Push enteroscopic cauterization: long-term follow-up of 83 patients with bleeding small intestinal angiodysplasia

Endoscopic therapy for gastrointestinal angiodysplasia

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of the different endoscopic management approaches for gastrointestinal angiodysplasia in symptomatic adults.

Angiodysplasia simulating variceal bleeding: a challenging case report of diagnosis and intervention

Introduction and importance

Angiodysplasia, a prevalent vascular anomaly in the gastrointestinal tract, often presents with upper gastrointestinal bleeding, sharing symptoms with gastric varices. The diagnostic challenge arises due to overlapping clinical features. This case report highlights the importance of considering angiodysplasia in the differential diagnosis, especially when variceal bleeding is less likely, and emphasizes the role of various diagnostic modalities in accurate identification.

Case presentation

A 52-year-old male presented with severe hematemesis and melena, mimicking variceal bleeding. Despite initial management, bleeding persisted. Contrast-enhanced computed tomography revealed dilated vascular channels, raising suspicion for both gastric varices and angiodysplasia. Endoscopy confirmed an angiomatous lesion, inadvertently disrupted during the procedure, necessitating angiography. The angiographic findings supported the diagnosis of angiodysplasia, and successful interventions included temporary glue embolization and argon laser coagulation during endoscopy. The patient was discharged with stable hemoglobin; a 2-year follow-up showed no recurrence.

Clinical discussion

The case discusses the challenges in differentiating angiodysplasia from varices, emphasizing the role of imaging and endoscopic modalities. It highlights the need for a tailored approach to treatment, including argon plasma coagulation, and underscores the significance of meticulous follow-up for recurrence.

Conclusion

This case report elucidates the diagnostic and therapeutic journey in managing a patient with angiodysplasia masquerading as variceal bleeding. It emphasizes the importance of considering vascular anomalies without typical signs and the significance of individualized interventions for optimal patient outcomes. The 2-year follow-up without recurrence signifies the successful management of the case.

Endocuff-assisted push enteroscopy increases the detection of proximal small-bowel gastrointestinal angiodysplasias

Gastrointestinal angiodysplasias (GIADs) are the most common causes for suspected small bowel bleeding. Fifty percent of GIADs do not need treatment due to bleeding cessation, while 45% have high re-bleeding rates, that significantly impact patient outcome and health resource utilization. We suspected that this high re-bleeding rate occurs because not all lesions are detected with present standard of care. This study evaluates whether device-assisted enteroscopy (DAE) utilizing the Endocuff (EC) device could improve GIAD detection. A retrospective chart review of a prospective data collection was performed from January 2006 to December 2018 at VA Loma Linda Healthcare System (VALLHCS) on both inpatients and outpatients referred for active and chronic suspected small bowel bleeding. The patients were initially monitored for bleeding lesions via video capsule endoscopy (VCE) after negative upper and lower endoscopy. GIADs observed between 0% to 40% small bowel transit time (SBTT) were referred for push enteroscopy (PE) with and without (±) the EC device. Twenty-five consecutive patients underwent PE ± EC. No patient had VCE done after PE ± EC. Using PE-EC, GIADs were detected in 9 of 25 (36%) of patients. Importantly, PE+EC detected GIADs in 23 of 25 (92%) patients. The sum of GIADs detected without EC was 26 ± 0.06 vs. 112 ± 0.2 using EC. The average detection rate for PE without EC was significantly lower (1.04 ± 0.06, mean ± SE) as compared to PE with EC (4.48 ± 0.23, mean ± SE, p<0.0005). Additionally, a positive correlation (r=0.51) between capsule enteroscopy (CE) location of GIADs and SBTT was found. The EC device increases the detection of GIADs in the proximal small bowel. We also reconfirm that the location of bleeding GIADs are within the reach of the push enteroscope (PE). Finally, PE + EC may also reduce GIAD miss rates, which may play a role in the reduction of re-bleeding episodes.

Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease

Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.

Evaluation and management of Non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.

New insights on an old medical emergency: non-portal hypertension related upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition and is the most common medical emergency managed by gastroenterologists. Despite being one of the most antique medical problems, recent studies have been slowly changing the management of these patients, which should nowadays include not only initial resuscitation, but also risk stratification, pre-endoscopic therapy, endoscopy treatment, and post-procedure care. The aim of this paper is to review the extended approach to the patient with non-portal hypertension related UGIB.

Outcome of endoscopy-negative iron deficiency anemia in patients above 65: A longitudinal multicenter cohort

After the age of 65 years, iron deficiency anemia (IDA) requires the elimination of digestive neoplasia and is explored with upper and lower gastrointestinal (GI) endoscopy. However, such explorations are negative in 14% to 37% of patients. To further evaluate this issue, we evaluated the outcomes of patients aged over 65 years with endoscopy-negative IDA.We retrospectively analyzed the outcomes of in-patients over the age of 65 years with IDA (hemoglobin <12 g/dL and ferritin <70 μg/L) who had negative complete upper and lower GI endoscopies in 7 tertiary medical hospitals. Death, the persistence of anemia, further investigations, and the final diagnosis for IDA were analyzed after at least 12 months by calling the patients' general practitioners and using hospital records.Between 2004 and 2011, 69 patients (74% women) with a median age of 78 (interquartile range (IQR) 75-82) years and hemoglobin and ferritin levels of 8.4 (IQR 6.8-9.9) g/dL and 14 (IQR 8-27) μg/L, respectively, had endoscopy-negative IDA, and 73% of these patients received daily antithrombotics. After a follow-up of 41 ± 22 months, 23 (33%) of the patients were dead; 5 deaths were linked with the IDA, and 45 (65%) patients had persistent anemia, which was significantly associated with death (P = 0.007). Further investigations were performed in 45 patients; 64% of the second-look GI endoscopies led to significant changes in treatment compared with 25% for the capsule endoscopies. Conventional diagnoses of IDA were ultimately established for 19 (27%) patients and included 3 cancer patients. Among the 50 other patients, 40 (58%) had antithrombotics.In endoscopy-negative IDA over the age of 65 years, further investigations should be reserved for patients with persistent anemia, and second-look GI endoscopy should be favored. If the results of these investigations are negative, the role of antithrombotics should be considered.

Tailored treatment of intestinal angiodysplasia in elderly

Background

Angiodysplasia of the gastrointestinal tract is an uncommon, but not rare, cause of bleeding and severe anemia in elderly. Different treatments exist for this kind of pathology.

