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Barash Y, Livne A, Klang E, Sorin V, Cohen I, Khaitovich B, Raskin D. Artificial Intelligence for Identification of Images with Active Bleeding in Mesenteric and Celiac Arteries Angiography. Cardiovasc Intervent Radiol 2024; 47:785-792. [PMID: 38530394 PMCID: PMC11164777 DOI: 10.1007/s00270-024-03689-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/20/2024] [Indexed: 03/28/2024]
Abstract
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.
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Affiliation(s)
- Yiftach Barash
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel.
- The Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
- DeepVision Lab, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel.
| | - Adva Livne
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel
- DeepVision Lab, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel
| | - Eyal Klang
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel
- The Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- DeepVision Lab, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel
- Sami Sagol AI Hub, ARC, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel
| | - Vera Sorin
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel
- The Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- DeepVision Lab, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel
| | - Israel Cohen
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel
- The Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Boris Khaitovich
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel
- The Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Daniel Raskin
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Emek Haela St. 1, 52621, Ramat Gan, Israel
- The Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Nilojan JS, Raviraj S, Anniestan A. Successful management of ileocecal angiodysplasia with an overt bleeding with supra selective transcatheter embolization-case report. Int J Surg Case Rep 2024; 118:109617. [PMID: 38636160 PMCID: PMC11027573 DOI: 10.1016/j.ijscr.2024.109617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 04/20/2024] Open
Abstract
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.
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Garg T, Khorshidi F, Habibollahi P, Shrigiriwar A, Fang A, Sakiani S, Harfouche M, Diaz JJ, Nezami N. How I Do It: Endovascular Management of Acute Nonvariceal Gastrointestinal Bleeding. Semin Intervent Radiol 2023; 40:475-490. [PMID: 37927517 PMCID: PMC10622246 DOI: 10.1055/s-0043-1775850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Tushar Garg
- Division of Vascular and Interventional Radiology, Russell H Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fereshteh Khorshidi
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Peiman Habibollahi
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Apurva Shrigiriwar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam Fang
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sasan Sakiani
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Melike Harfouche
- Division Acute Care Surgery, University of South Florida/Tampa General Hospital, Tampa, Florida
| | - Jose J. Diaz
- Division Acute Care Surgery, University of South Florida/Tampa General Hospital, Tampa, Florida
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Experimental Therapeutics Program, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
- The Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, Colleague Park, Maryland
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Martino A, Di Serafino M, Orsini L, Giurazza F, Fiorentino R, Crolla E, Campione S, Molino C, Romano L, Lombardi G. Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review. World J Gastroenterol 2023; 29:4222-4235. [PMID: 37545636 PMCID: PMC10401659 DOI: 10.3748/wjg.v29.i27.4222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/11/2023] [Accepted: 05/09/2023] [Indexed: 07/13/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.
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Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Francesco Giurazza
- Department of Interventional Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | | | - Enrico Crolla
- Department of Oncological Surgery, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Severo Campione
- Department of Pathology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Carlo Molino
- Department of Oncological Surgery, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Naples 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Naples 80131, Italy
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Martino A, Di Serafino M, Amitrano L, Orsini L, Pietrini L, Martino R, Menchise A, Pignata L, Romano L, Lombardi G. Role of multidetector computed tomography angiography in non-variceal upper gastrointestinal bleeding: A comprehensive review. World J Gastrointest Endosc 2022; 14:739-747. [PMID: 36567823 PMCID: PMC9782566 DOI: 10.4253/wjge.v14.i12.739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/30/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Upper gastrointestinal endoscopy is currently recommended as the gold standard modality for both diagnosis and treatment, with computed tomography traditionally playing a limited role in the diagnosis of acute NVUGIB. Following the introduction of multidetector computed tomography (MDCT), this modality is emerging as a promising tool in the diagnosis of NVUGIB. However, to date, evidence concerning the role of MDCT in the NVUGIB diagnosis is still lacking. The aim of our study was to review the current evidence concerning the role of MDCT in the diagnosis of acute NVUGIB.
