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.

Massive Hematochezia Secondary to Rectal Enema Injury: The Role of Sengstaken-Blakemore Tube for Hemostasis When Endoscopy Fails

In rare instances, rectal cleansing enemas may cause rectal injury, precipitating lower gastrointestinal hemorrhage (LGIH). In a subset of LGIH cases, the bleeding diathesis may fail to respond to traditional treatment modalities and can be life-threatening. We present a case of an 84-year-old female with cleansing enema induced rectal bleeding - she was a poor surgical candidate and due to lack of access to in-house interventional radiology teams, hemostasis was attempted with sui generis use of the Sengstaken-Blakemore tube. Our transanal application of the Sengstaken-Blakemore tube for the management of LGIH contributes further evidence supporting the use of balloon tamponade in achieving hemostasis in select patients when traditional therapeutic modalities are unavailable.

Dieulafoy lesion in a Hartmann stump

A 70-year-old man underwent laparoscopic anterior resection for sigmoid carcinoma, and on postoperative day 4, he required an emergency Hartmann procedure for bowel ischemia and anastomotic leakage. Five days after the emergency procedure, there was a massive hemorrhage through the anus that appeared in the abdominal drain. During exploration, the origin of the bleeding could not be found, and the rectal stump was closed over a urinary Foley catheter (with an inflated balloon) with the help of a purse-string suture. In the intensive care unit, massive hematochezia continued. Emergency transanal colonoscopy to the Hartmann stump found the rectum full of clotted blood. Active pulsatile arterial bleeding of a rectal Dieulafoy lesion was detected. After endoscopic hemostasis efforts failed, bleeding was stopped successfully by transanal suturing. The patient was discharged without any other problems, and no recurrent bleeding occurred during the 18-month follow-up. Here, we report a rectal Dieulafoy lesion in a Hartmann stump for the first time.

胶囊内镜在以便血为主诉的小肠疾病患儿中的应用价值

OBJECTIVE

To evaluate the value of capsule endoscopy in children with small intestinal diseases with hematochezia as the chief complaint.

METHODS

A retrospective analysis was performed on the clinical data and capsule endoscopy findings of 93 children with hematochezia who were admitted to Children's Hospital of Fudan University from May 2015 to January 2019 and underwent capsule endoscopy. According to the capsule endoscopy findings of the jejunum and the ileum, they were divided into a positive lesion group with 39 patients and a negative lesion group with 54 patients. Related clinical data and the features of lesion on capsule endoscopy were analyzed for the two groups.

RESULTS

There were no significant differences in age, sex, duration of capsule endoscopy, gastric transit time, and small intestinal transit time between the positive lesion and negative lesion groups (P>0.05). The positive lesion group had a significantly lower level of hemoglobin than the negative lesion group (P<0.05). Hemoglobin level was negatively correlated with the rate of positive lesions on capsule endoscopy (r=-0.342, P=0.001). Among the 39 patients with positive lesions on capsule endoscopy, the detection of Meckel's diverticulum was the highest (41%), followed by inflammatory bowel disease (21%).

CONCLUSIONS

Capsule endoscopy has a certain value in detecting small intestinal diseases, especially diseases in the jejunum and the ileum, in children with lower gastrointestinal hemorrhage.

Surgical Options and Approaches for Lower Gastrointestinal Bleeding: When do we operate and what do we do?

Lower gastrointestinal bleeding (LGIB) is a common entity encountered by the surgeon. Though most LGIB stops on its own, familiarity with the diagnoses and their treatments is critical to optimal patient care. Even in 2016, surgery may be required. Advances in imaging have led to an enhanced ability to localize bleeding. Newer anticoagulants have developed which provide ease of use to the patient, but challenges to caregivers when bleeding arises.

Role of hemostatic powders in the management of lower gastrointestinal bleeding: A review

Despite the recent advances in endoscopic hemostatic techniques, the management of lower gastrointestinal bleeding could be sometimes challenging. Hemostatic powders such as Hemospray, EndoClot, and Ankaferd Blood Stopper have found their way into digestive endoscopy and are licenced in many countries especially for use in upper gastrointestinal bleeding. We reviewed the literature on the use of these hemostatic powders in different situations in lower gastrointestinal bleeding and looked at the success rate and rebleeding rate. Most of the data are derived from case reports, retrospective and prospective case series with absence of any randomized controlled trials. Hemostatic powders were used as primary or salvage therapy to control bleeding from polypectomy site, colonic tumors, diverticula, arteriovenous malformations, radiation proctitis, ischemic colitis, and surgical intestinal anastomosis. The rate of immediate control of bleeding is in the range of 88-100% with a recurrence rate of 3-13% except for radiation proctitis bleeding where rebleeding rate can be as high as 77%. Although there are many advantages for the use of local hemostatic agents in lower gastrointestinal bleeding, future randomized controlled trials comparing them with conventional methods are needed.

Ultraselective embolization using a 1.7-Fr catheter and soft bare coil for small intestinal bleeding

OBJECTIVE

We aimed to evaluate the safety and efficacy of embolization using a 1.7-Fr catheter and soft bare coil to treat acute small intestinal bleeding.

MATERIAL AND METHODS

Subjects were five consecutive patients who experienced onset of melena with small intestinal bleeding and underwent transcatheter arterial embolization with 1.7-Fr catheters and 0.010-inch detachable bare coils (five procedures in total). Technical success, clinical success, relative post-procedural complications, arterial bleeding source and cause, and relationship between coagulopathy and embolization efficacy were examined by capsule endoscopy.

RESULTS

We achieved 100% technical and clinical success for the five transcatheter arterial embolizations. All catheterizations of the vasa recta of the bleeding artery (jejunal artery, n = 2; ileal artery, n = 3) were possible with a 1.7-Fr catheter. We achieved high embolization efficacy in two patients with coagulopathy. No rebleeding, intestinal ischemia, or necrosis was observed on follow-up capsule endoscopy. We confirmed that peptic ulcers/ulcer scars were the cause of bleeding for all patients.

CONCLUSION

Embolization with 0.010-inch coils using a 1.7-Fr catheter and catheterization of the vasa recta of bleeding vessels was effective and safe for treating small intestinal bleeding.

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.