Arterial embolisation in management of massive bleeding from gastric and duodenal ulcers

Embolization for acute nonvariceal bleeding of upper and lower gastrointestinal tract: a systematic review

BACKGROUND

Acute non-variceal gastrointestinal bleedings (GIBs) are pathological conditions associated with significant morbidity and mortality. Embolization without angiographic evidence of contrast media extravasation is proposed as an effective procedure in patients with clinical and/or laboratory signs of bleeding. The purpose of this systematic review is to define common clinical practice and clinical and technical outcomes of blind and preventive embolization for upper and lower gastrointestinal bleeding.

MAIN BODY

Through the PubMed, Embase and Google Scholar database, an extensive search was performed in the fields of empiric and preventive embolization for the treatment of upper and lower gastrointestinal bleedings (UGIB and LGIB). Inclusion criteria were: articles in English for which it has been possible to access the entire content; adults patients treated with empiric or blind transcatheter arterial embolization (TAE) for UGIB and/or LGIB. Only studies that analysed clinical and technical success rate of blind and empiric TAE for UGIB and/or LGIB were considered for our research. Exclusion criteria were: recurrent articles from the same authors, articles written in other languages, those in which the entire content could not be accessed and that articles were not consistent to the purposes of our research. We collected pooled data on 1019 patients from 32 separate articles selected according to the inclusion and exclusion criteria. 22 studies focused on UGIB (total 773 patients), one articles focused on LGIB (total 6 patients) and 9 studies enrolled patients with both UGIB and LGIB (total 240 patients). Technical success rate varied from 62% to 100%, with a mean value of 97.7%; clinical success rate varied from 51% to 100% with a mean value of 80%. The total number of complications was 57 events out of 1019 procedures analysed.

CONCLUSION

TAE is an effective procedure in the treatment of UGIB patients in which angiography does not demonstrate direct sign of ongoing bleeding. The attitude in the treatment of LGIBs must be more prudent in relation to poor vascular anastomoses and the high risk of intestinal ischemia. Blind and preventive procedures cumulatively present a relatively low risk of complications, compared to a relatively high technical and clinical success.

Massive bleeding from gastric ulcer-induced splenic artery pseudoaneurysm successfully treated with transcatheter arterial embolization and surgery: a case report

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a routine medical emergency. The most common non-variceal cause is peptic ulcer disease, while a rare presentation is peptic ulcer-induced splenic artery pseudoaneurysm (SAP). Primary endoscopic treatment is generally attempted for UGIB; however, it sometimes fails when arterial etiology is present. In such cases, either transcatheter arterial embolization (TAE) or surgery is necessary, but the choice of treatment is controversial. We present a case that illustrates the utility of both approaches in a gastric ulcer-induced SAP.

CASE PRESENTATION

A 33-year-old male presented with hemorrhagic shock secondary to UGIB. The source of bleeding was identified as an SAP that was caused by a gastric ulcer. TAE enabled temporary bleeding control despite the patient's poor overall condition and limited blood transfusion capability. However, rebleeding occurred soon after stabilization. Ultimately, we performed proximal gastrectomy and splenic artery ligation, and the patient survived.

CONCLUSIONS

SAP is an uncommon occurrence, and angiographic information is important for correctly identifying the source of bleeding. The treatment for SAP bleeding is basically the same as for endoscopically unmanageable non-variceal UGIB, since TAE and surgery each have a different utility, depending on the situation. If surgery is performed, especially SA ligation and gastrectomy, it is important to consider the circulation of the spleen and residual stomach. Using TAE and laparotomy, we managed to save the life of the patient with massive hemorrhage under limited circumstances.

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.

When all else fails - Radiological management of severe gastrointestinal bleeding

Although most cases of acute nonvariceal gastrointestinal bleeding (GIB) either spontaneously resolve or respond to medical management and endoscopic therapy, there are still a significant proportion of severe patients who require emergency angiography and endovascular treatment. Over the past three decades, transcatheter arterial embolization (TAE) has become the first-line therapy for the management of acute nonvariceal GIB that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer liquid embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the treatment of bleeding for a variety of indications. TAE is a safe and effective minimally invasive alternative to surgery, when endoscopic treatment fails to control acute bleeding from the gastrointestinal tract. In this article we review the current role of angiography and TAE in the management of acute nonvariceal GIB.

Successful endovascular treatment of endoscopically unmanageable hemorrhage from a duodenal ulcer fed by a renal artery: A case report

A 52-year-old woman was admitted with hypovolemic shock. Emergency endoscopy revealed three hemorrhagic duodenal ulcers (all stage A1) with exposed vessels. Two ulcers were successfully treated by endoscopic clipping; however, the remaining ulcer on the posterior wall of the horizontal portion of the duodenum could not be clipped. Because her vital signs were rapidly worsening, we performed transcatheter arterial embolization (TAE) as it is less invasive than surgery. Computed tomography aortography showed that the duodenal hemorrhage was sourced from the lower branch of the right renal artery. In general, the duodenum is fed by branches from the gastroduodenal artery or superior mesenteric artery. However, this patient had three right renal arteries. The lower branch of the right renal artery at the L3 vertebral level was at the same level as the horizontal portion of the duodenum. Complete hemostasis was achieved by TAE using metallic coils and n-butyl-2-cyanoacrylate. After TAE, she recovered from the hypovolemic shock and was discharged from hospital. She has had no recurrence of the hemorrhagic duodenal ulcer for over 1 yr, and follow-up endoscopy showed no necrosis or stricture of the duodenum. Although she developed a small infarct of her right kidney, her renal function was satisfactory. In summary, the present case is the first reported case of hemorrhagic duodenal ulcer in which the culprit vessel was a renal artery that was successfully treated by TAE. Computed tomography aortography before TAE provides valuable information regarding the source of a duodenal hemorrhage.

