Nonvariceal upper gastrointestinal bleeding

Artificial Intelligence for Identification of Images with Active Bleeding in Mesenteric and Celiac Arteries Angiography

PURPOSE

The purpose of this study is to evaluate the efficacy of an artificial intelligence (AI) model designed to identify active bleeding in digital subtraction angiography images for upper gastrointestinal bleeding.

METHODS

Angiographic images were retrospectively collected from mesenteric and celiac artery embolization procedures performed between 2018 and 2022. This dataset included images showing both active bleeding and non-bleeding phases from the same patients. The images were labeled as normal versus images that contain active bleeding. A convolutional neural network was trained and validated to automatically classify the images. Algorithm performance was tested in terms of area under the curve, accuracy, sensitivity, specificity, F1 score, positive and negative predictive value.

RESULTS

The dataset included 587 pre-labeled images from 142 patients. Of these, 302 were labeled as normal angiogram and 285 as containing active bleeding. The model's performance on the validation cohort was area under the curve 85.0 ± 10.9% (standard deviation) and average classification accuracy 77.43 ± 4.9%. For Youden's index cutoff, sensitivity and specificity were 85.4 ± 9.4% and 81.2 ± 8.6%, respectively.

CONCLUSION

In this study, we explored the application of AI in mesenteric and celiac artery angiography for detecting active bleeding. The results of this study show the potential of an AI-based algorithm to accurately classify images with active bleeding. Further studies using a larger dataset are needed to improve accuracy and allow segmentation of the bleeding.

Efficacy of Hemospray (TC-325) in the Treatment of Gastrointestinal Bleeding: An Updated Systematic Review and Meta-analysis

BACKGROUND

Hemospray (TC-325) is now approved for use in gastrointestinal bleeding. Data regarding their use pattern, efficacy, complications, and impact on clinical outcomes is limited.

METHODS

Electronic search from relevant databases was conducted up to January 2019. Etiologies, therapy characteristics, hemostasis rates, rebleed rates, additional procedures, complications and mortality rates were extracted and pooled.

RESULTS

Twenty-seven articles were included for analysis (n=1916). Pooled hemostasis was 94.5%. Pooled rebleed rate within 3 days was 9.9%, and within 30 days 17.6%. Pooled repeat Hemospray use was 13.6%. Radiology guided embolization was required with rate of 3.3% and surgery at rate of 4.7%. Rate of adverse events directly attributable to Hemospray was 0.7%. 30-day mortality was 11.8%. Comparison of conventional endoscopic therapy to Hemospray augmented therapy demonstrated that Hemospray therapy had increased immediate hemostasis [odds ratio (OR) 4.40]. There was no difference in rate of rebleeding at 8 days (OR 0.52) or overall mortality at 30 days (OR 0.53). Benign nonvariceal bleeds, malignant bleeds, and postprocedural bleeds had similar rates of hemostasis but rebleed rate at 30 days was less for postprocedural bleeding.

CONCLUSIONS

The addition of Hemospray to conventional therapy appears to increase immediate hemostasis but does not decrease rebleeding or mortality. As such, the use of Hemospray will likely be limited to clinical situations requiring urgent, but temporary, hemostasis to bridge to more definitive therapy.

Study on the preventive effect of intravenous esomeprazole in the management of nonvarices upper gastrointestinal bleeding

This retrospective study investigated the preventive effect of intravenous esomeprazole (IVEO) in the prevention of nonvarices upper gastrointestinal bleeding (NUGIB).This study enrolled 130 patients with NUGIB and all of them underwent successful endoscopic hemostasis, of which 65 cases received routine management and IVEO (Group A) and the other 65 cases received routine management alone (Group B). The primary outcome (recurrent bleeding rate within 72-hour, 7-day, and 30-day), and secondary outcomes ((all-cause mortality, bleeding-related mortality, blood transfused, hospital stay (day), and incidence of adverse events)) were compared between 2 groups.Patients in the group A showed lower recurrent bleeding rate within 72-hour(P < .05), 7-day (P < .05), and 30-day (P < .05), than that of patients in the group B. However, no significant differences were identified in all-cause mortality(P = .26), bleeding-related mortality (P = .57), blood transfused (P = .33), and hospital stay (P = .74) between 2 groups. In addition, both groups had similar safety profile.This study found that routine management and IVEO was superior to the routine management alone for preventing the recurrent bleeding rate after successful endoscopic hemostasis in patients with NUGIB.

