The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding

Twenty years of embolization for acute lower gastrointestinal bleeding: a meta-analysis of rebleeding and ischaemia rates

BACKGROUND

Transarterial embolization (TAE) for acute lower gastrointestinal bleeding (LGIB) can be technically challenging due to the compromise between achieving haemostasis and causing tissue ischaemia. The goal of the present study is to determine its technical success, rebleeding, and post-embolization ischaemia rates through meta-analysis of published literature in the last twenty years.

METHODS

PubMed, Embase, and Cochrane Library databases were queried. Technical success, rebleeding, and ischaemia rates were extracted. Baseline characteristics such as author, publication year, region, study design, embolization material, percentage of superselective embolization were retrieved. Subgroup analysis was performed based on publication time and embolization agent.

RESULTS

A total of 66 studies including 2121 patients who underwent embolization for acute LGIB were included. Endoscopic management was attempted in 34.5%. The pooled overall technical success, rebleeding, post-embolization ischaemia rates were 97.0%, 20.7%, and 7.5%, respectively. Studies published after 2010 showed higher technical success rates (97.8% vs 95.2%), lower rebleeding rates (18.6% vs 23.4%), and lower ischaemia rates (7.3% vs 9.7%). Compared to microcoils, NBCA was associated with a lower rebleeding rate (9.3% vs 20.8%) at the expense of a higher post-embolization ischaemia rate (9.7% vs 4.0%). Coagulopathy (P = .034), inotropic use (P = .040), and malignancy (P = .002) were predictors of post-embolization rebleeding. Haemorrhagic shock (P < .001), inotropic use (P = .026), malignancy (P < .001), coagulopathy (P = .002), blood transfusion (P < .001), and enteritis (P = .023) were predictors of mortality. Empiric embolization achieved a similarly durable haemostasis rate compared to targeted embolization (23.6% vs 21.1%) but a higher risk of post-embolization ischaemia (14.3% vs 4.7%).

CONCLUSION

For LGIB, TAE has a favourable technical success rate and low risk of post-embolization ischaemia. Its safety and efficacy profile has increased over the last decade. Compared to microcoils, NBCA seemed to offer a more durable haemostasis rate at the expense of higher ischaemia risk. Due to the heterogeneity of currently available evidence, future prospective and comparative studies are warranted.

ADVANCES IN KNOWLEDGE

(1) Acute LGIB embolization demonstrate a high technical success rate with acceptable rate of rebleeding and symptomatic ischaemia rates. Most ischaemic stigmata discovered during routine post-embolization colonoscopy were minor. (2) Although NBCA seemed to offer a more durable haemostasis rate, it was also associated with a higher risk of ischaemia compared to microcoils. (3) Coagulopathy, malignant aetiology, and inotropic use were predictors of rebleeding and mortality. (4) Routine post-embolization endoscopy to assess for ischaemia is not indicated.

Risk factors for difficult endoscopic hemostasis for colonic diverticular bleeding and efficacy and safety of transcatheter arterial embolization

This study aimed to investigate the risk factors for difficult endoscopic hemostasis in patients with colonic diverticular bleeding and to evaluate the efficacy and safety of transcatheter arterial embolization (TAE) for colonic diverticular bleeding. This study included 208 patients with colorectal diverticular hemorrhage. The non-interventional radiotherapy group consisted of patients who underwent successful spontaneous hemostasis (n = 131) or endoscopic hemostasis (n = 56), whereas the interventional radiotherapy group consisted of patients who underwent TAE (n = 21). Patient clinical characteristics were compared to identify independent risk factors for the interventional radiotherapy group. Furthermore, the hemostasis success rate, rebleeding rate, complications, and recurrence-free survival were compared between patients who underwent endoscopic hemostasis and those who underwent TAE. Bleeding from the right colon (odds ratio [OR]: 7.86; 95% confidence interval [CI]: 1.6-38.8; P = .0113) and systolic blood pressure <80 mm Hg (OR: 0.108; 95% CI: 0.0189-0.62; P = .0126) were identified as independent risk factors for the interventional radiology group. The hemostasis success rate (P = 1.00), early rebleeding rate (within 30 days) (P = .736), late rebleeding rate (P = 1.00), and recurrence-free survival rate (P = .717) were not significantly different between the patients who underwent TAE and those who underwent endoscopic hemostasis. Patients in the TAE group experienced more complications than those in the endoscopic hemostasis group (P < .001). Complications included mild intestinal ischemia (19.0%) and perforation requiring surgery (4.8%). Patients who required interventional radiotherapy were more likely to bleed from the right colon and presented with a systolic blood pressure of <80 mm Hg. TAE is an effective treatment for patients with colonic diverticular hemorrhage that is refractory to endoscopic hemostasis. However, complications must be monitored carefully.

Evaluation of the Jichi Medical University diverticular hemorrhage score in the clinical management of acute diverticular bleeding with emergency or elective endoscopy: A pilot study

BACKGROUND AND AIMS

Emergency endoscopic hemostasis for colonic diverticular bleeding is effective in preventing serious consequences. However, the low identification rate of the bleeding source makes the procedure burdensome for both patients and providers. We aimed to establish an efficient and safe emergency endoscopy system.

METHODS

We prospectively evaluated the usefulness of a scoring system (Jichi Medical University diverticular hemorrhage score: JD score) based on our experiences with past cases. The JD score was determined using four criteria: CT evidence of contrast agent extravasation, 3 points; oral anticoagulant (any type) use, 2 points; C-reactive protein ≥1 mg/dL, 1 point; and comorbidity index ≥3, 1 point. Based on the JD score, patients with acute diverticular bleeding who underwent emergency or elective endoscopy were grouped into JD ≥3 or JD <3 groups, respectively. The primary and secondary endpoints were the bleeding source identification rate and clinical outcomes.

