Selective Embolization for Post-Endoscopic Sphincterotomy Bleeding: Technical Aspects and Clinical Efficacy

소영호,최영호,정진욱,제환준,송순영,박재형 대한영상의학회 2012 Korean Journal of Radiology Vol.13 No.1

Objective: The objective of this study was to evaluate the technical aspects and clinical efficacy of selective embolization for post-endoscopic sphincterotomy bleeding. Materials and Methods: We reviewed the records of 10 patients (3%; M:F = 6:4; mean age, 63.3 years) that underwent selective embolization for post-endoscopic sphincterotomy bleeding among 344 patients who received arteriography for nonvariceal upper gastrointestinal bleeding from 2000 to 2009. We analyzed the endoscopic procedure, onset of bleeding, underlying clinical condition, angiographic findings, interventional procedure, and outcomes in these patients. Results: Among the 12 bleeding branches, primary success of hemostasis was achieved in 10 bleeding branches (83%). Secondary success occurred in two additional bleeding branches (100%) after repeated embolization. In 10 patients, post-endoscopic sphincterotomy bleedings were detected during the endoscopic procedure (n = 2, 20%) or later (n = 8, 80%), and the delay was from one to eight days (mean, 2.9 days; ± 2.3). Coagulopathy was observed in three patients. Eight patients had a single bleeding branch, whereas two patients had two branches. On the selective arteriography, bleeding branches originated from the posterior pancreaticoduodenal artery (n = 8, 67%) and anterior pancreaticoduodenal artery (n = 4, 33%), respectively. Superselection was achieved in four branches and the embolization was performed with n-butyl cyanoacrylate. The eight branches were embolized by combined use of coil, n-butyl cyanoacrylate, or Gelfoam. After the last embolization, there was no rebleeding or complication related to embolization. Conclusion: Selective embolization is technically feasible and an effective procedure for post-endoscopic sphincterotomy bleeding. In addition, the posterior pancreaticoduodenal artery is the main origin of the causative vessels of post-endoscopic sphincterotomy bleeding. Objective: The objective of this study was to evaluate the technical aspects and clinical efficacy of selective embolization for post-endoscopic sphincterotomy bleeding. Materials and Methods: We reviewed the records of 10 patients (3%; M:F = 6:4; mean age, 63.3 years) that underwent selective embolization for post-endoscopic sphincterotomy bleeding among 344 patients who received arteriography for nonvariceal upper gastrointestinal bleeding from 2000 to 2009. We analyzed the endoscopic procedure, onset of bleeding, underlying clinical condition, angiographic findings, interventional procedure, and outcomes in these patients. Results: Among the 12 bleeding branches, primary success of hemostasis was achieved in 10 bleeding branches (83%). Secondary success occurred in two additional bleeding branches (100%) after repeated embolization. In 10 patients, post-endoscopic sphincterotomy bleedings were detected during the endoscopic procedure (n = 2, 20%) or later (n = 8, 80%), and the delay was from one to eight days (mean, 2.9 days; ± 2.3). Coagulopathy was observed in three patients. Eight patients had a single bleeding branch, whereas two patients had two branches. On the selective arteriography, bleeding branches originated from the posterior pancreaticoduodenal artery (n = 8, 67%) and anterior pancreaticoduodenal artery (n = 4, 33%), respectively. Superselection was achieved in four branches and the embolization was performed with n-butyl cyanoacrylate. The eight branches were embolized by combined use of coil, n-butyl cyanoacrylate, or Gelfoam. After the last embolization, there was no rebleeding or complication related to embolization. Conclusion: Selective embolization is technically feasible and an effective procedure for post-endoscopic sphincterotomy bleeding. In addition, the posterior pancreaticoduodenal artery is the main origin of the causative vessels of post-endoscopic sphincterotomy bleeding.

