Role of angiography and embolization for massive gastroduodenal hemorrhage

The value of endoscopically-placed metal clips for transcatheter arterial embolization in the treatment of recurrent acute non-variceal upper gastrointestinal bleeding

OBJECTIVE

Acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) is a common clinical emergency. Transcatheter arterial embolization (TAE) is usually used to locate the bleeding site and provide interventional embolization. During TAE, there is a low positive rate of angiography, and localization of the culprit vessel is difficult. The purpose of this study was to demonstrate the role of preplaced metal clips in TAE for ANVUGIB patients.

MATERIALS AND METHODS

Patients with ANVUGIB in whom bleeding sites were identified endoscopically and treated with TAE from January 1st, 2005 to July 1st, 2021 were retrospectively included. According to the presence or absence of preplaced metal clips, they were divided into two groups. The main outcome measurements included the clinical success rate and rebleeding rate. Secondary outcome measurements included the mortality rate and the need for surgery. Predictors of the clinical success rate were assessed with univariate analysis and multivariate analysis.

RESULTS

A total of 102 patients were included in this study, and all of them had undergone arterial embolization. There were 73 cases in the group with metal clips and 29 cases in the group without metal clips with consistent baseline information. The group with metal clips had a higher clinical success rate (82.2% vs. 45.0%, P < 0.001), lower rebleeding rate (8.2% vs 27.6%, P = 0.039) and additional surgery rate (11.0% vs 20.7%, P < 0.001) than the group without metal clips. In univariate analysis, ROCKALL score and preplaced metal clip marking were shown to affect clinical success rate. In multivariate analysis, metal clip marking was found to facilitate clinical success (OR = 3.750, 95CI = 1.456-9.659, P = 0.004).

CONCLUSION

In ANVUGIB patients, preplaced metal clips could improve the clinical success rate of TAE and reduce the mortality rate and the risk of rebleeding.

Rare but critical: Aberrant vascular communication leading to multiorgan ischemia after prophylactic gastroduodenal artery embolization for refractory upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) carries a high risk of morbidity and mortality despite recent improvements in diagnosis and management. Many patients failed to respond to initial endoscopic and medical management. Transcatheter arterial embolization (TAE) is now considered the next line of therapy over surgery in refractory UGIB because of its good safety profile and high technical and clinical success rate. We discuss the case of a 66-year-old female patient who presented with massive UGIB and had TAE after endoscopic hemostasis failed. She developed widespread ischemia involving multiple organs following the procedure, including the liver, gallbladder, pancreas, spleen, and small intestine, as a result of an abnormal communication between the gastroduodenal artery (GDA) and superior mesenteric artery (SMA), resulting in PVA particle reflux and widespread ischemic injury. It is important to carefully evaluate the vascular anatomic variations before the procedure to avoid potential complications of ischemia.

[Radiologic Diagnosis of Gastrointestinal Bleeding]

Gastrointestinal (GI) bleeding is not a single disease but a symptom and clinical manifestation of a broad spectrum of conditions in the GI tract. According to its clinical presentation, GI bleeding can be classified into overt, occult, and obscure types. Additionally, it can be divided into upper and lower GI bleeding based on the Treitz ligament. Variable disease entities, including vascular lesions, polyps, neoplasms, inflammation such as Crohn's disease, and heterotopic pancreatic or gastric tissue, can cause GI bleeding. CT and conventional angiographies and nuclear scintigraphy are all radiologic imaging modalities that can be used to evaluate overt bleeding. For the work-up of occult GI bleeding, CT enterography (CTE) can be the first imaging modality. For CTE, an adequate bowel distention is critical for obtaining acceptable diagnostic performance as well as minimizing false positives and negatives. Meckel's scintigraphy can be complementarily useful in cases where the diagnosis of CTE is suboptimal. For the evaluation of obscured GI bleeding, various imaging modalities can be used based on clinical status and providers' preferences.

Transarterial Embolization for Active Gastrointestinal Bleeding: Predictors of Early Mortality and Early Rebleeding

Background: The aim of this study was to determine predictive factors of early mortality and early rebleeding (≤30 days) following transarterial embolization (TAE) for treatment of acute gastrointestinal bleeding. Methods: All consecutive patients admitted for acute gastrointestinal bleeding to the interventional radiology department in a tertiary center between January 2012 and January 2022 were included. Exclusion criteria were patients: (1) aged < 18-year-old, (2) referred to the operation room without TAE, (3) treated for hemobilia, (4) with mesenteric hematoma, (5) lost to follow-up within 30 days after the procedure. We evaluated pre and per-procedure clinical data, biological data, outcomes, and complications. Results: Sixty-eight patients were included: 55 (80.9%) experienced upper gastrointestinal bleeding and 13 (19.1%) lower gastrointestinal bleeding. Median age was 69 (61−74) years. There were 49 (72%) males. Median hemoglobin was 7.25 (6.1−8.3) g/dL. There were 30 (50%) ulcers. Coils were used in 46 (67.6%) procedures. Early mortality was 15 (22.1%) and early rebleeding was 17 (25%). In multivariate analysis, hyperlactatemia (≥2 mmol/L) were predictive of early mortality (≤30 days). A high number of red blood cells units was associated with early rebleeding. Conclusion: This study identified some predictive factors of 30-day mortality and early rebleeding following TAE. This will assist in patient selection and may help improve the management of gastrointestinal bleeding.

Patient and endoscopic characteristics and clinical outcomes in subjects with non-variceal GI bleeding referred for transarterial embolization: a single-center experience

PURPOSE

Management of massive non-variceal upper gastrointestinal bleeding (NV-UGIB) can be challenging. Transarterial Embolization (TAE) is often the first therapeutic approach when endoscopic therapy fails before surgery. The purpose of this study is to analyze the technical success, and outcome for our patients with an NV-UGIB referred for TAE.

METHOD

This retrospective analysis included 74 consecutive patients with an NV-UGIB in whom TAE was performed after endoscopic treatment between February 2016 to May 2019 at Prisma Health-Upstate Greenville Memorial Hospital.

