ANGIOGRAPHIC DIAGNOSIS AND ENDOVASCULAR TREATMENT OF GASTROINTESTINAL BLEEDING

Ces Radiol 2007; 61(2): 123–128

ANGIOGRAPHIC DIAGNOSIS AND ENDOVASCULAR TREATMENT OF GASTROINTESTINAL BLEEDING ANGIOGRAFICKÁ DIAGNÓZA A ENDOVASKULÁRNÍ LÉČBA KRVÁCENÍ DO GASTROINTESTINÁLNÍHO TRAKTU review

Antonín Krajina1 Josef Rösch2 Miroslav Lojík1 Jan Raupach1 Vendelín Chovanec1 Stanislav Rejchrt3 Pavel Vyroubal3 Department of Radiology, Teaching Hospital Hradec Kralové, Charles University in Prague 1

Charles Dotter Institute, Oregon Health Sciences University, Portland, Oregon 2

Department of Medicine, Teaching Hospital Hradec Kralové, Charles University in Prague 3

Accepted: 15. 4. 2007 Address for correspondence: prof. MUDr. Antonín Krajina, CSc. Department Radiology University Hospital 500 05 Hradec Kralové, Czech Republic e-mail: [email protected]

SUMMARY

SOUHRN

Krajina A, Rösch J, Lojík M, Raupach J, Chovanec V, Rejchrt S, Vyroubal P. Angiographic diagnosis and endovascular treatment of gastrointestinal bleeding

Krajina A, Rösch J, Lojík M, Raupach J, Chovanec V, Rejchrt S, Vyroubal P. Angiografická diagnóza a endovaskulární léčba krvácení do gastrointestinálního traktu

Since its introduction, selective arteriography of the gastrointestinal tract has transformed from purely a diagnostic technique to a therapeutic method of bleeding control in the upper and lower gastrointestinal tract. Coaxial microcatheter embolization is now considered an option for this treatment in centres. Embolotherapy and endoscopic treatment of arterial gastrointestinal bleeding appear to be complementary. Patients with massive arterial bleeding should be first evaluated with angiography with the intent to be embolized while patients with intermittent bleeding should undergo endoscopy first, and in case of lower gastrointestinal bleeding with previous bowel preparation. Detailed history of a patient together with precise diagnostic imaging (scintigraphy, CT, angiography) plays key role in this treatment. Key words: gastrointestinal tract – hemorrhage, gastrointestinal tract – angiography, embolization, endoscopy.

Angiografie se od doby svého zavedení transformovala z čistě diagnostické metody k metodě léčebné umožňující zástavu krvácení v horním a později i dolním gastrointestinálním traktu. Embolizace pomocí koaxiálně zavedených mikrokatétrů je nyní považována za další možnost léčby krvácení v centrech. Embolizace a endoskopická léčba arteriálního gastrointestinálního krvácení jsou metody se doplňující. Nemocní s masivním arteriálním krvácením by měli být nejprve vyšetřeni angiografií s cílem použít embolizační metody, zatímco nemocní s intermitentním krvácením by měli být nejprve vyšetření endoskopií a v případě krvácení do dolního gastrointestinálního traktu endoskopií s náležitou přípravou. Podrobná anamnéza a přesné diagnostické zobrazení (scintigrafie, CT, angiografie) hrají klíčovou roli v této léčbě. Klíčová slova: gastrointestinální trakt – krvácení, gastrointestinální trakt – angiografie, embolizace, endoskopie.

