Angiography in Poor-Risk Patients with Massive Nonvariceal Upper Gastrointestinal Bleeding Daniel T. Dempsey, MD, Dana R. Burke, roD, Rebecca S. Reilly, Ba, Gordon K. McLean, SaD, Ernest F. Rosato, MD, Philadelphia, Pennsylvania
The purpose of this retrospective study was to determine the diagnostic and therapeutic usefulness of gut angiography in patients with massive upper gastrointestinal bleeding from a nonvariceal source. All patients (n = 64) in this category who underwent a gut angiogram between 1980 and 1986 were studied. Pre-angiogram endoscopy was attempted in all patients and was nondiagnostic in 14 ( 2 2 % ) . Contrast extravasation at angiography was seen in 25 of 64 patients ( 3 9 % ) , and in over half of these patients endoscopy was nondiagnostic (n = 11) or wrong (n = 3 ) . Attempts to control bleeding in this group by selective arterial embolization (n = 14) or intra-arterial vasopressin (n = 11) successfully averted operation in 13 of 25 patients (52%) and was associated with a 50% reduction in mortality (83% versus 3 8 % ) . Selective embolization of vessels thought to be bleeding on clinical grounds without evidence of contrast extravasation (i.e., " b l i n d " embolization) was not helpful in controlling hemorrhage. Urgent gut angiography in patients with massive upper gastrointestinal bleeding of arteriocapillary source is a useful diagnostic and therapeutic maneuver and warrants continued application in this group of poor-risk patients.
cally [4] in selected populations with gastrointestinal bleeding, there are no large series that evaluate this relatively new technique in poor-risk patients with massive arterial hemorrhage from the upper gastrointestinal tract. Because of an aggressive institutional policy for angiography in patients with upper gastrointestinal bleeding, we are able to report such a series. The purpose of this review is to determine the diagnostic and therapeutic value of gut angiography in acute massive nonvariceal upper gastrointestinal bleeding.
PATIENTS AND METHODS All patients (n = 83) who underwent gut angiography for upper gastrointestinal bleeding at the Hospital of the University of Pennsylvania between 1980 and 1986 were reviewed. Nineteen patients were excluded based upon the following criteria: (1) onset of clinical bleeding (grossly bloody nasogastric aspirate or hematemesis) greater than 7 days prior to angiogram (n -- 2), (2) blood transfusion of less than 4 units whole blood or packed red blood cells prior to angiogram (n = 2), (3) variceal bleeding as defined by positive endoscopy or known cirrhosis and variees with no other bleeding site seen on endoscopy or angiography (n = 15). The remaining 64 patients with acute (within 7 days), massive (greater than 4 units of blood transfused), nonvariceal upper gastrointestinal bleeding form the basis for this study. Endoscopy was performed or attempted in all 64 patients prior to arteriography and the results noted. The following variables were recorded for each patient: age, sex, associated diseases, endoscopic diagnosis, transfusion requirement before and after angiography, angiographic findings, angiographic treatment (selective arterial embolization, selective intra-arterial vasopressin he operative mortality rate for massive upper gas- infusion, none), pre-angiogram laboratory data (protrointestinal bleeding (transfusion requirement of at thrombin time, partial thromboplastin time, platelet least 4 units per 24 hours) remains around 20% [1]. In count, creatinine), and in-hospital mortality. Angiopoor-risk populations, it is much higher [2]. Early and graphic diagnosis was compared with endoscopic diagnoaggressive resuscitation, diagnostic work-up, and opera- sis. All patients with angiographic evidence of bleeding tion is the preferred approach. Unfortunately, accurate (i.e., contrast extravasation) had either selective arterial diagnostic endoscopy is sometimes difficult in the patient embolization (n = 14) or selective intra-arterial vasopreswith massive hematemesis. Furthermore, in some pa- sin infusion (n -- 11). These two forms of angiotherapy tients, the risk of surgical intervention appears prohibitive were considered equivalent, and the choice was deterbecause of concomitant problems, such as overwhelming mined by specific patient anatomy, location of bleeding sepsis, persistent hemodynamic instability, and multiple site, and angiographer preference. Generally, those paorgan compromise. Although gut angiography has been tients in whom a stable superselective catheter position shown to be useful both diagnostically [3] and therapeuti- could be obtained in the angiographically demonstrated From the Departmentsof Surgeryand Radiology,Universityof Penn- bleeding vessels were treated with embolization using sylvaniaSchoolof Medicine,Philadelphia,Pennsylvania. Gelfoam pledgets or stainless steel coils, or both. Selective Requests for reprints should be addressedto DanielT. Dempsey, intra-arterial vasopressin therapy was used in those paMD, TempleUniversityHospital,3401 North BroadStreet, Philadel- tients whose vascular anatomy precluded stable supersephia, Pennsylvania19140. Manuscript submittedOctober25, 1988,revisedMarch 17, 1989, lective catheterization of the target vessels. Some exceptions to this general approach did occur because of and acceptedMarch 21, 1989.
