Non-VaricealGI Bleeding: Interventional Radiology Bleeding: Interventional Radiology Alex Colque, MD...

NonNon--VaricealVariceal GI GI Bleeding: Bleeding:

Interventional Interventional RadiologyRadiology

Alex Colque, MDAlex Colque, MDUniversity of Colorado University of Colorado Surgery Grand RoundsSurgery Grand Rounds

February 26, 2007February 26, 2007

GI BleedingGI Bleeding

Upper GI Bleeding:Upper GI Bleeding:–– 5050--150 per 100,000 150 per 100,000

in US each yearin US each year–– 300,000 US hospital 300,000 US hospital

admissions each admissions each yearyear

Lower GI Lower GI BLeedingBLeeding::–– 20 per 100,000 in 20 per 100,000 in

US each yearUS each year

GI BleedingGI Bleeding

Mortality 10Mortality 10--35%35%Age and Age and comorbiditiescomorbidities are independent are independent risk factors for mortality risk factors for mortality

Upper GI Upper GI BLeedingBLeeding

–– Sources:Sources:Peptic UlcerPeptic UlcerTumorsTumorsIschemiaIschemiaGastritisGastritisAVMsAVMsDieulafoyDieulafoy’’ss lesionslesionsMalloryMallory--Weiss tearsWeiss tearsTraumaTraumaIatrogenicIatrogenic

Lower GI BleedingLower GI Bleeding

Sources:Sources:–– DiverticulosisDiverticulosis (40%)(40%)–– AngiodysplasiaAngiodysplasia (AVM) (AVM) –– Colon CancerColon Cancer–– HemorrhoidsHemorrhoids–– Inflammatory Bowel Disease Inflammatory Bowel Disease –– Ischemic Conditions Ischemic Conditions

Colitis, Colitis, volvulusvolvulus

TreatmentTreatment

ResuscitationResuscitationEmergent Emergent EndoscopyEndoscopy–– EGDEGD–– Colonoscopy if prep Colonoscopy if prep

clears stoolclears stool

Angiography Angiography –– less less invasiveinvasiveSurgerySurgery

TretmentTretment

When When endoscopyendoscopy fails to control bleeding?fails to control bleeding?Locate Bleeding siteLocate Bleeding site–– RBC RBC ScintigraphyScintigraphyAngiography Angiography –– less invasiveless invasive–– GOLD STANDARD for diagnosisGOLD STANDARD for diagnosis–– Must have active bleeding (0.5Must have active bleeding (0.5--1.0 ml/min)1.0 ml/min)–– Also can be therapeuticAlso can be therapeutic

Vasopressin infusionVasopressin infusionEmbolizationEmbolization ((GelfoamGelfoam, coils, alcohol particles), coils, alcohol particles)

TreatmentTreatment

No prospective randomized trials that No prospective randomized trials that compare IR compare IR embolizationembolization to surgery.to surgery.Several retrospective case series show Several retrospective case series show that IR that IR embolizationembolization can be successful in can be successful in treating GI bleeding.treating GI bleeding.IR IR embolizationembolization can reduce the need for can reduce the need for surgery, especially in the high risk surgery, especially in the high risk patients.patients.

UGI BleedingUGI Bleeding

EndoscopyEndoscopyPPIsPPIsH. pylori treatmentH. pylori treatmentSuited to IR Suited to IR EmbolizationEmbolization therapytherapy–– CollateralsCollaterals–– Less ischemic complicationsLess ischemic complications–– 85% of UGI bleeding from Left Gastric Artery85% of UGI bleeding from Left Gastric Artery


2 retrospective case series2 retrospective case series–– University of PennsylvaniaUniversity of Pennsylvania–– CanadaCanada

Retrospective review comparing IR Retrospective review comparing IR embolizationembolization and surgery in bleeding PUD and surgery in bleeding PUD

