GI Bleed - Munoz.ppt

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GI Bleed - Munoz.ppt

  1. 1. Amanda A. Mu ñ oz, MD PGY-1 Trauma Conference December 18, 2006 GASTROINTESTINAL BLEEDING: Interventional Radiology Procedures and Indications for Operation
  2. 2. Quiz <ul><li>This picture includes: </li></ul><ul><li>a.) Amanda </li></ul><ul><li>b.) Cindy </li></ul><ul><li>c.) Bea </li></ul><ul><li>d.) Stephanie </li></ul>
  3. 3. GIB: Indications for IR <ul><li>Failure of endoscopic management (20%) </li></ul><ul><li>Non-diagnostic endoscopy (10%-40%) </li></ul><ul><li>Poor surgical candidates </li></ul><ul><li>Selective mesenteric angiography </li></ul><ul><li>Provocative angiography </li></ul><ul><li>GOALS: definitive treatment or reduction in surgical morbidity </li></ul>
  4. 4. GIB: IR Rx Options <ul><li>Intra-arterial vasopressin </li></ul><ul><ul><li>Arteriolar constriction and bowel wall contraction </li></ul></ul><ul><ul><li>Long half-life </li></ul></ul><ul><ul><li>Success rates 60-100% LGIB, complications 10-20%, rebleed 50% </li></ul></ul><ul><ul><li>Only controls 15-30% of pyloroduodenal sources </li></ul></ul><ul><li>Transcatheter embolization </li></ul><ul><ul><li>Gelatin sponge, microcoils, polyvinyl alcohol, balloon </li></ul></ul><ul><ul><li>- 73 -100% success rate, particularly in the UGI tract </li></ul></ul>
  5. 5. UGIB: IR Rx <ul><li>UGI lesions amenable to IR: </li></ul><ul><li>Dieulafoy lesions </li></ul><ul><li>Hemobilia: embolization of affected liver segment </li></ul><ul><li>PUD: GDA </li></ul><ul><li>Gastroduodenal AVMs </li></ul><ul><li>Atherosclerotic and false aneurysms </li></ul><ul><li>Varices (shunt planning in a non-transplant candidate) </li></ul>
  6. 6. LGIB: IR Rx <ul><li>LGI lesions amenable to IR eval or embolization: </li></ul><ul><li>Diverticular disease </li></ul><ul><li>Malignancy </li></ul><ul><li>Inflammatory bowel disease </li></ul><ul><li>Acute colitis </li></ul><ul><li>AV malformations </li></ul>
  7. 7. Quiz <ul><li>This picture includes: </li></ul><ul><li>a.) Amanda </li></ul><ul><li>b.) Cindy </li></ul><ul><li>c.) Bea </li></ul><ul><li>d.) Stephanie </li></ul>
  8. 8. GIB: IR Rx <ul><li>Vasopressin Infusion </li></ul><ul><li>Limited by atherosclerotic disease </li></ul><ul><li>Coagulopathy </li></ul><ul><li>Catheter must be maintained in proper position for the length of the infusion </li></ul><ul><li>2% rate of catheter dislodgement causing recurrent bleeding (Darcy, J Vasc Intervent Radiol, 2003) </li></ul>
  9. 9. GIB: IR Rx <ul><li>Success affected by vessel tortuosity, arterial spasm, collateral flow </li></ul><ul><li>Risk factors for rehemorrhage after embolization: </li></ul><ul><ul><li>intra-abdominal malignancy </li></ul></ul><ul><ul><li>Transfusion requirement > 10U prior to angio </li></ul></ul><ul><ul><li>source other than GDA (Keeling, Am Surg 2006) </li></ul></ul><ul><li>Diverticular bleeding may have the best results compared to other causes (Khanna, J Gastrointest Surg 2005) </li></ul>
