Endoscopic hemostasis makes the difference: Angiographic treatment in patients with lower gastrointestinal bleeding

Abstract

BACKGROUND The large majority of gastrointestinal bleedings subside on their own or after endoscopic treatment. However, a small number of these may pose a challenge in terms of therapy because the patients develop hemodynamic instability, and endoscopy does not achieve adequate hemostasis. Interventional radiology supplemented with catheter angiography (CA) and transarterial embolization have gained importance in recent times. AIM To evaluate clinical predictors for angiography in patients with lower gastrointestinal bleeding (LGIB). METHODS We compared two groups of patients in a retrospective analysis. One group had been treated for more than 10 years with CA for LGIB ( n = 41). The control group had undergone non-endoscopic or endoscopic treatment for two years and been registered in a bleeding registry ( n = 92). The differences between the two groups were analyzed using decision trees with the goal of defining clear rules for optimal treatment. RESULTS Patients in the CA group had a higher shock index, a higher Glasgow-Blatchford bleeding score (GBS), lower serum hemoglobin levels, and more rarely achieved hemostasis in primary endoscopy. These patients needed more transfusions, had longer hospital stays, and had to undergo subsequent surgery more frequently ( P < 0.001). CONCLUSION Endoscopic hemostasis proved to be the crucial difference between the two patient groups. Primary endoscopic hemostasis, along with GBS and the number of transfusions, would permit a stratification of risks. After prospective confirmation of the present findings, the use of decision trees would permit the identification of patients at risk for subsequent diagnosis and treatment based on interventional radiology.

Unmasking lower gastrointestinal bleeding under administration of norepinephrine

“…Angiography demonstrated the bleeding in 18 of 41 patients, and 20 patients underwent embolization (2 prophylactic embolizations). The angiography was technically successful in 16/18 cases, and clinically successful in 10/18 cases[ 6 ].…”

“…Our case series must be viewed in the context of other scientific investigations on bleeding site provocation in patients with GIB, using established endoscopic or angiographic procedures[ 6 ]. Permissive hypotension under sedation is a common phenomenon in patients with GIB and hemorrhagic shock.…”

“…Further prospective studies are needed to address this problem. The limitations of the previously published study[ 6 ] also apply. Many crucial points such as the fluctuating nature of GIB, the time point of endoscopy, the number of endoscopies to be performed, the role of CT diagnosis, and the optimal time point of angiography have not yet been clearly specified, and must be clarified in future investigations[ 6 ].…”

“…All patients who had undergone catheter angiography for gastrointestinal bleeding at our maximum-care hospital between 1 January, 2007 and 31 March, 2018 were included in the study[ 6 ]. Predictors of complicated angiographic treatment and the role of specific laboratory parameters and scores in predicting the likelihood of a successful intervention were identified.…”

“…Some patients require surgical or angiographic treatment. Although endoscopic hemostasis is effective and the treatment of choice for LGIB, the optimal technique remains to be determined[ 5 , 6 ]. A bleeding site may not be evident in some patients despite endoscopic evaluation.…”