الفهرس 
AnatomyOnly 14 pages are availabe for public view
 |  | from | 231 |  |  |
| | | from | 231 | | |
Abstract
GI bleeding is mostly a self-limited disorder with medical management mainly and the endoscopy comes as a second management. In refractory cases with persistent bleeding angiography is the preferred management before surgery. The clinical presentation is various including hematemesis, melena, bleeding per rectum and hematochezia. It classified anatomically into upper and lower GI bleeding according to the relation to ligament of Treitz. Diagnosis depends mainly on endoscopy and CT angiography can detect low flow bleeding less than 5ml/ sec while conventional angiography is needed for higher rates of bleeding. In cases in which the source of bleeding can’t be detected easily the role of scintigraphy shows up.
Upper GI bleeding is more common than the lower GI bleeding. The commonest cause of Upper GI bleeding is peptic ulcer and gastritis, esophageal erosions and varices followed by telangiectasia. While the most common in lower GI bleeding are Ischemic colitis, Hemorrhoids, Postpolypectomy bleeding, Infectious colitis, Radiation proctopathy, rectal varices, Angioectasia, Colorectal neoplasia, inflammatory bowel disease, NSAID, and Dieulafoy lesion.
Therapeutic upper endoscopy is the first choice of treatment regardless of the cause of bleeding and success of hemostasis is 80% to 90% while Transcatheter angiography and surgery are used when endoscopy fails. Both surgery and transcatheter embolization are equally effective and have similar rates of complications, including rebleeding and mortality. Although with the debilitated, elderly, or patients with coagulopathy, open surgery is not an option and embolization, which is minimally invasive, is the treatment of choice.
Technical success is defined as disappearance of extravasation or pseudoaneurysm on angiography after embolization. However clinical success is cessation of clinical evidence of hemorrhage like clearing of nasogastric tube aspirate or melena and no additional requirements for blood transfusions or invasive procedures to control bleeding, others used the concept of 30-day primary hemostasis.
In UGI bleeding, Super selective embolization is preferable in all situations except if there is non-identifiable source of bleeding by endoscopy or angiography so using empiric embolization is a choice. The empiric technique is not used in cases of lower GI tract bleeding, due to ischemic complications based on the fact that the lower GI tract with a smaller capillary network is morevulnerable to ischemia than the upper GI tract that has lots of anastomotic channels through the coeliac trunk, left gastric and gastroduodenal arteries.
New studies are raised in the use of empiric technique in LGI bleeding in treatment of hemorrhoidal bleeding.
Provocative angiography is used in lower GI bleeding with non-evident source of bleeding. Studies are limited yet it seems to be effective and safe according to some literatures.
Thechoice of occlusive agents used is dependent upon the location of the transcatheter embolization, the choice of the operator, material availability, and capability to perform super selective catheterization of the bleeding vessel.
In cases in which microcatheter can reach far away near the bleeder we can use Microcoils which is the preferred Embolizing material in most of literatures. While in cases with limited access to the bleeder using cyanoacrylate and Gelfoam is preferred. The combination of Embolizing materials seems to be more effective. NBCA is the Embolizing material of choice in lower GI bleeding.
Prediction of rebleeding is a pivotal principle in follow up and success. Recurrent bleeding defined as angiographic visualizationof recurrent extravasation within 3 days after confirmation of primary hemostasis. Predictors of rebleeding include the bad general condition of the candidate, coagulopathy, and using corticosteroids.
In conclusion; transcatheter embolization is as effective as surgery with less invasion and of wide varieties with multiple techniques and embolic materials to stop bleeding. Microcoils is the material of choice in UGI bleeding while NACB is of choice in LGI bleeding. Although, using combination of different embolic agents is more effective