Transcatheter treatment for lower gastrointestinal hemorrhage

Successful management of ileocecal angiodysplasia with an overt bleeding with supra selective transcatheter embolization-case report

INTRODUCTION

Angiodysplasia is the most common vascular abnormality in gastrointestinal tract, commonly occurs in right colon.

CASE PRESENTATION

42-year-old male presented with massive per rectal bleeding for one day duration. He is a known type 2 diabetes mellitus patient and not known to having any bleeding disorders or on any anticoagulant medication. He had no gastrointestinal red flag symptoms. He was hemodynamically stable, and rest of the examination was unremarkable. His hemoglobin level was dropped from 7.9 g/dl on admission to 4.1 g/dl. His biochemical investigations including coagulation profile were within normal limits and had unremarkable Oesophago-gastro-duodenoscopy (OGD) and colonoscopy. Computerised tomography mesenteric angiogram (CTA) revealed angiodysplasia at ileocecal junction and proceeded with supra selective trans cather angiography which showed bleeding from a branch of ileocecal artery for which the glue embolization done. Homeostasis achieved successfully and patient well recovered.

DISCUSSION

Presentation of angiodysplasia can be range from incidental finding to overt bleeding with varying degree of anaemia. Endoscopy is the preferred first line of investigation, although it has its limitations such as requiring bowel preparation and stable hemodynamic status for the procedure. CTA has a value in such circumstances to identify the site of bleeding and to guide angiographic intervention. Trans catheter angiography and embilozation is one of the suitable options in similar situation.

CONCLUSION

Ileocecal angiodysplasia which presents as an overt per-rectal bleeding where proceeding to surgery is difficult, can be managed successfully with supraselective transcatheter angiography and embolization.

Duodenal angiodysplasia: a case report

Background

Angiodysplasia (AD) is an abnormal, ectatic dilated, tortuous blood vessel that is found in the mucosa and the submucosa of the gastro-intestinal tract (GIT). While colonic angiodysplasia is a recognized finding of the lower intestinal tract in the elderly, small intestinal angiodysplasia is rare. However, it is an important reason of GIT bleeding so its detection and proper management can be a challenge. It should be considered among the differential diagnosis in the scenario of mild or intermittent GIT bleedings of obscure cause.

Case presentation

A 71-year-old woman was presented to our emergency department with hypovolemic shock due to lower GIT bleeding, and she was suffering of melena and severe anemia. The revision of past medical history revealed a history of hypertension, diabetes mellitus, and chronic renal disease. After stabilization, she underwent abdominal computed tomography (CT) which revealed a small abnormal vascular lesion along the anterior and posterior wall of the 2nd part of the duodenum. It appeared as blush of contrast in the arterial phase (representing dilated mucosal capillaries draining into tortuous submucosal vein) suggestive of vascular lesion (duodenal angiodysplasia). The patient was transferred to undergo an angiogram which confirmed the diagnosis of duodenal angiodysplasia. Super selective cannulation of the feeding artery was performed followed by post coiling angiogram which revealed successful embolization. No acute complications were encountered during or immediately after procedure.

Conclusion

AD is a rare but important cause that should be considered in the differential diagnosis of GIT bleeding especially in the older patients. It should be looked for in CT angiography done in such a clinical situation. Superselective coil embolization is a safe and effective technique to manage bowel AD.

Clinical applications of digital angiography with the harmonization function in body interventional radiology

Digital subtraction angiography (DSA) is frequently applied in interventional radiology (IR). When DSA is not useful due to misregistration, digital angiography (DA) as an alternative option is used. In DA, the harmonization function (HF) works in real time by harmonizing the distribution of gray steps or reducing the dynamic range; thus, it can compress image gradations, decrease image contrast, and suppress halation artifacts. DA with HF as a good alternative to DSA is clinically advantageous in body IR for generating DSA-like images and simultaneously reducing various motion artifacts and misregistrations caused by patient body motion, poor breath-holding, bowel and ureter peristalsis, and cardiac pulsation as well as halation artifacts often stemming from the lung field. Free-breath DA with HF can improve body IR workflow and decrease the procedure time by reducing the risk of catheter dislocation and using background structures as anatomical landmarks, demonstrating reduced radiation exposure relative to DSA. Thus, HF should be more widely and effectively utilized for appropriate purposes in body IR. This article illustrates the basic facts and principles of HF in DA, and demonstrates clinical advantages and limitations of this function in body IR.

