Digital subtraction angiography diagnosis and intervention for hemorrhage in Duchenne’s disease
Zhang Xuejun, Ma Heping, Zhen Yanli, Chao Lumeng
Dieulafoy disease, also known as ruptured submucosal constant diameter artery, accounts for only 1.2% to 5.8% of acute gastrointestinal hemorrhage [1], but it is not rare. With the popular use of electronic fiber endoscopy and the in-depth understanding and sufficient knowledge of the disease by medical workers, the number of reports on this disease has increased in recent years in relevant journals at home and abroad [1-4]. The disease is characterized by microscopic lesions, insidious location, sudden and aggressive onset, large bleeding, easy to recur, difficult to treat, life-threatening within a short period of time, and high mortality rate, so it is very important to choose a correct diagnosis and treatment method within the first time of onset, and at present, the diagnosis and treatment of the disease is still more recognized endoscopy and surgical resection by domestic and foreign scholars. The author has successfully treated 7 patients with massive hemorrhage of Duchenne disease who had failed to be treated by endoscopic or/and medical drugs through emergency diagnosis and intervention by digital subtraction angiography (DSA), and the clinical application value and significance of this method are analyzed and discussed with the literature as follows. Zhang Xuejun, Department of Interventional Radiology, People’s Hospital of Inner Mongolia Autonomous Region
I. Object and method
1. Subjects: 7 patients with upper gastrointestinal hemorrhage who had failed medical treatment were admitted to the Clinical Interventional Radiology Center of Inner Mongolia Autonomous Region Hospital from October 1999 to April 2006, 6 males and 1 female, with an average age of 64.43 years (58-74 years), including 1 case with previous ulcer disease, 4 cases with hypertensive disease, and 2 cases without clear medical history, none of the cases in this group had a history of liver disease, 7 cases All 7 cases had a history of alcohol consumption before the hemorrhage, 2 cases had taken small doses of enteric aspirin and anti-hypertensive drugs for a long time, and the remaining 3 cases had no aura symptoms and triggers; all 7 cases in this group had sudden massive vomiting of blood (bright red) as the first symptom, accompanied by black stool and epigastric pain and fullness, 2 cases had a history of long-term intermittent black stool, and 1 case had hemorrhagic shock at the time of consultation. The number of bleeding in this group was 1 to 2 times in 3 cases and more than 3 times in 4 cases, with an average bleeding volume of 1100 ml (800 ml to 1500 ml) in 24 h and an average hemoglobin of 71.8 g/L (49 g/L to 82 g/L). 7 cases received
Author Affiliation: 010017 Hohhot, Clinical Interventional Radiology Center, Inner Mongolia Autonomous Region Hospital
Before angiography and interventional treatment, six cases were diagnosed with Duchenne disease after routine emergency endoscopy, in which four cases were seen with mucosal abnormalities at the gastric wall in the fundus and lesser curvature area (including one case in the fundus, two cases in the anterior wall of the fundus and one case in the posterior wall of the fundus) and an exposed small vessel spurting blood into the stomach, and recurred 1-5 d after microscopic spraying of norepinephrine or electrocoagulation to stop the bleeding; two cases were seen microscopically with large accumulation of blood in the stomach and In two cases, a large amount of blood and dark red blood clots were seen in the stomach, and although endoscopy was performed two to three times, the disease was eventually suspected because the bleeding foci could not be detected or the fundic varices were excluded, so no microscopic treatment was performed; in one case, the patient was in shock at the time of consultation, and endoscopy was not performed in critical condition, and the disease was highly suspected clinically.
2. Treatment: In all 7 cases of massive hemorrhage, a standard Seldinger’s technique was used to puncture the femoral artery under a digital subtraction angiography machine, leave a catheter sheath in place, and introduce the catheter (we usually choose the 5F RH type or the left gastric artery) and selectively place its apex into the abdominal arterial trunk. After confirming the diagnosis, one haemostatic agent (Lithoplasty) is injected through the catheter first, then another Lithoplasty mixed with gelatin sponge granules + contrast agent is injected through the catheter to embolize the left gastric artery. After 5 min, the target angiography was performed again to confirm that there were no signs of bleeding and that the hemostasis was successful (Figure 1B-3B). The above angiography and intervention were performed under the conditions of establishing intravenous access, blood transfusion, cardiac monitoring and oxygen inhalation, etc. After the operation, the patient fasted for 36 h, and was treated with routine anti-inflammatory, acid suppression and symptomatic treatment and clinical observation and follow-up.
II. Results
In 7 cases, selective abdominal arterial trunk angiography showed that the left gastric artery emanated from this trunk in 6 cases (including 1 case from the left gastric artery to the right gastric artery, Figure 3A), and 1 case from the left hepatic artery. 7 cases had varying degrees of thickening of the left gastric artery, with abnormal tortuous branch vessels and aneurysmal dilatation of some small branches at the end of the target vessels. The bleeding site was in the gastric fundus or gastric lesser curvature area, which was consistent with the site of blood spurt on endoscopy, and the spillage was not obvious in two cases; six of the seven cases in this group received immediate hemostatic drug infusion and target vessel embolization treatment, and the immediate hemostasis rate (within 30 d after embolization) was 85.71%. The average follow-up of the six cases was 15.7 months (1 to 24 months) without recurrence and post-embolization complications. In one case, the black stool was still intermittent after 10 d, but no more blood was vomited.