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Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Lucio Amitrano
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Lorena Pietrini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Rossana Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Antonella Menchise
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luca Pignata
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples “Federico II”, Napoli 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
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Staiano M, Pellicano R. Why gastrointestinal bleeding could occur in COVID-19 patients? Minerva Gastroenterol (Torino) 2022; 68:489. [PMID: 35436842 DOI: 10.23736/s2724-5985.22.03184-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Maria Staiano
- Department of Medical Sciences, University of Turin, Turin, Italy.,Unit of Gastroenterology, Molinette Hospital, Turin, Italy
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Hassranah S, Maharajh S, Solomon S, Naraynsingh V. Massive Rectal Hemorrhage From a Stercoral Ulcer. Cureus 2022; 14:e26963. [PMID: 35989792 PMCID: PMC9382688 DOI: 10.7759/cureus.26963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 11/17/2022] Open
Abstract
Massive lower gastrointestinal (GI) bleeding from stercoral ulcers is exceedingly rare. We report a case of a middle-aged man who presented with progressively deteriorating neurologic function with constipation and subsequent massive GI bleeding per rectum. While an uncommon cause of GI bleeding, such patients require rapid resuscitation and timely diagnosis of these ulcers since the usual management of such cases will be futile and harmful due to potentially inappropriate surgical bowel resection.
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Bergamaschi G, Caprioli F, Lenti MV, Elli L, Radaelli F, Rondonotti E, Mengoli C, Miceli E, Ricci C, Ardizzone S, Vecchi M, Di Sabatino A. Pathophysiology and therapeutic management of anemia in gastrointestinal disorders. Expert Rev Gastroenterol Hepatol 2022; 16:625-637. [PMID: 35696485 DOI: 10.1080/17474124.2022.2089114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Anemia is a common complication of gastrointestinal (GI) disorders, with a prevalence up to 60% in celiac disease (CeD) and inflammatory bowel disease (IBD). Iron deficiency anemia (IDA) is the most prevalent form of anemia in these conditions, but chronic inflammation and vitamin B12 deficiency represent other common contributing mechanisms, especially in IBD. AREAS COVERED We discuss the pathogenesis of anemia in various medical GI disorders, the sometime problematic distinction between IDA, anemia of inflammation (AI) and the association of the two, and therapeutic and preventive measures that can be useful for the management of anemia in GI disorders. Unfortunately, with the exception of IDA and AI in IBD, large RCT concerning the treatment of anemia in GI disorders are lacking. EXPERT OPINION Anemia management strategies in GI disorders are outlined, with a focus on the main prevention, diagnostic, and therapeutic measures. Specific problems and situations such as the role of gluten-free diet for IDA treatment in CeD, the choice between oral and parenteral supplementation of iron or vitamin B12 in carential anemias, the use of endoscopic procedures to stop bleeding in intestinal angiodysplasia and preventive/treatment strategies for NSAID-associated GI bleeding are discussed.
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Affiliation(s)
- Gaetano Bergamaschi
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Flavio Caprioli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Luca Elli
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | | | | | - Caterina Mengoli
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Emanuela Miceli
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Chiara Ricci
- Gastroenterology Unit, Spedali Civili di Brescia and Department of Clinical and Experimental Sciences, University of Brescia, Brescia Italy
| | - Sandro Ardizzone
- Sacco, University of MilanGastroenterology and Digestive Endoscopy Unit, Department of Biochemical and Clinical Sciences L , Milano, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico and Università degli Studi di Milano, Milan, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy.,Department of Internal Medicine, University of Pavia, Pavia, Italy
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Usefulness of contrast-enhanced multi-detector computed tomography in identifying upper gastrointestinal bleeding: A retrospective study of patients admitted to the emergency department. PLoS One 2022; 17:e0266622. [PMID: 35390082 PMCID: PMC8989213 DOI: 10.1371/journal.pone.0266622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/23/2022] [Indexed: 11/19/2022] Open
Abstract
Upper gastrointestinal bleeding (UGIB) is a major cause of clinical deterioration worldwide. A large number of patients with UGIB cannot be diagnosed through endoscopy, which is normally the diagnostic method of choice. Therefore, this study aimed to investigate the diagnostic value of multi-detector computed tomography (MDCT) for patients with suspected UGIB. In this retrospective observational study of 386 patients, we compared contrast-enhanced abdominopelvic MDCT to endoscopy to analyze the performance of MDCT in identifying the status, location of origin, and etiology of UGIB. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were examined. In the assessment of bleeding status, MDCT was able to accurately identify 32.9% (21.9–43.9, 95% confidence interval [CI]) of patients with active bleeding, 27.4% (18.9–35.9, 95% CI) of patients with recent bleeding, and 94.8% (91.8–97.8, 95% CI) of patients without bleeding evidence (P<0.001). MDCT showed an accuracy of 60.9%, 60.6%, and 50.9% in identifying bleeding in the esophagus, stomach, and duodenum, respectively (P = 0.4028). The accuracy in differentiating ulcerative, cancerous, and variceal bleeding was 58.3%, 65.9%, and 56.6%, respectively (P = 0.6193). MDCT has limited use as a supportive screening method to identify the presence of gastrointestinal bleeding.