Gastrointestinal Angiodysplasia: Diagnosis and Management

Gastrointestinal angiodysplasia (GIAD) are red flat arborized lesions that are found throughout the entire gastrointestinal tract. GIAD can vary in size and have a range of presentation from occult to life-threatening bleeding. The typical presentation is intermittent bleeding in the setting of iron deficiency anemia. Endoscopy is the primary means of diagnosis and endoscopic therapy is noted to be initially effective. However, rebleeding can be as high as 40% to 50% in patients with small bowel GIAD. This review describes the pathophysiology for the development of GIAD and the current roles of endoscopic, medical, and surgical therapy in its treatment.

Use of endoscopic-assisted argon plasma coagulation for the treatment of colonic vascular ectasia (angiodysplasia) in an adult dog

CASE DESCRIPTION

A 10-year-old neutered male mixed-breed dog was evaluated for a 5-year history of intermittent hematochezia and chronic anemia that were unresponsive to medical treatment.

CLINICAL FINDINGS

Colonoscopy revealed multifocal areas of coalescing tortuous mucosal blood vessels throughout the colon and rectum. Colonic vascular ectasia (angiodysplasia) was diagnosed on the basis of the endoscopic appearance of the lesions.

TREATMENT AND OUTCOME

The dog failed to respond to traditional medical treatments for colonic vascular ectasia and required multiple plasma and blood transfusions. The dog received 4 endoscopic-assisted argon plasma coagulation treatments, which resulted in long-term resolution of gastrointestinal hemorrhage. Colonic perforation occurred during the third argon plasma coagulation treatment. The perforation was surgically repaired. The dog remained free from clinical signs of colonic vascular ectasia for > 1 year after the third argon plasma coagulation treatment and was euthanized because of clinical deterioration associated with progressive heart disease.

CLINICAL RELEVANCE

Endoscopic-assisted argon plasma coagulation treatment is a novel treatment for dogs with colonic vascular ectasia and provided long-term resolution of clinical signs for the dog of this report. In human patients, complications associated with endoscopic-assisted argon plasma coagulation treatment include colonic perforation, which also occurred in the dog of this report.

Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management

BACKGROUND

Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality.

AIM

To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors.

METHODS

A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract.

RESULTS

Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively.

CONCLUSIONS

Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.

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.

Endovascular management of nonvariceal upper gastrointestinal hemorrhage

Upper gastrointestinal bleeding (UGIB) remains a frequent presentation in the emergency department. There are several causes of UGIB, which can be generally classified into variceal and nonvariceal bleeding. Although most cases of nonvariceal UGIB spontaneously resolve or respond to medical management and/or endoscopic treatment, transcatheter arterial embolization (TAE) remains an important available tool in the emergency evaluation and management of nonvariceal UGIB. In this article, we will discuss the current strategies for rendering a specific diagnosis of nonvariceal UGIB, and we will focus on the various TAE techniques for its management. We will also provide an algorithm for the diagnostic work-up of these patients. The majority of patients with nonvariceal UGIB that is refractory to endoscopic treatment is successfully treated with minimally invasive TAE and can avoid undergoing surgery.

Angiographic evaluation and management of acute gastrointestinal hemorrhage

Although most cases of acute nonvariceal gastrointestinal hemorrhage either spontaneously resolve or respond to medical management or endoscopic treatment, there are still a significant number of patients who require emergency angiography and transcatheter treatment. Evaluation with noninvasive imaging such as nuclear scintigraphy or computed tomography may localize the bleeding source and/or confirm active hemorrhage prior to angiography. Any angiographic evaluation should begin with selective catheterization of the artery supplying the most likely site of bleeding, as determined by the available clinical, endoscopic and imaging data. If a hemorrhage source is identified, superselective catheterization followed by transcatheter microcoil embolization is usually the most effective means of successfully controlling hemorrhage while minimizing potential complications. This is now well-recognized as a viable and safe alternative to emergency surgery. In selected situations transcatheter intra-arterial infusion of vasopressin may also be useful in controlling acute gastrointestinal bleeding. One must be aware of the various side effects and potential complications associated with this treatment, however, and recognize the high re-bleeding rate. In this article we review the current role of angiography, transcatheter arterial embolization and infusion therapy in the evaluation and management of nonvariceal gastrointestinal hemorrhage.

Selective microcoil embolization of arterial gastrointestinal bleeding in the acute situation: outcome, complications, and factors affecting treatment success

OBJECTIVES

To evaluate microcoil embolization in the interventional treatment of acute upper and lower gastrointestinal bleeding.

