Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding

A systematic review of failed endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding

BACKGROUND

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a surgical emergency, usually managed via endoscopy. Approximately 2% of patients will have another significant bleed after therapeutic endoscopy and may require either transarterial embolization (TAE) or surgery. In 2011, the National Institute for Health and Care Excellence guidelines recommended that TAE should be the preferred option offered in this setting.

METHODS

This study aimed to conduct an appraisal of guidelines on NVUGIB using the Appraisal of Guidelines for Research and Evaluation II tool. A specific review of their recommendations on the management of adult patients with failed endoscopic hemostasis that required TAE or surgery was conducted.

RESULTS

The quality of the guidelines was moderate; most could be recommended with changes. However, their recommendations regarding TAE vs surgery were widely heterogeneous. A closer review of the underpinning evidence showed that most studies were retrospective, with a small sample size and missing data.

CONCLUSION

Because of the heterogeneity in evidence, the decision regarding TAE vs surgery requires further research. Deciding between these modalities is primarily based on TAE availability and patient comorbidities. However, surgery should not be dismissed as a key option after failed endoscopic hemostasis.

[Guidelines for Non-variceal Upper Gastrointestinal Bleeding]

Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an important cause for visiting the hospital and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there has been no previous guidelines regarding management of NVUGIB in Korea. Korea is a country with a high prevalence of Helicobacter pylori infection and patients have easy accessibility to receive endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB are mandatory. The Korean Society of Gastroenterology reviewed recent evidence and recommends practical management guidelines on NVUGIB in Korea.

Guidelines for Nonvariceal Upper Gastrointestinal Bleeding

Nonvariceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB requires hospitalization and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there have been no previous guidelines regarding management of NVUGIB in Korea. Korea has a high prevalence of Helicobacter pylori infections, and patients have easy accessibility to endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB in Korea are essential. The Korean Society of Gastroenterology reviewed the recent evidence and recommends practical management guidelines on NVUGIB in Korea.

[Vascular causes of clinically unclear acute abdomen]

CLINICAL ISSUE

Vascular abnormalities are a rare cause of an acute abdomen. They include arterial bleeding and ischemia, the latter being either in the arterial or venous system. The most common cause of an acute ischemic abdomen is acute mesenteric ischemia caused by a thromboembolic occlusion of the superior mesenteric artery, followed by thrombotic occlusion of the portal vein, the mesenteric vein as well as the hepatic veins and the suprahepatic part of the inferior vena cava. In the case of an acute abdomen due to internal bleeding, all abdominal arteries can be the source but most common are ruptures of aortic aneurysms and inflammatory-driven bleeding from the superior mesenteric artery.

PRACTICAL RECOMMENDATIONS

Due to the high mortality, vascular causes should be diagnosed as soon as possible. For this purpose, computed tomography (CT) has evolved into the preferred tool due to its high availability and speed. To differentiate various vascular causes of an acute abdomen, it is important to incorporate a CT protocol without contrast media as well as contrast-enhanced series in arterial and venous phases. Conventional angiography has been replaced by CT for the diagnosis of vascular pathologies causing an acute abdomen; however, it plays an increasing role in the treatment of these pathologies.

The role of metallic clips in transcatheter intravascular embolization for non-variceal upper gastrointestinal bleeding cases receiving unmanageable endoscopic therapy: A retrospective cohort study

INTRODUCTION

This study aims to explore whether metallic clips could be a kind of localizer and guider in transcatheter arterial embolization for patients with non-variceal upper gastrointestinal bleeding, who received an unmanageable endoscopic therapy.

METHODS

A total of 18 patients with non-variceal hemorrhage of the upper gastrointestinal tract, who received an unmanageable endoscopic therapy at *** Hospital of **** Province from July 2010 to December 2016, were included into this study. One or two metallic clips were placed on the margin of the bleeding point to be a mark during the endoscopic therapy. Then, all patients were immediately transferred to have an emergent upper gastrointestinal angiography. Bleeding vessels were embolized when found according to the guidance of the metallic clips. After the procedure, any changes of the patient's condition were closely observed and recorded.

RESULTS

The average transcatheter arterial embolization therapy time was 31 min, 17 patients immediately had a successful result, and the success rate of the arterial embolization therapy was 94.44%. However, the bleeding could not be stopped in one patient. This patient was transferred and underwent a surgical operation to stop the bleeding.