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9.82 THE AMERICAN JOURNAL OF SURGERY VOLUME159 MARCH1990
ANGIOGRAPHY IN UPPER GASTROINTESTINAL BLEEDING
angiographer or surgeon preference. In addition, about half of the patients in whom a bleeding site could not be conclusively demonstrated angiographically had selective embolization of the vessel thought most likely to be bleeding on clinical and endoscopic grounds (n = 20). However, there was a lack of consensus within the departments of surgery and angiography as to the therapeutic potential of this maneuver, so many patients without angiographic evidence of bleeding received no angiotherapy (n -- 19). The need for an operation after angiography to control bleeding (a clinical decision of the attending surgeon) was noted. No patient died of exsanguination. Data were analyzed by Student's t test for unpaired data and chi-square analysis with Yates' correction. RESULTS The age of the patients was 61 4- 16 years (mean 4SD), and men outnumbered women by approximately two to one (42 men, 22 women). Patients received an average of 9 4- 5 units of whole blood or packed red blood cells prior to angiography, which was performed 1.8 41.3 days after the onset of upper gastrointestinal bleeding. Thus, this group was bleeding at the rate of approximately 5.5 4- 4.7 units of blood per day. The mean serum bilirubin and creatinine levels were 3.7 4- 6.3 mg/dL and 1.9 4- 1.9 mg/dL, respectively. The overall mortality was 41% (26 of 64), and the average length of hospitalization after angiography until death or discharge was 23 4- 29 days. Table I defines this population as a high-risk group. Half the patients were over 65 years old, a third had significant cardiac problems, a fifth had pulmonary, liver, or renal insufficiency, and many were septic as defined by positive blood cultures. Most patients had two or more of these significant risk factors. Most patients were bleeding from duodenal (27%) or gastric (22%) ulcers, or gastritis (22%) (Table I). As mentioned above, patients thought to be bleeding from esophagogastric varices were purposely excluded. Patients were grouped according to whether a bleeding site was seen at angiography (contrast extravasation) and whether angiographic control of hemorrhage was attempted. Group 1 (n = 14) consisted of patients in whom extravasation was seen and selective intra-arterial embolization tried. Group 2 (n = 11) also showed angiographic extravasation, but selective intra-arterial vasopressin was infused (0.2 to 0.4 U/min) by an in-dwelling catheter for 24 to 48 hours. Group 3 (n = 20) showed no evidence of extravasation, but had selective arterial embolization based upon the best possible clinical diagnosis and upon the belief of some angiographers or surgeons that this maneuver might be useful in controlling hemorrhage. Group 4 (n = 19) had no extravasation seen and no angiographic therapy attempted. Results of angiographic and endoscopic evaluation are compared in Table II. Endoscopic results were nondiagnostic (n = 22) or wrong (n = 3) in 25 of 64 patients (39%), usually because of poor visibility secondary to massive hemorrhage. Bleeding was visualized by angiography (conclusive extravasation) in 25 of the 64 patients (39%). No bleeding was visualized
TABLE 1
Associated Problems and Diagnosis In 6 4 P a t i e n t s with Massive Upper Gastrointestinal (GI) Bleeding Patients Risk factors Age > 65 yrs CHF/MI/cardiac surgery ~ Ventilator Cirrhosis Renal insufficiency Positive blood cultures Cancer COPD/pneumonia/ARDS t Stroke Status post GI operation Diagnosist Duodenal ulcer Gastric ulcer Gastritis Mallory-Weiss syndrome Postop GI bleeding Other
n
%
32 21 14 14 13 12 12 7 5 4
50 33 22 22 20 19 19 10 8 6
17 14 14 9 4 6
27 22 22 14 6 9
* CHF = congestive heart failure; MI = recent (
The purpose of this retrospective study was to determine the diagnostic and therapeutic usefulness of gut angiography in patients with massive upper gastrointestinal bleeding from a nonvariceal source. All patients (n = 64) in this category who underwent a gut angiogram between 1980 and 1986 were studied. Pre-angiogram endoscopy was attempted in all patients and was nondiagnostic in 14 ( 2 2 % ) . Contrast extravasation at angiography was seen in 25 of 64 patients ( 3 9 % ) , and in over half of these patients endoscopy was nondiagnostic (n = 11) or wrong (n = 3 ) . Attempts to control bleeding in this group by selective arterial embolization (n = 14) or intra-arterial vasopressin (n = 11) successfully averted operation in 13 of 25 patients (52%) and was associated with a 50% reduction in mortality (83% versus 3 8 % ) . Selective embolization of vessels thought to be bleeding on clinical grounds without evidence of contrast extravasation (i.e., " b l i n d " embolization) was not helpful in controlling hemorrhage. Urgent gut angiography in patients with massive upper gastrointestinal bleeding of arteriocapillary source is a useful diagnostic and therapeutic maneuver and warrants continued application in this group of poor-risk patients.
