Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin

Provocative mesenteric angiography for occult gastrointestinal bleeding: a systematic review

Occult gastrointestinal bleeding (GIB) is a challenge for physicians to diagnose and treat. A systematic literature search of the PubMed and Embase databases was conducted up to January 1, 2023. Eligible studies included primary research studies with patients undergoing provocative mesenteric angiography (PMA) for diagnosis or localization of occult GIB. Twenty-seven articles (230 patients) were included in the review. Most patients (64.8%) presented with lower GIB. The average positivity rate for provocative angiography was 48.7% (58% with heparin and 46.7% in thrombolytics). Embolization was performed in 46.4% of patients, and surgical management was performed in 37.5%. Complications were rare. PMA can be an important diagnostic and treatment tool but studies with high-level evidence and standardized protocols are needed to establish its safety and optimal use.

Unmasking lower gastrointestinal bleeding under administration of norepinephrine

BACKGROUND

Bleeding in the gastrointestinal tract is common and transarterial embolization enables the clinician to control gastrointestinal bleeding. Contrast extravasation is a prerequisite for successful embolization. Provocative angiography is helpful in the detection of elusive bleeding.

AIM

We performed a retrospective analysis of angiographic treatment in patients with lower gastrointestinal hemorrhage and initially negative angiographies, as well as the role of norepinephrine (NE) in unmasking bleeding.

METHODS

We analyzed 41 patients with lower gastrointestinal bleeding after angiography who had undergone treatment over a period of 10 years. All patients had a positive shock index and needed intensive care.

RESULTS

In three of four patients, angiography disclosed the site of bleeding when NE was used during the procedure for hemodynamic stabilization.

CONCLUSION

We suggest that angiography performed after the administration of NE in unstable patients with gastrointestinal bleeding and an initially negative angiography has the potential to unmask bleeding sites for successful embolization. However, this statement must be confirmed in prospective studies.

Carbon Dioxide Angiography for the Detection of Lower Gastrointestinal Arterial Bleeding Initially Occult to Angiography with Iodinated Contrast Media

This study evaluated the utility of carbon dioxide (CO₂) in angiography for the detection of lower gastrointestinal arterial bleeding initially occult to angiography with iodinated contrast media. Fourteen patients underwent CO₂-enhanced angiography. In all patients, extravasation was identified by contrast-enhanced computed tomography but not by initial iodinated contrast-enhanced angiography. After iodinated contrast-enhanced angiography, CO₂-enhanced angiography was performed from the same catheter position. The detection capability for extravasation on CO₂-enhanced angiography was evaluated. CO₂-enhanced angiography allowed for the visualization of extravasation and subsequent transcatheter arterial embolization in 11 of 14 (79%) cases, with extravasation seen during either CO₂-enhanced angiography (n = 8) or subsequent repeat iodinated contrast-enhanced angiography immediately after negative CO₂-enhanced angiography (n = 3). Conservative treatment was performed in the remaining 3 cases. In conclusion, CO₂-enhanced angiography appears useful for identifying occult lower gastrointestinal bleeding.

The Role of Provocative Testing and Localization of the Video Capsule Endoscope in the Management of Small Intestinal Bleeding

The cause of small intestinal bleeding (SIB) may be elusive despite exhaustive testing. This article describes the current understanding of SIB regarding evaluation, with emphasis on the use of video capsule endoscopy (VCE) as a diagnostic procedure. This article addresses the utility of provocative testing in challenging cases and the performance of endoscopic procedures on active antithrombotic therapy. Specific recommendations accompany this article, including use of antithrombotic agents to stimulate bleeding when clearly indicated; performance of endoscopic procedures on active antithrombotic therapy; and progressive adoption of VCE and device-assisted enteroscopy in the inpatient setting.

Provocative Angiography, Followed by Therapeutic Interventions, in the Management of Hard-To-Diagnose Gastrointestinal Bleeding

BACKGROUND

Despite significant advances in imaging and endoscopic diagnostic techniques, adequate localization of gastrointestinal bleeding (GIB) can be challenging. Provocative angiography (PROVANGIO) has not been part of the standard diagnostic algorithms yet. We sought to examine the ability of PROVANGIO to identify the bleeding source when conventional radiography fails.