Methods

The aim of this work was to study 40 patients treated for intestinal angiodysplasia with two different kind of endoscopic treatments: argon plasma coagulation (APC) and bipolar electrocoagulation (BEC).

Results

Age of patients was similar in both groups (76,2 ± 10.8 years vs 74,8 ± 8,7 years, P = 0,005). Angiodysplasia treated were located in small bowel, right colon, left colon, transverse colon and cecum. We analysed number of treatment, recurrence, hospital discharge, needs of blood transfusions before and after endoscopic treatment. Number of treatment was the same in both groups (1,2 ± 0,2 vs 1,1 ± 0,1, P < 0,001). We had more recurrence in patients treated with BEC (4/20 vs 2/20, P < 0,001). Hospital discharge was comparable in both groups (5,3 ± 3,1 days vs 5,4 ± 2,8 years, P < 0.001)

Conclusions

Treatment of angiodysplasia in elderly is not easy. Different kinds of treatment could be adopted. APC and BEC are both safe and effective. The choice of a treatment should consider several factors: age, comorbidity, source of bleeding. In conclusion we think that treatment of bleeding for angiodysplasia in elder population should be a tailored treatment.

Enteroscopy

Noninvasive imaging with CT and magnetic resonance enterography or direct visualization with wireless capsule endoscopy can provide valuable diagnostic information and direct therapy. Enteroscopy technology and techniques have evolved significantly and allow diagnosis and therapy deep within the small bowel, previously attainable only with intraoperative enteroscopy. Push enteroscopy, readily available in most endoscopy units, plays an important role in the evaluation and management of lesions located up to the proximal jejunum. Currently available device-assisted enteroscopy systems, DBE, SBE, and spiral enteroscopy each have their technical nuances, clinical advantages, and limitations. Newer, on-demand enteroscopy systems appear promising, but further studies are needed. Despite slight differences in parameters such as procedural times, depths of insertion, and rates of complete enteroscopy, the overall clinical outcomes with all overtube-assisted systems appear to be similar. Endoscopists should therefore master the enteroscopy technology based on institutional availability and their level of technical expertise.

Is Endoscopic Therapy Effective for Angioectasia in Obscure Gastrointestinal Bleeding?: A Systematic Review of the Literature

GOAL

We aimed to summarize pooled rebleeding rates of angioectasia after therapeutic endoscopy, and compare these to historical control (no intervention) rates.

BACKGROUND

Obscure gastrointestinal bleeding continues to be challenging to diagnose and treat; in America, small bowel angioectasias are the most common cause. Technology advances led to higher diagnostic yield for these lesions; however, therapeutic impact of endoscopy remains unclear.

STUDY

A PubMed search (June 1, 2006 to September 19, 2013) with 2 independent reviews sought articles reporting rebleeding rates of symptomatic angioectasia without therapy (natural history) and after endoscopic treatment. This study list was added to studies in the 2007 American Gastroenterological Association systematic review. Data on number of patients who underwent endoscopic therapy, type of therapy used, number of patients who experienced rebleeding, and follow-up time were extracted. Rebleeding data were pooled and weighted averages were reported with 95% confidence intervals (CI).

RESULTS

Twenty-four articles (n=490 patients) with data on endoscopic therapy for angioectasia and 6 natural history cohorts (n=130) receiving no therapy for angioectasia were eligible. Of the endoscopic therapy patients, 121 at push enteroscopy and 427 at balloon-assisted enteroscopy; 209/490 (42.7%; 95% CI, 38%-47%) rebled. Of the control (no therapy) patients, 64/130 (49.2%; 95% CI, 40%-58%) rebled. Number needed to treat is estimated at 15 to 16.

CONCLUSIONS

Rebleeding rate after endoscopic therapy for symptomatic small bowel angioectasia may be comparable to that expected without therapy. Endoscopic therapy may be ineffective; if effective, the needed to treat is estimated to be high. Controlled studies, with intervention-stratified and etiology-stratified outcomes are needed.

Long-term outcome in patients with obscure gastrointestinal bleeding after capsule endoscopy

OBJECTIVE

This study aimed to identify the risk factors associated with rebleeding and long-term outcomes after capsule endoscopy (CE) for obscure gastrointestinal bleeding (OGIB) in a follow-up study.

METHODS

Data of consecutive patients who underwent CE due to OGIB from June 2002 to January 2012 were retrospectively reviewed. The Cox proportional hazard model was used to evaluate the risk factors associated with rebleeding, while Kaplan-Meier survival curves and the log-rank test were used to analyze cumulative rebleeding rates.

RESULTS

The overall rebleeding rate after CE in patients with OGIB was 28.6% (97/339) during a median follow-up of 48 months (range 12-112 months). Multivariate analysis showed that age ≥60 years (hazard ratio [HR] 2.473, 95% confidence interval [CI] 1.576-3.881, P = 0.000), positive CE findings (HR 3.393, 95% CI 1.931-5.963, P = 0.000), hemoglobin ≤70 g/L before CE (HR 2.010, 95% CI 1.261-3.206, P = 0.003), nonspecific treatments (HR 2.500, 95% CI 1.625-3.848, P = 0.000) and the use of anticoagulants, antiplatelet or non-steroidal anti-inflammatory drugs after CE (HR 2.851, 95% CI 1.433-5.674, P = 0.003) were independent risk factors associated with rebleeding. Univariate analysis showed that chronic hepatitis was independently associated with rebleeding in CE-negative patients (P = 0.021).

CONCLUSIONS

CE has a significant impact on the long-term outcome of patients with OGIB. Further investigation and close follow-up in patients with OGIB and those with negative CE findings are necessary.

