Zaman M U, Hussain R, Sajjad Z, Ahmad M N.
Localization of upper GI bleed on delayed imaging with 99mTc tagged RBC angiogram.
J Pak Med Assoc Jan ;54(9):490-1.

An 80 years old male presented with recent history of malena and severe anemia. Past history documented a CABG in 1996. His initial hemoglobin was 5.4 mg/dl and upper GI endoscopy revealed no bleeding focus and lower GI endoscopy showed clots of altered blood in the ascending colon. He was managed conservatively with transfusions. Next day he again dropped his hemoglobin with passage of malenetic stool. A Tc-99m tagged RBC study was performed which revealed no evidence of active intra-abdominal bleeding till 4 hrs after the injection. Again patient was transfused and managed conservatively. After 2 days he had another episode of hemoglobin drop and malena and a repeat tagged RBC study was performed. The initial study till 2 hours after the tracer injection showed no active bleeder. However, sequential images at 4 hours after tracer injection revealed abnormal tracer Accumulation in the left hypochondrium with progressive increase in tracer intensity and distal and medial traveling. These findings were consistent with bleeding from the duodenojujenal region. Immediately patient was transferred to catheterization laboratory. Selective angiogram of duodenal artery revealed extra-vasation of the contrast into the second part of the duodenum. Embolization of the bleeder was performed with platinum coil and poly-vinyl alcohol (PVA) with complete disappearance of spill. Patient stayed in hospital for 5 more days with no further episode of malena.

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