METHODS

Patients undergoing PROVANGIO for GIB during 2008-2014 were retrospectively included. Demographics and periprocedural patient characteristics were recorded. PROVANGIO was performed in a multidisciplinary setting, involving interventional radiology, surgery and anesthesiology teams, ready to intervene in case of uncontrolled bleeding. The procedure included conventional angiography of the celiac, superior and inferior mesenteric arteries (SMA, IMA) followed by a stepwise bleeding provocation with anticoagulating, vasodilating and/or thrombolytic agent administration, combined with angiography.

RESULTS

Twenty-three PROVANGIO were performed. Patients were predominantly male (15, 65.2%), and hematochezia was the most common presenting symptom (12, 52.2%). Patients with a positive PROVANGIO had lower Charlson comorbidity index (1 vs. 7, p = 0.009) and were less likely to have a prior history of GIB (14.3% vs. 87.5%, p = 0.001). PROVANGIO localized bleeding in 7 (30%) patients. In 6 out of 7 patients, the bleeding source was identified in the SMA and, in one case, in the IMA distribution. The bleeding was controlled angiographically in four cases, endoscopically in one case and surgically in the remaining two. No complications related to PROVANGIO were detected.

CONCLUSIONS

In our series, PROVANGIO safely identified the bleeding source, and provided that necessary safeguards are put into place, we recommend incorporating it in the diagnostic algorithms for GIB management.

Empiric cone-beam CT-guided embolization in acute lower gastrointestinal bleeding

OBJECTIVES

To evaluate the clinical effect and safety of cone-beam CT (CBCT)-guided empirical embolization for acute lower gastrointestinal bleeding (LGIB) in patients with a positive CT angiography (CTA) but subsequent negative digital subtraction angiography (DSA).

METHODS

A retrospective study of consecutive LGIB patients with a positive CTA who received a DSA within 24 h from January 2008 to July 2019. Patients with a positive DSA were treated with targeted embolization (TE group). Patients with a negative DSA underwent an empiric CBCT-guided embolization of the assumed ruptured vas rectum (EE group) or no embolization (NE group). Recurrent bleeding, major ischemic complications, and in-hospital mortality were compared by means of Fisher's exact test. Further subgroup analysis was performed on hemodynamic instability.

RESULTS

Eighty-five patients (67.6 years ± 15.7, 52 men) were included (TE group, n = 47; EE group, n = 19; NE group, n = 19). If DSA was positive, technical success of targeted embolization was 100% (47/47). If DSA was negative and the intention to treat by empiric CBCT-guided embolization, technical success was 100% (19/19). Recurrent bleeding rates in the TE group, EE group, and NE group were 17.0% (8/47), 21.1% (4/19), and 52.6% (10/19) respectively. Empiric CBCT-guided embolization reduced rebleeding significantly in patients with a negative DSA and hemodynamic instability (EE group, 3/10 vs NE group, 10/12, p = .027). Major ischemic complications occurred in one patient (TE group). Overall, the in-hospital mortality rate was 7.1% (6/85).

CONCLUSION

Empiric cone-beam CT-guided embolization proved to be a feasible, effective, and safe treatment strategy to reduce rebleeding and improve clinical success in hemodynamically unstable patients with acute LGIB, positive CTA but negative DSA.

KEY POINTS

• A novel transarterial embolization technique guided by cone-beam CT could be developed extending the "empiric" embolization strategy to lower gastrointestinal bleeding. • By implementing the empiric treatment strategy, nearly all patients with an active lower gastrointestinal bleeding on CTA will be eligible for a superselective empiric embolization, even if subsequent catheter angiography is negative. • In patients with a negative catheter angiography, empiric embolization reduces the rebleeding rate and, particularly in hemodynamically unstable patients, improves clinical success compared with a conservative "wait-and-see" management.

Sending in the ViCE Squad: Evaluation and Management of Patients with Small Intestinal Bleeding

Bleeding from the small intestine remains a clinically challenging diagnostic and therapeutic problem. It may be minor, requiring only supplemental iron treatment, to patients who have severe overt bleeding that requires multimodal intervention. This article provides an up-to-date review of the state-of-the-art of diagnosis and treatment of small intestinal bleeding.