Gastrodoudenal Embolization: Indications, Technical Pearls, and Outcomes

The gastroduodenal artery (GDA) is frequently embolized in cases of upper GI bleed that has failed endoscopic therapy. Additionally, it may be done for GDA pseudoaneurysms or as an adjunctive procedure prior to Yttrim-90 (Y90) treatment of hepatic tumors. This clinical review will summarize anatomy and embryology of the GDA, indications, outcomes and complications of GDA embolization.

Diagnosis and therapy of non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding (UGIB) is defined as bleeding proximal to the ligament of Treitz in the absence of oesophageal, gastric or duodenal varices. The clinical presentation varies according to the intensity of bleeding from occult bleeding to melena or haematemesis and haemorrhagic shock. Causes of UGIB are peptic ulcers, Mallory-Weiss lesions, erosive gastritis, reflux oesophagitis, Dieulafoy lesions or angiodysplasia. After admission to the hospital a structured approach to the patient with acute UGIB that includes haemodynamic resuscitation and stabilization as well as pre-endoscopic risk stratification has to be done. Endoscopy offers not only the localisation of the bleeding site but also a variety of therapeutic measures like injection therapy, thermocoagulation or endoclips. Endoscopic therapy is facilitated by acid suppression with proton pump inhibitor (PPI) therapy. These drugs are highly effective but the best route of application (oral vs intravenous) and the adequate dosage are still subjects of discussion. Patients with ulcer disease are tested for Helicobacter pylori and eradication therapy should be given if it is present. Non-steroidal anti-inflammatory drugs have to be discontinued if possible. If discontinuation is not possible, cyclooxygenase-2 inhibitors in combination with PPI have the lowest bleeding risk but the incidence of cardiovascular events is increased.

What if endoscopic hemostasis fails? Alternative treatment strategies: interventional radiology

Since the 1960s, interventional radiology has played a role in the management of gastrointestinal bleeding. What began primarily as a diagnostic modality has evolved into much more of a therapeutic tool. And although the frequency of gastrointestinal bleeding has diminished thanks to management by pharmacologic and endoscopic methods, the need for additional invasive interventions still exists. Transcatheter angiography and intervention is a fundamental step in the algorithm for the treatment of gastrointestinal bleeding.

Predictive factors for intractability to endoscopic hemostasis in the treatment of bleeding gastroduodenal peptic ulcers in Japanese patients

BACKGROUND/AIMS

Despite improvements in endoscopic hemostasis and pharmacological therapies, upper gastrointestinal (UGI) ulcers repeatedly bleed in 10% to 20% of patients, and those without early endoscopic reintervention or definitive surgery might be at a high risk for mortality. This study aimed to identify the risk factors for intractability to initial endoscopic hemostasis.

METHODS

We analyzed intractability among 428 patients who underwent emergency endoscopy for bleeding UGI ulcers within 24 hours of arrival at the hospital.

RESULTS

Durable hemostasis was achieved in 354 patients by using initial endoscopic procedures. Sixty-nine patients with Forrest types Ia, Ib, IIa, and IIb at the second-look endoscopy were considered intractable to the initial endoscopic hemostasis. Multivariate analysis indicated that age ≥70 years (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.07 to 4.03), shock on admission (OR, 5.26; 95% CI, 2.43 to 11.6), hemoglobin <8.0 mg/dL (OR, 2.80; 95% CI, 1.39 to 5.91), serum albumin <3.3 g/dL (OR, 2.23; 95% CI, 1.07 to 4.89), exposed vessels with a diameter of ≥2 mm on the bottom of ulcers (OR, 4.38; 95% CI, 1.25 to 7.01), and Forrest type Ia and Ib (OR, 2.21; 95% CI, 1.33 to 3.00) predicted intractable endoscopic hemostasis.

CONCLUSIONS

Various factors contribute to intractable endoscopic hemostasis. Careful observation after endoscopic hemostasis is important for patients at a high risk for incomplete hemostasis.

Embolization versus surgery for peptic ulcer bleeding after failed endoscopic hemostasis: a meta-analysis

BACKGROUND AND STUDY AIMS

A meta-analysis was conducted to assess the efficacy of transcatheter arterial embolization (TAE) compared with surgery in the management of patients with recurrent nonvariceal upper gastrointestinal bleeding (NVUGIB) after failure of endoscopic hemostasis.

PATIENTS AND METHODS

Publications in English and non-English literatures (OVID, MEDLINE, and EMBASE) and abstracts from major international conferences were searched for studies comparing TAE with surgery for treatment of NVUGIB after endoscopic hemostasis failure. Outcome measures included rebleeding rate, all-cause mortality rate, and need for additional interventions to secure hemostasis.

