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Falsarella PM, Katz M, Affonso BB, Galastri FL, Arcuri MF, Motta-Leal-Filho JMD, Araujo SEA, Garcia RG, Nasser F. Angiographic description of the superior rectal artery and its anatomical variations in patients undergoing embolization of the superior rectal arteries in hemorrhoidal disease treatment. EINSTEIN-SAO PAULO 2024; 22:eAO0688. [PMID: 39356943 DOI: 10.31744/einstein_journal/2024ao0688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 03/05/2024] [Indexed: 10/04/2024] Open
Abstract
BACKGROUND Angiography of the superior rectal artery showed that its branches were divided into four main branches (two left and two right) in 46.8%; the second most frequent variation was one right and two left branches in 26.6%, followed by two branches to the right and one to the left in 20%; the most uncommon variations were one to the right and one to the left without further subdivision in 6.6%. BACKGROUND ◼ The superior rectal artery, when it reaches the rectum, divides into two or more branches. BACKGROUND ◼ Four patterns were observed in the angiographic anatomy of the superior rectal artery. BACKGROUND ◼ Understanding the angiographic anatomy of the superior rectal artery is important to achieve optimal embolization results. OBJECTIVE To describe angiographic findings of the superior rectal artery, its branches, and anatomical variations in the hemorrhoidal plexus in patients undergoing rectal artery embolization for hemorrhoidal disease treatment. METHODS Angiographic findings of 15 patients were obtained from a single-center, prospective clinical study that compared superior rectal artery embolization with the Ferguson technique for hemorrhoidal disease between July 2018 and March 2020. RESULTS Angiography of the superior rectal artery showed that in seven patients (46.8%), its branches were divided into four main branches (two left and two right), while in four patients (26.6%), the branches divided into one right and two left branches. The most uncommon variation observed in three cases (20%) was the branches divided into two branches to the right and one to the left; no further subdivision into the main branches was observed in one case (6.6%). CONCLUSION Four patterns were observed in the angiographic anatomy of the superior rectal arteries. Knowledge of the angiographic anatomy of this region and its variations is essential to improve the effectiveness of superior rectal artery embolization. REGISTRY OF CLINICAL TRIALS NCT03402282.
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Affiliation(s)
- Priscila Mina Falsarella
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Marcelo Katz
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | | | | | | | | | | | - Felipe Nasser
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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2
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Inayat F, Hussain A, Yahya S, Weissman S, Sarfraz N, Faisal MS, Riaz I, Saleem S, Saif MW. Rectal Dieulafoy's lesion: a comprehensive review of patient characteristics, presentation patterns, diagnosis, management, and clinical outcomes. Transl Gastroenterol Hepatol 2022; 7:10. [PMID: 35243119 PMCID: PMC8826214 DOI: 10.21037/tgh.2020.02.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 02/10/2020] [Indexed: 08/10/2023] Open
Abstract
Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying mucosa, without primary ulceration or erosion. Although these lesions predominantly involve the stomach and upper small intestine, they are being detected with increasing frequency in the rectum. We conducted a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases for adult rectal Dieulafoy's lesion. After careful review of the search results, a total of 101 cases were identified. The data on patient characteristics, clinical features, colonoscopy findings, diagnosis, treatment, and clinical outcomes were collected and analyzed. The mean age of presentation was 66±17 years (range, 18-94 years), with 54% of cases reported in males. Clinical presentation was dominated by acute lower gastrointestinal bleeding in the form of bright-red blood per rectum 47% and hematochezia 36%, whereas 16% of patients were admitted with symptoms related to other medical conditions. Major underlying disorders were hypertension 29%, diabetes mellitus 21%, and chronic kidney disease 16%. The average number of colonoscopies required for the diagnosis of rectal Dieulafoy's lesion was 1.5±0.7. In regard to treatment, endoscopic therapy was applied in 80%, direct surgical suturing in 12%, angiographic embolization in 4%, and endoscopic therapy followed by surgical ligation was performed in 4% of patients. The endoscopic treatment was a feasible choice for rectal disease, with a primary hemostasis rate of 88%. Although the overall mortality rate was 6%, the causes of death were unrelated to this entity. This review illustrates that patients with rectal Dieulafoy's lesion can have a favorable clinical outcome. Prompt diagnosis and appropriate management are of paramount importance to prevent serious hemodynamic complications. The best therapeutic modality remains to be determined but the data presented here support the use of mechanical endoscopic methods as safe and effective.