Clinical features and endoscopic findings in patients with actively bleeding colonic angiodysplasia

Colonic angiodysplasia (AGD) is an important cause of lower gastrointestinal bleeding. However, most episodes of bleeding from colonic AGD stop spontaneously. To date, few data are available regarding the endoscopic findings of bleeding colonic AGD. In order to clarify the clinical features and endoscopic findings of actively bleeding colonic AGD, we conducted a retrospective study of patients treated with colonoscopy at our hospital. From November 2006 to March 2013 inclusive, 32,586 colonoscopies were performed at this hospital, among which 13 patients with bleeding colonic AGD were enrolled in the current study. The mean age was 84 years (range: 69-90 years). All patients had chronic heart disease and were currently using anticoagulant and/or antiplatelet drugs. Sites of bleeding AGD were localized in the left colon in two patients (15 %) and in the right colon in the remaining patients (85 %). A total of 77 % of the lesions (10/13) were 1-2 mm in size and two lesions were 4 mm in size; only one lesion was larger than 5 mm. Endoscopic treatment resulted in a therapeutic success rate of 100 %, and no recurrence of bleeding was observed in 85 % of the patients (11/13) after treatment. During the study period, two patients presented with bleeding from residual AGD and underwent endoscopic treatment. In the present study, most sites of bleeding colonic AGD were very small, termed "micro-angiodysplasia", and targeted endoscopic treatment for actively bleeding AGD was found to be effective and safe. It is essential that physicians consider the potential for actively bleeding colonic AGD, especially "micro-angiodysplasia", when performing colonoscopy in elderly patients with a history of cardiovascular disease and/or treatment with anticoagulant or antiplatelet therapy.

Emergency single-balloon enteroscopy in overt obscure gastrointestinal bleeding: Efficacy and safety

We aimed to evaluate the impact of emergency single-balloon enteroscopy (SBE) on the diagnosis and treatment for active overt obscure gastrointestinal bleeding (OGIB).

METHODS

SBE procedures for OGIB were retrospectively reviewed and sub-divided according to the bleeding types: active-overt and inactive-overt bleeding. The patient's history, laboratory results, endoscopic findings and therapeutic interventions were registered. Emergency SBE was defined as an endoscopy that was performed for active-overt OGIB, within 24 hours of clinical presentation.

RESULTS

Between January 2010 and February 2013, 53 SBEs were performed in 43 patients with overt OGIB. Seventeen emergency SBEs were performed in 15 patients with active overt-OGIB procedures (group A), which diagnosed the bleeding source in 14: angiodysplasia (n = 5), ulcers/erosions (n = 3), bleeding tumors (gastrointestinal stromal tumor (GIST), n = 3; neuroendocrine tumor, n = 1), and erosioned polyps (n = 2). Endoscopic treatment was performed in nine patients, with one or multiple hemostatic therapies: argon plasma coagulation (n = 5), epinephrine submucosal injection (n = 5), hemostatic clips (n = 3), and polypectomy (n = 2). Twenty-eight patients with inactive bleeding (group B) were submitted to 36 elective SBEs, which successfully diagnosed 18 cases. The diagnostic yield in group A (93.3%) was significantly higher than in group B (64.3%)-Fisher's exact test, p = 0.038.

CONCLUSION

This study revealed an important role of emergency SBE in the diagnosis of bleeding etiology in active overt OGIB.

Medical and endoscopic therapies for angiodysplasia and gastric antral vascular ectasia: a systematic review

BACKGROUND & AIMS

Few studies have compared the efficacy and complications of endoscopic or medical therapies for bleeding angiodysplasias or gastric antral vascular ectasias (GAVE). We conducted a systematic review to evaluate therapies.

METHODS

We performed a PubMed search for studies (written in English from January 1, 1980, through January 1, 2013) of medical or endoscopic treatment of bleeding angiodysplasias and GAVE. Measured outcomes included levels of hemoglobin, transfusion requirements, rebleeding rates, complications, treatment failures, and overall mortality.

RESULTS

We analyzed data from 63 studies that met inclusion criteria; 50 evaluated endoscopic treatment (1790 patients), 13 evaluated medical treatment (392 patients), and 12 were comparative studies. In patients with angiodysplasias, the combination of estrogen and progesterone did not significantly reduce bleeding episodes, compared with placebo (0.7/y vs 0.9/y, respectively), and increased mortality, compared with conservative therapy (33% vs 21%). A higher percentage of patients receiving octreotide were free of rebleeding at 1 and 2 years vs placebo (77% vs 55% and 68% vs 36%, respectively; P = .03). Thalidomide reduced the number of bleeding episodes (-8.96/y), compared with iron therapy (-1.38/y, P < .01), but neither treatment reduced mortality. More patients with GAVE treated by endoscopic band ligation were free from rebleeding (92%) than those treated with argon plasma coagulation (32%, P = .01).

CONCLUSIONS

In a systematic review, we found a low quality of evidence to support treatment of angiodysplasias with thalidomide or the combination of estrogen and progesterone and insufficient evidence to support treatment with octreotide. There is also insufficient evidence for endoscopic therapy of angiodysplasia or GAVE. Well-designed randomized controlled trials are needed to study the efficacy and complications of medical and endoscopic treatments for patients with angiodysplasias or GAVE.

Management of gastrointestinal angiodysplastic lesions (GIADs): a systematic review and meta-analysis

OBJECTIVES

Gastrointestinal angiodysplastic lesions (GIADs) are defined as pathologically dilated communications between veins and capillaries. The objective of this systematic review and meta-analysis was to determine the efficacy of available treatment modalities for GIADs.

METHODS

We identified eligible studies by searching through PubMed, SCOPUS, and Cochrane central register of controlled trials. We searched for clinical trials examining the efficacy of endoscopic, pharmacologic, or surgical therapy for GIADs. Data were pooled using a random-effects model, and the effect of response to medical or surgical therapy was reported as odds ratios with 95% confidence intervals (CIs). Data and quality indicators were extracted by two authors from 22 studies, including 831 individuals with GIADs. The analysis included 623 patients treated with endoscopic therapy, 63 with hormonal therapy, 72 patients with octreotide, and 73 status post aortic valve replacement surgery.

RESULTS

Hormonal therapy, based on two case-control studies, was not effective for bleeding cessation (odds ratio: 1.0, 95% CI: 0.5-1.96). On the basis of 14 studies including patients with gastric, colonic, and small-bowel GIADs, endoscopic therapy was effective as initial therapy, but the pooled recurrence bleeding rate was 36% (95% CI: 28-44%) over a mean (±s.d.) of 22±13 months. The event rate for re-bleeding increased to 45% (95% CI: 37-52%) when studies including only small-bowel GIADs were included (N=341). In four studies assessing the efficacy of somatostatin analogs, the pooled odds ratio was 14.5 (95% CI: 5.9-36) for bleeding cessation. In two studies assessing the role of aortic valve replacement (AVR) in 73 patients with Heyde's syndrome, the event rate for re-bleeding was 0.19 (95% CI: 0.11-0.30) over a mean follow-up period of 4 years postoperatively.