RESULTS

The JD ≥3 and JD <3 groups included 35 and 47 patients, respectively. The rate of bleeding source identification, followed by the hemostatic procedure, was significantly higher in the JD ≥3 group than in the JD <3 group (77% vs. 23%, p <0.001), with a higher JD score associated with a higher bleeding source identification rate. No significant difference was observed between the groups in terms of clinical outcomes, except for a higher incidence of rebleeding at one-month post-discharge and a higher number of patients requiring interventional radiology in the JD ≥3 group than in the JD <3 group. Subgroup analysis showed that successful identification of the bleeding source and hemostasis contributed to a shorter hospital stay.

CONCLUSION

We established a safe and efficient endoscopic scoring system for treating colonic diverticular bleeding. The higher the JD score, the higher the bleeding source identification, leading to a successful hemostatic procedure. Elective endoscopy was possible in the JD <3 group when vital signs were stable.

Management of acute lower gastrointestinal bleeding by pharmaco-induced vasospasm embolization therapy

BACKGROUND

To report the clinical outcomes of vasospasm embolization technique in treating lower gastrointestinal bleeding (LGIB).

METHODS

Fifty LGIB patients (32 men and 18 women; mean age, 70.4 years) with positive contrast extravasation on multidetector computed tomography were treated with pharmaco-induced vasospasm embolization by semiselective catheterization technique. Distal rectal bleeding was excluded. The bleedings in three patients were considered to be tumor related. Eighteen underwent regular hemodialysis, and 22 showed unstable hemodynamic at intervention.

RESULTS

Forty-two bleeders were found in superior mesenteric territory and eight in the inferior mesenteric territory. Successful, immediate hemostasis was achieved in 49 (98%) patients. Early recurrent bleeding (<30 days) was found in 13 (26.5%) patients with 6 local rebleeding (12.2%), 5 new-foci bleeding (10.2%), and 2 uncertain foci bleeding (4.1%). Repeated vasospasm embolization therapy was given to five patients, with successful hemostasis in four. All the three tumor-related bleeding patients undergoing vasospasm embolization had ceased bleeding and discharged. Patient-based primary and overall clinical successes were achieved in 73.5% and 83.7%, and lesion-based primary and overall clinical successes were 83.0% and 86.7%, respectively. The 30-day mortality rate was 21.3%, and the 1- and 2-year survival rates were 51.5% and 43.8%. No major procedure-related complications (eg, bowel ischemia) were encountered.

CONCLUSION

This study confirmed our prior preliminary conclusion that pharmaco-induced vasospasm embolization is easy, safe, and effective for LGIB. This treatment may be considered the first-line alternative approach for LGIB, especially for patients of advanced age with complex medical problems and/or when vasa rectal embolization isn't feasible.

ACR Appropriateness Criteria® Radiologic Management of Lower Gastrointestinal Tract Bleeding: 2021 Update

Diverticulosis remains the commonest cause for acute lower gastrointestinal tract bleeding (GIB). Conservative management is initially sufficient for most patients, followed by elective diagnostic tests. However, if acute lower GIB persists, it can be investigated with colonoscopy, CT angiography (CTA), or red blood cell (RBC) scan. Colonoscopy can identify the site and cause of bleeding and provide effective treatment. CTA is a noninvasive diagnostic tool that is better tolerated by patients, can identify actively bleeding site or a potential bleeding lesion in vast majority of patients. RBC scan can identify intermittent bleeding, and with single-photon emission computed tomography, can more accurately localize it to a small segment of bowel. If patients are hemodynamically unstable, CTA and transcatheter arteriography/embolization can be performed. Colonoscopy can also be considered in these patients if rapid bowel preparation is feasible. Transcatheter arteriography has a low rate of major complications; however, targeted transcatheter embolization is only feasible if extravasation is seen, which is more likely in hemodynamically unstable patients. If bleeding site has been previously localized but the intervention by colonoscopy and transcatheter embolization have failed to achieve hemostasis, surgery may be required. Among patients with obscure (nonlocalized) recurrent bleeding, capsule endoscopy and CT enterography can be considered to identify culprit mucosal lesion(s). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Efficacy, safety and outcomes of transcatheter arterial embolization with N-butyl cyanoacrylate glue for non-variceal gastrointestinal bleeding: A systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis to determine the safety, efficacy, and outcomes of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) as the single embolic agent for the management of non-variceal upper and lower gastrointestinal bleeding (GIB).

MATERIALS AND METHODS

A literature search using MEDLINE/PubMed, EMBASE, and SCOPUS databases was performed for studies published from January 1980 to December 2019. Data from eligible studies were extracted and evaluated by two independent reviewers. Exclusion criteria were sample size <5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. Technical success, clinical success, 30-day rebleeding, 30-day overall and major complications, and 30-day mortality were evaluated. The estimated overall rates were calculated with their 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. Heterogeneity across studies was assessed using the Q test and I² statistic.

RESULTS

Fifteen studies with 574 patients were included. For upper GIB (331 patients), the technical and clinical success rates, and 30-day rebleeding and mortality rates, were 98.8% (328 of 331 patients) and 88.0% (237 of 300 patients), and 12.5% (69 of 314 patients) and 15.9% (68 of 331 patients), respectively. Thirty-day overall and major complications occurred in 14.3% (28 of 331 patients) and 2.7% (7 of 331 patients) of patients, respectively. For lower GIB (243 patients), the technical and clinical success rates, and 30-day rebleeding and mortality rates, were 98.8% (78 of 78 patients) and 78.0% (145 of 189 patients), and 15.7% (33 of 218 patients) and 12.7% (14 of 78 patients), respectively. Thirty-day overall and major complications occurred in 13.0% (25 of 228 patients) and 8.6% (19 of 228 patients) of patients, respectively.