cally [4] in selected populations with gastrointestinal bleeding, there are no large series that evaluate this relatively new technique in poor-risk patients with massive arterial hemorrhage from the upper gastrointestinal tract. Because of an aggressive institutional policy for angiography in patients with upper gastrointestinal bleeding, we are able to report such a series. The purpose of this review is to determine the diagnostic and therapeutic value of gut angiography in acute massive nonvariceal upper gastrointestinal bleeding.
PATIENTS AND METHODS All patients (n = 83) who underwent gut angiography for upper gastrointestinal bleeding at the Hospital of the University of Pennsylvania between 1980 and 1986 were reviewed. Nineteen patients were excluded based upon the following criteria: (1) onset of clinical bleeding (grossly bloody nasogastric aspirate or hematemesis) greater than 7 days prior to angiogram (n -- 2), (2) blood transfusion of less than 4 units whole blood or packed red blood cells prior to angiogram (n = 2), (3) variceal bleeding as defined by positive endoscopy or known cirrhosis and variees with no other bleeding site seen on endoscopy or angiography (n = 15). The remaining 64 patients with acute (within 7 days), massive (greater than 4 units of blood transfused), nonvariceal upper gastrointestinal bleeding form the basis for this study. Endoscopy was performed or attempted in all 64 patients prior to arteriography and the results noted. The following variables were recorded for each patient: age, sex, associated diseases, endoscopic diagnosis, transfusion requirement before and after angiography, angiographic findings, angiographic treatment (selective arterial embolization, selective intra-arterial vasopressin he operative mortality rate for massive upper gas- infusion, none), pre-angiogram laboratory data (protrointestinal bleeding (transfusion requirement of at thrombin time, partial thromboplastin time, platelet least 4 units per 24 hours) remains around 20% [1]. In count, creatinine), and in-hospital mortality. Angiopoor-risk populations, it is much higher [2]. Early and graphic diagnosis was compared with endoscopic diagnoaggressive resuscitation, diagnostic work-up, and opera- sis. All patients with angiographic evidence of bleeding tion is the preferred approach. Unfortunately, accurate (i.e., contrast extravasation) had either selective arterial diagnostic endoscopy is sometimes difficult in the patient embolization (n = 14) or selective intra-arterial vasopreswith massive hematemesis. Furthermore, in some pa- sin infusion (n -- 11). These two forms of angiotherapy tients, the risk of surgical intervention appears prohibitive were considered equivalent, and the choice was deterbecause of concomitant problems, such as overwhelming mined by specific patient anatomy, location of bleeding sepsis, persistent hemodynamic instability, and multiple site, and angiographer preference. Generally, those paorgan compromise. Although gut angiography has been tients in whom a stable superselective catheter position shown to be useful both diagnostically [3] and therapeuti- could be obtained in the angiographically demonstrated From the Departmentsof Surgeryand Radiology,Universityof Penn- bleeding vessels were treated with embolization using sylvaniaSchoolof Medicine,Philadelphia,Pennsylvania. Gelfoam pledgets or stainless steel coils, or both. Selective Requests for reprints should be addressedto DanielT. Dempsey, intra-arterial vasopressin therapy was used in those paMD, TempleUniversityHospital,3401 North BroadStreet, Philadel- tients whose vascular anatomy precluded stable supersephia, Pennsylvania19140. Manuscript submittedOctober25, 1988,revisedMarch 17, 1989, lective catheterization of the target vessels. Some exceptions to this general approach did occur because of and acceptedMarch 21, 1989.