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Affiliation(s)
| | | | - Sidra Yahya
- Fatima Jinnah Medical University, Lahore, Pakistan
| | - Simcha Weissman
- Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | | | | | - Iqra Riaz
- Einstein Medical Center, Philadelphia, PA, USA
| | - Saad Saleem
- Mercy Saint Vincent Medical Center, Toledo, OH, USA
| | - Muhammad Wasif Saif
- The Feinstein Institute of Medical Research, Manhasset, NY, USA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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3
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Sirakaya M, O'Balogun A, Kassamali RH. Superior Rectal Artery Embolisation for Haemorrhoids: What Do We Know So Far? Cardiovasc Intervent Radiol 2021; 44:675-685. [PMID: 33388875 DOI: 10.1007/s00270-020-02733-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/27/2020] [Indexed: 01/02/2023]
Abstract
Haemorrhoids are abnormally enlarged anal cushions within the lower rectum. They are common, and have potential to significantly impact patients' quality of life. Superior rectal artery embolisation is a technique which has been discussed in the literature as far back as 40 years ago. More recently, there has been interest in the role of embolisation in the treatment for haemorrhoids, as an alternative to established minimally invasive and conventional surgical techniques. In this review, we discuss the current literature on the topic, with particular focus on technique, clinical outcomes and complications. Emerging procedural and technical considerations are discussed, with further review of the role of coil vs. particle embolisation.
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Affiliation(s)
| | | | - Rahil H Kassamali
- Department of Interventional Radiology, Hamad Medical Corporation, Doha, Qatar
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4
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Moussa N, Sielezneff I, Sapoval M, Tradi F, Del Giudice C, Fathallah N, Pellerin O, Amouyal G, Pereira H, de Parades V, Vidal V. Embolization of the superior rectal arteries for chronic bleeding due to haemorrhoidal disease. Colorectal Dis 2017; 19:194-199. [PMID: 27338153 DOI: 10.1111/codi.13430] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 03/09/2016] [Indexed: 12/13/2022]
Abstract
AIM The aim of this study was to assess the safety and efficacy of the emborrhoid technique (embolization of the superior haemorrhoidal arteries) in patients ineligible for surgery. METHODS Between January 2014 and April 2015, 30 consecutive patients (average age 58 years) suffering from disabling chronic bleeding due to haemorrhoidal disease and with a contraindication for surgery (n = 23) or with a failure of instrumental or surgical treatment (n = 7) underwent embolization. All cases were discussed at multidisciplinary meetings including a proctology specialist or a surgeon and an interventional radiologist. We performed super selective micro coil embolization (pushable 2-3 mm fibre coils) of the distal branches of the superior rectal arteries with a microcatheter, via a right femoral approach, under local anaesthesia. We assessed clinical outcome by evaluating bleeding and specific clinical scores relating to bleeding and changes in quality of life. RESULTS Immediate technical success, with no complication, was achieved in 93% of cases. A mean of 3.1 arteries per patient was embolized, with a mean of 7.6 coils per patient. Median follow-up was 5 months. Clinical score improvement was observed in 72%, in 17 patients after a single embolization session, and in four additional patients after a second embolization session. No improvement in bleeding was observed in eight patients (28%). CONCLUSION Distal coil embolization of the superior rectal arteries for disabling chronic bleeding due to haemorrhoidal disease is safe and effective in patients untreatable by surgery.