CONCLUSION

TAE with NBCA is safe and effective for treating non-variceal GIB, with high clinical success and very low major complication rates.

Localization and Definitive Control of Lower Gastrointestinal Bleeding with Angiography and Embolization

Angiography has long been a mainstay of lower gastrointestinal bleeding localization. More recently, angioembolism has been used therapeutically for bleeding control, but there are limited data on its efficacy. This study was designed to evaluate the efficacy of angiography and embolization for localizing and treating lower gastrointestinal bleeding as well evaluate the occurrence of bowel ischemia after embolization. This study is a retrospective descriptive review of all patients undergoing mesenteric angiography at a tertiary hospital over an eight-year period. Clinical data were recorded including patient demographics, causes of bleeding, procedures, and outcomes. Patients were excluded if the cause of bleeding was upper gastrointestinal bleeding or the medical record was missing data. Localization and definitive control of bleeding was the primary end point. One hundred fifty-nine angiograms were performed on 152 patients. Mean age was 72 years. Angiographic localization was successful in 23.7 per cent of patients. Although embolization after angiographic localization achieved definitive control of bleeding in 50 per cent of patients, the success rate was only 8.6 per cent of all patients who had angiography. One patient developed postembolization ischemia requiring laparotomy. Angiographic localization of lower gastrointestinal bleeding is successful in only 23.7 per cent of patients. Definitive hemostasis through embolization was successful in only 8.6 per cent of patients who underwent angiography for lower gastrointestinal bleeding.

Special considerations in the management of lower GI bleed by interventional radiology

Despite the rapid development of diagnostic and therapeutic modalities and techniques to manage LGIB patients from interventional radiology's standpoint, a successful localization of the bleeding site that leads to an effective embolotherapy remains a significant technical challenge. The interventional radiologist's decisions when managing patients with LGIB may significantly impact the clinical outcomes; therefore, management should be made based on careful and thorough considerations of factors such as etiology, locations, patient's comorbidities, and potential post-procedure complications, among others. The purpose of this paper is to review the management of LGIB by interventional radiology, focusing on a few challenging and common clinical situations that require special consideration by interventional radiologists.

Transcatheter Arterial Embolization in Lower Gastrointestinal Bleeding: Ischemia Remains a Concern Even with a Superselective Approach

PURPOSE

To evaluate the safety, efficacy, and feasibility of transcatheter arterial embolization (TAE) in the treatment of lower gastrointestinal bleeding (LGIB).

METHODS

Study group comprised all patients receiving angiography for LGIB in the Helsinki University Hospital during the period of 2004-2016. Hospital medical records provided the study data. Rebleeding, complication, and mortality rates (≤ 30 days) were the primary outcomes. Secondary outcomes included need for blood transfusions, durations of intensive care unit and hospital admissions, incidence of delayed rebleeding, and long-term complications, as well as overall survival.

RESULTS

During the study period, angiography for LGIB was necessary on 123 patients. Out of 123, 55 (45%) underwent embolization attempts. TAE was technically successful in 53 (96%). Rebleeding occurred in 14 (26%). The complication rate was 36%, minor complications occurring in 10 (19%) and major in nine (17%). Major complications resulted in bowel resection in seven (13%). Post embolization ischemia was the most common single complication seen in nine (17%). The mortality rate was 6%. Survival estimates of 1 and 5 years were 79 and 49%.

DISCUSSION

LGIB is a severe physiological insult occurring in patients who are often elderly and moribund. Although major post embolization complications occur, transcatheter arterial embolization should be the first-line approach over surgery in profuse LGIB in patients with hemodynamic instability, when colonoscopy fails or is unavailable, or when computerized tomography angiography detects small intestinal bleeding.

Transcatheter arterial embolisation for acute lower gastrointestinal haemorrhage: a single-centre study

OBJECTIVE

To investigate the safety and efficacy of transcatheter arterial embolisation (TAE) in the management of lower gastrointestinal bleeding (LGIB) and to identify predictors of clinical outcomes.

METHODS

Between December 2005 and April 2017, 274 patients underwent diagnostic angiography for signs and symptoms of LGIB; 134 patients with positive angiographic findings were retrospectively analysed. The technical success of TAE and clinical outcomes, including recurrent bleeding, major complications, and in-hospital mortality were evaluated. The associations of various clinical and technical factors with clinical outcomes were analysed. Predictors for clinical outcomes were evaluated using univariate and multivariate logistic regression analyses.

RESULTS

A total of 134 patients (mean age, 59.7 years; range, 14-82 years) underwent TAE for LGIB. The bleeding foci were in the small bowel in 74 patients (55.2%), colon in 35 (26.1%), and rectum in 25 (18.7%). Technical success was achieved in 127 patients (94.8%). The clinical success rate was 63% (80/127). The rates of recurrent bleeding, major complications, and in-hospital mortality were 27.9% (31/111), 18.5% (23/124), and 23.6% (33/127), respectively. Superselective embolisation and the use of N-butyl cyanoacrylate (NBCA) were significant prognostic factors associated with reduced recurrent bleeding (OR, 0.258; p = 0.004 for superselective embolisation, OR, 0.313; p = 0.01 for NBCA) and fewer major complications (OR, 0.087; p ˂ 0.001 for superselective embolisation, OR, 0.272; p = 0.007 for NBCA).

CONCLUSIONS

TAE is an effective treatment modality for LGIB. Superselective embolisation is essential to reduce recurrent bleeding and avoid major complications. NBCA appears to be a preferred embolic agent.

KEY POINTS

• Transcatheter arterial Embolisation (TAE) is a safe and effective treatment for lower gastrointestinal tract haemorrhage. • Superselective embolisation is essential to improve outcomes. • N-butyl cyanoacrylate (NBCA) appears to be a preferred embolic agent with better clinical outcomes.

