Gi fellows talk g tubes and gi bleeding


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Gi fellows talk g tubes and gi bleeding

  1. 1. GASTROINTESTINAL IR INTERVENTIONS A layfellow’s guide Justin McWilliams, MD Assistant ProfessorInterventional Radiology, UCLA
  2. 2. GASTROINTESTINAL IR INTERVENTIONS Feeding tubes Biliary drainage GI bleeding
  4. 4. INDICATIONS/CONTRAINDICATIONS Indications: Contraindications: Long-term nutritional support Colonic interpositionLong-term SBO decompression Portal HTN Moderate or large ascites Previous gastric surgery (relative) INR >1.5 Platelets <75K
  5. 5. PRE-PROCEDURE NPO 8 hoursConsider 200 cc of dilute barium suspension given the night prior Consider antibiotics (usually unnecessary) Consider glucagon 1 mg IV at start of procedure
  6. 6. PROCEDURE (PUSH TYPE)1. Ultrasound and mark liver edge2. Place small bore NG tube3. Insufflate stomach4. Fluoro to confirm safe window – use lateral if necessary5. 1% lidocaine, all the way into stomach along expected path (slightly rightward)6. 3 T-fasteners; watch under fluoro; inject to confirm position7. Puncture stomach and place 035 Amplatz wire8. Pre-load 8 mm x 4 cm balloon into 18F G tube9. Pass balloon/tube over wire, place balloon into tract and fully inflate10. Advance balloon and tube into stomach as balloon deflates11. Inflate G tube balloon with 10 cc sterile H20 and secure disk
  7. 7. PROCEDURE (PULL TYPE)1. Prophylactic antibiotics (Ancef 1 gram IV)2. Ultrasound and mark liver edge3. Place small bore orogastric tube4. Insufflate stomach5. Fluoro to confirm safe window – use lateral if necessary6. 1% lidocaine, all the way into stomach along expected path (toward fundus)7. Puncture stomach with 22 gauge Chiba needle, pass 018 wire and place Neff set8. Use 4F glide catheter through Neff set to guide 035 angled glide wire through GE junction, up esophagus, and out the mouth9. If this is not possible, place a 6F sheath in stomach, pass wire down esophagus through OG tube, and snare from stomach using goose-neck snare10. Secure tube onto wire from oral end and pull wire and tube through mouth and down through stomach and abdominal wall11. Trim tube and place hub; secure outer bumper against abdominal wall
  8. 8. PROCEDURE (GASTROJEJUNOSTOMY)1. Usually used for patients with gastric reflux, aspiration, or poor gastric emptying2. Initial steps same as push-type gastrostomy3. Once T-fasteners placed, puncture into stomach and place 6F sheath4. Use Kumpe catheter and stiff angled glide wire to cannulate pylorus and through duodenum into proximal jejunum5. Serial dilators with peel-away sheath (22F for 18F GJ tube) or balloon dilation of tract6. Pass GJ tube over stiff angled glidewire into jejunum; monitor under fluoro7. OK to use jejunal port immediately8. Compared to G tubes, GJ tubes: Technically more difficult Clog more frequently Require more expensive elemental diet Require slow infusion to prevent dumping
  9. 9. TECHNICAL TIPS Do not underestimate G tubes! Review CT scans prior to procedure Maintain stomach inflation for all steps Localize colon and stomach using AP and lateral fluoro Small bowel is only rarely anterior to stomach In difficult cases, use DynaCT Antrum or mid-body are best targets (careful of inferior epigastric artery) Avoid greater and lesser curvatures (gastric/gastroepiploic arteries) Watch all needle advancements into stomach under fluoro (look for tenting at needle tip; use logic and avoid needle over-advancement)If tube does not pass easily, re-inflate balloon, re-inflate stomach, and re-try (don’t force the tube in, may push stomach away instead)
  10. 10. POST-PROCEDURE CAREStomach rest for 24 hours (NPO, do not use tube except for decompression) T-fastener removal in 1 week Routine flushing of tube before and after each use Liquefy anything placed through tube (pills should be finely crushed and liquefied)