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Affiliation(s)
- N Moussa
- Sorbonne Paris Cité, Medicine Faculty, Paris Descartes University, Paris, France.,Assistance Publique - Hôpitaux de Paris, Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France
| | - I Sielezneff
- Department of Digestive and General Surgery, La Timone Hospital, Marseille, France.,Aix-Marseille University, Marseille, France.,INSERM, UMR-S 1076 VRCM (Vascular Research Centre of Marseille), Marseille, France
| | - M Sapoval
- Sorbonne Paris Cité, Medicine Faculty, Paris Descartes University, Paris, France.,Assistance Publique - Hôpitaux de Paris, Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France.,INSERM U970, Paris, France
| | - F Tradi
- Aix-Marseille University, Marseille, France.,Department of Radiology, La Timone Hospital, Marseille, France
| | - C Del Giudice
- Sorbonne Paris Cité, Medicine Faculty, Paris Descartes University, Paris, France.,Assistance Publique - Hôpitaux de Paris, Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France
| | - N Fathallah
- Sorbonne Paris Cité, Medicine Faculty, Paris Descartes University, Paris, France.,Assistance Publique - Hôpitaux de Paris, Georges Pompidou European Hospital, Gastro-enterology Department, Paris, France
| | - O Pellerin
- Sorbonne Paris Cité, Medicine Faculty, Paris Descartes University, Paris, France.,Assistance Publique - Hôpitaux de Paris, Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France.,INSERM U970, Paris, France
| | - G Amouyal
- Sorbonne Paris Cité, Medicine Faculty, Paris Descartes University, Paris, France.,Assistance Publique - Hôpitaux de Paris, Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France
| | - H Pereira
- Assistance Publique - Hôpitaux de Paris, Georges Pompidou European Hospital, Unité d'Épidémiologie et de Recherche Clinique, Paris, France.,INSERM, Centre d'Investigation Clinique 1418, Module d'Épidémiologie Clinique, Paris, France
| | - V de Parades
- Department of Proctology, Saint Joseph Hospital, Paris, France
| | - V Vidal
- Aix-Marseille University, Marseille, France.,Department of Radiology, La Timone Hospital, Marseille, France
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5
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Zakharchenko A, Kaitoukov Y, Vinnik Y, Tradi F, Sapoval M, Sielezneff I, Galkin E, Vidal V. Safety and efficacy of superior rectal artery embolization with particles and metallic coils for the treatment of hemorrhoids (Emborrhoid technique). Diagn Interv Imaging 2016; 97:1079-1084. [PMID: 27597728 DOI: 10.1016/j.diii.2016.08.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/23/2016] [Accepted: 08/01/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to comprehensively evaluate the short-term outcomes after percutaneous embolization of the superior rectal artery (SRA) with metallic coils and particles for the management of hemorrhoids. MATERIALS AND METHODS Forty patients (15 men, 25 women) with a mean age of 35±5 years (SD) (range: 25-65 years) were prospectively enrolled. All patients had symptomatic hemorrhoids. The distribution of internal hemorrhoids was as follows: grade I (n=6, 16%); grade II (n=28, 69%) and grade III (n=6; 15%). All patients had percutaneous embolization of the SRA with metallic coils and synthetic polyvinyl alcohol particles. Follow-up evaluation included clinical examination, rectoscopy, histopathological analysis of rectal mucosa, duplex Doppler blood flow quantification, electromyography, sphincterometry of the anal sphincter and analysis of patient satisfaction. RESULTS No immediate complications were observed and no patients had anal pain syndrome after embolization. Hemorrhoids showed a 43% size reduction after embolization (P<0.05). Taking into account the symptom resolutions such as irritation, discomfort, bloody discharge and pain, satisfaction was observed in 5/6 (83%) patients with grade III hemorrhoids and 32/34 patients (94%) with grades I-II hemorrhoids. One month after embolization, anal sphincter contractility normalized and no changes in anal electromyography were observed. Blood flow in the hemorrhoidal plexus dropped from 109±1.2ml/min/100g (SD) before treatment to 60.2±4.4ml/min/100g (SD) (P<0.05) the day after embolization and remained unchanged one month after embolization. CONCLUSION Our study demonstrates that embolization of SRA with particle and coils does not lead to ischemia in patients with symptomatic hemorrhoids. Short-term results with regard to symptom management for hemorrhoidal disease are very encouraging and should stimulate further prospective and multicenter studies.
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Affiliation(s)
- A Zakharchenko
- Department of general surgery, Krasnoyarsk state medical university, Krasnoyarsk Railwey clinical hospital, Krasnoyarsk, Russia
| | - Y Kaitoukov
- Department of diagnostic radiology and radio-oncology, centre hospitalier de l'université de Montréal, Montreal, Canada
| | - Y Vinnik
- Department of general surgery, Krasnoyarsk state medical university, Krasnoyarsk Railwey clinical hospital, Krasnoyarsk, Russia
| | - F Tradi
- Department of vascular and interventional radiology, hôpital de la Timone, 13005 Marseille, France
| | - M Sapoval
- Department of interventional radiology, hôpital Georges-Pompidou, 75015 Paris, France
| | - I Sielezneff
- Department of visceral surgery, Aix-Marseille university, hôpital de la Timone, 13005 Marseille, France
| | - E Galkin
- Department of vascular surgery and interventional radiology, Siberian clinical center FMBA, Krasnoyarsk, Russia
| | - V Vidal
- Department of vascular and interventional radiology, hôpital de la Timone, 13005 Marseille, France.