The Biomarkers for Prediction of Significant Bleeding Complication during ECMO Support

( Jin Ho Jang ),( Hye Ju Yeo ),( Woo Hyun Cho ),( Taehwa Kim ),( Yun Seong Kim ),( Doosoo Jeon ),( Jin Ook Jang ),( Eunjeong Son ) 대한결핵 및 호흡기학회 2020 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.128 No.0

Background Bleeding is the main complication of extracorporeal membrane oxygenation (ECMO) support. Currently, the mechanism of bleeding during ECMO is not fully understood. In previous studies, we have shown that ECMO has an effect of reducing platelet activation in the early stages. This preliminary study aimed to find a biomarker and clinical parameters for predicting bleeding complications. Methods We prospectively collected blood samples from ECMO patients on day 1, 3 and 7 and analyzed their plasma beta-thromboglobulin (beta-TG), platelet factor 4 (PF4), tumor necrosis factor alpha (TNF-α), and interleukin 1 beta (IL-1b). We retrospectively reviewed patient medical records and analyzed correlations between platelet function and inflammatory markers and bleeding. Results Overall, 54 patients who received ECMO for acute respiratory failure were included and classified by presence of bleeding complication (the bleeding group (n=11) and the non-bleeding group (n=45)). The mean TNF-α concentration on day 1 (p=0.026) and day 3 (p=0.018) were significantly different between two groups, respectively. Among the clinical parameters, ECMO application for more than 2 weeks (p=0.002) were significantly related to bleeding complication (p=0.002). The ROC curve revealed that the mean TNF-α concentration on day 1 and day 3 after ECMO application fairly discriminated bleeding group and non-bleeding group with an AUC of 0.734 (95% CI 0.60-0.84, p=0.001) and 0.778 (95% CI 0.65-0.88, P<0.001), respectively. However, the factors associated with platelet activity did not show any significant difference between the two groups (Fig. 2). Conclusion The early serum level of TNF-α may play a role as a significant biomarker of bleeding complication during ECMO. The marker of platelet activity, such as beta-TG and PF4 were not significant predictor of bleeding during ECMO support. Further research aiming the crosstalk of TNF-α and coagulation cascades is warranted.

Nonvariceal Upper Gastrointestinal Bleeding: the Usefulness of Rotational Angiography after Endoscopic Marking with a Metallic Clip

송지수,곽효성,정경호 대한영상의학회 2011 Korean Journal of Radiology Vol.12 No.4

Objective: We wanted to assess the usefulness of rotational angiography after endoscopic marking with a metallic clip in upper gastrointestinal bleeding patients with no extravasation of contrast medium on conventional angiography. Materials and Methods: In 16 patients (mean age, 59.4 years) with acute bleeding ulcers (13 gastric ulcers, 2 duodenal ulcers, 1 malignant ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. All patients had negative results from their angiographic studies. To localize the bleeding focus, rotational angiography and high pressure angiography as close as possible to the clip were used. Results: Of the 16 patients, seven (44%) had positive results after high pressure angiography as close as possible to the clip and they underwent transcatheter arterial embolization (TAE) with microcoils. Nine patients without extravasation of contrast medium underwent TAE with microcoils as close as possible to the clip. The bleeding was stopped initially in all patients after treatment of the feeding artery. Two patients experienced a repeat episode of bleeding two days later. Of the two patients, one had subtle oozing from the ulcer margin and that patient underwent endoscopic treatment. One patient with malignant ulcer died due to disseminated intravascular coagulation one month after embolization. Complete clinical success was achieved in 14 of 16 (88%) patients. Delayed bleeding or major/minor complications were not noted. Conclusion: Rotational angiography after marking with a metallic clip helps to localize accurately the bleeding focus and thus to embolize the vessel correctly. Objective: We wanted to assess the usefulness of rotational angiography after endoscopic marking with a metallic clip in upper gastrointestinal bleeding patients with no extravasation of contrast medium on conventional angiography. Materials and Methods: In 16 patients (mean age, 59.4 years) with acute bleeding ulcers (13 gastric ulcers, 2 duodenal ulcers, 1 malignant ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment. The metallic clip was placed in the fibrous edge of the ulcer adjacent to the bleeding point. All patients had negative results from their angiographic studies. To localize the bleeding focus, rotational angiography and high pressure angiography as close as possible to the clip were used. Results: Of the 16 patients, seven (44%) had positive results after high pressure angiography as close as possible to the clip and they underwent transcatheter arterial embolization (TAE) with microcoils. Nine patients without extravasation of contrast medium underwent TAE with microcoils as close as possible to the clip. The bleeding was stopped initially in all patients after treatment of the feeding artery. Two patients experienced a repeat episode of bleeding two days later. Of the two patients, one had subtle oozing from the ulcer margin and that patient underwent endoscopic treatment. One patient with malignant ulcer died due to disseminated intravascular coagulation one month after embolization. Complete clinical success was achieved in 14 of 16 (88%) patients. Delayed bleeding or major/minor complications were not noted. Conclusion: Rotational angiography after marking with a metallic clip helps to localize accurately the bleeding focus and thus to embolize the vessel correctly.