RESULTS

From 1234 citations, 6 retrospective comparative studies were included that involved 423 patients (TAE, 182, 56 % male; surgery, 241, 68 % male). TAE patients were older (mean age, TAE 75, surgery, 68). The risk of rebleeding was significantly higher in TAE patients compared with surgically treated patients (relative risk [RR] 1.82, 95 % confidence interval [95 %CI] 1.23 - 2.67), with no statistically significant heterogeneity among the included studies (P = 0.66, I (2) = 0.0 %). After sensitivity analysis excluding studies with a large age difference between the two groups, a higher risk of bleeding remained in the TAE group (RR 2.64, 95 %CI] 1.48 - 4.71). No significant difference in mortality (RR 0.87, 95 %CI 0.59 - 1.29) or requirement for additional interventions (RR 1.67, 95 %CI 0.75 - 3.70) was shown between the two groups.

CONCLUSION

A higher rebleeding rate was observed after TAE, suggesting surgery more definitively secured hemostasis, with no significant difference in mortality rate or requirement of additional interventions. The TAE patients were older and in poorer health, thus future randomized studies are needed for accurate comparison of the two modalities.

Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding

BACKGROUND

The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed.

METHODS

A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding.

RESULTS

Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding.

CONCLUSION

An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.

Transcatheter arterial embolization with N-butyl cyanoacrylate for acute life-threatening gastroduodenal bleeding uncontrolled by endoscopic hemostasis

PURPOSE

To investigate the feasibility, efficacy, and safety of transcatheter arterial embolization with N-butyl cyanoacrylate (NBCA) for gastroduodenal nonvariceal bleeding uncontrolled by endoscopic hemostasis.

MATERIALS AND METHODS

Between January 2006 and December 2011, a total of 317 patients underwent emergent endoscopic therapy for nonvariceal gastroduodenal bleeding, but hemostasis was not achieved in 20 cases. Emergent surgery was performed immediately following endoscopy in two patients. Arteriography was performed in the remaining 18 patients, and embolization with NBCA was performed in 15 patients (mean age, 71.3 y) in whom the bleeding site was detected on arteriography. For embolization, NBCA was mixed with iodized oil at a ratio of 1:1.5-1:4, and no other embolic material was used in the procedure. Technical and clinical success rates, recurrent bleeding, procedural time, complications, and clinical outcomes were determined for each procedure.

RESULTS

Embolization with NBCA was technically and clinically successful in all procedures, without major complications. No patient receiving embolization with NBCA experienced recurrent bleeding or required further treatment after the one-session procedure. All patients were discharged after clinical improvement. The time between puncture of the femoral artery and completion of embolization ranged from 25 to 240 minutes (mean, 66 min), and the time between the microcatheter reaching the ultimate catheter location selected for embolization and hemostasis ranged from 142 to 550 seconds (mean, 322s).

CONCLUSIONS

In this limited series, embolization with NBCA was found to be a safe, feasible, and effective treatment for gastroduodenal arterial bleeding when endoscopic hemostasis had failed.

Catastrophic bleeding from a marginal ulcer after gastric bypass

The authors describe a case of life-threatening hemorrhagic marginal ulcer eroding into the splenic artery that required surgical intervention.

Marginal ulceration at the gastrojejunal anastomosis is a common complication following Roux-Y gastric bypass (RYGB). Hemodynamically significant hemorrhagic marginal ulcers are usually treated either endoscopically or surgically. We describe a unique case of life-threatening hemorrhagic marginal ulcer eroding into the main splenic artery. This condition was initially managed with angiographic embolization, followed by surgical intervention.

Optimal nonsurgical management of peptic ulcer bleeding, including arterial embolization is associated with a mortality below 1%

BACKGROUND

Management of high-risk peptic ulcer bleeding (PUB) consists in a high-dose infusion of proton pump inhibitors (PPIs) with double endoscopic treatment. If bleeding recurs, a second endoscopic treatment is required. Surgical management should be performed in case of endoscopic treatment failure, or if a second rebleeding occurs. Arterial embolization of PUB has been shown efficient and safe in small retrospective series, but optimal medical treatment was not used.

OBJECTIVE

Prospective assessment of the feasibility and the efficacy of arterial embolization of endoscopically unmanageable PUB, after optimal medical treatment.

PATIENTS

All consecutive patients referred to our intensive care unit (ICU) for high-risk PUB received high-dose PPIs and underwent double endoscopic treatment when possible. Arterial embolization was proposed in primary failure to endoscopic treatment, in case of failure of the second endoscopic treatment, or if a second recurrence occurred.

RESULTS

One hundred and twenty-eight patients with PUB were enrolled between January 2008 and December 2009. Arterial embolization, performed in 11 patients, was efficient in nine patients. Surgery was performed in two patients (one after inefficient embolization, and one with embolization-related complication). One patient died during hospitalization.

CONCLUSION

Arterial embolization seems to be efficient for endoscopically unmanageable PUB. In our series, one patient developed severe complication related to the procedure and died. If arterial embolization could be proposed before surgery in case of refractory PUB, large prospective studies are needed.

