PMC6114244_01
(a) Dynamic imaging sequence of a 99Tc-labelled erythrocyte scan. The initial image (2 min image) demonstrates normal biodistribution of the radiotracer. A focus of increasing intensity is noted in the right upper abdomen at the 3 min image (red arrow). This focus of abnormal accumulation of the radiotracer shows antegrade and retrograde movement, confirming the bowel lumen appearance, and it crosses the midline several times (on cine images). This pattern is compatible with small bowel bleeding. (b) This selected late image from the 99Tc-labelled erythrocyte bleeding scan (59 min image) shows the typical pattern of small bowel bleeding (multiple red arrows).
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The study was positive for active bleeding, which had started primarily high in the right upper abdomen, supposedly from the region of the hepaticojejunostomy (Figures 1(a) and 1(b)).
(a) Digital subtraction angiogram (DSA) with selective injection through the common hepatic artery shows active extravasation from a small artery arising from the gastroduodenal artery stump. The red arrow indicates previous coil embolization in the right hepatic artery branch, due to previous hepatic trauma from the prior insertion of a percutaneous transhepatic biliary drain. (b) DSA shows the embolization coil placed in the gastroduodenal artery stump with excellent hemostasis (arrow).
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Then selective catheterization of the celiac trunk was followed by an angiogram, which showed small contrast extravasation originating from the proximal common hepatic artery, most likely from the gastroduodenal artery stump (Figure 2(a)). After that, an angiogram was performed that showed no extravasation and no abnormality (Figure 2(b)).