뇌기저부 골절후 발생된 과도한 구인두 출혈의 구인두 전체 신속압박에 의한 응급지혈: 증례보고

모동엽,유재하,최병호,김하랑,이천의,유미현,Mo, Dong-Yub,Yoo, Jae-Ha,Choi, Byung-Ho,Kim, Ha-Rang,Lee, Chun-Ui,Ryu, Mi-Heon 대한악안면성형재건외과학회 2010 Maxillofacial Plastic Reconstructive Surgery Vol.32 No.2

Excessive oral and maxillofacial bleeding causes upper airway obstruction, bronchotracheal & gastric aspiration and hypovolemic shock. Therefore, the rapid & correct bleeding control is very important for life-saving in the medical emergency room. In spite of the bleeding control methods of the wound suture & direct pressure, the postoperative bleeding can be occurred, because of the presence of various bleeding disorders & postoperative delayed wound infections. The proper care of bleeding disorders & wound infections are very important for the control of the delayed postoperative rebleeding. In spite of these methods, active oral bleeding can be presented by the other causes of head injury. A rare but particularly dangerous sort of bleeding that may have an especial importance to the patient with severe basal skull fracture that damage large vessels and even the cavernous sinus. The occurrence of profuse nasal or oropharyngeal bleeding may arise from damage to the anterior and posterior ethmoidal vessels, but when mixed with brain tissue it is evidence of mortal damage. In this condition, rapid entire oropharyngeal packing is essential for the control of active oral bleeding. This is a case report of rapid rational bleeding control method by much amount of wet gauze packings, in a 44-years-old male patient with active oropharyngeal bleeding by basal skull fractures.

The Clinical Outcomes of Transcatheter Microcoil Embolization in Patients with Active Lower Gastrointestinal Bleeding in the Small Bowel