  10. 10. IR Complications <ul><li>Vasopressin therapy (0-20%): </li></ul><ul><li>Ischemia (myocardial, peripheral), hypotension, Dysrhythmias, mesenteric thrombosis, intestinal infarction, puncture site, infusion into other site, SBP </li></ul><ul><li>Embolization (1-15%): </li></ul><ul><li>Ischemia, infarction, puncture site </li></ul>
  11. 11. Quiz <ul><li>This picture includes: </li></ul><ul><li>a.) Amanda </li></ul><ul><li>b.) Cindy </li></ul><ul><li>c.) Bea </li></ul><ul><li>d.) Stephanie </li></ul>
  12. 12. GIB: Indications for OR <ul><li>Uncontrolled hemorrhage or hemodynamic instability </li></ul><ul><li>Persistent bleeding despite medical therapy and endoscopic intervention </li></ul><ul><ul><li>>4U/24h, persistent for > 72h, rebleeding w/in 1 week </li></ul></ul><ul><li>Perforation </li></ul><ul><li>Obstruction </li></ul><ul><li>Need to rule out malignancy </li></ul>
  13. 13. UGIB: Indications for OR <ul><li>Ulcer disease: high risk endoscopic findings </li></ul><ul><ul><li>Visible GDA </li></ul></ul><ul><ul><li>Clot in base of ulcer </li></ul></ul><ul><ul><li>Giant ulcers </li></ul></ul><ul><li>SB diverticula, vascular malformations, </li></ul>
  14. 14. UGIB: Non-operative mgmt <ul><li>Mallory-Weiss tears </li></ul><ul><li>Acute hemorrhagic gastritis </li></ul><ul><li>Dieulafoy lesion </li></ul><ul><li>Delayed repair if stable: </li></ul><ul><ul><li>Paraesophageal or esophageal hiatal hernia </li></ul></ul>
  15. 15. LGIB: Indications for OR <ul><li>Diverticular disease: unlocalized, uncontrolled, recurrent </li></ul><ul><li>Ischemic colitis w/ peritonitis: sigmoid or L hemicolectomy </li></ul><ul><li>AEF </li></ul><ul><li>Meckel’s </li></ul>
  16. 16. Quiz <ul><li>This picture includes: </li></ul><ul><li>a.) Amanda </li></ul><ul><li>b.) Cindy </li></ul><ul><li>c.) Bea </li></ul><ul><li>d.) Stephanie </li></ul>
  17. 17. References <ul><li>Darcy, M. Treatment of lower gastrointestinal bleeding: vasopressin vs. embolization. J Vasc Interv Radiol. 2003: 14, 535-543. </li></ul><ul><li>Fiser, SM. The Absite Review. </li></ul><ul><li>Keeling WB et al. Risk factors for recurrent hemorrhage after sucessful mesenteric arterial embolization. Am Surg . 2006 Sep;72(9):802-6 </li></ul><ul><li>Khanna A, Ognibene SJ, Koniaris LJ. Embolization as first-line therapy for diverticulosis-related massive lower gastrointestinal bleeding: evidence from a meta-analysis. J Gastrointest Surg . 2005 Mar;9(3):343-52. </li></ul><ul><li>Kim, LT, Heldmann M, Turnage RH. Acute gastrointestinal hemorrhage. In Greenfield’ Surgery: Scientific principles and practice. Chapter 67, LW&W, Philadelphia, 2006. </li></ul><ul><li>Harold KL and Schlinkert RT. “Upper gastrointestinal bleeding.” In ACS Surgery Principles and Practice. </li></ul><ul><li>Lefkovitz, Z. Radiology in the daignosis and therapy of gastrointestinal bleeding. Gastrointest Clin N Am . June 2000 (2): 489. </li></ul><ul><li>Mulholland, MW. Gastroduodenal Ulceration. In Greenfield’s Surgery: Scientific Principles and Practice. Chapter 46, Lippincott, Williams & Wilkins, Philadelphia, 2006. </li></ul><ul><li>Rosen MJ and Ponsky JL. “Lower gastrointestinal bleeding.” In ACS Surgery Principles and Practice. </li></ul>

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