RESULTS

TAE was 98.7% technically successful, with a failure due to severe celiac stenosis, and 85.1% clinically successful. Most TAEs were performed empirically due to lack of extravasation yet were clinically as effective as targeted TAE. We noted a 30-day rebleeding rate and mortality rate of 14.8% and 13.5%, respectively. No complications were reported during the angiographic procedure. Subjects with coagulopathy had more rebleeding (45.5% vs. 17.5%, p = 0.040), and mortality (30% vs 7.4%, p = 0.012). Mortality was also associated with the number of transfused packed blood cells (13.6 ± 8.4 vs. 6.1 ± 5.4, p = 0.020) units and hypotension on admission (27.8% vs. 8.9%, p = 0.043). Interestingly, subjects that underwent left gastric artery (LGA) compared to non-LGA embolization had a higher rebleeding rate of (37.5% vs. 8.6%, p = 0.004) and a greater mortality rate of (37.5% vs. 6.9%, p = 0.002).

CONCLUSION

TAE is clinically effective in the presence or absence of contrast extravasation to treat uncontrolled or high-risk NV-UGIB. Less effective clinical outcomes regarding TAE targeting the LGA warrant further investigation.

Endovascular Treatment of Gastrointestinal Hemorrhage

Background and Objectives: Severe non-variceal gastrointestinal bleeding is a life-threatening condition with complicated treatment if endoscopic therapy fails. In such cases, transcatheter arterial embolization is recommended. The technical and clinical effects of this technique were analyzed in this group of patients, as well as its complication rate and 30-day mortality. Materials and Methods: Patient data over a one-decade period (from 2010 to 2019) were analyzed retrospectively; 27 patients (18 men and 9 women; median age 61 years) treated by endovascular embolization in our institution, with clinically significant gastrointestinal hemorrhage after unsuccessful or impossible endoscopic treatment, were identified, and their data were collected. Results: The source of bleeding was found in 88% of patients, but embolization was performed in 96% of them. The overall technical success rate was 96.8%, and the clinical success was 88.5%. Re-bleeding occurred in eight cases, five of whom had re-embolization that was technically successful in four cases. The incidence of re-bleeding was significantly higher in patients with two or more comorbidities (p = 0.043). There was one serious complication (4%) in the group, and minor difficulties occurred in 18% of patients; 30-day mortality reached 22%. Mortality was significantly higher in the group of patients with re-bleeding (p = 0.044). Conclusions: Transcatheter arterial embolization is a mini-invasive method with high technical success in patients with endoscopically untreatable gastrointestinal bleeding; it is also suitable for high-risk cases. Mortality (to a significant extent) depends on the occurrence of re-bleeding and the patient’s comorbidities.

Value of multiphase computed tomography for gastrointestinal bleeding before endovascular treatment in hemodynamically unstable patients

BACKGROUND

There has been no practice-based study regarding the multiphase computed tomography (CT) before endovascular treatment in hemodynamically unstable gastrointestinal bleeding (GIB) and concerns exist regarding the time delay.

PURPOSE

To evaluate the clinical efficacy of multiphase CT before endovascular treatment in hemodynamically unstable GIB and to investigate the predictors of angiographic localization and recurrent bleeding.

MATERIAL AND METHODS

The multicenter retrospective study included 93 consecutive hemodynamically unstable patients who underwent conventional angiography for non-variceal GIB after failed endoscopic localization. Enrolled patients were divided into a CT group (n = 61) and a non-CT group (n = 32).

RESULTS

The clinical characteristics did not differ between the two groups except for the time to angiography (CT group, 14.8±15.1 h; non-CT group, 9.2±11.7 h, P = 0.022). The rate of angiographic localization was significantly higher in the CT group than in the non-CT group only for lower GIB (P = 0.049). Indirect sign was significantly more frequent in the CT group than in the non-CT group (P = 0.014). CT localization was positive predictor (odd ratio [OR] = 7.66; 95% confidence interval [CI] = 2.1-27.94; P = 0.002) and prolonged time to angiography was negative predictor (OR = 0.94; 95% CI = 0.9- 0.98; P = 0.001) for angiographic localization. A higher systolic blood pressure until index angiography (OR = 0.95; 95% CI = 0.91-1; P = 0.044) was associated with a reduced risk of recurrent bleeding.

CONCLUSION

In hemodynamically unstable patients, multiphase CT is particularly useful for angiographic localization of lower GIB. It should be considered immediately after failed endoscopic hemostasis to reduce time to angiography.

Preventive covered stent placement at the gastroduodenal artery stump in angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy

PURPOSE

To evaluate the clinical outcomes of preventive covered stent placement at the gastroduodenal artery stump in patients with angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy.

METHODS

Between July 2006 and September 2018, patients undergoing computed tomography angiography or diagnostic angiography for sentinel hemorrhage after pancreaticoduodenectomy were retrospectively reviewed. Patients having angiogram-negative angiography and undergoing preventive covered stent placement or conservative treatment were included. Clinical outcomes, technique success, and complications were evaluated.

RESULTS

A total of 25 patients (mean age 62.5 years) were evaluated, including 15 patients underwent preventive covered stent placement at the gastroduodenal artery stump and 10 patients received conservative treatments. The clinical success rates were 50% (5/10) and 86.7% (13/15) for conservative treatments and covered stent groups, respectively (p = 0.07). In the conservative treatment group, delayed massive hemorrhage occurred in five patients, two of whom died of recurrent bleeding due to gastroduodenal artery pseudoaneurysm within 16 days, and two had intraluminal hemorrhage within 5 days. In the covered stent group, one patient had inferior pancreaticoduodenal artery pseudoaneurysm 1 day after the placement of the covered stent, and one had recurrent bleeding due to duodenal ulcer within 14 days. The 30-day mortality was 40% (4/10) and 0 in the conservative treatment and covered stent groups, respectively (p = 0.02). The difference in the overall survival was nonsignificant between the two groups (p = 0.23).

CONCLUSIONS

The preventive covered stent placement at the gastroduodenal artery stump is safe and reduces delayed massive hemorrhage and short-term mortality in patients with angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy.

Relationship between angiography timing and angiographic visualization of extravasation in patients with acute non-variceal gastrointestinal bleeding

Background

Angiographic embolization is now considered the first-line therapy for acute gastrointestinal (GI) bleeding refractory to endoscopic therapy. The success of angiographic embolization depends on the detection of the bleeding site. This study aimed to identify the clinical and procedural predictors for the angiographic visualization of extravasation, including angiography timing, as well as analyze the outcomes of angiographic embolization according to the angiographic visualization of extravasation.