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Cho Y, Park SJ, Lee S, Lee HN, Bae SH, Cho S. Gastrointestinal bleeding after failed endoscopic hemostasis: diagnostic efficacy of angiography compared with computed tomography and treatment outcomes of transcatheter arterial embolization. Jpn J Radiol 2022; 40:630-638. [PMID: 35038114 DOI: 10.1007/s11604-022-01246-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/31/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE This study compared the detection sensitivity of catheter angiography to that of contrast-enhanced multi-detector computed tomography (MDCT) for detecting acute non-variceal gastrointestinal bleeding (GIB) to elucidate the diagnostic efficacy of catheter angiography. We also determined GIB outcomes of transcatheter arterial embolization after failed endoscopic hemostasis. MATERIALS AND METHODS Data were collected retrospectively from 63 patients managed at four institutions who met the following criteria during a 3-year period: (1) ongoing non-variceal GIB confirmed during endoscopy; (2) failed endoscopic hemostasis; and (3) endoscopy, MDCT, and catheter angiography performed within 24 h. The diagnostic efficacies of MDCT, selective angiography with a 5-Fr catheter (5Fr-angiography), and super-selective angiography with a microcatheter (micro-angiography) were compared using endoscopic diagnosis as the reference method. The rates of technical success, clinical success, and complications were analyzed when arterial embolization was performed. RESULTS All transcatheter angiographies were performed after MDCT. Micro-angiography had a significantly higher GIB detection rate (73.0%) than MDCT (57.1%) and 5Fr-angiography (39.7%) (micro-angiography vs. MDCT, P = 0.021; MDCT vs. 5Fr-angiography, P = 0.043). Arterial embolization was attempted in 55 of 63 patients, with technical success achieved in 53 of 55 patients (96.4%) and clinical success in 38 of 42 patients (90.5%). Eleven patients were lost to follow-up. Three patients experienced complications, including bowel infarction (two patients) and common bile duct stricture (one patient). CONCLUSION In cases of endoscopic hemostasis failure, angiography can be performed even if MDCT yields negative results but should include micro-angiography; moreover, embolization can be performed safely and effectively. TRIAL REGISTRATION None.
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Affiliation(s)
- Youngjong Cho
- Department of Radiology, Gangneung Asan Hospital, Gangneung-si, Gangwon-do, South Korea
| | - Sung-Joon Park
- Department of Radiology, Korea University Ansan Hospital, Ansan-si, Gyeonggi-do, South Korea
| | - Sangjoon Lee
- Department of Radiology, Pohang St. Mary's Hospital, Daejamdong-gil 17, Nam-gu, Pohang-si, Gyeongsangbuk-do, Republic of Korea, 37661.
