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Rofo 2019; 191(12): 1073-1082
DOI: 10.1055/a-0891-1116
Review
© Georg Thieme Verlag KG Stuttgart · New York

Die endovaskuläre Therapie gastrointestinaler Blutungen

Article in several languages: English | deutsch
Anne Marie Augustin
  Department of Diagnostic and Interventional Radiology, University-Hospital of Würzburg, Germany
,
Friederika Fluck
  Department of Diagnostic and Interventional Radiology, University-Hospital of Würzburg, Germany
,
Thorsten Bley
  Department of Diagnostic and Interventional Radiology, University-Hospital of Würzburg, Germany
,
Ralph Kickuth
  Department of Diagnostic and Interventional Radiology, University-Hospital of Würzburg, Germany
› Author Affiliations
Further Information

Publication History

15 December 2018

19 March 2019

Publication Date:
26 April 2019 (online)

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Zusammenfassung

Hintergrund Bei den gastrointestinalen (GI) Blutungen handelt es sich um ein relativ häufig auftretendes Krankheitsbild mit einem breiten Spektrum an zugrunde liegenden Ursachen. In einem Großteil der Fälle sind diese akuten Blutungen mit konservativen, medikamentösen oder endoskopischen Verfahren gut zu therapieren. Jedoch erfordert ein Anteil endoskopisch nicht identifizierbarer oder beherrschbarer nichtvariköser GI-Blutungen nach wie vor alternative, teils chirurgische Therapiekonzepte. Die aktuelle S2k-Leitlinie „Gastrointestinale Blutung“ räumt dabei der interventionellen Radiologie mit ihren minimalinvasiven endovaskulären Verfahren einen wichtigen Stellenwert ein.

Methodik In dieser Übersichtsarbeit wird die Rolle der interventionellen Radiologie in der Therapie nichtvariköser oberer und unterer gastrointestinaler Blutungen anhand der aktuellen Literatur sowie der neuen Leitlinie diskutiert. In diesem Kontext werden Indikationen, technische Durchführung, Ergebnisse und Komplikationen endovaskulärer Therapieverfahren thematisiert.

Ergebnisse und Schlussfolgerung Unter Abwägung interdisziplinärer Therapieoptionen stellt die leitlinienorientierte endovaskuläre Versorgung gastrointestinaler Blutungen mittels Embolisation und Implantation gecoverter Stents einen Behandlungsansatz mit guten technischen und klinischen Erfolgsraten sowie einer geringen Rate an Komplikationen dar. In diesem Zusammenhang sind fundierte Kenntnisse der Gefäßanatomie essenziell, um eine adäquate Hämostase herbeizuführen.

Kernaussagen: 

  • Die interventionelle Radiologie kann in der Diagnostik und Therapie nichtvariköser gastrointestinaler Blutungen unterschiedlicher Ätiologie einen wichtigen Beitrag leisten.

  • Die S2k-Leitlinie „Gastrointestinale Blutung“ stellt hierbei die Grundlage für die Entscheidungsfindung zu einer endovaskulären Hämostase-Therapie dar.

  • Die Embolisation ist das Verfahren der ersten Wahl zur endovaskulären Behandlung gastrointestinaler Blutungen.

  • Ein adäquates periinterventionelles Management erhöht die Erfolgschancen der endovaskulären Therapie.

Zitierweise

  • Augustin AM, Fluck F, Bley T et al. Endovascular therapy of gastroinestinal bleeding. Fortschr Röntgenstr 2019; 191: 1073 – 1082