Role of super-selective embolization in lower gastrointestinal bleeding

BACKGROUND

Lower gastrointestinal bleeding (LGIB) is a common acute general surgical condition that is typically self-limiting; however in refractory cases it can necessitate life-saving intervention. When bleeding is refractory, super-selective embolization (SSE) becomes an important management strategy. This study aims to evaluate outcomes of this procedure at our institution and identify predictors of clinical success.

METHODS

A retrospective analysis of patients with positive computed tomography angiograms for LGIB at a tertiary centre between December 2007 and May 2017.

RESULTS

Of 87 600 acute general surgical admissions, 2700 were for LGIB. Computed tomography angiography demonstrated active bleeding in 104 patients who then had mesenteric angiograms. SSE was performed in 77 patients of whom 66 (86%) demonstrated active bleeding. Technical success was achieved in 75 patients (97%). Clinical success was achieved in 63 patients (81%). Re-bleeding occurred in 14 patients (19%), with four requiring surgery. One patient went forward for re-embolization. Bowel ischaemia occurred in four patients (5.2%), with two requiring bowel resection. A 30-day mortality following SSE was 6.5%, with one death attributable to bowel ischaemia and four deaths from medical comorbidity. Median age (years) of those who had clinical success was 78 (interquartile range (IQR) 16.4) and those who did not was 65 (IQR 20.2) (P = 0.031). Clinical success was more common in those who had diverticular related bleeding (61.9%) compared to other pathologies (38.1%) (P = 0.036).

CONCLUSION

SSE was successful in a high proportion of patients in this series with low complication rates. Clinical success was higher in those who were older or with diverticular related bleeding.

The use of super-selective mesenteric embolisation as a first-line management of acute lower gastrointestinal bleeding

Introduction

In this study, we aim to assess the efficacy and safety of digital subtraction angiography (DSA) and super-selective mesenteric artery embolisation in managing lower gastrointestinal bleeding (LGIB) at a multi-centre health service in Melbourne (Australia).

Method

A retrospective case series of patients with LGIB treated with superselective embolisation in our area health service. Patients with confirmed active LGIB, on either radionuclide scintigraphy (RS) or contrast-enhanced multi-detector CT angiography (CE-MDCT), were referred for DSA, and subsequently endovascular intervention. Data collected included patient characteristics; screening modality; bleeding territory; embolisation technique; technical and clinical success; short to mediumterm complications and mortality up to 30 days; and the need for surgery related to procedural failure or complications.

Results

There were 55 hospital admissions with acute unstable lower gastrointestinal bleeding that were demonstrable on CE-MDCT or RS over a 30-month period (from 1 January 2014 to 30 June 2016). Of these, eighteen patients were embolised. Immediate haemostasis was achieved in all embolised cases. Eight patients (44%) had clinical re-bleeding postembolisation and warranted repeated imaging. However, only one case (5.6%) had active bleeding identified and was re-embolised. There was no documented case of bowel ischemia or ischemic-stricture and none progressed on to surgery. 30 day mortality was zero.

Conclusion

Super-selective mesenteric embolisation is a viable, safe and effective first line management for localised LGIB. Our results overall compare favourably with the published experiences of other institutions. It is now accepted first-line practice at our institution to manage localised LGIB with embolisation.

•

A study into the efficacy of mesenteric embolisation in managing acute lower GI bleeding.

•

Mesenteric embolisation is an effective management for localised acute lower GI bleeding.

•

Our results compare favourably with published experiences of other institutions.

•

It is first-line practice at our institution to embolise localised acute lower GI bleeds.

Transcatheter Arterial Embolization of Gastrointestinal Bleeding with N-Butyl Cyanoacrylate: A Systematic Review and Meta-Analysis of Safety and Efficacy

PURPOSE

To evaluate the safety and efficacy of transcatheter arterial embolization with N-butyl cyanoacrylate (NBCA) for the treatment of gastrointestinal (GI) bleeding via a meta-analysis of published studies.

MATERIALS AND METHODS

The MEDLINE/PubMed and EMBASE databases were searched for English-language studies from January 1990 to March 2016 that included patients with nonvariceal GI bleeding treated with transcatheter arterial embolization with NBCA with or without other embolic agents. The exclusion criteria were a sample size of < 5, no extractable data, or data included in subsequent articles or duplicate reports.

RESULTS

The cases of 440 patients (mean age, 63.8 y ± 14.3; 319 men [72.5%] and 121 women [27.5%]) from 15 studies were evaluated. Of these patients, 261 (59.3%) had upper GI bleeding (UGIB) and 179 (40.7%) had lower GI bleeding (LGIB). Technical success was achieved in 99.2% of patients with UGIB (259 of 261) and 97.8% of those with LGIB (175 of 179). The pooled clinical success and major complication rates in the 259 patients with UGIB in whom technical success was achieved were 82.1% (95% confidence interval [CI], 73.0%-88.6%; P = 0.058; I² = 42.7%) and 5.4% (95% CI, 2.8%-10.0%; P = 0.427; I² = 0.0%), respectively, and those in the 175 patients with LGIB in whom technical success was achieved were 86.1% (95% CI, 79.9%-90.6%; P = 0.454; I² = 0.0%) and 6.1% (95% CI, 3.1%-11.6%; P = 0.382; I² = 4.4%), respectively.

CONCLUSIONS

Transcatheter arterial embolization with NBCA is safe and effective for the treatment of GI bleeding.

Lower GI bleeding: a review of current management, controversies and advances

PURPOSE

Lower gastrointestinal (GI) bleeding is defined as bleeding distal to the ligament of Treitz. In the UK, it represents approximately 3 % of all surgical referrals to the hospital. This review aims to provide review of the current evidence regarding the management of this condition.