Analysis of time delay between computed tomography and digital subtraction angiography on the technical success of interventional embolisation for treatment of lower gastrointestinal bleeding

INTRODUCTION

A retrospective study was undertaken to determine a potential relationship, based on the time delay, between a positive lower gastrointestinal bleed demonstrated on computed tomography (CT) and a positive digital subtraction angiographic (DSA) study and the impact on technical success.

METHODS

This study investigated the correlation of time delays between imaging modalities and technical success with endovascular embolisation procedures over a 10-year period.

RESULTS

A total of 110 patient events were analysed, and it was observed that the greater the time delay between modalities (up to 7 h), the weaker the correlation between a bleed observed on CT and DSA. This was also reflected by the technical success of the embolisation treatment. Patients experienced shorter delays when the event occurred out of normal business hours, however with decreased rates of technical success.

CONCLUSIONS

There is a suggestion patients should be escalated to the angiography suite for DSA imaging as soon as possible to maximise the ability to angiographically observe acute bleeding and treat appropriately with interventional embolisation. More research in this area is required to statistically confirm this.

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

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

Small Bowel Gastrointestinal Bleeding Diagnosis and Management-A Narrative Review

Background: Small bowel bleeding accounts for 5-10% of all gastrointestinal bleeding. Despite advances in imaging, endoscopy and minimally invasive therapeutic techniques, its diagnosis and treatment remains a challenge and a standardized algorithm for approaching suspected small bowel bleeding remains elusive. Furthermore, the choice of investigation is subject to timing of presentation and accessibility to investigations. The aim of this study was to construct a narrative review of recent literature surrounding the diagnosis and management of small bowel bleeding. Methods: A literature review was conducted examining the database pubmed with the following key words and Boolean operators: occult GI bleed OR mesenteric bleed OR gastrointestinal hemorrhage OR GI hemorrhage AND management. Articles were selected and reviewed based on relevance to the research topic. Where necessary, the full text was sought to further assess relevance. Results: In overt GI bleeding, CT angiography and red cell scintigraphy are both feasible and reliable diagnostic imaging modalities if standard endoscopy is negative. Red cell scintigraphy may be advantageous through detection of lower bleeding rates but it is subject to availability. Overt bleeding and a positive CT angiogram or red cell scan improves the diagnostic yield of formal angiography ± embolization. Video capsule endoscopy or double balloon endoscopy can be considered in occult GI bleeding following normal upper and lower endoscopy. Conclusions: Small bowel bleeding remains a rare but significant diagnostic and therapeutic challenge. Technological advances in diagnostics have aided evaluation but have not broadened the range of therapeutic interventions.

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.

The Clinician's Guide to Suspected Small Bowel Bleeding

Small bowel bleeding accounts for 5-10% of gastrointestinal bleeding. With the advent of capsule endoscopy, device-assisted enteroscopy, and multiphase CT scanning, a small bowel source can now be found in many instances of what has previously been described as obscure gastrointestinal bleeding. We present a practical review on the evaluation and management of small bowel bleeding for the practicing clinician.

Exploratory laparoscopy combined with pathological examination in the diagnosis of obscure gastrointestinal bleeding in a child: a case report

BACKGROUND

The diagnosis of obscure gastrointestinal bleeding (OGIB) which is defined as bleeding of unknown origin of the small bowel by routine evaluation in childhood is a challenge.

CASE PRESENTATION

Here we report a one-year-old Chinese girl who was suspected with idiopathic pulmonary haemosiderosis (IPH) and referred to our department for further diagnosis. Finally she was diagnosed with vascular malformations (VM) by exploratory laparoscopy combined with pathological examination.

CONCLUSIONS

Children OGIB could be easily misdiagnosed in the beginning, and OGIB children with active ongoing bleeding may benefit from proceeding directly to exploratory laparoscopy, followed by pathological confirmation of the diagnosis.

Unusual bleeding from hepaticojejunostomy controlled by side-to-side splenorenal shunt: A case report

RATIONALE

Ectopic variceal bleeding due to hepaticojejunostomy (HJ) is unusual and difficult to manage. Reports on the use of side-to-side splenorenal shunt for severe bleeding from varices at HJ anastomosis are lacking.

