Korean J Gastroenterol Vol. 71 No. 4, 219-228 https://doi.org/10.4166/kjg.2018.71.4.219 pissn 1598-9992 eissn 2233-6869 ORIGINAL ARTICLE 급성위장관출혈환자에서혈관조영술및색전술의임상성적 : 출혈부위및색전술방식에따른분석 노수민, 신지훈 1, 김하일, 이선호 2, 장기주 2, 송은미 2, 황성욱 2, 양동훈 2, 예병덕 2, 명승재 2, 양석균 2, 변정식 2 울산대학교의과대학서울아산병원내과, 영상의학과 1, 소화기내과 2 Clinical Outcomes of Angiography and Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding: Analyses according to Bleeding Sites and Embolization Types Soo Min Noh, Ji Hoon Shin 1, Ha Il Kim, Sun-Ho Lee 2, Kiju Chang 2, Eun Mi Song 2, Sung Wook Hwang 2, Dong-Hoon Yang 2, Byong Duk Ye 2, Seung-Jae Myung 2, Suk-Kyun Yang 2 and Jeong-Sik Byeon 2 Departments of Internal Medicine and Radiology 1, Division of Gastroenterology, Department of Internal Medicine 2, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Background/Aims: The clinical outcomes of angiography and transcatheter arterial embolization (TAE) for acute gastrointestinal bleeding (GIB) have not been completely assessed, especially according to bleeding sites. This study aimed to assess the efficacy of angiography and safety of TAE in acute GIB. Methods: This was a retrospective study evaluating the records of 321 patients with acute GIB who underwent angiography with or without TAE. Targeted TAE was conducted in 134 patients, in whom angiography showed bleeding sources. Prophylactic TAE was performed in 29 patients when the bleeding source was not detected but a specific vessel was strongly suspected by other examinations. The rate of technical success, clinical success, and complications were analyzed. Results: The detection rate of bleeding source via angiography was 50.8% (163/321), which was not different according to the bleeding sites. The detection rate was higher if the probable bleeding source had already been found by another investigation (59.7% vs. 35.8%, p<0.001). TAE sites were upper GIB in 67, mid GIB in 74, and lower GIB in 22. The technical success rate was 99.3% (133/134), and the clinical success rate was 63.0% (104/163). The prophylactic embolization group showed lower clinical success rate than the targeted embolization group (44.8% vs. 67.9%, p=0.06). The TAE-related complication rate was 12.9% (21/163). Ischemia and/or infarction was more common after TAE for mid and lower GIB than for upper GIB (15.6% vs. 3.0%, p=0.007). Conclusions: Angiography with or without TAE was an effective method for acute GIB. Targeted embolization should be performed if possible given that it has a higher clinical success rate. (Korean J Gastroenterol 2018;71:219-228) Key Words: Angiography; Embolization, therapeutic; Gastrointestinal hemorrhage 서론 원인불명위장관출혈은상부위장관내시경, 대장내시경및고식적영상검사로출혈원인을찾지못한위장관출혈을의 미한다. 