Use of Phil Embolic Agent for Bleeding in Non-Neurological Interventions

Objective: To evaluate the safety and efficacy of the Phil liquid embolic agent in non-neurological embolization procedures. M&M: Thirty-five patients with a mean age of 62.5 years underwent percutaneous embolization using Phil for the treatment of visceral arterial bleedings in 20/35 patients (including three gluteal, one bladder, two superior mesenteric, three epigastric, one deep femoral, five internal iliac, four intercostal, and one lingual arteries), splanchnic pseudoaneurysms in 11/35 patients (including three hepatic, five splenic, and three renal arteries), pancreatic bleeding metastasis in 1/35 patient, and gastric bleeding varices in 3/35 patients. Phil is composed of a non-adhesive copolymer dissolved in DMSO (Anhydrous Dimethyl Sulfoxide) with different viscosity. Procedures were performed slowly under continuous fluoroscopic guidance to avoid embolization of non-target vessels. Results: Clinical success was obtained with a single intervention in 34 cases (97.15%), while a repeated procedure was required in one case (2.85%). No technical complications nor non-target embolization occurred. A case of post-embolic syndrome was noted (2.85%) in one patient. DMSO administration-related pain was successfully controlled by medical therapy. Conclusion: Phil can be considered a safe and effective embolic agent for the treatment of non-neurologic bleeding.

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.

Current role of cyanoacrylate glue transcatheter embolization in the treatment of acute nonvariceal gastrointestinal bleeding

INTRODUCTION

Over the past three decades, transcatheter arterial embolization (TAE) has become the first-line therapy for the management of acute nonvariceal gastrointestinal bleeding (NVGIB) 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 acute NVGIB. Many embolic agents have been used successfully. However, no guidelines exist about the choice of the best embolic agent which is still controversial. Cyanoacrylate glue has gained acceptance over time. This article aims to address the current role of TAE using cyanoacrylate glue for the treatment of acute NVGIB.

AREAS COVERED

The authors undertook a literature review of the current evidence on the use of cyanoacrylate glue in treating patients with acute NVGIB.

EXPERT OPINION

The evidence shows that cyanoacrylate glue is the most clinically useful embolic agent in treating patients with acute NVGIB, despite the need for learning curve, especially in case of coagulopathy. At present, research is ongoing to assess liquid embolic agents in the treatment of patients presenting with acute NVGIB. More research is needed but cyanoacrylate glue show promise for the future.

[Interventional radiology as emergency therapy]

CLINICAL ISSUE

Both the progress of surgical techniques and the demographic development with increasing numbers of multimorbid patients demand and also encourage radiology in the setting of trauma and acute emergencies. In addition to a fast and precise diagnostics, this also includes image-guided, minimally invasive therapy to control and treat several acute pathologies.

STANDARD RADIOLOGICAL PROCEDURES

Computed tomography (CT) is not only important for the diagnosis of abscesses, active bleeding or other acute pathologies, but also allows minimally invasive therapy. While digital subtraction angiography (DSA) guides catheter-based procedures, e.g., to control bleedings or to place percutaneous transhepatic cholangiodrain (PTCD), fluoroscopy allows the 3D-visualization to drain abdominal and thoracic abscesses.

METHODOLOGICAL INNOVATION AND EVALUATION

Radiology has established itself in the treatment of acute emergencies or acute complications through gentle and usually fast minimally invasive procedures. Presumably, MRI interventions will become increasingly important in the near future and, thus, complement the portfolio.

PRACTICAL RECOMMENDATIONS

Every clinical radiologist who works on night shifts should be able to safely carry out some basic interventional techniques in order to stabilize the patient and at least ensure medically safe bridging to the next routine workday. Due to the diversity of materials and the rarity and difficulty of some procedures, the full portfolio requires years of expertise and will therefore remain restricted to specialized interventional radiologists.