Methods

The clinical and procedural data of 138 consecutive patients (mean age, 66.5 years; 65.9% men) who underwent angiography with or without embolization for acute non-variceal GI bleeding between February 2008 and July 2018 were retrospectively analyzed.

Results

Of the 138 patients, 58 (42%) had active extravasation on initial angiography and 113 (81.9%) underwent embolization. The angiographic visualization of extravasation was significantly higher in patients with diabetes (p = 0.036), a low platelet count (p = 0.048), high maximum heart rate (p = 0.002) and AIMS65 score (p = 0.026), upper GI bleeding (p = 0.025), and short time-to-angiography (p = 0.031). The angiographic embolization was successful in all angiograms, with angiographic visualization of extravasation (100%). The clinical success of patients without angiographic visualization of extravasation (83.9%) was significantly higher than that of patients with angiographic visualization of extravasation (65.5%) (p = 0.004). In multivariate analysis, the time-to-angiography (odds ratio 0.373 [95% CI 0.154–0.903], p = 0.029) was the only significant predictor associated with the angiographic visualization of extravasation. The cutoff value of time-to-angiography was 5.0 h, with a sensitivity and specificity of 79.3% and 47.5%, respectively (p = 0.012).

Conclusions

Angiography timing is an important factor that is associated with the angiographic visualization of extravasation in patients with acute GI bleeding. Angiography should be performed early in the course of bleeding in critically ill patients.

Perforated and bleeding peptic ulcer: WSES guidelines

Background

Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment.

Methods

The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached.

Conclusions

The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Embolization of Nonvariceal Upper Gastrointestinal Hemorrhage Complicated by Bowel Ischemia

Over the past three decades, transcatheter arterial embolization has become the first-line therapy for the management of acute nonvariceal upper gastrointestinal bleeding refractory to endoscopic hemostasis. Overall, transcatheter arterial interventions have high technical and clinical success rates. This review will focus on patient presentation and technical considerations as predictors of complications from transcatheter arterial embolization in the management of acute upper gastrointestinal hemorrhage.

When all else fails - Radiological management of severe gastrointestinal bleeding

Although most cases of acute nonvariceal gastrointestinal bleeding (GIB) either spontaneously resolve or respond to medical management and endoscopic therapy, there are still a significant proportion of severe patients who require emergency angiography and endovascular treatment. Over the past three decades, transcatheter arterial embolization (TAE) has become the first-line therapy for the management of acute nonvariceal GIB that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer liquid embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the treatment of bleeding for a variety of indications. TAE is a safe and effective minimally invasive alternative to surgery, when endoscopic treatment fails to control acute bleeding from the gastrointestinal tract. In this article we review the current role of angiography and TAE in the management of acute nonvariceal GIB.

Radiologic Assessment of Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding represents a broad differential of disease throughout the GI tract. The proper diagnostic evaluation of patients presenting with symptoms of GI bleeding depends on the overall clinical acuity and suspected source locations. The radiologic assessment of these patients is centered around computed tomography (CT) angiography, CT enterography, conventional angiography, and nuclear scintigraphy.

Diagnosis of acute overt gastrointestinal bleeding with CT-angiography: Comparison of the diagnostic performance of individual acquisition phases

PURPOSE

To compare the respective values of arterial phase, portal venous phase and combination of phases using 64-section multidetector computed tomography (MDCT) for diagnosing acute overt gastrointestinal bleeding (AOGIB).

PATIENTS AND METHODS

Forty-nine patients with AOGIB were included. There were 30 men and 19 women, with a mean age of 65.4±15.6 (SD) years [range, 34-91years]. Two observers reviewed MDCT examinations in consensus for presence of active bleeding, location of bleeding site and nature of causative lesion. The different acquisition phases were reviewed independently.

RESULTS

AOGIB was identified in 28/49 patients (57%) with the multiphasic set, in 26/49 patients (53%) with arterial phase and in 25/49 patients (51%) with portal venous phase. Multiphasic set helped locate the bleeding site in 40/49 patients (82%). The cause was elucidated in 23/49 patients (47%) with multiphasic set. The differences between set performances were not statistically significant. Sensitivity for depicting AOGIB with the multiphasic set was 92% and specificity was 76%.

CONCLUSION

Multiphasic 64-section MDCT has high diagnostic performances in patients with AOGIB. Further studies with a larger population are needed to reach statistical significance and demonstrate better diagnostic performance of multiphasic MDCT in comparison with the arterial or portal phase alone.

Predictors of Active Extravasation and Complications after Conventional Angiography for Acute Intraabdominal Bleeding

Conventional angiography is used to evaluate and treat possible sources of intraabdominal bleeding, though it may cause complications such as contrast-induced nephropathy (CIN). The study’s purpose was to identify factors predicting active extravasation and complications during angiography for acute intraabdominal bleeding. All conventional angiograms for acute bleeding (January 2013–June 2015) were reviewed retrospectively, including 75 angiograms for intraabdominal bleeding in 70 patients. Demographics, comorbidities, vital signs, complications within one month, and change in hematocrit (ΔHct) and fluids and blood products administered over the 24 h prior to angiography were recorded. Of 75 exams, 20 (27%) demonstrated extravasation. ΔHct was the only independent predictor of extravasation (p = 0.017), with larger ΔHct (−17%) in patients with versus those without extravasation (–1%) (p = 0.01). CIN was the most common complication, occurring in 10 of 66 angiograms (15%). Glomerular filtration rate (GFR) was the only independent predictor (p = 0.03); 67% of patients with GFR < 30, 29% of patients with GFR 30–60, and 8% of patients with GFR > 60 developed CIN. For patients with intraabdominal bleeding, greater ΔHct decrease over 24 h before angiography predicts active extravasation. Pre-existing renal impairment predicts CIN. Patients with large hematocrit declines should be triaged for rapid angiography, though benefits can be weighed with the risk of renal impairment.

