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Therapeutic options for endoscopic haemostatic failures: the place of the surgeon and radiologist in gastrointestinal tract bleeding

https://doi.org/10.1016/j.bpg.2007.10.018Get rights and content

The management of gastrointestinal tract bleeding has changed dramatically due to improvements of interventional endoscopy and radiology. The place of the radiologist has become very important, not only for diagnostic modalities but also for therapeutic embolisation to control the bleeding. The place of the surgeon is limited to the situation where both these less invasive techniques have failed to stop the bleeding. For arterial bleeding in the whole GI tract, angiography with subsequent embolisation is performed after failed endoscopy. For variceal bleeding the preferred treatment after endoscopic failure is transjugular intrahepatic portosystemic stent shunting (TIPS). Surgery is only needed in exceptional cases. Embolisation can be performed successfully without compromising the bowel vascularisation or inducing ischaemia, whereas surgery has a high rate of complications and mortality. For treatment of GI bleeding a multidisciplinary team including a gastroenterologist, radiologist and surgeon is mandatory.

Introduction

Gastrointestinal (GI) bleeding, in particular major GI bleeding, has been considered in the past as an emergency situation in surgery, leading to acute exploration and even to “blind” resections (right hemicolon) as a last resort. Surgical outcome was not always successful in terms of early complications and high mortality as well as re-bleeding.

The development of endoscopy, and endoscopic interventions in particular, in the past decades has radically changed the approach of GI bleeding and nowadays surgery remains only as the rescue treatment for endoscopic failures.

More recently, new developments in diagnostic radiology (CT, MRI) as well as in interventional radiology again have also changed the diagnostic work-up as well as the therapeutic approach to these patients. Angiographic embolisation is now a therapeutic option which will be used in most situations before surgery. It is therefore of the utmost importance that patients with GI haemorrhage are treated by a multidisciplinary team including gastroenterologists, (interventional) radiologists and surgeons, all experienced in this field.

In this review a short general overview will be provided of the developments in diagnostic radiology and radiological interventions and, more specifically, the role of radiology and surgery in the management of upper GI bleeding, hepato-pancreatico-biliary (HPB) bleeding and lower GI bleeding will be discussed.

Section snippets

Diagnostic Radiology and Radiological Intervention

Angiography has traditionally been the next diagnostic step after failure of endoscopy to detect and/or treat GI bleeding and still is the standard in most institutions. For many years angiography has been performed as a purely diagnostic procedure to locate the bleeding source. Nowadays, angiographic embolisation can be carried out during the same session as the diagnostic procedure, adding only limited time and contrast volume.

CT angiography is increasingly playing a role and recent

Bleeding peptic ulcer

Because surgery is no longer the first choice of treatment for bleeding peptic ulcers, the patients who need surgery for this have become more difficult to manage, due to negative selection. Mortality rates of these patients could therefore be as high as 20–25%. The only goal of surgery is to stop the bleeding and not to treat the underlying disease. Therefore, the indication for surgery of bleeding peptic ulcer disease is restricted to failure to stop the bleeding with repeated endoscopy or

Hpb Bleeding

Intestinal tract bleeding from HPB (hepato-pancreato-biliary) origin is a relatively rare condition. The bleeding will reach the intestinal tract via the papilla of Vater or from iatrogenic lesions. The papilla of Vater bleeding includes haemobilia (from biliary tract) as well as haemosuccus pancreaticus from the pancreatic duct.35, 36 Iatrogenic causes are perforation from the biliary tract to the duodenum (stone-related cholecystoduodenal fistula and erosion of the hepatic artery),

Lower Gi Bleeding

Bleeding of the lower GI tract occurs infrequently as compared to upper GI-tract bleeding.48 The clinical course of lower GI-tract haemorrhage often shows a self-limiting nature and initial treatment may be conservative in many cases. Most lower GI-tract bleeds are localised in the colon and the small bowel is rarely involved (e.g. bleeding Meckel's diverticulum). The most common aetiologies are diverticular disease, followed by angiodysplasia, colitis, or neoplasm.48

When conservative treatment

Summary

Gastrointestinal tract bleeding is preferably treated endoscopically. With a few exceptions, generally only failures will proceed to embolisation or surgery. CT angiography has improved dramatically and can localise haemorrhage, but diagnostic angiography has the advantage of the possibility of performing subsequent therapeutic embolisation in the same procedure. For all arterial bleeds in the GI tract angiographic embolisation has become the first option after endoscopy. Embolisation can be

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