곽효성,한영민,이수택 대한영상의학회 2009 Korean Journal of Radiology Vol.10 No.4

Objective: To assess the clinical outcomes of the transcatheter microcoil embolization in patients with active lower gastrointestinal (LGI) bleeding in the small bowel, as well as to compare the mortality rates between the two groups based on the visualization or non-visualization of the bleeding focus determined by an angiography. Materials and Methods: We retrospectively evaluated all of the consecutive patients who underwent an angiography for treatment of acute LGI bleeding between January 2003 and October 2007. In total, the study included 36 patients who underwent a colonoscopy and were diagnosed to have an active bleeding in the LGI tracts. Based on the visualization or non-visualization of the bleeding focus, determined by an angiography, the patients were classified into two groups. The clinical outcomes included technical success, clinical success (no rebleeding within 30 days), delayed rebleeding (> 30 days), as well as the major and minor complication rates. Results: Of the 36 patients, 17 had angiography-proven bleeding that was distal to the marginal artery. The remaining 19 patients did not have a bleeding focus based on the angiography results. The technical and clinical success rates of performing transcatheter microcoil embolizations in patients with active bleeding were 100% and 88%, respectively (15 of 17). One patient died from continued LGI bleeding and one patient received surgery to treat the continued bleeding. There was no note made on the delayed bleeding or on the major or minor complications. Of the 19 patients without active bleeding, 16 (84%) did not have recurrent bleeding. One patient died due to continuous bleeding and multi-organ failure. Conclusion: The superselective microcoil embolization can help successfully treat patients with active LGI bleeding in the small bowel, identified by the results of an angiography. The mortality rate is not significantly different between the patients of the visualization and non-visualization groups on angiography. Objective: To assess the clinical outcomes of the transcatheter microcoil embolization in patients with active lower gastrointestinal (LGI) bleeding in the small bowel, as well as to compare the mortality rates between the two groups based on the visualization or non-visualization of the bleeding focus determined by an angiography. Materials and Methods: We retrospectively evaluated all of the consecutive patients who underwent an angiography for treatment of acute LGI bleeding between January 2003 and October 2007. In total, the study included 36 patients who underwent a colonoscopy and were diagnosed to have an active bleeding in the LGI tracts. Based on the visualization or non-visualization of the bleeding focus, determined by an angiography, the patients were classified into two groups. The clinical outcomes included technical success, clinical success (no rebleeding within 30 days), delayed rebleeding (> 30 days), as well as the major and minor complication rates. Results: Of the 36 patients, 17 had angiography-proven bleeding that was distal to the marginal artery. The remaining 19 patients did not have a bleeding focus based on the angiography results. The technical and clinical success rates of performing transcatheter microcoil embolizations in patients with active bleeding were 100% and 88%, respectively (15 of 17). One patient died from continued LGI bleeding and one patient received surgery to treat the continued bleeding. There was no note made on the delayed bleeding or on the major or minor complications. Of the 19 patients without active bleeding, 16 (84%) did not have recurrent bleeding. One patient died due to continuous bleeding and multi-organ failure. Conclusion: The superselective microcoil embolization can help successfully treat patients with active LGI bleeding in the small bowel, identified by the results of an angiography. The mortality rate is not significantly different between the patients of the visualization and non-visualization groups on angiography.

간경변증 환자에서 t - PA , Euglobulin 섬유소용해능 및 Protein C , S 의 변화와 식도정맥류출혈과의 관계

황성규(Seong Gyu Hwang),백승호(Seung Ho Baik),양동호(Dong Ho Yang),이문호(Moon Ho Lee),조용욱(Yong Wook Cho),김순길(Soon Gil Kim),오도연(Don Yeun Oh),조성원(Sung Won Cho),김선주(Sun Joo Kim),홍세용(Sae Yong Hong) 대한내과학회 1992 대한내과학회지 Vol.43 No.6

Background: Bleeding is common complication and a leading cause of death in cirrhotic patients, Accelerated fibrinolysis and coagulation inhibitor were contributing factors to bleeding. Method: In a study of 20 normal control and 20 liver cirrhosis (10 liver cirrhosis without esophageal variceal bleeding and 10 liver cirrhosis with esophageal variceal bleeding), we tried to evaluate fibrinolytic activity 8r inhibitory factors of the coagulation in liver cirrhosis and to find correlation between variceal bleeding and parameters of fibrinolysis % coagulation inhibitors. Results: 1) t-PA antigen was significantly increased(p <0.05) in patients with liver cirrhosis(22.2±12.5ng/ml) than in normal contro1(3.9±1.9ng/ml), but there was no statistically significant increase in cirrhotic patients with bleeding(26.2±13.8ng/ml) as compared to cirrhotic patients without bleeding(18.2±10.1ng/ml). 2) Euglobulin fibrinolytic activity was significantly higher(p<0,05) in patients with liver cirrhosis(145±37.6 BAU) than in normal control(91±7.8 BAU), but there was no statistically significant increase in cirrhotic patients with bleeding(150±64 BAU)as compared to cirrhotic patients without bleeding(131±22 BAU). 3) The activities of protein C was significantly lower(p<0.05) in patient with bleeding(41±9%) than in patient siwthout bleeding(54±18%). 4) The activities of protein S was lower in patient with bleeding(62±18%) than in patients without bleeding group(77±17%), but there was no statistical significance. 5) There was a significantly linear correlatian between t-PA antigen and euglobulin fibrinolytic activity in normal control and in patients with liver cirrhosis (r=0.807, p<0.01). Conclusion: Fibrinolytic activity(t-PA k euglobulin fibrinolytic activity) was increased in cirrhotic patients, but there was no statistically significant increase of fibrinolytic activity with relation to esophageal variceal bleeding. The activities of protein C was significantly decreased in liver cirrhosis with relation to esophageal variceal bleeding.

