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Double-balloon enteroscopy (DBE) in patients presenting with obscure gastrointestinal bleeding (OGIB). Arab J Gastroenterol 2018; 18:228-233. [PMID: 29325750 DOI: 10.1016/j.ajg.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 08/07/2017] [Accepted: 11/12/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND STUDY AIMS Obscure gastrointestinal bleeding (OGIB) is defined as bleeding of unknown origin that persists or recurs after an initial negative investigation. Identifying the source of OGIB represents a diagnostic challenge that is frequently focused on visualizing the small intestine. Conventional diagnostic methods, such as push enteroscopy, small-bowel follow-through, radionuclide scanning, and angiography, each exhibit inherent limitations. Double balloon enteroscopy (DBE) was designed specifically to evaluate the entire small bowel. DBE allows for better visualization, biopsy of the identified lesions and application of therapeutic techniques. This study sought to assess the role of DBE in the diagnosis and management of patients with OGIB. PATIENTS AND METHODS This prospective study was conducted to analyse data from 31 patients presenting with OGIB referred for DBE in the Endoscopy Unit at the Internal Medicine Department of the Faculty of Medicine, Cairo University. RESULTS Five patients had lesions in locations other than the small intestine that accounted for GI bleeding. Thus, the potential source of OGIB was defined as the small intestine in 18 of 26 patients (69.2%), and negative DBE findings were noted in eight patients (30.8%). Major findings included small intestinal tumours in eight patients, vascular bleeding lesions in 8 patients and ulcerations in 2 patients. Endoscopic haemostasis was performed in eight patients with vascular lesions. The three patients with Petuz-Jegher syndrome underwent polypectomy of their major polyps. Patients with gastrointestinal tumours were referred for surgery. CONCLUSION DBE is an excellent endoscopic procedure that has a relatively high diagnostic and therapeutic yield. The procedure is feasible and exhibits a high safety profile with a low complication rate when performed by an experienced endoscopist.
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Randomized controlled trial comparing outcomes of video capsule endoscopy with push enteroscopy in obscure gastrointestinal bleeding. Can J Gastroenterol Hepatol 2015; 29:85-90. [PMID: 25803018 PMCID: PMC4373566 DOI: 10.1155/2015/897567] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Optimal management of obscure gastrointestinal bleeding (OGIB) remains unclear. OBJECTIVE To evaluate diagnostic yields and downstream clinical outcomes comparing video capsule endoscopy (VCE) with push enteroscopy (PE). METHODS Patients with OGIB and negative esophagogastroduodenoscopies and colonoscopies were randomly assigned to VCE or PE and followed for 12 months. End points included diagnostic yield, acute or chronic bleeding, health resource utilization and crossovers. RESULTS Data from 79 patients were analyzed (VCE n=40; PE n=39; 82.3% overt OGIB). VCE had greater diagnostic yield (72.5% versus 48.7%; P<0.05), especially in the distal small bowel (58% versus 13%; P<0.01). More VCE-identified lesions were rated possible or certain causes of bleeding (79.3% versus 35.0%; P<0.05). During follow-up, there were no differences in the rates of ongoing bleeding (acute [40.0% versus 38.5%; P not significant], chronic [32.5% versus 45.6%; P not significant]), nor in health resource utilization. Fewer VCE-first patients crossed over due to ongoing bleeding (22.5% versus 48.7%; P<0.05). CONCLUSIONS A VCE-first approach had a significant diagnostic advantage over PE-first in patients with OGIB, especially with regard to detecting small bowel lesions, affecting clinical certainty and subsequent further small bowel investigations, with no subsequent differences in bleeding or resource utilization outcomes in follow-up. These findings question the clinical relevance of many of the discovered endoscopic lesions or the ability to treat most of these effectively over time. Improved prognostication of both patient characteristics and endoscopic lesion appearance with regard to bleeding behaviour, coupled with the impact of therapeutic deep enteroscopy, is now required using adapted, high-quality study methodologies.
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Imai Y, Mizuno Y, Yoshino K, Watanabe K, Sugawara K, Motoya D, Oka M, Mochida S. Long-term efficacy of endoscopic coagulation for different types of gastric vascular ectasia. World J Gastroenterol 2013; 19:2799-2805. [PMID: 23687417 PMCID: PMC3653154 DOI: 10.3748/wjg.v19.i18.2799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Revised: 02/01/2013] [Accepted: 03/07/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine the long-term therapeutic efficacies of endoscopic cauterization for gastric vascular ectasia, according to the type of lesion.
