Korean J Radiol.  2011 Oct;12(5):568-578. 10.3348/kjr.2011.12.5.568.

Intra-Arterial Treatment in Patients with Acute Massive Gastrointestinal Bleeding after Endoscopic Failure: Comparisons between Positive versus Negative Contrast Extravasation Groups

• Chang WC
• Liu CH
• Hsu HH
• Huang GS
• Tung HJ
• Hsieh TY
• Tsai SH
• Hsieh CB
• Yu CY

• KMID: 1116442
• DOI: http://doi.org/10.3348/kjr.2011.12.5.568

Abstract

OBJECTIVE
To determine whether treatment outcome is associated with visualization of contrast extravasation in patients with acute massive gastrointestinal bleeding after endoscopic failure.
MATERIALS AND METHODS
From January 2007 to December 2009, patients that experienced a first attack of acute gastrointestinal bleeding after failure of initial endoscopy were referred to our interventional department for intra-arterial treatment. We enrolled 79 patients and divided them into two groups: positive and negative extravasation. For positive extravasation, patients were treated by coil embolization; and in negative extravasation, patients were treated with intra-arterial vasopressin infusion. The two groups were compared for clinical parameters, hemodynamics, laboratory findings, endoscopic characteristics, and mortality rates.
RESULTS
Forty-eight patients had detectable contrast extravasation (positive extravasation), while 31 patients did not (negative extravasation). Fifty-six patients survived from this bleeding episode (overall clinical success rate, 71%). An elevation of hemoglobin level was observed in the both two groups; significantly greater in the positive extravasation group compared to the negative extravasation group. Although these patients were all at high risk of dying, the 90-day mortality rate was significantly lower in the positive extravasation than in the negative extravasation (20% versus 42%, p < 0.05). A multivariate analysis suggested that successful hemostasis (odds ratio [OR] = 28.66) is the most important predictor affecting the mortality in the two groups of patients.
CONCLUSION
Visualization of contrast extravasation on angiography usually can target the bleeding artery directly, resulting in a higher success rate to control of hemorrhage.

Keyword

Acute massive gastrointestinal bleeding; Angiography; Contrast extravasation; Coil embolization; Vasopressin

MeSH Terms

Acute Disease
Adult
Aged
Aged, 80 and over
*Angiography
*Embolization, Therapeutic
Extravasation of Diagnostic and Therapeutic Materials/*radiography
Female
Gastrointestinal Hemorrhage/mortality/radiography/*therapy
Hemostasis, Endoscopic
Hemostatics/*administration & dosage
Humans
Infusions, Intra-Arterial
Male
Middle Aged
*Radiography, Interventional
Treatment Failure
Vasopressins/*administration & dosage
Young Adult

Figure

• 

  Fig. 1 54-year-old woman presented with acute melena and hemodynamic instability. Emergent endoscopy was performed and revealed bleeding ulcer over ascending colon. Bleeding site was difficult to access, and failed to reach hemostasis by endoscopy. Before angiography, woman was transfused with 8 units of blood. A. Angiography showed active extravasation of contrast medium from branch of superior mesenteric artery (right colic artery) in ascending colon (arrow). B. After embolization with metallic coils, superselective arteriography of right colic artery demonstrated that bleeding artery was completely occluded by coils and there was no further extravasation of contrast medium. Patient recovered and stopped melena in one day after angiographic intervention and was discharged from our hospital one week later.

• 

  Fig. 2 Kaplan-Meier technique showed relative survival curves at day 90. *p < 0.05.

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