Key words

abdomen - angiography - embolization - interventional procedures - hemorrhage
 

  • References

  • 1 Manning-Dimmitt LL, Dimmitt SG, Wilson GR. Diagnosis of gastrointestinal bleeding in adults. Am Fam Physician 2005; 71: 1339-1346
    PubMedGoogle Scholar
  • 2 Barnert J, Messmann H. Diagnosis and management of lower gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 2009; 6: 637-646
    PubMedGoogle Scholar
  • 3 Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc 1999; 49: 228-238
    CrossrefPubMedGoogle Scholar
  • 4 Gotz M, Anders M, Biecker E. et al. S2k Guideline Gastrointestinal Bleeding – Guideline of the German Society of Gastroenterology DGVS. Z Gastroenterol 2017; 55: 883-936
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Hreinsson JP, Kalaitzakis E, Gudmundsson S. et al. Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013; 48: 439-447
    CrossrefPubMedGoogle Scholar
  • 6 Sanjay P, Kellner M, Tait IS. The role of interventional radiology in the management of surgical complications after pancreatoduodenectomy. HPB (Oxford) 2012; 14: 812-817
    CrossrefPubMedGoogle Scholar
  • 7 Navuluri R, Kang L, Patel J. et al. Acute lower gastrointestinal bleeding. Semin Intervent Radiol 2012; 29: 178-186
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Zhang BL, Chen CX, Li YM. Capsule endoscopy examination identifies different leading causes of obscure gastrointestinal bleeding in patients of different ages. Turk J Gastroenterol 2012; 23: 220-225
    CrossrefPubMedGoogle Scholar
  • 9 Song SY, Chung JW, Yin YH. et al. Celiac axis and common hepatic artery variations in 5002 patients: systematic analysis with spiral CT and DSA. Radiology 2010; 255: 278-288
    CrossrefPubMedGoogle Scholar
  • 10 Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000; 356: 1318-1321
    CrossrefPubMedGoogle Scholar
  • 11 Cheng DW, Lu YW, Teller T. et al. A modified Glasgow Blatchford Score improves risk stratification in upper gastrointestinal bleed: a prospective comparison of scoring systems. Aliment Pharmacol Ther 2012; 36: 782-789
    CrossrefPubMedGoogle Scholar
  • 12 Gralnek IM, Dumonceau JM, Kuipers EJ. et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: a1-a46
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Denzer U, Beilenhoff U, Eickhoff A. et al. S2k guideline: quality requirements for gastrointestinal endoscopy, AWMF registry no. 021–022. Z Gastroenterol 2015; 53: E1-E227
    PubMedGoogle Scholar
  • 14 Koch A, Buendgens L, Duckers H. et al. Bleeding origin, patient-related risk factors, and prognostic indicators in patients with acute gastrointestinal hemorrhages requiring intensive care treatment. A retrospective analysis from 1999 to 2010. Med Klin Intensivmed Notfmed 2013; 108: 214-222
    CrossrefPubMedGoogle Scholar
  • 15 Green BT, Rockey DC, Portwood G. et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol 2005; 100: 2395-2402
    CrossrefPubMedGoogle Scholar
  • 16 Eriksson LG, Sundbom M, Gustavsson S. et al. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol 2006; 17: 959-964
    CrossrefPubMedGoogle Scholar
  • 17 Acute Upper Gastrointestinal Bleeding: Management. National Institute for Health and Clinical Excellence: Guidance. London: 2012
    PubMedGoogle Scholar
  • 18 Garcia-Blazquez V, Vicente-Bartulos A, Olavarria-Delgado A. et al. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. European radiology 2013; 23: 1181-1190
    CrossrefPubMedGoogle Scholar
  • 19 Chua AE, Ridley LJ. Diagnostic accuracy of CT angiography in acute gastrointestinal bleeding. J Med Imaging Radiat Oncol 2008; 52: 333-338
    CrossrefPubMedGoogle Scholar
  • 20 Gunderman R, Leef J, Ong K. et al. Scintigraphic screening prior to visceral arteriography in acute lower gastrointestinal bleeding. J Nucl Med 1998; 39: 1081-1083
    PubMedGoogle Scholar
  • 21 Miller Jr M, Smith TP. Angiographic diagnosis and endovascular management of nonvariceal gastrointestinal hemorrhage. Gastroenterol Clin North Am 2005; 34: 735-752
    CrossrefPubMedGoogle Scholar
  • 22 Wortman JR, Landman W, Fulwadhva UP. et al. CT angiography for acute gastrointestinal bleeding: what the radiologist needs to know. Br J Radiol 2017; 90: 20170076
    CrossrefPubMedGoogle Scholar
  • 23 Wildgruber M, Wrede CE, Zorger N. et al. Computed tomography versus digital subtraction angiography for the diagnosis of obscure gastrointestinal bleeding. Eur J Radiol 2017; 88: 8-14