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6
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Vidal V, Sapoval M, Sielezneff Y, De Parades V, Tradi F, Louis G, Bartoli JM, Pellerin O. Emborrhoid: a new concept for the treatment of hemorrhoids with arterial embolization: the first 14 cases. Cardiovasc Intervent Radiol 2014; 38:72-8. [PMID: 25366092 DOI: 10.1007/s00270-014-1017-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 10/09/2014] [Indexed: 12/11/2022]
Abstract
PURPOSE The 'emborrhoid' technique consists of the embolization of the hemorrhoidal arteries. The endovascular arterial occlusion is performed using coils placed in the terminal branches of the superior rectal arteries. The emborrhoid technique has been modeled after elective transanal Doppler-guided hemorrhoidal artery ligation which has been shown to be effective in hemorrhoidal disease. We report the first 14 cases of our experience with emborrhoid technique. MATERIALS AND METHODS Fourteen patients with disabling chronic rectal bleeding were treated using the emborrhoid technique (3 women, 11 men). The stage of the hemorrhoidal disease was II (10 patients), III (3), and IV (1). This treatment was decided by a multidisciplinary team (proctologist, visceral surgeon, and radiologist). Seven patients underwent previous proctological surgery. Ten patients had coagulation disorders (anticoagulants or cirrhosis). Superior rectal arteries were embolized with pushable microcoils (0.018). RESULTS Technical success of the embolization procedure was 100 %. Clinical success at 1 month was 72 % (10/14). Of the 4 patients who experienced rebleeding, two underwent additional embolization of the posterior rectal arteries with success. No pain or ischemic complications were observed in 13 patients. One patient experienced a temporary painful and edematous, perianal reaction. CONCLUSION Our case studies suggest that coil embolization of the superior rectal arteries is technically feasible, safe and well tolerated. Additional studies are needed to evaluate the efficacy of this new 'emborrhoid' technique in the management of hemorrhoidal disease.
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Affiliation(s)
- V Vidal
- Department of Radiology, Hôpital de la Timone, 264 rue Saint Pierre, 13385, Marseille, Cedex 05, France,
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7
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Embolization of the hemorrhoidal arteries (the emborrhoid technique): A new concept and challenge for interventional radiology. Diagn Interv Imaging 2014; 95:307-15. [DOI: 10.1016/j.diii.2014.01.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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8
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Cherian MP, Mehta P, Kalyanpur TM, Hedgire SS, Narsinghpura KS. Arterial interventions in gastrointestinal bleeding. Semin Intervent Radiol 2011; 26:184-96. [PMID: 21326563 DOI: 10.1055/s-0029-1225661] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The diagnosis and management of gastrointestinal (GI) bleeding are complicated. A multitude of pathologic processes results in GI bleeding, and often, the bleeding is intermittent in nature. Of the available diagnostic tools, angiography has been the gold standard. Management of patients requires a multidisciplinary approach involving gastroenterologists, interventional radiologists, and surgeons. Therapeutic arterial interventions include pharmacologic control with the use of intraarterial vasopressin, embolization with temporary and permanent embolizing materials, and catheter-induced vasospasm.