METHODS: Thirty-eight patients with hemorrhagic gastric vascular ectasia (VE) were treated by endoscopic cauterization: 13 by heater probe coagulationand 25 by argon plasma coagulation. Depending on the number of lesions, 14 and 24 patients were classified into localized VE (≤ 10; LVE) and extensive VE (> 10; EVE), respectively. The patients were followed-up by repeated endoscopic examinations after the therapy, and the incidences of VE recurrence and re-bleeding from the lesions were evaluated.
RESULTS: Although the VE lesions disappeared initially in all the patients after the therapy, the recurrence of VE developed in 25 patients (66%) over a mid-term observation period of 32 mo, and re-bleeding occurred in 15 patients (39%). The recurrence of VE was found in all patients with EVE, with re-bleeding occurring in 14 patients (58%). In contrast, only 1 patient (7%) with LVE showed recurrence of the lesions and complicating hemorrhage. Both the cumulative recurrence-free rates and cumulative re-bleeding-free rates were significantly lower in the EVE group than in the LVE group (P < 0.001 and P < 0.001, respectively). Moreover, the cumulative re-bleeding-free rate in the EVE group was 47.6% at 1 year and 25.4% at 2 years in patients with chronic renal failure, which were significantly lower than the rates in the patients without chronic renal failure (83.3% and 74.1%, respectively) (P < 0.05).
CONCLUSION: The recurrence of VE and re-bleeding from the lesions was more frequent in the patients with EVE, especially in those with complicating renal failure.
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Li X, Dai J, Lu H, Gao Y, Chen H, Ge Z. A prospective study on evaluating the diagnostic yield of video capsule endoscopy followed by directed double-balloon enteroscopy in patients with obscure gastrointestinal bleeding. Dig Dis Sci 2010; 55:1704-10. [PMID: 19672712 DOI: 10.1007/s10620-009-0911-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Accepted: 07/05/2009] [Indexed: 12/12/2022]
Abstract
AIMS Video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) are two novel methods for examining the small bowel and could be complementary to each other. The aim of the present study is to prospectively evaluate the diagnostic yield of VCE followed by a directed DBE in patients with obscure gastrointestinal (GI) bleeding. METHODS Patients with obscure gastrointestinal bleeding for a complete VCE examination were involved in the study. DBE was recommended after a negative or indeterminate finding of VCE. The diagnostic and follow-up data were collected for analysis. RESULTS A total of 190 patients with a complete VCE examination were enrolled in the study. The overall positive detection rate for small-bowel disease in the VCE group was 86.8% (165/190), while 63.7% (121/190) patients were definitely diagnosed. Fifty-one patients with indeterminate (44 cases) and negative (seven cases) findings of first VCE underwent DBE procedures. A total of 18 patients with negative VCE findings refused the further examination. DBE demonstrated a positive finding in 66.7% (34/51) patients, 33 from indeterminate group and one from the negative group. Following an unrevealing DBE, at surgical follow-up, three further negative DBE procedures were documented. The overall diagnostic yield was 88.9%, including 121 diagnoses made by VCE alone and 48 by both VCE and DBE (confirmed at surgery or other treatments). The negative predictive value (NPV) and positive predictive value (PPV) of DBE in indeterminate VCE were 81.8 and 100%, respectively. CONCLUSIONS Capsule endoscopy followed by directed double-balloon enteroscopy is a good strategy for investigating the causes of obscure GI bleeding and especially in confirming indeterminate and negative findings from VCE.
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Affiliation(s)
- Xiaobo Li
- Department of Gastroenterology, Shanghai Renji Hospital, Shanghai Institute of Digestive Disease, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Abstract
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.
