Role of Interventional Radiology in the Emergent Management of Acute Upper Gastrointestinal Bleeding

Abstract

Approximately 100,000 cases of upper gastrointestinal bleeding (UGIB) require inpatient admission annually in the United States. When medical management and endoscopic therapy are inadequate, endovascular intervention can be lifesaving. These emergent situations highlight the importance of immediate competence of the interventional radiologist in the preangiographic evaluation as well as the endovascular treatment of UGIB. We describe a case of UGIB managed with endovascular embolization and detail the angiographic techniques used. The case description is followed by a detailed discussion of the treatment approach to UGIB, with attention to both nonvariceal and variceal algorithms.

Keywords

embolization - upper gastrointestinal hemorrhage - emergent - TIPS

• References

• 1 Peura DA, Lanza FL, Gostout CJ, Foutch PG. The American College of Gastroenterology Bleeding Registry: preliminary findings. Am J Gastroenterol 1997; 92 (6) 924-928
• 2 Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1995; 90 (2) 206-210
• 3 de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2005; 43 (1) 167-176
• 4 Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W ; Practice Guidelines Committee of the American Association for the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46 (3) 922-938
• 5 Greenspoon J, Barkun A. A summary of recent recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Pol Arch Med Wewn 2010; 120 (9) 341-346
• 6 Vreeburg EM, Snel P, de Bruijne JW, Bartelsman JF, Rauws EA, Tytgat GN. Acute upper gastrointestinal bleeding in the Amsterdam area: incidence, diagnosis, and clinical outcome. Am J Gastroenterol 1997; 92 (2) 236-243
• 7 Bjorkman DJ, Zaman A, Fennerty MB, Lieberman D, Disario JA, Guest-Warnick G. Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study. Gastrointest Endosc 2004; 60 (1) 1-8
• 8 Lim JK, Ahmed A. Endoscopic approach to the treatment of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7 (3) 123-129
• 9 Lau JY, Sung JJ, Lam YH , et al. Endoscopic treatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 1999; 11 (340) 751-756
• 10 Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med 1994; 331 (11) 717-727
• 11 Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012; 107 (3) 345-360 ; quiz 361
• 12 Yoon W, Jeong YY, Shin SS , et al. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology 2006; 239 (1) 160-167
• 13 Kuhle WG, Sheiman RG. Detection of active colonic hemorrhage with use of helical CT: findings in a swine model. Radiology 2003; 228 (3) 743-752
• 14 Yann G, Rodallec MH, Boulay-Coletta I , et al. Multidetector CT angiography in acute gastrointestinal bleeding: why, when and how. Radiographics 2011; 31: E35-46
• 15 Millward SF. ACR appropriateness criteria on treatment of acute nonvariceal gastrointestinal tract bleeding. J Am Coll Radiol 2008; 5 (4) 550-554
• 16 Eriksson LG, Ljungdahl M, Sundbom M, Nyman R. Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure. J Vasc Interv Radiol 2008; 19 (10) 1413-1418
• 17 Ripoll C, Bañares 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 (5) 447-450
• 18 Defreyne L, Vanlangenhove P, De Vos M , et al. Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology 2001; 218 (3) 739-748
• 19 Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol 2010; 33 (6) 1088-1100
• 20 Sandhu C, Buckenham TM, Belli AM. Using CO₂-enhanced arteriography to investigate acute gastrointestinal hemorrhage. AJR Am J Roentgenol 1999; 173 (5) 1399-1401
• 21 Aina R, Oliva VL, Therasse E , et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001; 12 (2) 195-200
• 22 Padia SA, Geisinger MA, Newman JS, Pierce G, Obuchowski NA, Sands MJ. Effectiveness of coil embolization in angiographically detectable versus non-detectable sources of upper gastrointestinal hemorrhage. J Vasc Interv Radiol 2009; 20 (4) 461-466