UGI Bleeding UGI Bleeding –– U. of PennU. of Penn

Retrospective review of 178 patients with Retrospective review of 178 patients with nonnon--varicealvariceal UGIB who underwent IR UGIB who underwent IR embolizationembolization from 1988from 1988--20002000Evaluated 163 with complete recordsEvaluated 163 with complete recordsCompared mortality rates of clinically Compared mortality rates of clinically successful (cessation of bleeding) and successful (cessation of bleeding) and unsuccessful unsuccessful embolizationembolization

SchenkerSchenker et alet al


If no active If no active extravizationextravization was seen, was seen, empericemperic embolizationembolization was performedwas performed–– Left gastric artery for gastric bleedingLeft gastric artery for gastric bleeding–– GastroduodenalGastroduodenal artery for duodenal bleedingartery for duodenal bleeding

Evaluated subgroups of patients with MOF Evaluated subgroups of patients with MOF and and coagulopathycoagulopathy at the time of at the time of embolizationembolization



n=163n=163 Successful Successful EmbolizationEmbolization

Unsuccessful Unsuccessful EmbolizationEmbolization

OverallOverall 95 (58%)95 (58%) 68 (42%)68 (42%)

Mortality Mortality 54 (33%)54 (33%)

10 (11%)10 (11%) 44 (68%)44 (68%)

MOF MOF 38 (23% of pts)38 (23% of pts)

13 13 (69% mortality(69% mortality

9/13)9/13)

25 25 (96% mortality(96% mortality

24/25)24/25)SchenkerSchenker et alet al


93 (57%) of patients had 93 (57%) of patients had coagulopathycoagulopathy–– 2.8 times more likely to fail 2.8 times more likely to fail embolizationembolization–– 3.4 times more likely to die3.4 times more likely to dieComplications:Complications:–– 17 (10%)17 (10%)–– 5 were major (unstable coils in 5 were major (unstable coils in splenicsplenic

branches, branches, embolizationembolization of of rtrt hepatic artery, hepatic artery, dissection of SMA, 2 ARF)dissection of SMA, 2 ARF)



Conclusion:Conclusion:–– Successful IR Successful IR embolizationembolization decreased decreased

mortality in UGI bleeding, even in the setting mortality in UGI bleeding, even in the setting of MOF or of MOF or coagulopathycoagulopathy..

–– IR IR embolizationembolization should be considered the first should be considered the first line approach for managing nonline approach for managing non--varicealvariceal UGI UGI bleeding refractory to bleeding refractory to endoscopicendoscopic control.control.


UGI Bleeding UGI Bleeding -- CanadaCanada

75 Consecutive patients form a tertiary 75 Consecutive patients form a tertiary hospital in Canada from 1988hospital in Canada from 1988--1998 with 1998 with nonnon--varicealvariceal UGI bleeding that failed UGI bleeding that failed endoscopicendoscopic treatmenttreatment57 (76%) primarily successful57 (76%) primarily successful5 more had secondary success within 12 5 more had secondary success within 12 days (83% overall success)days (83% overall success)Overall, only 12 (16%) needed surgical Overall, only 12 (16%) needed surgical interventionintervention

AniaAnia et alet al

UGI Bleeding UGI Bleeding -- CanadaCanada

Conclusion:Conclusion:–– IR IR embolizationembolization is an effective treatment of is an effective treatment of

nonnon--varicealvariceal UGI bleeding and may reduce UGI bleeding and may reduce the need for surgery.the need for surgery.

–– Repeat Repeat embolizationembolization can be attempted in can be attempted in cases of bleeding recurrence.cases of bleeding recurrence.

AniaAnia et alet al

UGI Bleeding UGI Bleeding ––Peptic UlcersPeptic Ulcers

Retrospective review of 1,350 patients Retrospective review of 1,350 patients with bleeding ulcerwith bleeding ulcer85 (6.2%) required further therapy due to 85 (6.2%) required further therapy due to uncontrolled bleeding or reuncontrolled bleeding or re--bleedingbleedingEvaluated 70 with complete recordsEvaluated 70 with complete records–– IR IR EmbolizationEmbolization –– 3131

Older, with higher incidence of cardiac disease and Older, with higher incidence of cardiac disease and anticoagulant therapyanticoagulant therapy

–– Surgery Surgery –– 3939Ripoll et al. Ripoll et al.