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Zakaria MS, El-Serafy MA, Hamza IM, Zachariah KS, El-Baz TM, Bures J, Tacheci I, Rejchrt S. The role of capsule endoscopy in obscure gastrointestinal bleeding. Arab J Gastroenterol 2009. [DOI: 10.1016/j.ajg.2009.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Moawad FJ, Veerappan GR, Wong RKH. Small bowel is the primary source of obscure gastrointestinal bleeding. Gastroenterology 2008; 135:1016. [PMID: 18694750 DOI: 10.1053/j.gastro.2008.05.083] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Accepted: 05/06/2008] [Indexed: 12/02/2022]
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Capsule endoscopy for obscure GI bleeding yields a high incidence of significant treatable lesions within reach of standard upper endoscopy. J Clin Gastroenterol 2008; 42:962-3. [PMID: 18645532 DOI: 10.1097/mcg.0b013e31811edce5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Apostolopoulos P, Liatsos C, Gralnek IM, Kalantzis C, Giannakoulopoulou E, Alexandrakis G, Tsibouris P, Kalafatis E, Kalantzis N. Evaluation of capsule endoscopy in active, mild-to-moderate, overt, obscure GI bleeding. Gastrointest Endosc 2007; 66:1174-81. [PMID: 18061718 DOI: 10.1016/j.gie.2007.06.058] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Accepted: 06/25/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND The role of capsule endoscopy (CE) in the diagnosis of active mild-to-moderate GI bleeding (GIB) immediately after a negative EGD and ileocolonoscopy has not been prospectively evaluated. OBJECTIVE To estimate the diagnostic yield and clinical significance of CE in patients with acute, obscure, overt, mild-to-moderate GIB. DESIGN A single-center prospective study. PATIENTS During a 3-year period, 573 patients admitted to the hospital with acute mild-to-moderate GIB were included in this study. Among them, 37 patients (6.5%) with negative endoscopic findings, after urgent upper- and lower-GI endoscopies, underwent CE within the first 48 hours to identify the source of bleeding. RESULTS CE revealed active bleeding in 34 patients and a diagnostic yield of 91.9%, including angiodysplasias in 18 patients, ulcers in 3 patients, and tumors in 2 patients. In the remaining 11 patients (32%), CE revealed the site of bleeding: distal duodenum in 1 case (9%), jejunum in 6 cases (54%), ileum in 2 cases (18%), and cecum in 2 cases (18%). From the 37 bleeders, 16 were managed conservatively, 14 endoscopically, and 7 surgically. During a 12-month follow-up period, bleeding recurrence was observed in 5 of 32 (15.6%). LIMITATIONS This study had a limited number of patients. CONCLUSIONS CE appeared to have a high diagnostic yield in patients with acute, mild-to-moderate, active hemorrhage of obscure origin when performed in the hospital after a negative standard endoscopic evaluation and has important clinical value in guiding medical management.
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Beard C, Poulos JE, Kalle J, Kumar A, Kodali V. Capsule endoscopy: what role for this new technology? JAAPA 2007; 20:32-3, 35-6, 38. [PMID: 17902540 DOI: 10.1097/01720610-200709000-00013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christina Beard
- Fayetteville Gastroenterology Associates, Fayetteville, North Carolina, USA
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Lee BJ, Park JJ, Seo YS, Kim JH, Kim A, Yeon JE, Kim JS, Byun KS, Bak YT. Upper gastrointestinal bleeding from duodenal vascular ectasia in a patient with cirrhosis. World J Gastroenterol 2007; 13:5154-7. [PMID: 17876885 PMCID: PMC4434649 DOI: 10.3748/wjg.v13.i38.5154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We report a cirrhotic patient with duodenal vascular ectasia and spontaneous bleeding. The bleeding was successfully controlled with argon plasma coagulation. Duodenal vascular ectasia may be a cause of upper gastrointestinal bleeding in patients with cirrhosis, and argon plasma coagulation may be effective and safe to achieve hemostasis of this lesion.
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Affiliation(s)
- Beom Jae Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Guro Hospital, Gurodong-gil 97, Guro-gu, Seoul 152-703, Korea
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Chen HL, Lin SC, Chang WH, Yang TL, Chen YJ. Identification of ectopic pancreas in the ileum by capsule endoscopy. J Formos Med Assoc 2007; 106:240-3. [PMID: 17389169 DOI: 10.1016/s0929-6646(09)60246-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Ectopic pancreas, an uncommon submucosal tumor in the gastrointestinal (GI) tract, is histologically similar to normal pancreatic tissue. We present a case of ectopic pancreas in the ileum. A 35-year-old man had intermittent dark bloody stool for 2 months accompanied by epigastric pain and postprandial abdominal fullness. Esophagogastroduodenoscopy and colonoscopy did not reveal any abnormalities. Capsule endoscopy revealed a small red polyp in the ileum. Abdominal computed tomography scan and small bowel barium follow-through study were not of any help. GI bleeding and abdominal discomfort were resolved after the lesion was surgically removed. Pathologic examination demonstrated pancreatic acinar cells and a secretory duct in the ileal submucosa, consistent with ectopic pancreas. Ectopic pancreas in the small intestine may be a rare cause of obscure GI bleeding. Capsule endoscopy seems to be a good, noninvasive tool for identification in the small bowel, particularly when other imaging modalities fail to detect any abnormalities.