| | - Hyoung Nam Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan-si, Republic of Korea
| | - Suk Hyun Bae
- Department of Radiology, Inje University College of Medicine, Ilsan Paik Hospital, Goyang-si, Korea
| | - Seongwhi Cho
- Department of Radiology, Kangwon National University Hospital, Chuncheon-si, Gangwon-do, South Korea
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Shaw MYV, Asokkumar R, Tan Kwong Wei EJ, Seow-En I. Colonic angiodysplasia: a culprit of obscure gastrointestinal bleeding in a patient with Heyde syndrome. BMJ Case Rep 2022; 15:15/1/e247595. [PMID: 35027388 PMCID: PMC8762101 DOI: 10.1136/bcr-2021-247595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
A 77-year-old woman presented with obscure gastrointestinal bleeding requiring multiple hospitalisations and blood transfusions. The patient underwent repeated investigations over four hospital admissions across a span of two months. These included upper and lower gastrointestinal endoscopy, video capsule endoscopy as well as CT enterography, without definitive localisation or treatment of the source of bleeding. Finally, a technetium-99m-labelled red blood cell scan demonstrated a ‘blush’ at the proximal transverse colon on delayed imaging. Targeted colonoscopic evaluation showed a subcentimetre angiodysplastic lesion in the corresponding spot at the proximal transverse colon with slow persistent oozing. Endoscopic clips were applied with successful haemostasis. The patient recovered well without further symptom recurrence 5 months postdischarge. We review the literature on colonic angiodysplasias and discuss the diagnostic challenges in obscure gastrointestinal bleeding.
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Affiliation(s)
| | | | | | - Isaac Seow-En
- General Surgery, Singapore General Hospital, Singapore
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Ali TA, Ibrahim W, Tawab MA, ElHariri MAG. Duodenal angiodysplasia: a case report. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Musilanga N, Hongli Z, Hongyu C. Reappraising the spectrum of bleeding gastrointestinal angioectasia in a degenerative calcific aortic valve stenosis: Heyde’s syndrome. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.1186/s43162-021-00046-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The occurrence of bleeding gastrointestinal angioectasia in elderly patients with degenerative calcific aortic stenosis is one of the most challenging clinical scenarios. A number of studies have shown that this clinical phenomenon is known as Heyde’s syndrome.
Main body of the abstract
The pathogenesis of Heyde’s syndrome is mainly due to the loss of high-molecular-weight von Willebrand factor (HMW vWF) multimers, as a consequent fragmentation of HMW vWF multimers as they pass through the stenosed aortic valve leading to acquired von Willebrand syndrome type IIA. Aortic valve replacement has proven to be a more effective management approach in the cessation of recurrent episodes of gastrointestinal bleeding.
Short conclusion
Physicians should have a high index of suspicion when dealing with elderly patients with established aortic stenosis presenting with iron deficiency anemia or unclear gastrointestinal bleeding. Parallel consultations between different specialties are essential for appropriate management.
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Pech M, Serafin Z, Fischbach F, Damm R, Jargiełło T, Seidensticker M, Powerski M. Transarterial embolization of acute iatrogenic hemorrhages: predictive factors for mortality and outcome. Br J Radiol 2020; 93:20190413. [PMID: 32142365 PMCID: PMC10993211 DOI: 10.1259/bjr.20190413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 02/28/2020] [Accepted: 03/04/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Iatrogenic hemorrhages occur in 0.5-16% of medical procedures. A retrospective study was conducted to analyze technical and clinical outcome of transarterial embolization (TAE) used for acute iatrogenic hemorrhage and to identify factors predicting outcome. METHODS All patients undergoing TAE for acute iatrogenic bleeding from 2006 to 2013 were retrospectively analyzed. Primary end points were technical and clinical success or failure and 30 day mortality. RESULTS A total of 153 patients underwent 182 TAEs. Factors associated with clinical failure were lower blood hemoglobin concentration, use of higher number of units of red blood cell concentrate, TAE performed at night or weekend, embolization of more than one vessel, shock state before digital subtraction angiography (DSA), and intensive care before TAE. In multivariate analysis, independent factors for clinical success were hemoglobin concentration, number of units of red blood cell concentrate, and TAE of more than one vessel. Technical failure was associated with female gender, failure to detect signs of bleeding in DSA, TAE of more than one vessel, and shock state before DSA. Bleeding related to anticoagulation medication resulted in a significantly higher mortality rate compared with bleeding due to the remaining causes (30% vs 15%, p < 0.05). CONCLUSION Despite excellent technical success, the mortality rate was significant. The only factors affecting clinical success were bleeding intensity and extent of injury. Bleeding attributed to anticoagulation is related to high mortality and therefore requires special attention. ADVANCES IN KNOWLEDGE This study gives insights into morbidity and mortality of iatrogenic bleedings and the technical and clinical success rates of TAE in a large study population.
