Outcome of acute nonvariceal gastrointestinal haemorrhage after nontherapeutic arteriography compared with embolization

Abstract

In acute nonvariceal gastrointestinal (GI) bleeding, immediate arteriographic haemostasis is presently assumed to be a therapeutic advantage. This study assesses whether the risk of a delayed haemostasis, caused by arteriographic findings precluding embolization, might influence patient outcome. We performed a 5.5-year retrospective database search to find all patients referred for arteriography to arrest acute nonvariceal GI bleeding with embolization. The embolized and nonembolized patients were compared for differences in baseline characteristics and bleeding parameters. In both groups the outcome of all endoscopic or surgical interventions after catheterization was included in the follow-up. Clinical success (at 30 days, after all therapy) and in-hospital mortality in the embolized and nonembolized group were compared. We retrieved 63 nonembolized bleedings in 58 patients and 49 embolized bleedings in 49 patients. In the nonembolized group, transfusion need and haemodynamic instability were significantly less severe. Forty-two of 63 (66%) nonembolized bleedings persisted requiring haemostasis by surgery (n=23), endoscopy (n=13) or supportive transfusions. Thirteen of 49 (27%) embolized bleedings recurred and were managed by surgery (n=7), endoscopy (n=3) or transfusion. Overall clinical success rate was 88.9% (56 of 63) in the nonembolized and 87.8% (43 of 49) in the embolized group. Mortality rate was 17.2% (10 of 58) in the nonembolized vs 30.6% (15 of 49) in the embolized patients (P=0.115). Whether or not arteriographic findings afforded the opportunity to embolize, outcome of acute nonvariceal GI bleeding did not differ significantly; however, patients undergoing embolization were more critically bleeding and ill.

Nonvariceal upper gastrointestinal bleeding

“…Assessing intermittent bleeding remains a clinical challenge. Defreyne et al [14] and Whitaker and Gregson [20] independently indicate that the most important determinant of the timing of angiography may be the findings of an experienced endoscopist when faced with intractable bleeding. While the onset and severity of a GI bleed may affect the timing of interventional treatment, once the diagnosis of a GI bleed has been made, further work-up is traditionally needed to localize the source.…”

“…Drop in blood counts, tachycardia, hypotension, and transfusion requirements have been postulated by many investigators to indicate ongoing blood loss [17][18][19]. However, these factors are dependent upon the effectiveness of resuscitation of the patient and not directly with the finding on endoscopy or angiography [14]. Assessing intermittent bleeding remains a clinical challenge.…”

“…Likewise, the amount of bleeding may affect treatment strategy with continued active bleeding requiring emergency angiography primarily without pre-procedural testing. The amount of bleeding for massive GI bleeding has traditionally been set at 4 units of packed red blood cells in 24 h [14,[16][17][18]. Drop in blood counts, tachycardia, hypotension, and transfusion requirements have been postulated by many investigators to indicate ongoing blood loss [17][18][19].…”

“…Upper GI bleeding often presents as a lower GI bleed. Acute GI bleeding is arbitrarily defined as bleeding Table 1 Causes of upper gastrointestinal (GI) bleeding [2-5, 8, 9] Source of bleeding Frequency (%) within 7 days and subacute bleeding within 1 month [14]. Chronic, intermittent bleeding occurring over 1 month in duration can usually be evaluated on a semi-elective basis and may require provocative angiography for diagnosis.…”

Transcatheter arterial embolization in gastric cancer patients with acute bleeding

“…Extravasation of contrast medium or presence of a pseudoaneurysm was regarded as active bleeding. Mucosal blush with abnormal vessels was regarded as tumor staining [16]. Evidence of active bleeding or tumor staining on the angiograms led to transcatheter arterial embolization to control the bleeding.…”