Twenty years of embolization for acute lower gastrointestinal bleeding: a meta-analysis of rebleeding and ischaemia rates

BACKGROUND

Transarterial embolization (TAE) for acute lower gastrointestinal bleeding (LGIB) can be technically challenging due to the compromise between achieving haemostasis and causing tissue ischaemia. The goal of the present study is to determine its technical success, rebleeding, and post-embolization ischaemia rates through meta-analysis of published literature in the last twenty years.

METHODS

PubMed, Embase, and Cochrane Library databases were queried. Technical success, rebleeding, and ischaemia rates were extracted. Baseline characteristics such as author, publication year, region, study design, embolization material, percentage of superselective embolization were retrieved. Subgroup analysis was performed based on publication time and embolization agent.

RESULTS

A total of 66 studies including 2121 patients who underwent embolization for acute LGIB were included. Endoscopic management was attempted in 34.5%. The pooled overall technical success, rebleeding, post-embolization ischaemia rates were 97.0%, 20.7%, and 7.5%, respectively. Studies published after 2010 showed higher technical success rates (97.8% vs 95.2%), lower rebleeding rates (18.6% vs 23.4%), and lower ischaemia rates (7.3% vs 9.7%). Compared to microcoils, NBCA was associated with a lower rebleeding rate (9.3% vs 20.8%) at the expense of a higher post-embolization ischaemia rate (9.7% vs 4.0%). Coagulopathy (P = .034), inotropic use (P = .040), and malignancy (P = .002) were predictors of post-embolization rebleeding. Haemorrhagic shock (P < .001), inotropic use (P = .026), malignancy (P < .001), coagulopathy (P = .002), blood transfusion (P < .001), and enteritis (P = .023) were predictors of mortality. Empiric embolization achieved a similarly durable haemostasis rate compared to targeted embolization (23.6% vs 21.1%) but a higher risk of post-embolization ischaemia (14.3% vs 4.7%).

CONCLUSION

For LGIB, TAE has a favourable technical success rate and low risk of post-embolization ischaemia. Its safety and efficacy profile has increased over the last decade. Compared to microcoils, NBCA seemed to offer a more durable haemostasis rate at the expense of higher ischaemia risk. Due to the heterogeneity of currently available evidence, future prospective and comparative studies are warranted.

ADVANCES IN KNOWLEDGE

(1) Acute LGIB embolization demonstrate a high technical success rate with acceptable rate of rebleeding and symptomatic ischaemia rates. Most ischaemic stigmata discovered during routine post-embolization colonoscopy were minor. (2) Although NBCA seemed to offer a more durable haemostasis rate, it was also associated with a higher risk of ischaemia compared to microcoils. (3) Coagulopathy, malignant aetiology, and inotropic use were predictors of rebleeding and mortality. (4) Routine post-embolization endoscopy to assess for ischaemia is not indicated.

Computed Tomography Angiography and Conventional Angiography for the Diagnosis and Treatment of Non-variceal Gastrointestinal Bleeding at a Tertiary Cancer Center

INTRODUCTION

To evaluate the diagnostic value of computed tomography angiography (CTA) and conventional angiography (CA) and the therapeutic value of transarterial embolization for acute gastrointestinal bleeding in patients with malignancy.

METHODS

A retrospective review of 100 patients who underwent CTA and/or CA for gastrointestinal bleeding at a comprehensive cancer center between the years 2011-2021 was performed. Clinical and patient outcome data were collected and analyzed using Kruskal-Wallis tests for continuous variables and chi-square tests or Fisher's exact tests (whichever is appropriate) for categorical variables in univariate analysis. All tests were two-sided at a significance level of 0.05. Analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC).