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Affiliation(s)
- Mathew P Cherian
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
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9
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Costouros NG, Niho H, Mahadevan U, Kerlan RK, Bloom AI. Angiographic embolization for control of life-threatening hemorrhage from benign rectal ulcers. J Vasc Interv Radiol 2009; 20:561-2. [PMID: 19246210 DOI: 10.1016/j.jvir.2008.12.418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Revised: 12/19/2008] [Accepted: 12/19/2008] [Indexed: 01/26/2023] Open
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10
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Kickuth R, Rattunde H, Gschossmann J, Inderbitzin D, Ludwig K, Triller J. Acute Lower Gastrointestinal Hemorrhage: Minimally Invasive Management with Microcatheter Embolization. J Vasc Interv Radiol 2008; 19:1289-96.e2. [DOI: 10.1016/j.jvir.2008.06.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 05/15/2008] [Accepted: 06/02/2008] [Indexed: 11/24/2022] Open
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11
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Berczi V, Gopalan D, Cleveland TJ. Embolization of a Hemorrhoid Following 18 Hours of Life-Threatening Bleeding. Cardiovasc Intervent Radiol 2007; 31:183-5. [PMID: 17334848 DOI: 10.1007/s00270-006-0179-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hemorrhoids usually do not pose diagnostic difficulties and they rarely cause massive bleeding. We report a case of massive rectal bleeding over 18 h needing 22 U blood transfusion treated by superselective transcatheter coil embolization 12 h following operative treatment performed in a different hospital. Diagnostic angiography with a view to superselective embolization, following failure of sigmoidoscopy to localize and treat the cause of hemorrhage, might act as a life-saving treatment in massive rectal bleeding, obviating the need for repeated endoscopy or emergency surgery.
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Affiliation(s)
- Viktor Berczi
- Sheffield Vascular Institute, Northern General Hospital, Sheffield, UK.
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12
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Yoshikumi Y, Mashima H, Suzuki J, Yamaji Y, Okamoto M, Ogura K, Kawabe T, Omata M. A case of rectal Dieulafoy's ulcer and successful endoscopic band ligation. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2006; 20:287-90. [PMID: 16609760 PMCID: PMC2659908 DOI: 10.1155/2006/345387] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Dieulafoy's ulcer is a rare cause of gastrointestinal bleeding. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. A 44-year-old man was admitted to hospital due to cerebral infarction. On the 23rd day of hospitalization, he showed massive hematochezia. He underwent an urgent colonoscopy. There was a visible protuberant vessel without significant ulceration at the fundus of the rectum, consistent with a Dieulafoy's ulcer. It was treated by endoscopic hemoclipping. However, rebleeding occurred three times despite repeated hemoclipping. Finally, endoscopic band ligation was successfully performed to achieve permanent hemostasis. Endoscopic band ligation is an effective treatment for bleeding rectal Dieulafoy's ulcer.
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Affiliation(s)
| | - Hirosato Mashima
- Correspondence and reprints: Dr Hirosato Mashima, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655. Telephone 81-3-3815-5411 ext 37194, fax 81-3-5800-9738, e-mail
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13
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Hung HY, Changchien CR, You JF, Chen JS, Chiang JM, Yeh CY, Fan CW, Tang R, Hsieh PS, Tasi WS. Massive hematochezia from acute hemorrhagic rectal ulcer in patients with severe comorbid illness: rapid control of bleeding by per anal suturing of bleeder using anoretractor. Dis Colon Rectum 2006; 49:238-43. [PMID: 16465586 DOI: 10.1007/s10350-005-0158-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Massive hematochezia from acute hemorrhagic rectal ulcer can arise in patients with severe comorbid illness who are bedridden for long periods. If the bleeder is not found and treated immediately, the bleeding will cause deterioration of health and even threaten life. The results of the current study show how quickly and safely per anal suturing can treat acute hemorrhagic rectal ulcer. METHODS From January 2003 to December 2003, the records of 26 patients who underwent per anal suturing of acute hemorrhagic rectal ulcer were retrospectively reviewed. The identification of acute hemorrhagic rectal ulcer was confirmed by clinical and anoscopic examination. RESULTS Most of these patients were elderly and bedridden (14 men; median age 69 years). Main comorbid illnesses existed in all patients and included liver cirrhosis (8 patients, 31 percent), sepsis (13 patients, 50 percent), cerebral vascular accident (15 patients, 58 percent), respiratory failure (13 patients, 50 percent), and malignancy (7 patients, 27 percent). Effective hemostasis was achieved in all patients by direct suture of bleeding ulcer. No complications developed relative to the per anal suturing procedure among any patients. Although 11 patients developed recurrent hematochezia, 9 patients responded to repeated therapy. The risk factors associated with recurrent bleeding were severity of disease and abnormal coagulation. CONCLUSIONS When massive hematochezia occurs in bedridden patients with severe comorbid illness, it is essential to investigate the lower rectum, which often is affected by acute hemorrhagic rectal ulcer. Recognition of this clinical presentation will result in early identification and therapy. Per anal suturing of a bleeder at the bedside provides a quick, safe, and successful management of acute hemorrhagic rectal ulcer.