PATIENT CONCERNS

A 43-year-old man was admitted to our hospital with repeated episodes of hematemesis. He has a history of right hemihepatectomy with HJ reconstruction to the left hepatic duct for hilar cholangiocarcinoma. Two years after surgery, he presented with repeated episodes of hematemesis and underwent blood transfusion.

DIAGNOSES

Imaging tests and endoscopic investigation failed to identify the bleeding source. When conservative management failed to control his bleeding, he underwent emergency laparotomy, which revealed hemorrhage from ectopic varices at the HJ anastomosis.

INTERVENTIONS

To arrest the bleeding, a side-to-side venovenal anastomosis was created between the splenic and left renal veins to form a shunt for decompression of the varices at the HJ anastomosis.

OUTCOMES

After the surgery, the patient's symptoms ceased, and a no bleeding in the digestive tract was noted at 2-year follow-up.

LESSONS

The present patient is the first reported case of unusual bleeding from HJ controlled by a side-to-side splenorenal shunt. We believe this approach is a useful and effective surgical treatment for severe bleeding from varices at the HJ anastomosis.

The Role of Transcatheter Arterial Embolization in the Management of Nonvariceal Upper Gastrointestinal Bleeding

Nearly 50 years ago, catheter angiography was introduced as a means of both diagnosing and treating nonvariceal upper gastrointestinal bleeding. Technological advances and innovations have resulted in the introduction of microcatheters that, using a coaxial technique, are capable of selecting third-order arterial branches and of delivering a wide array of embolic agents. This article reviews the imaging diagnosis of nonvariceal upper gastrointestinal bleeding, the techniques of diagnostic and therapeutic angiography, the angiographic appearance of the various etiologies of nonvariceal upper gastrointestinal bleeding, the rationale behind case-specific selection of embolic agents as well as the anticipated outcome of transcatheter arterial embolization.

Pharmacologic provocation combined with endoscopy in refractory cases of GI bleeding

BACKGROUND AND AIMS

The source of GI bleeding may elude us despite exhaustive testing in some cases. Bleeding in these cases is often related to a vascular lesion that is discernible only when actively bleeding. The objective of this study was to determine the efficacy and safety of endoscopy combined with the administration of antiplatelet and/or anticoagulant agents to stimulate bleeding in order to define a source.

METHODS

A retrospective review of a database of device-assisted enteroscopy (DAE) procedures was completed to identify cases in which provocation with antiplatelet or anticoagulant agents was used as part of a GI bleeding evaluation. Procedures were divided into 3 groups based on the method of provocation: patients with a history of bleeding associated with an antiplatelet/anticoagulant (provocation-experienced); patients naïve to these medications (provocation-naïve); and cases of recurrent, overt GI bleeding in which a combination of clopidogrel and intravenous heparin was administered for provocation (Lousiana State University [LSU] protocol).

RESULTS

A review of 824 DAE procedures was completed to identify a total of 38 instances in which provocation was attempted in 27 patients. These cases were subdivided into 13 provocation-experienced procedures, 18 provocation-naïve procedures, and 7 LSU protocol procedures. The diagnostic yield of provocative testing per procedure was 53% in the provocation-experienced group, 27% in the provocation-naïve group, and 71% in the full protocol group. Provocative testing was revealing in 15 of 27 patients; angioectasias and Dieulafoy lesions were the most common pathologies. Provocative testing was not beneficial in 4 patients who were eventually diagnosed with bleeding caused by intestinal angioectasias (3) and an aorto-enteric fistula (1). There were no adverse events.

CONCLUSIONS

Provocative testing combined with endoscopy can be justified as an option in the diagnostic algorithm of complex cases of GI bleeding when intermittent bleeding related to a vascular lesion, such as an angioectasia or Dieulafoy, is suspected. However, this novel technique should be considered only after standard management has failed to define a bleeding source, and bleeding continues to recur. This is the first reported case series of provocative testing combined with endoscopy.

Spontaneous soft-tissue hemorrhage in anticoagulated patients: safety and efficacy of embolization

OBJECTIVE

The purpose of this study was to report the effectiveness and safety of selective arterial embolization for the management of anticoagulation-related soft-tissue bleeding.

