interventional radiology in the management of gastrointestinal bleeding
DESCRIPTION
Interventional Radiology in the Management of Gastrointestinal BleedingTRANSCRIPT
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!!