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Acute gastrointestinal (GI) bleeding encompasses a wide spectrum of symptoms ranging from scant hematochezia, which can safely be evaluated in the outpatient setting, to massive hemorrhage resulting in shock (1, 2). There are three possible categories of patients who can be referred for visceral angiography, when patients with minor bleeding are excluded. The first category is comprised of patients with chronic intermittent bleeding resulting in sideropenic anemia. Angiography is indicated here to reveal vascular pathology, but never contrast extravazation. These patients have the greatest benefit from endoscopy alone. The second category includes patients with severe life threatening bleeding that suddenly stops and the patient becomes hemodynamically stable with another episode of hemorrhage to occur. The intensity of bleeding can vary even from minute to minute (3). Angiography in these patients should be targeted by positive nuclear medicine scanning or by repeating identical angiograms within a few minutes. In extreme cases, provocative bleeding studies with intraarterial infusion of vasodilators, heparin or thrombolytics can be useful to identify the site of bleeding and decrease the number of negative angiograms (4). The third category comprises patients with continued active bleeding. These patients progress rapidly into shock, and are best managed by urgent angiography with transcatheter bleeding control. A clinical distinction must be made between upper GI and lower GI bleeding. Up to 90 % of all severe GI bleedings are from a lesion proximal to the ligament of Treitz which is borderline between upper and lower GI bleeding. Endoscopy is crucial both for excluding bleeding from gastroesophageal varices and for diagnosis of transpapillary bleeding (hemobilia and hemosuccus pancreaticus). The causes of bleeding from the upper GI tract referred for endovascular treatment included duodenal ulcer (51 %), gastric ulcer (12 %), postsurgical bleeding (11 %), tumor (11 %), inflammatory condition (8 %), gastritis (3 %), postendoscopic sphincterotomy (3 %), and trauma (3 %). This group of patients despite adequate treatment had mortality rates as high as 25 to 30 % (5). Reports of angiographic accuracy have ranged from 60 % to 86 %. Patients with lower GI bleeding tend to be more elderly than those with gastric and duodenal lesions. Angiographic accuracy is only 40–48 %. Localization of a bleeding site is of paramount importance, because limiting the extent of emergency bowel resection can drop operative mortality in cases when bleeding control cannot be performed by embolization. Diverticular disease is found in 2/3 of patients older than 80 years. Diverticula are formed at the site where vasa recta penetrates the muscular wall of the colon. Bleeding occurs from ruptured vasa recta at the lesion neck or when fecalith erodes a vessel over the apex of diverticulum. While diverticula are found in the left colon more frequently, right-sided diverticula appear to have a higher incidence of bleeding. So called angiodysplasia is characterized by multiple arteriovenous shunts and predominates in the right colon and cecum and has a high tendency for recurrent hemorrhage. Both benign adenomatous polyps and adenocarcinoma may cause life-threatening bleeding. The colonoscopy is highly recommended even after successful transcatheter treatment.

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Iatrogenic bleeding after colonoscopic polypectomy may also occur and present even in up to 14 days after the intervention (2, 6).

HISTORY For extravasation to be detectable, bleeding must exceed 0.5 ml/min. Since its introduction in 1963, selective arteriography has transformed from purely a diagnostic technique to a therapeutic method of bleeding control. First, the selective arterial infusion of vasoconstrictive agents through the same catheter used to identify the bleeding site and then transcatheter embolizations were utilized widely to stop bleeding in the upper GI tract (7). Embolization of proximal arterial branches of the colon using 5–6F catheters was used less frequently as in some reports led to the bowel infarction in up to 33 %. The advent of the microcatheters led to renewed interest in embolization in the lower GI tract in the 1990´s. Technique of the superselective catheterization has increased possibilites of targeted embolization. Improvement resulted from increased reliability of selective arterial occlusion by closer embolic agent delivery to the bleeding site, and introduction of more reliable, but also more aggressive embolic agents (nonresorbable particles, acrylic glue) that do not cause collateral ischemia when delivered more selectively (2). Embolotherapy is now considered by many interventional radiologists as a primary option for treating both the upper and lower GI bleeding. Embolotherapy has several advantages over local vasoconstrictive therapy, including quicker completion of therapy and decreased likelihood of systemic complications (6). Superselective embolotherapy, however, is more technically demanding and probably more expensive because of used microcatheters, microwires and dedicated embolic agents.

ANGIOGRAPHIC DIAGNOSIS The use of the meticulous technique is crucial for revealing extravasation in angiographic studies for gastrointestinal bleeding. Opacification of the celiac trunk and superior mesenteric artery followed by selective arteriography of the left gastric, gastroduodenal and splenic arteries is necessary for evaluation of upper GI bleeding. In patients with lower GI bleeding, the inferior mesenteric artery should be injected first so that the rectosigmoid can be seen free of the contrast filled bladder. This injection should be done in a slight right anterior oblique projection to separate the loops of the sigmoid colon. The operator must be sure that the whole anatomical area has been properly screened. Two injections with different centering in both superior and inferior mesenteric arteries are usually required in adults when 40 cm image intensifier is used for digital subtraction angiography (DSA). Large volume of injected contrast agent and thorough filming is mandatory to increase chance of extravasation detection. The butylscopolamine (20 mg i.v.) or glucagon (0.2–0.5 mg i.v.) may be administered after endoscopy when intensive bowel peristalsis interferes with digital subtraction images.

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In patients with supported respiration, temporary breathing disconnection may be helpful to eliminate respiratory artefacts on digital subtraction angiograms. When extravasation of contrast medium is demonstrated at angiography, embolic therapy is performed as selectively as possible with microcatheter coaxially inserted into a 5F catheter.