소화성궤양 가이드라인 출혈 소화성궤양 치료의 가이드라인

정일권 ( Il Kwun Chung ),이동호 ( Dong Ho Lee ),김흥업 ( Heung Up Kim ),성인경 ( In Kyung Sung ),김진호 ( Jin Ho Kim ) 대한소화기학회 2009 대한소화기학회지 Vol.54 No.5

Peptic ulcer (PU) bleeding is the main cause of non-variceal gastrointestinal bleeding. Negative outcomes include re-bleeding and death, and many of the deaths are associated with decompensation of coexisting medical conditions precipitated by acute bleeding event. Accurate analysis of risk for clinical features can help physician to decide treatment modality. Endoscopy can detect bleeding stigmata and perform therapeutic hemostasis. Proton pump inhibitor (PPI) compared with placebo or H2RA reduces mortality following PU bleeding among patients with high-risk endoscopic findings, and reduces re-bleeding rates and surgical intervention. PPI treatment initiated prior to endoscopy in upper gastrointestinal (UGI) bleeding significantly reduces the proportion of patients with stigmata of recent hemorrhage (SRH) at index endoscopy but does not reduce mortality, re-bleeding or the need for surgery. The strategy of giving oral PPI before and after endoscopy, with endoscopic hemostasis for those with major SRH, is likely to be the most cost-effective. The treatment of H. pylori infection was found to be more effective than anti-secretory therapy in preventing recurrent bleeding from PU. H. pylori eradication alone and eradication followed by misoprostol (with switch to PPI, if misoprostol is not tolerated) are the two most cost-effective strategies to prevent ulcer bleeding among H. pylori-infected NSAID users, although the data cannot exclude PPIs also being cost-effective treatment. This review focuses specifically on the current treatment of patients with acute bleeding from a peptic ulcer. (Korean J Gastroenterol 2009;54:298-308)

Warfarin 복용 고령 환자의 출혈 현황 및 위험성 예측

남주연,최경숙,정영미,남궁형욱,이은숙,이병구,신완균 한국병원약사회 2010 병원약사회지 Vol.27 No.3

Warfarin, an effective agent for the prevention of serious thromboembolism, frequently causes bleeding complication, especially in elderly patients. In the literature, a number of different bleeding risk indices were proposed to predict the bleeding risk in patients with warfarin. However, the predictability of these indices has not been systemically evaluated in Korean patients. Therefore, the aims of the study were to determine the bleeding rate in elderly Korean patients treated with warfarin and to evaluate the predictability of the bleeding risk indices by comparing the indices with the actual bleeding rate. Electronic Medical Records(EMRs) of the patients enrolled in Anti-Coagulation Service(ACS) in Seoul National University Bundang Hospital(SNUBH) between May 10, 2003 and March 31, 2007 were reviewed. Patients, who were over the age of 65 years and received warfarin for at least 90 days with a targeted therapeutic International Normalized Ratio(INR) of 2.0~3.0, were participated in the present study. The patients were divided into 3 risk groups(i.e., low, moderate, high), as defined by the indices. Bleeding was considered ‘major’if the location was either intracranial or retroperitoneal, if the bleeding was associated with a decline in hemoglobin concentration of at least 2g/dL, or if a transfusion of 2U or more of red blood cells was necessary. Within one year, out of 323 patients, 94(29%) patients have experienced bleeding; 11 cases were classified as major bleeding. Major bleeding rates according to Shireman et al were 2.5%(5/197) and 5.2%(6/116) for the groups with low and moderate risk, respectively. No major bleeding was found in the high risk group based on the Shireman index. Major bleeding rates according to Kuijer et al were 3.3%(10/306) and 5.9%(1/17) for the groups with moderate and high risk, respectively. Major bleeding rates according to Beyth et al were 3.3%(9/271) and 3.8%(2/52) for the groups with moderate and high risk, respectively. There was no statistically significant difference among the bleeding risk groups. Further study will be necessary for the development of bleeding risk index optimized for elderly Korean patients.