The role of imaging in gastrointestinal bleed

Gastrointestinal (GI) bleed accounts for approximately 20% of emergency visits; 2% of hospital admissions and its incidence has been increasing. In patients where the GI bleed does not stop spontaneously, intervention is required to identify the source of bleeding and stop the hemorrhage. Although identifying the source of bleeding can be challenging due to the vast number of underlying etiologies, radiology plays a vital role in patients where endoscopy and/or medical management fail. Radiology offers both non-invasive and invasive options for the diagnosis as well as management of GI bleeds. Scintigraphy and computed tomography angiography (CTA) are the most important non-invasive imaging tests that can identify presence of and help locate the site of bleeding and are used when the patient is hemodynamically stable. If the patient is hemodynamically unstable, conventional angiography (CA) allows diagnosis of the presence, site of bleeding as well as the means of treating the bleed by embolization. Our review article focuses on the various etiologies of GI bleed, the role of imaging in diagnosis as well as treatment of these patients based on the underlying etiologies, the merits and disadvantages of each of these modalities with emphasis on triaging patients for the most appropriate imaging test to guide the most suitable management.

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.

Analysis of negative DSA findings in patients with acute nonvariceal gastrointestinal bleeding: A retrospective study of 133 patients

Purpose

To analyze causes of acute nonvariceal gastrointestinal bleeding (GIB) with negative digital subtraction angiography (DSA) results.

Materials and methods

The clinical and follow-up data of 133 patients - recruited between February 2008 and November 2016 - with acute nonvariceal GIB and negative DSA results were included in this study. DSA results, diagnoses, and clinical outcomes were recorded.

Results

The DSA results were negative in all 133 patients. Of the total, 55 patients (41.4%) chose to undergo surgery and 78 (58.6%) opted for conservative treatment. Within 30 days, there was no significant difference in the rebleeding or mortality rates between the two groups (P < .05). Of all 133 patients, 76 (57.1%) had upper GIB and 57 (42.9%) had lower GIB; within 30 days, the rebleeding rate in the upper GIB group (44.7%, 34/76) was significantly higher than that in the lower GIB group (26.3%, 15/57). There was no significant statistical difference (P < .05) within 30 days in the mortality rates between the two groups.

Among patients with upper GIB, 26 (34.2%, 26/76) opted to undergo surgery and 50 (65.8%, 50/76) chose conservative treatment; within 30 days, the rebleeding rate in the group that chose surgery (61.5%, 16/26) was higher than that in the conservative treatment group (36%, 18/50). There was no significant difference (P < .05) within 30 days in the mortality rate between the two groups.

Among the patients with lower GIB, 29 (50.9%, 29/57) chose to undergo surgery and 28 (49.1%, 28/57) opted for conservative treatment. Within 30 days, the rebleeding rate in the surgery group (13.8%, 4/29) was lower than that in conservative treatment group (39.3%, 11/28). There was no significant difference (P < .05) within 30 days in the mortality rate between the two groups.

Sixteen patients underwent prophylactic arterial embolization; in 6 of these, bleeding was stopped for 30 days. DSA was then repeated in these 16 patients after a median interval of 1 day, and a positive bleeding site was found in 9 of the 16. Causes of bleeding were found in 111 patients by surgery or endoscopy, whereas the causes remained unknown in 22 patients.

Conclusions

Upper GIB with negative DSA results was stopped by conservative treatment, whereas lower GIB required surgery to detect the culprit bleeding site. Rare causes of GIB should be considered and appropriate management selected in a timely manner in order to detect unusual causes.

The role of metallic clips in transcatheter intravascular embolization for non-variceal upper gastrointestinal bleeding cases receiving unmanageable endoscopic therapy: A retrospective cohort study

INTRODUCTION

This study aims to explore whether metallic clips could be a kind of localizer and guider in transcatheter arterial embolization for patients with non-variceal upper gastrointestinal bleeding, who received an unmanageable endoscopic therapy.

METHODS

A total of 18 patients with non-variceal hemorrhage of the upper gastrointestinal tract, who received an unmanageable endoscopic therapy at *** Hospital of **** Province from July 2010 to December 2016, were included into this study. One or two metallic clips were placed on the margin of the bleeding point to be a mark during the endoscopic therapy. Then, all patients were immediately transferred to have an emergent upper gastrointestinal angiography. Bleeding vessels were embolized when found according to the guidance of the metallic clips. After the procedure, any changes of the patient's condition were closely observed and recorded.

