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    J Korean Soc Radiol. 2013 Aug;69(2):123-130. Korean.
    Published online Aug 09, 2013.
    https://doi.org/10.3348/jksr.2013.69.2.123
    Copyright © 2013 The Korean Society of Radiology
    Original Article

    Usefulness of Angiographic Embolization after Endoscopic Metallic Clip Placement in Patient with Non-Variceal Upper Gastrointestinal Bleeding

    Min Jae Yoon, MD,1 Cheol Mog Hwang, MD,1 Ho Jun Kim, MD,1 Young Jun Cho, MD,1 Jae Young Seo, MD,1 Byung Seok Shin, MD,2 Joon Young Ohm, MD,2 Seok Hwan Bae, PhD,3 and Chae Hoon Kang, MD4
      • 1Department of Radiology, Konyang University Hospital, Daejeon, Korea.
      • 2Department of Radiology, Chungnam National University College of Medicine, Daejeon, Korea.
      • 3Department of Radiological Science, Konyang University, Daejeon, Korea.
      • 4Department of Radiology, Inje University College of Medicine, Pusan Paik Hospital, Busan, Korea.
    • Corresponding author: Min Jae Yoon, MD. Department of Radiology, Konyang University Hospital, Konyang University College of Medicine, 158 Gwanjeodong-ro, Seo-gu, Daejeon 302-718, Korea. Tel. 82-42-600-9148, Fax. 82-42-600-9193, Email: hushymj@hanmail.net
    Received April 24, 2013; Accepted May 31, 2013.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    Purpose

    The aim of this study is to assess the usefulness of angiographic embolization after endoscopic metallic clip placement around the edge of non-variceal upper gastrointestinal bleeding ulcers.

    Materials and Methods

    We have chosen 41 patients (mean age, 65.2 years) with acute bleeding ulcers (22 gastric ulcers, 16 duodenal ulcers, 3 malignant ulcers) between January 2010 and December 2012. We inserted metallic clips during the routine endoscopic treatments of the bleeding ulcers. Subsequent transcatheter arterial embolization was performed within 2 hours. We analyzed the angiographic positive rates, angiographic success rates and clinical success rates.

    Results

    Among the 41 patients during the angiography, 19 patients (46%) demonstrated active bleeding points. Both groups underwent embolization using microcoils, N-butyl-cyano-acrylate (NBCA), microcoils with NBCA or gelfoam particle. There are no statistically significant differences between these two groups according to which embolic materials are being used. The bleeding was initially stopped in all patients, except the two who experienced technical failures. Seven patients experienced repeated episodes of bleeding within two weeks. Among them, 4 patients were successful re-embolized. Another 3 patients underwent gastrectomy. Overall, clinical success was achieved in 36 of 41 (87.8%) patients.

    Conclusion

    The endoscopic metallic clip placement was helpful to locate the correct target vessels for the angiographic embolization. In conclusion, this technique reduced re-bleeding rates, especially in patients who do not show active bleeding points.

    Keywords
    Gastrointestinal Bleeding; Embolization; Angiography; Nonvariceal

    Figures

    Fig. 1
    A 64-year-old man who presented with massive upper gastrointestinal bleeding.

    A. About 5 cm in size, large ulcer covered with hematoma and whitish plaque at greater curvature side of gastric body on endoscopy.

    B. There is no definite bleeding site on left gastric artery angiography.

    C. Super-selective angiography using microcatheter demonstrates extravasation (arrow) from one of the branches of left gastric artery.

    D. After embolization using microcoils (arrow). No visible extravasation is noted on post-embolization angiography.

    E. 3 weeks later, the follow-up endoscopy shows no hemorrhagic plaque nor active hemorrhage and the atrophic change of the ulcer is noted.

    Fig. 2
    A 79-year-old man who presented with gastric ulcer.

    A. On endoscopy, there is active ulcer in lesser curvature side of mid-body of stomach, with dark hematoma around ulcer mound.

    B. No evidence of active extravasation on angiography, but we performed super-selective angiographic embolization using micro-coils around metallic clips.

    C. Two days after the follow-up endoscopy, there is trace of bleeding (arrow) at ulcer site but no active bleeding is noted.

    D. One day after the endoscopy, he presented with large amount of melena and unstable vital sign. Subsequent 2nd angiography demonstrates recanalization (open arrows) of distal portion of the previous embolization coil (white arrow) and we performed re-embolization which was successful.

    Fig. 3
    A 51-year-old man who presented with gastric ulcer bleeding on endoscopy.

    A. There is active bleeding site from branch vessels of left gastric artery toward metallic clips (arrows) on microangiography.

    B. Angiographic embolization of these vessels using microcoil.

    C. 5 days after embolization, re-bleeding is noted on the follow-up endoscopy. We performed angiography, demonstrating bleeding (arrows) from surrounding collateral vessels toward metallic clips.

    D. Successful embolization using the additional micro-coil (arrow).

    Tables

    Table 1
    Prevalence of Active Bleeding on Angiography

    Table 2
    Clinical Success Rate of Embolization

    Table 3
    Prevalence of Causative Vessels of Bleeding and Usage of Materials for Embolization

    Table 4
    Correlation of Angiographic Finding and Rebleeding

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    MeSH Terms
    Angiography
    Duodenal Ulcer
    Gastrectomy
    Gelatin Sponge, Absorbable
    Hemorrhage
    Humans
    Stomach Ulcer
    Ulcer
    Metrics
    Share
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    Tables
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