    CrossrefPubMedGoogle Scholar
  • 24 Marx G, Schindler AW, Mosch C. et al. Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33: 488-521
    CrossrefPubMedGoogle Scholar
  • 25 Wells M, Chande N, Adams P. et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012; 35: 1267-1278
    CrossrefPubMedGoogle Scholar
  • 26 Gambiez LP, Ernst OJ, Merlier OA. et al. Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis. Arch Surg 1997; 132: 1016-1021
    PubMedGoogle Scholar
  • 27 Wente MN, Veit JA, Bassi C. et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142: 20-25
    CrossrefPubMedGoogle Scholar
  • 28 Kim J, Shin JH, Yoon HK. et al. Endovascular intervention for management of pancreatitis-related bleeding: a retrospective analysis of thirty-seven patients at a single institution. Diagn Interv Radiol 2015; 21: 140-147
    CrossrefPubMedGoogle Scholar
  • 29 Kickuth R, Rattunde H, Gschossmann J. et al. Acute lower gastrointestinal hemorrhage: minimally invasive management with microcatheter embolization. J Vasc Interv Radiol 2008; 19: 1289-1296 e2
    CrossrefPubMedGoogle Scholar
  • 30 Wildgruber M, Huff M, Meier R. et al. Embolization Therapy for Pancreas-Related Bleeding: A Retrospective Analysis With Focus on End-Organ Ischemia. Pancreas 2017; 46: e22-e23
    CrossrefPubMedGoogle Scholar
  • 31 Scharinger L, Aigner E, Datz C. Diagnostik der obskuren gastrointestinalen Blutung-Stellenwertvon Kapselendoskopie und Doppelballonenteroskopie. Journal für gastroenterologische und hepatologische Erkrankungen 2007; 5: 22-27
    PubMedGoogle Scholar
  • 32 Radeleff B. Gastrointestinale Blutungen. In: Radeleff B. editor Angiofibel. Berlin Heidelberg: Springer-Verlag; 272-274
    Google Scholar
  • 33 Maleux G, Roeflaer F, Heye S. et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009; 104: 2042-2046
    CrossrefPubMedGoogle Scholar
  • 34 Loffroy R, Rao P, Ota S. et al. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol 2010; 33: 1088-1100
    CrossrefPubMedGoogle Scholar
  • 35 Ryan JM, Key SM, Dumbleton SA. et al. Nonlocalized lower gastrointestinal bleeding: provocative bleeding studies with intraarterial tPA, heparin, and tolazoline. J Vasc Interv Radiol 2001; 12: 1273-1277
    CrossrefPubMedGoogle Scholar
  • 36 Aina R, Oliva VL, Therasse E. et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001; 12: 195-200
    CrossrefPubMedGoogle Scholar
  • 37 Mensel B, Kuhn JP, Kraft M. et al. Selective microcoil embolization of arterial gastrointestinal bleeding in the acute situation: outcome, complications, and factors affecting treatment success. Eur J Gastroenterol Hepatol 2012; 24: 155-163
    CrossrefPubMedGoogle Scholar
  • 38 Koo HJ, Shin JH, Kim HJ. et al. Clinical outcome of transcatheter arterial embolization with N-butyl-2-cyanoacrylate for control of acute gastrointestinal tract bleeding. Am J Roentgenol 2015; 204: 662-668
    CrossrefPubMedGoogle Scholar
  • 39 Loffroy R, Guiu B, D'Athis P. et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol 2009; 7: 515-523
    CrossrefPubMedGoogle Scholar
  • 40 Toyoda H, Nakano S, Kumada T. et al. Estimation of usefulness of N-butyl-2-cyanoacrylate-lipiodol mixture in transcatheter arterial embolization for urgent control of life-threatening massive bleeding from gastric or duodenal ulcer. J Gastroenterol Hepatol 1996; 11: 252-258
    CrossrefPubMedGoogle Scholar
  • 41 Urbano J, Manuel Cabrera J, Franco A. et al. Selective arterial embolization with ethylene-vinyl alcohol copolymer for control of massive lower gastrointestinal bleeding: feasibility and initial experience. J Vasc Interv Radiol 2014; 25: 839-846
    CrossrefPubMedGoogle Scholar
  • 42 Lenhart M, Paetzel C, Sackmann M. et al. Superselective arterial embolisation with a liquid polyvinyl alcohol copolymer in patients with acute gastrointestinal haemorrhage. European radiology 2010; 20: 1994-1999
    CrossrefPubMedGoogle Scholar
  • 43 Kurihara N, Kikuchi K, Tanabe M. et al. Partial resection of the second portion of the duodenum for gastrointestinal stromal tumor after effective transarterial embolization. Int J Clin Oncol 2005; 10: 433-437
    CrossrefPubMedGoogle Scholar
  • 44 Kuo WT, Lee DE, Saad WE. et al. Superselective microcoil embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2003; 14: 1503-1509
    CrossrefPubMedGoogle Scholar
