Interventional radiology in the management of gastrointestinal bleeding

Interventional Radiology in the Management of Gastrointestinal Bleeding

Department of Interventional Radiology The Fifth Affiliated Hospital of SYSU

Zhang Zefu M.D. [email protected]

Ulcer 55%～ 74% Variceal Bleeding 5% ～ 14%

Mallory-Weiss syndrome 2% ～ 7%

Vascular disease 2%～ 3%

Tumors 2%～ 5%

Diverticulitis 20% ～ 55%

Vascular abnormalities 3% ～ 40%

Tumors 8% ～ 26%

Inflammation 6% ～ 22%

Benign anorectal disease 9% ～ 10%

High Risks

Age（ >60Y）

Severe concomitant diseases

Severe / Recurrent bleeding

Special sites （ Variceal bleeding）

Mortality： 3.6-5.0%

Bleeding with ulcer

Conservative treatment ： 75-85%

Arterial bleeding

Venous bleeding

A B C

D E F

G H

Squamous cell carcinoma within adistal esophageal diverticulum. A. esophageal mass lesion. B. PET-diverticularmass lesion. C. Celiac arteriogram. D-F. Left gastric arteriogram and embolizationG、 H. Successful embolization

A

C D

E

F

B

Hereditary polyposis and colectomy two weeks later. A-D. Abdominal CT shows a large intraperitoneal haematoma and active bleeding and/or (pseudo)aneurysm; E-F. Superior mesenteric arteriography and embolization

A B

C

D

Rectal Dieulafoy lesion. A. Dieulafoy lesion within the distal rectum 5 cm from the anal verge . B. Inferior mesenteric artery arteriogram. C. Superior rectal artery angiogram. D. Inferior mesenteric artery arteriogram after embolization.

Arterial Phase

Venous Phase

Extravasated Contrast Medium

After Embolization

1M later

Arterial Phase

Venous Phase

Angiography

Endoscopy

PET/ECT

CT/MRI

Interventional Radiology

Radiology

Nuclear Medicine

GastroenterologyGeneral surgery Three Points:

※What?※Where?※How?

Sven-Ivar Seldinger (1921-1999) Seldinger technical

NBCA Glue

Vasopressin

Coils

Vasopressin

0.2U/min

YES

0.4U/min

20min

NO

0.2U/min

12-24h

NO

12-24h

YES

END

Nitroglycerin

EmbolizationSurgery

Overall technical successes 80-93%

Clinical successes 56-67%

Rebleeding 30-45%

Complication: 6-9% Access site hematoma

Contrast nephropathy

Bowel ischemia

Nontarget embolization

Arterial dissection

Reasons for failure

Improper use of materials

Not completely embolism

Embolic material degradation

Collateral circulation

Primary disease progression

Clinical Outcome

A.D.1998， Yangtze River

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO)

Portal Hypertension

Esophageal /Gastric Varices Bleeding

Percutaneous Transhepatic Variceal Embolization (PTVE)

Percutaneous Transhepatic Variceal Embolization， PTVE

Indications

Medical treatment is ineffective

Acute bleeding

Can not tolerate surgery

Rebleeding

Complication: 5-10% Abdominal hemorrhage Hepatic subcapsular hematoma Fistula formation Bile peritonitis

Portal vein thrombosis

Pneumothorax Adjacent organs injury

Technical Successes 75-95%

Rebleeding

in 6m 55%

in 1y 66%

in 2y 80%

in 3y 90%

Clinical Outcome

Balloon-Occluded Retrograde Transvenous Obliteration, BRTO

Procedure

Common anatomy

A CB

F E D

Balloon-occluded retrograde transvenous obliteration of gastric varices in 67-year-old man. A. Endoscopic image;B. enhanced CT scan; C. Retrograde left adrenal venogram; D. After microcoil and gelatin sponge embolization of inferior phrenic vein; E. Contrast-enhanced CT scan obtained 4 days after BRTO; F. Endoscopic image obtained 6 weeks after BRTO.

Indications Gastric varices with active bleeding or Gastric varices with prior bleeding

High-risk gastric varices with no prior bleed

Refractory hepatic encephalopathy

Significant ascites or hydrothorax

Uncontrolled esophageal varices

Portal vein thrombosis after recannulation

Contraindications

Severe uncorrected coagulopathy

Splenic vein thrombosis

Portal vein thrombosis

Uncontrolled esophageal variceal bleeding

The Strategy for The Treatment of Gastric Varices

Technical Success Rate 79-100%

Controlling Actively Bleeding 91-100%

Exacerbation of Existing GVs/EVs

1Y 27–35 %

2Y 45–66 %

3Y 45–91 %

Rebleed Rate 19-31%

GVs 3.2-8.7%

EVs 0-20%

Survival rates

1Y 83-89%

2Y 76-79%

3Y 66-85%

5Y 39-69%

Clinical Outcome

B.C.2000， Yellow River

A B C

D FE

Conventional TIPS Creation Technique

Indications

Efficacy determined by controlled trials

Secondary prevention variceal bleeding

Refractory cirrhotic ascites

Efficacy assessed in uncontrolled series Refractory acutely bleeding varices

Portal hypertensive gastropathy

Bleeding gastric varices

Gastric antral vascular ectasia

Refractory hepatic hydrothorax

Hepatorenal syndrome Type 1 Type 2

Budd-Chiari syndrome

Veno-occlusive disease

Hepatopulmonary syndrome

Absolute

Primary prevention of variceal bleeding

Congestive heart failure

Multiple hepatic cysts

Uncontrolled systemic infection or sepsis

Unrelieved biliary obstruction

Severe pulmonary hypertension

Contraindications

Relative

Hepatoma especially if central

Obstruction of all hepatic veins

Portal vein thrombosis

Severe coagulopathy (INR>5)

Thrombocytopenia of 20,000/cm3

Moderate pulmonary hypertension

ComplicationsComplications Frequency (%) TIPS dysfunction

Thrombosis 10-15 Occlusion/stenosis 18-78 Transcapsular puncture 33 Intraperitoneal bleed 1-2 Hepatic infarction <1 Fistulae Rare Hemobilia <5 Sepsis 2-10 Infection of TIPS Rare Hemolysis 10-15 Encephalopathy

New/worse 10-44 Chronic 5-20 Stent migration or placement into IVC or too far into portal vein 10-20

Medical/endoscopic Treatment TIPS

One-year cumulative rebleeding 85-97% 45-50%

One-year cumulative Survival 50-60% 48-90%

One-year cumulative Ascites 33-40% 10-13%

One-year cumulative hepatic encephalopahty 40-45% 20-28%

Clinical Outcome

B.C.2000， Yellow River

Thank You!!