MATERIALS AND METHODS

All consecutive patients from June 1, 2003, to June 1, 2010, with intractable anticoagulation-related soft-tissue bleeding treated by embolization were included. The clinical files, MDCT angiographic examinations, and procedure details were reviewed. The primary goal of this study was to report the safety and efficacy of embolization for the management of anticoagulation-related soft-tissue bleeding. The secondary goal was to evaluate the correlation between the MDCT angiography (MDCTA) findings and conventional catheter angiography.

RESULTS

Thirty-six consecutive patients were included. All patients were under anticoagulant therapy. Overdosage of the anticoagulant was found in 12 (33%) patients. MDCT was performed with multiphasic contrast media injection in 30 patients (83%) and showed extravasation in 22 (73.3%) of those 30 patients. Catheter angiography revealed extravasation in 27 of 36 (75%) patients, and no active bleeding was observed in nine patients who were empirically embolized. The sensitivity of MDCTA for depicting ongoing active bleeding was 87%. The transfusion requirement for RBC units decreased from 4.0 (range, 0-12.0) before to 0 (range, 0-4.0) after embolization. Nine patients underwent a second embolization but only one in the same vascular territory. Eleven patients died within 30 days despite the embolization. No complications related to embolization were reported.

CONCLUSION

Anticoagulation-related soft-tissue bleeding can be efficiently and safely treated by selective arterial embolization. However, this serious pathologic condition may be fatal in many cases, and rebleeding is not rare. MDCTA could help to guide treatment.

Obscure gastrointestinal bleeding: diagnosis and treatment

Small-bowel bleeding comprises a majority of obscure gastrointestinal bleeding, but is caused by various kinds of diseases. For its diagnosis, history-taking and physical examination is requisite, leading to a suspicion of what diseases are involved. Next, cross-sectional imaging such as computed tomography should be done, followed by the latest enteroscopy, videocapsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient conditions. After comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected.

Evaluation of gastrointestinal bleeding: Update of current radiologic strategies

Gastrointestinal bleeding (GIB) is a common presentation with significant associated morbidity and mortality, the prevalence of which continues to rise with the ever-increasing aging population. Initial evaluation includes an esophagoduodeonscopy and/or colonoscopy, which may fail to reveal a source. Such cases prove to be a dilemma and require collaboration between gastroenterology and radiology in deciding the most appropriate approach. Recently, there have been a number of radiologic advances in the approach to GIB. The purpose of this review is to provide an evidence-based update on the most current radiologic modalities available and an algorithmic approach to GIB.

New insights to occult gastrointestinal bleeding: From pathophysiology to therapeutics

Obscure gastrointestinal bleeding is still a clinical challenge for gastroenterologists. The recent development of novel technologies for the diagnosis and treatment of different bleeding causes has allowed a better management of patients, but it also determines the need of a deeper comprehension of pathophysiology and the analysis of local expertise in order to develop a rational management algorithm. Obscure gastrointestinal bleeding can be divided in occult, when a positive occult blood fecal test is the main manifestation, and overt, when external sings of bleeding are visible. In this paper we are going to focus on overt gastrointestinal bleeding, describing the physiopathology of the most usual causes, analyzing the diagnostic procedures available, from the most classical to the novel ones, and establishing a standard algorithm which can be adapted depending on the local expertise or availability. Finally, we will review the main therapeutic options for this complex and not so uncommon clinical problem.

Small bowel bleeding: a comprehensive review

The small intestine is an uncommon site of gastro-intestinal (GI) bleeding; however it is the commonest cause of obscure GI bleeding. It may require multiple blood transfusions, diagnostic procedures and repeated hospitalizations. Angiodysplasia is the commonest cause of obscure GI bleeding, particularly in the elderly. Inflammatory lesions and tumours are the usual causes of small intestinal bleeding in younger patients. Capsule endoscopy and deep enteroscopy have improved our ability to investigate small bowel bleeds. Deep enteroscopy has also an added advantage of therapeutic potential. Computed tomography is helpful in identifying extra-intestinal lesions. In cases of difficult diagnosis, surgery and intra-operative enteroscopy can help with diagnosis and management. The treatment is dependent upon the aetiology of the bleed. An overt bleed requires aggressive resuscitation and immediate localisation of the lesion for institution of appropriate therapy. Small bowel bleeding can be managed by conservative, radiological, pharmacological, endoscopic and surgical methods, depending upon indications, expertise and availability. Some patients, especially those with multiple vascular lesions, can re-bleed even after appropriate treatment and pose difficult challenge to the treating physician.

