Intra-Arterial Treatment in Patients with Acute Massive Gastrointestinal Bleeding after Endoscopic Failure: Comparisons between Positive versus Negative Contrast Extravasation Groups

OBJECTIVE: To determine whether treatment outcome is associated with visualization of contrast extravasation in patients with acute massive gastrointestinal bleeding after endoscopic failure. MATERIALS AND METHODS: From January 2007 to December 2009, patients that experienced a first attack of acute gastrointestinal bleeding after failure of initial endoscopy were referred to our interventional department for intra-arterial treatment. We enrolled 79 patients and divided them into two groups: positive and negative extravasation. For positive extravasation, patients were treated by coil embolization; and in negative extravasation, patients were treated with intra-arterial vasopressin infusion. The two groups were compared for clinical parameters, hemodynamics, laboratory findings, endoscopic characteristics, and mortality rates. RESULTS: Forty-eight patients had detectable contrast extravasation (positive extravasation), while 31 patients did not (negative extravasation). Fifty-six patients survived from this bleeding episode (overall clinical success rate, 71%). An elevation of hemoglobin level was observed in the both two groups; significantly greater in the positive extravasation group compared to the negative extravasation group. Although these patients were all at high risk of dying, the 90-day mortality rate was significantly lower in the positive extravasation than in the negative extravasation (20% versus 42%, p < 0.05). A multivariate analysis suggested that successful hemostasis (odds ratio [OR] = 28.66) is the most important predictor affecting the mortality in the two groups of patients. CONCLUSION: Visualization of contrast extravasation on angiography usually can target the bleeding artery directly, resulting in a higher success rate to control of hemorrhage.

Using Multidetector-Row CT for the Diagnosis of Afferent Loop Syndrome Following Gastroenterostomy Reconstruction

PURPOSE: To assess the clinical manifestations and multidetector-row computed tomography (MDCT) findings of afferent loop syndrome (ALS) and to determine the role of MDCT on treatment decisions. MATERIALS AND METHODS: From January 2004 to December 2008, 1,100 patients had undergone gastroenterostomy reconstruction in our institution. Of these, 22 (2%) patients were diagnosed as ALS after surgery that included Roux-en-Y gastroenterotomy (n=9), Billroth-II gastrojejunostomy (n=7), and Whipple's operation (n=6). Clinical manifestations and MDCT features of these patients were recorded and statistically analyzed. The presumed etiologies of obstruction shown on the MDCT were correlated with clinical information and confirmed by surgery or endoscopic biopsy. RESULTS: The most common clinical symptom was acute abdominal pain, presenting in 18 patients (82%). We found that a fluid-filled C-shaped afferent loop in combination with valvulae conniventes projecting into the lumen was the most common MDCT features of ALS. Malignant causes of ALS, such as local recurrence and carcinomatosis, are the most common etiologies of obstruction. These etiologies and associated complications can be predicted 100% by MDCT. CONCLUSION: Our results suggest that MDCT is a reliable modality for assessing the etiologies of ALS and guiding treatment decisions.