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Affiliation(s)
- Hsin-Yuan Hung
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.
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14
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d'Othée BJ, d'Othée BJ, Surapaneni P, Rabkin D, Nasser I, Clouse M. Microcoil Embolization for Acute Lower Gastrointestinal Bleeding. Cardiovasc Intervent Radiol 2005; 29:49-58. [PMID: 16328695 DOI: 10.1007/s00270-004-0301-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess outcomes after microcoil embolization for active lower gastrointestinal (GI) bleeding. METHODS We retrospectively studied all consecutive patients in whom microcoil embolization was attempted to treat acute lower GI bleeding over 88 months. Baseline, procedural, and outcome parameters were recorded following current Society of Interventional Radiology guidelines. Outcomes included technical success, clinical success (rebleeding within 30 days), delayed rebleeding (>30 days), and major and minor complication rates. Follow-up consisted of clinical, endoscopic, and pathologic data. RESULTS Nineteen patients (13 men, 6 women; mean age +/- 95% confidence interval = 70 +/- 6 years) requiring blood transfusion (10 +/- 3 units) had angiography-proven bleeding distal to the marginal artery. Main comorbidities were malignancy (42%), coagulopathy (28%), and renal failure (26%). Bleeding was located in the small bowel (n = 5), colon (n = 13) or rectum (n = 1). Technical success was obtained in 17 patients (89%); 2 patients could not be embolized due to vessel tortuosity and stenoses. Clinical follow-up length was 145 +/- 75 days. Clinical success was complete in 13 (68%), partial in 3 (16%), and failed in 2 patients (11%). Delayed rebleeding (3 patients, 27%) was always due to a different lesion in another bowel segment (0 late rebleeding in embolized area). Two patients experienced colonic ischemia (11%) and underwent uneventful colectomy. Two minor complications were noted. CONCLUSION Microcoil embolization for active lower GI bleeding is safe and effective in most patients, with high technical and clinical success rates, no procedure-related mortality, and a low risk of bowel ischemia and late rebleeding.
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Affiliation(s)
- B Janne d'Othée
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215-5400, USA.
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Pichon N, François B, Pichon-Lefièvre F, Mathonnet M, Maubon A, Vignon P. Embolization of Rectal Arteries: An Alternative Treatment for Hemorrhagic Shock Induced by Traumatic Intrarectal Hemorrhage. Cardiovasc Intervent Radiol 2005; 28:515-7. [PMID: 16010510 DOI: 10.1007/s00270-004-0168-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Rectal injuries caused by foreign bodies or iatrogenic insertions may lead to severe complications whose therapeutic management remains controversial. At times, both the rapid identification and treatment of subsequent active rectal bleeding may be challenging, especially when endoscopy fails to locate and control the arterial hemorrhage. We present the first two successful cases of middle rectal artery embolization in patients presenting with sustained bleeding and hemorrhagic shock.
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Affiliation(s)
- Nicolas Pichon
- Dupuytren University Hospital, 2 Avenue Martin Luther King, Limoges, 87042, France.
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16
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Kuo WT, Lee DE, Saad WEA, Patel N, Sahler LG, Waldman DL. Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2004; 14:1503-9. [PMID: 14654483 DOI: 10.1097/01.rvi.0000099780.23569.e6] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate the safety and effectiveness of superselective microcoil embolization for the treatment of lower gastrointestinal (LGI) hemorrhage. MATERIALS AND METHODS A retrospective review of LGI superselective microcoil embolization data for a 10-year period was performed. During this period, twenty-two patients with evidence on angiography of LGI bleeding underwent superselective microcoil embolization. Hemorrhage was treated in the colon (n = 19) and jejunum (n = 3). Ivalon was used adjunctively in two patients and gelfoam was used as a secondary agent in two additional patients. Postembolization ischemia was evaluated objectively in 14 patients by colonoscopy (n = 10), surgical specimen (n = 3), and barium enema (n = 1). All patients were followed for clinical evidence of bowel ischemia. Four patients died before further follow-up could be performed. Additionally, 122 cases of LGI hemorrhage treated with superselective microcoil embolization were identified in a review of the literature. A meta-analysis was then performed, combining the data in this study and the data from the literature, to estimate the rate of major and minor ischemic complications on a total of 144 superselective microcoil embolizations. RESULTS Immediate hemostasis was achieved in all 22 patients in this study. Complete clinical