UGI Bleeding UGI Bleeding ––Peptic UlcersPeptic UlcersOutcomeOutcome IR IR EmbolizationEmbolization

3131SurgerySurgery

3939

Mean Mean pRBCpRBCUnitsUnits

4.24.2 4.14.1

Recurrence of Recurrence of BleedingBleeding

9 (29%)9 (29%) 9 (23%)9 (23%)

SurgerySurgery 5 (16%)5 (16%) 12 (30%)12 (30%)

DeathDeath 8 (26%)8 (26%) 8 (21%)8 (21%)

Ripoll et alRipoll et al


Surgery after initial treatmentSurgery after initial treatment–– IR: IR:

4 due to recurrent bleeding4 due to recurrent bleeding1 due to perforation1 due to perforation

–– Surgery: Surgery: 5 due to recurrent bleeding5 due to recurrent bleeding7 due to surgical complications7 due to surgical complications

No technical complications or ischemic No technical complications or ischemic events in the IR events in the IR EmbolizationEmbolization group.group.



ConclusionConclusion–– No difference in the outcomes of bleeding No difference in the outcomes of bleeding

recurrence, transfusion requirements, surgery recurrence, transfusion requirements, surgery or deathor death

–– IR group was higher riskIR group was higher risk


LGI BleedingLGI Bleeding

Colonoscopy limited due to active Colonoscopy limited due to active hemorrhage obscuring bleeding pointhemorrhage obscuring bleeding pointSurgery has high mortality of 10Surgery has high mortality of 10--35%35%IR IR embolizationembolization–– Less collateral blood supplyLess collateral blood supply–– Higher ischemic complications Higher ischemic complications


Colonoscopy limited due to active Colonoscopy limited due to active hemorrhage obscuring bleeding pointhemorrhage obscuring bleeding pointSurgery has high mortality of 10Surgery has high mortality of 10--35%35%IR IR embolizationembolization–– Less collateral blood supplyLess collateral blood supply–– Higher ischemic complications Higher ischemic complications

Superselective catheterization – Distal arteries smaller than 1 mm in diameter– Less ischemic complications


2 case series of 2 case series of superselectivesuperselective IR IR embolizationembolizationReview of multiple case series of IR Review of multiple case series of IR embolizationembolization for LGI Bleedingfor LGI Bleeding

LGI Bleeding LGI Bleeding –– U of RochesterU of Rochester

Retrospective review of 22 patients Retrospective review of 22 patients undergoing undergoing superselectivesuperselective embolizationembolization of of LGI bleeding from 1992LGI bleeding from 1992--20022002Colonoscopy performed in only 3 patients Colonoscopy performed in only 3 patients prior to angiographyprior to angiographyMean transfusion requirement was 6.8 Mean transfusion requirement was 6.8 units units pRBCspRBCsINR corrected to <1.3 when neededINR corrected to <1.3 when needed

KuoKuo et alet al

LGI Bleeding LGI Bleeding –– U of RochesterU of RochesterIR IR EmbolizationEmbolization

N=22N=22

Technical success Technical success –– immediate immediate hemostasishemostasis

22(100%)22(100%)

Bleeding recurrenceBleeding recurrence 3 (14%)3 (14%)

Need for SurgeryNeed for Surgery 3 (14%)3 (14%)

Bowel infarctionBowel infarction 00

Minor ischemiaMinor ischemia 1 (4.5%)1 (4.5%)KuoKuo et alet al

LGI Bleeding LGI Bleeding –– U of RochesterU of Rochester

Conclusions:Conclusions:–– Modern Modern superselectivesuperselective IR IR embolizationembolization is a is a

safe and effective treatment for LGI Bleeding.safe and effective treatment for LGI Bleeding.–– SuperselectiveSuperselective IR IR embolizationembolization should be should be

attempted when LGI bleeding is detected by attempted when LGI bleeding is detected by angiography.angiography.