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Affiliation(s)
- Huan-Lin Chen
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
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Abstract
Obscure gastrointestinal bleeding (OGIB) is defined as an intermittent or continuous loss of blood in which the source has not been identified after upper endoscopy and colonoscopy. It constitutes a diagnostic and therapeutic challenge for the general internist and the gastroenterologist. This article provides an overview of the etiology, clinical presentation, and diagnostic modalities of OGIB including push enteroscopy, double balloon enteroscopy, wireless capsule endoscopy, enteroclysis, angiography, bleeding scanning with labeled red blood cells, and surgery with intraoperative enteroscopy. Therapeutic modalities including iron replacement, combined hormones, octreotide acetate, therapeutic endoscopy, and surgery are also discussed. In addition, a rational approach to patients with OGIB according to the clinical presentation is presented herein.
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Affiliation(s)
- Ronald Concha
- Division of Gastroenterology, University of Miami, Miller School of Medicine/Mt. Sinai Medical Center, Miami Beach, FL 33140, USA
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van Tuyl SAC, Letteboer TGW, Rogge-Wolf C, Kuipers EJ, Snijder RJ, Westermann CJJ, Stolk MFJ. Assessment of intestinal vascular malformations in patients with hereditary hemorrhagic teleangiectasia and anemia. Eur J Gastroenterol Hepatol 2007; 19:153-8. [PMID: 17273001 DOI: 10.1097/01.meg.0000252633.88419.04] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Fix OK, Simon JT, Farraye FA, Oviedo JA, Pratt DS, Chen WT, Cave DR. Obscure gastrointestinal hemorrhage from mesenteric varices diagnosed by video capsule endoscopy. Dig Dis Sci 2006; 51:1169-74. [PMID: 16944004 DOI: 10.1007/s10620-006-8027-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Accepted: 08/04/2005] [Indexed: 01/24/2023]
Affiliation(s)
- Oren K Fix
- Section of Gastroenterology, Boston University Medical Center, Boston, MA, and Division of Gastroenterology, Rhode Island Hospital, Providence, USA.
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Yau KK, Siu WT, Law BKB, Yip KF, Tang WL, Li MKW. Laparoscopy-assisted surgical management of obscure gastrointestinal bleeding secondary to Meckel's diverticulum in a pediatric patient: case report and review of literature. Surg Laparosc Endosc Percutan Tech 2006; 15:374-7. [PMID: 16340574 DOI: 10.1097/01.sle.0000191587.46367.7b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Despite advances in endoscopy and imaging, acute gastrointestinal (GI) bleeding of obscure origin in children presents a challenge to pediatric gastroenterologist. Bleeding Meckel's diverticulum (MD) commonly presents with acute episode of lower GI bleeding. A conventional diagnostic algorithm includes endoscopy, technetium 99m pertechnetate scintigraphy, angiography, and exploratory laparotomy. The advent of minimal access surgery prompts the use of laparoscopy for children with obscure GI bleeding. Laparoscopy assists in the diagnosis and can offer definitive treatment of patients with MD. Herein, we report a case of pediatric GI bleeding of obscure origin associated with MD that was successfully diagnosed and managed via laparoscopy. This article updates the current management for pediatric patients with obscure GI bleeding and the role of laparoscopy in the management of MD.
