I and I've been honoured to be the Graham Plant professor, the Royal College of Radiologists and the BSI,
ah, have award me this honour, but Graham Plant was one of the senior figures in the UK.
He worked out of Basingstoke, so some of you may have know him have met him, but he was one of the father figures of interventional practise.
You're probably more likely to know what he Fletcher, who was one of our own,
who was an interventional radiologist out of Oxford, and he founded the BSR and International Practise in the UK.
And just by way of background, I just want to share with you where we are because it was 55 years ago that interventional radiology really started,
and this chap here challenged doctor who carried out the first intellectual procedures here is to carry out the angioplasty,
which was the first in the world which resulted in the healing of this Lady al-Aziz ulcer and saved her leg.
And it was a first. It really transformed the way we think about coming out into practise.
This sadly didn't always get on with his baska surgical colleagues, and he was called the Mad Dog Charlie or Charlie Crazy Charlie.
I think partly because some of his surgical colleagues didn't entirely agree.
I don't understand why it's called mad, but he was then closely followed by a couple of other people,
and he developed the first balloon technology that we use.
And both he and Charles Dossa really talked about the evolution of air as a as a speciality,
which can deliver a minimum of six treatments using small tubes and catheters,
including what I'm going to talk about today dealing with patients who are bleeding, as well as opening up blood vessels,
potentially blocking them off and produce these tubes on his kitchen table, firstly to get access to blood vessels.
And he did for some of the first country work and cardiac angioplasties, and the first balloon, which was about eight or nine French to begin with.
And then we had Holbert, who then developed the sort of more typical sausage shaped angioplasty balloons and the smaller catheters,
and then eventually things developed from these big Teflon donators, stiff wires,
wires with little balloons on to the sort of more modern technologies we have today,
with the more refined as balloon stent stent grafts and getting ever, ever smaller so that we're now using small, full French systems.
And that means we can get pretty much anywhere in the body,
and it means we can carry out treatments in arterial and non arterial pathologies pretty much anywhere in the body.
So GI bleeding. There are several guidelines out there.
The most recent of the and support guidelines, and quite a lot of what I'm going to say is come from there.
This is a difficult and complex area, and as you be aware, GI bleeding is often a serious and life threatening conditions.
Clinically, we want to differentiate between upper and lower GI haemorrhage, although it's becoming apparent we need a common pathway really.
For both metastases, Molina suggests bleeding from the upper GI tract.
Lower GI bleeding presents with fresh rectal blood, as you know.
But of course, profuse bleeding from anywhere in the tract can present with bright red blood and can be a confusion.
If you're not thinking the protocols now,
suggest that we should be thinking about marrying using some of these patients as outpatients so patients with upper GI bleeds.
Think about early discharge if the young the stable at presentation.
No obvious haemorrhage at the time for committees and then not a current inpatient and for large eye bleeds again.
If there's no fresh rectal bleeding and there's an obvious anal rectal cause, then one can treat or manage.
Then again, these could be considered for discharge.
Now I'm going to mention the Oakland school because Oakland with various colleagues Richard Guy and Mike Murphy myself.
We did a study with look, two and a half thousand patients, which we published in The Lancet recently,
and we produced this score where you use clinical parameters such as the age,
gender, systolic pressures and haemoglobin to risk stratify patients again thinking about early discharge for these patients.
Using this score, you could strongly discriminate for those patients who was, it was safe or not safe to discharge.
And this seems to be more sensitive and specific than the currently available risk stratification guidelines,
many of which are modified from upper GI bleeding. Whereas this is much more specific to large eyes.
So a score of less than eight predicts a 95 percent probability of safe discharge if the patients is
older and they're unstable and there's active bleeding and a history of liver disease with viruses.
And clearly these patients do need to be admitted and simply for low GI bleeds,
they're more likely to have major bleeds with non-steroidal and aspirin.
And if they have severe co-morbidities now, one of the guidelines at the RNC put is that these patients, regardless of upper lower GI bleed,
should be admitted to a dedicated unit and there is a team leader with a multidisciplinary approach to managing these patients.
It does take a big team of people to look after these patients, and most appropriately,
the upper GI bleeding the rock hall store is pretty much the standard.
Shocked patients require some degree of volume replacement, but that really should be.
Chris Lloyd's red cells should be reserved until they've either got a 30 percent volume loss or drop the haemoglobin to less than seven platelets.