CONCLUSIONS

Over one-third of patients with GIADs experienced re-bleeding after endoscopic therapy. Somatostatin analogs and AVR for Heyde's syndrome appeared to be effective therapy for GIADs.

Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management

BACKGROUND

Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality.

AIM

To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors.

METHODS

A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract.

RESULTS

Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively.

CONCLUSIONS

Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.

Current treatment of lower gastrointestinal hemorrhage

Massive lower gastrointestinal bleeding is a significant and expensive problem that requires methodical evaluation, management, and treatment. After initial resuscitation, care should be taken to localize the site of bleeding. Once localized, lesions can then be treated with endoscopic or angiographic interventions, reserving surgery for ongoing or recurrent bleeding.

Lower gastrointestinal bleeding in chronic hemodialysis patients

Gastrointestinal (GI) bleeding is more common in patients with chronic kidney disease and is associated with higher mortality than in the general population. Blood losses in this patient population can be quite severe at times and it is important to differentiate anemia of chronic diseases from anemia due to GI bleeding. We review the literature on common causes of lower gastrointestinal bleeding (LGI) in chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. We suggest an approach to diagnosis and management of this problem.

Diagnosis and management of mid-gastrointestinal bleeding by double-balloon endoscopy

The new methods of capsule endoscopy (CE) and double-balloon endoscopy (DBE) have revolutionized the diagnostic approach to middle (mid) gastrointestinal bleeding (MGIB) in recent years. DBE also has therapeutic options and enables us to treat the MGIB endoscopically. In this review, we discuss endoscopic diagnosis and management of three major categories of sources of MGIB - vascular lesions, ulcers/erosions and tumors/polyps.

Treatment of gastrointestinal angiodysplasia and unmet needs

BACKGROUND

Gastrointestinal angiodysplasia (GIAD) may either be asymptomatic or induce overt or obscure bleeding with a high risk of recurrence. Numerous therapeutic options are available but evidence bases are lacking.

AIM

We conducted a comprehensive review of pharmacological and endoscopic treatments for previous or active bleeding GIAD and established the unmet needs of the clinicians.

METHODS

Clinical trials, series, and reports, having been selected through PubMed inquiry, manual searching, and reference list reviewing, were classified by levels of evidence.

RESULTS

Controlled studies focusing on GIAD treatment, excluding other GI vascular malformations, are rare. Endoscopic destruction, preferably using non-contact endoscopic techniques, is most often proposed as a first-line treatment for GIAD (expert level). In addition, APC is preferred over Nd:Yag laser due to the lower risk of perforation (expert level). Pharmacological treatments for GIAD are considered either when endoscopy fails to access the AD or in order to prevent rebleeding for "chronic bleeding patients." Octreotide and oestroprogestative treatments are the best evaluated drugs; however, no appropriate comparison on cost-effectiveness and tolerance has been performed.

CONCLUSIONS

The most effective therapeutic strategy for bleeding GIAD is currently inconclusive, and new trials should be performed to address unmet needs.

The role of endoscopy in the management of obscure GI bleeding

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, we performed a search of the medical literature by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).(1) The strength of individual recommendations is based both upon the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as "we suggest," whereas stronger recommendations are typically stated as "we recommend." This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Occult and obscure gastrointestinal bleeding: causes and clinical management

Occult gastrointestinal bleeding, defined as bleeding that is unknown to the patient, is the most common form of gastrointestinal bleeding and can be caused by virtually any lesion in the gastrointestinal tract. Patients with occult gastrointestinal bleeding include those with fecal occult blood and iron-deficiency anemia (IDA). In men and postmenopausal women, IDA should be considered to be the result of gastrointestinal bleeding until proven otherwise. Indeed, the possibility of gastrointestinal tract malignancy in these patients means that gastrointestinal evaluation is nearly always indicated. Obscure gastrointestinal bleeding is defined as obvious bleeding from a difficult to identify source and is always recurrent. This form of bleeding accounts for approximately 5% of all cases of clinically evident gastrointestinal bleeding and is most commonly caused by bleeding from the small intestine. Capsule endoscopy and deep enteroscopy have had a major impact on the way that patients with occult and, in particular, obscure bleeding are managed. In this Review the causes, diagnostic evaluation and treatment of occult and obscure gastrointestinal bleeding are discussed.

High diagnostic and clinical impact of small-bowel capsule endoscopy in patients with hereditary hemorrhagic telangiectasia with overt digestive bleeding and/or severe anemia

BACKGROUND

Patients with hereditary hemorrhagic telangiectasia (HHT) often present with recurrent anemia because of epistaxis or GI bleeding in relation to telangiectases mostly located in the stomach or small bowel. Capsule endoscopy is considered a major diagnostic tool for small-bowel diseases, but the impact of capsule endoscopy imaging on patient management in HHT is poorly understood.

OBJECTIVE

To clarify the contribution of capsule endoscopy in selected patients with HHT.

DESIGN

Prospective, descriptive study.

SETTING

Multicenter, two university hospital tertiary-care centers, from January 2003 to June 2007.

PATIENTS

This study involved 30 patients with HHT and severe anemia (hemoglobin <9 g/dL; normal: 11-15 g/dL) and minimal epistaxis or moderate anemia but overt GI bleeding.

INTERVENTION

Capsule endoscopy investigation.

MAIN OUTCOME MEASUREMENTS

Clinical characteristics and capsule endoscopy results and their clinical consequences.

RESULTS

Capsule endoscopy detected gastric and small-bowel telangiectases in 14 (46.7%) and 26 (86.7%) cases, respectively. Active bleeding was present in 36.7% of cases. Diffuse telangiectases were detected in 42.3% without correlation with age, sex, or type of HHT mutation. Further investigations were carried out as a consequence of the capsule endoscopy results in 67% of cases. Treatment, consisting mostly of endoscopic argon plasma coagulation, was scheduled in 46.7% of patients.

LIMITATIONS

Our population was essentially composed of patients with the ALK1 mutation.

CONCLUSION

This study shows that there is a high diagnostic yield for capsule endoscopy in selected patients with HHT. Capsule endoscopy makes possible precise mapping of lesions and has a considerable impact on the management of these selected patients by using a predefined algorithm: a limited number of accessible lesions is suitable for endoscopic treatment, whereas innumerable diffuse lesions require a medical approach. We suggest that capsule endoscopy could be a first-line, noninvasive, digestive tract examination in selected patients with HHT.

