Provocative Mesenteric Angiography for Occult Gastrointestinal Bleeding: A Single Center Retrospective Review of 56 Patients

Background Occult gastrointestinal bleeding is the most common type of bleeding from the gastrointestinal tract and is often a diagnostic challenge. Endoscopic evaluation and radiology studies have relatively low success in identify the source of occult bleeding. Similarly, conventional mesenteric angiography is limited by the intermittent nature of bleeding and bleeding rates below detection threshold. Provocative mesenteric angiography uses pharmacologic agents to promote bleeding for localization and intervention in difficult cases. However, there is significant lack of data regarding the use of provocative mesenteric angiography. This study reports the experience with the largest single cohort of patients undergoing provocative mesenteric angiography for occult gastrointestinal bleeding. Results 56 patients underwent provocative mesenteric angiography for occult gastrointestinal bleeding. 7 (12.5%) patients had a positive study, and 49 (87.5%) patients had a negative study. 41 (73.2%), 36 (64.2%), 27 (48.2%), 8 (14.3%), and 2 (3.5%) patients received intra-arterial nitroglycerin, heparin, tissue plasminogen activator, reteplase, or papaverine, respectively. Mean dose of nitroglycerin, heparin, tissue plasminogen activator, reteplase, and papaverine was 227.8 ± 274.6 mcg, 4,958.3 ± 2839.0 units, 7.8 ± 5.8 mg, 2.9 ± 1.5 units, and 18.1 ± 4.1 mg, respectively. Of those with a positive angiogram, 6 (85.7%) patients were managed successfully with endovascular intervention. There was 1 immediate minor complication of hypotension and bradycardia. There were no major complications. Conclusion With the largest cohort of patients to date undergoing provocative mesenteric angiography for occult gastrointestinal bleeding, this study found a lower positive provocation rate compared to prior reports. Nearly all positive cases underwent successful endovascular intervention, with no mortalities and only one minor complication reported. Future studies are needed with larger patient samples, standardized protocols and comparative arms.