, Catot L, Donoso L. Factors predicting failure of endoscopic injection therapy in bleeding duodenal ulcer. Gastrointest Endosc 1996; 43 (2 Pt 1): 111-116
  • 14 Valek V, Husty J. Quality improvement guidelines for transcatheter embolization for acute gastrointestinal nonvariceal hemorrhage. Cardiovasc Intervent Radiol 2013; 36 (03) 608-612
  • 15 Raniga SB, Mittal AK, Bernstein M, Skalski MR, Al-Hadidi AM. Multidetector CT in vascular injuries resulting from pelvic fractures: a primer for diagnostic radiologists. Radiographics 2019; 39 (07) 2111-2129
  • 16 Song SY, Chung JW, Kwon JW. et al. Collateral pathways in patients with celiac axis stenosis: angiographic-spiral CT correlation. Radiographics 2002; 22 (04) 881-893
  • 17 Kallamadi R, Demoya MA, Kalva SP. Inferior pancreaticoduodenal artery aneurysms in association with celiac stenosis/occlusion. Semin Intervent Radiol 2009; 26 (03) 215-223
  • 18 Jeong S-J, Lim NY, Jang N-K. et al. Transcatheter coil embolization of an Arc of Buhler aneurysm. Korean J Radiol 2008; 9 (Suppl) S77-S80
  • 19 Lin PH, Chaikof EL. Embryology, anatomy, and surgical exposure of the great abdominal vessels. Surg Clin North Am 2000; 80 (01) 417-433 , xiv
  • 20 Walker TG. Mesenteric vasculature and collateral pathways. Semin Intervent Radiol 2009; 26 (03) 167-174
  • 21 Gourley EJ, Gering SA. The meandering mesenteric artery: a historic review and surgical implications. Dis Colon Rectum 2005; 48 (05) 996-1000
  • 22 Rosenblum JD, Boyle CM, Schwartz LB. The mesenteric circulation. Anatomy and physiology. Surg Clin North Am 1997; 77 (02) 289-306
  • 23 Reuter SR, Redman HC, Cho KJ. Gastrointestinal Angiography. 3rd ed.. Philadelphia, PA: WB Saunders; 1986
  • 24 Winston CB, Lee NA, Jarnagin WR. et al. CT angiography for delineation of celiac and superior mesenteric artery variants in patients undergoing hepatobiliary and pancreatic surgery. AJR Am J Roentgenol 2007; 189 (01) W13-9
  • 25 Koops A, Wojciechowski B, Broering DC, Adam G, Krupski-Berdien G. Anatomic variations of the hepatic arteries in 604 selective celiac and superior mesenteric angiographies. Surg Radiol Anat 2004; 26 (03) 239-244 9
  • 26 Covey AM, Brody LA, Maluccio MA, Getrajdman GI, Brown KT. Variant hepatic arterial anatomy revisited: digital subtraction angiography performed in 600 patients. Radiology 2002; 224 (02) 542-547
  • 27 Grosse U, Syha R, Ketelsen D. et al. Cone beam computed tomography improves the detection of injured vessels and involved vascular territories in patients with bleeding of uncertain origin. Br J Radiol 2018; 91 (1088): 20170562
  • 28 Wortman JR, Landman W, Fulwadhva UP, Viscomi SG, Sodickson AD. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90 (1075): 20170076
  • 29 Kohanteb PA, Lipshutz HG, Okonkwo B. et al. provocative mesenteric angiography for localizing ambiguous gastrointestinal hemorrhage. Am J Interv Radiol 2021; 5: 18
  • 30 Kodani M, Yata S, Ohuchi Y, Ihaya T, Kaminou T, Ogawa T. Safety and risk of superselective transcatheter arterial embolization for acute lower gastrointestinal hemorrhage with N-butyl cyanoacrylate: angiographic and colonoscopic evaluation. J Vasc Interv Radiol 2016; 27 (06) 824-830
  • 31 Funaki B. Superselective embolization of colonic bleeding. Semin Intervent Radiol 2005; 22 (02) 139-140
  • 32 Gwon DI, Ko GY, Sung KB, Shin JH, Kim JH, Yoon HK. Endovascular management of extrahepatic artery hemorrhage after pancreatobiliary surgery: clinical features and outcomes of transcatheter arterial embolization and stent-graft placement. AJR Am J Roentgenol 2011; 196 (05) W627-34 17
  • 33 Song HH, Won YD, Kim YJ. Transcatheter N-butyl cyanoacrylate embolization of pseudoaneurysms. J Vasc Interv Radiol 2010; 21 (10) 1508-1511