T
9.82 THE AMERICAN JOURNAL OF SURGERY VOLUME159 MARCH1990
ANGIOGRAPHY IN UPPER GASTROINTESTINAL BLEEDING
angiographer or surgeon preference. In addition, about half of the patients in whom a bleeding site could not be conclusively demonstrated angiographically had selective embolization of the vessel thought most likely to be bleeding on clinical and endoscopic grounds (n = 20). However, there was a lack of consensus within the departments of surgery and angiography as to the therapeutic potential of this maneuver, so many patients without angiographic evidence of bleeding received no angiotherapy (n -- 19). The need for an operation after angiography to control bleeding (a clinical decision of the attending surgeon) was noted. No patient died of exsanguination. Data were analyzed by Student's t test for unpaired data and chi-square analysis with Yates' correction. RESULTS The age of the patients was 61 4- 16 years (mean 4SD), and men outnumbered women by approximately two to one (42 men, 22 women). Patients received an average of 9 4- 5 units of whole blood or packed red blood cells prior to angiography, which was performed 1.8 41.3 days after the onset of upper gastrointestinal bleeding. Thus, this group was bleeding at the rate of approximately 5.5 4- 4.7 units of blood per day. The mean serum bilirubin and creatinine levels were 3.7 4- 6.3 mg/dL and 1.9 4- 1.9 mg/dL, respectively. The overall mortality was 41% (26 of 64), and the average length of hospitalization after angiography until death or discharge was 23 4- 29 days. Table I defines this population as a high-risk group. Half the patients were over 65 years old, a third had significant cardiac problems, a fifth had pulmonary, liver, or renal insufficiency, and many were septic as defined by positive blood cultures. Most patients had two or more of these significant risk factors. Most patients were bleeding from duodenal (27%) or gastric (22%) ulcers, or gastritis (22%) (Table I). As mentioned above, patients thought to be bleeding from esophagogastric varices were purposely excluded. Patients were grouped according to whether a bleeding site was seen at angiography (contrast extravasation) and whether angiographic control of hemorrhage was attempted. Group 1 (n = 14) consisted of patients in whom extravasation was seen and selective intra-arterial embolization tried. Group 2 (n = 11) also showed angiographic extravasation, but selective intra-arterial vasopressin was infused (0.2 to 0.4 U/min) by an in-dwelling catheter for 24 to 48 hours. Group 3 (n = 20) showed no evidence of extravasation, but had selective arterial embolization based upon the best possible clinical diagnosis and upon the belief of some angiographers or surgeons that this maneuver might be useful in controlling hemorrhage. Group 4 (n = 19) had no extravasation seen and no angiographic therapy attempted. Results of angiographic and endoscopic evaluation are compared in Table II. Endoscopic results were nondiagnostic (n = 22) or wrong (n = 3) in 25 of 64 patients (39%), usually because of poor visibility secondary to massive hemorrhage. Bleeding was visualized by angiography (conclusive extravasation) in 25 of the 64 patients (39%). No bleeding was visualized
TABLE 1
Associated Problems and Diagnosis In 6 4 P a t i e n t s with Massive Upper Gastrointestinal (GI) Bleeding Patients Risk factors Age > 65 yrs CHF/MI/cardiac surgery ~ Ventilator Cirrhosis Renal insufficiency Positive blood cultures Cancer COPD/pneumonia/ARDS t Stroke Status post GI operation Diagnosist Duodenal ulcer Gastric ulcer Gastritis Mallory-Weiss syndrome Postop GI bleeding Other
n
%
32 21 14 14 13 12 12 7 5 4
50 33 22 22 20 19 19 10 8 6
17 14 14 9 4 6
27 22 22 14 6 9
* CHF = congestive heart failure; MI = recent (