Emergency transcatheter arterial embolization for patients with acute massive duodenal ulcer hemorrhage

AIM: To evaluate the efficacy and safety of emergency transcatheter arterial embolization (ETAE) for patients with acute massive duodenal ulcer hemorrhage.

METHODS: Twenty-nine consecutive patients with acute massive bleeding of duodenal ulcer were admitted to our hospital from 2006 to 2011. Superselective angiography of the celiac and gastroduodenal arteries was performed to find out the bleeding sites before ETAE, then, embolotherapy was done with gelatin sponge particles or microstrips via a 5 French angiographic catheter or 3 French microcatheter. After ETAE, further superior mesenteric arteriography was undertaken in case collateral circulation supplied areas of the duodenal ulcer. Technical and clinical success rates were analyzed. Changes in the mucous membrane were observed using endoscopy following ETAE.

RESULTS: Angiography showed active bleeding with extravasation of contrast medium in seven cases with a 24% positive rate of celiac artery bleeding, and in 19 cases with a 65.5% rate of gastroduodenal artery bleeding. There were no angiographic signs of bleeding in three patients who underwent endoscopy prior to ETAE. Twenty-six patients achieved immediate hemostasis and technical success rate reached 90%. No hemostasis was observed in 27 patients within 30 d after ETAE and clinical success rate was 93%. Recurrent hemorrhage occurred in two patients who drank a lot of wine who were treated by a second embolotherapy in the same way. Five patients underwent transient ischem with light abdominal pain under xiphoid, spontaneous restoration without special treatment. No mucous necrosis happened to 29 cases for ischem of gastroduodenal arteries embolized.

CONCLUSION: ETAE is an effective and safe measure to control acute massive bleeding of duodenal ulcer.

The efficacy of transcatheter arterial embolization as the first-choice treatment after failure of endoscopic hemostasis and endoscopic treatment resistance factors

AIM

The aim of this retrospective study was to evaluate the efficacy of transcatheter arterial embolization (TAE) as the first-choice treatment in patients with bleeding peptic ulcer after the failure of endoscopic hemostasis. An additional objective was to clarify endoscopic treatment resistance factors.

METHODS

Between April 2004 and December 2010, 554 patients were admitted to Kasugai Municipal Hospital for necessary endoscopic hemostasis for bleeding gastric ulcer or duodenal ulcer. In the patients for whom endoscopic hemostasis failed, TAE was attempted. If TAE failed, the patients underwent surgery. The backgrounds of the patients in whom endoscopic treatment was successful and in whom it failed were compared.

RESULTS

TAE was attempted in 15 patients (2.7%). In 12 (80.0%) of 15 patients, embolization with coils was successful. In one patient (6.7%), embolization was ineffective. This patient underwent emergent salvage surgery. In two (13.3%) of 15 patients, no extravasation was observed during arteriography. These patients were cured with medication. In two patients, ulcer perforation was observed during endoscopy after rebleeding. These patients underwent surgery. In total, 3 (0.5%) of 554 patients underwent surgery. No recurrent bleeding was observed after TAE. Hemoglobin level <8 g/dL at presentation (P = 0.02), Rockall score ≥7 at presentation (P = 0.002), and Forrest class Ia/Ib at initial endoscopic hemostasis (P < 0.001) were found to be independent significant endoscopic treatment resistance factors.

CONCLUSIONS

TAE is a safe and effective first-choice treatment for patients in whom endoscopic hemostasis has failed.

Recent advances in endovascular techniques for management of acute nonvariceal upper gastrointestinal bleeding

Over the past two decades, transcatheter arterial embolization has become the first-line therapy for the management of upper gastrointestinal bleeding that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the management of hemorrhage for a variety of indications, such as peptic ulcer bleeding, malignant disease, hemorrhagic Dieulafoy lesions and iatrogenic or trauma bleeding. Transcatheter interventions include the following: selective embolization of the feeding artery, sandwich coil occlusion of the gastroduodenal artery, blind or empiric embolization of the supposed bleeding vessel based on endoscopic findings and coil pseudoaneurysm or aneurysm embolization by three-dimensional sac packing with preservation of the parent artery. Transcatheter embolization is a fast, safe and effective, minimally invasive alternative to surgery when endoscopic treatment fails to control bleeding from the upper gastrointestinal tract. This article reviews the various transcatheter endovascular techniques and devices that are used in a variety of clinical scenarios for the management of hemorrhagic gastrointestinal emergencies.

Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review

AIM

To assess the published evidence on the endovascular treatment of non-variceal upper gastrointestinal haemorrhage.

MATERIALS AND METHODS

An Ovid Medline search of published literature was performed (1966-2009). Non-English literature, experimental studies, variceal haemorrhage and case series with fewer than five patients were excluded. The search yielded 1888 abstracts. Thirty-five articles were selected for final analysis.