원인불명위장관출혈은전체위장관출혈의 5% 정도를차지하며, 소장출혈이가장흔한원인으로생각된다. 2000년대이후캡슐내시경, 이중풍선소장내시경 (double balloon enteroscopy), 전산화단층촬영 (computed tomography, CT)/ Received July 26, 2017. Revised November 8, 2017. Accepted January 3, 2018. CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2018. Korean Society of Gastroenterology. 교신저자 : 변정식, 05505, 서울시송파구올림픽로 43길 88, 울산대학교의과대학서울아산병원소화기내과 Correspondence to: Jeong-Sik Byeon, Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3905, Fax: +82-2-476-0824, E-mail: jsbyeon@amc.seoul.kr Financial support: None. Conflict of interest: None. Korean J Gastroenterol, Vol. 71 No. 4, April 2018 www.kjg.or.kr
220 노수민등. 급성위장관출혈환자에서혈관조영술및색전술의성적 magnetic resonance (MR) 소장조영술 (enterography) 과같은새로운소장검사법이도입되면서과거에비해높은소장출혈병소진단율을보여주고있다. 1 따라서, 전통적으로상부및하부출혈의두유형으로분류되던위장관출혈이최근에는식도부터바터팽대부 (ampulla of Vater) 까지를상부, 바터팽대부에서말단회장까지를중부, 말단회장이하대장까지를하부위장관출혈로구분하여접근하고있다. 2 위장관출혈, 특히토혈, 혈변또는흑색변을보이는급성위장관출혈에있어내시경은가장중요한진단적역할을할뿐아니라내시경지혈술을통해수술등보다침습적치료없이내과적치료로경과를호전시키는데크게기여한다. 그러나급성위장관출혈환자의일부는내시경으로출혈부위를찾지못하며, 원인병소를찾더라도내시경지혈술로지혈에실패하거나지혈후재출혈이발생하기도한다. 특히재출혈은환자의예후를결정하는중요한인자로알려져있다. 3-5 따라서, 내시경으로출혈병소를찾지못하거나내시경지혈술이어려운경우다른진단및지혈법을고려해야한다. 혈관조영술 (angiography) 및경도관동맥색전술 (transcatheter arterial embolization) 은이와같이내시경으로진단및지혈에실패한경우고려할수있는중재시술이다. 그런데, 이러한혈관조영술및색전술의유용성및안정성은상부위장관출혈을대상으로한연구에서여러차례검토되었으며, 6,7 중부위장관이하의출혈에대해서는연구결과가충분하지는않다. 우리나라급성위장관출혈환자를대상으로하였던한국내연구가식도출혈 3명, 위십이지장출혈 41명, 소장출혈 38명, 대장출혈 15명을포함함으로써상부, 중부, 하부위장관출혈환자를비교적골고루대상으로하여초선택동맥색전술 (superselective arterial embolization) 후임상결과를분석하여혈관조영술및색전술의유용성에대하여보고한바있다. 8 그러나이연구에서도여전히위십이지장출혈이가장주된분석대상이었고, 대장출혈증례는많지않았으며, 최근원인불명위장관출혈환자에서소장병소확인을위해유용하게사용되고있는캡슐내시경과이중풍선내시경검사는함께분석되지않은제한점이있다. 또한, 색전술후발생할수있는소장또는대장허혈이나경색, 천공의빈도와경과등다양한합병증의빈도및치료성적도충분히연구되어있지않다. 따라서이연구에서는원인불명위장관출혈을포함하는급성위장관출혈환자에서혈관조영술및색전술의유용성및안정성에대해알아보고자하였으며, 특히상부, 중부, 하부위장관출혈사이에혈관조영술및색전술성적에차이가있는지확인해보고자하였다. 대상및방법 1. 대상환자 1999년 12월부터 2016년 8월까지토혈, 혈변, 흑색변등의급성위장관출혈로서울아산병원을내원하여혈관조영술및색전술을시행하였던환자를대상으로하였다. 영상의학과중재시술팀의혈관조영술및색전술시술명단을통해대상환자를확인하였다. 식도및위정맥류출혈환자는제외하였다. 결과적으로급성비정맥류위장관출혈로혈관조영술을시행하였던 321명의환자가분석대상이되었다. 이연구는서울아산병원임상연구심의위원회에승인되었다 (IRB number: 2017-0806). 2. 혈관조영술및색전술방법위장관출혈진단및치료과정은시기와임상의에따라약간의차이는있었으나, 대체로다음과같은원칙에따라진행되었다. 상부위장관출혈이의심되는경우상부위장관내시경을, 하부위장관출혈이의심되는경우대장내시경을먼저시행하였다. 내시경에서출혈병소가확인되지않은경우복부 CT, 적혈구스캔, 캡슐내시경등을시행하였고, 진단및치료목적으로필요시이중풍선소장내시경검사를시행하였다. 혈관조영술은이상의검사들로발견한출혈병소에대하여지혈목적으로또는출혈병소를찾지못하였는데출혈이지속되거나대량출혈로활력징후가불안정할때시행하였다. 혈관조영술은대퇴동맥을통한 Seldinger 기법으로시행되었다. 복강동맥, 상장간막동맥과하장간막동맥조영술을시행하여출혈부위를확인하였다. 색전술은혈관조영술에서분지동맥 (branch artery) 이하의혈관으로부터직접적인조영제의유출 (extravasation) 이있거나출혈원인이되는가성동맥류 (pseudoaneurysm) 가발견되었을때시행하였으며, 해당혈관부위를초선택 (superselction) 하여선택적색전술 (targeted embolization) 을시행하였다. 색전물질은 microcoils (MicroNester or Tornado; Cook Medical Korea, Seoul, Korea) 또는 gelatin sponge particles (Spongostan; Johnson & Johnson Medical Korea Ltd., Seoul, Korea) 또는둘을함께사용하였다. 일부환자에서는혈관조영술에서출혈병소를찾지못하였더라도, 혈관조영술전에시행한상부 / 하부위장관내시경, 복부 CT, 적혈구스캔, 캡슐내시경또는소장내시경에서출혈원인병소로강력히의심되는병변이있었던경우해당부위혈관에대해예방적색전술 (prophylactic embolization) 을시행하였고, 혈관조영술에서출혈혈관을확인하였는데색전술시행할당시에는출혈이멈춘경우에도혈관조영술당시출혈이있던혈관부위를추정하여예방적색전술을시행하였다. 혈관조영술및색전술은 6-27년간혈관조영술및색전술시행경험이있는 7명의중재영상의학전문의에의하여수행되었다. The Korean Journal of Gastroenterology
