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OBSCURE GI BLEED Talat Bessissow, MC CM, FRCPC Assistant Professor, Department of Medicine Division of Gastroenterology McGill University Health Center Definition • Definition = GI bleeding of uncertain etiology after EGD, C-scope, and small bowel radiography • Overt OGIB = hematochezia, melena, hematemesis or CG emesis • Occult OGIB = FOB + in abscence of visible blood, Iron deficiency Anemia Fecal occult blood testing • Guaiac-based tests: The pseudoperoxidase activity of hemoglobin turns the guaiac compound blue in the presence of hydrogen peroxide Epidemiology 300,000 pts hospitalized/yr in US ... 5% of these will have normal EGD and C-scopes Median time for diagnosis is 2 years Average cost $33,630 per patient Average 7.3 tests per patient Paradigm shift since introduction of VCE and DBE Etiology of Obscure GI Bleeding 5% of patients presenting with GI hemorrhage have no source found by upper endoscopy and colonoscopy. Of these, 75% are 2ndry to small bowel lesions Of these, 30-60% angiectasias Am J Surg 1992;163:90–92 Br Med J (Clin Res Ed)1984;288:1663–1665. Etiology of Obscure GI Bleeding Upper and lower GI bleeding overlooked Mid GI bleeding Cameron’s erosions Tumors Fundic varices Meckel’s diverticulum Peptic ulcer Dieulafoy’s lesion Angiectasia Crohn’s disease Dieulafoy’s lesion Celiac disease GAVE Angiectasia Neoplasms NSAID enteropathy Erosive gastritis Hemobilia Ischemic colitis/UC Aortoenteric fistula Large polyps Vasculitis Etiology • 40% of OGIB - due to angiectasias (AVMs) Angiectasias : ectatic blood vessels made of thin wall with or without endothelial lining o Natural history of angiectasias is not well known o Only 10% of all patients with angioectasia will eventually bleed o Once a lesion has bled up to 50% will not rebleed --predictors of rebleeding: multiple bleeding episodes, transfusion requirement o Bleeding angiectasias are associated with abnormal von Willebrand’s factor (vWF) AVM • Conditions/diseases associated with angiodysplastic lesions: • Elderly • CRF • Aortic valve disease (Heyde’s syndrome) • Cirrhosis • Collagen vascular disease AVM What is Heyde’s syndrome ? Heyde’s syndrome: Bleeding from angiectasias in patients with AS. o Increased consumption of high-molecular-weight multimers of VWF due to shear stress of the abnormal valve which corrects after aortic valve replacement with decreased severity of bleeding Transfus Med Rev 2003;17:272–286.; Abdom Imaging (2009) 34:311–319 Small Bowel Bleeding • Etiology depends on the age of the patient • Young: small intestinal tumors, Meckel’s diverticulum, Dieulafoy lesion, Crohn’s disease • Older: (>40) vascular lesions, NSAID-induced SB disease • Uncommon: hemobilia, hemosuccus pancreaticus, aortoenteric fistula History and Physical Examination The nature of the exact presenting symptom is important in deciding a practical, efficient, and cost-effective evaluation plan Hematemesis indicate upper GI bleed Melena can be anywhere from the nose to the right colon Hematochezia can be a lower GI bleed or a fast upper GI bleed History of medications (mainly OTC) Family history Skin signs Hereditary hemorrhagic telangiectasia Blue rubber bleb nevus syndrome Dermatitis herpetiformis Plummer–Vinson syndrome Tylosis Investigation options I. Repeat G & C II. CTE III. Capsule endoscopy IV. Enteroscopy - push or SBE/DBE V. Angiography VI. Tagged RBC scan Common lesions that are overlooked • EGD: Cameron’s erosions, fundic varices, PUD, angioectasias, Dieulafoy lesion, GAVE • C-scope: angioectasias, neoplasms Investigation o Repeat standard endoscopy, especially if anemia and overt GI bleeding: Overlooked lesions: fundus o high lesser curvature antrum C loop of duodenum, posterior wall of duodenal bulb Random SB Bx can be + for celiac disease in up to 12% The yield of repeat colonoscopy is 6%, yield of repeat EGD is 29% (ASGE) Am J Gastroenterol 1996;91:2099–2102 Investigation Consider side-viewing scope if pancreatobiliary pathology is