Risk factors for recurrence of acute gastrointestinal bleeding from angiodysplasia

BACKGROUND AND AIMS

Recurrent bleeding from gastrointestinal (GI) angiodysplasia remains a therapeutic challenge. Identification of factors predicting poor outcome of haemorrhage from angiodysplasia would help us to select the patients who may likely benefit from further therapy. Thus, we analysed risk factors for recurrence of acute GI haemorrhage from angiodysplasia.

PATIENTS AND METHODS

62 patients admitted consecutively with acute GI bleeding from angiodysplasia, between June 2002 and June 2006, were included. Bivariate, multivariate and survival analysis were performed to identify risk factors for recurrence of bleeding after hospital discharge.

RESULTS

Recurrence of acute haemorrhage after hospital discharge occurred in 17 of 57 (30%) patients (38 men; mean age: 74+/-6 years), after a mean follow-up (33+/-40 months). On Cox analysis, earlier history of bleeding with a high bleeding rate, over anticoagulation and the presence of multiple lesions were predictive factors of recurrence in a multivariate analysis. In contrast, endoscopic argon plasma coagulation (APC) therapy was not associated with lower rates of recurrent bleeding.

CONCLUSION

In patients with acute GI haemorrhage from angiodysplasia, earlier bleeding with a high bleeding rate, over anticoagulation and multiple angiodisplasic lesions predict an increased risk of recurrent bleeding. Although there is a trend towards better management with endoscopic APC therapy for the prevention of recurrence of bleeding, endoscopic APC therapy is not predictive of a lower rate of recurrence.

Spiral enteroscopy and push enteroscopy

Spiral enteroscopy is a new technique for endoscopic evaluation of the small bowel. Currently, more than 3000 cases have been performed worldwide. The Discovery SB device has been approved by the Food and Drug Administration and has been granted a CE mark. The technique is safe and effective for management and detection of small bowel pathology. Recent studies of spiral enteroscopy have demonstrated diagnostic yield, total time of procedure, and depth of insertion that compare favorably with double and single balloon enteroscopy. The strengths of spiral enteroscopy are rapid advancement in the small bowel and controlled, stable withdrawal that facilitates therapy. Future studies will be needed to compare competing technologies. Push enteroscopy is a readily available, safe and effective technique for detecting and treating proximal gut pathology. If performed without an overtube, complications are rare. Use of a dedicated push enteroscope with an overtube is generally reserved for specific indications in which a moderate increase in depth of insertion into the small bowel is required. When capsule endoscopy and deep small bowel enteroscopy are not available, push enteroscopy is a reasonable option with low risk and moderate yield. Push enteroscopy will remain an important part of the armamentarium of the modern endoscopist.

Enteroscopy in the diagnosis and management of obscure gastrointestinal bleeding

Capsule endoscopy and balloon-assisted enteroscopy, have revolutionized our approach to the diagnosis and management of patients with obscure gastrointestinal bleeding, largely replacing intraoperative enteroscopy and conventional barium studies. Despite its limitations, capsule endoscopy may well be the most reasonable initial diagnostic strategy to evaluate most patients with obscure gastrointestinal bleeding, leaving balloon-assisted enteroscopy in reserve as a complementary tool. This article reviews the data on enteroscopy, with particular emphasis on the use of capsule endoscopy and balloon-assisted enteroscopy for the diagnosis and management of patients with obscure gastrointestinal bleeding.

Enteroscopy: an overview

Although the small intestine has long been considered the final frontier of endoscopy, a vast amount of progress has led to increased diagnostic and therapeutic capabilities. With the increasing prevalence of capsule endoscopy, the need for enteroscopy also continues to increase. The endoscopic options currently available include double and single balloon-assisted enteroscopy, spiral enteroscopy, and lastly, intraoperative enteroscopy. The majority of published literature has focused on double balloon enteroscopy, but further studies have to provide information on the safety and yield of the newer techniques. Although intraoperative enteroscopy may be practiced less frequently, it has a role in the management of lesions that may not be approachable by other endoscopic means and a role in the guidance of surgical management.

Outcome after enteroscopy for patients with obscure GI bleeding: diagnostic comparison between double-balloon endoscopy and videocapsule endoscopy

BACKGROUND

Double-balloon endoscopy (DBE) and videocapsule endoscopy (VCE) have been useful in managing obscure GI bleeding (OGIB).

OBJECTIVE

This study compared diagnostic yields of OGIB between DBE and VCE, and evaluated the outcome after DBE.

DESIGN

A single-center retrospective study.

SETTING

A tertiary-referral hospital.

PATIENTS

Between June 2003 and February 2007, 162 consecutive patients with OGIB were enrolled and treated. The diagnostic yield between VCE and DBE was compared in 74 patients.

MAIN OUTCOME MEASUREMENTS

Comparison of diagnostic yields between DBE and VCE, and the prognosis after DBE.

RESULTS

Of 162 patients, 95 (59%) were diagnosed with small-bowel diseases. They were treated by medical, enteroscopic, and surgical therapies (n = 35, 30, and 30, respectively). A comparison of the overall diagnostic yield between DBE (64%) and VCE (54%) was not significantly different. The 4 VCE-positive DBE-negative cases were because of inaccessibility of DBE. The 11 VCE-negative DBE-positive cases were because of a failure to detect lesions in the proximal small bowel and the Roux-en-Y loop, and because of diverticula. At a median follow-up of 555 days after DBE, 11 patients with small-bowel diseases developed rebleeding; all were treated by enteroscopic or medical therapies. Vascular diseases, comorbidities, especially portal hypertensive disease and chronic renal failure that required hemodialysis, and severe anemia (Hb </=7.0 g/dL) were associated with rebleeding.

LIMITATIONS

A retrospective comparative study, and participation bias.

CONCLUSIONS

A complementary combination between DBE and VCE was useful for the management of OGIB. In particular, patients with vascular disease, comorbidities, and severe anemia should be intensively treated.

Cost-effectiveness analysis of management strategies for obscure GI bleeding

BACKGROUND AND AIMS

Of patients who are seen with GI hemorrhage, approximately 5% will have a small-bowel source. Management of these patients entails considerable expense. We performed a decision analysis to explore the optimal management strategy for obscure GI hemorrhage.