Noh SM, et al. Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding 221 3. 임상경과분석대상환자들의의무기록과혈관조영술및색전술검사결과지, 영상을확인하고검토하였다. 혈관조영술시행이유를조사하였고혈관조영술에서출혈병변발견율을조사하였다. 색전술을통한지혈성공여부를확인하였다. 기술적성공 (technical success) 은색전술시행후혈관조영술에서기존에관찰되던조영제의누출또는가성동맥류가사라져보이지않는경우로정의하였으며, 따라서, 출혈혈관또는가성동맥류에대해선택적색전술을시행한환자들에대해서만조사하였다. 임상적성공 (clinical success) 은색전술시행후토혈, 혈변, 흑색변등의임상증상이소실되고, 이후 30일동안재출혈이없어수술이나추가시술이필요하지않았던경우로정의하였다. 따라서, 색전술후출혈이지속되거나 30일이내에재출혈이발생한경우는임상적실패 (clinical failure) 로간주하였다. 합병증중장허혈또는경색은장으로충분한혈액이공급되지못하는상태를일컫는것으로, 장허혈은점막층을중심으로장벽내측표층에허혈손상이국한된경우, 장경색은장벽전층으로허혈괴사 (transmural bowel infarction) 가진행한경우로정의하였다. 9-11 임상적으로장허혈및경색은색전술후복통, 혈변, 발열등의증상을보일경우조영증강감소또는소실을보이는복부 CT 소견이나부종, 출혈, 괴사를보이는내시경검사소견을통하여진단하였다. 이상의임상경과를전체급성위장관출혈환자를대상으로분석하였고, 상부, 중부, 하부위장관출혈로구분하여비교분석도시행하였다. 상부, 중부, 하부위장관출혈분류는전술한바와같이바터팽대부와말단회장을경계로출혈병변의위치에따라정의하였다. 4. 통계처리통계처리는 SPSS for Window TM Release (SPSS Inc., Chicago, IL, USA) 를이용하였다. 혈관조영술이전출혈병소발견여부와혈관조영술시행하여출혈병소발견과의관련성, 선택적또는예방적동맥색전술의임상결과, 출혈병소에따른색전술결과를확인하기위하여 Pearson χ 2 test, Fisher s exact test를실시하였다. 나이, 성별, 색전술시행당시환자의활력징후변수를보정하여분석하였으며, p값 0.05 미만을통계적으로의미있다고평가하였다. 결과 1. 환자군의임상적특성급성위장관출혈로혈관조영술을시행하여이연구의분석대상이된 321명의연령은평균 58.9세였으며, 연령범위는 18-94세였다. 남성환자가 216명 (67.3%) 이었다. 내시경, 영상검사및혈관조영술등다양한검사를통해상부위장관출혈로확인된환자가 99명, 중부위장관출혈은 150명, 하부위장관출혈은 48명이었고, 여러검사를종합한후에도출혈부위가명확하지않은환자가 24명이었다 (Table 1). 진단또는치료목적으로혈관조영술을시행하게된상부위장관출혈의가장흔한원인은소화성궤양이었고, 중부위장관출혈의가장흔한원인은수술문합부출혈, 하부위장관출혈의가장흔한원인은게실출혈이었다. 출혈부위별출혈원인은 Table 1. Patient Demographic Data and Clinical Parameters (n=321) Variable No. of patients Male 216 (67.3) Age (yr) 18-60 61-80 81 154 (48.0) 146 (45.5) 21 (6.5) Medications a 82 (25.5) Coagulopathy b 87 (27.1) Hemodynamic instability c 165 (51.4) Bleeding site UGI Peptic ulcer disease Malignant Acute gastroduodenal lesion Dieulafoy s lesion Others d No source identified MGI No source identified Postoperative anastomotic bleeding Malignant Angioectasia Inflammatory bowel disease Others e LGI Diverticulosis Post operation bleeding Angioectasia Others f No source identified 99 (30.8) 36 22 6 4 17 14 150 (46.7) 46 19 18 17 15 35 48 (15.0) 16 4 4 21 3 Unknown 24 (7.5) Values are presented as n (%). UGI, upper gastrointestinal; MGI, mid gastrointestinal; LGI, lower gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; PT, prothrombin time; INR, international normalized ratio; CMV, cytomegalovirus. a Antiplatelet agents/anticoagulants/nsaids