ANGIOEMBOLIZATION AS AN OPTION FOR ACUTE LOWER GASTROINTESTINAL BLEEDING

Andrés Miranda, Juan Rabellino, Fabiana Domínguez, Noelia Brito, Marcelo Viola

Department of Uruguayan Medical Surgery (MUCAM)

Montevideo - Uruguay

ABSTRACT

Acute lower gastrointestinal bleeding is relatively frequent and its incidence is increasing. Up to 15% of patients require invasive therapies such as endoscopy, surgery, or angioembolization. We present a 17-year-old male with significant lower gastrointestinal bleeding from a vessel that supplied the splenic flexure, diagnosed by CT angiography. He was treated by angioembolization with good outcome.

Keywords: lower gastrointestinal bleeding; arteriography; angioembolization

INTRODUCTION

Lower GI bleeding (LGIB) is defined as any bleeding that occurs distal to the ligament of Treitz. It constitutes about 20% of all GIBs. The vast majority come from the colon, rectum and anus and only between 5 and 10% originates in the small intestine.(1) The annual incidence varies between 20.5 and 27 cases per 100,000 adults.

Overall mortality is 2 to 4%. It occurs more frequently in elderly patients with an age range of 63 to 77 years.(1,2)

LGIB is probably increasing due to the aging of the population, higher rates of comorbidities, and the increasing use of aspirin, anticoagulants, and non-steroidal anti-inflammatory drugs.(2)

Since there is no specific treatment, the management of LGIB is still based on intravascular volume replacement, hemodynamic stabilization, and close monitoring of patients.(2) Up to 15% of patients require invasive therapies.(3) Endoscopy is the mainstay for diagnosis and subsequent hemostasis in acute LGIB. However, endoscopic treatment has limitations in patients with hemodynamic instability, poor bowel preparation, small bowel bleeding, or in whom the bleeding source is not localized due to massive hemorrhage.

Other therapeutic options are surgery and angioembolization.(3) Emergency surgery has mortality rates of up to 30%. In addition, when the source of bleeding is not localized, the mortality rate from surgery increases by up to 50%.(4) Meanwhile, superselective angioembolization is a safe and effective procedure to control GI bleeding.(3)

Our objective was to present a patient with acute LGIB resolved by angioembolization.

CASE

A 17-year-old male patient, with a history of double outlet right ventricle, operated on at 2 years, underwent new corrective cardiac surgery, performed without incident. In the postoperative period, he began with significant enterorrhagia consisting of blood mixed with feces and fresh clots, associated with a functional anemic syndrome.

On examination, he presented mucosal hypocoloration, tachycardia (100 bpm), normotension, and absence of abdominal pain. In the laboratory, anemia of 7.7 g/dl stands out. A fibrogastroscopy showed no active bleeding, ruling out an upper GI source.

Fluid and electrolyte replacement is started and six units of red blood cells are transfused. Given the persistence of bleeding, a computed tomography angiography was performed, which showed active bleeding in the splenic flexure (Fig. 1). An angiography of the mesenteric vessels was requested with eventual angioembolization. During the procedure, extravasation of contrast medium was identified in a branch that supplies the splenic flexure, dependent on the superior mesenteric artery. In addition, a parietal hematoma of the splenic flexure was identified. The bleeding branch is accessed with an Echelon 10 microcatheter on a Traxcess 14® microguide and it was embolized with 30% Histoacryl®(Fig. 2). The angiographic control showed complete exclusion of the branch (Fig. 3).

The patient presented a good outcome and was discharged in the following day.

Figure 1. CT angiography showing active bleeding at the splenic flexure (arrow).

Figure 2. Angiogram showing extravasation of contrast (arrow).

Figure 3. Angiogram showing the occluded vessel, without extravasation of contrast media.

DISCUSSION

According to the British Gastroenterology Society guidelines, after initial resuscitation, the diagnosis and treatment of LGIB remains a challenge for surgeons. Identifying the origin of the bleeding is a clinical priority and can be more difficult than in upper digestive bleeding.(4) Particularly in our case, the presence of this pathology in a young patient is striking.

Options for diagnosing the source of bleeding include CT angiography, catheter mesenteric angiography, and colonoscopy.(4)

Colonoscopy is the diagnostic procedure of choice in stable patients with prior bowel preparation, which improves visibility and favors the possibility of finding the source of bleeding.(4)

CT angiography should be the first diagnostic option in patients with active bleeding. It is preferred over colonoscopy in unstable patients because it can locate the source of bleeding throughout the GI tract, is widely available, can be quickly accessed, and does not require bowel preparation.(4)

Angiography is a tool that is not available as a therapeutic option in our environment in all centers, so we do not always keep it in mind. It can provide both localization and treatment. Angiography localizes the source of bleeding in 25-70% of cases. Superselective angioembolization achieves immediate hemostasis in almost 100% of cases, with a rebleeding rate ranging from 0-50%. The main complication is intestinal ischemia, although its frequency is low (1-4% of cases).(5)

We emphasize the importance of using diagnostic and therapeutic algorithms when dealing with LGIB, with angioembolization, if available, being a fundamental tool to take into account.

References

1. Adegboyega T, Rivadeneira D. Lower GI bleeding: An update on incidences and causes. Clin Colon Rectal Surg. 2020; 33:28-34.

2. Diamantopoulou G, Konstantakis C, Kottorοu A, Skroubis G, Theocharis G, Theopistos V, et al. Acute lower gastrointestinal bleeding: characteristics and clinical outcome of patients treated with an intensive protocol. Gastroenterol Res. 2017; 10:352-58.

3. Kickuth R, Rattunde H, Gschossmann J, Inderbitzin D, Ludwig K, Triller J. Acute lower gastrointestinal hemorrhage: minimally invasive management with microcatheter embolization. J Vasc Interv Radiol. 2008; 19:1289-96.e2.

4. Oakland K, Chadwick G, East JE, Guy R, Humphries A, Jairath V, et al. Diagnosis and management of acute lower gastrointestinal bleeding: Guidelines from the British Society of Gastroenterology. Gut. 2019; 68:776-89.

5. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol. 2016; 111:459-74.