Angiographically Negative Acute Arterial Upper and Lower Gastrointestinal Bleeding: Incidence, Predictive Factors, and Clinical Outcomes

김진형,신지훈,윤현기,채은영,명승재,고기영,권동일,성규보 대한영상의학회 2009 Korean Journal of Radiology Vol.10 No.4

Objective: To evaluate the incidence, predictive factors, and clinical outcomes of angiographically negative acute arterial upper and lower gastrointestinal (GI) bleeding. Materials and Methods: From 2001 to 2008, 143 consecutive patients who underwent an angiography for acute arterial upper or lower GI bleeding were examined. Results: The angiographies revealed a negative bleeding focus in 75 of 143 (52%) patients. The incidence of an angiographically negative outcome was significantly higher in patients with a stable hemodynamic status (p < 0.001), or in patients with lower GI bleeding (p = 0.032). A follow-up of the 75 patients (range: 0-72 months, mean: 8 14 months) revealed that 60 of the 75 (80%) patients with a negative bleeding focus underwent conservative management only, and acute bleeding was controlled without rebleeding. Three of the 75 (4%) patients underwent exploratory surgery due to prolonged bleeding; however, no bleeding focus was detected. Rebleeding occurred in 12 of 75 (16%) patients. Of these, six patients experienced massive rebleeding and died of disseminated intravascular coagulation within four to nine hours after the rebleeding episode. Four of the 16 patients underwent a repeat angiography and the two remaining patients underwent a surgical intervention to control the bleeding. Conclusion: Angiographically negative results are relatively common in patients with acute GI bleeding, especially in patients with a stable hemodynamic status or lower GI bleeding. Most patients with a negative bleeding focus have experienced spontaneous resolution of their condition. Objective: To evaluate the incidence, predictive factors, and clinical outcomes of angiographically negative acute arterial upper and lower gastrointestinal (GI) bleeding. Materials and Methods: From 2001 to 2008, 143 consecutive patients who underwent an angiography for acute arterial upper or lower GI bleeding were examined. Results: The angiographies revealed a negative bleeding focus in 75 of 143 (52%) patients. The incidence of an angiographically negative outcome was significantly higher in patients with a stable hemodynamic status (p < 0.001), or in patients with lower GI bleeding (p = 0.032). A follow-up of the 75 patients (range: 0-72 months, mean: 8 14 months) revealed that 60 of the 75 (80%) patients with a negative bleeding focus underwent conservative management only, and acute bleeding was controlled without rebleeding. Three of the 75 (4%) patients underwent exploratory surgery due to prolonged bleeding; however, no bleeding focus was detected. Rebleeding occurred in 12 of 75 (16%) patients. Of these, six patients experienced massive rebleeding and died of disseminated intravascular coagulation within four to nine hours after the rebleeding episode. Four of the 16 patients underwent a repeat angiography and the two remaining patients underwent a surgical intervention to control the bleeding. Conclusion: Angiographically negative results are relatively common in patients with acute GI bleeding, especially in patients with a stable hemodynamic status or lower GI bleeding. Most patients with a negative bleeding focus have experienced spontaneous resolution of their condition.

고령자 상부위장관 출혈에 관한 임상적 고찰

김태두,주영은,김신묵,성종호,안영주,정용환,양대현,유종선,윤종만 全南大醫大 1993 전남의대학술지 Vol.30 No.1