Upper Gastrointestinal Hemorrhage and Transcatheter Embolotherapy: Clinical and Technical Factors Impacting Success and Survival

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PURPOSE

To identify clinical and technical factors influencing the outcome of transcatheter embolotherapy for nonvariceal upper gastrointestinal (GI) hemorrhage and to quantify the impact of successful intervention on patient survival.

MATERIALS AND METHODS

A retrospective review was performed of all patients (n = 163) who underwent arterial embolization for acute upper GI hemorrhage at a university hospital over an 11.5-year period. Clinical success was defined as target area devascularization that resulted in the clinical cessation of bleeding and stabilization of hemoglobin level. The clinical condition of each patient at intervention was defined by history, laboratory examination, and two composite indicator variables. With use of logistic regression, the dependent variable, clinical success, was modeled on two categories of clinical and technical variables. A final model regressed patient survival on clinical success and other clinical variables.

RESULTS

None of the procedural variables analyzed had a significant influence on clinical success. Several clinical variables did impact clinical success, including multiorgan system failure (OR, 0.36; P = .030), coagulopathy (OR, 0.36; P = .026), and bleeding subsequent to trauma (OR, 7.1; P = .040) or invasive procedures (OR, 6.5; P = .009). Regardless of their clinical condition at intervention, patients who underwent clinically successful embolization were 13.3 times more likely to survive than those who had an unsuccessful procedure (CI, 4.54–39.2; P = .000). Nevertheless, patients with multiorgan system failure were 17.5 times more likely to die, independent of the outcome of the procedure (CI, 0.014–0.229; P = .000).

CONCLUSION

Arresting nonvariceal upper GI hemorrhage with transcatheter embolotherapy has a large positive effect on patient survival, independent of clinical condition or demonstrable extravasation at intervention. Aggressive treatment with transcatheter embolotherapy is advisable in patients with acute nonvariceal upper GI hemorrhage.

Section snippets

Patients

We conducted a retrospective review of all patients (n = 178) who underwent arterial embolization for acute nonvariceal upper GI hemorrhage at a university hospital between December 1988 and May 2000. Fifteen cases were excluded because of incomplete medical records. All the remaining patients (n = 163) had an episode of massive acute bleeding within 7 days of the procedure. Patients requiring at least four units of blood per 24 hours were classified as having massive hemorrhage. This cohort

Clinical and Angiographic Data

The cause of bleeding was determined endoscopically, surgically and, in one case, angiographically. One hundred forty-seven of 163 patients (90%) had endoscopy immediately before or within 12 hours of angiography. The remaining patients were referred for angiography after bleeding was demonstrated by exploratory laparotomy (8), computed tomography (3), or hemobilia from a percutaneous drain (3) or duodenostomy (1). Findings at follow-up endoscopy were used whenever possible to confirm diagnoses.

DISCUSSION

The vast majority of patients with acute upper GI hemorrhage respond to conservative measures or endoscopic intervention (15). However, conservative therapy failed in all our patients and they faced surgery or imminent death from continued massive upper GI hemorrhage. A large body of literature supports the use of transcatheter embolotherapy in patients with upper GI hemorrhage (16, 17, 18, 19, 20, 21, 22, 23, 24). In 1986, Gomes et al (9) established the superiority of embolotherapy over

Acknowledgments

The authors thank Evelyn Stainthorpe, our Clinical Research Coordinator, for helping to collect and organize a portion of the raw data used in this study.

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    1

    Current address: Department of Radiology, The Reading Hospital and Medical Center, Reading, PA.

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