The Case for Preventive Transarterial Embolization after Endoscopic Hemostasis of Bleeding
Peptic Ulcers

Global lifetime prevalence of peptic ulcer disease (PUD) has been estimated around 5-10% with annual
incidence 0.1-0.3% per year (1). PUD, while decreasing in incidence in high and middle income countries
due to decreasing rates of H. pylori infection, continues to remain a significant cause of mortality and
morbidity, especially amongst the elderly. PUD bleeding is mainly a disease affecting older patients, with
68% of PUD patients over the age of 60 and 27% over the age of 80 (2). The mainstay of treatment of
non-variceal upper GI bleeds is endoscopic hemostasis. However, PUD bleeds are also at frequent risk of
rebleeding, especially amongst elderly patients who may have multiple comorbidities and/or are taking
medications that increase the risk of bleeding, such as NSAIDs or antithrombotic agents (3).
Current guidelines indicate that transarterial embolization (TAE) is a reasonable alternative to surgery in
patients who rebleed after primary endoscopic hemostasis is achieved, and it may be preferred in highly
morbid patients who cannot undergo surgery (4). However, the guidelines do not consider the role of TAE
as a means of tertiary prophylaxis following endoscopic hemostasis of a primary PUD bleed.
A 2019 single-center retrospective cohort study analyzed patient outcomes over 5 years from 2014-2018
with respect to the use of preventive TAE (P-TAE) for PUD patients that were at high risk of rebleeding,
based on a Forrest Classification of Ia, Ib, IIa, or IIb with a Rockall score of 5+. Of 399 patients who were
classified as having a bleeding peptic ulcer at high risk of rebleeding, 58 agreed to undergo P-TAE after
endoscopic hemostasis. P-TAE involved embolization of either the left gastric artery or the
gastroduodenal artery, depending on ulcer location. The other 341 patients in the cohort were also
classified as having a high rebleeding risk after endoscopic hemostasis but chose not to undergo P-TAE.
Exclusion criteria included hemodynamic instability and systemic introduction of contrast media. With no
significant differences in patient characteristics or comorbidities between the cohorts, the study found a
significant decrease in rebleeding, use of packed red blood cells, and use of fresh frozen plasma in
the cohort of patients that underwent P-TAE. However, the study did not find a significant decrease in
hospital stay or mortality (5).
Although the experimental design of this study is limited by its being a retrospective cohort, the quality of
the data along with the volume of patients in each cohort indicate that the use of TAE as a preventive
measure should be considered alongside its currently accepted use as a treatment option for refractory
PUD bleeds. Tertiary prophylaxis is especially important in highly morbid patients who may have many
risk factors for rebleeding after primary endoscopic hemostasis; while many more high-quality studies are
needed to provide definitive evidence, the use of P-TAE has shown to be safe and effective in reducing
the rates of rebleeding and need for blood products, thus lowering overall morbidity and financial burden
for patients with high-risk PUD bleeds.

Works Cited

1. Lanas A, Chan FK. Peptic Ulcer Disease. The Lancet. 2017;390:10094613-624
2. Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J
   Med. 2008;359(9):928–37.
3. Laine LCLINICALPRACTICE. Upper gastrointestinal bleeding due to a peptic ulcer. N Engl J
   Med. 2016;374(24):2367–76.
4. Kim JS, Kim BW, Kim DH, Park CH, Lee H, Joo MK, Jung DH, Chung JW, Choi HS, Baik GH,
   Lee JH, Song KY, Hur S. Guidelines for Nonvariceal Upper Gastrointestinal Bleeding. Gut Liver.
   2020 Sep 15;14(5):560-570. doi: 10.5009/gnl20154.
5. Kaminskis, A., Ivanova, P., Kratovska, A. et al. Endoscopic hemostasis followed by preventive
   transarterial embolization in high-risk patients with bleeding peptic ulcer: 5-year experience.
   World J Emerg Surg. 2019;14, 45. https://doi.org/10.1186/s13017-019-0264-z

By Sai Surya Maddike