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:
Corresponding author: Johannes Wilhelm Rey, MD, Chief Doctor, Department of Gastroenterology and Endoscopy, Medical Center Osnabrueck, Germany, Am Finkenhügel 1, Osnabrueck 49076, Niedersachsen, Germany.
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
Research background

The large majority of lower gastrointestinal bleedings (LGIB) subside on their own or after endoscopic treatment. A small number of these may pose a challenge in terms of therapy when endoscopy does not achieve hemostasis. Based on what we know, transarterial embolization (TAE) enables the clinician to control gastrointestinal bleeding.

Research motivation

The timing and value of computed tomography angiography (CTA) and catheter angiography (CA) after failed primary hemostasis in endoscopy should be given greater attention in the course of treatment. The use of easily determined diagnostic and treatment parameters for identifying the best time point of escalation therapy in terms of angiography is the principal motivation in this field of science.

Research objectives

The aim was to evaluate clinical predictors for CA in patients with LGIB and create a practical decision-making aid based on these. It was shown that endoscopic hemostasis in primary endoscopy, along with GBS and the number of transfusions, were the most important factors in predicting CA.

Research methods

We performed a retrospective analysis of all patients with LGIB who received CA over a 10-year period in a maximum-care hospital (CA-LGIB group). A group of patients with LGIB who underwent conservative treatment served as the reference group (K-LGIB group). We used mean decrease in impurity, a random forest-based metric for variable importance, to assess the suitability of the collected data. Conditional inference trees were employed to build decision-making aids based on binary splits.

Research results

Most patients with LGIB and no hemostasis received angiography within three days after admission. We designed the treatment on the basis of the most important clinical parameters [Glasgow-Blatchford bleeding score (GBS), shock index, and serum hemoglobin levels]; these should help the clinician in making decisions about early radiological treatment with CA and TAE. Endoscopic hemostasis proved to be the crucial difference between CA and conservative treatment.

Research conclusions

Primary endoscopic hemostasis, along with the GBS and the number of transfusions, could permit a stratification of risks. Courses of treatment might serve as a crucial basis for making decisions about scheduling a patient to undergo CA. The present data are intended to enhance the clinician’s awareness of angiographic diagnostic investigation and treatment after or during failed endoscopic treatment.

Research perspectives

The timing of the CTA, the procedure for a negative CTA in hemodynamically unstable patients and the benefits of provocative CA should be investigated further. Contrast extravasation in CA and subsequent TAE should be the endpoint of future prospective studies. Hospitals will need strategies to transfer people with failed hemostasis in primary endoscopy to interventional radiology.