or steroid; b Prolonged PT (INR >1.5) or thrombocytopenia (<50,000 μl); c During or before the procedure, heart rate>120 beats per minute or systolic blood pressure <90 mmhg; d Iatrogenic, angiodysplagia, diverticular, fistula, Crohn s disease, vasculitis, esophageal hematoma, pseudoaneurysm, esophagitis; e Diverticulum, NSAIDs induced ulcer, vasculitis, trauma, radiation enteritis, salmonellosis, portal enteropathy, pseudoaneurysm, post procedure; f Rectal ulcer, post polypectomy bleeding, neoplasia, inflammatory bowel disease, CMV infection, ischemic colitis, stercoral ulceration, NSAIDs induced colopathy, fistula, Dieulafoy's lesion, iliac artery aneurysm. Vol. 71 No. 4, April 2018
222 노수민등. 급성위장관출혈환자에서혈관조영술및색전술의성적 Table 2. Indications and Diagnostic Yields of Angiography Angiography after detection of bleeding focus by other investigations (n=201) Angiography with unknown bleeding focus (n=120) p-value Diagnostic studies detecting bleeding focus prior to angiography Upper and/or lower gastrointestinal endoscopy (n=90) Abdominopelvic CT scan (n=37) Bleeding scan (n=31) CT enterography (n=25) Enteroscopy (n=14) Others a (n=4) Diagnostic yield Overall detection rate 120 (59.7%) 43 (35.8%) <0.001 UGI lesion detection rate 39/74 (52.7%) 14/25 (56.0%) 0.775 MGI lesion detection rate 59/91 (64.8%) 25/59 (42.4%) 0.007 LGI lesion detection rate 22/33 (66.7%) 4/15 (26.7%) 0.014 UGI, upper gastrointestinal; MGI, mid gastrointestinal; LGI, lower gastrointestinal, CT, computed tomography. a By high clinical suspicion such as previous surgery site, etc. Fig. 1. Flowchart of patients who underwent angiography with or without embolization. Table 1에정리하였다. 2. 혈관조영술적응증및출혈병소발견율 321명환자중혈관조영술이전에다른검사를통해출혈병소가확인되었고, 이에대한색전술목적으로혈관조영술을시행한환자는 201명 (62.6%) 이었으며, 120명 (37.4%) 은다른검사들에서출혈병소를찾지못한상태에서출혈병소진단및필요시색전술을추가할목적으로혈관조영술을시행하였다. 혈관조영술시행전에출혈병소를확인하였던 201명의출혈병소진단방법은 Table 2에정리하였다. 혈관조영술을시행하였던 321명중 163명에서혈관조영술로출혈병소가확인되어혈관조영술의전체적인출혈병소발견율은 50.8% 였다. 다른검사로출혈병소를확인한상태에서혈관조영술을시행한경우와출혈병소를모르는상태에 서혈관조영술을시행한경우의출혈병소발견율은각각 59.7% (120/201) 와 35.8% (43/120) 으로유의한차이를보였다 (p<0.001) (Table 2). 적혈구출혈스캔및 CT 소장조영술에서출혈병소가확인되었던환자의각각 54.8% (17/31) 와 72.0% (18/25) 가혈관조영술을통하여병변을확인할수있었다. 상부, 중부, 하부위장관부위별혈관조영술의출혈병소발견율은각각 53.5% (53/99), 56.0% (84/150), 54.2% (26/48) 로차이가없었다 (p=0.924). 출혈병소에따라세부분석해보았을때중부위장관출혈환자에서는다른검사로출혈병소를확인한후이에대한색전술목적으로혈관조영술시행한경우와출혈병소를찾지못한상태에서혈관조영술시행한경우의출혈병소발견율은각각 64.8% 와 42.4% (p=0.007) 로유의한차이가있었고, 하부위장관출혈환자에 The Korean Journal of Gastroenterology