  11. 11. COMPLICATIONSGastrointestinal perforation (especially transverse colon) If just needle: Usually OK to withdraw, re-direct, and continue procedure (give antibiotics) If tract dilated or G tube placed: Consult surgery (do not remove tube)Peritoneal positioning Be critical of final G tube injection to confirm intragastric position; feeding into peritoneum can be a potentially lethal event If access to stomach lost during tract dilation, OK to re-puncture and continue; consider antibiotics and longer stomach rest before feedingWound infection Local skin care; consider Keflex 500 mg PO BID x 7-10 days Consider tube exchange or removal; Consider CT scan to evaluate for abscessAspiration Consider conversion to GJ tubeCatheter falls out Have ER place something in tract (Foley catheter) Can usually re-cannulate established tract within 24 hours of tube dislodgement
  12. 12. THE RIGHT WAY
  13. 13. THE WRONG WAY
  14. 14. OUTCOMES Technical success rate ~98%Lower morbidity and mortality rate than surgical tube placementEquivalent morbidity and mortality to endoscopic tube placement 2% major complication rate 6% minor complication rate
  15. 15. CONTROVERSIES Gastropexy? P u l l ve r s u s P u s h ?Randomized study of 90 patients (48 Pull-type advantages: No gastropexy, 42 not) gastropexy, no balloon which can G tube successful in 100% of pexy rupture, mushroom retention device patients very effectiveG tube failed (placed into peritoneal Pull-type disadvantages: Sometimescavity) in 10% of non-pexy patients hard to snare wire inExcoriation or pain seen around pexy stomach, chance of abdominal wall site in 10% of pexy patients infection, may be harder to convert Increased number of punctures can to GJ increase bleeding risk
  16. 16. TROUBLESHOOTING Tu b e o c c l u s i o n Tu b e l e a k a g e1. Flush with water or saline 1. Secure disc so that balloon is well-2. Flush with Coca-Cola apposed to inner margin of stomach3. Pass a wire under fluoro 2. Ensure that balloon is not obstructing gastric outlet4. Replace tube 3. Antacids 4. Local antibiotic ointment 5. Paracentesis (if ascites) 6. Upsize tube 7. Use suture to tighten tract
  18. 18. INDICATIONS/CONTRAINDICATIONS Indications: Contraindications (all are relative): Relieve biliary obstruction when Marked ascitesERCP has failed or is not indicated Multiple obstructed, isolated biliary (complete CBD obstruction, segments (sclerosing complex hilar lesion, Roux-en-Y) cholangitis, mets) Manage cholangitis Diagnosis INR >1.5 Platelets <75
  19. 19. PRE-PROCEDURE Antibiotics: Zosyn 3.375 grams IV or Ceftriaxone 1 gram IV Alternative for PCN allergy: Cipro 400 mg IV +/- Flagyl 500 mg IV Review cross sectional imaging Choose desired approach:Right side: Generally easier to perform under fluoro, less radiation to hands Left side: Generally easier to perform under ultrasound
  20. 20. PROCEDURE1. Wide prep and insonate liver with ultrasound2. Advance 21 or 22 gauge Chiba under US and/or fluoro, at a level below lateral costophrenic angle at full inspiration3. Attach contrast syringe with extension tubing, gentle injection as needle is withdrawn4. When duct entered, opacify biliary tree with contrast and decide if suitable; if not, repuncture suitable duct5. Once accessed, pass 018 wire, upsize to Accustick catheter6. Use 4F glide catheter and 035 angled glide wire to navigate through occlusion (optional, not performed if infected/septic)7. Place stiff wire, consider stricture dilation (4- 8 mm, 2 minute inflation)8. Place biliary drain (8-10 French)9. Confirm positioning with contrast injection; side holes should be upstream from the obstruction and the pigtail should be in the duodenum