success was achieved in 86% of patients (19 of 22 patients). Rebleeding occurred in 14% of patients (3 of 22 patients) and each underwent colonoscopic intervention with success. Postembolization objective follow-up was performed in 64% of patients (14 of 22 patients). Ten patients underwent follow-up colonoscopy; one patient received a follow-up barium enema; and three patients underwent subsequent surgery. Colonic resection (one partial and one total) was performed in two patients. The partial colectomy was performed in a patient who had been diagnosed with colonic polyps and dysplasia. The total colectomy was performed on a patient with history of chronic LGI bleeding complicated by long-term anticoagulation therapy and a history of tubular adenoma resection. The third surgical patient (16 months old) underwent a follow-up exploratory laparotomy after embolization of a proximal jejunal branch of the superior mesenteric artery. None of the three patients who underwent surgery were found to have postembolic ischemic changes in the bowel specimen. Four patients in this study died, for reasons unrelated to hemorrhage or embolization, before further follow-up could be performed. The last four patients were followed clinically and experienced no symptoms of intestinal ischemia. A minor ischemic complication was reported in 4.5% of patients (1 of 22 patients), and there were no major ischemic complications (0%) in this series. A review of the data from 122 cases of LGI superselective microcoil embolization in the literature is also presented. Combined with the data in this study, the minor complication rate was 9% (13 of 144 patients), and the major complication rate was 0% (0 of 144 patients). CONCLUSION Superselective microcoil embolization is a safe and effective treatment for LGI hemorrhage.
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Affiliation(s)
- William T Kuo
- Department of Diagnostic Radiology, Division of Vascular and Interventional Radiology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Hendrickson RJ, Diaz AA, Salloum R, Koniaris LG. Benign rectal ulcer: an underground cause of inpatient lower gastrointestinal bleeding. Surg Endosc 2003; 17:1759-65. [PMID: 12616389 DOI: 10.1007/s00464-002-8594-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2002] [Accepted: 11/05/2002] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although it is uncommon, significant bleeding per rectum presents one of the most difficult emergency problems. Bleeding from a rectal ulcer is not well recognized as a cause of such bleeding. METHODS From July 2000 through December 2000, 195 consecutive patients with significant blood loss per rectum were reviewed. RESULTS Forty-eight cases in whom significant gastrointestinal (GI) bleeding occurred following prior hospitalization were identified. Sources of bleeding were gastroduodenal in 38 cases (79%) and colorectal in 10 cases (21%). The causes of inpatient colorectal bleeding were benign rectal ulcer (n = 4), ischemic colitis (n = 3), neoplasia (n = 2), and diversion colitis (n = 1). CONCLUSION The differential diagnosis for inpatients who develop new inpatient GI bleeding differs from that of patients who develop outpatient GI bleeding. Careful examination of the rectum following rectal instrumentation is critical. In addition to the standard resuscitative measures, the identification and treatment of rectal ulcers in this group of patients is of paramount importance. The treatment options for bleeding rectal ulcer include conservative therapy, cauterization, embolization, banding, and local excision.
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Affiliation(s)
- R J Hendrickson
- Department of Surgery, University of Rochester School of Medicine, 601 Elmwood Avenue, Rochester, NY 14642, USA
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Darcy M. Treatment of lower gastrointestinal bleeding: vasopressin infusion versus embolization. J Vasc Interv Radiol 2003; 14:535-43. [PMID: 12761306 DOI: 10.1097/01.rvi.0000064862.65229.8a] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Traditionally, embolization has been reserved for treatment of upper gastrointestinal bleeding whereas lower gastrointestinal (LGI) bleeding has been controlled with vasopressin infusion. This is based on findings in older literature in which infarction frequently complicated LGI embolization. With modern embolization techniques, clinically significant bowel ischemia has become an uncommon complication. Although the efficacies of vasopressin and embolization are fairly comparable, embolotherapy has advantages in terms of quicker completion of therapy and decreased likelihood of systemic complications. Although vasopressin is still probably preferable for diffuse lesions and cases in which superselective catheterization is not technically possible, embolization should be considered a primary option for treating LGI bleeding.
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Affiliation(s)
- Michael Darcy
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, St. Louis, Missouri 63110, USA.