METHODS

We used a cost-effectiveness analysis to compare no therapy (reference arm) to 5 competing modalities for a 50-year-old patient with obscure overt bleeding: (1) push enteroscopy, (2) intraoperative enteroscopy, (3) angiography, (4) initial anterograde double-balloon enteroscopy (DBE) followed by retrograde DBE if the patient had ongoing bleeding, and (5) small-bowel capsule endoscopy (CE) followed by DBE guided by the CE findings. The model included prevalence rates for small-bowel lesions, sensitivity for each intervention, and the probability of spontaneous bleeding cessation. We examined total costs and quality-adjusted life years (QALY) over a 1-year time period.

RESULTS

An initial DBE was the most cost-effective approach. The no-therapy arm cost $532 and was associated with 0.870 QALYs compared with $2407 and 0.956 QALYs for the DBE approach, which resulted in an incremental cost-effectiveness ratio of $20,833 per QALY gained. Compared to the DBE approach, an initial CE was more costly and less effective. The initial DBE arm resulted in an 86% bleeding cessation rate compared to 76% for the CE arm and 59% for the no-therapy arm. The model results were robust to a wide range of sensitivity analyses.

LIMITATIONS

The short time horizon of the model, because of the lack of long-term data about the natural history of rebleeding from small-intestinal lesions.

CONCLUSIONS

An initial DBE is a cost-effective approach for patients with obscure bleeding. However, capsule-directed DBE may be associated with better long-term outcomes because of the potential for fewer complications and decreased utilization of endoscopic resources.

Impact of capsule endoscopy on outcome in mid-intestinal bleeding: a multicentre cohort study in 285 patients

BACKGROUND

Capsule endoscopy (CE) sensitively detects the bleeding source in the small bowel. However, the influence of CE on long-term outcome is not well established.

METHODS

In five tertiary hospitals, all CE investigations were retrospectively identified dating back to 3 years. Patients with intestinal bleeding and negative bidirectional endoscopy were included, and relapse of bleeding was recorded.

RESULTS

A bleeding source was detected in 219 of 285 patients (76.8%); CE provided the diagnosis in 175 of 219 (79.9%) and other, repeated investigations in 44 cases (20.1%). Follow-up (mean+/-SD=20.7+/-9.4 months) in 240 patients identified rebleeding in 65 (27.1%), and readmission to a hospital in 42 (17.5%). Hospital readmission was most frequent in patients with angiectasias (31.3%, relative risk (RR)=5.0; 95% confidence interval (CI)=2.4-10.4). Other risk factors included patients being older than 60 years of age (RR=3.8; 95% CI=1.5-9.5), and anticoagulant medication (RR=3.0; 95% CI=1.5-6.0). Therapeutic measures had a mean recurrence rate of 3.7% in surgical candidates (Meckel's diverticulum, tumor), 40% in endoscopically treated and 16% in medically treated patients. In case all the detected angiectasias had been cauterized, the relapse rate was low (11.8%), but in incompletely treated patients, it was high (85.7%). Bleeding relapse was never lethal.

CONCLUSION

CE guides therapeutic measures and predicts the risk of recurrent bleeding in small intestinal bleeding. High risk of rebleeding in angiectasias is significantly reduced by the cauterization of all demonstrable lesions.

Initial experience with double-balloon enteroscopy at a U.S. center

BACKGROUND

Double-balloon enteroscopy (DBE) allows direct visualization and intervention in the entire small intestine. Concerns include long procedure times and a long learning curve after training.

OBJECTIVES

To analyze the initial experience of a single endoscopist when using DBE; assess resource utilization, safety, clinical utility, and the learning curve.

DESIGN

Prospective study.

SETTING

Tertiary-referral center.

PATIENTS

A total of 137 consecutive patients with bleeding or other small-intestine disorders.

MAIN OUTCOME MEASURES

Clinical impact at the time of DBE and changes in the procedure time and extent with experience.

RESULTS

Two hundred DBE procedures were performed without major complications. For 115 oral DBEs, the mean (SD) procedure duration was 101 +/- 35 minutes and length of examined small intestine was 220 +/- 80 cm, with no significant change with experience. For 85 anal DBEs, the mean (SD) procedure duration was 96 +/- 33 minutes, and the length examined was 124 +/- 60 cm; the length examined increased with experience, but the duration did not decrease. The percentage of patients in which a DBE had a helpful clinical impact rose from 58% in the first 50 DBEs, to 86% in the last 50 of 200 DBEs. The total enteroscopy rose from 8% in the first 50 DBEs, to 63% in the last 50 of 200 DBEs.

LIMITATIONS

No follow-up data on outcomes.

CONCLUSIONS

DBEs required significant time and did not always allow for a total enteroscopy. DBEs were safe and helpful in the management of most patients. An experienced endoscopist may perform a safe and useful DBE after limited training, but the development of expertise may require more than 100 to 150 DBE procedures.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.

Push enteroscopy in the era of capsule endoscopy

GOALS

To evaluate the diagnostic yield of push enteroscopy in relation to indication and compare the yield in patients who had capsule endoscopy followed by push enteroscopy against capsule endoscopy naive patients.

BACKGROUND

With the advent of capsule endoscopy the role of push enteroscopy needs to be reevaluated.

STUDY

Patients who underwent push enteroscopy from January 2002 to May 2006 were included.

RESULTS

One hundred fifty-five patients underwent push enteroscopy: 93 females, average age 55 years. There were 74 cases where both push enteroscopy (PE) and capsule endoscopy (CE) were performed. Indications for PE were iron deficiency anemia (n=51), overt bleeding (n=31), suspected celiac disease (n=32), refractory celiac disease (n=19), assessment for Crohn's disease (n=10), and miscellaneous (n=12). In 148 patients, an average length of 70 cm of small bowel was examined (range 30 to 130 cm). PE was unsuccessful in 7 patients due to anatomic strictures or patient distress. The overall diagnostic yield was 30% with the highest yield in overt bleeding when compared with other subgroups (P<0.001). Nine percent of lesions were within the reach of a standard endoscope. Comparison of the diagnostic yield in patients who had CE followed by PE against CE naive patients was 41% versus 47%, respectively (P<1). There were no cases where push enteroscopy recognized a lesion that had not been already detected by capsule endoscopy.

CONCLUSIONS

Push enteroscopy has the greatest diagnostic yield in patients with overt bleeding when compared with other referral indications. PE should be used as an adjuvant to CE for therapeutic intervention.

American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding

This literature review and the recommendations therein were prepared for the AGA Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on March 12, 2007, and by the AGA Institute Governing Board on May 19, 2007.

