Amanda A. Mu oz, MD PGY-1 Trauma Conference December 18, 2006

1. Amanda A. Mu�oz, MD PGY-1 Trauma Conference December 18, 2006

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3. 3 GIB: Indications for IR Failure of endoscopic management (20%) Non-diagnostic endoscopy (10%-40%) Poor surgical candidates Selective mesenteric angiography Provocative angiography GOALS: definitive treatment or reduction in surgical morbidity Need to be bleeding 1cc/min (3U/day) for angio to pick up extrav.Need to be bleeding 1cc/min (3U/day) for angio to pick up extrav.

4. 4 GIB: IR Rx Options Intra-arterial vasopressin Arteriolar constriction and bowel wall contraction Long half-life Success rates 60-100% LGIB, complications 10-20%, rebleed 50% Only controls 15-30% of pyloroduodenal sources Transcatheter embolization Gelatin sponge, microcoils, polyvinyl alcohol, balloon - 73 -100% success rate, particularly in the UGI tract vasopressin causes arteriolar constriction and bowel wall contraction. Success rate 60-100%, but 10-20% complication rate, 50% rebleed rate. Infuse at 0.2 - 0.4U per min, then repeat angio in 20-30 min. If bleeding is controlled, then continuous infusion for 6-12h, then 50% dose for 6-12h, then continuous saline. If no recurrence, catheter is removed. Vasopressin has a long half life. SEs: myocardial ischemia, peripheral ischemia, hypertension, dysrhythmias, mesenteric thrombosis, intestinal infarction, and death, can give IV nitro to counteract. Embo: success rates of 90-100% for stopping bleeding, 0% rebleeding rates, SE = intestinal infarction. May become the first choice for angiographic treatment of LGIB. Risk factors for rehemorrhage included intra-abdominal malignancy (P < 0.05), transfusion requirement greater than 10 units before angiography (P < 0.05), and the source of hemorrhage other than solitary gastroduodenal artery hemorrhage (P < 0.05). The failure of initial embolization was associated with an increased incidence of death (55.6% v 5%) and operative intervention. - UGIB more likely larger vessels, LGIBs may have fewer collaterals vasopressin causes arteriolar constriction and bowel wall contraction. Success rate 60-100%, but 10-20% complication rate, 50% rebleed rate. Infuse at 0.2 - 0.4U per min, then repeat angio in 20-30 min. If bleeding is controlled, then continuous infusion for 6-12h, then 50% dose for 6-12h, then continuous saline. If no recurrence, catheter is removed. Vasopressin has a long half life. SEs: myocardial ischemia, peripheral ischemia, hypertension, dysrhythmias, mesenteric thrombosis, intestinal infarction, and death, can give IV nitro to counteract. Embo: success rates of 90-100% for stopping bleeding, 0% rebleeding rates, SE = intestinal infarction. May become the first choice for angiographic treatment of LGIB. Risk factors for rehemorrhage included intra-abdominal malignancy (P < 0.05), transfusion requirement greater than 10 units before angiography (P < 0.05), and the source of hemorrhage other than solitary gastroduodenal artery hemorrhage (P < 0.05). The failure of initial embolization was associated with an increased incidence of death (55.6% v 5%) and operative intervention. - UGIB more likely larger vessels, LGIBs may have fewer collaterals

5. 5 UGIB: IR Rx UGI lesions amenable to IR: Dieulafoy lesions Hemobilia: embolization of affected liver segment PUD: GDA Gastroduodenal AVMs Atherosclerotic and false aneurysms Varices (shunt planning in a non-transplant candidate) If the venous anatomy is suitable?that is, if the diameter of the splenic vein is greater than 0.75 cm (preferably greater than 1.0 cm) and the vein is within one vertebral body of the renal vein on venography?a distal splenorenal shunting procedure should be feasible. If the venous anatomy is not suitable, then esophageal transection, a mesocaval venous graft, or a portacaval shunt is required.If the venous anatomy is suitable?that is, if the diameter of the splenic vein is greater than 0.75 cm (preferably greater than 1.0 cm) and the vein is within one vertebral body of the renal vein on venography?a distal splenorenal shunting procedure should be feasible. If the venous anatomy is not suitable, then esophageal transection, a mesocaval venous graft, or a portacaval shunt is required.

6. 6 LGIB: IR Rx LGI lesions amenable to IR eval or embolization: Diverticular disease Malignancy Inflammatory bowel disease Acute colitis AV malformations If the venous anatomy is suitable?that is, if the diameter of the splenic vein is greater than 0.75 cm (preferably greater than 1.0 cm) and the vein is within one vertebral body of the renal vein on venography?a distal splenorenal shunting procedure should be feasible. If the venous anatomy is not suitable, then esophageal transection, a mesocaval venous graft, or a portacaval shunt is required.If the venous anatomy is suitable?that is, if the diameter of the splenic vein is greater than 0.75 cm (preferably greater than 1.0 cm) and the vein is within one vertebral body of the renal vein on venography?a distal splenorenal shunting procedure should be feasible. If the venous anatomy is not suitable, then esophageal transection, a mesocaval venous graft, or a portacaval shunt is required.