Again, think about transfusing if it goes to below 50 millimetres per litre,
proton pumps should not be started until they've had their upper endoscopy.
This is, of course, for upper GI bleed. No anticoagulants can be really difficult.
More and more of our patients are already on anticoagulation to various degrees.
And again, the guidelines suggest we need to really think about why they're on those anticoagulants.
And as appropriate, we may be worth reversing, particularly the iron on very high of two point five.
But in some instances, we might be able to modify it, but not completely stop because of the potential consequences.
We need to test for peptic ulcer disease and instigate treatments if that's positive for upper GI ulcers and bleeding.
And then we need to remember that we used to test for H.
Pylori while they're off PPIs,
and then they should go into pieces after the initial treatment and up and GI
endoscopy stop the non-steroidal and only reintroduce if it's absolutely necessary.
And then with a, of course, start in the eye once you've started or completed treatment with four H.
Pylori, if that's appropriate. If you think about the incidence of bleeds,
it's much more common to have upper GI haemorrhage around one hundred and three
per 100000 the UK now endoscopy is pretty much the mainstay of treatment.
It'll identify and manage and treat these patients in over 90 percent of patients.
There's around 10 percent where upper GI endoscopy fails it, despite having a second look and repeat endoscopy.
And that's where radiology has got involved with more and more in the past.
There's a short list of other causes for upper GI bleeding.
The one thing I will highlight is that even in the presence of viruses, about a third of patients will still have an arterial cause.
So we mustn't forget that to look for an actual issue in these patients as well.
Low GI bleeding As I say, it's about a quarter of upper GI bleeds and increases significantly as you get older.
Up to 200 fold by the time you're 80 diverticular, disease is the most common.
Cause is closely followed in the literature by Andrew Dysplasia. Now here's again another short list of other causes.
One of the areas that we often get caught out by is bleeding piles.
You might think it's not very frequent, but it can be up to 15 percent of studies showing bleeding paths.
And this is one of our patients. And a simple anal rectal examination would have resolved it.
This patient went all the way to angiography and to determine that this was coming from bleeding piles.
So this is where it's important just to have a quick look at the tail end before we start instigating a whole
host of treatments is much easier to get to it from below than to try and get a case all the way round.
The and tear voluntary and separated branches about five to 30 percent will have an
underlying cancer and three to five percent of bleeds are actually from the small bowel.
Most of these will be under dysplasia not easy to get to with endoscopy, and this is where other techniques emulsify.
C.T. and more recently, capsule endoscopy have come into their for their really useful for picking up
these slow intermittent bleed or where they're in difficult to get places.
The good news for low GI bleeding is the vast majority will stop on their own without any specific treatment.
A third will bleed once, and half of these will bleed for a third time.
The published mortality is actually quite low for around three point six percent, but it's significantly higher,
as I'll show you a bit later for patients who are already inpatients now in the past.
The role of radiology was to help localise the bleeds before aggressive treatments such as surgical
U.S. could be undertaken by nuclear imaging was really an excellent technique is still used lies,
but not so frequently. It's very sensitive compared to conventional and angiography and C.T. and it pick up
bleed rates as low as point zero for two point five miles per minute on animal studies.
They're very sensitive and specific, but you know,
we can get false areas of positivity because of leaching of the agent and moving of the agents through the bowel.
During the course procedure, but can help you in terms of localising prior to angiography and or potentially surgery.
Scans can be done very rapidly and quickly. Only lasts about four hours.
Labelled red cell scans can be scanned for up to 24 hours until the red cells are eaten up by the spleen,
and this can allow you to pick up smaller and intermittent bleed.
The main issue with nuclear scanning is that it's really pretty much nine to five Monday to Friday,
and the agents may not even be available during the daytime because they have to be in and ready to be utilised or produced.
If you're looking at rates, those scans now angiography many years was said to be the gold standard for picking up bleeds,
and you can pick up quite slow bleeds of about 0.5 to one minute per minute.
The sensitivity and specificity for upper and lower GI bleeding is highly variable,
and that's not surprising because the patient has to be bleeding when you actually do the examination.
Unlike nuclear scans, we have a large window here. The patient, when you do, the contrast injection has to be bleeding at the time.
So the fact you don't see it doesn't mean they're not bleeding just means you've not done the time.