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Kanwal F, Dulai G, Jensen DM, Gralnek IM, Kovacs TOG, Machicado GA, Jutabha R. Major stigmata of recent hemorrhage on rectal ulcers in patients with severe hematochezia: Endoscopic diagnosis, treatment, and outcomes. Gastrointest Endosc 2003; 57:462-8. [PMID: 12665754 DOI: 10.1067/mge.2003.147] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Endoscopic diagnosis and treatment of hematochezia caused by rectal ulcers is poorly described. METHODS Consecutive patients hospitalized with severe hematochezia underwent urgent colonoscopy after purge. Those with rectal ulcers were divided into 2 groups based on the absence or presence of major stigmata of recent hemorrhage: active bleeding, visible vessel, or adherent clot. Major stigmata were treated with epinephrine injection and coagulation with a bipolar probe. The primary outcome endpoint was recurrent bleeding within 4 weeks of diagnosis. RESULTS Rectal ulcers were identified in 23 of 285 (8%) patients. Twelve of 23 patients had major stigmata; these patients had an arithmetically greater decrease in hematocrit and required more blood transfusions than patients without major stigmata. Initial hemostasis was achieved in all, but bleeding recurred in 5 with stigmata. Four patients died of comorbid conditions. There was no recurrent bleeding or death in those without stigmata. CONCLUSIONS Patients with rectal ulcers harboring major stigmata are at high risk for severe bleeding, recurrent bleeding, and death. For ulcers with major stigmata, endoscopic hemostasis is feasible but rates of recurrent bleeding are high.
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Affiliation(s)
- Fasiha Kanwal
- Division of Digestive Diseases and Department of Medicine, UCLA School of Medicine, Los Angeles, California, USA
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ABE TAKASHI, OKADA NORIKO, AKAMATSU HIROKI, HASHIMOTO KEISUKE, HAYASHI TAMOTSU, TANABE JUN, TANIMURA HIROHISA, MEREN HARUYA, KUBO MITSUHIKO, MASUZAWA MANABU, MURATA HIROAKI, KAWANO SUNAO. SUCCESSFUL ENDOSCOPIC HEMOSTASIS OF RECTAL DIEULAFOY's ULCER BY CLIPPING: AGING MAY BE A FACTOR. Dig Endosc 2003. [DOI: 10.1046/j.1443-1661.2003.00207.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - HIROAKI MURATA
- Department of Clinical Laboratory Science, School of Allied Health Sciences, Faculty of Medicine, Osaka University, Osaka, Japan
| | - SUNAO KAWANO
- Department of Clinical Laboratory Science, School of Allied Health Sciences, Faculty of Medicine, Osaka University, Osaka, Japan
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Rivera Vaquerizo PA, Barajas Martínez JM, Blasco Colmenarejo M, Vicente Gutiérrez M, García García V, Pérez Flores R. [Lower gastrointestinal bleeding due to Dieulafoy's in the upper colon]. GASTROENTEROLOGIA Y HEPATOLOGIA 2001; 24:343-5. [PMID: 11481069 DOI: 10.1016/s0210-5705(01)70190-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Dieulafoy's lesion is a vascular anomaly generally located in the proximal stomach, although it has also been documented in other areas such as the colorectum. It is mainly found in men aged between 50 and 70 years, and represents less than 2% of acute gastrointestinal hemorrhagic episodes.A 66-year-old woman who was undergoing oral Diclofenac treatment presented with black stools. Endoscopy revealed acute duodenal erosions with no signs of bleeding. Black stools persisted after Diclofenac was discontinued and omeprazole treatment was started and the patient was admitted to hospital after 7 days. Colonoscopy revealed active bleeding in the upper colon, which ceased after sclerosis with ethanolamine oleate. The patient was discharged from hospital but was readmitted 10 days later because of rebleeding. The results of upper endoscopy were normal and colonoscopy performed 3 days later detected neither lesions nor bleeding. The pathogenesis of Dieulafoy's lesion is not well known, although it could be caused by erosion of the mucous lining of a vessel. Definitive diagnosis is histologic, although certain endoscopic diagnostic signs have been described. Endoscopic diagnosis is sometimes difficult; in such cases, arteriography should be employed, both for diagnostic and therapeutic purposes. The treatment of choice is endoscopic and the use of two hemostatic methods is advisable. If these procedures fail, surgery is required. Arteriography is the most suitable alternative in patients who are poor candidates for surgery.
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