Change ratio of hemoglobin has predictive value for upper gastrointestinal bleeding

The present study aimed to identify novel predictors of upper gastrointestinal (GI) bleeding by assessing change ratios of blood test variables. Records of 1,023 patients (431 men and 592 women) who underwent endoscopy between October 2014 and September 2015 at the National Hospital Organization Shimoshizu Hospital (Yotsukaido, Japan) were retrospectively analyzed. Patients whose blood test variables for the time-point of endoscopy and three months previously were available were enrolled and subsequently categorized into a group with and another one without upper GI bleeding (n=32 and 84, respectively), and the respective change ratios were calculated for each group. One-way analysis of variance revealed that in patients with upper GI bleeding, change ratios of white blood cell count and alkaline phosphatase were significantly higher than those in patients without, while change ratios of hemoglobin (Hb), total protein and albumin were significantly reduced. Logistic regression analysis demonstrated that the change ratio of Hb was significantly correlated with upper GI bleeding. Receiver-operator characteristic analysis revealed that an 18.7% reduction of Hb was the threshold value for the prediction of upper GI bleeding. In conclusion, the present study revealed that a ≥18.7% reduction in Hb over three months has predictive value for upper GI bleeding.

Low hemoglobin levels are associated with upper gastrointestinal bleeding

Upper gastrointestinal (GI) bleeding can be fatal. Blood test variables were reviewed in search of threshold values to detect the presence of occult upper GI bleeding. The records of 1,023 patients who underwent endoscopy at the National Hospital Organization Shimoshizu Hospital from October 2014, to September 2015, were retrospectively reviewed. Of those, 95 had upper GI bleeding. One-way analysis of variance was applied to blood test variables comparing patients with and without upper GI bleeding. Logistic regression analysis was applied to detect the association of blood test parameters with upper GI bleeding, and receiver-operator characteristics were applied to establish threshold values. White blood cell count (WBC), platelet (Plt) count, and blood urea nitrogen (BUN) levels were higher, and hemoglobin (Hb) and albumin (Alb) levels were lower in patients with upper GI bleeding. Logistic regression analysis showed that low Hb was significantly associated with upper GI bleeding and a Hb value of 10.8 g/dl was established as the threshold for the diagnosis. In patients with upper GI bleeding, WBC, Plt count, and BUN levels were higher and Hb and Alb levels were reduced. Hb at 10.8 g/dl was established as a threshold value to detect upper GI bleeding.

Making decisions using radiology in lower GI hemorrhage

Acute lower gastrointestinal bleeding (LGIB) is a common diagnosis in current practice that may warrant hospitalization and invasive management. There is a shift in the paradigm in the management of this condition away from traditional extensive operative intervention to minimally invasive radiological techniques. These newer modalities offer an opportunity to provide more accurate information on location of bleeding and subsequent management. The increased ease of access to interventional radiology units in major teaching hospitals represents an opportunity to adopt its use in the management of gastrointestinal bleeding. Further, with technological improvements, it is becoming an increasingly favoured option. Traditional endoscopic techniques have been fraught with poor vision in the acute setting, requiring the colon to be purged to aide in better visualization. The use of these newer technologies have been the subject of many reviews which highlight their efficacy in providing a road map to the bleeding site and eventual intervention. We aim to review the literature regarding the use of radiology in the management of LGIB, to provide surgeons with a discourse with regards to the approach in synthesizing the data and applying it when deciding its use.

Laboratory test variables useful for distinguishing upper from lower gastrointestinal bleeding

AIM: To distinguish upper from lower gastrointestinal (GI) bleeding.

METHODS: Patient records between April 2011 and March 2014 were analyzed retrospectively (3296 upper endoscopy, and 1520 colonoscopy). Seventy-six patients had upper GI bleeding (Upper group) and 65 had lower GI bleeding (Lower group). Variables were compared between the groups using one-way analysis of variance. Logistic regression was performed to identify variables significantly associated with the diagnosis of upper vs lower GI bleeding. Receiver-operator characteristic (ROC) analysis was performed to determine the threshold value that could distinguish upper from lower GI bleeding.

RESULTS: Hemoglobin (P = 0.023), total protein (P = 0.0002), and lactate dehydrogenase (P = 0.009) were significantly lower in the Upper group than in the Lower group. Blood urea nitrogen (BUN) was higher in the Upper group than in the Lower group (P = 0.0065). Logistic regression analysis revealed that BUN was most strongly associated with the diagnosis of upper vs lower GI bleeding. ROC analysis revealed a threshold BUN value of 21.0 mg/dL, with a specificity of 93.0%.

CONCLUSION: The threshold BUN value for distinguishing upper from lower GI bleeding was 21.0 mg/dL.

Embolization versus surgery for peptic ulcer bleeding after failed endoscopic hemostasis: a meta-analysis

BACKGROUND AND STUDY AIMS

A meta-analysis was conducted to assess the efficacy of transcatheter arterial embolization (TAE) compared with surgery in the management of patients with recurrent nonvariceal upper gastrointestinal bleeding (NVUGIB) after failure of endoscopic hemostasis.

PATIENTS AND METHODS

Publications in English and non-English literatures (OVID, MEDLINE, and EMBASE) and abstracts from major international conferences were searched for studies comparing TAE with surgery for treatment of NVUGIB after endoscopic hemostasis failure. Outcome measures included rebleeding rate, all-cause mortality rate, and need for additional interventions to secure hemostasis.

RESULTS

From 1234 citations, 6 retrospective comparative studies were included that involved 423 patients (TAE, 182, 56 % male; surgery, 241, 68 % male). TAE patients were older (mean age, TAE 75, surgery, 68). The risk of rebleeding was significantly higher in TAE patients compared with surgically treated patients (relative risk [RR] 1.82, 95 % confidence interval [95 %CI] 1.23 - 2.67), with no statistically significant heterogeneity among the included studies (P = 0.66, I (2) = 0.0 %). After sensitivity analysis excluding studies with a large age difference between the two groups, a higher risk of bleeding remained in the TAE group (RR 2.64, 95 %CI] 1.48 - 4.71). No significant difference in mortality (RR 0.87, 95 %CI 0.59 - 1.29) or requirement for additional interventions (RR 1.67, 95 %CI 0.75 - 3.70) was shown between the two groups.

CONCLUSION

A higher rebleeding rate was observed after TAE, suggesting surgery more definitively secured hemostasis, with no significant difference in mortality rate or requirement of additional interventions. The TAE patients were older and in poorer health, thus future randomized studies are needed for accurate comparison of the two modalities.

