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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