Published online Jul 16, 2021. doi: 10.4253/wjge.v13.i7.221
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
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.
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.
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.
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.
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.
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.
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.