And that's why we always ask that the patient is unstable and actively bleeding when we see them.
And then there's other issues. There's bound peristalsis and overlying loops, which can make it very.
You could see small bleeds as he may need to repeat it several times to actually find the bleed site.
You need people who are skilled and geographers and have a good knowledge of the anatomy.
There's multiple variants so that you can not forget about potential collateral sites of bleeding,
which can occur if you can't see it on the first runs. There are techniques to try and improve on geography.
Stopping peristalsis with glucagon and bus CPAN can be quite helpful.
Provocative techniques so giving heparin thrombolytic agents, or vaisseaux dilate, is to try and reduce spasm,
which often occurs at the time of bleeding, which is how often the vessels stop the blood loss.
And then you allow yourself the opportunity to find that bleed and treat it.
Using longer injections and CO2 in the last six or seven years has been advocated, and we've used a few times where because the CO2 as it comes out,
as a gas expands, it gives you a much bigger area and makes it much more obvious where the bleed is coming from.
Of course, if I've had endoscopy, then placing clips of some sort of marker could be quite helpful for targeting the angiogram and of course,
good standard techniques using multiple oblique views to try and throw off overlying vessels.
Now I've put anaesthetic support at the bottom. This is something we hardly ever have and I think is really crucial.
These are by the time they get to, it's very sick patients and one wouldn't really contemplate trying to make these patients
when they are shocked and bleeding on the table and you're trying to carry and embolisation,
it's really important to have some form of medical and ideally assessing support.
They don't have to be anaesthetised,
but somebody needs to be keeping them safe and managing their airway if necessary when we're trying to do these patients.
This is not one of my patients, and I think this caused a lot of excitement when it did happen.
So this was a fistula, as you might have seen from an aneurysm into the rectum,
giving the patient lots of fluids and probably also brown fluid to the angiography as well.
When he saw these pictures, and fortunately, he was able to analyse the entire country which saved this patient's life.
Okay. Now, now, with the advent of Multi City, this is really transformed the way we image patients with GI bleeding city,
unlike all the other techniques, is almost universally available in all hospitals now in the UK.
It is very sensitive. Animal models will pick up bleed rates lower than that for standard angiography, around 0.3 mils per minute.
So that's actually very good. With a modern bullseye scanners, we've got scan times of one to two seconds.
So it reduces a lot of the artefacts that we get from movement and peristalsis and respiration.
So that's really good. And even if you don't see active extrapolation, you might see the underlying pathology causing that place.
So it's really improved the way we look at things.
So here's an example of just a patient who's got an upper GI bleed.
You can see the anatomy reconstructed the GDA show the branch vessel causing the bleed and
then confirmed at the time of angiography and then selectively analysed with micro coils.
Another patient here you can see this is actually bleeding from the sigmoid branch.
You can see contrast translating for this branch, the Coronil oblique reconstruction showing the precise vessel.
And then we can actually target this selectively and analyse this with multiple coils.
This is a different cause. There's a tumour involving the superior mesenteric artery.
You could see false aneurysms as a consequence. This is more harder to treat because you really can't.
It blows the whole of the SMA, but you might be able to target small branches.
This is another patient who's got an ambulance into the SMI. And again, it's an alternative cause to bleeds.
This was this patient had upper GI bleeding.
It could see bleeding blood in the Judean on endoscopy, but they couldn't see where it was coming from within the city.
And then you can see here this is blush of contrast, sitting in the gallbladder with which also has some gas in it.
And then inside the genome, you've got this lovely gallstone, which is laminated.
And this patient had a coloured fistula causing bleeding sitting in the genome of this point and then angiography,
we could find the cystic artery in the devastation. Here it is.
Get the catheter into it and then embolism with multiple coils into this patient.
Another patient here with this is that part of the transit colon. You can see this abnormal enhancement of the city.
This is what it looks like on colonoscopy. And geographically, this is an early draining vein.
As a patient with Andrew Dysplasia, another patient with reconstruction with under dysplasia,
again showing a nice draining vein early with multiple abnormal vessels.
And again, a list of 100 dysplasia type vessels in the colon.
As I alluded to earlier, whichever type of imaging you use, the patient needs to be actively bleeding at the time.
So one of the markers is that they've had a significant volume of transfusion
over the previous 24 hours and that they should be hemodynamically unstable.
