Small bowel bleeding: a comprehensive review

The small intestine is an uncommon site of gastro-intestinal (GI) bleeding; however it is the commonest cause of obscure GI bleeding. It may require multiple blood transfusions, diagnostic procedures and repeated hospitalizations. Angiodysplasia is the commonest cause of obscure GI bleeding, particularly in the elderly. Inflammatory lesions and tumours are the usual causes of small intestinal bleeding in younger patients. Capsule endoscopy and deep enteroscopy have improved our ability to investigate small bowel bleeds. Deep enteroscopy has also an added advantage of therapeutic potential. Computed tomography is helpful in identifying extra-intestinal lesions. In cases of difficult diagnosis, surgery and intra-operative enteroscopy can help with diagnosis and management. The treatment is dependent upon the aetiology of the bleed. An overt bleed requires aggressive resuscitation and immediate localisation of the lesion for institution of appropriate therapy. Small bowel bleeding can be managed by conservative, radiological, pharmacological, endoscopic and surgical methods, depending upon indications, expertise and availability. Some patients, especially those with multiple vascular lesions, can re-bleed even after appropriate treatment and pose difficult challenge to the treating physician.

Comparison of encapsulated versus nonencapsulated (14) C-urea breath test for the detection of Helicobacter pylori infection: a scintigraphy study

BACKGROUND AND AIMS

(14) C-urea breath test ((14) C-UBT) is considered as "gold standard" for detection of active gastric H. pylori infection. However, till date no comparative study using encapsulated and non-encapsulated (14) C-UBT protocols has been conducted in same subjects in identical conditions. We monitored gastric fate of capsule containing (14) C-urea with real time display and compared sensitivities of these protocols at different time points of breath collection.

METHODS

Non-encapsulated (14) C-UBT was performed using 74 kBq of (14) C-urea in 100 dyspeptic patients by collecting breath samples at 10, 15 and 20 minutes. Thereafter, within 2 days a gelatin capsule containing (14) C-urea along with 6.0 MBq of (99m) Tc-diethylene triamine penta-acetic acid was administered to each patient for real time display of capsule movement and its fate in gastrointestinal tract by gamma camera. Simultaneously, breath samples were collected for (14) CO2 measurement during image acquisition.

RESULTS

Employing non-encapsulated (14) C-UBT, 74 out of 100 dyspeptic patients were found to be H. pylori positive. Discordant (14) C-UBT results were obtained in 4/74 (5.4%) cases using these two protocols. By employing encapsulated and nonencapsulated (14) C-UBT protocols, sensitivities of (14) C-UBT were found to be 90.5 versus 98.6% at 10 and 91.8 versus 97.2% at 15 minutes respectively; while these were 94.6 versus 100, 90.7 versus 98.6 and 83.7 versus 93.2% considering any one, two or all three positive values respectively.

CONCLUSIONS

Incomplete/non-resolution of (14) C-urea capsule in stomach during the phase of breath collections appears to decrease sensitivity of encapsulated (14) C-UBT as compared to nonencapsulated protocol for detection of H. pylori infection.

Combined Placement of Covered Self-Expanding Metallic Stents and Nasojejunal Tube for Managing Large Lower Esophageal Perforations

Covered self-expanding metallic stents (cSEMSs) have emerged as effective treatment option for esophageal perforations. However, the large lower esophageal perforations where the cSEMS is placed across gastroesophageal junction have lower healing rates because refluxed gastric contents constantly irritate perforation and also there is increased risk of stent migration. Moreover, gastric mucosa tends to prolapse into lumen of lower end of stent causing its obstruction, leading to seepage of saliva and fluids from upper end of stent even in the patients who are on parenteral nutrition. We present our experience of a novel technique of combined cSEMS and nasojejunal tube (NJT) placement in four patients (two males) with benign large lower esophageal perforations. The NJT was placed through the stent into the jejunum through which patients were given enteral feeding. The stents were placed 5 - 21 days after esophageal perforation with the size of perforation ranging from 4 to 6 cm. As the NJT formed a loop in stomach, it prevented migration of stent. And also its presence in lumen of stent prevented its obstruction by prolapsing gastric mucosa, thereby preventing seepage of saliva and fluids from side of stent. Both stents and NJT were removed after 6 weeks and leak closed in all patients. Combined cSEMS and NJT placement seems to be safe and effective for treating large lower esophageal perforations. NJT placement seems to decrease risk of migration, prevents seepage of fluids and permits early enteral nutrition, thereby improving the healing rates.

Morphological features of fluid collections on endoscopic ultrasound in acute necrotizing pancreatitis: do they change over time?

BACKGROUND

There have been attempts to develop universally applicable nomenclature for pancreatic fluid collections (PFCs) in acute pancreatitis. But PFCs following acute necrotizing pancreatitis (ANP) has not been studied by sensitive imaging techniques like endoscopic ultrasound (EUS). The aim of the study was to prospectively study morphological structure of pancreatic fluid collections occurring after ANP by serial EUS.