Assessment of intestinal vascular malformations in patients with hereditary hemorrhagic teleangiectasia and anemia

INTRODUCTION

Hereditary hemorrhagic teleangiectasia (HHT) is an autosomal dominant disorder with mucocutaneous teleangiectasia and visceral arteriovenous malformations. Mutations of endoglin and Activin A receptor like kinase-1 have different phenotypes, HHT1 and HHT2, respectively. The gastrointestinal tract is frequently affected, but limited information is available on the relationship with genotype.

AIM

To determine whether different genotypes have different phenotypes with respect to intestinal teleangiectasia.

METHODS

HHT patients, referred for anemia, underwent videocapsule endoscopy. Chart review was performed for information on genotype and HHT manifestations.

RESULTS

Twenty-five patients were analyzed (men/women 13/9, mean age 49+/-15 years.), 14 HHT1, eight HHT2 and three without known mutation. Epistaxis occurred in 96% of patients. Gastroduodenoscopy revealed teleangiectasia in 7/12 (58%) HHT1 and 3/8 (38%) HHT2 patients. Videocapsule endoscopy found teleangiectasia in all HHT1 and 5/8 (63%) HHT2 patients. In 9/14 HHT1 patients, teleangiectasia were large. Teleangiectasia in the colon was restricted to 6/11 (55%) HHT1 patients. Hepatic arteriovenous malformations were present in 1/7 HHT1 and 5/6 HHT2 patients.

CONCLUSION

Large teleangiectasia in small intestine and colon appear to occur predominantly in HHT1. Hepatic arteriovenous malformations are mainly found in HHT2. In HHT patients with unexplained anemia, videocapsule endoscopy should be considered to determine the size and extent of teleangiectasia and exclude other abnormalities.

Long-term outcome of argon plasma ablation therapy for bleeding in 100 consecutive patients with colonic angiodysplasia

PURPOSE

Angiodysplasia is a frequent cause of colonic bleeding. Argon plasma coagulation was reported to be useful in endoscopic hemostasis. However, the long-term outcomes have been poorly evaluated. This study was designed to assess the long-term outcomes of bleeding patients with colonic angiodysplasia treated by argon plasma coagulation.

METHODS

A cohort of 100 patients with gastrointestinal bleeding caused by colonic angiodysplasia was studied prospectively. The endoscopic intervention was considered successful if there was no further overt bleeding and hemoglobin concentration was stabilized (primary end point). Secondary end points were the requirement of blood transfusions, the need for surgery, bleeding-related mortality, and overall mortality.

RESULTS

Overt bleeding resolved and hemoglobin levels were stabilized without transfusions or iron therapy in 85 of 100 patients (85 percent) after a median follow-up of 20 (range, 6-62) months. Transfusion requirements ceased in 90 percent of patients and only one required surgery. No patient died because of hemorrhage. In the subgroup of patients with anemia, mean hemoglobin levels increased from 9.3 (range, 5.5-12.2) g/dl before treatment to 12.6 (range, 7.4-16.7) g/dl after treatment (P < 0.01). The probability of remaining free of rebleeding at one and two year follow-up was 98 percent (95 percent confidence interval, 96-100) and 90 percent (95 percent confidence interval, 83-97), respectively. Among 118 procedures, only two complications were observed (1.7 percent).

CONCLUSIONS

Endoscopic argon plasma ablation therapy is useful in the management of bleeding from colonic angiodysplasia.

Diagnosis of obscure gastrointestinal bleeding by intra-operative enteroscopy in 81 consecutive patients

AIM: To analyze the results and complications of intra-operative enteroscopy (IOE) by investigating a series of selected patients with bleeding suspected to originate from the small intestine.

METHODS: Eighty-one patients (mean age: 65 years) including 40 males (49.4%) and 41 females (50.6%) with obscure gastrointestinal bleeding underwent IOE between 1990 and 2004. The patients were identified from a database and data were selected from the patients’ charts retrospectively. All the patients had undergone at least one non-diagnostic esophagogastroduodenoscopy, colonoscopy, standard enteroscopy and a negative abdominal ultrasound scan before IOE.

RESULTS: The median minimal hemoglobin level in the patients was 59 + 15 g/L and 72.8% of the patients required transfusion of packed erythrocytes previously. A bleeding source was detected in 68 (84%) of the patients during IOE. Angiodysplasiae were found in 44 patients (54.3%) and 9 patients (11.1%) were affected by ulcers in the small intestine. A tumor in the small intestine was detected in another 6 patients. The treatment consisted of argon-plasma-coagulation, surgical suture or limited resection in most of the patients.

CONCLUSION: Intra-operative enteroscopy is still used for the diagnosis of suspected small bowel bleeding. Recent developments such as wireless capsule endoscopy and double balloon enteroscopy, may lead to the replacement of IOE in the future.

Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up

BACKGROUND

The long-term efficacy of argon plasma coagulation (APC) in the management of gastrointestinal vascular lesions has not been evaluated in a large and well-defined series. The impact of APC on transfusion requirements and hemoglobin, and technical parameters including complications and number of treatment sessions, is assessed in this series.

METHODS

Patients who underwent APC for bleeding gastrointestinal vascular lesions were identified via interrogation of an established endoscopic database, excluding patients with radiation proctitis, tumors, residual polypectomy tissue and acute ulcer bleeding. Follow-up data were collected via interview with patients and referring doctors, review of medical records, and follow-up blood tests.

RESULTS

One hundred patients were enrolled, males = 46, median age = 74 yr (range: 19-99 yr). Median follow-up time was 16 months (range: 4-47 months). Lesions treated were arteriovenous malformations (n = 74) and gastric antral vascular ectasia (n = 26). Fifty-three patients required transfusion. In this group, median hemoglobin improved from 66 g/L (range: 35-114) to 111 g/L (range: 55-155, p < 0.001). Median transfusion velocity fell from 2 units/month (range: 0.1-6) to 0 units/month (range: 0-4, p < 0.001). Transfusion requirement was abolished in 77%. In non-transfusion-requiring patients, median hemoglobin improved from 105 g/L (range: 58-143) to 123 g/L (range: 79-158, p < 0.001). No complications occurred.

CONCLUSIONS

APC is effective and safe in the management of gastrointestinal vascular lesions.