RESULTS

The total number of pooled patients was 927. The technical and clinical success of embolization ranged from 52-100% and 44-100%, respectively. The pooled mean technical/clinical success rate in primary upper gastrointestinal tract haemorrhage (PUGITH) only, trans-papillary haemorrhage (TPH) only, and mixed studies were 84%/67%, 93%/89%, and 93%/64%, respectively. Clinical outcome was adversely affected by multi-organ failure, shock, corticosteroids, transfusion, and coagulopathy. The anatomical source of haemorrhage and procedural variables did not affect the outcome. A successful embolization improved survival by 13.3 times. Retrospective comparison with surgery demonstrated equivalent mortality and clinical success, despite embolization being applied to a more elderly population with a higher prevalence of co-morbidities.

CONCLUSIONS

Embolization is effective in this very difficult cohort of patients with outcomes similar to surgery.

Is transcatheter arterial embolization a safer alternative than surgery when endoscopic therapy fails in bleeding duodenal ulcer?

OBJECTIVE

Emergency surgery after unsuccessful endoscopic therapy for bleeding duodenal ulcer has been reported to have a high mortality. Transcatheter arterial embolization (TAE) of the gastroduodenal artery is an alternative strategy when endoscopic therapy fails. This study is a retrospective analysis comparing these two treatment strategies.

MATERIAL AND METHODS

Patients who underwent TAE (n = 24) or open surgery (n = 50) after unsuccessful endoscopic therapy for bleeding duodenal ulcers at two university hospitals between 2000 and 2007 were compared. Mortality, morbidity, length of hospital stay, age, number of endoscopic interventions and acute physiology and chronic health evaluation (APACHE) II score were evaluated.

RESULTS

The groups were comparable concerning gender and length of hospital stay. The mean age (69.6 +/- 16.1 versus 61.9 +/- 14.1 years; P = 0.043), APACHE II score (17.0 +/- 5.1 versus 12.8 +/- 5.7; P = 0.004) and number of gastroscopies (P = 0.009) were significantly higher in the embolization group. Five patients (20.8%) died in the embolization group compared to 11 (22%) in the surgery group. However, mortality in high-risk patients (APACHE II score >or= 16.5) was lower in the TAE group (23.1% versus 50.0%; P = 0.236). Method-related as well as other complications were not significantly different between the two groups. There was, however, a higher re-bleeding rate in the TAE group.

CONCLUSIONS

TAE of the gastroduodenal artery appears to be a safe alternative when endoscopic therapy for bleeding duodenal ulcer fails, at least in high-risk patients. The role of TAE in low-risk patients with bleeding from duodenal ulcer needs to be defined by means of a prospective controlled trial.

[Guidelines of treatment for bleeding peptic ulcer disease]

Peptic ulcer (PU) bleeding is the main cause of non-variceal gastrointestinal bleeding. Negative outcomes include re-bleeding and death, and many of the deaths are associated with decompensation of coexisting medical conditions precipitated by acute bleeding event. Accurate analysis of risk for clinical features can help physician to decide treatment modality. Endoscopy can detect bleeding stigmata and perform therapeutic hemostasis. Proton pump inhibitor (PPI) compared with placebo or H2RA reduces mortality following PU bleeding among patients with high-risk endoscopic findings, and reduces re-bleeding rates and surgical intervention. PPI treatment initiated prior to endoscopy in upper gastrointestinal (UGI) bleeding significantly reduces the proportion of patients with stigmata of recent hemorrhage (SRH) at index endoscopy but does not reduce mortality, re-bleeding or the need for surgery. The strategy of giving oral PPI before and after endoscopy, with endoscopic hemostasis for those with major SRH, is likely to be the most cost-effective. The treatment of H. pylori infection was found to be more effective than anti-secretory therapy in preventing recurrent bleeding from PU. H. pylori eradication alone and eradication followed by misoprostol (with switch to PPI, if misoprostol is not tolerated) are the two most cost-effective strategies to prevent ulcer bleeding among H. pylori-infected NSAID users, although the data cannot exclude PPIs also being cost-effective treatment. This review focuses specifically on the current treatment of patients with acute bleeding from a peptic ulcer.

Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers

Intractable bleeding from gastric and duodenal ulcers is associated with significant morbidity and mortality. Aggressive treatment with early endoscopic hemostasis is essential for a favourable outcome. In as many as 12%-17% of patients, endoscopy is either not available or unsuccessful. Endovascular therapy with selective catheterization of the culprit vessel and injection of embolic material has emerged as an alternative to emergent operative intervention in high-risk patients. There has not been a systematic literature review to assess the role for embolotherapy in the treatment of acute upper gastrointestinal bleeding from gastroduodenal ulcers after failed endoscopic hemostasis. Here, we present an overview of indications, techniques, and clinical outcomes after endovascular embolization of acute peptic-ulcer bleeding. Topics of particular relevance to technical and clinical success are also discussed. Our review shows that transcatheter arterial embolization is a safe alternative to surgery for massive gastroduodenal bleeding that is refractory to endoscopic treatment, can be performed with high technical and clinical success rates, and should be considered the salvage treatment of choice in patients at high surgical risk.

Effectiveness of coil embolization in angiographically detectable versus non-detectable sources of upper gastrointestinal hemorrhage

PURPOSE

To determine whether the effectiveness of arterial embolization in patients with acute upper gastrointestinal hemorrhage is related to the visualization of contrast medium extravasation at angiography.