• 23 Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011; 66 (6) 500-509
• 24 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 (6) 433-437
• 25 Fidelman N, Freed RC, Nakakura EK, Rosenberg J, Bloom AI. Arterial embolization for the management of gastrointestinal hemorrhage from metastatic renal cell carcinoma. J Vasc Interv Radiol 2010; 21 (5) 741-744
• 26 Lee CW, Liu KL, Wang HP, Chen SJ, Tsang YM, Liu HM. Transcatheter arterial embolization of acute upper gastrointestinal tract bleeding with N-butyl-2-cyanoacrylate. J Vasc Interv Radiol 2007; 18 (2) 209-216
• 27 Jae HJ, Chung JW, Jung AY, Lee W, Park JH. Transcatheter arterial embolization of nonvariceal upper gastrointestinal bleeding with N-butyl cyanoacrylate. Korean J Radiol 2007; 8 (1) 48-56
• 28 Lang EK. Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology 1992; 182 (3) 703-707
• 29 Darcy M. Treatment of lower gastrointestinal bleeding: vasopressin infusion versus embolization. J Vasc Interv Radiol 2003; 14 (5) 535-543
• 30 Lundgren JA, Matsushima K, Lynch FC, Frankel H, Cooney RN. Angiographic embolization of nonvariceal upper gastrointestinal bleeding: predictors of clinical failure. J Trauma 2011; 70 (5) 1208-1212
• 31 Poultsides GA, Kim CJ, Orlando III R, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008; 143 (5) 457-461
• 32 Avgerinos A, Armonis A. Balloon tamponade technique and efficiency in variceal hemorrhage. Scaud J Gastroenterol Suppl 1994; 207: 11-16
• 33 Lee EW, Laberge JM. Differential diagnosis of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7 (3) 112-122
• 34 Brett BT, Hayes PC, Jalan R.. Primary prophylaxis of variceal bleeding in cirrhosis. Eur J Gastroenterol Hepatol 2001; 13 (4) 349-358
• 35 Ginès P, Cárdenas A, Arroyo V, Rodés J. Management of cirrhosis and ascites. N Engl J Med 2004; 350 (16) 1646-1654
• 36 Infante-Rivard C, Esnaola S, Villeneuve JP. Role of endoscopic variceal sclerotherapy in the long-term management of variceal bleeding: a meta-analysis. Gastroenterology 1989; 96 (4) 1087-1092
• 37 de Franchis R, Primignani M. Why do varices bleed?. Gastroenterol Clin North Am 1992; 21 (1) 85-101
• 38 Smith JL, Graham DY. Variceal hemorrhage: a critical evaluation of survival analysis. Gastroenterology 1982; 82 (5 Pt 1) 968-973
• 39 de Dombal FT, Clarke JR, Clamp SE, Malizia G, Kotwal MR, Morgan AG. Prognostic factors in upper G.I. bleeding. Endoscopy 1986; 18 (Suppl. 02) 6-10
• 40 Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology 1981; 80 (4) 800-809
• 41 Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD ; Practice Guidelines Committee of American Association for Study of Liver Diseases; Practice Parameters Committee of American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol 2007; 102 (9) 2086-2102
• 42 Tesdal IK, Filser T, Weiss C, Holm E, Dueber C, Jaschke W. Transjugular intrahepatic portosystemic shunts: adjunctive embolization of collateral vessels in the prevention of variceal rebleeding. Radiology 2005; 236 (1) 360-367
• 43 Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31 (4) 864-871
• 44 Kamath PS, Wiesner RH, Malinchoc M , et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001; 33 (2) 464-470
• 45 Kamath PS, Kim WR ; Advanced Liver Disease Study Group. The model for end-stage liver disease (MELD). Hepatology 2007; 45 (3) 797-805
• 46 Saxon RR. A new era for transjugular intrahepatic portosystemic shunts?. J Vasc Interv Radiol 2004; 15 (3) 217-219
• 47 Ferral H, Gamboa P, Postoak DW , et al. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score. Radiology 2004; 231 (1) 231-236
• 48 Ferral H, Patel NH. Selection criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status. J Vasc Interv Radiol 2005; 16 (4) 449-455
• 49 Montgomery A, Ferral H, Vasan R, Postoak DW. MELD score as a predictor of early death in patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures. Cardiovasc Intervent Radiol 2005; 28 (3) 307-312