THE USE OF CARBON DIOXIDE IN DIAGNOSIS OF EXTRAVASATION CO2 gas reduces the attenuation of the blood vessel and its low viscosity allows it to pass through tiny arteries and small arterial tears. When CO2 enters the bowel, it rapidly expands giving an angiographic sign of enlarging bubble. Even nonselective CO2 angiography can reveal extravasation that is not seen on conventional angiography. Image quality of CO2 angiograms, however, is limited due to the low contrast of CO2 gas and nonbleeding vascular abnormalities cannot be detected. Therefore, CO2 angiography should be used as a complementary angiographic technique to the conventional angiography. Hand injection of CO2 is very easy to perform and with use of 60 ml syringe even large vessels can be opacified. CO2 must never be delivered direct from the high pressure gas cylinder as potentially dangerous volume could be injected. The syringe should be filled through pressure reducing valve in a passive way and not using aspiration to avoid air contamination. The filled syringe is disconnected from the gas cylinder and simply attached to the diagnostic catheter. The catheter is purged of saline prior to injection. This manoeuvre ensures a rapid smooth injection rather than explosive delivery that breaks up the gas bolus. The angiographer must be aware of potential hazards of CO2 angiography such as neurotoxicity of CO2 and transient ischemia. The latter is caused by trapped CO2 gas interfering with normal blood flow. This so called vapor lock has been reported in the mesenteric arteries. Its clinical presentation was selflimiting hemorrhagic diarrhea (8).

PITFALLS, TIPS AND TRICKS IN THE ANGIOGRAPHIC DIAGNOSIS OF BLEEDING The intermittent bleeding can result in a negative angiographic examination if, during the injection, the bleeding has decreased or ceased. In this case, we usually repeat injection in 10 minutes, or inject vasodilatators intrarterially if we are sure that we are evaluating the proper vessel. Endoscopy-directed “blind” embolization could be successfull when technique of microcatheters is used. No difference was found of clinical outcome between upper GI bleeders who underwent the “blind” embolization and those who underwent embolization after a bleeding site had been demonstrated angiographically (5, 9). Angiographic examination of the stomach and duodenum should also be carried out if a negative superior and inferior mesenteric angiograms are obtained in a patient presenting with lower GI bleeding.

A prepyloric ulcer that is actively bleeding can mimic a duodenal location of extravasation similarly as a duodenal bleeding from the inferior pancreaticoduodenal artery may seem to be located in the transverse colon. This problem can be resolved by repeating the injection in a right anterior oblique position. The normal parenchymal blushes should not be confused with extravasation, particularly the superimposed left adrenal gland on the gastric fundus, and corpora cavernosa on the rectum. The hyperemic appearance of the gastric wall can be caused by gastritis that is frequently present in patients bleeding from other causes such as duodenal ulcers or Mallory-Weiss tears. We should always look for bleeding from a colonic diverticle even if we have found angiodysplasia at first. The bleeding segment of the small bowel can be opacified by methylene blue via selectively placed microcatheter into the bleeding superior mesenteric branch. The pathologic segment of the small bowel can be easily detected at the laparotomy.

EMBOLIZATION Possible mechanisms of embolization of a bleeding vessel include decreased arterial perfusion pressure to the bleeding site, local vasospasm, the patient´s ability to form clot and effect of delivered embolic agent. The microcatheter-microwire locally induced vasospasm (10) or local infusion of platelets (11) were reported to be effective in some patients to stop GI bleeding even without embolization. Generally, correction of preexisting coagulopathy is the most important factor for a durable outcome (5, 12, 13). The angiogram documenting extravasation is used as a roadmap to navigate a 3F microcatheter that is inserted coaxially through the 5F diagnostic catheter. This occasionally requires oblique views, more selective and stable position of the guiding catheter and use of magnification angiography. Selection of the embolic agent depends on location of a bleeding site (upper or lower GI bleeding), selectivity of a microcatheter position in relation to bleeding site and also on personal experience of the angiographer. The n-butyl-2-cyanoacrylate (Histoacryl Blue, Braun, Germany) is the most efficient embolic agent used in large upper GI bleeding. Its injection requires special skills because its dilution with oily contrast medium (Lipiodol Ultrafluide, Guerbet, France) changes dramatically the time of its solidifying in the bloodstream. Ideally, the glue should pass the bleeding site, get outside of the artery and fill also the proximal part of the bleeding vessel. The microcatheter is removed immediately after injection of the glue (Fig. 1). A new microcatheter is necessary if extravasation persists. Embolization with microcoils and polyvinylalcohol microparticles is performed step-by-step and the same microcatheter can be used for selective injections to follow the bleeding site (14, 15). This technique is utilized in the lower GI tract since complete devascularization is undesirable in the bowel. The microcatheter is ideally placed into the vasa rectae or to the border of the colon (the marginal artery) to control bleeding and limit risk of ischemia. The used