  21. 21. TECHNICAL TIPS Pre-procedure CT or MRCP whenever possible; liberal use of narcotics (painful!)For left access, use ultrasound liberally; can manipulate needle with forceps; segment 3 best but bile duct usually posterior to PV; angle rightward to produce favorable wire trajectory For right access, be careful of pleural reflection; access below 10 th rib laterally; advance along course of posterior rib, parallel to floor; redirect if unsuccessful (cranial/posterior) Contrast injections should be gentle to avoid sepsis; use table tilt or rolling patient to achieve satisfactory cholangiogram without overfilling Unfilled (isolated) segments are easily missed; LPO projection may help Peripheral bile ducts are preferred for drain placement due to lower risk of hemobiliaIf using ultrasound and bile ducts are sufficiently dilated, 21 gauge Chiba is easier to direct than 22 gauge Chiba If drainage catheter does not advance through stricture, can use angioplasty, stiffer guidewire, or peel-away sheath If obstruction difficult to cross, best to place external drainage catheter and bring patient back in 48-72 hours for repeat attempt
  22. 22. POST-PROCEDURE CARE Keep site clean and dry; no swimming or baths For showering, site should be covered (e.g. Tegaderm) and kept out of direct stream of waterClose post-procedure monitoring; consider patient admission and continuation of antibiotics depending on health statusDrainage catheter to external drainage for at least 24 hours; can then consider capping tube for internal drainage; uncap if pain or fever Fluid loss from external bile drainage can be high; PO or IV fluids Consider flushing with 10 cc saline BID to prevent bile clogging Benign strictures short course: 1. Initial PTC, cholangioplasty, place 10F internal-external drain, cap at 24h 2. Return in 6 weeks, re-inject; if patent, place external drain, cap at 24h 3. If no symptoms develop, remove tube 1-2 weeks later Benign strictures long course: 1. Initial PTC, cholangioplasty, place 10F internal-external drain, cap at 24h 2. At 6 weeks, repeat cholangioplasty, upsize to 12F, cap at 24h 3. At 12 weeks, repeat cholangioplasty, upsize to 14F, cap at 24h 4. At 18 weeks, re-assess, if patent, place external drain, cap at 24h 5. If no symptoms develop, remove tube 1-2 weeks later
  23. 23. COMPLICATIONSPain The procedure is painful, especially if bile contacts peritoneum; use lots of lidocaine and liberal sedation If a duct cannot be accessed after 20-30 needle passes, may need to abortBacteremia/shock/sepsis More common with biliary drainage than with PTC ICU, IV antibiotics, fluid resuscitation, ensure adequate biliary drainageHemobilia Blood-stained bile and/or intraluminal clots on cholangiography Perform cholangiogram to see if vascular communication If dark, nonpulsatile bleeding, upsize tube to tamponade vein If arterial bleeding, perform angiography, occlude distal and proximal to siteBiliary peritonitis Usually results from side holes left outside the liver Reposition catheter, and drain the fluid collection with a second catheterPneumothorax/biliary effusion Usually occurs from high right puncture; drainage may be needed
  24. 24. OUTCOMESTechnical success rate 95-100% (dilated system); 67-80% (nondilated system) Complication rate of PTC: 3.4%(Sepsis 1.4%; bile leak 1.4%; intraperitoneal hemorrhage 0.4%; death 0.2%) For biliary drainage, complication rates are higher (Hemobilia 3-9%, septicemia 4-12%)
  25. 25. CONTROVERSIES Multiple or single drain for Right vs. left approach hilar obstr uction Right access may incompletely fill Hilar obstruction often isolates right left ducts and left ductsLeft duct has more acute angle with Drain largest segment of functional common duct, making cannulation liver more difficult Palliation can usually be achievedLeft ducts often easier to target with with drainage of one side only ultrasound Multiple drains needed if both lobes More radiation to hands with left contain infected bile, or if symptoms puncture not relieved by a single catheter
