Endovascular Therapy of Gastrointestinal Bleeding

Abstract

Background Gastrointestinal (GI) bleeding is a frequently occurring disease pattern, with a broad variety of possible causes. The most acute bleeding responds well to conservative, medicinal and endoscopic therapies. Nevertheless, a certain amount of endoscopically not-identifiable or controllable non-varicose GI-bleeding requires alternative, sometimes surgical, therapy concepts. The updated S2k guideline “gastrointestinal bleeding” makes the case for interventional radiology with its minimally invasive endovascular techniques.

Methods This review article discusses the role of interventional radiology in the therapy of non-variceal upper and lower gastrointestinal bleeding according to the current literature and updated guideline. In this regard it covers the indications, techniques, results and complications of endovascular therapy.

Results and conclusion Considering interdisciplinary therapy options, the guideline-oriented endovascular treatment of gastrointestinal bleeding, using embolization and implantion of covered stents, shows to be a reasonable option with good technical and clinical success rates and a low rate of complications. In this context solid knowledge of vascular anatomy is essential to acquire adequate hemostasis.

Key points: 

• Interventional radiology contributes significantly to the diagnosis and treatment of non-variceal bleedings of various etiologies.

• In this context the S2K guideline “gastrointestinal bleeding” is the foundation for the decision-making process for hemostatic therapy.

• Embolization is the first choice when it comes to endovascular treatment of gastrointestinal bleeding.

• Adequate periinterventional management increases the success rate of endovascular therapy.

Citation Format

• Augustin AM, Fluck F, Bley T et al. Endovascular therapy of gastroinestinal bleeding. Fortschr Röntgenstr 2019; 191: 1073 – 1082