III. Discussion
This disease was first reported by Garland in 1884, and in 1908, Georges Dieulafoy, a French surgeon, also reported 3 cases and named “Dieulafoy’s disease” – Duchenne’s disease, because this disease is a congenital malformation of the left gastric artery, and its branching small arteries The pathological changes are mucosal ischemia and erosion due to compression of the mucosa by the thick constant diameter artery, distortion of the submucosal vessels, thickening of the wall, thinning of the wall of the exposed artery, and loss of some elastic fibers [2], with 80% of the lesions occurring in the gastric fundic portal region and a few in other locations of the intestine [ 3], the lesion is a small, isolated mucosal erosion or superficial ulcer with a central exposed pulsatile constant diameter artery, which ruptures and bleeds under the influence of digestive juices, gastric peristaltic wear and tear plus triggers such as drugs, alcohol consumption or stress. The clinical manifestations are sudden and massive vomiting of blood (bright red), black stool and abdominal pain and distension, which are often misdiagnosed due to the rapid onset, aggressive and repeated massive bleeding, and can endanger the patient’s life within a short time. At present, scholars at home and abroad are more recognized diagnosis and treatment methods are endoscopy and surgical resection, while the diagnosis rate of endoscopy is only 35%-75% [4], and the diagnosis and treatment of dissection is blinded and damaged.
The application value of DSA for the diagnosis and intervention of hemorrhage in Duchenne’s disease: there are very few reports on this in the domestic and foreign literature, and Duchenne’s disease is a left gastric arteriovenous malformation, and we believe that DSA examination can be the most direct and effective diagnostic method, because DSA has the functions of instantaneous subtraction, real-time display, retrieval and re-display, high contrast resolution and dynamic observation, etc. Various signs of hemorrhage through DSA of contrast spillage at the lesion -The diffusion, patchy aggregation and retention of contrast agent at the end of the artery can accurately show the site and extent of bleeding, especially during active gastrointestinal bleeding DSA examination, with a 96% confirmation rate [5], and through these functional advantages of DSA can also accurately show the starting course, opening direction and variation of the bleeding target vessel, for selective insertion of the catheter tip into the target vessel The DSA can also provide a road map, which reduces the time and contrast dosage and shortens the interventional time compared with conventional angiography, facilitating the successful treatment of such diseases. By dynamically displaying the size of the bleeding lesion and the diameter of the target vessel in real time, the most appropriate treatment plan can be formulated intraoperatively, such as additional embolic agents, judging the degree of embolization, and whether to end the treatment. In the interval of bleeding, the positive rate of microscopic examination is not only low but also impossible to stop the bleeding microscopically due to the large amount of blood and blood clots in the stomach, so I believe that although DSA examination cannot show the direct signs of bleeding at the lesion, it can confirm the diagnosis of the disease by showing the indirect signs such as thickened left gastric artery and abnormal tortuous or tumor-like dilated branch vessels. This is an effective method for Duchenne disease at the critical moment. In this group, all seven cases were diagnosed by DSA of the left gastric artery and successfully stopped by target vessel embolization. Efficacy and influencing factors: (1) Due to the rapid onset of Duchenne disease, it is difficult to confirm the diagnosis and stop the hemorrhage by endoscopy when there is a large amount of blood and blood clots in the stomach, and the efficacy of conventional conservative hemostasis in internal medicine is poor, and it is difficult for patients with recurrent bleeding and hemorrhagic shock to undergo surgical procedures. The healing and survival rate of patients with hemorrhage are closely related to the timely use of arterial angiography and interventional embolization to stop the bleeding [6], and 7 cases in this group eventually stopped bleeding after actively choosing this method of diagnosis and treatment. (2) The technique of cannulation is related to the correct diagnosis of the disease and the success of embolization and hemostasis, which is mostly in elderly people. In one case, because the left gastric artery originated from the left hepatic artery and was tortuous and prolonged, it was difficult to place the catheter into the target vessel, making it difficult to release the embolic agent. With the continuous development of interventional medicine, the corresponding interventional materials are also being updated, such as the emergence of microcatheter system will become simple and easy for those who were once considered difficult to insert and had to give up the tortuous variant of the vessel today. (3) The choice of embolization materials, gastric vessels are very rich and anastomosing with each other, and Duchenne’s disease is only a rupture of the malformed left gastric artery vasculature, the target vessel is relatively thin, unlike the hemorrhage caused by the rupture of pseudoaneurysms of internal organs that are supplied by the participation of thick arterial vessels, because of the thick lumen of its blood supply artery, fast blood flow and high pressure, the simple application of gelatin sponge is not able to completely embolize the target vessel, which is easily dissolved and absorbed The author believes that the choice of mild and inexpensive gelatin sponge can stop the hemorrhage, which is not suitable for local tissue ischemia and necrosis, and is not easy to recur. (4) Local infusion of hemostatic agents, the group of 7 cases of bleeding patients are local infusion of local hemostasis, because hemostatic agents can promote vasoconstriction of small broken arteries, which is conducive to platelet aggregation, making the formation of thrombus in the lumen of the blood vessels to help stop bleeding, but the author believes that the use of simple effect is not good, the group of one case of recurrence is both, the remaining 6 cases are perfusion + embolization, no case of recurrence and serious complications occurred during the follow-up period. (5) The data of this group shows that DSA diagnosis and interventional treatment can definitely have the efficacy of 1+1>2 for Duchenne hemorrhage, which can not only accurately find the target vessel of hemorrhage and locate the bleeding site, but also quickly instill local hemostatic agent through catheter and release embolic agent at the same time to achieve immediate hemostasis. We believe that DSA and interventional techniques are a new minimally invasive, safe, time-saving, and effective method after electronic endoscopy and surgery in the treatment of Duchenne hemorrhage.