CONCLUSION

Metallic clips could play an important role in accurately locating the bleeding vessel during the trans catheter arterial embolization therapy. Furthermore, it could also improve the success rate of stopping the bleeding during intravascular embolization therapy, and shorten the time of intravascular embolization therapy.

Transcatheter arterial embolization for iatrogenic bleeding after endoscopic ultrasound-guided pancreaticobiliary drainage

PURPOSE

The purpose of this study was to report the incidence of massive bleeding after endoscopic ultrasound-guided transmural pancreaticobiliary drainage (EUS-TPBD) and the clinical outcomes in patients with this condition treated with transcatheter arterial embolization (TAE).

PATIENTS AND METHODS

We performed a 9-year retrospective analysis of 797 EUS-TPBD procedures (excluding gallbladder or pseudocysts) in 729 patients. Among them, twelve (12/729, 1.65%) patients were referred for TAE to manage active bleeding adjacent to the TPBD sites. There were 8 men and 4 women with a mean age of 66.1 years±13.4 (SD) (range: 45-89 years). The clinical and procedure data of these 12 patients were reviewed.

RESULTS

Thirteen TAE procedures in 12 patients were performed. The bleeding sites were the left hepatic artery (n=7), the right hepatic artery (n=3), the left gastric artery (n=1), the left accessory gastric artery (n=1) and gastroduodenal artery (n=1). TAE was performed with gelatin sponge particles (n=1), coil (n=1) and n-butyl-2 cyanoacrylate with/without coils (n=11), with technical and clinical success rates of 100% (13/13) and 85% (11/13), respectively. Re-bleeding following embolization with gelatin sponge particles occurred in one patient. Procedure-related ischemic hepatitis was observed in another patient with pancreatic cancer with portal vein involvement.

CONCLUSION

On the basis of our results, TAE using n-butyl-2 cyanoacrylate seems safe and effective for the treatment of bleeding after EUS-TPBD procedures. When the portal vein is compromised, TAE of the hepatic artery can cause ischemic liver damage.

Multidisciplinary Approach to Refractory Upper Gastrointestinal Bleeding: Case Series of Angiographic Embolization

Although medical and endoscopic hemostasis is now considered as the first-line therapy for nonvariceal upper gastrointestinal (UGI) bleeding, refractory bleeding still occurs in 5%-10% of the patients. In these patients, transcatheter arterial embolization (TAE) or surgery is required, but research on embolization for unmanageable UGI bleeding in Korea is scanty. We reviewed the medical records of 518 patients who underwent endoscopic hemostasis during 4 years. Among these subjects, 8 patients who required embolization due to failure of endoscopic hemostasis were enrolled. Mean patient age was 74.00 ± 8.25 years, and rebleeding occurred in 4 patients within 48 hours after TAE. Three patients with duodenal rebleeding underwent surgery, and the other patient with a gastric ulcer underwent endoscopic hemostasis. Nonvariceal UGI bleeding remains a serious clinical challenge, especially in older patients. A multidisciplinary approach including endoscopists, interventional radiologists, and surgeons may be important for the treatment of nonvariceal UGI bleeding.

Gastrointestinal Bleeding Successfully Treated Using Interventional Radiology

Gastrointestinal (GI) bleeding is an emergency medical condition that leads to hemorrhagic shock or circulatory instability if left untreated. A mainstay for treating GI bleeding is endoscopic therapy; more than 90% of GI bleeding can be staunched by endoscopic hemostasis. However, patients with unstable hemodynamics or GI bleeding that cannot be controlled by endoscopy require transcatheter embolization or surgical intervention. The development of several devices and embolization agents that are used in interventional radiology (IVR) leads to safe and accessible treatment via IVR. If endoscopic treatment fails, IVR is the second strategy. Herein, we report cases of GI bleeding that were successfully treated by IVR and discuss the therapeutic strategy.