Key words

abdomen - angiography - embolization - interventional procedures - hemorrhage

• References

• 1 Manning-Dimmitt LL, Dimmitt SG, Wilson GR. Diagnosis of gastrointestinal bleeding in adults. Am Fam Physician 2005; 71: 1339-1346
• 2 Barnert J, Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 2009; 6: 637-646
• 3 Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc 1999; 49: 228-238
• 4 Gotz M, Anders M, Biecker E. et al. S2k Guideline Gastrointestinal Bleeding – Guideline of the German Society of Gastroenterology DGVS. Z Gastroenterol 2017; 55: 883-936
• 5 Hreinsson JP, Kalaitzakis E, Gudmundsson S. et al. Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013; 48: 439-447
• 6 Sanjay P, Kellner M, Tait IS. The role of interventional radiology in the management of surgical complications after pancreatoduodenectomy. HPB (Oxford) 2012; 14: 812-817
• 7 Navuluri R, Kang L, Patel J. et al. Acute lower gastrointestinal bleeding. Semin Intervent Radiol 2012; 29: 178-186
• 8 Zhang BL, Chen CX, Li YM. Capsule endoscopy examination identifies different leading causes of obscure gastrointestinal bleeding in patients of different ages. Turk J Gastroenterol 2012; 23: 220-225
• 9 Song SY, Chung JW, Yin YH. et al. Celiac axis and common hepatic artery variations in 5002 patients: systematic analysis with spiral CT and DSA. Radiology 2010; 255: 278-288
• 10 Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000; 356: 1318-1321
• 11 Cheng DW, Lu YW, Teller T. et al. A modified Glasgow Blatchford Score improves risk stratification in upper gastrointestinal bleed: a prospective comparison of scoring systems. Aliment Pharmacol Ther 2012; 36: 782-789
• 12 Gralnek IM, Dumonceau JM, Kuipers EJ. et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: a1-a46
• 13 Denzer U, Beilenhoff U, Eickhoff A. et al. S2k guideline: quality requirements for gastrointestinal endoscopy, AWMF registry no. 021–022. Z Gastroenterol 2015; 53: E1-E227
• 14 Koch A, Buendgens L, Duckers H. et al. Bleeding origin, patient-related risk factors, and prognostic indicators in patients with acute gastrointestinal hemorrhages requiring intensive care treatment. A retrospective analysis from 1999 to 2010. Med Klin Intensivmed Notfmed 2013; 108: 214-222
• 15 Green BT, Rockey DC, Portwood G. et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol 2005; 100: 2395-2402
• 16 Eriksson LG, Sundbom M, Gustavsson S. et al. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol 2006; 17: 959-964
• 17 Acute Upper Gastrointestinal Bleeding: Management. National Institute for Health and Clinical Excellence: Guidance. London: 2012
• 18 Garcia-Blazquez V, Vicente-Bartulos A, Olavarria-Delgado A. et al. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. European radiology 2013; 23: 1181-1190
• 19 Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding. J Med Imaging Radiat Oncol 2008; 52: 333-338
• 20 Gunderman R, Leef J, Ong K. et al. Scintigraphic screening prior to visceral arteriography in acute lower gastrointestinal bleeding. J Nucl Med 1998; 39: 1081-1083
• 21 Miller Jr M, Smith TP. Angiographic diagnosis and endovascular management of nonvariceal gastrointestinal hemorrhage. Gastroenterol Clin North Am 2005; 34: 735-752
• 22 Wortman JR, Landman W, Fulwadhva UP. et al. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90: 20170076
• 23 Wildgruber M, Wrede CE, Zorger N. et al. Computed tomography versus digital subtraction angiography for the diagnosis of obscure gastrointestinal bleeding. Eur J Radiol 2017; 88: 8-14
• 24 Marx G, Schindler AW, Mosch C. et al. Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33: 488-521
• 25 Wells M, Chande N, Adams P. et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012; 35: 1267-1278
• 26 Gambiez LP, Ernst OJ, Merlier OA. et al. Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis. Arch Surg 1997; 132: 1016-1021
• 27 Wente MN, Veit JA, Bassi C. et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142: 20-25
• 28 Kim J, Shin JH, Yoon HK. et al. Endovascular intervention for management of pancreatitis-related bleeding: a retrospective analysis of thirty-seven patients at a single institution. Diagn Interv Radiol 2015; 21: 140-147
• 29 Kickuth R, Rattunde H, Gschossmann J. et al. Acute lower gastrointestinal hemorrhage: minimally invasive management with microcatheter embolization. J Vasc Interv Radiol 2008; 19: 1289-1296 e2
• 30 Wildgruber M, Huff M, Meier R. et al. Embolization Therapy for Pancreas-Related Bleeding: A Retrospective Analysis With Focus on End-Organ Ischemia. Pancreas 2017; 46: e22-e23
• 31 Scharinger L, Aigner E, Datz C. Diagnostik der obskuren gastrointestinalen Blutung-Stellenwertvon Kapselendoskopie und Doppelballonenteroskopie. Journal für gastroenterologische und hepatologische Erkrankungen 2007; 5: 22-27
• 32 Radeleff B. Gastrointestinale Blutungen. In: Radeleff B. editor Angiofibel. Berlin Heidelberg: Springer-Verlag; 272-274
• 33 Maleux G, Roeflaer F, Heye S. et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009; 104: 2042-2046
• 34 Loffroy R, Rao P, Ota S. et al. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol 2010; 33: 1088-1100
• 35 Ryan JM, Key SM, Dumbleton SA. et al. Nonlocalized lower gastrointestinal bleeding: provocative bleeding studies with intraarterial tPA, heparin, and tolazoline. J Vasc Interv Radiol 2001; 12: 1273-1277
