HELIOS Klinikum Erfurt
HELIOS Klinikum Erfurt
LINC 2015
Embolization treatment for
acute gastrointestinal
bleeding
S. Basche
HELIOS Klinikum Erfurt LINC 2015
GIB
Upper GIB
Ulcus
Varicosis
Mallory-Weiss-S
Cancer
Oesophagus
Gaster
Duodenum
HELIOS Klinikum Erfurt LINC 2015
GIB
Prognosis
- 80% of GI- bleedings suspend spontaneous
- 20% recidivate within 3 days after therapy
- Emergency operation up to 50 % (Mortality)
HELIOS Klinikum Erfurt LINC 2015
GIB
Category Activity of bleeding
Rezidiv bleeding
I Ia Ib II IIa IIb IIc III
Acute hemorrhage Spurting hemorrhage Oozing hemmorrhage Recent hemorrhage Visible vessel Adherent clot Hemantin on ulcer base Lesions without signs of
recent hemorrhage
90% 30%
50 – 100% 20 – 50%
< 5%
< 5%
Forrest classification
HELIOS Klinikum Erfurt LINC 2015
Recurrence bleeding (high risk)
• Depending on:
– Forrest Ia/Ib 55%
– Forrest II 14 - 36%
– ulceration size > 1cm
– Localisation (posterior wall)
– Age
– Comorbidities and drugs (anticoagulation)
HELIOS Klinikum Erfurt LINC 2015
Upper GIB
23 Pat. with duodenal bleeding
I. Langner et al. Emerg Radiolog. 2008
Coiling operativ
Ulcus duodenale 8 10
Pancreatitis 1 2
Unknown 2 0
secondary hemorrhage 3 2
Ischemia 0 0
Mortality 3 2
HELIOS Klinikum Erfurt LINC 2015
GIB
n 69
Vessel n Coil Glue C + G Recurrence Comp.
A.
gastroduo.
56 32 9 15 6 0
SMA 4 0 4 0 0 1
A. lienalis 8 4 0 4 0 0
A. gastrica 1 0 1 0 0 0
Personal results, 2012
HELIOS Klinikum Erfurt LINC 2015
„blind TAE“
• It means:
– Patient after endoscopic therapy and high risk
for recurrence bleeding
– 28 patients
– technical success 100 %
– recurrence bleeding 2/28
Dr.med. Juliane Huber (2014)
HELIOS Klinikum Erfurt LINC 2015
GIB
Lower GIB
Tumor
Polyposis
Meckel - Divertikel
Divertikulitis
Morbus Crohn
Colitis Ulcerosa
Angiodysplasie
Infarct / Embolie
Duodenum
Jejunum
Ileum
Colon
Rectum
HELIOS Klinikum Erfurt LINC 2015
Lower GIB
Long term resuts after TAE
n %
Embolisation 75 100
techn. success 73 97
Recurrence
bleeding
12 16
Ischemia 5 7
30d Mortality 8 11
secondary hemo
rrhage
8 11
T.Lipof et al. Dis Colon Rectum, 2008
Summary: TAE – first line therapy
HELIOS Klinikum Erfurt LINC 2015
Case 1
Patient: f; 75 y
• severe GIB after clipping in duodenal ulcer
• Therapy:
Embolisation with Histoacryl / Lipiodol
HELIOS Klinikum Erfurt LINC 2015
Case 2
Patient: m ; 64 y
• chronic repeated pancreatitis
• Tumor of pancreatic head
• severe GIB
• Therapy:
Coil- Embolisation
HELIOS Klinikum Erfurt LINC 2015
Case 3
Patient: f ; 83 y
• repeated severe GIB
• Angiodysplasie of Colon
• Therapy:
Embolisation of four Feederarteries with glue
HELIOS Klinikum Erfurt LINC 2015
Case 4
Patient: m ; 66 y
• after 2/3 Resektion in gastric cancer
• insufficient Anastomosis
• severe GIB out of sigmoid,
• coloskopic Therapy on diverticulosis not possible
• Therapy:
Embolisation of one Feederartery with glue
HELIOS Klinikum Erfurt LINC 2015
Case 5
Patient: m ; 68 y
• acute pancreatitis
• acute abdominal pain
• respiratory insufficiency
• AMI
symptomatically growing aneurysm of A.lienalis
• Therapy:
Coil and glue embolisation
HELIOS Klinikum Erfurt LINC 2015
Summary (Material)
• Coil (larger vessels)
• Glue (smaller vessels, target restriction)
• Covered stent
• Beads
• All together ?
• Whats the best???
• Your own experience
HELIOS Klinikum Erfurt LINC 2015
Conclusion
CONCLUSIO: endovascular at first
Endovaskular therapies of GIB
„questions“ - answers
Rekanalisation after Coiling ? Low risk of occluding procedures
Downer 2008,
Organ-Ischemia liver/ splenic/ pancreas ? Target restriction!
Sessa 2004, Chiesa 2005
Stent-Grafts in septic Aneurysm ? Unlimited indication
Sachdev 2006, Tulsyan 2007, deFreitas 2007, Rossi 2008
Long time patency of Stent-Grafts ? Sufficient evidence based
Kasirajan 2001, Gabelmann 2002, Sessa 2004, Rossi 2008
Secondary Aneurysma-Expansion (inflammatoric No valid data
etiology) ?