Noh SM, et al. Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding 223 Fig. 2. Clinical outcomes after embolization for acute gastrointestinal bleeding. Table 3. Embolization Results according to the Bleeding Site Type of embolization Targeted embolization Prophylactic embolization Bleeding focus detected prior to angiography Technical success Clinical success Complication Upper GI bleeding (n=67) 45 (67.2) 22 (32.8) 50 (74.6) 45 (100) 43 (64.2) 4 (6.0) Mid GI bleeding (n=74) 67 (90.5) 7 (9.5) 49 (66.2) 67 (100) 43 (58.1) 13 (17.6) Lower GI Bleeding (n=22) 22 (100) 0 (0) 19 (86.4) 21 (95.5) 18 (81.8) 4 (18.2) p-value <0.001 0.184 0.164 0.267 0.06 Values are presented as n (%). GI, gastrointestinal. 서도 66.7% 와 26.7% (p=0.014) 로유의한차이가있었다. 상부위장관출혈에서는이전검사에서출혈병소발견여부에따라혈관조영술의병소발견율에차이가없었다. 병소발견율에대한자세한성적을 Table 2에기술하였다. 3. 색전술의기술적성공률과임상적성공률혈관조영술로출혈병소를발견한 163명중 151명에서색전술을시행하였으며, 혈관조영술로출혈병소를발견할수없었던 158명중 27명에서다른검사또는임상적판단에의해의심되는부위에예방적색전술을시행하여총 178명의환자가색전술을시행하였다 (Fig. 1). 이들 178명중색전술시행후사망이외에다른이유로 30일이상추적조사가이루어지지못한 15명을제외한 163명의환자를대상으로색전술의임상성적및경과를조사하였다. 163명의사망까지기간또는추적관찰기간중앙값은 276일 (0-5221일) 이었다. 색전술직후기술적성공률을선택적색전술을시행한 134명에서조사하였다 (Fig. 1). 시술중심정지가발생한 1명을제 외하고 133명환자에서색전술후조영제의혈관외유출이소실되어선택적색전술의기술적성공률은 99.3% 였다. 임상적성공률은색전술을시행하였던 163명전체를대상으로검토하였으며, 색전술후 30일이내에출혈지속또는재출혈을보인환자는 59명이었다. 결과적으로색전술의임상적성공률은 63.0% (104/163) 였다. 지혈에실패한 59명중다시혈관조영술을시행한환자는 21명이었으며, 이들중 13명에서 2차색전술을시행하였다. 2차색전술을시행한 13명중지혈에성공한환자는 2명 (15.4%) 이었다. 색전술후임상적성공을포함하는임상경과를 Fig. 2에자세히도식화하였다. 출혈부위별색전술성적을분석하였을때, 상부, 중부, 하부위장관색전술후추적관찰한 67명, 74명, 22명의임상적성공률은각각 64.2%, 58.1%, 81.8% 로하부위장관출혈색전술에서가장높은경향을보였으나통계적으로유의한차이는없었다 (p=0.267). 출혈부위별색전술후임상경과를 Table 3에정리하였다. 예방적색전술시행후추적관찰된 29명 (Fig. 1) 의연령은 Vol. 71 No. 4, April 2018
224 노수민등. 급성위장관출혈환자에서혈관조영술및색전술의성적 Table 4. Summary of 21 Complications of Embolization No Final diagnosis Embolization vessel Detection time a /diagnosis Complication Outcome 1 Gastric ulcer with Crohn s disease Both GA 6 hr/ct Splenic infarction Recovery & discharged 2 Dieulafoy s lesion below SMA br 144 hr/egd Ischemic ulcer & Recovery & discharged esophagojejunostomy ring bleeding 3 Duodenal ulcer GDA 3 month/egd Duodenal stricture Observation 4 Pancreatitis induced duodenal bleeding GDA 181 hr/egd Ischemic duodenitis Recovery & discharged 5 Duodenal angiodysplasia Both GA, left IPA 14 hr/laboratory test Acute kidney injury Died of hyperkalemia after 4 days 6 SB bleeding SMA br 6 hr/clinically Ischemic enteritis Recovery & discharged 7 Radiotherapy related enteritis SMA br 55 hr/ct Ischemic enteritis Operation & discharged 8 SB traumatic bleeding SMA br 44 hr/colonoscopy Ischemic enteritis Recovery & discharged 9 SB angiodysplasia SMA br 21 hr/ct Ischemic enteritis Operation & discharged 10 SB bleeding SMA br 45 hr/ct SB infarction with Operation & discharged perforation 11 SB bleeding SMA br 27 hr/ct Ischemic enteritis Recovery & discharged 12 SB bleeding SMA br 66 hr/ct Ischemic enteritis Operation & successful hemostasis but died of leukemia 13 SB angiodysplasia SMA