METHODS

Patients with ANP having PFC at ≥4 weeks of onset of symptoms seen at our center from October 2011 to November 2012 were prospectively followed up with EUS at 6 weeks, 3 months and 6 months respectively and the amount of solid content in the collection was quantified as percentage amount of echogenic material. The symptomatic patients undergoing EUS/percutaneous drainage also underwent EUS prior to drainage for assessment of solid content.

RESULTS

Of the 54 patients enrolled, 7 patients were lost to follow up or refused EUS. Forty seven patients (34 males; mean age 36.7±11.6 years) were studied. Etiology of acute pancreatitis was alcohol (n=22), gallstones (n=10), idiopathic (10), gallstones+alcohol (n=3) and drug induced (n=2). Contrast enhanced computed tomography done after 3 days of onset of ANP had shown less than 30%, 30-50% and more than 50% necrosis in 6 (13%), 14 (30%) and 27 (57%) patients respectively. On EUS at 6 weeks, 41/47 (87%) patients had fluid collection with solid debris. Follow up EUS at 3 and 6 months revealed progressively decreasing solid content in PFCs.

CONCLUSIONS

All PFCs following ANP may not have solid necrotic content and over a period of time necrotic content tends to liquefy. This may have therapeutic implications.

Vascular invasion does not discriminate between pancreatic tuberculosis and pancreatic malignancy: a case series

BACKGROUND

Pancreatic tuberculosis is very rare and most commonly involves the head and uncinate process of the pancreas. It closely mimics pancreatic malignancy and is often diagnosed after pancreatico-duodenectomy. Vascular invasion is believed to be a hallmark of malignant lesions and described as a point of differentiating benign lesions from malignant lesions. We herein retrospectively evaluated the patients with pancreatic tuberculosis seen at our unit over the last 4 years for features of vascular invasion.

METHODS

We retrospectively analyzed the collected database of all patients diagnosed with pancreatic tuberculosis at our unit over the last four years and identified patients who had evidence of local vascular invasion and their clinical and imaging findings were retrieved.

RESULTS

Over the last four years, 16 patients (12 males) with pancreatic tuberculosis were seen and five of these 16 patients had imaging features of vascular invasion by the pancreatic head mass. Of these five patients, four were males and the mean age was 32.0±5.47 years. Of these five patients, three had involvement of portal vein and superior mesenteric vein and two had involvement of hepatic artery.

CONCLUSION

Presence of vascular invasion does not distinguish pancreatic tuberculosis and malignancy, and, therefore, cytopathological confirmation is mandatory to differentiate between the two.

Clinical and endoscopic parameters at presentation that predict the need for long-term immunosuppression in ulcerative colitis

Introduction: The clinical course of ulcerative colitis (UC) ranges from a mild course with prolonged periods of remission to severe disease requiring long-term immunosuppression for disease control. There is limited data on the predictors of need for immunosuppression at presentation. Objective: The aim was to evaluate clinical, endoscopic and histopathological parameters at presentation in patients with UC that predict the need for long-term immunosuppressive therapy. Materials and Methods: We studied 81 patients (males; 40; mean age 38.69 ± 12.90 years) with UC (41 prospectively and 40 retrospectively). The clinical presentation, duration, extra-intestinal features, extent of disease, haematological and biochemical features, histology and outcome (drugs, surgery, and mortality) were recorded and analyzed. Subgroup analysis was done after dividing the patients into two groups depending upon whether they needed long term immunosuppressants or not. Results: The presenting symptoms were bloody stools (100%), mucus in stools (98.8%), abdominal pain (35.8%), anorectal pain (14.8%) and extra-intestinal symptoms (4.9%). Of these 81 patients, 7 (8.6%) patients required surgery and 2 (2.4%) patients died. Long term immunosuppressants were used in 19 patients (Azathioprine 16, Mycophenolate mofetil 2 and Tacrolimus 1). The patients who received immunosuppressants had a higher prevalence of pancolitis (47.4% vs. 16.1%, P = 0.005). Other clinical, hematological and histological parameters such as inflammatory grade, chronicity grade, cellular infiltrates, submucosal fibrosis, Paneth cell metaplasia, and the presence of neuronal cells were similar in the two groups. Conclusion: Of the clinical, biochemical, endoscopic and histological features at presentation only the presence of pancolitis predicts the need for long term immunosuppressants in ulcerative colitis.

Can early endoscopic ultrasound predict pancreatic necrosis in acute pancreatitis?

BACKGROUND

Presence of pancreatic/extrapancreatic necroses (PN/EPN) is an important prognostic indicator in acute pancreatitis (AP) and their early detection is a challenge. Endoscopic ultrasound (EUS) provides high resolution images of pancreas but there is paucity of data on its role in AP.

METHODS

Consecutive patients with AP seen at our center from December 2012-November 2013 and presenting within 5 days of onset of symptoms were prospectively enrolled. EUS was done on the day of admission with a radial echoendoscope and pancreatic/peripancreatic findings were compared with the abdominal computed tomography (CT) findings performed on day 7.