METHODS

Literature was searched using Medline, Pubmed, and Cochrane for relevant evidence by two researchers. This was conducted in a manner that enabled a narrative review of the evidence covering the aetiology, clinical assessment and management options of continuously bleeding patients.

FINDINGS

The majority of patients with acute lower GI bleeding can be treated conservatively. In cases where ongoing bleeding occurs, colonoscopy is still the first line of investigation and treatment. Failure of endoscopy and persistent instability warrant angiography, possibly preceded by CT angiography and proceeding to superselective embolisation. Failure of embolisation warrants surgical intervention.

CONCLUSIONS

There are still many unanswered questions. In particular, the development of a more reliable predictive tool for mortality, rebleeding and requirement for surgery needs to be the ultimate priority. There are a small number of encouraging developments on combination therapy with regard to angiography, endoscopy and surgery. Additionally, the increasing use of haemostatic agents provides an additional tool for the management of bleeding endoscopically in difficult situations.

Long-term results of microcoil embolization for colonic haemorrhage: how common is rebleeding?

OBJECTIVE

To determine the long-term results of patients undergoing transcatheter coil embolization for the treatment of acute colonic haemorrhage.

METHODS

Patients undergoing angiography for suspected colonic bleeding between January 2002 and December 2012 were reviewed (average age, 60 years; 38.4% male). Baseline, procedural and outcome parameters were recorded following the Society of Interventional Radiology guidelines. Primary outcome measures included early (<30 days) and delayed (>30 days) rebleeding events and adverse procedure-related complication. Average follow-up time was 996 days (median, 232 days; range, 30-3663 days).

RESULTS

One or multiple sites of bleeding were identified in 40 cases. Coil embolization was performed in 39 patients, 26 (66.7%, 26/39) of whom were treated successfully without technical/clinical failure (n = 12) or loss to follow-up (n = 1). Three patients (11.5%, 3/26) rebled in the early period within 30 days; one patient went on to hemicolectomy. Four patients (15.3%, 4/26) experienced delayed rebleeding after 30 days; two of whom also underwent hemicolectomy. No major complication occurred. One minor complication of short segment arterial dissection was seen in the clinical failure group. One case of asymptomatic ischaemia was identified on a patient undergoing pre-operative colonoscopy for elective bowel resection. No instances of ischaemic stricture were seen. All-cause mortality of successfully treated and all patients at 1 year was 31% (8/26) and 30% (12/40), respectively.

CONCLUSION

Transcatheter coil embolization is a durable treatment option with a technical and clinical success rate of 67% in the setting of acute colonic haemorrhage. A modest level of rebleeding was seen among successfully treated patients in both the early and delayed periods; in the majority of patients, embolization proved to be definitive therapy.

ADVANCES IN KNOWLEDGE

Transcatheter coil embolization is a durable and potentially definitive therapy in the management of acute colonic haemorrhage.

Lower gastrointestinal bleeding: Role of 64-row computed tomographic angiography in diagnosis and therapeutic planning

AIM: To determine the value of computed tomographic angiography (CTA) for diagnosis and therapeutic planning in lower gastrointestinal (GI) bleeding.

METHODS: Sixty-three consecutive patients with acute lower GI bleeding underwent CTA before endovascular or surgical treatment. CTA was used to determine whether the lower GI bleeding was suitable for endovascular treatment, surgical resection, or conservative treatment in each patient. Treatment planning with CTA was compared with actual treatment decisions or endovascular or surgical treatment that had been carried out in each patient based on CTA findings.

RESULTS: 64-row CTA detected active extravasation of contrast material in 57 patients and six patients had no demonstrable active bleeding, resulting in an accuracy of 90.5% in the detection of acute GI bleeding (57 of 63). In three of the six patients with no demonstrable active bleeding, active lower GI bleeding recurred within one week after CTA, and angiography revealed acute bleeding. The overall location-based accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the detection of GI bleeding by 64-row CTA were 98.8% (249 of 252), 95.0% (57 of 60), 100% (192 of 192), 100% (57 of 57), and 98.5% (192 of 195), respectively. Treatment planning was correctly established on the basis of 64-row CTA with an accuracy, sensitivity, specificity, PPV and NPV of 98.4% (248 of 252), 93.3% (56 of 60), 100% (192 of 192), 100% (56 of 56), and 97.5% (192 of 196), respectively, in a location-based evaluation.

CONCLUSION: 64-row CTA is safe and effective in making decisions regarding treatment, without performing digital subtraction angiography or surgery, in the majority of patients with lower GI bleeding.

Does the timing of an invasive mesenteric angiography following a positive CT mesenteric angiography make a difference?

BACKGROUND

Computed tomographic mesenteric angiography (CTMA) is integral in the management of patients with acute lower gastrointestinal tract bleeding (LGIB). An invasive mesenteric angiography (MA) with a view to embolize the site of bleeding is usually performed if active contrast extravasation was seen on the CTMA scans. However, the bleeding may have ceased by the time the invasive MA is performed. This study aims to identify predictors for active extravasation in invasive MA following a positive CTMA in patients with massive LGIB.

METHODOLOGY

A single-center retrospective study of all patients who underwent an invasive MA following a positive CTMA for LGIB from August 2007 to October 2013 was performed. Comparison was performed between patients who had positive and negative invasive MA after a positive CTMA.

RESULTS

Forty-eight invasive MA scans were performed in patients with LGIB following a positive CTMA scan. Twenty-three (47.9%) were due to diverticular disease while 20 (41.7%) bled from the small bowel. The median delay from a positive CTMA to invasive MA was 144 (32-587) min. Of the 48 invasive MA, 25 demonstrated active extravasation. Invasive MA scans that was performed within 90 min after a positive CTMA scan were 8.56 (95% CI 0.96-76.1, p = 0.05) times more likely to detect a positive extravasation.