br 21 hr/ct Ischemic enteritis Recovery & discharged 14 SB bleeding SMA br 41 hr/ct SB infarction with Operation & discharged perforation 15 Splenic artery aneurysm Splenic artery 116 hr/ct Splenic infarction Recovery & discharged 16 Jejunostomy site bleeding SMA br 17 hr/ct Ischemic enteritis Operation & discharged 17 Jejunostomy site bleeding SMA br 179 hr/ct SB infarction Operation & discharged 18 Ascending colon diverticular bleeding SMA br 551 hr/clinically Ischemic colitis Recovery & discharged 19 Post polypectomy bleeding SMA br 13 hr/ct Ischemic colitis Operation & discharged 20 Post polypectomy bleeding SMA br 16 hr/ct Ischemic colitis Recovery & discharged 21 Rectal AVM IMA br 61 hr/sigmoidoscopy Ischemic colitis Operation & discharged GA, indicates gastric artery; hr, hour; CT, computed tomography; SMA, superior mesenteric artery; br, branch; EGD, esophagogastroduodenoscopy; GDA, gastroduodenal artery; IPA, inferior phrenic artery; SB, small bowel; AVM, arteriovenous malformation; IMA, inferior mesenteric artery. a Time interval from the beginning of embolization to the time when the complications were detected and diagnosed. 29-84세 ( 평균연령 57.3세 ) 였으며남성이 21명이었다. 상부위장관출혈 22명, 중부위장관출혈 7명이었다. 이중 8명이동시에두혈관이상에서색전술을시행하였으며, 대상혈관은좌위동맥 14예, 우위동맥 8예, 위십이지장동맥 5예, 상장간동맥의분지동맥 5예, 우위그물막동맥 3예, 상췌십이지장동맥 2예, 짧은위동맥, 왼위그물막동맥, 하췌십이지장동맥, 좌하횡격막동맥이각각 1예였다. 예방적색전술후임상적성공률은 44.8% (13/29) 로선택적색전술시행후의 67.9% (91/134) 에비하여낮았으나통계적으로유의한차이는아니었다 (p=0.06). 4. 색전술합병증색전술과관련된합병증발생률은 12.9% (21/163) 였으며, 상부위장관색전술후 6.0% (4/67), 중부위장관색전술후 17.6% (13/74), 하부위장관색전술후 18.2% (4/22) 에서합병증이발생하여중부및하부위장관색전술후합병증발생률이높은경향을보였지만, 통계적으로유의한차이는없었다 (p=0.06) (Table 3). 색전술방법에따라분석하였을때, 예방적색전술후합병증발생률은 10.3% (3/29) 로선택적색전술후 14.2% (19/134) 와유의한차이는없었다 (p=1.00). 합병증의종류로는천공을동반하지않은장허혈또는경색이 15예 (71.4%) 로가장흔하였으며, 천공을동반한경색 2예, 지라경색 2예, 십이지장협착 1예, 급성신손상 (acute kidney injury) 1예가발생하였다. 천공을포함하여허혈및경색이발생한 17예중중부위장관색전술후가 11예 (14.9%) 하부위장관색전술후가 4예 (18.2%) 로상부위장관색전술후발생한 3.0% (2/67) 에비해유의하게흔하여색전술후허혈이나경색의위험도는중부위장관이하에서높았다 (p=0.007). 이들허혈성합병증 17예중추적내시경에서허혈성십이지장염이진단되었던 1예 (Table 4의 4번환자 ) 를제외한 16예는모두복통이나재출혈등의증상으로검사진행후허혈성합병증이진단되었다. 색전술후합병증에대한치료경과는 Table 4에기술하였다. 천공 2예는모두수술로호전되었다. 허혈또는경색 15명중 7명은장절제술, 나머지 8명은항생제를포함한내과적치료로허혈및경색은호전되었다. 한편, 색전술합병증과연관되어사망한환자는 163명중 1명 (0.6%) 있었는데, 색전술후발생한급성신손상및이에동반된고칼륨혈증으로사망하였다. 결과적으로색전술합병증으로인해사망하거나수술을시행한경우는 6.1% (10/163) 였다. The Korean Journal of Gastroenterology