MATERIALS AND METHODS

Transcatheter embolization was performed in 108 patients who experienced acute upper gastrointestinal hemorrhage during a 5-year period. Patient charts were retrospectively reviewed. Thirty-six patients who underwent embolization after angiography demonstrated active contrast medium extravasation from an involved artery. Seventy-two patients underwent embolization in the absence of contrast medium extravasation into a bowel lumen. Embolization technique, requirement for further blood products, need for further surgery, and 30-day mortality were recorded.

RESULTS

The gastroduodenal artery (GDA) was embolized in 26 of the 36 patients (72%) with extravasation, and the left gastric artery was embolized in 10 (28%). The GDA was embolized in 64 of the 72 patients (89%) without extravasation, and the left gastric artery was embolized in 13 (18%). After embolization, 23 of the 36 patients (64%) with extravasation and 44 of the 72 (61%) without extravasation required additional blood product transfusions. Seven of the 36 patients (19%) with extravasation and 16 of the 72 (22%) without extravasation required subsequent surgery secondary to bleeding. Thirty-day hemorrhage-related mortality was 17% (six of 36 patients) in the positive extravasation group and 22% (16 of 72 patients) in the negative extravasation group. The treatment success rate was 44% (16 of 36 patients) in the positive extravasation group and 44% (32 of 72 patients) in the negative extravasation group.

CONCLUSIONS

In patients with acute upper gastrointestinal hemorrhage, arterial embolization is equally effective in patients who demonstrate active contrast medium extravasation at angiography as in those who do not show contrast extravasation.

Management of massive peptic ulcer bleeding

Massive bleeding from a peptic ulcer remains a challenge. A multidisciplinary team of skilled endoscopists, intensive care specialists, experienced upper gastrointestinal surgeons, and intervention radiologists all have a role to play. Endoscopy is the first-line treatment. Even with larger ulcers, endoscopic hemostasis can be achieved in the majority of cases. Surgery is clearly indicated in patients in whom arterial bleeding cannot be controlled at endoscopy. Angiographic embolization is an alternate option, particularly in those unfit for surgery. In selected patients judged to belong to the high-risk group--ulcers 2 cm or greater in size located at the lesser curve and posterior bulbar duodenal, shock on presentation, and elderly with comorbid illnesses--a more aggressive postendoscopy management is warranted. The optimal course of action is unclear. Most would be expectant and offer medical therapy in the form of acid suppression. Surgical series suggest that early elective surgery may improve outcome. Angiography allows the bleeding artery to be characterized, and coil embolization of larger arteries may further add to endoscopic hemostasis. The role of early elective surgery or angiographic embolization in selected high-risk patients to forestall recurrent bleeding remains controversial. Prospective studies are needed to compare different management strategies in these high-risk ulcers.

Emergent embolization of the gastroduodenal artery in the treatment of upper gastrointestinal bleeding. The experience from a surgeon-initiated interventional program

BACKGROUND

Intractable nonvariceal upper gastrointestinal bleeding (UGIB) is associated with significant morbidity and mortality. Endovascular therapy is an alternative to surgery for high-risk patients.

MATERIALS AND METHODS

Review of prospectively collected data from patients who underwent emergent gastroduodenal artery embolization for UGIB.

RESULTS

Eight patients (mean age 68.5 years) were identified. They all had significant comorbidities and were deemed to be at high risk for surgical intervention. Endoscopy was performed in 7 patients. Active extravasation was present at the time of embolization in 5 (62.5%) patients. The technical success and clinical response rates were each 100%. The 30-day mortality rate was 12.5%. [corrected] There were no procedure-related complications. During mean follow-up of 9 months, 1 patient developed recurrent bleeding that was managed conservatively.

COMMENTS

Endovascular embolization is a safe alternative to open surgical intervention after failed endoscopic treatment for UGIB. Surgeons with endovascular skills can perform this procedure with superior results.

Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure

PURPOSE

To retrospectively compare the outcome of transcatheter arterial embolization (TAE) and surgery as salvage therapy of upper gastrointestinal bleeding after failed endoscopic treatment.

MATERIALS AND METHODS

From January 1998 to December 2005, 658 patients were referred to diagnostic/therapeutic emergency endoscopy and diagnosed with upper gastrointestinal bleeding. Ninety-one of these 658 patients (14%) had repeat bleeding or continued to bleed. Forty of those 91 patients were treated with TAE and 51 were treated with surgery. From the medical records, the following variables were recorded: demographic data, endoscopic diagnoses, comorbidities, lowest hemoglobin levels, total transfusion requirements, lengths of hospitalization stays, postprocedure complications, and mortality rates. The relative survival rate was calculated, and survival probability was calculated with the Kaplan-Meier technique.

RESULTS

Patients treated with TAE were older (mean age, 76 years; age range, 40-94 years) and had slightly more comorbidities compared to patients who underwent surgery (mean age, 71 years; age range, 45-89 years). The 30-day mortality rate in patients treated with TAE was one of 40 (3%) compared to seven of 51 (14%) in patients treated with surgery (P < .07). Most repeat bleeding could be effectively treated with TAE, both in the surgical and TAE groups.