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Affiliation(s)
- Maciej Pech
- Department of Radiology and Nuclear Medicine, University of
Magdeburg, Magdeburg,
Germany
- Department of Radiology, Medical University of
Gdańsk, Gdańsk,
Poland
| | - Zbigniew Serafin
- Department of Radiology and Diagnostic Imaging, Nicolaus
Copernicus University, Bydgoszcz,
Poland
| | - Frank Fischbach
- Department of Radiology and Nuclear Medicine, University of
Magdeburg, Magdeburg,
Germany
| | - Robert Damm
- Department of Radiology and Nuclear Medicine, University of
Magdeburg, Magdeburg,
Germany
| | - Tomasz Jargiełło
- Department of Interventional Radiology and Neuroradiology,
Medical University of Lublin,
Lublin, Poland
| | - Max Seidensticker
- Department of Radiology, University Hospital
Munich, Munich,
Germany
| | - Maciej Powerski
- Department of Radiology and Nuclear Medicine, University of
Magdeburg, Magdeburg,
Germany
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Control of postpartum hemorrhage in women with placenta accreta spectrum using prophylactic balloon occlusion combined with Pituitrin intra-arterial infusion. Eur Radiol 2020; 30:4524-4533. [PMID: 32222796 DOI: 10.1007/s00330-020-06813-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 02/26/2020] [Accepted: 03/13/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The aim of this study is to evaluate the efficacy of prophylactic internal iliac artery balloon occlusion combined with Pituitrin intra-arterial infusion in the control of postpartum hemorrhage in women with placenta accreta spectrum (PAS). METHODS This is a prospective and non-randomized controlled study. The participants were assigned into three groups: without balloon catheterization (non-BC) group, balloon catheterization (BC) group, and Pituitrin combined with balloon catheterization (PBC) group. The primary outcomes were estimated blood loss (EBL) and the units of transfused packed red blood cells (PRBC). The secondary outcome was the incidence of hysterectomy. RESULTS A total of 100 participants were recruited between August 2013 and November 2018 and assigned into the respective groups as follows: 27 in the non-BC group, 22 in the BC group, and 51 in the PBC group. No statistical differences were found in demographic characteristics among the three groups. There was a trend of lower EBL, PRBC, and hysterectomy rate in the BC group than those in the non-BC group, while all values showed no significant differences (all p > 0.05). Patients in the PBC group had significantly lower EBL, PRBC, and hysterectomy rate compared with those in the non-BC group (all p < 0.05). Linear regression analysis revealed that the PBC (vs. others) was negatively correlated with EBL and the non-BC (vs. others) independently predicted more EBL. CONCLUSIONS Balloon occlusion combined with Pituitrin infusion is an effective treatment method which significantly reduced EBL, PRBC, and hysterectomy rate in patients with PAS. KEY POINTS • Internal iliac artery balloon occlusion combined with Pituitrin intra-arterial infusion can significantly decrease EBL, PRBC, and hysterectomy rate during cesarean section in patients with PAS. • Cesarean section without balloon occlusion and placenta accreta depth are two independent risk factors for EBL in patients with PAS.
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García-Compeán D, Del Cueto-Aguilera ÁN, Jiménez-Rodríguez AR, González-González JA, Maldonado-Garza HJ. Diagnostic and therapeutic challenges of gastrointestinal angiodysplasias: A critical review and view points. World J Gastroenterol 2019; 25:2549-2564. [PMID: 31210709 PMCID: PMC6558444 DOI: 10.3748/wjg.v25.i21.2549] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/19/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal angiodysplasias (GIADs), also called angioectasias, are the most frequent vascular lesions. Its precise prevalence is unknown since most of them are asymptomatic. However, the incidence may be increasing since GIADs affect individuals aged more than 60 years and population life expectancy is globally increasing worldwide. They are responsible of about 5% to 10% of all gastrointestinal bleeding (GIB) cases. Most GIADs are placed in small bowel, where are the cause of 50 to 60% of obscure GIB diagnosed with video capsule endoscopy. They may be the cause of fatal severe bleeding episodes; nevertheless, recurrent overt or occult bleeding episodes requiring repeated expensive treatments and disturbing patient’s quality-of-life are more frequently observed. Diagnosis and treatment of GIADs (particularly those placed in small bowel) are a great challenge due to insidious disease behavior, inaccessibility to affected sites and limitations of available diagnostic procedures. Hemorrhagic causality out of the actively bleeding lesions detected by diagnostic procedures may be difficult to establish. No treatment guidelines are currently available, so there is a high variability in the management of these patients. In this review, the epidemiology and pathophysiology of GIADs and the status in the diagnosis and treatment, with special emphasis on small bowel angiodysplasias based on multiple publications, are critically discussed. In addition, a classification of GIADs based on their endoscopic characteristics is proposed. Finally, some aspects that need to be clarified in future research studies are highlighted.