7. 7 Quiz This picture includes: a.) Amanda b.) Cindy c.) Bea d.) Stephanie

8. 8 GIB: IR Rx Vasopressin Infusion Limited by atherosclerotic disease Coagulopathy Catheter must be maintained in proper position for the length of the infusion 2% rate of catheter dislodgement causing recurrent bleeding (Darcy, J Vasc Intervent Radiol, 2003) vasopressin causes arteriolar constriction and bowel wall contraction. Success rate 60-100%, but 10-20% complication rate, 50% rebleed rate. Infuse at 0.2 - 0.4U per min, then repeat angio in 20-30 min. If bleeding is controlled, then continuous infusion for 6-12h, then 50% dose for 6-12h, then continuous saline. If no recurrence, catheter is removed. Vasopressin has a long half life. SEs: myocardial ischemia, peripheral ischemia, hypertension, dysrhythmias, mesenteric thrombosis, intestinal infarction, and death, can give IV nitro to counteract. Embo: success rates of 90-100% for stopping bleeding, 0% rebleeding rates, SE = intestinal infarction. May become the first choice for angiographic treatment of LGIB. Risk factors for rehemorrhage included intra-abdominal malignancy (P < 0.05), transfusion requirement greater than 10 units before angiography (P < 0.05), and the source of hemorrhage other than solitary gastroduodenal artery hemorrhage (P < 0.05). The failure of initial embolization was associated with an increased incidence of death (55.6% v 5%) and operative intervention. vasopressin causes arteriolar constriction and bowel wall contraction. Success rate 60-100%, but 10-20% complication rate, 50% rebleed rate. Infuse at 0.2 - 0.4U per min, then repeat angio in 20-30 min. If bleeding is controlled, then continuous infusion for 6-12h, then 50% dose for 6-12h, then continuous saline. If no recurrence, catheter is removed. Vasopressin has a long half life. SEs: myocardial ischemia, peripheral ischemia, hypertension, dysrhythmias, mesenteric thrombosis, intestinal infarction, and death, can give IV nitro to counteract. Embo: success rates of 90-100% for stopping bleeding, 0% rebleeding rates, SE = intestinal infarction. May become the first choice for angiographic treatment of LGIB. Risk factors for rehemorrhage included intra-abdominal malignancy (P < 0.05), transfusion requirement greater than 10 units before angiography (P < 0.05), and the source of hemorrhage other than solitary gastroduodenal artery hemorrhage (P < 0.05). The failure of initial embolization was associated with an increased incidence of death (55.6% v 5%) and operative intervention.

9. 9 GIB: IR Rx Success affected by vessel tortuosity, arterial spasm, collateral flow Risk factors for rehemorrhage after embolization: intra-abdominal malignancy Transfusion requirement > 10U prior to angio source other than GDA (Keeling, Am Surg 2006) Diverticular bleeding may have the best results compared to other causes (Khanna, J Gastrointest Surg 2005) vasopressin causes arteriolar constriction and bowel wall contraction. Success rate 60-100%, but 10-20% complication rate, 50% rebleed rate. SEs:vasopressin causes arteriolar constriction and bowel wall contraction. Success rate 60-100%, but 10-20% complication rate, 50% rebleed rate. SEs:

10. 10 IR Complications Vasopressin therapy (0-20%): Ischemia (myocardial, peripheral), hypotension, Dysrhythmias, mesenteric thrombosis, intestinal infarction, puncture site, infusion into other site, SBP Embolization (1-15%): Ischemia, infarction, puncture site can add continuous NG infusion to counteract vasopressin effects Complications of vasopressin often confounded by patient selection and underlying comorbidities Embolic material used may affect the risk of infarction can add continuous NG infusion to counteract vasopressin effects Complications of vasopressin often confounded by patient selection and underlying comorbidities Embolic material used may affect the risk of infarction

