HELIOS Klinikum Erfurt

Embolization treatment for acute gastrointestinal bleeding S. Basche

HELIOS Klinikum Erfurt

LINC 2015

GIB

Upper GIB Ulcus Varicosis Mallory-Weiss-S Cancer

HELIOS Klinikum Erfurt

Oesophagus Gaster Duodenum

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 Forrest classification

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Category

Activity of bleeding

Rezidiv bleeding

I Ia Ib

Acute hemorrhage Spurting hemorrhage Oozing hemmorrhage

90% 30%

II IIa IIb IIc

Recent hemorrhage Visible vessel Adherent clot Hemantin on ulcer base

III

Lesions without signs of recent hemorrhage

LINC 2015

50 – 100% 20 – 50% < 5% < 5%

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

Coiling

operativ

Ulcus duodenale

8

10

Pancreatitis

1

2

Unknown

2

0

secondary hemorrhage

3

2

Ischemia

0

0

Mortality

3

2

I. Langner et al. Emerg Radiolog. 2008

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

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Duodenum Jejunum Ileum Colon Rectum

LINC 2015

GIB

Symptoms Haematemesis Melaena Haematochezie

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 1

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 2

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 3

HELIOS Klinikum Erfurt

LINC 2015

Case 3

HELIOS Klinikum Erfurt

LINC 2015

Case 3

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 4

HELIOS Klinikum Erfurt

LINC 2015

Case 4

HELIOS Klinikum Erfurt

LINC 2015

Case 4

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

Case 5

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 Endovaskular therapies of GIB „questions“ - answers Low risk of occluding procedures

Rekanalisation after Coiling ?

Downer 2008,

Organ-Ischemia

Target restriction!

liver/ splenic/ pancreas ?

Sessa 2004, Chiesa 2005

Unlimited indication

Stent-Grafts in septic Aneurysm ?

Sachdev 2006, Tulsyan 2007, deFreitas 2007, Rossi 2008

Sufficient evidence based

Long time patency of Stent-Grafts ?

Kasirajan 2001, Gabelmann 2002, Sessa 2004, Rossi 2008

Secondary Aneurysma-Expansion (inflammatoric

No valid data

etiology) ?

CONCLUSIO: endovascular at first HELIOS Klinikum Erfurt

LINC 2015

HELIOS Klinikum Erfurt

Embolization treatment for acute gastrointestinal bleeding S. Basche

HELIOS Klinikum Erfurt

LINC 2015