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Affiliation(s)
- Diego García-Compeán
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Ángel N Del Cueto-Aguilera
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Alan R Jiménez-Rodríguez
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - José A González-González
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
| | - Héctor J Maldonado-Garza
- Gastroenterology Service and Department of Internal Medicine, Faculty of Medicine, University Hospital "Dr. José E. González”, Universidad Autónoma de Nuevo León, Monterrey 64700, Nuevo León, Mexico
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Powerski M, Meyer-Wilmes P, Omari J, Damm R, Seidensticker M, Friebe B, Fischbach F, Pech M. Transcatheter arterial embolization of acute bleeding as 24/7 service: predictors of outcome and mortality. Br J Radiol 2018; 91:20180516. [PMID: 30102552 DOI: 10.1259/bjr.20180516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To analyze times of occurrence and identify risk factors (RFs) for technical and clinical failure and mortality of transcatheter arterial embolization (TAE) of acute bleeding in a major hospital. METHODS All TAEs performed at our hospital from 2006 to 2013 (n = 327) were retrospectively analyzed. RESULTS TAEs were performed during regular weekday hours in 165 (50%) and during off-hours in 162 (50%) cases. With 40 regular and 128 off-hours/week, 3.25 times more TAEs were performed during regular hours. There was an even distribution across weekdays (Mon-Fri:16.9 ± 1.5%), while fewer TAEs were performed on weekends (Sat: 8.3%, Sun: 7.3%). Technical success of TAEs was 93.9% with a clinical success of 79.2% and a 30-day mortality of 18.4%. Shock was an RF for technical failure (p = 0.022). RFs for clinical failure were low hemoglobin (Hb) (p = 0.021) and transfusion of ≥6 units packed cells (p = 0.009). Independent RFs for mortality were clinical failure (p < 0.001), coagulopathy (p = 0.005), and shock (p < 0.001). CONCLUSION Our results provide no evidence for a subjectively perceived increase in TAEs during off-hours but rather appear to show that most TAEs are performed during regular hours. Prompt TAE to control acute bleeding is crucial to prevent a drop in Hb with shock and the need for transfusion, which may promote coagulopathy and rebleeding, all of which are risk factors for a negative outcome. ADVANCES IN KNOWLEDGE The presented analysis provides insights of occurrences and risk factors for success of transcatheter arterial embolization in acute bleeding in a large study population.
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Affiliation(s)
- Maciej Powerski
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Philipp Meyer-Wilmes
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Jazan Omari
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Robert Damm
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Max Seidensticker
- 2 Klinik und Poliklinik für Radiologie, Klinikum der Universität München , München , Germany
| | - Björn Friebe
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Frank Fischbach
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany
| | - Maciej Pech
- 1 Department of Radiology and Nuclear Medicine, Otto-von-Guericke University , Magdeburg , Germany.,3 Department of Radiology, Medical University of Gdansk , Gdańsk , Poland
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Ray DM, Srinivasan I, Tang SJ, Vilmann AS, Vilmann P, McCowan TC, Patel AM. Complementary roles of interventional radiology and therapeutic endoscopy in gastroenterology. World J Radiol 2017; 9:97-111. [PMID: 28396724 PMCID: PMC5368632 DOI: 10.4329/wjr.v9.i3.97] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 11/12/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
Acute upper and lower gastrointestinal bleeding, enteral feeding, cecostomy tubes and luminal strictures are some of the common reasons for gastroenterology service. While surgery was initially considered the main treatment modality, the advent of both therapeutic endoscopy and interventional radiology have resulted in the paradigm shift in the management of these conditions. In this paper, we discuss the patient’s work up, indications, and complementary roles of endoscopic and angiographic management in the settings of gastrointestinal bleeding, enteral feeding, cecostomy tube placement and luminal strictures. These conditions often require multidisciplinary approaches involving a team of interventional radiologists, gastroenterologists and surgeons. Further, the authors also aim to describe how the fields of interventional radiology and gastrointestinal endoscopy are overlapping and complementary in the management of these complex conditions.