RESULTS

The average transcatheter arterial embolization therapy time was 31 min, 17 patients immediately had a successful result, and the success rate of the arterial embolization therapy was 94.44%. However, the bleeding could not be stopped in one patient. This patient was transferred and underwent a surgical operation to stop the bleeding.

CONCLUSION

Metallic clips could play an important role in accurately locating the bleeding vessel during the trans catheter arterial embolization therapy. Furthermore, it could also improve the success rate of stopping the bleeding during intravascular embolization therapy, and shorten the time of intravascular embolization therapy.

Transcatheter arterial embolization for upper gastrointestinal tract bleeding

Introduction

Transcatheter arterial embolization is a possible treatment for patients with recurrent bleeding from the upper gastrointestinal tract after failed endoscopic management and is also an alternative to surgical treatment.

Aim

To analyze the outcomes of transcatheter arterial embolization and identify the clinical and technical factors that influenced the rates of morbidity and mortality.

Material and methods

A retrospective analysis was carried out, based on the data of 36 patients who underwent transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding in 2013 to 2015 in our center. An analysis was performed between early rebleeding rates, mortality and the following factors: patient sex, age, number of units of packed red blood cells and packed plasma administered to the patients, length of hospital stay, therapeutic or prophylactic embolization.

Results

The technical success rate of the embolization procedure was 100%. There were 15 (41.70%) therapeutic embolizations and 21 (58.3%) prophylactic embolizations. There was a 77.8% clinical success rate. Following embolization, 10 (27.80%) patients had repeated bleeding and 9 (25.0%) patients died. Significant associations were found between rebleeding and prophylactic embolization (OR = 10.53; p = 0.04) and between mortality and prophylactic embolization (OR = 10.53; p = 0.04) and units of packed red blood cells (OR = 1.25; p < 0.01).

Conclusions

In our experience, transcatheter arterial embolization is a safe treatment method for acute nonvariceal upper gastrointestinal bleeding and a possible alternative to surgery for high-risk patients.

Superselective Embolization for Arterial Upper Gastrointestinal Bleeding Using N-Butyl Cyanoacrylate: A Single-Center Experience in 152 Patients

PURPOSE

To evaluate 30-day safety and efficacy of superselective embolization for arterial upper gastrointestinal bleeding (UGIB) using N-butyl cyanoacrylate (NBCA).

MATERIALS AND METHODS

This single-center retrospective 10-year study included 152 consecutive patients with UGIB (gastric, n = 74; duodenal, n = 78) who underwent embolization with NBCA for angiographically positive arterial bleeding. The primary endpoint was clinical success rate defined as achievement of hemostasis without rebleeding or UGIB-related mortality within 30 days after embolization. Mean systolic blood pressure and heart rate were 121.2 mm Hg ± 27.4 and 97.9 beats/minute ± 22.5; 31.1% of patients needed intravenous inotropes, and 36.6% had coagulopathy. The etiology of bleeding was ulcer (80.3%) or iatrogenic injury (19.7%). Statistical analysis was performed to identify predictive factors for outcomes.

RESULTS

Technical success rate was 100%. Clinical success, 1-month mortality, and major complication rates were 70.4%, 22.4%, and 0.7%. There were significant differences in the clinical success rates between gastric and duodenal bleeding (79.4% vs 62.2%; P = .025). The need for intravenous inotropes at the time of embolization was a significant negative predictive factor in both gastric (odds ratio [OR] = 0.091, P = .004) and duodenal (OR = 0.156, P = .002) bleeding. The use of a microcatheter with a smaller tip (2 F) was associated with better outcomes in duodenal bleeding (OR = 7.389, P = .005).

CONCLUSIONS

Superselective embolization using NBCA is safe and effective for angiographically positive arterial UGIB.

