Endoscopic ultrasound-guided therapy safe for severe gastrointestinal bleeding patients

A new Mayo Clinic study found that endoscopic ultrasound-guided therapy appears to be a safe and effective treatment for patients with severe gastrointestinal bleeding for whom conventional therapies have failed.

The study was published in this month's issue of American Journal of Gastroenterology.

Gastrointestinal bleeding can be caused by a variety of conditions, most commonly peptic ulcer disease, esophagogastric varices, arteriovenous malformations, Mallory-Weiss tears, tumors, erosions, and Dieulafoy's lesion. Rare lesions such as pseudoaneurysms that often result from pancreatic disease can also lead to life-threatening bleeding. Standard endoscopic therapies, radiologically-guided interventions and surgery are the conventional treatments used to stop gastrointestinal bleeding.

"Despite advances in conventional therapies, recurrent bleeding is common in many patients," says Michael Levy, M.D., an author of this study and a gastroenterologist at Mayo Clinic. "At times there are no options for patients with severe and refractory bleeding and, unfortunately in this setting, the morbidity and mortality are high."

Dr. Levy and a team of Mayo Clinic physicians set out to identify more effective therapies to control bleeding and manage recurrent bleeding if standard therapies do not work. The team reviewed the results of five patients with severe gastrointestinal bleeding who received endoscopic ultrasound- guided therapy.

Endoscopic ultrasound imaging often provides more detailed information about the appearance, size, and precise location of bleeding than other endoscopic or radiologic imaging modalities," says Dr. Levy. "Equally important, endoscopic ultrasound provides specific details about the anatomy of the blood vessels surrounding the bleeding so therapy can be precisely delivered to the most effective location."

This study, the first of its kind to be published, sheds light on an additional therapy that appears to be both safe and effective in halting severe and refractory gastrointestinal bleeding. Each patient in the study had experienced at least two episodes of severe bleeding and at least two attempts at conventional therapy to control the bleeding had not worked. Using endoscopic ultrasound guidance, the team was able to identify and characterize the location of each patient's bleeding. With the specific site of bleeding in view, various agents such as 99 percent alcohol or medical glue were injected directly into the source to stop the bleeding. Following this therapy, none of the five patients experienced recurrent bleeding and no complications were reported.

Bill Janecek, a Mayo Clinic patient from Lindstrom, Minn., was the first patient to receive this experimental therapy. According to Janacek, who had severe bleeding in his gastrointestinal tract caused by pancreatitis, the therapy saved his life. Janecek had received 17 blood transfusions in 18 days and all conventional therapies had not stopped the bleeding. He was left with few options. The first option and standard of therapy was surgery to remove the abnormal blood vessel and most of his pancreas. His physicians' felt that he was not healthy enough to undergo this major operation and that the risk of death during surgery was too great. Even if possible, the surgery would have left Janecek at high risk of diabetes and malabsorption, explained Dr. Levy. Therefore, several attempts were made to control the bleeding by accessing the abnormal blood vessel by radiologic means, which were unsuccessful. Finally, after the team of physicians met with Janecek and his family, they opted for the experimental endoscopic ultrasound-guided therapy. It was successful, and he left the hospital just three days later. Now, after more than two years, the bleeding has not recurred.

"I was out of options, and this procedure truly saved my life," says Janecek. "Today, I'm healthy and thankful for every day I spend watching my 14 grandchildren grow up."

Dr. Levy and his team have continued to perform and evaluate this therapy to confirm its safety and effectiveness and to identify the type of patient most likely to benefit from endoscopic ultrasound-guided therapy. This therapy is considered only in carefully selected patients following consideration by a multidisciplinary team of endosonographers, clinicians, surgeons and interventional radiologists.

Other members of the Mayo Clinic research team included Louis Wong Kee Song, M.D.; Michael Farnell, M.D.; Sanjay Misra, M.D.; Michael Sarr, M.D.; and Christopher Gostout, M.D.

Mayo Clinic is a world leader in the diagnosis and treatment of digestive diseases. For more information about the treatment of gastrointestinal bleeding at Mayo Clinic, visit http://www.mayoclinic.org/gastrointestinal- bleeding/. For more information on the treatment of digestive diseases at Mayo Clinic, visit http://www.mayoclinic.org/gi/.

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