  26. 26. TROUBLESHOOTING Leakage around tube Cholangitis1. Cholangiogram 1. RUQ pain, fever, jaundice2. Tube exchange, ensure proper 2. IV antibiotics usually suffice if position of sideholes biliary drainage is adequate3. Consider upsizing 3. CT or MR to evaluate for abscess and ensure that bile ducts are well drained 4. Consider further biliary drainage if isolated ducts are seen
  29. 29. UPPER GI BLEEDING 85% of GI bleeding comes from the upper GI tract (above ligament of Treitz) Differential for nonvariceal upper GI bleeding Peptic ulcer disease Mallory-Weiss tear Hemorrhagic gastritis Tumor Arteriovenous malformation Hemobilia Aortoduodenal fistulaEndoscopy is 95% successful in identifying the source of upper GI bleeding
  30. 30. APPROACH TO UPPER GI BLEEDING Medical management Volume replacement H2 blockers or proton pump inhibitors Correction of coagulopathy Early endoscopy Determine etiology Attempt treatment (place clip if unsuccessful) Angiography if medical management and endoscopy fail to control bleeding (5 -10% of patients) Surgery if all other treatment modes fail 30-day mortality higher with surgery (14%) than angiography (3%)Eriksson LG, et al (2008) Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopyfailure. J Vasc Interv Radiol 19:1413-1418.
  31. 31. INDICATIONS FOR ANGIOGRAPHY Massive bleeding Hemodynamic instabilityTransfusion requirement of at Systolic BP <100 mm Hg least 4 units in 24 hours OR Heart rate >100 AND Bleeding has failed to respond to conservative medical therapy Bleeding has failed to respond to endoscopic control
  32. 32. TECHNIQUECeliac angiogram (Cobra, Simmons, Levin-1) – 6/30If negative, then perform subselective angiograms Gastroduodenal artery Left gastric artery Splenic artery Superior mesenteric angiogram Especially if repeat hemorrhage after prior embolization Positive findings (seen in 60%) Extravasation of contrast into bowel lumen Pseudoaneurysm Abnormal blush (if correlated with endoscopic findings)
  33. 33. EMBOLIZATION TECHNIQUE Acceptable techniques Superselective catheterization with embolization Gelfoam, coils, particles, glue Sandwich technique (especially in GDA) Coil distal and proximal to injury site May add gelfoam or particles if desired Scatter embolization If cannot reach bleeding site Gelfoam, glue or particles (at least 300-500 micron)Evaluate for dual blood supply and back-door supply– embolize both if present Superior pancreaticoduodenal – inferior pancreaticoduodenal Right gastroepiploic – left gastroepiploic Right gastric – left gastric
  34. 34. EMPIRIC EMBOLIZATION If no extravasation seen, consider empiricembolization of most likely bleeding territory (GDA or left gastric) Coils +/- particles or gelfoam Guide by endoscopy Clinical success is equal to targeted embolization
  35. 35. OUTCOME AND COMPLICATIONS Study # patients Technical Clinical Empiric Ischemia success success treatment Aina 2001 75 99% 76% 38% 4% Schenker 2001 163 95% 58% 63% 1% Poultsides 2008 57 94% 51% 38% 7% Loffroy 2009 60 95% 72% - 0%Aina R, et al (2001) Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 12:195-200.Schenker M, et al (2001) Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival. J VascInterv Radiol 12:1263-1271.Poultsides G, et al (2008) Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy and predictors of outcome. Arch Surg 143:457-461.Loffroy R, et al (2009) Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. ClinGastroenterol Hepatol [Epub ahead of print]
  36. 36. UPPER GI BLEEDING – LAST WORD Perform angiography earlyDelay in angiography, multiorgan failure and high transfusion requirement are all predictors of clinical failure Clinical failure is common in coagulopathic patients Do not use coils alone in these patients Empiric embolization is effective if no extravasation is seen Ischemia is rare Usually self-limited Higher risk in post-operative patients