KuoKuo et alet al

LGI Bleeding LGI Bleeding -- HartfordHartford

Retrospective review of 27 patients undergoing Retrospective review of 27 patients undergoing superselectivesuperselective embolizationembolization of LGI bleeding from of LGI bleeding from 19931993--19991999Colonoscopy performed in 6 patients prior to Colonoscopy performed in 6 patients prior to angiography (5 negative, 1 not control bleeding)angiography (5 negative, 1 not control bleeding)Mean transfusion requirement was 2.4 units Mean transfusion requirement was 2.4 units pRBCspRBCsAll had followAll had follow--up colonoscopy at 1 year to up colonoscopy at 1 year to evaluate for ischemiaevaluate for ischemia

DeBarrosDeBarros et alet al


IR IR EmbolizationEmbolizationN=27N=27

Technical success Technical success –– immediate immediate hemostasishemostasis

27(100%)27(100%)

Bleeding recurrenceBleeding recurrence 6 (22%)6 (22%)

Need for SurgeryNeed for Surgery 5 (19%)5 (19%)

Bowel infarction Bowel infarction –– required required surgerysurgery

1 (4%)1 (4%)

Minor ischemiaMinor ischemia 1 (4%)1 (4%)DeBarrosDeBarros et alet al


Conclusions:Conclusions:–– SuperselectiveSuperselective IR IR embolizationembolization is a safe and is a safe and

effective treatment for LGI Bleeding.effective treatment for LGI Bleeding.–– When angiographic location of LGI Bleeding is When angiographic location of LGI Bleeding is

possible, possible, superselectivesuperselective IR IR embolizationembolizationshould be considered as the primary should be considered as the primary therapeutic alternative.therapeutic alternative.

DeBarrosDeBarros et alet al

LGI Bleeding LGI Bleeding -- ReviewReview

Retrospective review of 10 patients undergoing Retrospective review of 10 patients undergoing IR IR embolizationembolization of LGI bleeding from 1998of LGI bleeding from 1998--2000 2000 at University Hospitals of Clevelandat University Hospitals of ClevelandReviewed their results and 7 additional previous Reviewed their results and 7 additional previous LGI bleeding LGI bleeding embolizationembolization case seriescase series

GadyGady et alet al

LGI Bleeding LGI Bleeding -- ReviewReviewStudyStudy nn RebleedRebleed IschemiaIschemia SurgerySurgery

BrooksteinBrookstein (1978)(1978) 77 2 (29%)2 (29%) -- 2 (29%)2 (29%)

MatoloMatolo (1979)(1979) 44 0 (0%)0 (0%) -- 1 (25%)1 (25%)

Guy (1991)Guy (1991) 99 3 (33%)3 (33%) 2 (22%)2 (22%) 2 (22%)2 (22%)

Gordon (1997)Gordon (1997) 1414 2 (14%)2 (14%) 1 (17%)1 (17%) 1 (7%)1 (7%)

Nicholson (1998)Nicholson (1998) 1414 2 (14%)2 (14%) 3 (21%)3 (21%) 2 (14%)2 (14%)

LuchtefeldLuchtefeld (2000)(2000) 1717 1 (6%)1 (6%) 1 (6%)1 (6%) 2 (12%)2 (12%)

Funaki (2001)Funaki (2001) 2727 3 (11%)3 (11%) 2 (7%)2 (7%) 3 (11%)3 (11%)

GadyGady (2002)(2002) 1010 3 (30%)3 (30%) 1 (10%)1 (10%) 4 (40%)4 (40%)

Gady et al

LGI Bleeding LGI Bleeding -- ReviewReview

Conclusions:Conclusions:–– IR IR embolizationembolization is a safe and effective is a safe and effective

treatment for LGI Bleeding.treatment for LGI Bleeding.–– IR IR embolizationembolization hemostasishemostasis, even when , even when

temporary, allows for semitemporary, allows for semi--elective staging of elective staging of operative resection.operative resection.