Noh SM, et al. Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding 225 고찰 급성위장관출혈환자에서혈관조영술및색전술의임상성적을분석한이연구에서혈관조영술의병소발견율은상부, 중부, 하부위장관부위에따라차이는없었고, 다른검사에서출혈병변이발견된후혈관조영술을시행할때혈관조영술의병소발견율이높았다. 한편, 색전술의임상적성공률은 63.0% 였으며, 혈관조영술에서출혈병소확인이안되었는데임상적으로의심되는부위에예방적색전술을시행한경우에비해혈관조영술로출혈병소를확인하여선택적색전술을시행한경우의임상적성공률이통계적으로유의하지는않지만높은경향을보였다. 색전술후임상적으로중대한합병증은드물었으며, 허혈이나경색은상부위장관에비해중부및하부위장관색전술후더흔히발생하였다. 혈관조영술은내시경이나 CT 등다른검사들로출혈원인을찾지못한급성위장관출혈환자에서시행하는중재영상검사이다. 이연구에서혈관조영술의출혈병소발견율은 50.8% 였는데, 이는급성위장관출혈환자를대상으로한과거연구들에서보고된혈관조영술의병소발견율 35-86% 의범위내에드는성적이다. 12-16 Pennoyer 등은어떠한요인들이급성출혈환자를대상으로시행한혈관조영술의민감도에영향을주는지연구하였다. 17 그결과적혈구동위원소스캔결과양성, 이전위장관출혈과거력, 수혈력, 기립성저혈압, 빈맥과같은환자요인은혈관조영술의출혈병소발견율을높이지못하며, 따라서혈관조영술시행전, 모든환자에서적혈구동위원소스캔검사는권장되지않는다고하였다. 그러나다른연구에서는혈관조영술시행전적혈구스캔결과가양성일경우, 혈관조영술의출혈병소발견율이 22% 에서 53% 까지증가하였다고보고하였다. 18 하지만모든환자에서적혈구스캔을시행하면검사시간으로인해혈관조영술시행까지지연되게되므로, 생체징후가불안정한급성출혈환자는바로혈관조영술을시행하고, 상대적으로생체징후가안정적일경우적혈구스캔을시행하는것이혈관조영술에서출혈병소발견율을높이는데도움이된다고하였다. 저자들의이번연구에서는적혈구스캔이나 CT 소장조영술등다른검사로출혈위치를확인한상태에서혈관조영술을시행한경우의출혈병소발견율은 59.7% 로출혈위치를모르는상태에서혈관조영술을시행한경우의출혈병소발견율 35.8% 에비해유의하게높았다. 혈관조영술이전검사의이와같은유용성은상부위장관출혈에서는뚜렷하지않은반면, 중부및하부위장관출혈의경우에는유의하였다. 상부위장관출혈은대량출혈이면서생체징후가불안정한경우가상대적으로더흔해다른검사없이긴급하게혈관조영술을시행하는경우가많고, 대량출혈이므로병변발견율도높아다른검사에서원인 이발견된후혈관조영술시행시병변발견율과차이가없었을것으로생각한다. 과거연구들에서도혈관조영술은특이도가 100% 에가깝게높지만, 분당 0.5-1.5 ml에이르는활동성출혈이있어야출혈부위를찾을수있어, 급성하부위장관출혈환자에있어민감도는 42-86% 로낮은것으로보고된바있다. 15,19 이상의내용, 즉, 혈관조영술의병변발견율관점에서고려해볼때, 생체징후가안정된급성위장관출혈환자에서원인발견을위해서는가급적다른검사들을먼저시행하는것이옳겠고, 다른검사에서병변이발견된경우에한해색전술등의목적으로조영술을시행하는것이바람직할것으로보이며, 이러한전략은특히중부및하부위장관출혈에서더욱적합할것으로생각한다. 미국소화기학회 (American College of Gastroenterology) 의최근지침에서도혈역학적으로안정된환자라면상부및하부위장관내시경, CT 소장조영술, 캡슐내시경또는소장내시경을우선적으로권고하고있으며, 출혈의속도가빠르고불안정한상태에한해혈관조영술을즉시시행해볼수있다고언급하고있다. 1,20 경도관동맥색전술은 1990년대후반미세도관을이용한초선택색전술과다양한색전물질이개발되면서위장관출혈치료에널리이용되고있다. 전신상태가불량한경우에도시술가능한장점이있으며, 내시경지혈이힘든경우나재출혈이발생한경우수술전에시행할수있는인터벤션치료로이용이점차증가하고있다. 21-23 이번연구에서도색전술의기술적성공률은 99.3%, 임상적성공률은 63.0% 로급성위장관출혈환자에서비교적높은지혈률을보였다. 위장관출혈환자들을대상으로한이전의연구들에서도기술적성공률은 92-100%, 임상적성공률은 51-83% 로보고하고있어유사한결과를보였다. 24-29 기술적성공률에비해임상적성공률이낮은것은, 색전술직후에는출혈이멈추었다하더라도불완전한색전술로인한재출혈, 색전술시행한혈관이외다른병변으로부터의재출혈, 색전술에합병한장허혈이나경색으로인한재출혈등다양한원인에의해재출혈이발생할가능성으로부터기인한다고생각된다. 따라서, 색전술의기술적성공이후에도주의깊은경과관찰이필요하다고하겠다. 흥미로운점은예방적색전술의경우선택적색전술에비해낮은임상적성공률이낮은경향을보였다는점이다 (44.8% vs. 67.9%). Arrayeh 등과 Ichiro 등 30,31 의이전연구에서도십이지장출혈시예방적색전술은재출혈발생률을낮추는데도움이되었지만, 위를포함한상부위장관출혈전체를분석하였을때예방적색전술의재출혈발생률억제효과는없었다. 따라서, 가급적혈관조영술을통해출혈병소를확인한후선택적색전술을시행할수있도록노력해야겠고, 이를위해사전검사를통한원인병변예측이라든지활동성출혈시즉각혈관조영술을시행하여병변발견율을높이려는노력 Vol. 71 No. 4, April 2018
226 노수민등. 급성위장관출혈환자에서혈관조영술및색전술의성적 등이요구된다고하겠다. 한편, 예방적색전술후합병증빈도는선택적색전술후에비해유의하게높지는않았다. 따라서, 안전성측면에서예방적색전술의위험을크게우려하지는않아도되지않을까생각되며, 그러므로다양한검사에도불구하고출혈이지속적으로재발한다면예방적색전술도조심스럽게고려해볼수는있겠다. 하지만 20명내외의예방적색전술을시행한환자를포함하는상부위장관출혈환자에서예방적색전술은임상적결과에영향을끼치지않았다는보고들도있어, 27,32 대규모위장관출혈환자를대상으로하여출혈원인및색전술대상혈관, 색전물질에따라예방적색전술의효과가어떻게달라지는지에대한추가연구가필요하며, 예방적색전술의유용성및안전성에대한확립된지침이없는현시점에서는주의깊은접근이필요하다고생각한다. 혈관조영술시행후 0-10% 에서천자부위혈종, 가성동맥류, 위장관허혈, 동맥박리, 조영제유발신증과같은합병증이발생할수있으며, 중대한합병증은 2% 미만환자에서발생하는것으로알려져있다. 33 색전술후전체합병증빈도는 4.6-25%, 대표적합병증인장허혈또는경색의빈도는 0-25% 까지발생한다고보고되고있으며, 112명의중부위장관이하출혈에대한색전술후 1.8% 에서소장천공이발생하였다는보고가있다. 12,34-38 이번연구에서색전술관련합병증발생률은 12.9% 로기존연구들과유사한빈도를보였다. 