  38. 38. LOWER GI BLEEDING15% of gastrointestinal hemorrhage comes from the lower GI tract (beyond the ligament of Treitz) Resolves spontaneously in 80% of cases Differential diagnosis for lower GI bleeding Older: Diverticulosis, angiodysplasia, hemorrhoids, tumor, ischemia Younger: IBD, infection
  39. 39. APPROACH TO LOWER GI BLEEDINGNonmassive bleeding, stable Intermittent bleeding:patient Colonoscopy Conservative management Consider tagged RBC scan with 24 hour images Elective colonoscopy Consider angiography +/- provocationMassive bleeding, stable patient Massive bleeding, unstable Tagged RBC scan or MDCT patient Positive: Angiography Prompt angiography Negative: Colonoscopy Surgery if angiography fails Or, just go to angio
  40. 40. TECHNIQUE Superior mesenteric angiogram (Cobra, Sos, Levin-1) – 6/30 Inferior mesenteric angiogram (Sos, Simmons, Mikaelsson) – 2-3/15 If negative, celiac angiogram About 15% of hematochezia has upper GI source Variant middle colic artery (from dorsal pancreatic) If all are negative, consider internal iliac angiograms Inferior and middle rectal arteries (from internal iliac) If repeated angiograms have been negative, consider provocation Heparin 5000 units, nitroglycerin 200 ug, tPA 4 mg Repeat angio in 5-10 minutes; can repeat dosing if negative Successful in 31%, no hemorrhagic complicationsKim CY, Suhocki PV, Miller MJ, et al (2010) Provocative mesenteric angiography for lower gastrointestinal hemorrhage: results from a single-institution study. JVasc Interv Radiol 21:477-483.
  41. 41. EMBOLIZATION TECHNIQUE Microcatheterize bleeding vessel If distal vasa recta can be reached Proceed with superselective embolization Microcoils or particles If distal vasa recta cannot be reachedSelective coil embolization at marginal artery level (likely increases ischemic risk) -or- Vasopressin Park catheter in proximal SMA or IMA 0.2 units/minute, repeat angio at 20 minutes Can increase to 0.4 units/minute
  42. 42. 65 y/o male with massive bleeding – superselective coil embolization
  43. 43. 52 y/o with intermittent rectal bleeding, endoscopies negative
  44. 44. Superselective embolization unsuccessful – marginal artery coiled
  45. 45. Patient began having rightabdominal painLactate remained normalCT with mild wall thickening butno pneumatosisColonoscopy 2 weeks latershowed ascending colon ulcer, nobleedingManaged expectantly with gradualresolution
  46. 46. OUTCOME AND COMPLICATIONSStudy # Primary embolic Technical Clinical success Major patients success (immediate/durable) ischemiaBandi 2001 48 PVA particles* 73% 69/44% 0%Gordon 1997 17 Microcoils* 82% 76/76% 0%Kuo 2003 22 Microcoils** 100% 86/86% 0%Funaki 2001 27 Microcoils** 93% 96/81% 7%D’Othee 2006 19 Microcoils** 89% 89/68% 11%* Embolization only performed if distal vasa recta could be reached** Embolization performed at vasa recta or marginal artery Gordon R, et al (1997) Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg 174:24-28. Kuo W, et al (2003) Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 14:1503-9. Bandi R, Shetty PC et al (2001) Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 12:1399–1405. Funaki B, Kostelic JK et al (2001) Superselective microcoil embolization of colonic hemorrhage. AJR 177:829–836. d’Othée BJ, Surapaneni P et al (2006) Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol 29:49–58
  47. 47. LOWER GI BLEEDING – LAST WORD Frequency of positive angiograms is low Consider tagged RBC scan to improve yield Superselective embolization Embolize at distal vasa recta whenever possibleEmbolization at marginal artery level is usually safe if necessary Microcoils or particles Less collateral supply than upper GI tract But, ischemia remains relatively uncommon
  48. 48. THANK