Obscure gastrointestinal bleeding

Obscure GI bleeding is a relatively common problem facing internists, gastroenterologists, and surgeons in a typical clinical practice. The etiology is occasionally suggested by the patient's age, history, and medications. Management is complicated and typically requires a team-oriented approach, with input from the internist, gastroenterologist, radiologist, and surgeon alike. SBFT and enteroclysis seem to have a limited role, unless there is a high suspicion of a small bowel mass lesion or Crohn's disease. Scintigraphy may be performed in patients with active bleeding in whom endoscopy has failed oris contraindicated. Angiography may be used in patients with an early positive nuclear imaging or failed endoscopic therapy. Provocative angiography probably has a lower diagnostic yield than previously reported, and should be performed only in experienced centers. Helical CT is a new and potentially important option in patients with obscure bleeding, but is currently considered experimental. All patients with obscure GI bleeding should undergo repeat upper endoscopy and perhaps colonoscopy to rule out missed lesions. SBE seems to be complementary to capsule endoscopy, and it is unknown whether this should be performed before capsule endoscopy or only if capsule endoscopy yields a positive proximal small bowel finding. Double balloon enteroscopy seems promising, but the technique requires further study. Surgery should be reserved for patients who have a positive capsule endoscopy requiring surgical therapy or patients who have persistent GI bleeding requiring recurrent blood transfusions in whom all other modalities have failed. Treatment for vascularectasias, the most common cause of obscure GI bleeding, is currently inadequate,and typically requires a combination of multiple management approaches.

Small Bowel Bleeding

The management of patients with small bowel bleeding remains a diagnostic and therapeutic challenge. In most gastrointestinal bleeding episodes, the source of hemorrhage is localized to either the upper gastrointestinal tract or colon; however, in about 5% of cases, upper endoscopy and colonoscopy are nondiagnostic, and the small intestine is the site of bleeding. Patients with suspected small bowel source of bleeding may present with either occult blood loss or recurrent overt gastrointestinal hemorrhage requiring frequent blood transfusions and hospitalizations. Knowing the etiology and site of hemorrhage is essential prior to initiating appropriate therapy. The most common causes of small bowel bleeding are vascular ectasia, tumors, ulcerative diseases, and Meckel's diverticula. For patients with severe obscure bleeding, push enteroscopy with a 220- to 250-cm enteroscope is strongly recommended. This procedure provides not only a thorough examination for diagnosis, but also allows for biopsy, tattooing, and hemostasis of lesions. If enteroscopy is nondiagnostic, capsule endoscopy is recommended. A diagnostic capsule endoscopy will direct appropriate medical, endoscopic, or surgical intervention, depending on whether the lesion is single or multiple, and whether the patient is a surgical candidate for intraoperative enteroscopy. Intraoperative enteroscopy should be strongly considered in patients with recurrent bleeding and a nondiagnostic evaluation. Laparoscopy and intraoperative enteroscopy is highly recommended in young patients (< 50 years of age) because there is an increased frequency of small bowel tumors and Meckel's diverticulum which are amenable to surgical therapy.

N/A

N/A

Argon plasma coagulation for prevention of recurrent bleeding from GI angiodysplasias

BACKGROUND

Angiodysplasia is a frequent cause of GI bleeding. Argon plasma coagulation has been shown to arrest bleeding, but its efficacy for prevention of recurrent bleeding has not been thoroughly evaluated. This study assessed the effectiveness and the safety of argon plasma coagulation for prevention of recurrent bleeding from GI angiodysplasias.

METHODS

A total of 60 patients with GI bleeding caused by angiodysplasia were included. The endoscopic intervention was considered successful if there was no further overt bleeding and if the Hb level stabilized. Recurrent bleeding was defined as any detectable bleeding episode (hematemesis, melena, or hematochezia) or a decrease in Hb level.

RESULTS

Overt bleeding was resolved, and the Hb level stabilized without transfusion or supplemental iron therapy in 50 of the 60 patients (83%) at a median follow-up of 18 months (range 6-38 months). In the subgroup of patients with anemia, mean Hb level increased from 8.6 g/dL (range 5.1-12.2 g/dL) to 12 g/dL (range 8.0-15.2 g/dL) ( p < 0.01). The estimated probability of remaining free of recurrent bleeding at 1- and 2-year follow-up was 86%: 95% CI [73%, 93%] and 80%: 95% CI [64%, 89%], respectively. Among 72 procedures, only two were associated with a complication (2.8%).

CONCLUSIONS

Endoscopic argon plasma coagulation is both effective and safe for prevention of recurrent bleeding from GI angiodysplasia.

Push enteroscopy for gastrointestinal bleeding

AIM

Little is known about the long-term course of patients explored by push enteroscopy for gastrointestinal bleeding of obscure origin. This study aimed to determine the diagnostic yield and the therapeutic impact of enteroscopy, the rate of rebleeding and predictive factors of rebleeding in these patients.

PATIENTS AND METHODS

One hundred nineteen patients underwent push enteroscopy for overt bleeding (N=66) or anemia (N=53).

RESULTS

Enteroscopy was positive in 42% of patients (colon 17%, stomach 13%, small bowel 12%) and diagnosed arteriovenous malformations in two-thirds of patients. Twenty-five additional diagnoses were established during the 2-month follow-up. Treatment was definitive in 13% of patients, without recurrent bleeding. Rebleeding occurred in 45% of patients, and was more frequent when a lesion was visualized (73% vs 28% after 5 years, P=0.02). In multivariate analysis, a lesion visualized by enteroscopy was the only independent predictive factor.

CONCLUSION

Enteroscopy is not a high-performance diagnostic tool for obscure gastrointestinal bleeding and enables definitive treatment in less than 15% of patients.

Angiodisplasia múltiple de intestino delgado. Un reto diagnóstico y terapéutico

Small bowel bleeding is infrequent and presents a challenge to the clinician. Approximately 30-40% of gastrointestinal bleeding localized in the small bowel is due to angiodysplasia, a vascular malformation. We present the case of a patient with multiple angiodysplasia of the small bowel who required push enteroscopy and capsule endoscopy to establish the diagnosis. Treatment with subcutaneous octreotide was successful. In conclusion, in doubtful cases or in patients with persistent hemorrhage, capsule endoscopy can improve the diagnostic yield of enteroscopy in bleeding gastrointestinal vascular lesions such as angiodysplasia. Endoscopic treatment (laser coagulation) and drug therapy (somatostatin or analogs) are valid alternatives in inoperable or non-resectable cases.

Obscure gastrointestinal bleeding

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.