[Lower gastrointestinal bleeding: the great unknown]

Angiography and transcatheter embolizaion for acute lower gastrointestinal hemorrhage: clinical value and influencing factors of diagnosis and treatment

AIM: To evaluate the clinical value of angiography and transcatheter embotherapy in patients with acute massive lower gastrointestinal (GI) hemorrhage, and to analyze the influencing factors.

METHODS: We retrospectively analyzed data of 39 cases with acute massive arterial hemorrhage of lower gastrointestinal tract, including such data as transfusion amount, blood pressure and hemoglobin (Hb) before and after embolization. Baseline, procedural, and outcome parameters were recorded in accordance with current Society of Interventional Radiology guidelines. Follow-up time was three to six months. Outcomes included technical success (Immediate disappearance of bleeding signs or obstruction of leaking-blood artery after embotherapy), clinical success (without rebleeding within 30 days), delayed rebleeding (more than 30 days), and major or minor complication rates.

RESULTS: Twenty-six patients of the 39 with acute massive lower GI hemorrhage received blood transfusion before embolization, and only 4 patents with HB below 40 g/L before embolization, received the transfusion post-embolization. The positive diagnostic rates of lower GI hemorrhage of angiograms were 31% with catheter-tips located at 2^nd-grade-blood vessels (superior mesenteric arteries, inferior mesenteric arteries), and 69% at 3^rd-grade-blood vessels (jejunal artery, iliac artery, iliac-cecal artery, cecal artery, and marginal artery), respectively. The total positive diagnostic rate of angiography about lower GI bleeding reached 100%. Embolization was performed with injection of gelatin sponge particles or thin strips via catheter following angiogram with angiographical catheter (5French size) or with microcatheter (3French size). Immediate cessation bleeding post-embolization was 92%. The technical success rates and clinical success rates reached 100% and 89.7%, respectively. Transient epigastric pains occurred to 4 patients because of superior mesenteric artery spasm, 2 cases were managed with medications, and the others were relieved spontaneously. Three days after transcatheter embolization, endoscopy examination of four patients showed the areas of mucosal erythema, swelling and pallor. None of major complications was found such as necrosis or serious ischemia of lower GI.

CONCLUSION: Angiography and transcatheter embolization are effective and safe methods to locate the bleeding spot and stop bleeding immediately, which can be considered as alternatives to diagnosis and treatment of acute massive lower GI hemorrhage. The positive-bleeding-diagnostic rates of angiograms in lower GI hemorrhage and the efficacy of embolization are influenced by varied factors.

Surgical treatment concepts for acute lower gastrointestinal bleeding

BACKGROUND AND PURPOSE

To this day, the diagnostic and therapeutic strategy for acute lower gastrointestinal hemorrhage requiring transfusion varies among different hospitals. The purpose of this paper was to evaluate our own data on the group of patients presented and to outline our diagnostic and therapeutic regime taking into account the literature of the past 30 years.

METHODS

Following prospective data collection on 63 patients of a university hospital (40 male, 23 female patients) who received surgical intervention for acute lower intestinal hemorrhage requiring transfusion, we retrospectively analyzed the data. After a medical history had been taken, all patients underwent clinical examination, including digital palpation; 62 patients underwent procto-rectoscopy, 38 gastroscopy and colonoscopy, 52 patients colonoscopy only, and 45 patients gastroscopy only. Angiography was applied in 14 cases and scintigraphy in 20 cases.

RESULTS

Diagnostic procedures to localize hemorrhage were successful in 61 cases, 41 of which through endoscopy, 12 through angiography, and eight through scintigraphy. Of our group of patients, 32 suffered from a bleeding colonic diverticulum, eight from angiodysplasia, and five from bleeding small bowel diverticula. Five patients had inflammatory bowel disease and three neoplasia. Among the surgical interventions, segmental resections were performed most frequently (15 sigmoidectomies, 11 small bowel segmental resections, 11 left hemicolectomies, seven right hemicolectomies, one proctectomy). Subtotal colectomies were carried out in ten cases. The complication rate for this group of critically ill, negatively selected patients was 60.3% and the mortality rate was 15.9%.

CONCLUSIONS

Examination and stabilization of the patient is directly followed by diagnostic localization. Today, we primarily rely on nonsurgical control of hemorrhage by endoscopy or angiography; the indication for surgery is mainly limited to peracute, uncontrollable, and recurrent forms. In the case of surgery, intestinal segmental resection is recommended after identification of the lesion; if the localization of colonic hemorrhage is uncertain, subtotal resection is the method of choice. For stable patients with unverifiable small-bowel hemorrhage we recommend regular re-evaluation.