Outcome and predictive factors of successful transarterial embolization for the treatment of acute gastrointestinal hemorrhage

BACKGROUND

Transarterial embolization (TAE) is an effective procedure for the treatment of acute gastrointestinal bleeding (GIB). Factors associated with clinical success have not been well delineated.

PURPOSE

To evaluate the technical and clinical successes of TAE for acute GIB in order to identify factors influencing clinical success and in-hospital mortality.

MATERIAL AND METHODS

This was a retrospective study of 70 consecutive patients with GIB who underwent angiography and embolization between January 2004 and December 2011. The technical success rate, clinical success rate, and in-hospital mortality were calculated by percentage. Clinical parameters, angiographic, and embolization data were assessed for factors influencing clinical success and in-hospital survival using univariate and multivariate analysis. Statistical significance was set at P value <0.05.

RESULTS

The technical success rate was 98.6%. The primary clinical success rate was 71.4% and the secondary clinical success rate after repeat embolization was 78.6%. Bowel infarction was the most serious complication of three (4.3%) patients. Failure to achieve 30-day hemostasis can be predicted in patients who have one or more of the following factors: hemoglobin concentration <8 g/dL (P = 0.004), coagulopathy (P = 0.005), upper GIB (P = 0.02), contrast extravasation (P = 0.012), and more than one embolized vessel (P = 0.005). In-hospital survival is affected by the amount of transfused packed red blood cells before embolization (P = 0.008) and post-embolization bowel infarction (P = 0.005).

CONCLUSION

TAE is a feasible and effective management of acute GIB with high technical and clinical success rates. The factors influencing clinical success include hemoglobin concentration, coagulopathy, upper GIB, contrast extravasation, and more than one embolized vessel. The number of units of transfused packed red blood cells and post-embolization bowel infarction are important factors associated with in-hospital mortality.

Effects of vasopressin infusion aided prophylactic gastroduodenal artery embolization in DSA-negative gastrointestinal bleeding patients

AIM: To investigate the effects of prophylactic gastroduodenal artery embolization and/or prophylactic mesenteric artery catheter infusion of vasopressin in digital subtraction angiography (DSA)-negative gastrointestinal bleeding patients.

METHODS: One hundred subjects recruited at our hospital from May 2012 to June 2013 with negative DSA examination results were randomly divided into three groups to receive preventive embolization and vasopressin therapy, embolization alone, and conservative treatment. Therapeutic effects and adverse events were compared between the three groups.

RESULTS: The success rate was greater in the preventive embolization and vasopressin treatment group (91.2%) than in the embolization alone group (81.8%) and the conservative treatment group (57.6%), and the difference between the combination group and conservative treatment group was statistically significant (P < 0.05). Adverse reactions were rare in patients of each group, and the combination group had a relatively low incidence (5.9%).

CONCLUSION: Preventive gastroduodenal artery embolization and/or prophylactic mesenteric artery catheter infusion of vasopressin have important therapeutic value in DSA negative gastrointestinal bleeding patients.

Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding

BACKGROUND

The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed.

METHODS

A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding.

RESULTS

Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding.

CONCLUSION

An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.

Glue embolization for gastroduodenal ulcer bleeding: contribution to hemodynamics and healing process

BACKGROUND

Although the morbidity of bowel ischemic events after glue embolization has been suggested, a causal relationship between glue and ischemia has not been clearly established.

PURPOSE

To evaluate the efficiency and safety of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA-TAE) for upper gastrointestinal hemorrhage (GIH).

MATERIAL AND METHODS

Between October 2006 and October 2012, 21 patients with upper GIH underwent NBCA-TAE, and endoscopic data were obtained within 30 days of follow-up. Shock index prior to and immediately after NBCA-TAE were compared to determine changes in hemodynamics. Days to Forrest type III, as assessed by follow-up endoscopy, was used as an indicator of the healing process. Other clinical outcomes included days for starting ingestion and for hospital discharge.

RESULTS

Sixteen gastric and five duodenal ulcers, classified into Forrest type I, were treated. Immediate hemostasis was achieved in all the patients, and no re-bleeding occurred within the follow-up period. Shock index significantly (P < 0.001) improved from before (0.99 ± 0.076) to immediately after NBCA-TAE (0.67 ± 0.038). Sequential mucosal healing processes were observed in all the patients, and the number of days to Forrest type III was 9.6 ± 7.1. The number of days for starting ingestion and hospital discharge was 9.0 ± 4.5 and 15 ± 7.7 days, respectively.

CONCLUSION

NBCA-TAE is an effective and safe method for the control of nonvariceal upper GIH, in terms of contribution to hemodynamics and healing process of the gastroduodenal mucosa.

Transcatheter arterial embolization for upper gastrointestinal nonvariceal hemorrhage: is empiric embolization warranted?

PURPOSE

To determine whether transcatheter arterial embolization performed in the setting of active gastric or duodenal nonvariceal hemorrhage is efficacious when the bleeding source cannot be identified angiographically.

METHODS

Records of 115 adult patients who underwent visceral angiography for endoscopically documented gastric (50 patients) or duodenal (65 patients) nonvariceal hemorrhage were retrospectively reviewed. Patients were subdivided into three groups according to whether angiographic evidence of arterial hemorrhage was present and whether embolization was performed (group 1 = no abnormality, no embolization; group 2 = no abnormality, embolization performed [empiric embolization]; and group 3 = abnormality present, embolization performed). Thirty-day rates and duration of primary hemostasis and survival were compared.

RESULTS

For patients with gastric sources of hemorrhage, the rate of primary hemostasis at 30 days after embolization was greater when embolization was performed in the setting of a documented angiographic abnormality than when empiric embolization was performed (67% vs. 42%). The rate of primary hemostasis at 30 days after angiography was greater for patients with duodenal bleeding who either underwent empiric embolization (60%) or embolization in the setting of angiographically documented arterial hemorrhage (58%) compared with patients who only underwent diagnostic angiogram (33%). Patients with duodenal hemorrhage who underwent embolization were less likely to require additional invasive procedures to control rebleeding (p = 0.006).