RESULTS

Fifty-two percent of our patients underwent CTA alone, 29% underwent CA alone, and 19% underwent both procedures. Overall, CTA was positive in 11.3% (8/71) of patients and CA was positive in 22.9% (11/38) of patients. Of patients who underwent both studies, 52.6% (10/19) were positive for both. ICU admission was associated with CTA and/or CA positivity (p=0.015). Of 48 patients with data for embolization, 50% of patients underwent transarterial embolization for bleeding, 11 patients had identifiable bleeding on CA, and 13 patients underwent prophylactic embolization at the site of suspected bleeding. Rebleeding following embolization was found in 33.3% (8/24) of patients, including six patients who underwent prophylactic embolization and two patients who were treated for visualized bleeding.

CONCLUSION

CTA and CA are two critical studies for patients with GI bleeding and a history of malignancy. Neither alone can effectively exclude an identifiable source of bleeding. In patients with a history of malignancy, transarterial embolization may be an effective treatment of both angiographically visible and occult sources of GI bleeding.

Risk factors for difficult endoscopic hemostasis for colonic diverticular bleeding and efficacy and safety of transcatheter arterial embolization

This study aimed to investigate the risk factors for difficult endoscopic hemostasis in patients with colonic diverticular bleeding and to evaluate the efficacy and safety of transcatheter arterial embolization (TAE) for colonic diverticular bleeding. This study included 208 patients with colorectal diverticular hemorrhage. The non-interventional radiotherapy group consisted of patients who underwent successful spontaneous hemostasis (n = 131) or endoscopic hemostasis (n = 56), whereas the interventional radiotherapy group consisted of patients who underwent TAE (n = 21). Patient clinical characteristics were compared to identify independent risk factors for the interventional radiotherapy group. Furthermore, the hemostasis success rate, rebleeding rate, complications, and recurrence-free survival were compared between patients who underwent endoscopic hemostasis and those who underwent TAE. Bleeding from the right colon (odds ratio [OR]: 7.86; 95% confidence interval [CI]: 1.6-38.8; P = .0113) and systolic blood pressure <80 mm Hg (OR: 0.108; 95% CI: 0.0189-0.62; P = .0126) were identified as independent risk factors for the interventional radiology group. The hemostasis success rate (P = 1.00), early rebleeding rate (within 30 days) (P = .736), late rebleeding rate (P = 1.00), and recurrence-free survival rate (P = .717) were not significantly different between the patients who underwent TAE and those who underwent endoscopic hemostasis. Patients in the TAE group experienced more complications than those in the endoscopic hemostasis group (P < .001). Complications included mild intestinal ischemia (19.0%) and perforation requiring surgery (4.8%). Patients who required interventional radiotherapy were more likely to bleed from the right colon and presented with a systolic blood pressure of <80 mm Hg. TAE is an effective treatment for patients with colonic diverticular hemorrhage that is refractory to endoscopic hemostasis. However, complications must be monitored carefully.

A Review of Colonoscopy in Intestinal Diseases

Since the development of the fiberoptic colonoscope in the late 1960s, colonoscopy has been a useful tool to diagnose and treat various intestinal diseases. This article reviews the clinical use of colonoscopy for various intestinal diseases based on present and future perspectives. Intestinal diseases include infectious diseases, inflammatory bowel disease (IBD), neoplasms, functional bowel disorders, and others. In cases of infectious diseases, colonoscopy is helpful in making the differential diagnosis, revealing endoscopic gross findings, and obtaining the specimens for pathology. Additionally, colonoscopy provides clues for distinguishing between infectious disease and IBD, and aids in the post-treatment monitoring of IBD. Colonoscopy is essential for the diagnosis of neoplasms that are diagnosed through only pathological confirmation. At present, malignant tumors are commonly being treated using endoscopy because of the advancement of endoscopic resection procedures. Moreover, the characteristics of tumors can be described in more detail by image-enhanced endoscopy and magnifying endoscopy. Colonoscopy can be helpful for the endoscopic decompression of colonic volvulus in large bowel obstruction, balloon dilatation as a treatment for benign stricture, and colon stenting as a treatment for malignant obstruction. In the diagnosis of functional bowel disorder, colonoscopy is used to investigate other organic causes of the symptom.

WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting

BACKGROUND

Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons.