Water-Borne Endovascular Embolics Inspired by the Undersea Adhesive of Marine Sandcastle Worms

Transcatheter embolization is used to treat vascular malformations and defects, to control bleeding, and to selectively block blood supply to tissues. Liquid embolics are used for small vessel embolization that require distal penetration. Current liquid embolic agents have serious drawbacks, mostly centered around poor handling characteristics and toxicity. In this work, a water-borne in situ setting liquid embolic agent is described that is based on electrostatically condensed, oppositely charged polyelectrolytes-complex coacervates. At high ionic strengths, the embolic coacervates are injectable fluids that can be delivered through long narrow microcatheters. At physiological ionic strength, the embolic coacervates transition into a nonflowing solid morphology. Transcatheter embolization of rabbit renal arteries demonstrated capillary level penetration, homogeneous occlusion, and 100% devascularization of the kidney, without the embolic crossing into venous circulation. The benign water-borne composition and setting mechanism avoids many of the problems of current liquid embolics, and provides precise temporal and spatial control during endovascular embolization.

[Endovascular arterial embolization for duodenal bleeding as an alternative to surgical approach]

AIM

To present possibilities of transcatheter arterial embolization (TAE) in duodenal bleeding management.

MATERIAL AND METHODS

Treatment of 212 patients with acute duodenal bleeding for the period from 2012 to 2014 was analyzed. In 32 (22.5%) patients of the study group bleeding recurrence or its high risk was indication for TAE.

RESULTS

Change of surgical tactics for bleeding from upper gastrointestinal tract including endoscopic hemostasis optimization, wide introduction of TAE and sharp decrease of surgical activity reduced overall mortality to 1.6% in 2012--2014.

CONCLUSION

TAE is effective to control bleeding and reduces mortality rate especially in high risk and elderly patients.

Management of Patients with Rebleeding

Peptic ulcer bleeding is a common emergency. Management of ulcer bleeding requires prompt risk stratification, initiation of pharmacotherapy, and timely evaluation for endoscopy. Although endoscopy can achieve primary hemostasis in more than 90% of peptic ulcer bleeding, rebleeding may occur in up to 15% of patients after therapeutic endoscopy and is associated with heightened mortality. Early identification of high-risk patients for rebleeding is important. Depending on bleeding severity and center availability, patients with rebleeding may be managed by second endoscopy, transarterial angiographic embolization, or surgery. This article reviews the current management of peptic ulcers with an emphasis on rebleeding.

Endoscopic management of nonvariceal upper gastrointestinal bleeding: state of the art

Nonvariceal upper gastrointestinal (GI) bleeding is one of the most common reasons for hospitalization and a major cause of morbidity and mortality worldwide. Recently developed endoscopic devices and supporting apparatuses can achieve endoscopic hemostasis with greater safety and efficiency. With these advancements in technology and technique, gastroenterologists should have no concerns regarding the management of acute upper GI bleeding, provided that they are well prepared and trained. However, when endoscopic hemostasis fails, endoscopy should not be continued. Rather, endoscopists should refer patients to radiologists and surgeons without any delay for evaluation regarding the appropriateness of emergency interventional radiology or surgery.

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.

Highlights of international digestive endoscopy network 2013

Rapid advances in the technology of gastrointestinal endoscopy as well as the evolution of science have made it necessary for us to continue update in either various endoscopic techniques or state of art lectures relevant to endoscopy. International Digestive Endoscopy Network (IDEN) 2013 was held in conjunction with Korea-Japan Joint Symposium on Gastrointestinal Endoscopy (KJSGE) during June 8 to 9, 2013 at Seoul, Korea. Two days of impressive scientific program dealt with a wide variety of basic concerns from upper gastrointestine (GI), lower GI, pancreaticobiliary endoscopy to advanced knowledge including endoscopic submucosal dissection forum. IDEN seems to be an excellent opportunity to exchange advanced information of the latest issues on endoscopy with experts from around the world. In this special issue of Clinical Endoscopy, we prepared state of art review articles from contributing authors and the current highlights will skillfully deal with very hot spots of each KJSGE, upper GI, lower GI, and pancreaticobiliary sessions by associated editors of Clinical Endoscopy.

Refractory gastrointestinal bleeding: role of angiographic intervention

Although endoscopic hemostasis remains initial treatment modality for nonvariceal gastrointestinal (GI) bleeding, severe bleeding despite endoscopic management occurs in 5% to 10% of the patients, requiring surgery or transcatheter arterial embolization (TAE). TAE is now considered the first-line therapy for massive GI bleeding refractory to endoscopic management. GI endoscopists need to be familiar with indications, principles, outcomes, and complications of TAE, as well as embolic materials available.