Current treatment of lower gastrointestinal hemorrhage

Massive lower gastrointestinal bleeding is a significant and expensive problem that requires methodical evaluation, management, and treatment. After initial resuscitation, care should be taken to localize the site of bleeding. Once localized, lesions can then be treated with endoscopic or angiographic interventions, reserving surgery for ongoing or recurrent bleeding.

Aberrant celio-mesenteric supply of the splenic flexure: Provoking a bleed

Lower gastrointestinal hemorrhage presents a common indication for hospitalization and account for over 300000 admissions per year in the United States. Multimodality imaging is often required to aid in localization of the hemorrhage prior to therapeutic intervention if endoscopic treatment fails. Imaging includes computer tomography angiography, red blood cell tagged scintigraphy and conventional angiography, with scintigraphy being the most sensitive followed by computer tomography angiography. Aberrant celio-mesenteric supply occurs in 2% of the population; however failure to identify this may result in failed endovascular therapy. Computer tomography angiography is sensitive for arterial hemorrhage and delineates the anatomy, allowing the treating physician to plan an endovascular approach. If at the time of conventional angiography, the active bleed is not visualized, but the site of bleeding has been identified on computer tomography angiography, provocative angiography can be utilized in order to stimulate bleeding and subsequent targeted treatment. We describe a case of lower gastrointestinal hemorrhage at the splenic flexure supplied by a celio-mesenteric branch in a patient and provocative angiography with tissue plasminogen activator utilized at the time of treatment to illicit the site of hemorrhage and subsequent treatment.

Angiographic evaluation and management of acute gastrointestinal hemorrhage

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

Therapeutic management options for patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is one of the most challenging disorders faced by gastroenterologists because of its evasive nature and difficulty in identifying the exact source of bleeding. Recent technological advances such as video capsule endoscopy and small bowel deep enteroscopy have revolutionized the diagnosis and management of patients with OGIB. In this paper, we review the various diagnostic and therapeutic options available for the management of patients with OGIB.

A comparison of the results of arterial embolization for bleeding and non-bleeding gastroduodenal ulcers

BACKGROUND

Although some authors have advocated the practice of arterial embolization for angiographically negative acute hemorrhage from gastroduodenal ulcers, this technique remains controversial.

PURPOSE

To compare the results of arterial embolization for bleeding (BU) and non-bleeding (NBU) gastroduodenal ulcers.

MATERIAL AND METHODS

Transcatheter embolization was performed in 57 patients (39 men, 18 women, mean age 69.8 years) who experienced acute bleeding from gastroduodenal ulcers. At the time of embolization active contrast extravasation was seen in 36 of 57 patients, while in the remaining 21 patients embolization was based on endoscopic findings. Patient demographics, clinical success, need for re-intervention secondary to re-bleeding, and 30-day complication and mortality rates were reviewed and compared between the two groups by using statistical analyses.

RESULTS

In the BU group, the gastroduodenal artery (GDA) was embolized in 31 patients (86.1%), the left gastric artery (LGA) in three patients (8.3%), and the left gastroepiploic artery (LGEA) in two patients (5.6%). In the NBU group, the GDA was embolized in 18 patients (85.7%), and the LGA in three patients (14.3%). Clinical success (61.9 vs. 75.0%, P = 0.30), need for re-intervention (38.1 vs. 27.8%, P = 0.42), and 30-day complication (9.5 vs. 5.6%, P = 0.57), and mortality (28.6 vs. 25%, P = 0.77) rates were not statistically different between the two groups. Embolization in patients in NBU group did not have impact on clinical success (OR, 0.54; 95%CI, 0.17-1.72; P = 0.30).

CONCLUSION

Arterial embolization in patients with angiographically NBU is as safe and effective as embolization in patients with BU.

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.

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Empiric transcatheter arterial embolization for massive bleeding from duodenal ulcers: efficacy and complications

PURPOSE

To evaluate the efficacy and safety of empiric transcatheter arterial embolization (TAE) for patients with massive bleeding from duodenal ulcers.