상부위장관색전술후에비해중부또는하부위장관색전술후합병증빈도가높은경향을보였으며, 특히장허혈또는경색은상부에비해중부또는하부위장관색전술후유의하게많이발생하였다. 이번연구에서도측부혈행 (collateral blood supply) 이충분한상부위장관에서는색전술후장허혈또는경색위험도가 1% 정도로드문데비해측부혈행이충분하지않은중부위장관이하에서는장허혈또는경색위험도가높아이전연구와동일한결과를보였으며, 34 이러한측부혈행의부족이이번연구에서확인된천공합병증의위치가모두소장이었던것과연관될가능성이있다고생각한다. 이번연구에서선택적색전술비율이하부위장관 (100%) 에서상부위장관 (67.2%) 보다높았던이유도중부및하부위장관에서의장허혈및경색위험도를고려하여예방적색전술을최소화하였기때문으로추정된다. 한편, 다행히천공이없었던이들허혈성합병증은모두수술또는보존적치료를통하여회복되어환자의장기적예후와는무관하였다. 그러나입원기간연장및이로인한의료비증가등부수적비용을감안할때, 합병증관점에서도중부및하부위장관출혈의경우색전술시행시보다세심한적응증검토가필요하며, 가급적다른검사등으로원인병변이확인된경우에한해주의깊은선택적색전술을시행하는것이좋겠다. 본연구에는몇가지제한점이있다. 첫째, 본연구는후향 적코호트연구였고, 이에따라일부정보수집이불완전하였으며, 출혈로내원한환자들에대한진단과치료접근에있어일관된전략을통해일정한검사가진행되지는않았다는점이다. 둘째, 불완전한기록등으로인해색전물질에따른성적분석을하지못하였다는점이다. 셋째, 환자군의특성및의료진의술기능력등이편향될수있는단일기관연구였으므로, 이연구의결론을일반화할수있을지에대해서는추가연구가필요하다. 이러한제한점에도불구하고, 이연구는비교적많은수의환자를대상으로색전술후 30일이상충분한기간동안추적관찰한결과를분석함으로써혈관조영술및색전술의유용성과안전성을체계적으로보여줄수있었다. 결론적으로, 급성위장관출혈에서혈관조영술및색전술은임상적으로유용하고안전한시술이다. 예방적색전술에비해선택적색전술의임상적지혈성공률이높은경향을보이므로혈관조영술중출혈병변을찾기위한노력이필요하며, 중부및하부위장관색전술후허혈이나경색이상부위장관색전술후에비해더흔히발생하므로시술후세심한추적진료가필요하다. 요약 목적 : 급성위장관출혈에서혈관조영술및색전술의상부, 중부, 하부위장관부위에따른성적및합병증빈도에대한연구는충분하지않다. 또한, 선택적색전술과예방적색전술의임상경과에대한분석도부족하다. 본연구에서는이러한내용에대한체계적분석을해보고자하였다. 대상및방법 : 급성위장관출혈로혈관조영술을시행하고필요시색전술을추가하였던 321명환자의의무기록을후향적으로검토하였다. 혈관조영술에서출혈혈관이발견된경우선택적색전술을시행하였으며 (n=134), 출혈혈관을찾지못하였더라도다른검사에서특정부위의출혈이의심되었던경우예방적색전술을시행하였다 (n=29). 혈관조영술의병변발견율, 선택적색전술의기술적성공률, 색전술전체의임상적성공률, 색전술합병증등을검토하였다. 결과 : 혈관조영술의출혈병변발견율은 50.8% (163/321) 였다. 상부, 중부, 하부위장관등출혈부위에따른혈관조영술병변발견율에차이는없었다. 다른검사에서원인병소가발견되었던경우에혈관조영술의출혈병변발견율이유의하게높았다 (59.7% vs. 35.8%, p<0.001). 색전술부위는상부위장관이 67명, 중부위장관이 74명, 하부위장관이 22명이었다. 선택적색전술의기술적성공률은 99.3% (133/134) 였고, 색전술전체의임상적성공률은 63.0% (104/163) 였다. 예방적색전술의임상적성공률은선택적색전술후에비해낮은경향을보였다 (44.8% vs. 67.9%, p=0.06). 색전술연관합병증빈 The Korean Journal of Gastroenterology
Noh SM, et al. Transcatheter Arterial Embolization for Acute Gastrointestinal Bleeding 227 도는 12.9% (21/163) 였다. 허혈이나경색은상부위장관색전술후에비해중부위장관이하색전술후에더흔히발생하였다 (3.0% vs. 15.6%, p=0.007). 결론 : 혈관조영술및색전술은급성위장관출혈에서유용한시술이다. 보다높은임상적성공률을고려하였을때가급적선택적색전술을시행하는것이바람직하며, 중부나하부위장관색전술후에는허혈및경색에대해주의깊은관찰이필요하다. 색인단어 : 혈관조영술 ; 동맥색전술 ; 위장관출혈 REFERENCES 1. Dye CE, Gaffney RR, Dykes TM, Moyer MT. Endoscopic and radiographic evaluation of the small bowel in 2012. Am J Med 2012; 125:1228.e1-1228.e12. 2. Raju GS, Gerson L, Das A, Lewis B; American Gastroenterological Association. American Gastroenterological Association (AGA) institute medical position statement on obscure gastrointestinal bleeding. Gastroenterology 2007;133:1694-1696. 3. Church NI, Palmer KR. Ulcers and nonvariceal bleeding. Endoscopy 2003;35:22-26. 4. Barkun A, Bardou M, Marshall JK; Nonvariceal Upper GI Bleeding Consensus Conference Group. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. 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