suspected Small bowel series/SBFT: o When compared with capsule endoscopy • diagnostic yield 8% vs 67% • clinically significant finding 6% vs 42% (NNT 3) o Used if SB obstruction is suspected Gastroenterology 2002;123:999–1005 Investigation CT Enterography: o Thin sections and large volumes of enteric contrast material to better display the small bowel lumen and wall. o Neutral enteric contrast + IV contrast o 1.5 – 2 L of milk, PEG electrolytes or low-concentration barium Investigation CT Enterography: o Advantages: displays entire wall thickness examination of deep ileal loops mesentery & perienteric fat no need for NGT CTE Investigation Technetium-99m–labeled RBC scan: Limited value Blood loss of 0.1-0.4 ml/min (2U PRBCs /d) Poor localization of SB bleeding - not enough to direct operative therapy Angiography: Useful in massive bleeding (>0.5ml/min) Diagnostic & therapeutic Nucl Med Commun 2002;23:591–594 Investigation Endoscopic imaging: o Intraoperative enteroscopy; Terminal ileum can be reached in 90% of cases • diagnostic yield 58-88% • mortality up to 17% Investigations Push enteroscopy: Length 220-250 cm usually limited to 150 cm diagnostic yield up to 70% angioectasias in up to 60% some suggest push enteroscopy over repeat EGD as second look Capsule endoscopy oSize 11x26 mm oObtains images and transmits the data via radiofrequency to a recording device oThe capsule is disposable oExamination takes at least 8 hours (57,600 images) oReading 60 – 120 minutes oSB obstruction is a contraindication Capsule endoscopy Capsule endoscopy: yield 63% vs 23% for push enteroscopy Sensitivity 89 - 95% Specificity 75 – 95% +ve predictive value 97% -ve predictive value 86% Diagnostic Yield Obscure/Overt GI Bleeding Obscure/Occult GI Bleeding • Unexplained Fe-def Anemia Yield Gain Over Push Enteroscopy Yield Gain Over SB Barium Study • • • • • • Lin, GIE 2008 Rastogi et al. GIE 2004 Pennazio et al. Gastroenterol 2004 Apostolopoulos et al. Endoscopy 2006 Estevez et al. Eur J Gastro Hep 2006 Delvaux et al. Endoscopy 2004 • 36-92% 41-63% 42-57% + 30% + 36% Study Sens (%) Spec (%) PPV (%) NPV (%) Pennazio 2004, Gastroenterol 88.9 95 97 82.6 Hartmann 2005, GIE 95 75 95 86 • Superior yield to other diagnostic modalities in both active and inactive obscure GI bleeds * Marmo, APT 2005, Triester, AJG 2005, Saperas AJG 2007 Double Balloon Enteroscopy Double Balloon Enteroscopy (DBE) o 1st described in 2001 o 200-cm enteroscope o 140-cm overtube Double Balloon Enteroscopy (DBE) o Antegrade approach: mean distance 240 +/- 100 cm mean time 72.5 +/- 23 min • Retrograde approach: mean distance 140 +/- 90 cm mean time 75 +/- 28 min How Effective is DBE? Study Diagnostic Yield (%) Kaffes 2004, Clin Gastro Hep 76 Mehdizadeh 2006, GIE 51 Yamamoto 2006, Am J Gastro 76 Jacobs 2007, GIE 75 Tanaka 2008, GIE 54 Yadav 2010, abstract DDW 52% How Effective is DBE? Study Patients (n) Yield Matsumoto 2005, Endo 13 Equivalent May 2005, GIE 52 DBE better Hadithi 2006, Am J Gastro 35 CE better Mehdizadeh 2006, GIE 115 Equivalent Ohmiya 2007, GIE 74 Equivalent Kameda 2008, J Gastroenterol 32 Equivalent Teshima 2010, DDW (Meta-) 1293 CE favoured although nearly equivalent Complications - Perforation – 0.3-1.1% - Bleeding (post-polypectomy) – 1.4-1.9% - Pancreatitis – 0.2-0.3% Melsink Endoscopy 2007, Gerson ACG 2008 Single Balloon Enteroscopy - Much more recent - Simpler to set up, works with existing Olympus equipment - Same specifications as DBE without the second balloon on the endoscope Hartmann, Endoscopy 2007 Single Balloon Enteroscopy Kawamura GIE 2008 SBE versus DBE • Efthymiou, abstract 2010 • RCT involving 79 patients recruited for mainly OvGIB/ObGIB • About half had SBE • Depth of insertion retrograde was identical (100 cm) • Depth of insertion orally favoured DBE (250 versus 205 cm but not significant) • Therapeutic yield was 54% DBE, 37% SBE (not significant) • Targetted biopsies or application of cautery or argon plasma Pennazio et al. Endoscopy 2005 & AGA Technical Insitute. Gastroenterol 2007