MATERIALS AND METHODS

During January 2000 and December 2009, 59 patients with duodenal ulcer bleeding in whom TAE was attempted after endoscopic therapy failed were retrospectively analyzed. The patients were divided into empiric TAE (n = 36) and identifiable TAE (n = 23) groups according to angiographic findings with or without identification of the bleeding sites. The technical and clinical success rate, recurrent bleeding rate, procedure-related complications, and clinical outcomes were evaluated.

RESULTS

The technical and clinical success rates of TAE were 100% and 83%. The recurrent bleeding rate, clinical success, duodenal stenosis, and 30-day mortality after TAE were not significantly different between the empiric and identifiable TAE groups.

CONCLUSIONS

A high rate of technical and clinical success was obtained with empiric TAE comparable to identifiable TAE in patients with massive bleeding from duodenal ulcers. There were no severe complications. Empiric TAE is an effective and safe method when a bleeding site cannot determined by angiography.

Imaging of gastrointestinal bleeding

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.

The role of endoscopy in the management of obscure GI bleeding

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, we performed a search of the medical literature by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).(1) The strength of individual recommendations is based both upon the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as "we suggest," whereas stronger recommendations are typically stated as "we recommend." This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Occult and obscure gastrointestinal bleeding: causes and clinical management

Occult gastrointestinal bleeding, defined as bleeding that is unknown to the patient, is the most common form of gastrointestinal bleeding and can be caused by virtually any lesion in the gastrointestinal tract. Patients with occult gastrointestinal bleeding include those with fecal occult blood and iron-deficiency anemia (IDA). In men and postmenopausal women, IDA should be considered to be the result of gastrointestinal bleeding until proven otherwise. Indeed, the possibility of gastrointestinal tract malignancy in these patients means that gastrointestinal evaluation is nearly always indicated. Obscure gastrointestinal bleeding is defined as obvious bleeding from a difficult to identify source and is always recurrent. This form of bleeding accounts for approximately 5% of all cases of clinically evident gastrointestinal bleeding and is most commonly caused by bleeding from the small intestine. Capsule endoscopy and deep enteroscopy have had a major impact on the way that patients with occult and, in particular, obscure bleeding are managed. In this Review the causes, diagnostic evaluation and treatment of occult and obscure gastrointestinal bleeding are discussed.

The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding

There are multiple strategies for evaluating and treating lower intestinal bleeding (LIB). Colonoscopy has become the preferred initial test for most patients with LIB because of its diagnostic and therapeutic capabilities and its safety. However, few studies have directly compared colonoscopy with other techniques and there are controversies regarding the optimal timing of colonoscopy, the importance of colon preparation, the prevalence of stigmata of hemorrhage, and the efficacy of endoscopic hemostasis. Angiography, radionuclide scintigraphy, and multidetector computed tomography scanning are complementary modalities, but the requirement of active bleeding at the time of the examination limits their routine use. In addition, angiography can result in serious complications. This review summarizes the available evidence regarding colonoscopy and radiographic studies in the management of acute LIB.

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

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

Acute gastrointestinal hemorrhage

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

The evaluation and management of obscure and occult gastrointestinal bleeding

Gastrointestinal (GI) bleeding is a common clinical presentation increasing in an aging population, frequently requiring hospitalization and emergent intervention, with significant morbidity, mortality, and costs. It may manifest overtly as hematemesis, melena, or hematochezia, or as an asymptomatic occult bleed. Management typically involves an esophagogastroduodenoscopy or a colonoscopy; these in combination sometimes do not identify a source of bleeding, with the source remaining obscure. Further work up to identify an obscure source frequently requires radiologically detecting the leakage of an intravascular tracer (using tagged red blood cells or angiography) with brisk bleeding or in other cases CT enterography (CTE) to detect bowel wall changes consistent with a bleeding source. Recent advances including capsule endoscopy, CTE, and double-balloon endoscopy have helped to identify bleeding sources beyond the reach of conventional endoscopy. Clinical decision-making about their use is complex and evolving. Knowing their relative merits and weaknesses including yield, contraindications, complications, and cost is essential in coming up with an appropriate management plan. This review covers the rationale for clinical management of obscure sources of GI bleeding, mentioning the approach to and the yield of conventional methods, with an emphasis on the recent advances mentioned above.