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Affiliation(s)
- Kwok Kay Yau
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, SAR, China
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Hadithi M, Heine GDN, Jacobs MAJM, van Bodegraven AA, V Bodegraven AA, Mulder CJJ. A prospective study comparing video capsule endoscopy with double-balloon enteroscopy in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2006; 101:52-7. [PMID: 16405533 DOI: 10.1111/j.1572-0241.2005.00346.x] [Citation(s) in RCA: 181] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Obscure gastrointestinal bleeding from jejunal and ileal lesions remains undiagnosed using traditional imaging techniques (radiologic, endoscopic). This prospective study compares the diagnostic detection rate of small-bowel lesions using wireless video capsule endoscopy (VCE) with the detection rate using double-balloon enteroscopy (DBE) in patients with obscure gastrointestinal bleeding (OGIB). Tolerance, adverse events, endoscopic interventions, and prognosis were described as secondary aims. METHODS Thirty-five consecutive patients with obscure gastrointestinal bleeding were evaluated (22 males and 13 females; mean age 63.2 yr; range, 19-86 yr). The detection rates of the Given M2A wireless VCE and DBE were compared. RESULTS Small-bowel abnormalities were detected using VCE in 28 (80%) of the 35 patients with OGIB, compared with 21 (60%) of the 35 patients using DBE (p = 0.01). Both examinations were well tolerated, but VCE was more acceptable to patients. No major adverse event occurred after either examination. Biopsies (n = 27), argon plasma coagulation (n = 19), tattoo injection (n = 8), and polypectomy (n = 2) were feasible with DBE when indicated in 27 of the 35 patients (77%). During a median (range) follow-up period of 5 (2-12) months, 26 (74%) patients remained clinically stable and did not require blood transfusions after DBE procedures. Eighteen (51%) of those who remained clinically stable had received APC therapy. CONCLUSIONS High detection rates of the causes of OGIB are feasible with VCE and DBE. Although the detection rate of VCE was superior, our results indicate that the procedures are complementary; an initial diagnostic imaging employing VCE might be followed by therapeutic and interventional DBE.
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Affiliation(s)
- Muhammed Hadithi
- Small Bowel Diseases Unit, Department of Gastroenterology, VU University Medical Center, Amsterdam, the Netherlands
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Pei K, Zemon H, Venbrux A, Brody F. Laparoendoscopic Techniques for Occult Gastrointestinal Bleeding. J Laparoendosc Adv Surg Tech A 2005; 15:615-9. [PMID: 16366869 DOI: 10.1089/lap.2005.15.615] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Up to 5% of gastrointestinal bleeds occur between the ligament of Treitz and the ileocecal valve. These patients present with occult bleeding and pose diagnostic and therapeutic challenges. Currently, an array of technology exists for diagnostic purposes, including upper and lower endoscopies, capsule endoscopy, nuclear scans, angiography, and intraoperative endoscopy. All of these modalities have advantages and disadvantages. However, the diagnostic gold standard for occult gastrointestinal bleeding does not exist. We present a case of an 18-year-old male with occult gastrointestinal bleeding to illustrate the variety of available modalities. Initially, the patient underwent upper, lower, and push endoscopies. Subsequently, he had a nuclear bleeding scan, video capsule endoscopy, and an angiogram. Ultimately, the patient had a diagnostic laparoscopy with mobilization of the terminal ileum and right colon. The bowel was exteriorized and an intraoperative endoscopy was performed through a small bowel enterotomy. Multiple arteriovenous malformations (AVMs) were ascertained and resected. This case is presented in detail and the technique of intraoperative endscopy is reviewed. The diagnostic literature regarding AVMs is also reviewed.
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Affiliation(s)
- K Pei
- Department of Surgery, The George Washington University Medical Center, Washington, DC 20037, USA
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Abstract
A randomized controlled trial (RCT) of routine urgent colonoscopy in severe lower gastrointestinal tract bleeding is reported in this journal from Duke. The only significant differences in results between the standard management (emergency red blood cell (RBC) scanning and angiography with elective colonoscopy) and urgent colonoscopy were in rates of finding a definitive bleeding site-one with a major stigmata of hemorrhage-and in not making a diagnosis. The trial was stopped early for logistics reasons a decade ago. The strengths and limitations of the study are discussed and contrasted with recent reports of other investigators. Similar to management of patients with non-variceal upper gastrointestinal tract (UGI) hemorrhage, triaging patients to level of care by comorbidity scores and stigmata of hemorrhage, successful colonoscopic hemostasis of focal lesions, and individualization of long-term medical, endoscopic, and surgical care are recommended based on promising reports by other investigators. Meanwhile, further RCTs for patients with severe hematochezia are warranted.
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Abstract
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.