METHOD

A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019.

CONCLUSIONS

Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.

ACR Appropriateness Criteria® Radiologic Management of Lower Gastrointestinal Tract Bleeding: 2021 Update

Diverticulosis remains the commonest cause for acute lower gastrointestinal tract bleeding (GIB). Conservative management is initially sufficient for most patients, followed by elective diagnostic tests. However, if acute lower GIB persists, it can be investigated with colonoscopy, CT angiography (CTA), or red blood cell (RBC) scan. Colonoscopy can identify the site and cause of bleeding and provide effective treatment. CTA is a noninvasive diagnostic tool that is better tolerated by patients, can identify actively bleeding site or a potential bleeding lesion in vast majority of patients. RBC scan can identify intermittent bleeding, and with single-photon emission computed tomography, can more accurately localize it to a small segment of bowel. If patients are hemodynamically unstable, CTA and transcatheter arteriography/embolization can be performed. Colonoscopy can also be considered in these patients if rapid bowel preparation is feasible. Transcatheter arteriography has a low rate of major complications; however, targeted transcatheter embolization is only feasible if extravasation is seen, which is more likely in hemodynamically unstable patients. If bleeding site has been previously localized but the intervention by colonoscopy and transcatheter embolization have failed to achieve hemostasis, surgery may be required. Among patients with obscure (nonlocalized) recurrent bleeding, capsule endoscopy and CT enterography can be considered to identify culprit mucosal lesion(s). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Colonoscopy in Acute Lower Gastrointestinal Bleeding: Diagnosis, Timing, and Bowel Preparation

Lower gastrointestinal bleeding is bleeding from a colonic source. Rapid colon purge using 4 to 6 L of polyethylene glycol followed by early colonoscopy, within 24 hours of presentation, is recommended to optimize the detection and management of bleeding sources. Although the data are mixed, early colonoscopy seems to be associated with higher detection of bleeding lesions and therapeutic interventions. There is no clear benefit for early colonoscopy in terms of reduced duration of stay, rebleeding, transfusion requirement, or surgery compared with patients undergoing elective colonoscopy. Further studies are needed to determine the effect of early colonoscopy on clinically important outcomes.

CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know

Acute gastrointestinal (GI) bleeding is a common cause of both emergency department visits and hospitalizations in the USA and can have a high morbidity and mortality if not treated rapidly. Imaging is playing an increasing role in both the diagnosis and management of GI bleeding. In particular, CT angiography (CTA) is a promising initial test for acute GI bleeding as it is universally available, can be performed rapidly and may provide diagnostic information to guide management. The purpose of this review was to provide an overview of the uses of imaging in the diagnosis and management of acute GI bleeding, with a focus on CTA.

ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding

This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.

Lower GI bleeding: a review of current management, controversies and advances

PURPOSE

Lower gastrointestinal (GI) bleeding is defined as bleeding distal to the ligament of Treitz. In the UK, it represents approximately 3 % of all surgical referrals to the hospital. This review aims to provide review of the current evidence regarding the management of this condition.

METHODS

Literature was searched using Medline, Pubmed, and Cochrane for relevant evidence by two researchers. This was conducted in a manner that enabled a narrative review of the evidence covering the aetiology, clinical assessment and management options of continuously bleeding patients.

FINDINGS

The majority of patients with acute lower GI bleeding can be treated conservatively. In cases where ongoing bleeding occurs, colonoscopy is still the first line of investigation and treatment. Failure of endoscopy and persistent instability warrant angiography, possibly preceded by CT angiography and proceeding to superselective embolisation. Failure of embolisation warrants surgical intervention.

CONCLUSIONS

There are still many unanswered questions. In particular, the development of a more reliable predictive tool for mortality, rebleeding and requirement for surgery needs to be the ultimate priority. There are a small number of encouraging developments on combination therapy with regard to angiography, endoscopy and surgery. Additionally, the increasing use of haemostatic agents provides an additional tool for the management of bleeding endoscopically in difficult situations.