CardioVascular and Interventional Radiology

, Volume 31, Issue 5, pp 897–905 | Cite as

Therapeutic Decision-Making in Endoscopically Unmanageable Nonvariceal Upper Gastrointestinal Hemorrhage

  • Luc DefreyneEmail author
  • Ignace De Schrijver
  • Johan Decruyenaere
  • Georges Van Maele
  • Wim Ceelen
  • Danny De Looze
  • Peter Vanlangenhove
Clinical Investigation


The purpose of this study was to identify endoscopic and clinical parameters influencing the decision-making in salvage of endoscopically unmanageable, nonvariceal upper gastrointestinal hemorrhage (UGIH) and to report the outcome of selected therapy. We retrospectively retrieved all cases of surgery and arteriography for arrest of endoscopically unmanageable UGIH. Only patients with overt bleeding on endoscopy within the previous 24 h were included. Patients with preceding nonendoscopic hemostatic interventions, portal hypertension, malignancy, and transpapillar bleeding were excluded. Potential clinical and endoscopic predictors of allocation to either surgery or arteriography were tested using statistical models. Outcome and survival were regressed on the choice of rescue and clinical variables. Forty-six arteriographed and 51 operated patients met the inclusion criteria. Univariate analysis revealed a higher number of patients with a coagulation disorder in the catheterization group (41.4%, versus 20.4% in the laparotomy group; p = 0.044). With multivariate analysis, the identification of a bleeding peptic ulcer at endoscopy significantly steered decision-making toward surgical rescue (OR = 5.2; p = 0.021). Taking into account reinterventions, hemostasis was achieved in nearly 90% of cases in both groups. Overall therapy failure (no survivors), rebleeding within 3 days (OR = 3.7; p = 0.042), and corticosteroid use (OR = 5.2; p = 0.017) had a significant negative impact on survival. The odds of dying were not different for embolotherapy or surgery. In conclusion, decision-making was endoscopy-based, with bleeding peptic ulcer significantly directing the choice of rescue toward surgery. Unsuccessful hemostasis and corticosteroid use, but not the choice of rescue, negatively affected outcome.


Upper gastrointestinal hemorrhage Esophagogastroduodenoscopy Embolization Surgery 