CONCLUSION

Invasive MA should be executed promptly after a positive CTMA to increase the probability of detecting the site of bleed to allow superselective embolization.

Pharmaco-induced vasospasm therapy for acute lower gastrointestinal bleeding: a preliminary report

PURPOSE

To report a novel technique and preliminary clinical outcomes in managing lower gastrointestinal bleeding (LGIB).

MATERIALS AND METHODS

Eighteen LGIB patients (11 men and 7 women, mean age: 66.2 years) were treated with artificially induced vasospasm therapy by semi-selective catheterization technique. Epinephrine bolus injection was used to initiate the vascular spasm, and followed by a small dose vasopressin infusion (3-5 units/h) for 3h. The technical success, clinical success, recurrent bleeding and major complications of this study were evaluated and reported.

RESULTS

Sixteen bleeders were in the superior mesenteric artery and 2 in the inferior mesenteric artery. All patients achieved successful immediate hemostasis. Early recurrent bleeding (<30 days) was found in 4 patients with local and new-foci re-bleeding in 2 (11.1%) each. Repeated vasospasm therapy was given to 3 patients, with clinical success in 2. Technical success for the 21 bleeding episodes was 100%. Lesion-based and patient-based primary and overall clinical successes were achieved in 89.4% (17/19) and 77.7% (14/18), and 94.7% (18/19) and 88.8% (16/18), respectively. None of our patients had complications of bowel ischemia or other major procedure-related complications. The one year survival of our patients was 72.2 ± 10.6%.

CONCLUSIONS

Pharmaco-induced vasospasm therapy seems to be a safe and effective method to treat LGIB from our small patient-cohort study. Further evaluation with large series study is warranted. Considering the advanced age and complex medical problems of these patients, this treatment may be considered as an alternative approach for interventional radiologists in management of LGIB.

Safety and efficacy of transcatheter arterial embolization for lower gastrointestinal bleeding: a single-center experience with 112 patients

PURPOSE

To assess the safety and efficacy of transcatheter arterial embolization for lower gastrointestinal bleeding (LGIB) and to determine the prognostic factors that affect clinical outcome.

MATERIALS AND METHODS

All patients diagnosed with LGIB by angiography at a single institution from April 2006 to January 2013 were included in a retrospective study. The rates of technical success, early recurrent bleeding, major complications, clinical success, and in-hospital mortality for transcatheter arterial embolization were determined. The influence of possible prognostic factors on the outcome was analyzed.

RESULTS

A total of 112 patients were included (36 with small-bowel LGIB, 36 with colon LGIB, and 40 with rectal LGIB). N-butyl cyanoacrylate (NBCA) was the embolic agent for 84 patients (75.0%), whereas gelatin sponge pledgets (n = 20), microcoils (n = 2), polyvinyl alcohol particles with adjunctive gelatin sponge pledgets (n = 1), and blood clots (n = 1) were used in the other patients. The technical success rate was 96.4%. For the entire group, the rates of early recurrent bleeding, major complications, clinical success, and in-hospital mortality were 17.4%, 4.6%, 74.5%, and 25.0%, respectively. These were 15.2%, 4.8%, 75.3%, and 26.2%, respectively, in the NBCA group. Hematologic malignancy, immobilization status, and coagulopathy were significant prognostic factors for clinical outcomes.

CONCLUSIONS

Transcatheter arterial embolization is a safe and effective treatment for LGIB. NBCA could be used as a primary embolic agent for this procedure.

Transarterial embolization in acute colonic bleeding: review of 11 years of experience and long-term results

BACKGROUND

Lower gastrointestinal bleeding represents 20 % of all gastrointestinal bleedings. Interventional radiology has transformed the treatment of this pathology, but the long-term outcome after selective embolization has been poorly evaluated. The aim of this study is thus to evaluate the short-term and long-term outcomes after selective embolization for colonic bleeding.

METHODS

From November 1998 to December 2010, all acute colonic embolizations for hemorrhage were retrospectively reviewed and analyzed. The risk factors for post-embolization ischemia were also assessed.

RESULTS

Twenty-four patients underwent colonic embolization. There were 6 men and 18 women with a median age of 80 years (range, 42-94 years). The underlying etiologies included diverticular disease (41.9 %), post-polypectomy bleeding (16.7 %), malignancy (8.2 %), hemorrhoid (4.1 %), and angiodysplasia (4.1 %). In 23 patients, bleeding stopped (95.8 %) after selective embolization. One patient presented a recurrence of bleeding with hemorrhagic shock and required urgent hemorrhoidal ligature. Four patients required an emergent surgical procedure because of an ischemic event (16.7 %). One patient died of ileal ischemia (mortality, 4.1 %). The level of embolization and the length of hypoperfused colon after embolization were the only risk factors for emergent operation. Mean hospital stay was 18 days (range, 9-44 days). After a mean follow-up of 28.6 months (range, 4-108 months), no other ischemic events occurred.

CONCLUSION

In our series, selective transarterial embolization for acute colonic bleeding was clinically effective with a 21 % risk of bowel ischemia. The level of embolization and the length of the hypoperfused colon after embolization should be taken into consideration for emergent operation.

The efficacy and long-term outcome of microcoil embolotherapy for acute lower gastrointestinal bleeding

OBJECTIVE

To evaluate the clinical efficacy as well as long-term clinical outcomes of superselective microcoil embolization for lower gastrointestinal bleeding (LGIB).