That means a shock index of greater than one, so a systolic of less than 100 hundred and tachycardia greater than 100.
Why? Because if they if the patient is stable, that almost invariably means they've stopped bleeding.
It's not a hundred percent, but usually no matter how quickly you put the blood in in the fluids, they will still remain hypertensive.
If the active bleeding, once you stabilise them and we often get this, the patients are actually controlled.
We've got fluid again, but they actually are stable and they're stabilised in either i2 or head up on the ward,
which means by the time we get down, the bleeding has stopped. So I really would prefer them down control with somebody with them,
but unstable so we can actually get on to see what the bleed is and then we can treat them.
Based on our experience with C.T.,
we published this protocol in one international radiological journals where we put pretty much at the forefront of investigations.
It doesn't stop doing other imaging and other investigations,
but it means that we can get definitive information much more quickly in a significant number of patients.
We also used CT to risk stratify, and we published this paper,
which showed that you could risk stratify patients and those with GI bleeds if they had a negative CT were unlikely to bleed again,
as opposed to upper GI bleed invariably and needed something further. Doing so means we.
To be much more aggressive with Upper GI Bleed, as I alluded to earlier,
so we're much more involved now in the therapeutic side in treating patients and trans arterial embolisation
is in many senses become the standard of care went up a gentle squeeze felt and almost first line.
When we're talking about lower GI bleeds and for the reasons we talked about, we can see the bleeds, extrapolation, the anatomy and direct treatment.
And the reason we are able to do this now is because we've got really excellent kids.
We've got catheters which are three and four or five French micro catheters, which are two in three French,
which means we can get out to very small branches and deal with those microwaves.
And the further out you can get into those branch vessels, the less likely to cause ischaemia and give an effective embolisation.
We've got a variety of embolic agents available. And what you use depends on many factors, including what the anatomy is like, what the findings are,
where you can get your catheter to, and often, of course, what the operator is used to.
Some people like using glue.
Some find it very difficult and actually is dangerous if you don't know what you're doing, so choose what you're really familiar with.
And, of course, the vessel diameters most commonly, people use coils and gel foam.
Now, if you only use coils, there's a significant increased incidence of bleeding or bleeding, where if you combine the agents,
it seems to be a lower risk of bleed glue, as I said, and onyx are increasing use, but you need to be familiar with them and stent grafts.
So things like hepatic aneurysms and splenic aneurysms where we've had bleeding, we've often put in stent grafts,
preserves the vessel, which makes it safer, but also, of course, is effective at stopping the bleeding.
So these can be really, really useful in different positions. This is a paper we published a few years ago about personalisation for upper GI bleeds.
This is just highlighting that even if you don't see active externalisation at the time,
you can count on embolisation, which would control the bleeding now.
The important thing is empiric is a bit of a misnomer because we often have an idea of the territory of the bleed.
So, you know,
I've had an endoscopy or they've had C.T. or something to tell you that actually there's blood in the third part of the genome of the second part.
So you can have a pretty good idea. And other studies have.
Similarly, I can confirm subsequently that actually this is this is very effective.
So just trying to analyse what you think is likely to be works,
this is less so for lower GI bleeding because it's much more critical to get the right vessel and and often it's impossible to predict.
So there'll be several papers who've looked at the outcomes of embolisation relatively small numbers.
The clinical success is perhaps being slightly more disappointing for upper GI bleeding compared to low GI bleeds, but it is very effective.
They seem to be better for low GI bleeds for diabetics. These compared to anjou dysplasia.
The main reasons are you can't get selectively enough into that vessel, and inexperienced and torturous is also another major factor.
Overall, reblogged rates vary widely depending on whether you talk about upper and lower GI bleeds and the
cause of bleeding between nine and 47 percent for low GI bleeds is less generally 10 to 15 percent.
30 day mortality again varies hugely depending on the site and cause of bleeding.
Predictors of three bleeds are if the coagulopathy they take a long time to get to angiography,
previous surgery and trauma, cancers and of course, using cause as the only agent, a multi-organ failure.
Some of the studies have used just vasopressin to try and less invasive or treat these patients,
and it can be very effective in initially controlling bleeding because you're causing invasive spasm into the vessel.
But unfortunately, as soon as you turn it off, there's a high rate bleed rate in these patients.