  • 34 Shin JH. Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol 2012; 13 (Suppl 1, Suppl 1): S31-S39
  • 35 Loffroy R, Favelier S, Pottecher P. et al. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: indications, techniques and outcomes. Diagn Interv Imaging 2015; 96 (7-8): 731-744
  • 36 Rabuffi P, Bruni A, Antonuccio EMG, Saraceni A, Vagnarelli S. Transarterial embolization of acute non-neurologic bleeding using ethylene vinyl alcohol copolymer: a single-centre retrospective study. CVIR Endovasc 2023; 6 (01) 2
  • 37 Kim PH, Tsauo J, Shin JH, Yun SC. Transcatheter arterial embolization of gastrointestinal bleeding with N-butyl cyanoacrylate: a systematic review and meta-analysis of safety and efficacy. J Vasc Interv Radiol 2017; 28 (04) 522-531.e5
  • 38 Vaidya S, Tozer KR, Chen J. An overview of embolic agents. Semin Intervent Radiol 2008; 25 (03) 204-215
  • 39 Loffroy R, Guiu B, D'Athis P. et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol 2009; 7 (05) 515-523
  • 40 Aina R, Oliva VL, Therasse É. et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001; 12 (02) 195-200
  • 41 Walker TG, Salazar GM, Waltman AC. Angiographic evaluation and management of acute gastrointestinal hemorrhage. World J Gastroenterol 2012; 18 (11) 1191-1201
  • 42 Lang EV, Picus D, Marx MV, Hicks ME. Massive arterial hemorrhage from the stomach and lower esophagus: impact of embolotherapy on survival. Radiology 1990; 177 (01) 249-252
  • 43 Encarnacion CE, Kadir S, Beam CA, Payne CS. Gastrointestinal bleeding: treatment with gastrointestinal arterial embolization. Radiology 1992; 183 (02) 505-508
  • 44 Abdel-Aal AK, Bag AK, Saddekni S, Hamed MF, Ahmed FY. Endovascular management of nonvariceal upper gastrointestinal hemorrhage. Eur J Gastroenterol Hepatol 2013; 25 (07) 755-763
  • 45 Lee EW, Laberge JM. Differential diagnosis of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7 (03) 112-122
  • 46 Lee HJ, Shin JH, Yoon HK. et al. Transcatheter arterial embolization in gastric cancer patients with acute bleeding. Eur Radiol 2009; 19 (04) 960-965
  • 47 Seya T, Tanaka N, Yokoi K, Shinji S, Oaki Y, Tajiri T. Life-threatening bleeding from gastrointestinal stromal tumor of the stomach. J Nippon Med Sch 2008; 75 (05) 306-311
  • 48 Lang EK. Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology 1992; 182 (03) 703-707
  • 49 Hur S, Jae HJ, Lee M, Kim HC, Chung JW. Safety and efficacy of transcatheter arterial embolization for lower gastrointestinal bleeding: a single-center experience with 112 patients. J Vasc Interv Radiol 2014; 25 (01) 10-19
  • 50 Yata S, Ihaya T, Kaminou T. et al. Transcatheter arterial embolization of acute arterial bleeding in the upper and lower gastrointestinal tract with N-butyl-2-cyanoacrylate. J Vasc Interv Radiol 2013; 24 (03) 422-431
  • 51 Huang CC, Lee CW, Hsiao JK. et al. N-butyl cyanoacrylate embolization as the primary treatment of acute hemodynamically unstable lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2011; 22 (11) 1594-1599
  • 52 Frodsham A, Berkmen T, Ananian C, Fung A. Initial experience using N-butyl cyanoacrylate for embolization of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2009; 20 (10) 1312-1319
  • 53 Ripoll C, Bañares R, Beceiro I. et al. Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. J Vasc Interv Radiol 2004; 15 (05) 447-450
  • 54 Jairath V, Kahan BC, Logan RF. et al. National audit of the use of surgery and radiological embolization after failed endoscopic haemostasis for non-variceal upper gastrointestinal bleeding. Br J Surg 2012; 99 (12) 1672-1680
  • 55 Abdulmalak G, Chevallier O, Falvo N. et al. Safety and efficacy of transcatheter embolization with Glubran®2 cyanoacrylate glue for acute arterial bleeding: a single-center experience with 104 patients. Abdom Radiol (NY) 2018; 43 (03) 723-733