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Obr. 1 A

Obr. 1 B

Obr. 1 D

Obr. 1 E

Fig. 1. 69-year-old female with upper GI bleeding 8 days after abdominal surgery She underwent nephrectomy on the right side and partial duodenal resection because of the renal cell carcinoma ingrowth. The endoscopic therapy failed to stop bleeding. A – the hepatic angiogram revealed extravasation from the gastroduodenal artery branch; B – selective gastroduodenal angiogram; C – selective injection through the microcatheter before injection of the n-butyl-2-cyanoacrylate mixed with oily contrast medium in ratio 1:9; D – the completion angiogram revealed no extravasation; E – the superior mesenteric angiogram excluded continued extravasation through collaterals

microparticles of the PVA should be larger than 250 µm. The microcoils range in length from 2 to 20 mm. Embolization should be continued until arterial extravasation is arrested. The completion angiogram performed through the guiding 5F catheter must be carefully assessed to exclude filling of bleeding site via collaterals. CO2 extravasation can persists after sufficient embolization therefore iodinated contrast medium is preferred for follow up studies. Repeat angiogram should be performed 10 to 15 minutes after embolization to confirm stable occlusion and exclude extravasation.

RESULTS Embolotherapy using microcatheters in patients with upper GI bleeding from peptic ulcers is used when endoscopic therapy failed. Embolization carries risk of recurrent bleeding (29 %), additional surgery (16 %), and mortality (25 %) in patients with mean age 75 years, particularly in those with higher (i.e. 67 %) incidence of heart disease and previous

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Obr. 1 C

Obr. 1. Devětašedesátiletá žena s krvácením do horního zažívacího traktu 8 dní po břišní operaci Byla provedena nefrektomie a částečná resekce duodena pro prorůstající Grawitzův nádor. Pokus o endoskopickou léčbu selhal. A – angiografie a. hepatica prokázala extravazaci z gastroduodenální tepny; B – cílený nástřik a. gastroduodenalis; C – selektivní nástřik mikrokatétrem před embolizací n-butyl-2-kyanoakrylátem smíchaným s olejovou kontrastní látkou v poměru 1:9; D – kontrolní angiografie neprokazuje extravazát; E – angiografie a. mesenterica superior vyloučila pokračující krvácení cestou kolaterál

anticoagulation medication (25 %). These numbers are comparable with surgical results despite the surgical patients are significantly younger (average difference 12 years), and have lower incidence of heart disease and lower rate of anticoagulation treatment (16). Pre-existing coagulopathy and the use of coils as the only embolic agent were found to be associated with a higher risk of rebleeding (5). In patients with persistent extravasation at superior mesenteric arteriography after embolization of the gastroduodenal artery synchronous embolization of the inferior pancreaticoduodenal artery can be an effective therapy. This procedure carries the risk of pancreatic and duodenal necrosis (17). Embolotherapy in lower GI bleeding (Fig. 2) is not used as frequently as in upper GI bleeding. This is because of its much lower frequency of bleeding in comparison to the bleeding into the upper part of GI tract. The second reason is more difficult microcatheter navigation in the both mesenteric arteries that requires certain level of skills, and the last reason is risk of the bowel ischemia. More than 170 patients treated by the embolization technique described above

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Obr. 2 A

Obr. 2 B

Obr. 2 D

Obr. 2 E

were reviewed in literature (2). Their metaanalysis revealed clinical success rate ranging from 76 % to 91 %, and risk of major ischemic complications ranging from 0 % to 6 % when microcoils and/or microparticles were used. The only exception was 22 % rate of major bowel ischemia when a liquid embolic agent was used for embolization. Diverticular bleeding responds best to embolization. Bleeding from angiodysplasia and bleeding from the cecum has had a rebleeding rate up to 75 %. A high rate of rebleeding after cecal embolization is explained by a higher rate of angiodysplasia and rich collateral network.

CONCLUSION Transcatheter therapy has proven to have its stable place in therapeutic algorithm in the therapy of GI bleeding. Coaxial

LITERATURA 1. Bloomfeld RS, Rockey DC. Diagnosis and management of lower gastrointestinal bleeding. Current Opinion Gastroenterol 2000; 16: 89–97. 2. Funaki B. Microcatheter embolization of lower gastrointestinal hemorrhage: an old idea whose time has come. Cardiovasc Intervent Radiol 2004; 27: 591– 599.