MATERIALS AND METHODS

Between 1997 and 2009, 26 patients with intended transcatheter embolotherapy for LGIB were retrospectively reviewed. Embolization was performed only when the catheter could be advanced to or distal to the mesenteric border of the bowel. The main purpose of our study was to assess technical success, recurrent bleeding rate and complications. We also evaluated the long-term clinical outcome, including late recurrent LGIB, bowel ischemia and the survival rate.

RESULTS

Twenty-two bleeding sources were in the territory of superior mesenteric artery and four in the inferior mesenteric artery. Technical success was achieved in 22 patients (84.6%). The target vessel of embolization was vasa recta in seventeen patients and marginal artery in the remaining five patients. Early rebleeding occurred in two patients (7.7%) and bowel ischemia in two patients, of whom the embolized points were both at the marginal artery. Delayed recurrent bleeding (> 30 days) occurred in two angiodysplasia patients. Five patients (19.2%) died within the first 30 days of intervention. Long-term follow-up depicted estimated survival rates of 58.2 and 43.1% after one, and five years, respectively.

CONCLUSION

Transcatheter embolotherapy to treat LGIB is effective with low rebleeding and ischemic complications. Considering the advanced age and complex medical problems of these patients, the minimal invasive embolotherapy may be used as both a primary and potentially definitive treatment of LGIB.

Detection and localization of active gastrointestinal bleeding with multidetector row computed tomography angiography: a 5-year prospective study in one medical center

GOAL

To prospectively assess the utility of multidetector row computed tomography angiography (MDCTA) in the diagnosis of active gastrointestinal bleeding (GIB).

BACKGROUND

MDCTA is a relatively recent advance in CT scanning technology enabling excellent vascular visualization and detection of various vascular abnormalities. However, there is no prospective study with a large population evaluating the role of MDCTA in the diagnosis of active GIB.

STUDY

From January 2006 to January 2011, 113 consecutive patients with clinical signs of active GIB underwent MDCTA (16-slice, 64-slice, or dual-source). The criteria for positive CT findings included active extravasation of contrast material within bowel lumen, abnormal bowel mucosal enhancement, vascular malformation, abnormally enhancing polyp or diverticulum, or tumor. Two radiologists reviewed the images and assessed CT findings in consensus. The standards of reference included digital subtraction angiography, endoscopy, surgery, or final pathology reports. Sensitivity, specificity, positive and negative predictive values, and accuracy of MDCTA for detection of active GIB were evaluated.

RESULTS

Positive CT findings for active GIB were identified in 80 of 113 patients (70.8%), all of which were confirmed by 1 or more reference standard. Negative MDCTA results were obtained in 33 patients (29.2%). Of these, 27 patients did not require any further intervention and were discharged without incident. The overall sensitivity, specificity, positive and negative predictive values, and accuracy of MDCTA was 86.0%, 100%, 100%, 60.6%, and 88.5%, respectively.

CONCLUSIONS

MDCTA is an accurate first-line screening method for detection and localization of GIB and can guide triage in patients with active GIB.

Mesenteric embolization for lower gastrointestinal bleeding

PURPOSE

Mesenteric embolization is an established treatment for lower gastrointestinal bleeding. The aim of this study was to determine the outcome of angiography and embolization and its influencing factors.

METHODS

A prospective database of all mesenteric angiograms performed for lower gastrointestinal bleeding at a tertiary center between 1998 and 2008 was analyzed in combination with chart review.

RESULTS

There were 107 angiograms performed during 83 episodes of lower gastrointestinal bleeding in 78 patients. Active bleeding was identified in 40 episodes (48%), and embolizations were performed in 37 (45%). One patient without active bleeding on angiogram also underwent embolization, making a total of 38 embolizations. Overall mortality was 7% with 4 deaths due to rebleeding and 2 deaths due to a medical comorbidity (respiratory failure, pneumonia). Short-term complications of angiography were false aneurysm (1 patient) and Enterobacter sepsis (1 patient). Long-term complications were groin lymphocele (1 patient) and late rebleed from collateralization (1 patient). In 43 episodes, angiography did not demonstrate active bleeding. Twelve (28%) of these patients continued to bleed, 9 of whom had successful surgery. Of the 38 patients who had embolizations, all had immediate cessation of bleeding. Nine patients (24%) later rebled; 5 of these patients required surgery and 3 had reembolizations. Of the 3 patients who underwent reembolization, 2 developed ischemic bowel and 1 stopped bleeding; surgery was required in 1 patient.

CONCLUSIONS

Mesenteric angiography for lower gastrointestinal bleeding effectively identifies the site of bleeding in 48% of patients and allows embolization in 45%. Embolization achieves clinical success in 76% of patients but repeat embolization is associated with a high rate of complications.

[Severe lower gastrointestinal tract bleeding due to diverticulosis]

INTRODUCTION

Diverticulosis is the most frequent cause of lower gastrointestinal (GI) bleeding in adults in western countries. The aims of the present study were to analyze: 1) the diagnostic and therapeutic management of patients with severe lower GI bleeding due to diverticulosis; 2) associated morbidity and mortality; 3) the need for surgery, and 4) bleeding recurrence rates after hospital discharge.

MATERIAL AND METHODS

Were retrospectively reviewed 42 patients with severe lower GI bleeding due to diverticulosis. Patients with rectorrhagia requiring transfusion of at least three packed red blood cell units and those with a decrease in hematocrit of 10 points or more were included. As a control group, we used 133 patients with severe lower GI hemorrhage due to causes other than colonic diverticular disease.

RESULTS

All patients were stabilized with conservative measures except one who required emergency surgery. Colonoscopy was performed in 39 patients and the most frequent finding consisted of recent signs of bleeding independently of whether colonoscopy was performed early or was delayed. Endoscopic treatment with Argon laser electrocoagulation was performed in one patient. Bleeding recurrence after hospital discharge occurred in 13 patients (31%); of these, seven (16%) required hospital readmission.