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Abstract
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.
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20
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Angiographic Evaluation and Management of Nonvariceal Gastrointestinal Hemorrhage. AJR Am J Roentgenol 2015; 205:753-63. [DOI: 10.2214/ajr.15.14803] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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21
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Eid JJ, Radecke JM, Murr MM. Gastrointestinal bleeding from the excluded stomach: a proposed algorithmic approach to management. Surg Obes Relat Dis 2014; 11:e11-4. [PMID: 25449066 DOI: 10.1016/j.soard.2014.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 09/16/2014] [Indexed: 12/21/2022]
Affiliation(s)
- Joseph J Eid
- University of Balamand, School of Medicine and Medical Sciences, Beirut, Lebanon.
| | - Jason M Radecke
- Department of Surgery, University of South Florida, Tampa General Hospital, Tampa, Florida
| | - Michel M Murr
- Department of Surgery, University of South Florida, Tampa General Hospital, Tampa, Florida
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Ramaswamy RS, Choi HW, Mouser HC, Narsinh KH, McCammack KC, Treesit T, Kinney TB. Role of interventional radiology in the management of acute gastrointestinal bleeding. World J Radiol 2014; 6:82-92. [PMID: 24778770 PMCID: PMC4000612 DOI: 10.4329/wjr.v6.i4.82] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 02/20/2014] [Accepted: 03/11/2014] [Indexed: 02/06/2023] Open
Abstract
Acute gastrointestinal bleeding (GIB) can lead to significant morbidity and mortality without appropriate treatment. There are numerous causes of acute GIB including but not limited to infection, vascular anomalies, inflammatory diseases, trauma, and malignancy. The diagnostic and therapeutic approach of GIB depends on its location, severity, and etiology. The role of interventional radiology becomes vital in patients whose GIB remains resistant to medical and endoscopic treatment. Radiology offers diagnostic imaging studies and endovascular therapeutic interventions that can be performed promptly and effectively with successful outcomes. Computed tomography angiography and nuclear scintigraphy can localize the source of bleeding and provide essential information for the interventional radiologist to guide therapeutic management with endovascular angiography and transcatheter embolization. This review article provides insight into the essential role of Interventional Radiology in the management of acute GIB.
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23
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Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2014; 39:15-34. [PMID: 24138285 DOI: 10.1111/apt.12527] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/14/2013] [Accepted: 09/18/2013] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- S S Sami
- Nottingham Digestive Diseases Centre & NIHR Biomedical research Unit, Queens Medical Centre, Nottingham, UK
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Outcomes following "rescue" superselective angioembolization for gastrointestinal hemorrhage in hemodynamically unstable patients. J Trauma Acute Care Surg 2013; 75:398-403. [PMID: 23928742 DOI: 10.1097/ta.0b013e31829a8b7a] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Therapeutic angioembolization is a relatively new "rescue treatment" modality for gastrointestinal hemorrhage (GIH) for unstable patients who fail primary treatment approaches; however, the effectiveness of this treatment and the incidence of ischemic necrosis following embolization for acute GIH are poorly described. The purpose of this study was to evaluate the effectiveness and safety of "rescue" transcatheter superselective angioembolization (SSAE) for the treatment of hemodynamically unstable patients with GIH. METHODS A 10-year retrospective review of all hemodynamically unstable patients (systolic blood pressure < 90 mm Hg and ongoing transfusion requirement) who underwent "rescue" SSAE for GIH after failed endoscopic management was performed. All patients with evidence of active contrast extravasation were included. Data were collected on demographics, comorbidities, clinical presentation, and type of intravascular angioembolic agent used. Outcomes included technical success (cessation of extravasation), clinical success (no rebleeding requiring intervention within 30 days), and incidence of ischemic complications. RESULTS Ninety-eight patients underwent SSAE for GIH during the study period; 47 were excluded owing to lack of active contrast extravasation. Of the remaining 51 patients, 22 (43%) presented with a lower GIH and 29 (57%) with upper GIH. The majority underwent embolization with a permanent agent (71%), while the remaining patients received either a temporary agent (16%) or a combination (14%). The overall technical and clinical success rates were 98% and 71%, respectively. Of the 14 patients with technical success but clinical failure (rebleeding within 30 days) and the 1 patient with technical failure, 4 were managed successfully with reembolization, while 2 underwent successful endoscopic therapy, and 9 had surgical resections. Only one patient had an ischemic complication (small bowel necrosis) requiring resection. CONCLUSION SSAE, with reembolization if necessary, is an effective rescue treatment modality for hemodynamically unstable patients with active GIH. Of the patients, 20% will fail SSAE and require additional intervention. Ischemic complications are extremely rare. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Abstract
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.