Provocative Endoscopy to Identify Bleeding Site in Upper Gastrointestinal Bleeding: A Novel Approach in Transarterial Embolization

This report describes a novel approach to endoscopically induce bleeding by removing a clot from the bleeding site during angiography for upper gastrointestinal (UGI) hemorrhage. This procedure enabled accurate identification of the bleeding site, allowing for successful targeted embolization despite a negative initial angiogram. Provocative endoscopy may be a feasible and useful option for angiography of obscure bleeding sites in patients with UGI arterial hemorrhage.

Transcatheter arterial embolization with N-butyl cyanoacrylate for arterial esophageal bleeding in esophageal cancer patients

Background

The aim of this study is to evaluate the clinical efficacy and safety of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) for the treatment of arterial esophageal bleeding in esophageal cancer patients.

Methods

Between November 2008 and December 2014, five esophageal cancer patients underwent TAE with NBCA for the treatment of arterial esophageal bleeding. We retrospectively evaluated the technical and clinical success, recurrent bleeding, and procedure-related complications.

Results

All of the patients had bleeding from the esophageal artery and were in shock at the beginning of TAE. Four patients had a coagulopathy at the time of TAE; however, the TAE could successfully arrest bleeding in all five patients. After TAE, they immediately recovered from the shock state. Two patients were discharged without event, one patient is currently hospitalized for another complication, and the other two patients died due to multiorgan failure. In addition, no procedure-related complications such as esophageal infarction and recurrence of arterial esophageal bleeding were observed during this study.

Conclusions

TAE with NBCA can arrest bleeding in esophageal cancer patients with active arterial esophageal bleeding, even in those with a pre-existing coagulopathy.

Clinical outcome of transcatheter arterial embolization with N-butyl-2-cyanoacrylate for control of acute gastrointestinal tract bleeding

OBJECTIVE. The purpose of this article is to evaluate the clinical effectiveness of trans-catheter arterial embolization (TAE) with N-butyl-2-cyanoacrylate (NBCA), with or without other embolic materials for acute nonvariceal gastrointestinal tract bleeding, and to determine the factors associated with clinical outcomes. MATERIALS AND METHODS. TAE using NBCA only or in conjunction with other materials was performed for 102 patients (80 male and 22 female patients; mean age, 61.3 years) with acute nonvariceal gastrointestinal tract bleeding. Technical success, clinical success, and clinical factors, including age, sex, bleeding tendency, endoscopic attempts at hemostasis, number of transfusions, and bleeding causes (i.e., cancer vs noncancer), were retrospectively evaluated. Univariate and multivariable logistic regression analyses were performed to evaluate clinical factors and their ability to predict patient outcomes. Survival curves were obtained using Kaplan-Meier analyses and log-rank tests. RESULTS. There were 36 patients with cancer-related bleeding and 66 with non-cancer-related bleeding. Overall technical and clinical success rates were 100% (102/102) and 76.5% (78/102), respectively. Procedure-related complications included bowel infarction, which was noted in two patients. Recurrent bleeding and bleeding-related 30-day mortality rates were 15.7% (16/102) and 8.8% (9/102), respectively. Cancer-related bleeding increased clinical failure significantly (p = 0.003) and bleeding-related 30-day mortality with marginal significance (p = 0.05). Overall survival was poorer in patients with cancer-related bleeding. CONCLUSION. TAE with NBCA with or without other embolic agents showed high technical and clinical effectiveness in the management of acute nonvariceal gastrointestinal tract bleeding. Cancer-related bleeding was the only factor related to clinical failure, and possibly related to bleeding-related 30-day mortality.

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.

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.

Incidence and management of bleeding complications following percutaneous radiologic gastrostomy

Objective

Upper gastrointestinal (GI) bleeding is a serious complication that sometimes occurs after percutaneous radiologic gastrostomy (PRG). We evaluated the incidence of bleeding complications after a PRG and its management including transcatheter arterial embolization (TAE).

Materials and Methods

We retrospectively reviewed 574 patients who underwent PRG in our institution between 2000 and 2010. Eight patients (1.4%) had symptoms or signs of upper GI bleeding after PRG.