Fig. 2. 83-year-old male with nassive bleeding after mucosectomy in the rectum which was not controlable by endoscopic therapy A – the inferior mesenteric artery angiogram revealed extravasation; B – navigation of a microcatheter; C – the final selective position of the microcatheter; D – completion angiogram after selective embolization with the n-butyl-2-cyanoacrylate Obr. 2. Třiaosmdesátiletý muž s masivním krvácením po mukosektomii v rektu Krvácení nebylo stavitelné endoskopicky. A – angiografie a. mesenterica inferior prokázala extravazaci; B – zavedení mikrokatétru; C – konečná poloha mikrokatétru; D – kontrolní angiografie po provedené cílené embolizaci n-butyl-2-kyanoakrylátem

microcatheter embolization is now considered a primary option for this treatment (18), also due to advances in microcatheter and embolic agent technology (19). Infusion of vasoconstrictors (i.e. vasopressin) is still preferable for diffusely bleeding lesions and cases in which superselective catheterization is not possible (6). The main disadvantage of embolotherapy over endoscopy and surgery is its limited availability outside of medical centers. Embolotherapy and endoscopic treatment of arterial GI bleeding appear to be complementary. Patients with massive arterial bleeding should be first evaluated with angiography with the intent to be embolized while patients with intermittent bleeding should undergo endoscopy first, and in case of lower GI bleeding with previous bowel preparation (1). Detailed history of a patient (20, 21) together with precise angiographic imaging plays key role in this treatment. We expect increasing role of multidetector row helical CT in the diagnosis of GI bleeding in the future (22).

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ting success and survival. J Vasc Interv Radiol 2001; 12: 1263–1271. 13. Lang EV, Picus D, Marx MV, Hicks ME. Massive arterial hemorrhage from the stomach and lower esophagus: impact of embolotherapy on survival. Radiology 1990; 177: 249–252. 14. d´Othée BJ, Surapaneni P, Rabkin D, Nasser I, Clouse M. Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol 2006; 29: 49–58. 15. Kuo WT, Lee DE, Saad WEA, Patel N, Sahler LG, Waldman DL. Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2003; 14: 1503–1509. 16. Ripoll C, Banares R, Beceiro I, et al. Comparison of trancatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. J Vasc Interv Radiol 2004; 15: 447–450. 17. Bell SD, Lau KY, Sniderman KW. Synchronous embolization of the gastroduodenal artery and the inferior pancreaticoduodenal artery in patients with massive duodenal hemorrhage. J Vasc Interv Radiol 1995; 6: 531–536.

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Antonín Krajina, Jan H. Peregrin:

INTERVENČNÍ RADIOLOGIE. MINIINVAZIVNÍ TERAPIE Hradec Králové: Olga Čermáková 2006; 835 s.

Během posledních dvou desetiletí se v rámci radiodiagnostiky utvářela její svébytná subspecializace intervenční radiologie a v současné době dosáhla již charakteru svébytné odbornosti podobně jako například cévní chirurgie v oboru chirurgie. Vlivem technologického rozvoje nových instrumentů i implantovatelných materiálů se původně úzký – endovaskulární – profil intervenční radiologie rozšířil na téměř veškeré orgánové systémy. Monografie „Intervenční radiologie“ encyklopedickým charakterem mapuje celou problematiku intervenční radiologie, přičemž všechny statě jsou svébytným a úplným pohledem na konkrétní problematiku jednotlivých výkonů. Práce je rozsahem nejobjemnějším dílem čes-

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ké radiologické literatury. Navazuje na v devadesátých letech 20. století vydanou monografii Antonínů Hlavy a Krajiny, je obsahem výjimečná i ve světovém měřítku. Kniha je členěna na 14 oddílů, které se věnují od přípravy intervenčního výkonu, přes provádění výkonů při revaskularizaci, na žilním řečišti, při léčbě aneuryzmat, dále v kardiologii, neurologii a neurochirurgii, oftalmologii, pneumologii, gastroenterologii a hematologii, urologii a gynekologii, onkologii, traumatologii a pediatrii. Nejrozsáhlejšími oddíly jsou právem kapitoly věnované výkonům na arteriálním řečišti periferních tepen, na aortě a neurovaskulárním intervencím. Kniha je poučením nejen novým adeptům intervenční radiologie, ale vítaným svazkem i v knihovně nás, kteří jsme stáli na začátku cesty české intervenční radiologie na přelomu šedesátých a sedmdesátých let minulého století. MUDr. Milan Novák