PATIENTS AND METHODS

Forty-four patients (29 men, 15 women) with active arterial gastrointestinal bleeding were treated with microcoil embolization. The analysis included technical/clinical success, morbidity, mortality, and intervention-related mortality. Age, sex, underlying malignant disease, number of embolizations, preinterventional and postinterventional hemoglobin levels, blood products administered peri-interventionally, amount of embolization material used, duration of fluoroscopy, and use of contrast medium were evaluated for possible effects on technical and clinical success.

RESULTS

The primary technical success rate of microcoil embolization for acute gastrointestinal bleeding was 88.6% with a clinical success rate of 56.8%. Minor and major complications occurred in 13.6 and 18.2% of patients, respectively. Intervention-associated mortality, due to intestinal ischemia, accounted for 4.6% of the total 18.2% mortality rate. Patients with technically successful embolization had a statistically significant increase in hemoglobin (P<0.01) after the intervention and a decrease in need for packed red blood cells, (P<0.01), fresh frozen plasma (P<0.01), and coagulation products (P<0.01). A smaller postinterventional fresh frozen plasma requirement was associated with a better clinical outcome (P=0.02).

CONCLUSION

Microcoil embolization of arterial gastrointestinal bleeding in the acute situation has a high-technical success rate. The number of transfusions required before and after the intervention has no significant effect on technical success. Postinterventional fresh frozen plasma demand negatively correlates with clinical success.

N-butyl cyanoacrylate embolization as the primary treatment of acute hemodynamically unstable lower gastrointestinal hemorrhage

PURPOSE

To evaluate N-butyl cyanoacrylate (NBCA) embolization as the primary treatment for patients with severe and acute hemodynamically unstable lower gastrointestinal bleeding.

MATERIALS AND METHODS

Twenty-seven patients with acute, unstable hemodynamics caused by lower gastrointestinal bleeding underwent therapeutic NBCA microcatheter embolization over a period of 27 months. The inclusion criteria were hematochezia or melena and hypotension refractory to conservative treatment and requiring blood transfusion. Bleeding was localized to the rectum, colon, or small intestine in all nine such cases. Fifteen patients had severe underlying comorbidities, including sepsis, respiratory failure, malignancy, or renal failure.

RESULTS

The procedure was technically successful in all patients. Twenty-six patients were treated solely with NBCA, and one required microcoil embolization. Embolization was performed at the level of the arteria recta or as close as possible to the point of bleeding. Immediate hemostasis occurred in all cases. Four patients experienced repeat hemorrhage, one of whom died. The other three were treated successfully with repeat NBCA embolization. None of the surviving patients had evidence of bowel ischemia. In addition, none of the patients with severe underlying disease died during the follow-up period (range, 3 mo to 2 y).

CONCLUSIONS

The present findings suggest that NBCA embolization may be a safe alternative treatment for the management of lower gastrointestinal bleeding. Further studies are warranted to confirm the findings.

Gastroenterologists and interventional radiologists: friends or foes? A multidisciplinary approach for solving gastrointestinal problems

While endoscopy used to have more therapeutic abilities than radiology, interventional radiology is now racing to lead the minimally invasive diagnostic and therapeutic techniques in medicine as well as surgery. Expecting the new epidemic of hepatocellular carcinoma, radiologists and gastroenterologists are on the run competing in many procedures that are needed. While some radiologists worry about non-radiologists who "intervene" in radiology, many gastroenterologists defend their specialty. Both gastroenterologists and radiologists are invited to collaborate in diagnosing and treating many diseases. Treatment of upper gastrointestinal bleeds should be multidisciplinary involving a team of gastroenterologists, radiologists and surgeons. The role of the interventional radiologist and surgeon arises only after the failure of the endoscopic treatment. Transjugular intrahepatic portosystemic shunt (TIPS) is the preferred treatment for variceal bleeding after failed endoscopy. As the entire field of gastroenterology continues towards less invasive, safer and more effective means of diagnosing and treating diseases, digestive endoscopy will continue to expand the ways in which this unique and minimally invasive technology can be applied to the benefit of patients. In line with this trend, there will be a decline in simple diagnostic standard endoscopies. Development of new techniques, such as CT colonography and capsule endoscopy will actually increase the demand for digestive endoscopy. The trend of future digestive endoscopy will continue to move from diagnostic to therapeutic modalities. Future gastroenterologists will be trained and expected to become micro-surgeons of the gastrointestinal tract working in multispecialty teams along with their colleagues: surgeons and radiologists.

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.