CONCLUSION

Empiric arterial embolization may be advantageous in patients with a duodenal source of hemorrhage but not in patients with gastric hemorrhage.

Optimal nonsurgical management of peptic ulcer bleeding, including arterial embolization is associated with a mortality below 1%

BACKGROUND

Management of high-risk peptic ulcer bleeding (PUB) consists in a high-dose infusion of proton pump inhibitors (PPIs) with double endoscopic treatment. If bleeding recurs, a second endoscopic treatment is required. Surgical management should be performed in case of endoscopic treatment failure, or if a second rebleeding occurs. Arterial embolization of PUB has been shown efficient and safe in small retrospective series, but optimal medical treatment was not used.

OBJECTIVE

Prospective assessment of the feasibility and the efficacy of arterial embolization of endoscopically unmanageable PUB, after optimal medical treatment.

PATIENTS

All consecutive patients referred to our intensive care unit (ICU) for high-risk PUB received high-dose PPIs and underwent double endoscopic treatment when possible. Arterial embolization was proposed in primary failure to endoscopic treatment, in case of failure of the second endoscopic treatment, or if a second recurrence occurred.

RESULTS

One hundred and twenty-eight patients with PUB were enrolled between January 2008 and December 2009. Arterial embolization, performed in 11 patients, was efficient in nine patients. Surgery was performed in two patients (one after inefficient embolization, and one with embolization-related complication). One patient died during hospitalization.

CONCLUSION

Arterial embolization seems to be efficient for endoscopically unmanageable PUB. In our series, one patient developed severe complication related to the procedure and died. If arterial embolization could be proposed before surgery in case of refractory PUB, large prospective studies are needed.

Early angiographic embolization is more effective than delayed angiographic embolization in patients with duodenal ulcer bleeding

BACKGROUND AND AIM

Though angiographic embolization (AE) is a type of effective treatment modality for duodenal ulcer bleeding, the optimum time at which to perform the procedure, early or delayed, is unknown. The authors compared the prognosis of early AE (EAE) and delayed AE (DAE) in patients with duodenal ulcer bleeding.

METHODS

A total of 54 patients with duodenal ulcer bleeding were evaluated with first-look endoscopy followed by AE. The patients were divided into two groups, the EAE group and DAE group, according to endoscopic attempts to stop the bleeding during the first-look endoscopy.

RESULTS

The success rate of AE, rebleeding rate, and number of patients who underwent surgery was not significantly different between the EAE group and DAE group (91.3% vs 93.5%, 21.7% vs 29.0% and 4.3% vs 16.1%, respectively; P > 0.05). With respect to death and intensive care unit (ICU) care rate, multivariate analysis showed more favorable results in the EAE group (0% vs 22.6%, P = 0.016 and 4.3% vs 57.4%, P = 0.003, respectively). Multivariate analysis also showed that prolonged prothrombin time (PT) > 1.2 international normalized ratio and the endoscopic attempt were independent factors associated with ICU care.

CONCLUSION

When the AE was performed early with correction for prolonged PT, the patients with duodenal ulcer bleeding had a more favorable prognosis.

Recent update of embolization of upper gastrointestinal tract bleeding

Nonvariceal upper gastrointestinal (UGI) bleeding is a frequent complication with significant morbidity and mortality. Although endoscopic hemostasis remains the initial treatment modality, severe bleeding despite endoscopic management occurs in 5-10% of patients, necessitating surgery or interventional embolotherapy. Endovascular embolotherapy is now considered the first-line therapy for massive UGI bleeding that is refractory to endoscopic management. Interventional radiologists need to be familiar with the choice of embolic materials, technical aspects of embolotherapy, and the factors affecting the favorable or unfavorable outcomes after embolotherapy for UGI bleeding.

A comparison of the results of arterial embolization for bleeding and non-bleeding gastroduodenal ulcers

BACKGROUND

Although some authors have advocated the practice of arterial embolization for angiographically negative acute hemorrhage from gastroduodenal ulcers, this technique remains controversial.

PURPOSE

To compare the results of arterial embolization for bleeding (BU) and non-bleeding (NBU) gastroduodenal ulcers.

MATERIAL AND METHODS

Transcatheter embolization was performed in 57 patients (39 men, 18 women, mean age 69.8 years) who experienced acute bleeding from gastroduodenal ulcers. At the time of embolization active contrast extravasation was seen in 36 of 57 patients, while in the remaining 21 patients embolization was based on endoscopic findings. Patient demographics, clinical success, need for re-intervention secondary to re-bleeding, and 30-day complication and mortality rates were reviewed and compared between the two groups by using statistical analyses.

RESULTS

In the BU group, the gastroduodenal artery (GDA) was embolized in 31 patients (86.1%), the left gastric artery (LGA) in three patients (8.3%), and the left gastroepiploic artery (LGEA) in two patients (5.6%). In the NBU group, the GDA was embolized in 18 patients (85.7%), and the LGA in three patients (14.3%). Clinical success (61.9 vs. 75.0%, P = 0.30), need for re-intervention (38.1 vs. 27.8%, P = 0.42), and 30-day complication (9.5 vs. 5.6%, P = 0.57), and mortality (28.6 vs. 25%, P = 0.77) rates were not statistically different between the two groups. Embolization in patients in NBU group did not have impact on clinical success (OR, 0.54; 95%CI, 0.17-1.72; P = 0.30).

CONCLUSION

Arterial embolization in patients with angiographically NBU is as safe and effective as embolization in patients with BU.

Sixty-four multi-detector computerised tomography in the detection of lower gastrointestinal bleeding: A prospective study

INTRODUCTION

Acute gastrointestinal bleeding (AGIB) is a serious and life-threatening condition. Many diagnostic procedures and tests are being used to detect the site of bleeding with different success rates. The aim of our study is to prospectively evaluate accuracy of 64-slice multi-detector computerised tomography (MDCT) in the diagnosis of lower AGIB.

METHODS

Between September 2007 and January 2009, patients with presumed lower AGIB were referred to the radiology department of our institution for 64-slice MDCT examination as part of the investigation for the lower AGIB. Any abnormalities to account for bleeding, such as tumours, bowel wall enhancement and increased intraluminal density, were recorded.