CONCLUSIONS

The results of this study suggest that, after failure of therapeutic endoscopy for upper gastrointestinal bleeding, TAE should be the treatment of choice before surgery and that TAE can also be used to effectively control bleeding after failed surgery or TAE. There was a clear trend to lower 30-day mortality with use of TAE instead of surgery.

Transcatheter arterial embolization in the management of bleeding duodenal ulcers: a 5.5-year retrospective study of treatment and outcome

OBJECTIVE

The mortality rate associated with bleeding duodenal ulcer disease is about 10%. Primary endoscopic hemostasis is successful in over 90% of patients, but in 15-25%, the bleeding cannot be controlled endoscopically or the patient rebleeding, requiring alternative treatment. Percutaneous transcatheter arterial embolization (TAE) has been proposed as an alternative to surgery and was introduced at Ullevål University Hospital in Oslo, Norway, in June 2000. In this study we report our experiences in 36 patients.

MATERIAL AND METHODS

A retrospective review identified all patients admitted to Ullevål University Hospital with hematemesis and/or melena and endoscopically verified duodenal ulcer from June 2000 to 2005. The indication for TAE was endoscopically unmanageable bleeding/rebleeding or rebleeding after surgery. Technical success was defined as acute hemostasis. Clinical success was defined as technical success without rebleeding within 30 days.

RESULTS

A total of 278 patients (mean age 73 years) were included in the study. Primary endoscopic hemostasis failed in 13 patients (5%) and 53 patients (20%) experienced rebleeding. An attempt was made to treat 36 patients with TAE. Technical success in the TAE group was 92% and clinical success was 72%. In total, 10 patients underwent surgery, 3 because of rebleeding after TAE. The 30-day mortality was 10% for all patients, 19% in the TAE group, and 20% in the surgical group.

CONCLUSIONS

High technical and clinical success was obtained with TAE in patients with bleeding duodenal ulcer after failure of endoscopic treatment. TAE appears to be a treatment alternative to surgery in this group of patients.

Therapeutic options for endoscopic haemostatic failures: the place of the surgeon and radiologist in gastrointestinal tract bleeding

The management of gastrointestinal tract bleeding has changed dramatically due to improvements of interventional endoscopy and radiology. The place of the radiologist has become very important, not only for diagnostic modalities but also for therapeutic embolisation to control the bleeding. The place of the surgeon is limited to the situation where both these less invasive techniques have failed to stop the bleeding. For arterial bleeding in the whole GI tract, angiography with subsequent embolisation is performed after failed endoscopy. For variceal bleeding the preferred treatment after endoscopic failure is transjugular intrahepatic portosystemic stent shunting (TIPS). Surgery is only needed in exceptional cases. Embolisation can be performed successfully without compromising the bowel vascularisation or inducing ischaemia, whereas surgery has a high rate of complications and mortality. For treatment of GI bleeding a multidisciplinary team including a gastroenterologist, radiologist and surgeon is mandatory.

Shock Index Correlates with Extravasation on Angiographs of Gastrointestinal Hemorrhage: A Logistics Regression Analysis

We applied multivariate analysis to the clinical findings in patients with acute gastrointestinal (GI) hemorrhage and compared the relationship between these findings and angiographic evidence of extravasation. Our study population consisted of 46 patients with acute GI bleeding. They were divided into two groups. In group 1 we retrospectively analyzed 41 angiograms obtained in 29 patients (age range, 25-91 years; average, 71 years). Their clinical findings including the shock index (SI), diastolic blood pressure, hemoglobin, platelet counts, and age, which were quantitatively analyzed. In group 2, consisting of 17 patients (age range, 21-78 years; average, 60 years), we prospectively applied statistical analysis by a logistics regression model to their clinical findings and then assessed 21 angiograms obtained in these patients to determine whether our model was useful for predicting the presence of angiographic evidence of extravasation. On 18 of 41 (43.9%) angiograms in group 1 there was evidence of extravasation; in 3 patients it was demonstrated only by selective angiography. Factors significantly associated with angiographic visualization of extravasation were the SI and patient age. For differentiation between cases with and cases without angiographic evidence of extravasation, the maximum cutoff point was between 0.51 and 0.0.53. Of the 21 angiograms obtained in group 2, 13 (61.9%) showed evidence of extravasation; in 1 patient it was demonstrated only on selective angiograms. We found that in 90% of the cases, the prospective application of our model correctly predicted the angiographically confirmed presence or absence of extravasation. We conclude that in patients with GI hemorrhage, angiographic visualization of extravasation is associated with the pre-embolization SI. Patients with a high SI value should undergo study to facilitate optimal treatment planning.

Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding

PURPOSE

To enable accurate transcatheter arterial embolization (TAE) of the target vessel, a new technique to localize the exact position of a bleeding ulcer was tested that involves endoscopic marking of the ulcer with a metallic clip.

MATERIALS AND METHODS

In 13 patients (mean age, 75 years) with acute bleeding ulcers (11 duodenal ulcers, two malignant ulcers), a metallic clip was placed at gastroscopy followed or preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. In 10 patients, TAE was indicated as a result of continued or recurrent bleeding. The artery was embolized with microcoils as close as possible to the clip. In three patients, there was no indication for TAE, so plain abdominal radiography was performed to determine whether the marking clip was still in place.