Results

The initial presentation was hematemesis (n = 3), melena (n = 2), hematochezia (n = 2) and bloody drainage through the gastrostomy tube (n = 1). The time interval between PRG placement and detection of bleeding ranged from immediately after to 3 days later (mean: 28 hours). The mean decrease in hemoglobin concentration was 3.69 g/dL (range, 0.9 to 6.8 g/dL). In three patients, bleeding was controlled by transfusion (n = 2) or compression of the gastrostomy site (n = 1). The remaining five patients underwent an angiography because bleeding could not be controlled by transfusion only. In one patient, the bleeding focus was not evident on angiography or endoscopy, and wedge resection including the tube insertion site was performed for hemostasis. The other four patients underwent prophylactic (n = 1) or therapeutic (n = 3) TAEs. In three patients, successful hemostasis was achieved by TAE, whereas the remaining one patient underwent exploration due to persistent bleeding despite TAE.

Conclusion

We observed an incidence of upper GI bleeding complicating the PRG of 1.4%. TAE following conservative management appears to be safe and effective for hemostasis.

[Gastrointestinal bleeding: the role of radiology]

Gastrointestinal bleeding represents a diagnostic challenge both in its acute presentation, which requires the point of bleeding to be located quickly, and in its chronic presentation, which requires repeated examinations to determine its etiology. Although the diagnosis and treatment of gastrointestinal bleeding is based on endoscopic examinations, radiological studies like computed tomography (CT) angiography for acute bleeding or CT enterography for chronic bleeding are becoming more and more common in clinical practice, even though they have not yet been included in the clinical guidelines for gastrointestinal bleeding. CT can replace angiography as the diagnostic test of choice in acute massive gastrointestinal bleeding, and CT can complement the endoscopic capsule and scintigraphy in chronic or recurrent bleeding suspected to originate in the small bowel. Angiography is currently used to complement endoscopy for the treatment of gastrointestinal bleeding.

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.

Nonvariceal upper gastrointestinal bleeding: the usefulness of rotational angiography after endoscopic marking with a metallic clip

Objective

We wanted to assess the usefulness of rotational angiography after endoscopic marking with a metallic clip in upper gastrointestinal bleeding patients with no extravasation of contrast medium on conventional angiography.

Materials and Methods

In 16 patients (mean age, 59.4 years) with acute bleeding ulcers (13 gastric ulcers, 2 duodenal ulcers, 1 malignant ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. All patients had negative results from their angiographic studies. To localize the bleeding focus, rotational angiography and high pressure angiography as close as possible to the clip were used.

Results

Of the 16 patients, seven (44%) had positive results after high pressure angiography as close as possible to the clip and they underwent transcatheter arterial embolization (TAE) with microcoils. Nine patients without extravasation of contrast medium underwent TAE with microcoils as close as possible to the clip. The bleeding was stopped initially in all patients after treatment of the feeding artery. Two patients experienced a repeat episode of bleeding two days later. Of the two patients, one had subtle oozing from the ulcer margin and that patient underwent endoscopic treatment. One patient with malignant ulcer died due to disseminated intravascular coagulation one month after embolization. Complete clinical success was achieved in 14 of 16 (88%) patients. Delayed bleeding or major/minor complications were not noted.

Conclusion

Rotational angiography after marking with a metallic clip helps to localize accurately the bleeding focus and thus to embolize the vessel correctly.

Risk factors for rebleeding after angiographically negative acute gastrointestinal bleeding

AIM: To identify possible predictive factors for rebleeding after angiographically negative findings in patients with acute non-variceal gastrointestinal bleeding.

METHODS: From January 2000 to July 2007, 128 patients with acute non-variceal gastrointestinal bleeding had negative findings after initial angiography. Clinical and laboratory parameters were analyzed retrospectively.

RESULTS: Among 128 patients, 62 had no recurrent gastrointestinal bleeding and 66 had recurrent gastrointestinal bleeding within 30 d. As determined by the use of multivariate analysis, an underlying malignancy, liver cirrhosis and hematemesis were significant factors related to recurrent gastrointestinal bleeding.

CONCLUSION: Clinical factors including underlying malignancy, liver cirrhosis, and hematemesis are important predictors for rebleeding after angiographically negative findings in patients with acute non-variceal gastrointestinal bleeding.