CONCLUSION

Severe lower GI bleeding due to diverticulosis can usually be resolved with conservative treatment although the percentage of bleeding recurrence is high. Early endoscopy is not as important as in the remaining causes of severe lower GI bleeding.

Impact of hospital institutional volume on postoperative mortality after major emergency colorectal surgery in English National Health Service Trusts, 2001 to 2005

PURPOSE

The aim of this study was to investigate the effects of institutional volume on postoperative mortality in patients undergoing emergency major colorectal surgical procedures in England between 2001 and 2005.

METHODS

All of the emergency excisional colorectal procedures performed between the above dates were included from the Hospital Episode Statistics data set. Institutions were divided into high-, medium-, and low-volume tertiles according to the total major emergency colorectal caseload.

RESULTS

During the study period, 37,094 emergency excisional colorectal procedures were performed in 166 English National Health Service institutions. Overall 30-day postoperative mortality was 15.49%, increasing to 29.18% at 1 year after surgery. Overall 30- and 365-day mortality rates were similar among institutional volume tertiles (P > .05) after adjustment for age, sex, social deprivation, diagnosis, procedure type, and comorbidity score.

CONCLUSION

Hospital Episode Statistics data suggest that institutions with high volumes of emergency colorectal caseload do not demonstrate lower mortality after emergency major excisional colorectal surgery.

Acute lower GI bleeding for the acute care surgeon: current diagnosis and management

Lower gastrointestinal bleeding is a common cause for hospital admission that results in significant morbidity and mortality. After initial resuscitation of the patient, the diagnosis and treatment of lower gastrointestinal bleeding remains a challenge for acute care surgeons. Identifying the source of bleeding can be difficult since many patients bleed intermittently or stop bleeding spontaneously. It is therefore important for the acute care surgeon to be familiar with the different diagnostic and therapeutic modalities and their advantages and disadvantages in order to guide the management of the acutely bleeding patient. This review summarizes the current methods available for the diagnosis and treatment of acute lower gastrointestinal bleeding and proposes an algorithm for the management of these patients.

Can superselective embolization be definitive for colonic diverticular hemorrhage? An institution's experience over 9 years

INTRODUCTION

Superselective mesenteric embolization is effective in arresting colonic diverticular hemorrhage with minimal complications, but long-term results are lacking. We aimed to review the short- and long-term outcome of superselective embolization in arresting colonic diverticular hemorrhage in an Asian population.

METHODS

A retrospective review of all patients who underwent superselective embolization for bleeding colonic diverticula from December 2000 to March 2009 was performed. These cases were drawn from a database of embolization for active gastrointestinal hemorrhage. Short-term outcomes (< or =30 days from procedure) identified included rebleeding, ischemia, or any further intervention for any of these two complications. Readmission for rebleeding and/or definitive surgery after 30 days (long-term outcome) was also documented.

RESULTS

Twenty-three patients, median age 65 years (range 41-79 years), formed the study group. Nineteen (82.6%) patients had active hemorrhage from right colonic diverticula while four (17.4%) had left-sided diverticular bleeding. Technical success was achieved in all 23 (100%) patients. SHORT-TERM OUTCOME: Five (21.7%) patients rebled within the same admission, and all underwent surgery. One patient perished from ensuing anastomotic dehiscence and septic shock and accounted for the only mortality (4.3%) in our series. There was no patient with ischemic complications. Another two (8.7%) patients underwent elective surgical resection on the advice of their surgeons in the absence of rebleeding. LONG-TERM OUTCOME: The median follow-up was 40 months (5-99 months). Of the remaining 16 (69.6%) patients for whom the procedure was definitive initially, four (25.0%) rebled within 2 years from the primary procedure, and elective surgery was performed in one of them. Another had repeat embolization, while the other two were successfully managed conservatively. These three patients refused surgical intervention. One patient was lost to follow-up, and the remaining 11 patients had no further complications.

CONCLUSION

Superselective embolization for active colonic diverticular hemorrhage is safe and effective and should be considered as a first line treatment if possible and available. The procedure could act as a bridge to a subsequent more definitive elective surgery or be definitive as seen in over 50% of our patients over a period of 40 months.

Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage

OBJECTIVES

We sought to assess the safety, short- and long-term efficacy, and durability of transcatheter embolization for lower gastrointestinal hemorrhage (LGH) unresponsive to endoscopic therapy and to analyze the overall survival of the embolized patients.

METHODS

Between January 1997 and January 2008, 122 patients were referred for angiographic evaluation to control major LGH. Overall, 43 patients (35.3%) presented with angiographic signs of contrast extravasation. In 39 patients (26 men, 13 women; mean age 67.7 years), a transcatheter embolization was performed to stop the bleeding.

RESULTS

In all 39 patients, no contrast extravasation could be depicted on completion of angiography after embolization. Rebleeding occurred in eight patients (20%), in six of them within the first 30 days after embolization. Ischemic intestinal complications requiring surgery occurred in four patients (10%) within 24 h after embolization. Long-term follow-up depicted estimated survival rates of 70.6, 56.5, and 50.8% after 1, 3, and 5 years, respectively.

CONCLUSIONS

Transcatheter embolotherapy to treat lower gastrointestinal bleeding is very effective, with a relatively low rebleeding and ischemic complication rate, mostly occurring within the first month after the embolization. Long-term follow-up shows a very low late rebleeding rate, and half of the embolized patients survive more than 5 years. This study shows that the majority of patients presenting with lower gastrointestinal bleeding, unresponsive to endoscopic therapy, do not benefit from transcatheter embolization. In cases of angiography extravasation, a good immediate clinical outcome-defined as high immediate success with acceptable rebleeding-and ischemic complication rate may be obtained.

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.