Acute gastrointestinal hemorrhage

Although most cases of acute gastrointestinal (GI) hemorrhage either spontaneously resolve or respond to medical management and/or endoscopic treatment, there remain a significant number of patients who require emergency evaluation and treatment by the interventional radiologist. Any angiographic evaluation should begin with selective catheterization of the artery supplying the most likely site of bleeding, as determined by the available clinical, endoscopic, and imaging data. If a source of hemorrhage is identified, superselective catheterization followed by transcatheter embolization with microcoils is the most effective means of successfully controlling hemorrhage while minimizing potential complications. This is now well-recognized as a viable and safe alternative to emergency surgery. In selected situations transcatheter intra-arterial infusion of vasopressin may also be useful in controlling acute GI bleeding. One must be aware of the various side effects and potential complications associated with this treatment, however, and recognize the high rebleeding rate. In this article, we review the current role of angiography, transcatheter arterial embolization, and infusion therapy in the evaluation and management of GI hemorrhage.

Initial experience using N-butyl cyanoacrylate for embolization of lower gastrointestinal hemorrhage

PURPOSE

To report initial experience using N-butyl cyanoacrylate (n-BCA) to control lower gastrointestinal hemorrhage (LGIH).

MATERIALS AND METHODS

From May 2005 to March 2009, 14 patients with LGIH underwent mesenteric angiography and transcatheter arterial embolization using n-BCA. Candidacy was primarily based on the patient's hemodynamic stability and the risk for future LGIH, determined by the presence of at least one of the following risk factors: more than one arterial feeder supplying the bleeding vessel, underlying coagulopathy, or need to resume anticoagulation after embolization. Outcome measures included technical success (immediate postembolic hemostasis confirmed with completion angiography showing no further extravasation of contrast medium), clinical success (postembolic hemostasis in the absence of complications 30 days after the procedure), and clinical failure (recurrence of LGIH necessitating repeat embolization or surgical treatment).

RESULTS

Fourteen patients with active LGIH were treated with n-BCA, with 100% technical success. Two patients had rebleeds resulting in bowel resection. One patient experienced a minor rebleed that spontaneously resolved. One patient died secondary to multiorgan failure in the setting of multiple medical problems. The remaining 10 patients had complete clinical success, experiencing no signs of rebleeding or infarction.

CONCLUSIONS

The results suggest that n-BCA can be a useful alternative embolic agent for the treatment of hemodynamically unstable patients with LGIH when standard microcoiling techniques fail or are not feasible and in patients with coagulopathy.

Accurate localization of life threatening colonic hemorrhage during nuclear medicine bleeding scan as an aid to selective angiography

Purpose

To describe a new technique to help localize life threatening colorectal bleeding during nuclear medicine bleeding scan to aid in selective angiography.

Methods

During the gastrointestinal bleeding scan, a simple metallic marker (paper clip) was used to localize the bleeding site on the patient body. Angiography was then performed within 2 hours. The marker was then used to guide superselective angiography and embolization.

Results

5 cases of patients with colorectal bleeding were performed using this technique with cessation of bleeding in 4/5 initial attempts. 1 patient required a repeat angiogram that did demonstrate the bleeding on the second attempt allowing superselective angiography and embolization that resulted in cessation of bleeding. This patient with a rectal bleed required selection of additional vessels guided by the marker on the second attempt.

Conclusion

The dilemma of positive scintigraphic evidence of colonic bleeding with negative arteriography can be resolved with the use of a metal marker during the scintigram to guide superselective angiography. Although in our small series of patients this technique appears to be simple and effective, further clinical investigation is warranted with a larger patient population. This technique may offer a role in therapy in coordination with the colorectal surgeon for the high risk patient in an otherwise life threatening situation.

Interventional management of lower gastrointestinal bleeding

Lower gastrointestinal bleeding (LGIB) arises from a number of sources and is a significant cause of hospitalization and mortality in elderly patients. Whereas most episodes of acute LGIB resolve spontaneously with conservative management, an important subset of patients requires further diagnostic workup and therapeutic intervention. Endovascular techniques such as microcatheter embolization are now recognized as safe, effective methods for controlling LGIB that is refractory to endoscopic intervention. In addition, multidetector CT has shown the ability to identify areas of active bleeding in a non-invasive fashion, enabling more focused intervention. Given the relative strengths and weaknesses of various diagnostic and treatment modalities, a close working relationship between interventional radiologists, gastroenterologists and diagnostic radiologists is necessary for the optimal management of LGIB patients.