Catheter-directed middle hemorrhoidal artery embolization for life-threatening rectal bleeding

Anatomical classification of middle rectal arteries regarding detailed vasculature patterns

This study aimed to clarify the anatomy of middle rectal artery and pelvic vasculature patterns, and to provide schematic information in a manner applicable to the total mesorectal excision. Forty sides of pelvis from 20 formalin-embalmed cadavers (10 male, 10 female) were dissected, and all the pelvic vasculatures from the internal iliac artery were investigated, focusing on the middle rectal artery. Middle rectal arteries were classified into major types depending on their vascular origins. Each type was subdivided into minor types according to variability of the pelvic vasculature. A middle rectal artery was identified in 18 out of 20 cadavers, and in 25 out of 40 pelvic sides. In most cases, the middle rectal artery originated from the internal pudendal artery or inferior gluteal artery. These two arteries arose directly from the anterior trunk of the internal iliac artery or were bifurcated from the gluteal-pudendal trunk. In rare cases, these arteries arose from the posterior trunk of the internal iliac artery. The other origins of the middle rectal artery included the gluteal pudendal trunk, inferior vesical artery, internal iliac artery, obturator artery, and the prostatic artery, and the pelvic vasculatures in these cases also presented variability. The detailed anatomical findings related to the middle rectal artery and pelvic vasculatures are noteworthy for their improved clinical applicability.

The middle anorectal artery - a systematic review and meta-analysis of 880 patients / 1905 pelvic sides

INTRODUCTION

The middle anorectal artery (MAA) is considered to supply the middle and lower parts of the rectum however its prevalence and point of origin vary across the literature. Clinical importance of the MAA becomes evident in the total mesorectal excision during the colorectal surgery of rectal cancer in both sexes, as well as interventional radiology procedures utilizing the prostatic vasculature in males.

MATERIALS AND METHODS

Major electronic medical databases were investigated for terms pertaining to the MAA and its associated variations. Compatible data regarding the artery's prevalence, laterality, origin, and distribution in both sexes was acquired. The risk of bias within the studies was assessed utilizing the AQUA tool.

RESULTS

In total, 28 works (n=880 patients / 1905 pelvic sides) were included in this systematic review and meta-analysis, and their publication date ranged from 1897 until 2021. The overall pooled prevalence estimate for the MAA was 59.8% of the patients, and 55.2% of the pelvic sides studied. The vessel was identified more frequently in cadaveric pelvic sides evaluations (79.3%). The artery was found bilaterally more often (56.7%), and most commonly originated from the internal pudendal artery (50.3%). Anastomoses between the MAA and the other anorectal arteries were reported in 78.1%.

CONCLUSIONS

The MAA is predominantly a present vessel, with various point of origin. Its direct clinical significance is yet to be discovered in larger study samples, providing more detailed and unified reports of its anatomical features, especially regarding its branches.

Use of colour Doppler to eliminate rectal bleeding from trans-rectal ultrasound-guided biopsy of the prostate

Bleeding is one of the complications of trans-rectal ultrasound (TRUS)-guided biopsy of the prostate. Urethral bleeding could be prevented by avoiding the trajectory on the urethra. However, rectal bleeding is difficult to predict because the peri-prostatic, intra-prostatic and rectal vessels cannot be seen on an ordinary ultrasound scan. Use of colour Doppler to map out the vessels cognitively before injection of local anaesthesia prevents puncture of the vessels, which is a key cause of rectal bleeding.

Level of evidence:

Not applicable.

Super selective arterial embolization to treat radiation-induced hemorrhagic gastritis: a case report and review of the literature

Radiation-induced hemorrhagic gastritis (RIHG) is a rare but potentially fatal event following radiotherapy for locally advanced gastric cancer; the treatment of this condition is not standardized. Only few cases of RIHG have been reported, treated with different therapeutic approaches. Here we report the case of a 79-year-old patient who underwent subtotal gastrectomy for gastric cancer, followed by adjuvant chemo-radiotherapy. Approximately 3 months after the end of the treatment, she developed recurrent diffuse bleeding originating from the entire mucosa of the gastric pouch and from a marginal ulcer. As the bleeding was refractory to several endoscopic treatments and surgery was not indicated, the patient underwent two sessions of transcatheter selective arterial embolization, with resolution of bleeding. Arterial embolization has already been reported for the treatment of hemorrhagic cystitis, developing after irradiation of the pelvis for prostate, bladder, rectum, and cervix cancer. However, to our knowledge, it has never been reported as a treatment for hemorrhagic gastritis. Based on this case, we suggest arterial embolization as an option in the management of RIHG, when standard endoscopic treatment fails.

The management of rectal bleeding following transrectal prostate biopsy: A review of the current literature

INTRODUCTION

Since the advent of prostate-specific antigen (PSA)-based testing, transrectal ultrasound (TRUS)-guided prostate biopsy has become a standard part of the diagnostic pathway for prostate cancer (PCa). Rectal bleeding is one of the common side effects of this transrectal route. While rectal bleeding is usually mild and self-limiting, it can be life-threatening. In this article, we examine rectal bleeding post-TRUS-guided prostate biopsy and explore the literature to evaluate techniques and strategies aimed at preventing and managing this common and important complication.

METHODS

A PubMed literature search was carried out using the keywords "transrectal-prostate-biopsy-bleed." A search of the bibliography of reviewed studies was also conducted. Additionally, papers in non-PubMed-listed journals of which the authors were aware were appraised.

RESULTS

Numerous modifiable risk factors for this bleeding complication exist, particularly anticoagulants/antiplatelets and the number of core biopsies taken. Successfully described corrective measures for such rectal bleeding include tamponade (digital/packs/catheter/tampon/condom), endoscopic sclerotherapy/banding/clipping, radiological embolization, and surgical intervention.

CONCLUSIONS

We advocate early consultation with the colorectal/gastroenterology and interventional radiology services and a progressive, stepwise approach to the management of post-biopsy rectal bleeding, starting with resuscitation and conservative tamponade measures, moving to endoscopic hemostasis ± radiological embolization ± transanal surgical methods. Given the infrequent but serious nature of major rectal bleeding after TRUS biopsy, we recommend the establishment of centralized databases or registries forthwith to prospectively capture such data. To the best of our knowledge, this is the first comprehensive look specifically at the management of post-TRUS biopsy rectal bleeding.

Traumatic Pseudoaneurysm of Superior Rectal Artery - an Unusual Cause of Massive Lower Gastrointestinal Bleed: A Case Report

Traumatic pseudoaneurysm of superior rectal artery is an unusual cause of massive lower gastrointestinal bleed. We are reporting the first case as we could not come across any similar report in the literature. Patient underwent exploratory laparotomy, diversion sigmoid loop colostomy, perineal wound debridement and antiseptic dressing for traumatic perineal wound. Patient had repeated episode of massive lower gastrointestinal bleeding and was diagnosed as a case of bleeding from superior rectal artery pseudoaneurysm which was managed by selective superior rectal artery embolization after failure of surgical treatment.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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