RESULTS

Out of 139 patients with AGIB that were admitted to our casualty department, 27 patients (19 men and 8 women) in the age range of 24-88 years (mean age, 56 years) were suspected to have lower AGIB. Sixty-four-slice MDCT was performed and considered positive for bleeding in 19 (70%) cases, and in all the cases, the bleeding source was indentified in the arterial phase, showing a focal dense wall enhancement in 8 (42%) cases, circumferential wall enhancement in 4 (22%) cases and progressive increasing intraluminal density in 7 (36%) cases. The venous phase scan showed increased dispersion of the contrast within the lumen as an additional clue for active extravasation in 15 (79%) out of the 19 cases. Delayed 5-min scanning showed the same findings as venous phase in all the 19 positive cases and failed to depict any additional findings in the eight cases that were negative on arterial or venous phases.

CONCLUSION

The study supports the high accuracy of 64-slice MDCT in locating the site of AGIB in patients thought to have a distal source of bleeding. Its accuracy in clinically proximal bleeding is not clear from this study, but MDCT is capable of showing such sources.

Multidetector CT angiography in acute gastrointestinal bleeding: why, when, and how

Acute gastrointestinal (GI) bleeding remains an important cause of emergency hospital admissions, with substantial related morbidity and mortality. Bleeding may relate to the upper or lower GI tract, with the dividing anatomic landmark between these two regions being the ligament of Treitz. The widespread availability of endoscopic equipment has had an important effect on the rapid identification and treatment of the bleeding source. However, the choice of upper or lower GI endoscopy is largely dictated by the clinical presentation, which in many cases proves misleading. Furthermore, there remains a large group of patients with negative endoscopic results or failed endoscopy, in whom additional techniques are required to identify the source of GI bleeding. Multidetector computed tomography (CT) with its speed, resolution, multiplanar techniques, and angiographic capabilities allows excellent visualization of both the small and large bowel. Multiphasic multidetector CT allows direct demonstration of bleeding into the bowel and is helpful in the acute setting for visualization of the bleeding source and its characterization. Thus, multidetector CT angiography provides a time-efficient method for directing and planning therapy for patients with acute GI bleeding. The additional information provided by multidetector CT angiography before attempts at therapeutic angiographic procedures leads to faster selective catheterization of bleeding vessels, thereby facilitating embolization. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.313105206/-/DC1.

Intra-arterial treatment in patients with acute massive gastrointestinal bleeding after endoscopic failure: comparisons between positive versus negative contrast extravasation groups

Objective

To determine whether treatment outcome is associated with visualization of contrast extravasation in patients with acute massive gastrointestinal bleeding after endoscopic failure.

Materials and Methods

From January 2007 to December 2009, patients that experienced a first attack of acute gastrointestinal bleeding after failure of initial endoscopy were referred to our interventional department for intra-arterial treatment. We enrolled 79 patients and divided them into two groups: positive and negative extravasation. For positive extravasation, patients were treated by coil embolization; and in negative extravasation, patients were treated with intra-arterial vasopressin infusion. The two groups were compared for clinical parameters, hemodynamics, laboratory findings, endoscopic characteristics, and mortality rates.

Results

Forty-eight patients had detectable contrast extravasation (positive extravasation), while 31 patients did not (negative extravasation). Fifty-six patients survived from this bleeding episode (overall clinical success rate, 71%). An elevation of hemoglobin level was observed in the both two groups; significantly greater in the positive extravasation group compared to the negative extravasation group. Although these patients were all at high risk of dying, the 90-day mortality rate was significantly lower in the positive extravasation than in the negative extravasation (20% versus 42%, p < 0.05). A multivariate analysis suggested that successful hemostasis (odds ratio [OR] = 28.66) is the most important predictor affecting the mortality in the two groups of patients.

Conclusion

Visualization of contrast extravasation on angiography usually can target the bleeding artery directly, resulting in a higher success rate to control of hemorrhage.

Recent advances in endovascular techniques for management of acute nonvariceal upper gastrointestinal bleeding

Over the past two decades, transcatheter arterial embolization has become the first-line therapy for the management of upper gastrointestinal bleeding that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the management of hemorrhage for a variety of indications, such as peptic ulcer bleeding, malignant disease, hemorrhagic Dieulafoy lesions and iatrogenic or trauma bleeding. Transcatheter interventions include the following: selective embolization of the feeding artery, sandwich coil occlusion of the gastroduodenal artery, blind or empiric embolization of the supposed bleeding vessel based on endoscopic findings and coil pseudoaneurysm or aneurysm embolization by three-dimensional sac packing with preservation of the parent artery. Transcatheter embolization is a fast, safe and effective, minimally invasive alternative to surgery when endoscopic treatment fails to control bleeding from the upper gastrointestinal tract. This article reviews the various transcatheter endovascular techniques and devices that are used in a variety of clinical scenarios for the management of hemorrhagic gastrointestinal emergencies.

Angiographic embolization of nonvariceal upper gastrointestinal bleeding: predictors of clinical failure

BACKGROUND

Angiographic embolization (AE) has emerged as an important therapy for patients with nonvariceal upper gastrointestinal bleeding (UGIB). We hypothesized that discrete factors predictive of AE failure could be identified.

METHODS

A retrospective review was performed for patients with nonvariceal UGIB who underwent AE from 1999 to 2009 at Penn State Milton S. Hershey Medical Center. AE clinical failure was defined as requirement for another intervention (surgery, endoscopic therapy, or another AE) for nonvariceal UGIB and/or death from bleeding after AE. Statistical analysis was performed using Fisher's exact test and Student's t test to explore the risk of AE failure.

RESULTS

Of 48 total AE cases, 17 patients (35.4%) had clinically failed AE. Mortality rate was significantly higher in patients with AE clinical failure than in patients with AE clinical success (64.7% vs. 12.9%, p=0.001). Factors associated with AE clinical failure include anticoagulant use before admission (p=0.001), use of corticosteroids before admission (p=0.045), pre-AE vasopressor use (p=0.038), and embolization using either coils alone (p=0.05) or using coils with or without additional embolic materials (p=0.018).

CONCLUSIONS

AE clinical failure portends poor prognosis. Caution should be exercised when considering AE, particularly AE using coils, in patients with a history of anticoagulant, corticosteroid, or vasopressor use.