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Quality improvement guidelines for transcatheter embolization for acute gastrointestinal nonvariceal hemorrhage. Cardiovasc Intervent Radiol 2012; 36:608-12. [PMID: 23150119 DOI: 10.1007/s00270-012-0462-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 07/05/2012] [Indexed: 12/28/2022]
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27
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Johnson JO. Diagnosis of Acute Gastrointestinal Hemorrhage and Acute Mesenteric Ischemia in the Era of Multi-Detector Row CT. Radiol Clin North Am 2012; 50:173-82. [DOI: 10.1016/j.rcl.2011.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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28
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Elfert AA, El-Kalla FS. Gastroenterologists and interventional radiologists: friends or foes? A multidisciplinary approach for solving gastrointestinal problems. Arab J Gastroenterol 2011; 12:5-10. [PMID: 21429447 DOI: 10.1016/j.ajg.2011.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 08/20/2010] [Accepted: 09/25/2010] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Asem Ahmed Elfert
- Department of Tropical Medicine and Infectious Diseases, Tanta University, Faculty of Medicine, Tanta, Egypt.
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Abstract
Radiological techniques are important in evaluating patients with gastrointestinal bleeding. Scintigraphic, computed tomographic angiographic, and enterographic techniques are sensitive tools in identifying the source of bleeding and may be useful in identifying patients likely to have a benign course and in selecting patients for therapeutic intervention. Angiography plays a key role in bleeding localization, and modern embolization techniques make this a viable therapeutic option. With the refining developments in body imaging and related reconstructive techniques, it is likely that radiological interventions will play an expanding and critical role in evaluating patients with gastrointestinal hemorrhage in the future.
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Wu LM, Xu JR, Yin Y, Qu XH. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: A meta-analysis. World J Gastroenterol 2010; 16:3957-63. [PMID: 20712058 PMCID: PMC2923771 DOI: 10.3748/wjg.v16.i31.3957] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the accuracy of computed tomography (CT) angiography in the diagnosis of acute gastrointestinal (GI) bleeding.
METHODS: The MEDLINE, EMBASE, Cancerlit, Cochrane Library database, Sciencedirect, Springerlink and Scopus, from January 1995 to December 2009, were searched for studies evaluating the accuracy of CT angiography in diagnosing acute GI bleeding. Studies were included if they compared CT angiography to a reference standard of upper GI endoscopy, colonoscopy, angiography or surgery in the diagnosis of acute GI bleeding. Meta-analysis methods were used to pool sensitivity and specificity and to construct summary receiver-operating characteristic.
RESULTS: A total of 9 studies with 198 patients were included in this meta-analysis. Data were used to form 2 × 2 tables. CT angiography showed pooled sensitivity of 89% (95% CI: 82%-94%) and specificity of 85% (95% CI: 74%-92%), without showing significant heterogeneity (χ2 = 12.5, P = 0.13) and (χ2 = 22.95, P = 0.003), respectively. Summary receiver operating characteristic analysis showed an area under the curve of 0.9297.
CONCLUSION: CT angiography is an accurate, cost-effective tool in the diagnosis of acute GI bleeding and can show the precise location of bleeding, thereby directing further management.
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