  • 56 Khanna A, Ognibene SJ, Koniaris LG. Embolization as first-line therapy for diverticulosis-related massive lower gastrointestinal bleeding: evidence from a meta-analysis. J Gastrointest Surg 2005; 9 (03) 343-352
  • 57 Larssen L, Moger T, Bjørnbeth BA, Lygren I, Kløw NE. Transcatheter arterial embolization in the management of bleeding duodenal ulcers: a 5.5-year retrospective study of treatment and outcome. Scand J Gastroenterol 2008; 43 (02) 217-222
  • 58 Eriksson LG, Ljungdahl M, Sundbom M, Nyman R. Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure. J Vasc Interv Radiol 2008; 19 (10) 1413-1418
  • 59 Venclauskas L, Bratlie SO, Zachrisson K, Maleckas A, Pundzius J, Jönson C. Is transcatheter arterial embolization a safer alternative than surgery when endoscopic therapy fails in bleeding duodenal ulcer?. Scand J Gastroenterol 2010; 45 (03) 299-304
  • 60 Wong TC, Wong KT, Chiu PW. et al. A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers. Gastrointest Endosc 2011; 73 (05) 900-908
  • 61 Ang D, Teo EK, Tan A. et al. A comparison of surgery versus transcatheter angiographic embolization in the treatment of nonvariceal upper gastrointestinal bleeding uncontrolled by endoscopy. Eur J Gastroenterol Hepatol 2012; 24 (08) 929-938
  • 62 Katano T, Mizoshita T, Senoo K. et al. The efficacy of transcatheter arterial embolization as the first-choice treatment after failure of endoscopic hemostasis and endoscopic treatment resistance factors. Dig Endosc 2012; 24 (05) 364-369
  • 63 Yap FY, Omene BO, Patel MN. et al. Transcatheter embolotherapy for gastrointestinal bleeding: a single center review of safety, efficacy, and clinical outcomes. Dig Dis Sci 2013; 58 (07) 1976-1984
  • 64 Teng HC, Liang HL, Lin YH. et al. The efficacy and long-term outcome of microcoil embolotherapy for acute lower gastrointestinal bleeding. Korean J Radiol 2013; 14 (02) 259-268
  • 65 Lee HH, Park JM, Chun HJ, Oh JS, Ahn HJ, Choi MG. Transcatheter arterial embolization for endoscopically unmanageable non-variceal upper gastrointestinal bleeding. Scand J Gastroenterol 2015; 50 (07) 809-815
  • 66 Tanveer-Ul-Haq, Idris M, Salam B, Akhtar W, Jamil Y. Comparison of microcoils and polyvinyl alcohol particles in selective microcatheter angioembolization of non variceal acute gastrointestinal hemorrhage. Pak J Med Sci 2015; 31 (04) 751-756
  • 67 Nykänen T, Peltola E, Kylänpää L, Udd M. Bleeding gastric and duodenal ulcers: case-control study comparing angioembolization and surgery. Scand J Gastroenterol 2017; 52 (05) 523-530
  • 68 Lee HH, Oh JS, Park JM. et al. Transcatheter embolization effectively controls acute lower gastrointestinal bleeding without localizing bleeding site prior to angiography. Scand J Gastroenterol 2018; 53 (09) 1089-1096
  • 69 Kwon JH, Han YH. Efficacy and safety of superselective trans-catheter arterial embolization of upper and lower gastrointestinal bleeding using N-butyl-2-cyanoacrylate. Emerg Radiol 2018; 25 (02) 111-120
  • 70 Nykänen T, Peltola E, Kylänpää L, Udd M. Transcatheter arterial embolization in lower gastrointestinal bleeding: ischemia remains a concern even with a superselective approach. J Gastrointest Surg 2018; 22 (08) 1394-1403
  • 71 Senadeera SC, Vun SV, Butterfield N, Eglinton TW, Frizelle FA. Role of super-selective embolization in lower gastrointestinal bleeding. ANZ J Surg 2018; 88 (09) E644-E648
  • 72 Muhammad A, Awais M, Sayani R. et al. Empiric transcatheter arterial embolization for massive or recurrent gastrointestinal bleeding: ten-year experience from a single tertiary care center. Cureus 2019; 11 (03) e4228