Transcatheter arterial embolization of arterial esophageal bleeding with the use of N-butyl cyanoacrylate

Objective

To evaluate the clinical efficacy and safety of a transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) for the treatment of arterial esophageal bleeding.

Materials and Methods

Between August 2000 and April 2008, five patients diagnosed with arterial esophageal bleeding by conventional angiography, CT-angiography or endoscopy, underwent a TAE with NBCA. We mixed NBCA with iodized oil at ratios of 1:1 to 1:4 to supply radiopacity and achieve a proper polymerization time. After embolization, we evaluated the angiographic and clinical success, recurrent bleeding, and procedure-related complications.

Results

The bleeding esophageal artery directly originated from the aorta in four patients and from the left inferior phrenic artery in one patient. Although four patients had an underlying coagulopathy at the time of the TAE, angiographic and clinical success was achieved in all five patients. In addition, no procedure-related complications such as esophageal infarction were observed during this study.

Conclusion

NBCA can be an effective and feasible embolic agent in patients with active arterial esophageal bleeding, even with pre-existing coagulopathy.

Angiographically negative acute arterial upper and lower gastrointestinal bleeding: incidence, predictive factors, and clinical outcomes

OBJECTIVE

To evaluate the incidence, predictive factors, and clinical outcomes of angiographically negative acute arterial upper and lower gastrointestinal (GI) bleeding.

MATERIALS AND METHODS

From 2001 to 2008, 143 consecutive patients who underwent an angiography for acute arterial upper or lower GI bleeding were examined.

RESULTS

The angiographies revealed a negative bleeding focus in 75 of 143 (52%) patients. The incidence of an angiographically negative outcome was significantly higher in patients with a stable hemodynamic status (p < 0.001), or in patients with lower GI bleeding (p = 0.032). A follow-up of the 75 patients (range: 0-72 months, mean: 8 +/- 14 months) revealed that 60 of the 75 (80%) patients with a negative bleeding focus underwent conservative management only, and acute bleeding was controlled without rebleeding. Three of the 75 (4%) patients underwent exploratory surgery due to prolonged bleeding; however, no bleeding focus was detected. Rebleeding occurred in 12 of 75 (16%) patients. Of these, six patients experienced massive rebleeding and died of disseminated intravascular coagulation within four to nine hours after the rebleeding episode. Four of the 16 patients underwent a repeat angiography and the two remaining patients underwent a surgical intervention to control the bleeding.

CONCLUSION

Angiographically negative results are relatively common in patients with acute GI bleeding, especially in patients with a stable hemodynamic status or lower GI bleeding. Most patients with a negative bleeding focus have experienced spontaneous resolution of their condition.

Selective angiographic diagnosis and transcatheter arterial embolization of iatrogenic massive upper gastrointestinal bleeding

AIM: To study the clinical value of angiography and transcatheter arterial embolization (TAE) for the iatrogenic upper gastrointestinal hemorrhage.

METHODS: Thirty seven cases with iatrogenic hemorrhage in the upper digestive tract received emergency selective angiography. According to the interval from bleeding onset to angiographic time, patients were divided into two groups, that is, the emergency group (n = 28 cases) and non-emergency group (n = 9 cases). According to find out positions and causes of bleeding during angiography, all patients underwent arterial embolization with different embolic agents.

RESULTS: DSA revealed positive result in 33 cases of 37cases with a total positive rate of 89.2% (33/37). The positive rate for the emergency group was 96.4% (27/28) and 66.7%(6/9) for non-emergency group. Positive rate of angiography was significantly higher in emergency group than in non-emergency group (P < 0.05). Arterial embolization was successfully carried out in 31 positive cases; 2 severe pancreatitis cases rebled 1 week after embolization and was treated successfully with re-embolization. One severe pancreatitis case had no bleeding, but died of multi-organ function failure 13 days later. Of four cases with negative angiography who undertook trial embolizing therapy, bleeding ceased in 3 cases; 1 case who failed bleeding was given surgery to stop bleeding. During the 3-12 month-follow-up, there were no relapse or complications.

CONCLUSION: Emergency selective angiography improves positive rate and plays an important role in detecting the sites of iatrogenic upper gastrointestinal massive bleeding. Selective arterial embolization is a safe and effective hemostatic measure.