–– All patients with an All patients with an angiographicallyangiographicallydemonstrable lesion should undergo demonstrable lesion should undergo embolizationembolization, with bowel prep and , with bowel prep and colonoscpycolonoscpywithin 48 hrs to confirm diagnosis and within 48 hrs to confirm diagnosis and evaluate for mucosal ischemia.evaluate for mucosal ischemia.

GadyGady et alet al

ConclusionConclusion

IR IR embolizationembolization should be considered in all should be considered in all patients with nonpatients with non--varicealvariceal GI Bleeding that GI Bleeding that cannot be controlled cannot be controlled endoscopicallyendoscopically..SuperselectiveSuperselective IR IR embolizationembolization should can should can be done safely in LGI Bleeding.be done safely in LGI Bleeding.The decision to proceed with IR The decision to proceed with IR embolizationembolization should be made with the should be made with the consultation of a surgeon. consultation of a surgeon.

ConclusionConclusion

It is important to evaluate patients for It is important to evaluate patients for postpost--embolizationembolization ischemia by clinical ischemia by clinical signs or signs or endoscopicendoscopic evaluation.evaluation.IR IR embolizationembolization only treats the symptom only treats the symptom of bleeding and not the underlying of bleeding and not the underlying disease.disease.

References:References:AniaAnia R, et al: Arterial R, et al: Arterial embolotherapyembolotherapy for upper gastrointestinal hemorrhage: for upper gastrointestinal hemorrhage: outcome outcome assesmentassesment. J . J VascVasc IntervInterv RadiolRadiol 12:19512:195--200, 2001.200, 2001.DeBarrosDeBarros J, et al: The Changing Paradigm for the Treatment of Colonic J, et al: The Changing Paradigm for the Treatment of Colonic Hemorrhage. Hemorrhage. DisDis Colon Rectum 45(6):802Colon Rectum 45(6):802--808.808.GadyGady JS et al: Selective Arterial JS et al: Selective Arterial EmbolizationEmbolization for Control of Lower for Control of Lower GastointestinalGastointestinal Bleeding: Recommendations for a Clinical Management Bleeding: Recommendations for a Clinical Management Pathway. Pathway. CurrCurr SurgSurg 60(3):34460(3):344--347, 2003.347, 2003.KuoKuo WT, et al: WT, et al: SuperselectiveSuperselective MicrocoilMicrocoil EmbolizationEmbolization for the Treatment of for the Treatment of Lower Gastrointestinal Hemorrhage. J Lower Gastrointestinal Hemorrhage. J VascVasc IntervInterv RadiolRadiol 14:150314:1503--1509, 1509, 2003.2003.Ripoll, et al: Comparison of Ripoll, et al: Comparison of TranscatheterTranscatheter Arterial Arterial EmbolizationEmbolization and Surgery and Surgery for the Treatment of Bleeding Peptic Ulcer after for the Treatment of Bleeding Peptic Ulcer after EndoscopicEndoscopic Treatment Treatment Failure. J Failure. J VascVasc IntervInterv RadiolRadiol 15:44715:447--450, 2004.450, 2004.SchenkerSchenker MP, et al: Upper gastrointestinal hemorrhage and MP, et al: Upper gastrointestinal hemorrhage and transcathetertranscatheterembolotherapyembolotherapy: clinical and technical factors impacting success and : clinical and technical factors impacting success and survival. J survival. J VascVasc IntervInterv RadiolRadiol 12:126312:1263--1271, 2001.1271, 2001.

Non-VaricealGI Bleeding: Interventional Radiology Bleeding: Interventional Radiology Alex Colque, MD...

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