RESULTS

In 11 patients, the clip was still in place on radiography; in two, it had disappeared. Hemostasis was achieved in eight of 10 patients after TAE. In six patients, the clip was essential to identify the bleeding vessel.

CONCLUSION

Marking of the bleeding ulcer with a clip before TAE enhances the possibility that the correct vessel is embolized. This will most likely minimize the risk of recurrent bleeding after embolization, especially in patients who do not show contrast medium extravasation.

Duodenoportal fistula caused by peptic ulcer after extended right hepatectomy for hilar cholangiocarcinoma

Background

A fistula between the duodenum and the main portal vein near a peptic ulcer is extremely rare, and only two cases of duodenal ulcers have been reported in the past.

Case presentation

We report a 68-year-old man with a diagnosis of anemia who had a history of extended right hepatectomy for hilar cholangiocarcinoma 20 months previously. The first endoscopic examination revealed a giant peptic ulcer with active bleeding at the posterior wall of the duodenal bulbs, and hemostasis was performed. Endoscopic treatment and transarterial embolization were performed repeatedly because of uncontrollable bleeding from the duodenal ulcer. Nevertheless, he died of sudden massive hematemesis on the 20^th hospital day. At autopsy, communication with the main portal vein and duodenal ulcer was observed.

Conclusion

It should be borne in mind that the main portal vein is exposed at the front of the hepatoduodenal ligament in cases with previous extrahepatic bile duct resection.

Pancreatic Cancer Presenting with Hematemesis from Directly Invading the Duodenum: Report of an Unusual Manifestation and Review

Pancreatic cancer is a rare cause of gastrointestinal bleeding, and it is extremely rare for hematemesis to be the initial manifestation of invasive pancreatic cancer. We report the case of a 67-year-old man with hematemesis who was found to have invasive pancreatic cancer with a bleeding duodenal ulcer. The patient was not icteric, but repeated sudden hematemesis. An urgent pancreatoduodenectomy was performed with a favorable outcome. Microscopic examination revealed that an adenocarcinoma originating from the pancreatic head extended to the muscularis propria of the duodenum. Furthermore, an exposed vessel and narrow fistula were found. The diagnosis, pathological findings, preoperative events, and postoperative outcome in this unusual case are reviewed.

Treatment of gastrointestinal hemorrhage

BACKGROUND

We assessed the value of selective arteriography in the diagnosis and management of acute gastrointestinal hemorrhage.

METHODS

We reviewed the records of 107 consecutive patients who had gastrointestinal hemorrhage and underwent selective arteriography between January 1992 and October 2003: 10 had upper gastrointestinal bleeding, 79 had lower gastrointestinal bleeding, and 18 had varicose bleeding with portal hypertension. Selective embolization was attempted in 15 patients to obtain hemostasis. Angiographic findings were reviewed and prospective reports were compared with the final diagnosis and outcome.

RESULTS

Of 129 angiographic studies, 36 correctly revealed the bleeding site and 93 were negative. Extravasation was seen in 24 cases at the level of stomach (n = 2), duodenum (n = 1), small bowel (n = 5), or colon (n = 16). Indirect signs of bleeding sources were identified in 12 patients (stomach in one, small bowel in four, large bowel in four, liver in three). Transcatheter embolization induced definitive hemostasis in 11 of 15 patients (73%), namely in the stomach (n = 2), small bowel (n = 3), colon (n = 7), and liver (n = 3). Three patients required surgery after embolization.

CONCLUSION

Abdominal arteriography may localize gastrointestinal bleeding sources in approximately one-third of cases. Selective embolization may provide definitive hemostasis in most instances.

Late-onset life threatening hemorrhage of omeprazole-resistant duodenal ulcer managed by interventional radiology: report of a case

A 67-year-old diabetic man was emergently hospitalized in our department because of a huge duodenal ulcer without visible vessels. Despite of intravenous administration of 40 mg omeprazole and fasting with intravenous nutritional support, endoscopically unmanageable massive bleeding occurred on the 8th hospital day. Emergent angiography showed extravasation of contrast media from a duodenal branch of the proper hepatic artery, and superselective arterial embolization was successfully achieved. The patient recovered from the hemorrhagic shock and underwent subsequent successful surgery. Analysis of CYP2C19 enzyme genotype indicated the patient was a homozygous extensive metabolizer, considered a poor responder for omeprazole treatment.

[Endoscopic treatment of bleeding ulcers: has everything been said and done?]

Endoscopic treatment reduces bleeding recurrence, the need for surgery and mortality in patients with bleeding ulcers. However endoscopic treatment fails in 10-15% of patients, leading to high morbidity and mortality. The therapeutic measures with demonstrated effectiveness in reducing the risk of hemorrhagic recurrence and its complications are combined endoscopic treatment (adrenaline plus a second hemostatic intervention) and proton pump inhibitors. Also useful, although there is less evidence, are immediate resuscitation and <<second look>> endoscopy. Some studies suggest that activated recombinant factor VII infusion or supra-selective arterial embolization can be useful in severe hemorrhage. Further studies are required to determine optimal treatment according to the characteristics of each patient.