Analysis of Findings and Intervention on Upper Endoscopy with Outcomes for Patients with Nonvariceal Upper Gastrointestinal Bleeding Undergoing Angiography and Empiric Embolization Ian Rumball1, Zohaib Bagha1, Kan Chen2 MD, Eric Gandras2 MD, Craig Greben2 MD, and Jonathan Weinstein2 MD 1Donald
and Barbara Zucker School of Medicine at Hofstra/Northwell of Interventional Radiology, Northwell Health
2Department
Background
Results
• Percutaneous transcatheter embolization has become the preferred treatment for nonvariceal upper GI bleeding that is refractory to medical and endoscopic therapy (1). • The incidence of peptic ulcer disease (i.e. gastric and duodenal ulcers) has been reported as 3.18 per 1000 person-years, while the incidence of peptic ulcer bleeding is 0.57 per 1000 person-years (2). • Several retrospective studies have shown that embolization of the gastroduodenal artery (GDA) empirically is effective for duodenal ulcers if no source of bleeding is identified on angiography (3,4). • We sought to evaluate which patients and ulcer characteristics may demonstrate better responses to empiric GDA embolization.
Conclusions
Figure 1 – (A) Celiac arteriogram demonstrating no active extravasation in a patient with GI bleeding. (B) Coil embolization of the gastroduodenal artery (C) Forrest Class Ia duodenal ulcer
A
B
C
Hypothesis
Future Direction
We hypothesize that endoscopic findings and interventions performed prior to angiography, including Forest classification and ulcer size, may predict success of empiric embolization in patients who require angiography after endoscopy and in whom no angiographic abnormality is identified.
Methods
Table 2 – Description of Clinical Characteristics and Endoscopy Findings
• We retrospectively identified consecutive cases of empiric embolization of the GDA in the setting of nonvariceal upper GI bleeding related to duodenal ulcers from multiple hospitals in our health system from the past 5 years. From these cases, we identified 62 consecutive cases for which prior endoscopy reports were available electronically. • We analyzed endoscopy reports and classified duodenal ulceration and bleeding using the Forrest Classification system (Table 1), and assessed factors such as ulcer location, ulcer number, and endoscopic interventions. • We noted clinical characteristics including those related to platelet dysfunction (e.g. platelet count, BUN) or coagulopathy (e.g. INR, preembolization PRBC requirement). Table 1 – Forrest Classification of endoscopic findings in gastrointestinal bleeding Forrest Classification Endoscopic Finding
I (Active bleeding)
II (Stigmata of Bleeding)
Ia
Ib
IIa
IIb
Spurting bleed
Oozing bleed
Visible vessel
Adherent clot
IIc
III
Flat Clean ulcer pigmented base spot
• The data was analyzed against clinical outcomes including transfusion requirement, 30-day mortality, and 30-day reintervention (including angiography, endoscopy, or surgery), as well as against a composite outcome of 30-day mortality or reintervention. • Among descriptive statistics, continuous data were described as mean ± standard deviation and categorical data was described as frequencies. • We used Fisher’s Exact test to describe association between categorical independent variables and categorical dependent variables. • Logistic regression was utilized to model the occurrence of binary outcome variables (e.g. 30-day morality) based on categorical or continuous predictor variables. A P value > 0.05 was considered statistically significant.
• Selected patients undergoing empiric GDA embolization that experienced the analyzed outcomes of 30-day mortality, 30-day reintervention, or 30-day composite outcome were more likely to have signs of platelet dysfunction or coagulopathy than embolization patients without the clinical outcomes. • This reflects the trend described in previous literature (5,6,7) in which clinical and demographic factors associated with primary hemostasis or coagulation were associated with adverse outcomes. • The number of duodenal ulcers on endoscopy was a statistically significant predictor of 30-day reintervention. • Though ulcer location and Forrest Classification were not associated with our analyzed outcomes, the association of ulcer number and reintervention indicates that endoscopic findings may be relevant in predicting clinical outcome.
Patient Characteristics Age (Years) Male (%) On antiplatelet (%) On anticoagulant (%) INR (unit) PTT (s) Plt Count (K/uL) BUN (mg/dL) Cirrhosis (%) Pre-endoscopy PRBC requirement (unit) Ulcer Number Ulcer Forrest Classification (%) III IIc IIb IIa Ib Ia 30-day mortality (%)
N=62 71.73 ± 13.26 38 (61.29%) 18 (29.03%) 7 (11.29%) 1.51 ± 0.78 30.25 ± 8.80 230.21 ± 107.79 53.87 ± 30.27 4 (6.45%) 6.82 ± 4.68
1.61 ± 0.82
4 (6.45%) 8 (12.90%) 15 (24.19%) 6 (9.68%) 12 (19.35%) 17 (27.42) 9 (14.52%)
Table 3 – Correlation of Clinical Factors and Endoscopic Findings with Post-Embolization Outcomes Factor (Unit)
30- day Mortality
30-day Reintervention
30-day Composite
INR (unit)
p=0.008 OR 2.957
p=0.828
p=0.119
Platelets (K/uL)
p=0.116
p=0.015 OR 0.989
p =0.014 OR 0.991
BUN (mg/dL)
p=0.396
p=0.051 OR=1.020
p=0.029 OR 1.021
• These predictive factors might assist clinicians in triaging cases based on likelihood of successful outcome. • Future studies could assess the utility of these predictors in assessing which patients should be selected for more intensive care (e.g. monitored more closely for bleeding, prioritized for repeat endoscopy, or more aggressive management, such as surgical options).
Resources 1. 2.
3.
Preembolization PRBC transfusion (unit)
p=0.032 OR 1.173
p=0.353
p=0.070 OR 1.122
4.
Number of ulcers on endoscopy*
p=0.819
p=0.049 OR 2.043
p=0.214
5.
Ulcer(s) isolated to duodenal bulb
p=0.735
p=0.361
p =0.843
6.
Forest Class Ia/Ib
p=0.483
p=0.381
p=0.277
OR: Odds Ratio *ulcers listed as “multiple” on endoscopy report were coded as 3
7.
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