  • 45 Lang EK. Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology 1992; 182: 703-707
    CrossrefPubMedGoogle Scholar
  • 46 Walsh RM, Anain P, Geisinger M. et al. Role of angiography and embolization for massive gastroduodenal hemorrhage. J Gastrointest Surg 1999; 3: 61-65 ; discussion 6
    CrossrefPubMedGoogle Scholar
  • 47 Defreyne L, Vanlangenhove P, De Vos M. et al. Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology 2001; 218: 739-748
    CrossrefPubMedGoogle Scholar
  • 48 Schenker MP, Duszak Jr R, Soulen MC. et al. Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival. J Vasc Interv Radiol 2001; 12: 1263-1271
    CrossrefPubMedGoogle Scholar
  • 49 Lundgren JA, Matsushima K, Lynch FC. et al. Angiographic embolization of nonvariceal upper gastrointestinal bleeding: predictors of clinical failure. J Trauma 2011; 70: 1208-1212
    CrossrefPubMedGoogle Scholar
  • 50 Nanavati SM. What if endoscopic hemostasis fails? Alternative treatment strategies: interventional radiology. Gastroenterol Clin North Am 2014; 43: 739-752
    CrossrefPubMedGoogle Scholar
  • 51 Ripoll C, Banares R, Beceiro I. et al. Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. J Vasc Interv Radiol 2004; 15: 447-450
    CrossrefPubMedGoogle Scholar
  • 52 Eriksson LG, Ljungdahl M, Sundbom M. et al. Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure. J Vasc Interv Radiol 2008; 19: 1413-1418
    CrossrefPubMedGoogle Scholar
  • 53 Wong TC, Wong KT, Chiu PW. et al. A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers. Gastrointest Endosc 2011; 73: 900-908
    CrossrefPubMedGoogle Scholar
  • 54 Stampfl U, Hackert T, Sommer CM. et al. Superselective embolization for the management of postpancreatectomy hemorrhage: a single-center experience in 25 patients. J Vasc Interv Radiol 2012; 23: 504-510
    CrossrefPubMedGoogle Scholar
  • 55 Hassold N, Wolfschmidt F, Dierks A. et al. Effectiveness and outcome of endovascular therapy for late-onset postpancreatectomy hemorrhage using covered stents and embolization. J Vasc Surg 2016; 64: 1373-1383
    CrossrefPubMedGoogle Scholar
  • 56 Kickuth R, Hoppe H, Saar B. et al. Superselective transcatheter arterial embolization in patients with acute peripancreatic bleeding complications: review of 44 cases. Abdom Radiol (NY) 2016; 41: 1782-1792
    CrossrefPubMedGoogle Scholar
  • 57 Nicholson AA, Patel J, McPherson S. et al. Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications. J Vasc Interv Radiol 2006; 17: 1279-1285
    CrossrefPubMedGoogle Scholar
  • 58 Lang EV, Picus D, Marx MV. et al. Massive arterial hemorrhage from the stomach and lower esophagus: impact of embolotherapy on survival. Radiology 1990; 177: 249-252
    CrossrefPubMedGoogle Scholar
  • 59 d'Othee BJ, Surapaneni P, Rabkin D. et al. Microcoil embolization for acute lower gastrointestinal bleeding. Cardiovasc Intervent Radiol 2006; 29: 49-58
    CrossrefPubMedGoogle Scholar
  • 60 Weldon DT, Burke SJ, Sun S. et al. Interventional management of lower gastrointestinal bleeding. European radiology 2008; 18: 857-867
    CrossrefPubMedGoogle Scholar
  • 61 Encarnacion CE, Kadir S, Beam CA. et al. Gastrointestinal bleeding: treatment with gastrointestinal arterial embolization. Radiology 1992; 183: 505-508
    CrossrefPubMedGoogle Scholar
  • 62 Loffroy R, Favelier S, Pottecher P. et al. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging 2015; 96: 731-744
    CrossrefPubMedGoogle Scholar
  • 63 Loffroy R, Guiu B, Cercueil JP. et al. Endovascular therapeutic embolisation: an overview of occluding agents and their effects on embolised tissues. Curr Vasc Pharmacol 2009; 7: 250-263
    CrossrefPubMedGoogle Scholar
  • 64 Lipof T, Sardella WV, Bartus CM. et al. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum 2008; 51: 301-305
    CrossrefPubMedGoogle Scholar
  • 65 Ikoma A, Kawai N, Sato M. et al. Ischemic effects of transcatheter arterial embolization with N-butyl cyanoacrylate-lipiodol on the colon in a Swine model. Cardiovasc Intervent Radiol 2010; 33: 1009-1015
    CrossrefPubMedGoogle Scholar
  • 66 Bandi R, Shetty PC, Sharma RP. et al. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001; 12: 1399-1405
    CrossrefPubMedGoogle Scholar
  • 67 Funaki B, Kostelic JK, Lorenz J. et al. Superselective microcoil embolization of colonic hemorrhage. Am J Roentgenol 2001; 177: 829-836
    CrossrefPubMedGoogle Scholar