Empiric transcatheter arterial embolization for massive bleeding from duodenal ulcers: efficacy and complications

PURPOSE

To evaluate the efficacy and safety of empiric transcatheter arterial embolization (TAE) for patients with massive bleeding from duodenal ulcers.

MATERIALS AND METHODS

During January 2000 and December 2009, 59 patients with duodenal ulcer bleeding in whom TAE was attempted after endoscopic therapy failed were retrospectively analyzed. The patients were divided into empiric TAE (n = 36) and identifiable TAE (n = 23) groups according to angiographic findings with or without identification of the bleeding sites. The technical and clinical success rate, recurrent bleeding rate, procedure-related complications, and clinical outcomes were evaluated.

RESULTS

The technical and clinical success rates of TAE were 100% and 83%. The recurrent bleeding rate, clinical success, duodenal stenosis, and 30-day mortality after TAE were not significantly different between the empiric and identifiable TAE groups.

CONCLUSIONS

A high rate of technical and clinical success was obtained with empiric TAE comparable to identifiable TAE in patients with massive bleeding from duodenal ulcers. There were no severe complications. Empiric TAE is an effective and safe method when a bleeding site cannot determined by angiography.

Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review

AIM

To assess the published evidence on the endovascular treatment of non-variceal upper gastrointestinal haemorrhage.

MATERIALS AND METHODS

An Ovid Medline search of published literature was performed (1966-2009). Non-English literature, experimental studies, variceal haemorrhage and case series with fewer than five patients were excluded. The search yielded 1888 abstracts. Thirty-five articles were selected for final analysis.

RESULTS

The total number of pooled patients was 927. The technical and clinical success of embolization ranged from 52-100% and 44-100%, respectively. The pooled mean technical/clinical success rate in primary upper gastrointestinal tract haemorrhage (PUGITH) only, trans-papillary haemorrhage (TPH) only, and mixed studies were 84%/67%, 93%/89%, and 93%/64%, respectively. Clinical outcome was adversely affected by multi-organ failure, shock, corticosteroids, transfusion, and coagulopathy. The anatomical source of haemorrhage and procedural variables did not affect the outcome. A successful embolization improved survival by 13.3 times. Retrospective comparison with surgery demonstrated equivalent mortality and clinical success, despite embolization being applied to a more elderly population with a higher prevalence of co-morbidities.

CONCLUSIONS

Embolization is effective in this very difficult cohort of patients with outcomes similar to surgery.

Is transcatheter arterial embolization a safer alternative than surgery when endoscopic therapy fails in bleeding duodenal ulcer?

OBJECTIVE

Emergency surgery after unsuccessful endoscopic therapy for bleeding duodenal ulcer has been reported to have a high mortality. Transcatheter arterial embolization (TAE) of the gastroduodenal artery is an alternative strategy when endoscopic therapy fails. This study is a retrospective analysis comparing these two treatment strategies.

MATERIAL AND METHODS

Patients who underwent TAE (n = 24) or open surgery (n = 50) after unsuccessful endoscopic therapy for bleeding duodenal ulcers at two university hospitals between 2000 and 2007 were compared. Mortality, morbidity, length of hospital stay, age, number of endoscopic interventions and acute physiology and chronic health evaluation (APACHE) II score were evaluated.

RESULTS

The groups were comparable concerning gender and length of hospital stay. The mean age (69.6 +/- 16.1 versus 61.9 +/- 14.1 years; P = 0.043), APACHE II score (17.0 +/- 5.1 versus 12.8 +/- 5.7; P = 0.004) and number of gastroscopies (P = 0.009) were significantly higher in the embolization group. Five patients (20.8%) died in the embolization group compared to 11 (22%) in the surgery group. However, mortality in high-risk patients (APACHE II score >or= 16.5) was lower in the TAE group (23.1% versus 50.0%; P = 0.236). Method-related as well as other complications were not significantly different between the two groups. There was, however, a higher re-bleeding rate in the TAE group.

CONCLUSIONS

TAE of the gastroduodenal artery appears to be a safe alternative when endoscopic therapy for bleeding duodenal ulcer fails, at least in high-risk patients. The role of TAE in low-risk patients with bleeding from duodenal ulcer needs to be defined by means of a prospective controlled trial.

Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers

Intractable bleeding from gastric and duodenal ulcers is associated with significant morbidity and mortality. Aggressive treatment with early endoscopic hemostasis is essential for a favourable outcome. In as many as 12%-17% of patients, endoscopy is either not available or unsuccessful. Endovascular therapy with selective catheterization of the culprit vessel and injection of embolic material has emerged as an alternative to emergent operative intervention in high-risk patients. There has not been a systematic literature review to assess the role for embolotherapy in the treatment of acute upper gastrointestinal bleeding from gastroduodenal ulcers after failed endoscopic hemostasis. Here, we present an overview of indications, techniques, and clinical outcomes after endovascular embolization of acute peptic-ulcer bleeding. Topics of particular relevance to technical and clinical success are also discussed. Our review shows that transcatheter arterial embolization is a safe alternative to surgery for massive gastroduodenal bleeding that is refractory to endoscopic treatment, can be performed with high technical and clinical success rates, and should be considered the salvage treatment of choice in patients at high surgical risk.

Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding

BACKGROUND

Upper and lower acute gastrointestinal bleeding (AGIB) is associated with high rates of mortality and morbidity. The latest computerized tomography (CT) imaging techniques play an important role in the treatment of this pathology.

METHODS

Twenty-nine patients with severe AGIB (11 upper, 18 lower), all hemodynamically stable, underwent endoscopy followed by a multi-detector row CT (MDCT) scan. Endoscopic and MDCT accuracy for the anatomical localization and etiology of AGIB was assessed, the diagnosis being considered correct when the two procedures were concordant or when the diagnosis was confirmed by angiographic, surgical, or post-mortem findings.

RESULTS

The sensitivity in identifying the site and etiology of bleeding was, respectively, 100% and 90.9% for the MDCT scan, compared with 72.7% and 54.5% for endoscopy in upper AGIB, and 100% and 88.2% for the MDCT scan, compared with 52.9% and 52.9% for endoscopy, in lower AGIB.

CONCLUSIONS

Considering the advantages of MDCT over endoscopy, we propose a new diagnostic algorithm for AGIB.