Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jul 16, 2021; 13(7): 221-232
Published online Jul 16, 2021. doi: 10.4253/wjge.v13.i7.221
Endoscopic hemostasis makes the difference: Angiographic treatment in patients with lower gastrointestinal bleeding
David John Werner, Till Baar, Ralf Kiesslich, Nicolai Wenzel, Nael Abusalim, Achim Tresch, Johannes Wilhelm Rey
David John Werner, Radiologie Rhein-Nahe, Krankenhaus am St. Marienwörth, Bad Kreuznach 55543, RLP, Germany
David John Werner, Nicolai Wenzel, Nael Abusalim, Department of Radiology, Helios Dr. Horst-Schmidt-Clinic, Germany, Wiesbaden 65199, Hessen, Germany
Till Baar, Achim Tresch, Institute for Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Germany, Cologne 50923, NRW, Germany
Ralf Kiesslich, Department of Internal Medicine II, Helios Dr. Horst-Schmidt-Clinic, Wiesbaden, Germany, Wiesbaden 65199, Hessen, Germany
Nael Abusalim, Department of Diagnostic and Interventional Radiology, Medical Center Hanau, Germany, Hanau 63450, Hessen, Germany
Achim Tresch, CECAD, University of Cologne, Germany, Cologne 50923, NRW, Germany
Achim Tresch, Center for Data and Simulation Science, University of Cologne, Germany, Cologne 50923, NRW, Germany
Johannes Wilhelm Rey, Department of Gastroenterology and Endoscopy, Medical Center Osnabrueck, Germany, Osnabrueck 49076, Niedersachsen, Germany
Author contributions: Rey JW and Werner DJ designed the topic and wrote the paper; Wenzel N collected the data and edited the text; Baar T and Tresch A analyzed the data. Kiesslich R performed endoscopy and Abusalim N performed interventional angiography; Werner DJ and Baar T contributed equally to the work.
Institutional review board statement: The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki, and was approved by the ethics committee of the Regional Medical Society of Hessen (Landesärztekammer Hessen), approval number 2016/2017, on 31 August 2017.
Informed consent statement: Written informed consent was obtained from each patient included in the registry.
Conflict-of-interest statement: We have no financial relationships to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Johannes Wilhelm Rey, MD, Chief Doctor, Department of Gastroenterology and Endoscopy, Medical Center Osnabrueck, Germany, Am Finkenhügel 1, Osnabrueck 49076, Niedersachsen, Germany. johannes.rey@klinikum-os.de
Received: April 5, 2021
Peer-review started: April 5, 2021
First decision: June 7, 2021
Revised: June 17, 2021
Accepted: July 7, 2021
Article in press: July 7, 2021
Published online: July 16, 2021
Abstract
BACKGROUND

The large majority of gastrointestinal bleedings subside on their own or after endoscopic treatment. However, a small number of these may pose a challenge in terms of therapy because the patients develop hemodynamic instability, and endoscopy does not achieve adequate hemostasis. Interventional radiology supplemented with catheter angiography (CA) and transarterial embolization have gained importance in recent times.

AIM

To evaluate clinical predictors for angiography in patients with lower gastrointestinal bleeding (LGIB).

METHODS

We compared two groups of patients in a retrospective analysis. One group had been treated for more than 10 years with CA for LGIB (n = 41). The control group had undergone non-endoscopic or endoscopic treatment for two years and been registered in a bleeding registry (n = 92). The differences between the two groups were analyzed using decision trees with the goal of defining clear rules for optimal treatment.

RESULTS

Patients in the CA group had a higher shock index, a higher Glasgow-Blatchford bleeding score (GBS), lower serum hemoglobin levels, and more rarely achieved hemostasis in primary endoscopy. These patients needed more transfusions, had longer hospital stays, and had to undergo subsequent surgery more frequently (P < 0.001).

CONCLUSION

Endoscopic hemostasis proved to be the crucial difference between the two patient groups. Primary endoscopic hemostasis, along with GBS and the number of transfusions, would permit a stratification of risks. After prospective confirmation of the present findings, the use of decision trees would permit the identification of patients at risk for subsequent diagnosis and treatment based on interventional radiology.

Keywords: Lower gastrointestinal bleeding, Endoscopy, Angiography, Embolization, Computed tomography angiography, Intervention

Core Tip: Transarterial embolization enables the clinician to control gastrointestinal bleeding with high rates of technical and clinical success. We still do not know when the clinician should conclude endoscopic procedures to control gastrointestinal bleeding. This retrospective study compared patients with conservative treatment and patients who underwent catheter angiography. Patients in the catheter angiography group had a higher shock index, a higher Glasgow-Blatchford score and more rarely achieved hemostasis in primary endoscopy. These patients needed more transfusions, had longer hospital stays and had to undergo subsequent surgery more frequently. Endoscopic hemostasis proved to be the crucial difference between the two patient groups.