  1. 1.
    Cook DJ, Guyatt GH, Salena BJ et al (1992) Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology 102:139–148PubMedGoogle Scholar
  2. 2.
    Laine L, Peterson WL (1994) Bleeding peptic ulcer. N Engl J Med 331(11):717–727PubMedCrossRefGoogle Scholar
  3. 3.
    van Leerdam ME, Vreeburg EM, Rauws EA et al (2003) Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterol 98(7):1494–1499PubMedCrossRefGoogle Scholar
  4. 4.
    Hurlstone DP, Sanders DS, Carter MJ et al (2003) Simplified acute physiology score. II. A valid role in the assessment of patients with medically refractory upper gastrointestinal bleeding? J Gastroenterol Hepatol 18(8):903–909PubMedCrossRefGoogle Scholar
  5. 5.
    Marmo R, Rotondano G, Bianco MA et al (2003) Outcome of endoscopic treatment for peptic ulcer bleeding: Is a second look necessary? A meta-analysis. Gastrointest Endosc 57(1):62–67PubMedCrossRefGoogle Scholar
  6. 6.
    Rockall TA (1998) Management and outcome of patients undergoing surgery after acute upper gastrointestinal haemorrhage. Steering Group for the National Audit of Acute Upper Gastrointestinal Haemorrhage. J Roy Soc Med 91(10):518–523PubMedGoogle Scholar
  7. 7.
    Lau JY, Sung JJ, Lam YH et al (1999) Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 340(10):751–756PubMedCrossRefGoogle Scholar
  8. 8.
    Wiboltt KS, Petersson BG (1994) Treatment of acute upper gastrointestinal bleeding: a retrospective study of the results in a surgical clinic. Eur J Surg 160(6–7):375–379PubMedGoogle Scholar
  9. 9.
    Qvist P, Arnesen KE, Jacobsen CD et al (1994) Endoscopic treatment and restrictive surgical policy in the management of peptic ulcer bleeding. Five years’ experience in a central hospital. Scand J Gastroenterol 29(6):569–576PubMedCrossRefGoogle Scholar
  10. 10.
    Cochran TA (1993) Bleeding peptic ulcer: surgical therapy. Gastroenterol Clin North Am 22:751–778PubMedGoogle Scholar
  11. 11.
    Schein M, Gecelter G (1989) APACHE II score in massive upper gastrointestinal haemorrhage from peptic ulcer: prognostic value and potential clinical applications. Br J Surg 76(7):733–736PubMedCrossRefGoogle Scholar
  12. 12.
    Lieberman DA, Keller FS, Katon RM et al (1984) Arterial embolization for massive upper gastrointestinal tract bleeding in poor surgical candidates. Gastroenterology 86(5; Pt 1):876–885PubMedGoogle Scholar
  13. 13.
    Dempsey DT, Burke DR, Reilly RS et al (1990) Angiography in poor-risk patients with massive nonvariceal upper gastrointestinal bleeding. Am J Surg 159(3):282–286PubMedCrossRefGoogle Scholar
  14. 14.
    Lang EV, Picus D, Marx MV et al (1990) Massive arterial hemorrhage from the stomach and lower esophagus: impact of embolotherapy on survival. Radiology 177(1):249–252PubMedGoogle Scholar
  15. 15.
    Okazaki M, Higashihara H, Ono H et al (1992) Embolotherapy of massive duodenal hemorrhage. Gastrointest Radiol 17:319–323PubMedCrossRefGoogle Scholar
  16. 16.
    Toyoda H, Nakano S, Takeda I et al (1995) Transcatheter arterial embolization for massive bleeding from duodenal ulcers not controlled by endoscopic hemostasis. Endoscopy 27(4):304–307PubMedGoogle Scholar
  17. 17.
    Walsh RM, Anain P, Geisinger M et al (1999) Role of angiography and embolization for massive gastroduodenal hemorrhage. J Gastrointest Surg 3:61–65PubMedCrossRefGoogle Scholar
  18. 18.
    Schenker MP, Duszak RJ, Soulen MC et al (2001) Upper gastrointestinal hemorrhage and transcatheter embolotherapy: clinical and technical factors impacting success and survival. J Vasc Interv Radiol 12:1263–1271PubMedCrossRefGoogle Scholar
  19. 19.
    Funaki B (2002) Endovascular intervention for the treatment of acute arterial gastrointestinal hemorrhage. Gastroenterol Clin North Am 31(3):701–713PubMedCrossRefGoogle Scholar
  20. 20.
    Defreyne L, Vanlangenhove P, De Vos M et al (2001) Embolization as a first approach with endoscopically unmanageable acute nonvariceal gastrointestinal hemorrhage. Radiology 218(3):739–748PubMedGoogle Scholar
  21. 21.
    Aina R, Oliva VL, Therasse E et al (2001) Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 12(2):195–200PubMedCrossRefGoogle Scholar
  22. 22.
    Wang BW, Mok KT, Chang HT et al (1998) APACHE II score: a useful tool for risk assessment and an aid to decision-making in emergency operation for bleeding gastric ulcer. J Am Coll Surg 187(3):287–294PubMedCrossRefGoogle Scholar
  23. 23.
    Forrest JA, Finlayson ND, Shearman DJ (1974) Endoscopy in gastrointestinal bleeding. Lancet 2(7877):394–397PubMedCrossRefGoogle Scholar
  24. 24.
    Defreyne L (2006) Upper GI-bleeding. In: Golzarian J (ed) Vascular embolotherapy: a comprehensive approach: general principles, chest, abdomen and great vessels. Springer Verlag, New York, pp 49–72Google Scholar
  25. 25.
    Drooz EA, SCVIR Standards of Practice Committee (1997) Quality improvement guidelines for percutaneous transcatheter embolization. JVIR 8:889–894Google Scholar
  26. 26.
    Cheng CL, Lee CS, Liu NJ et al (2002) Overlooked lesions at emergency endoscopy for acute nonvariceal upper gastrointestinal bleeding. Endoscopy 34(7):527–530PubMedCrossRefGoogle Scholar
  27. 27.
    Defreyne L, Uder M, Vanlangenhove P et al (2003) Angiography for acute lower gastrointestinal hemorrhage: efficacy of cut film compared with digital subtraction techniques. J Vasc Interv Radiol 14(3):313–322PubMedGoogle Scholar
  28. 28.
    Ripoll C, Banares R, Beceiro I et al (2004) Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. J Vasc Interv Radiol 15(5):447–450PubMedGoogle Scholar
  29. 29.
    Hunt PS, McIntyre RL (1990) Choice of emergency operative procedure for bleeding duodenal ulcer. Br J Surg 77(9):1004–1006PubMedCrossRefGoogle Scholar
  30. 30.
    De Wispelaere JF, De Ronde T, Trigaux JP et al (2002) Duodenal ulcer hemorrhage treated by embolization: results in 28 patients. Acta Gastroenterol Belg 65(1):6–11PubMedGoogle Scholar
  31. 31.
    Branicki FJ, Coleman SY, Pritchett CJ et al (1991) Emergency surgical treatment for nonvariceal bleeding of the upper part of the gastrointestinal tract. Surg Gynecol Obstet 172(2):113–120PubMedGoogle Scholar
  32. 32.
    Chau CH, Siu WT, Law BK et al (2003) Randomized controlled trial comparing epinephrine injection plus heat probe coagulation versus epinephrine injection plus argon plasma coagulation for bleeding peptic ulcers. Gastrointest Endosc 57(4):455–461PubMedCrossRefGoogle Scholar
  33. 33.
    Lang EK (1992) Transcatheter embolization in management of hemorrhage from duodenal ulcer: long-term results and complications. Radiology 182(3):703–707PubMedGoogle Scholar
  34. 34.
    Lee CW, Liu KL, Wang HP et al (2007) Transcatheter arterial embolization of acute upper gastrointestinal tract bleeding with N-butyl-2-cyanoacrylate. J Vasc Interv Radiol 18(2):209–216PubMedCrossRefGoogle Scholar
  35. 35.
    Jae HJ, Chung JW, Jung AY et al (2007) Transcatheter arterial embolization of nonvariceal upper gastrointestinal bleeding with N-butyl cyanoacrylate. Korean J Radiol 8(1):48–56PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Luc Defreyne
    • 1
    Email author
  • Ignace De Schrijver
    • 1
    • 6
  • Johan Decruyenaere
    • 2
  • Georges Van Maele
    • 3
  • Wim Ceelen
    • 4
  • Danny De Looze
    • 5
  • Peter Vanlangenhove
    • 1
  1. 1.Department of Interventional RadiologyGhent University HospitalGhentBelgium
  2. 2.Department of Intensive CareGhent University HospitalGhentBelgium
  3. 3.Department of Medical Informatics & StatisticsGhent University HospitalGhentBelgium
  4. 4.Department of Digestive SurgeryGhent University HospitalGhentBelgium
  5. 5.Department of GastroenterologyGhent University HospitalGhentBelgium
  6. 6.Flandre ImagerieClinique de FlandreCoudekerque-Branche CedexFrance

Personalised recommendations