So it can be if you've got no other options, an effective treatment,
but you need to be prepared to go back into it again or do some different treatment.
In terms of complications, a proper GI bleeds embolisation is considered very safe.
There are some risk factors for a significant CV if they've had previous surgery,
radiotherapy or atherosclerosis is marked or using liquid agents against glue seems to be a culprit here,
and small particles causing much more distal embolisation.
One small study reported stricture rates of around 16 percent for lower GI bleeds.
You also get a ischaemia in around a quarter of patients with franking function varying widely between zero and 20 percent if they do.
In fact, there isn't really much else to do than to get Chris and colleagues to come in and recite the colon.
Here's a patient who's got active extermination from the sigmoid.
Again, this is a dangerous place. It was obliged, and unfortunately, we've got an infarction of the bowel with ischaemic change.
This is what it looked like resection compared to surgery.
Some studies suggest similar efficacy rate, bleed mortality and morbidity rates.
Other studies have suggested that actually the rates are significantly higher compared to surgery.
Again, the similar risk factors that we've mentioned about Coyle's or gel foam as the only agents.
This was the study I alluded to earlier with colleagues in Oxford looking at low GI bleeding.
And it confirms many of the things we've already talked about that diabetic disease is the commonest cause,
but benign conditions are also quite frequent.
Almost 17 percent shock was pretty uncommon, but a lot of patients still got transfused, which was perhaps an appropriate flexible.
Sigmoidoscopy was the most common investigation, but only around two percent actually went on to have a therapeutic.
And he was Stacey's, which was a shame. Having found the bleed embolisation which surprised me, was also it was very rare.
Surgery didn't surprise me so much, but embolisation did.
Around just under one percent actually had embolisation, which I thought, I suppose you always kind of think about your own local practise,
but clearly nationally, embolisation is not very widely available, and that's borne out by recent surveys.
And certainly, perhaps not people are not so aware of it, either.
About just under 40 percent had re bleeds during the admission, and just under five were readmitted with bleeding in 28 days.
The in-hospital mortality that we talked about was again very similar to previous literature, around 3.4 percent.
And as I mentioned earlier, much higher in patients who are already inpatients just under 18 percent rates of around ten point one percent.
Don't worry about this complex flowchart.
He's just putting together all the things that we've talked about, but it just highlights that intervention and surgery still come very much later on.
So just to finish off and conclude,
I was just going to say that the most recent guidelines suggest and recommend that regardless of whether the upper and lower GI bleeds,
they should be admitted to a dedicated unit which is used to dealing with these second shot patients.
There should be a named lead clinician who is responsible for that treatment of that patient,
whether it's over that 24 hour period or throughout the entire episode that is specified.
But it needs to be somebody who knows that patient is going to manage them.
They should undergo some formal risk stratification for upper GI bleeds.
If this standard is Rockwall, there are those, of course, blanch for the straight, but Rocco is most commonly utilised.
And of course, for larger bleeds, we would advocate using the Oakland school to try and risk stratify patients who
could be discharged early and those that really need to be managed as inpatients.
Clearly, patients will need a degree of resuscitation,
but that needs to be balanced up by not over transfusing and initially they should be with Chris.
Lloyd's endoscopy is very much the mainstay Robert GI bleeding and some
assessment of the rectal tract from below colonoscopy is an excellent technique,
but can be very difficult in the acute setting with his active bleeding.
So often it may be delayed till the next day when there's a bit more visibility.
Merseyside city now has become very much on the forefront of investigation of these patients because this can be done 24 hours a day,
seven days a week and can be extremely useful.
But regardless of whatever imaging we use, we need the patient to be bleeding at the time.
So waiting to they stabilised to get them down to the department isn't always the ideal.
Nuclear studies are pretty much set. And division in terms of trying to find slow,
difficult intermittent bleeds rather than the massive active housing that we're trying to see capsule
endoscopy again is a useful tool for appropriate patients more the sort of chronic slow bleeds,
particularly in the mid gut and geography.
As I say, it is even the second or third line in terms of trying to pick up.
Please, we do do them if we have a negative message, but usually we need to have a good reason because we're very unlikely to see anything.
And then, of course, some patients will need intellectual treatment and much less frequently.
Now they're going off to surgery. I'm going to leave you with a picture of my Charlie, who started interventional radiology practise 55 years ago.
Thank you very much for your attention.