Angiography in the diagnosis and therapy of bleeding from gastroesophageal varices

Uses of angiography of diagnoses in variceal bleeding. 1. Diagnoses of variceal bleeding. 2. Evaluation for portosystemic shunt surgery through artenographic, venographic and manometric studies. Celiac, hepatic, superior mesenteric and splenic angiograms are taken. Manometric studies of the hepatic vein, right arteries and inferior vena cava help to assess degree of portal hypertension and exclude a constriction of the inferior vena cava by a cirrhotic liver. After portosystemic shunt, angiography can determine shunt patency. 3. Catheter therapy in variceal bleeding. Selective intraarterial vasopressin infusion into the superior mesenteric artery is used to control massive variceal bleeding in mild as moderate liver damage. It is unreliable in advanced cirrhoses, liver failure and faulty coagulation. (a) Low dose continuous intravenous vasopressin infusion in amounts of 0.2 to 0.3 U/min has replaced intraarterial infusions. It is given with or without esophageal balloon tamponade. It has a 79% effectivivity. Others use it in 0.66 U/min combined with isoproterenol infusion 0.0002 mg/min. (b) Intravascular tamponade of the gastric coronary vein and varices for bleeding gastroesophageal varices. It involves direct catheterization of the portal circulation via the umbilical vein or liver puncture by a transperitoneal or transvenous approach. The latter involves inserting a catheter needle system percutaneously into the internal jugular vein and advanced through the right atrium into a hepatic vein from which site the needle punctures the liver and enters a major intrahepatic portal branch. The catheter follows the needle and is advanced into the portal vein. We routinely use this for transhepatic cholangiography and occasionally for liver biopsy. (c) For intravascular blockage of bleeding varices, a catheter is introduced into the gastric coronary vein. For temporary tamponade, a balloon catheter is used. For permanent blockage, injection of concentrated glucose or thrombin or gelfoam is used.