RESULTS

Of the 46 patients evaluated, 14 were excluded, and 32 patients (22 male; age 40.68±12.46 years) underwent EUS at admission. The etiology of AP was alcohol in 16, gallstones in 13, and idiopathic in 3 patients. Necrotizing pancreatitis was present in 20 (62%) patients, and mean CT severity index was 6.45±2.96. In patients without PN (n=12), EUS revealed normal echo pattern in 6 patients and diffusely hyperechoic and enlarged pancreas in 6 patients. In patients with PN/EPN, EUS revealed multiple hypoechoic areas (>5 mm) in 5 patients, multiple hyperechoic areas (>5 mm) in 7 patients and mixed hypo and hyperechoic areas in 8 patients. Also, 13 of these patients had peripancreatic hypoechoic areas that correlated with EPN. Moreover, EUS detected common bile duct (CBD) stones in two patients, pleural effusion in 17 patients, and ascites in 15 patients.

CONCLUSION

EUS done at admission can reliably detect PN and co-existent disorders like CBD stones.

Endoscopic therapy for pancreatic duct leaks and disruptions

Pancreatitis, whether acute or chronic, can lead to a plethora of complications, such as fluid collections, pseudocysts, fistulas, and necrosis, all of which are secondary to leakage of secretions from the pancreatic ductal system. Partial and side branch duct disruptions can be managed successfully by transpapillary pancreatic duct stent placement, whereas patients with disconnected pancreatic duct syndrome require more complex endoscopic interventions or multidisciplinary care for optimal treatment outcomes. This review discusses the current status of endoscopic management of pancreatic duct leaks and emerging concepts for the treatment of disconnected pancreatic duct syndrome.

Comparative evaluation of barium meal follow-through and barium enteroclysis before capsule endoscopy in obscure gastrointestinal bleeding

BACKGROUND/AIMS

Small bowel radiological investigations have lower diagnostic yield in comparison to capsule endoscopy (CE) and are inaccurate in predicting capsule impaction. Most studies have used barium meal follow-through (BAMFT) and more sensitive barium enteroclysis (BE) is infrequently used. This study was done to retrospectively compare results of performing BAMFT or BE before CE in patients with obscure gastrointestinal bleeding.

METHODOLOGY

Sixtyfive patients with obscure gastrointestinal bleeding underwent barium examination (BE or BAMFT depending upon patient's preference) and CE was performed if barium examination was normal. The demographic data, barium examination results and CE findings were retrospectively collected.

RESULTS

Sixteen patients underwent BAMFT and 49 patients underwent BE prior to CE. BAMFT was normal in all 16 patients whereas CE was normal in only 1/16 patient. Seven of 49 (14.2%) patients had stricture or mass on BE. In these 7 patients CE was not performed. In contrast to BAMFT, 22/41 (53.6%) patients with normal BE had normal CE findings also. The capsule got stuck in one patient with NSAID induced diaphragm disease who had normal BE and required surgical removal.

CONCLUSIONS

BE should be preferred over BAMFT as the radiological imaging technique for evaluation of small bowel before CE in patients with obscure gastrointestinal bleeding as it may detect unexpected strictures and intraluminal masses. However, radiological findings either on BAMFT or BE cannot predict passage of capsule endoscope through small bowel.

Superiority of non-capsulated 14C-urea breath test over capsule based method for detection of Helicobacter pylori infection - a preliminary report

BACKGROUND

14C-urea breath test (14C-UBT) is employed as a 'gold standard' technique for the detection of active gastric Helicobacter pylori infection and is recommended as the best option for "test-and-treat" strategy in primary health care centers.

AIM

To compare the performance of capsulated and non-capsulated 14C-UBT protocols for the detection of H. pylori infection in patients.

METHODS

Fifty eight H. pylori infected patients underwent routine upper GI endoscopy and biopsies were processed for rapid urease test (RUT) and histopathology examination. Capsulated 14C-UBT was done in a novel way by using 74 kBq of 14C-urea along with 6.0 MBq of 99mTc-diethylene triamine penta-acetic acid (99mTc-DTPA) to simultaneously monitor the movement and the fate of ingested capsule after delineating the stomach contour by using 20.0 MBq of 99mTechnetium pertechnetate (99mTcO4-) under dual head gamma camera. Non-capsulated 14C-UBT was performed within 2 days of the previous test and the results of these protocols were compared.

RESULTS

In 3 out of 58 H. pylori positive cases (5.17%), 14C-UBT results were found to be negative by using the capsulated method. Interestingly, on monitoring the real time images of the capsule in these cases it was found that misdiagnosis of H. pylori infection occurred mainly due to either rapid transit of the 14C-urea containing capsule from the upper gastric tract or its incomplete resolution in the stomach during the phase of breath collection.

CONCLUSION

Use of non-capsulated '4C-UBT protocol appears to be a superior option than the conventional capsule based technique for the detection of H. pylori infection.