11. 11 Quiz This picture includes: a.) Amanda b.) Cindy c.) Bea d.) Stephanie

12. 12 GIB: Indications for OR Uncontrolled hemorrhage or hemodynamic instability Persistent bleeding despite medical therapy and endoscopic intervention >4U/24h, persistent for > 72h, rebleeding w/in 1 week Perforation Obstruction Need to rule out malignancy If bleeding continues despite medical and endoscopic therapy, it should be managed surgically. In addition, certain patients whose bleeding was controlled endoscopically?such as those with a visible gastroduodenal artery and a clot in the base of the ulcer, those who experience rebleeding despite medical and endoscopic therapy, and those with giant ulcers?should be strongly considered for surgical therapy. Surgical management may be accomplished either laparoscopically or via an open approach. The latter [see 5:20 Gastroduodenal Procedures] begins with an upper midline incision. The duodenum is mobilized and an anterior longitudinal duodenotomy performed over the site of the ulcer. The bleeding vessel, which is usually on the posterior wall of the first portion of the duodenum, is ligated with nonabsorbable sutures at sites proximal and distal to the bleeding point. A third stitch is placed posterior to the bleeding vessel. Pains must be taken to avoid injury to the common bile duct during the placement of these sutures. The duodenotomy is then closed.The role of vagotomy in the management of bleeding duodenal ulcers has been called into question. Previously, proximal gastric vagotomy was recommended for stable patients. It was considered preferable to truncal vagotomy because it is less likely to result in gastric atony, alkaline reflux gastritis, dumping, and diarrhea. In unstable patients, truncal vagotomy was typically performed in conjunction with pyloroplasty [see 5:20 Gastroduodenal Procedures]. Frozen section to confirm the presence of nerve tissue is helpful for ensuring that the vagotomy is complete.If bleeding continues despite medical and endoscopic therapy, it should be managed surgically. In addition, certain patients whose bleeding was controlled endoscopically?such as those with a visible gastroduodenal artery and a clot in the base of the ulcer, those who experience rebleeding despite medical and endoscopic therapy, and those with giant ulcers?should be strongly considered for surgical therapy. Surgical management may be accomplished either laparoscopically or via an open approach. The latter [see 5:20 Gastroduodenal Procedures] begins with an upper midline incision. The duodenum is mobilized and an anterior longitudinal duodenotomy performed over the site of the ulcer. The bleeding vessel, which is usually on the posterior wall of the first portion of the duodenum, is ligated with nonabsorbable sutures at sites proximal and distal to the bleeding point. A third stitch is placed posterior to the bleeding vessel. Pains must be taken to avoid injury to the common bile duct during the placement of these sutures. The duodenotomy is then closed.The role of vagotomy in the management of bleeding duodenal ulcers has been called into question. Previously, proximal gastric vagotomy was recommended for stable patients. It was considered preferable to truncal vagotomy because it is less likely to result in gastric atony, alkaline reflux gastritis, dumping, and diarrhea. In unstable patients, truncal vagotomy was typically performed in conjunction with pyloroplasty [see 5:20 Gastroduodenal Procedures]. Frozen section to confirm the presence of nerve tissue is helpful for ensuring that the vagotomy is complete.

13. 13 UGIB: Indications for OR Ulcer disease: high risk endoscopic findings Visible GDA Clot in base of ulcer Giant ulcers SB diverticula, vascular malformations, Clot in ulcer base = stigmata of recent bleed. 30% of pts with stigmatta of recent bleed on endoscopy will rebleed. Those that rebleed have a higher mortality rate, so take them to the OR sooner. Clot in ulcer base = stigmata of recent bleed. 30% of pts with stigmatta of recent bleed on endoscopy will rebleed. Those that rebleed have a higher mortality rate, so take them to the OR sooner.

14. 14 UGIB: Non-operative mgmt Mallory-Weiss tears Acute hemorrhagic gastritis Dieulafoy lesion Delayed repair if stable: Paraesophageal or esophageal hiatal hernia Mallory Weiss tears usually stop on their own, if not, endoscopic coagulation. If persists, can do gastrostomy and oversewing of tear. Can also microcoil but done less often. Acute hemorrhagic gastritis always rx w PPI and h pylori Hiatal hernia w chronic blood loss from erosions usually rx w PPI and h pylor, then electively repaired via lap nissen or diaphragmatic repair LGA or short gastrics for mallory weiss, LGA for erosions Mallory Weiss tears usually stop on their own, if not, endoscopic coagulation. If persists, can do gastrostomy and oversewing of tear. Can also microcoil but done less often. Acute hemorrhagic gastritis always rx w PPI and h pylori Hiatal hernia w chronic blood loss from erosions usually rx w PPI and h pylor, then electively repaired via lap nissen or diaphragmatic repair LGA or short gastrics for mallory weiss, LGA for erosions

15. 15 LGIB: Indications for OR Diverticular disease: unlocalized, uncontrolled, recurrent Ischemic colitis w/ peritonitis: sigmoid or L hemicolectomy AEF Meckel�s

16. 16 Quiz This picture includes: a.) Amanda b.) Cindy c.) Bea d.) Stephanie

17. 17 References Darcy, M. Treatment of lower gastrointestinal bleeding: vasopressin vs. embolization. J Vasc Interv Radiol. 2003: 14, 535-543. Fiser, SM. The Absite Review. Keeling WB et al. Risk factors for recurrent hemorrhage after sucessful mesenteric arterial embolization. Am Surg. 2006 Sep;72(9):802-6 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. Kim, LT, Heldmann M, Turnage RH. Acute gastrointestinal hemorrhage. In Greenfield� Surgery: Scientific principles and practice. Chapter 67, LW&W, Philadelphia, 2006. Harold KL and Schlinkert RT. �Upper gastrointestinal bleeding.� In ACS Surgery Principles and Practice. Lefkovitz, Z. Radiology in the daignosis and therapy of gastrointestinal bleeding. Gastrointest Clin N Am. June 2000 (2): 489. Mulholland, MW. Gastroduodenal Ulceration. In Greenfield�s Surgery: Scientific Principles and Practice. Chapter 46, Lippincott, Williams & Wilkins, Philadelphia, 2006. Rosen MJ and Ponsky JL. �Lower gastrointestinal bleeding.� In ACS Surgery Principles and Practice.