• 36 Aina R, Oliva VL, Therasse E. et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001; 12: 195-200
• 37 Mensel B, Kuhn JP, Kraft M. et al. Selective microcoil embolization of arterial gastrointestinal bleeding in the acute situation: outcome, complications, and factors affecting treatment success. Eur J Gastroenterol Hepatol 2012; 24: 155-163
• 38 Koo HJ, Shin JH, Kim HJ. et al. Clinical outcome of transcatheter arterial embolization with N-butyl-2-cyanoacrylate for control of acute gastrointestinal tract bleeding. Am J Roentgenol 2015; 204: 662-668
• 39 Loffroy R, Guiu B, D'Athis P. et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol 2009; 7: 515-523
• 40 Toyoda H, Nakano S, Kumada T. et al. Estimation of usefulness of N-butyl-2-cyanoacrylate-lipiodol mixture in transcatheter arterial embolization for urgent control of life-threatening massive bleeding from gastric or duodenal ulcer. J Gastroenterol Hepatol 1996; 11: 252-258
• 41 Urbano J, Manuel Cabrera J, Franco A. et al. Selective arterial embolization with ethylene-vinyl alcohol copolymer for control of massive lower gastrointestinal bleeding: feasibility and initial experience. J Vasc Interv Radiol 2014; 25: 839-846
• 42 Lenhart M, Paetzel C, Sackmann M. et al. Superselective arterial embolisation with a liquid polyvinyl alcohol copolymer in patients with acute gastrointestinal haemorrhage. European radiology 2010; 20: 1994-1999
• 43 Kurihara N, Kikuchi K, Tanabe M. et al. Partial resection of the second portion of the duodenum for gastrointestinal stromal tumor after effective transarterial embolization. Int J Clin Oncol 2005; 10: 433-437
• 44 Kuo WT, Lee DE, Saad WE. et al. Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2003; 14: 1503-1509
• 45 Lang EK. Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology 1992; 182: 703-707
• 46 Walsh RM, Anain P, Geisinger M. et al. Role of angiography and embolization for massive gastroduodenal hemorrhage. J Gastrointest Surg 1999; 3: 61-65 ; discussion 6
• 47 Defreyne L, Vanlangenhove P, De Vos M. et al. Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology 2001; 218: 739-748
• 48 Schenker MP, Duszak Jr R, Soulen MC. et al. Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival. J Vasc Interv Radiol 2001; 12: 1263-1271
• 49 Lundgren JA, Matsushima K, Lynch FC. et al. Angiographic embolization of nonvariceal upper gastrointestinal bleeding: predictors of clinical failure. J Trauma 2011; 70: 1208-1212
• 50 Nanavati SM. What if endoscopic hemostasis fails? Alternative treatment strategies: interventional radiology. Gastroenterol Clin North Am 2014; 43: 739-752
• 51 Ripoll C, Banares R, Beceiro I. et al. Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. J Vasc Interv Radiol 2004; 15: 447-450
• 52 Eriksson LG, Ljungdahl M, Sundbom M. et al. Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure. J Vasc Interv Radiol 2008; 19: 1413-1418
• 53 Wong TC, Wong KT, Chiu PW. et al. A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers. Gastrointest Endosc 2011; 73: 900-908
• 54 Stampfl U, Hackert T, Sommer CM. et al. Superselective embolization for the management of postpancreatectomy hemorrhage: a single-center experience in 25 patients. J Vasc Interv Radiol 2012; 23: 504-510
• 55 Hassold N, Wolfschmidt F, Dierks A. et al. Effectiveness and outcome of endovascular therapy for late-onset postpancreatectomy hemorrhage using covered stents and embolization. J Vasc Surg 2016; 64: 1373-1383
• 56 Kickuth R, Hoppe H, Saar B. et al. Superselective transcatheter arterial embolization in patients with acute peripancreatic bleeding complications: review of 44 cases. Abdom Radiol (NY) 2016; 41: 1782-1792
• 57 Nicholson AA, Patel J, McPherson S. et al. Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications. J Vasc Interv Radiol 2006; 17: 1279-1285
• 58 Lang EV, Picus D, Marx MV. et al. Massive arterial hemorrhage from the stomach and lower esophagus: impact of embolotherapy on survival. Radiology 1990; 177: 249-252
• 59 d'Othee BJ, Surapaneni P, Rabkin D. et al. Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol 2006; 29: 49-58
• 60 Weldon DT, Burke SJ, Sun S. et al. Interventional management of lower gastrointestinal bleeding. European radiology 2008; 18: 857-867
• 61 Encarnacion CE, Kadir S, Beam CA. et al. Gastrointestinal bleeding: treatment with gastrointestinal arterial embolization. Radiology 1992; 183: 505-508
• 62 Loffroy R, Favelier S, Pottecher P. et al. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging 2015; 96: 731-744
• 63 Loffroy R, Guiu B, Cercueil JP. et al. Endovascular therapeutic embolisation: an overview of occluding agents and their effects on embolised tissues. Curr Vasc Pharmacol 2009; 7: 250-263
• 64 Lipof T, Sardella WV, Bartus CM. et al. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum 2008; 51: 301-305
• 65 Ikoma A, Kawai N, Sato M. et al. Ischemic effects of transcatheter arterial embolization with N-butyl cyanoacrylate-lipiodol on the colon in a Swine model. Cardiovasc Intervent Radiol 2010; 33: 1009-1015
• 66 Bandi R, Shetty PC, Sharma RP. et al. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001; 12: 1399-1405
• 67 Funaki B, Kostelic JK, Lorenz J. et al. Superselective microcoil embolization of colonic hemorrhage. Am J Roentgenol 2001; 177: 829-836