Introduction
Lower gastrointestinal tract bleeding can be a cause of high mortality and morbidity. Time is a major factor influencing outcome, as it does for most procedures carried out in an emergency. Compared to two-dimensional angiography, technological advances enable faster detection and reaching the bleeding site. Nonselective cone-beam CT (Computerized Tomography) arteriography can identify a damaged vessel. Twenty to thirty percent of patients with major gastrointestinal bleeding also have lower gastrointestinal bleeding, which is quite common. Elderly patients and those on multiple medications have a higher probability.
What Is Lower GI Bleeding?
Any bleeding that takes place inside the gastrointestinal tract, from the mouth to the anus, is referred to as gastrointestinal (GI) bleeding. Upper gastrointestinal hemorrhages occur close to the ligament, whereas lower GI bleeds occur farther away. Three other types of lower gastrointestinal hemorrhages can be major, moderate, and intermittent bleeding. Patients older than 65 with many health problems are more likely to experience massive bleeding, which is seen as hematochezia or bright red blood from the rectum. When a patient's Heart Rate (HR) is less than or equal to 100 beats per minute, their Systolic Blood Pressure (SBP) is equal to or less than 90 mmHg, and their urine output is poor, they are typically hemodynamically unstable.
What Are the Symptoms of Lower GI Bleeding?
The symptoms and indicators that patients with lower GI bleeding present can vary. Hence, a complete history is required. Patients may show up bleeding profusely or minimally. Relevant data from the history should include an in-depth evaluation of the patient's medications, such as antiplatelets, anticoagulants, and NSAIDs, and if the bleeding is intermittent or recurrent in the event and related symptoms. It is important to take note of any family history of inflammatory bowel disease (IBD) or colon cancer.
How Is Lower GI Bleeding Diagnosed?
When a patient presents with lower gastrointestinal bleeding, an abdominal examination and a digital rectal examination should be performed. Proctoscopy should also be taken into consideration if accessible. An abdominal examination may show a tumor, distension, or pain, depending on the etiology. Check for hemorrhoids and other anorectal pathologies during the digital rectal examination (DRE). Studies show that right colonic bleeding is typically maroon in color and may include clots, while left colonic bleeding is typically bright red. However, it has been observed in practice that right-sided bleeds that are rapid and substantial can also result in brilliant red blood per rectum.
What Is Transcatheter Arterial Embolization in Lower Gastrointestinal Bleeding?
Transcatheter arterial embolization (TAE) is a non-surgical, image-guided treatment that lowers abnormal blood flow to the injured area, which helps to lessen pain and inflammation. When doing diagnostic testing to locate bleeding sites before transcatheter arterial embolization, computed tomography angiography is a viable option. As a rule of thumb, surgery should only be considered as a last resort when all other treatments have failed for acute lower gastrointestinal bleeding.
Rocsh and Dotter first reported transcatheter arterial embolization in 1972, and it has been used ever since. Transcatheter arterial embolization has proven successful in managing GI bleeding and lowering mortality because of advancements in embolization technology and materials. Although multiple studies on upper gastrointestinal bleeding have evaluated the safety and effectiveness of transcatheter arterial embolization, the outcomes did not demonstrate adequate control of lower gastrointestinal bleeding. Limited research has examined the prognostic factors that predict mortality in upper and lower gastrointestinal bleeding, as well as the clinical outcomes of transcatheter arterial embolization.
How Is Transcatheter Arterial Embolization Done?
When a dynamic contrast-enhanced Computed Tomography (CT) scan reveals significant extravasation or active bleeding in the lower gastrointestinal tract and when catheter access is feasible, transcatheter arterial embolization is usually carried out. Depending on the patient's place of origin (emergency care unit or inpatients, respectively), a multidisciplinary team consisting of at least radiologists, surgeons, endoscopists, and clinicians in intensive care or emergency care was responsible for prescribing transcatheter arterial embolization. Gastrointestinal bleedings that were either acute, massive, or recurrent and for which endoscopy had failed or was not practical were included. Before digital subtraction angiography (DSA), CT angiography (CTA) involving at least a basal, an arterial, and a venous phase was obtained in most patients with clinical suspicion for sub or acute bleeding to locate the bleeding location and evaluate the vascular anatomy.
Transcatheter arterial embolization has a very high overall success rate and is now a great way to reduce different kinds of gastrointestinal bleeding. The most significant drawback of transcatheter arterial embolization is the potential for rebleeding. It is believed that several factors, including incomplete embolization, rebleeding from lesions in vessels other than the embolized vessel, ischemia after embolization, and coagulopathy (a bleeding disorder where the ability of the blood to clot is impaired), even after prompt treatment of gastrointestinal bleeding following transcatheter arterial embolization, are to blame for the low clinical success rate when compared to the technical success rate. Coagulationopathy was a major factor in the higher chance of bleeding subsequently.
What Are the Adverse Effects of Transcatheter Arterial Embolization Done?
Less than ten percent of transcatheter arterial embolization operations may result in adverse events like injection site hematoma, arterial dissection, and problems associated with the contrast agent. It is estimated that just over two percent of patients experience severe adverse effects. Other adverse effects can include post-TAE ischemia or infarction and gastrointestinal perforation.
Conclusion
Measures to control bleeding are necessary for GI bleeding patients who are not responding to medication, in whom endoscopic intervention has failed, or who are not able to have endoscopy, angiographic intervention, or surgery. Transcatheter arterial embolization is a feasible therapeutic option for management if endoscopic treatment is unsuccessful. This is especially because transcatheter arterial embolization significantly lowers hospital stays and complications while having the same death rate as surgery. In conclusion, when endoscopic hemostasis therapy fails or is not feasible, transcatheter arterial embolization is a useful and potentially life-saving technique to manage lower gastrointestinal bleeding. Before transcatheter arterial embolization, every attempt should be made to manage coagulopathy as it poses a substantial risk for both rebleeding and death.