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Affiliation(s)
- Thomas O G Kovacs
- Division of Digestive Diseases, CURE Digestive Diseases Research Center, David Geffen UCLA School of Medicine, Building 115, Room 212, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, USA
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Sears DM, Avots-Avotins A, Culp K, Gavin MW. Frequency and clinical outcome of capsule retention during capsule endoscopy for GI bleeding of obscure origin. Gastrointest Endosc 2004; 60:822-7. [PMID: 15557969 DOI: 10.1016/s0016-5107(04)02019-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Capsule endoscopy is now commonly performed for GI bleeding of obscure origin. Regional transit abnormality refers to slowed capsule movement during capsule endoscopy. The frequency and clinical outcome of capsule retention and regional transit abnormalities are unknown. METHODS Initial capsule endoscopies performed at a single institution in 52 patients with GI bleeding of obscure origin were reviewed retrospectively. For patients with capsule retention or regional transit abnormality, preprocedural characteristics, and post-procedural outcomes were recorded. OBSERVATIONS Capsule retention occurred in 7 patients, all of whom remained asymptomatic. Regional transit abnormality was noted in 3 patients. Sources of bleeding were localized in all cases. Seven patients underwent surgery. Stricture induced by non-steroidal anti-inflammatory drugs was the major cause of retention. In all patients, anemia resolved during follow-up. CONCLUSIONS Capsule retention and regional transit abnormality occurred in almost 20% of patients who had capsule endoscopy for GI bleeding of obscure origin. These capsule movement abnormalities led to the diagnosis of bleeding sources and thereby influenced patient management. A history of non-steroidal anti-inflammatory drugs use may be associated with an increased risk of capsule retention.
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Affiliation(s)
- Dawn M Sears
- Division of Gastoenterology, Scott and White Memorial Hospital, Texas A&M Health Sciences Center, Temple, USA
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22
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Wassef W. Upper gastrointestinal bleeding. Curr Opin Gastroenterol 2004; 20:538-45. [PMID: 15703679 DOI: 10.1097/00001574-200411000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW This review discusses key issues in the management of upper gastrointestinal bleeding including patient preparation, sedation, hemostatic techniques, disposition, and recommended pharmacologic interventions. RECENT FINDINGS Optimal resuscitation before endoscopy and proper pharmacologic interventions after endoscopy seem to be as crucial to the management of patients with upper gastrointestinal bleeding as meticulous hemostatic techniques during the procedure. In a retrospective evaluation of patients with upper gastrointestinal bleeding, multivariate analysis demonstrated significantly reduced morbidity and mortality in those who underwent aggressive preendoscopic resuscitation. In a prospective, randomized clinical trial, patients who received intravenous proton pump inhibitor therapy after endoscopic intervention had a significantly reduced rebleeding rate compared with their placebo control group. SUMMARY The algorithms described in this review can be applied clinically today and should directly lead to improved outcome. Nevertheless, even with the latest care available, results are not optimal. This review points to two major areas where we can benefit from improvement: primary hemostasis and recurrent bleeding. By pointing to these limitations, it is hoped that this review can help stimulate research in the field by applying new technologies to solve these problems. Endoscopic ultrasound, for example, could be used to help identify feeding vessels that can be treated endoscopically, thus potentially decreasing the incidence of failed primary hemostasis. Endoscopic suturing, when more fully developed, may provide a better hemostatic technique that can reduce the incidence of recurrent bleeding. It is only through these reviews that our state of knowledge in the field can be constantly reevaluated to update today's clinician with the latest knowledge and stimulate tomorrow's researchers with challenging problems.
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Affiliation(s)
- Wahid Wassef
- Division of Gastroenterology, University of Massachusetts Medical School, University of Massachusetts Memorial Health Care, Worcester, Massachusetts 01655, USA.
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Abstract
BACKGROUND Upper-GI vascular ectasias, including angiodysplasia and gastric antral vascular ectasia may present with either acute or chronic bleeding. Endoscopic thermal modalities have been used to control acute bleeding and reduce transfusion requirements. METHODS Endoscopic experience was reviewed for a 6-year period during which 32 patients requiring blood transfusions for upper-GI angiodysplasia or gastric antral vascular ectasia were evaluated. Patients seen during the first 5 years were treated with either Nd:YAG laser photocoagulation or multipolar electrocoagulation. During the most recent 12 months, all patients were treated by argon plasma coagulation. Response to therapy was assessed by change in mean Hb and transfusion requirements. RESULTS Overall, 16 patients were treated by laser photoablation alone; 9, argon plasma coagulation with or without laser; and 7, multipolar electrocoagulation with or without laser. Mean follow-up for all patients was 19 months. After therapy, mean Hb concentration rose from 76 to 114 g/L for patients with gastric antral vascular ectasia and from 85 to 118 g/L for those with angiodysplasia. Endoscopic therapy abolished or reduced transfusion requirements in 93% of patients with gastric antral vascular ectasia and 76% with angiodysplasia. Patients with gastric antral vascular ectasia required a mean of 6 treatment sessions, while those with angiodysplasia required one to two sessions. CONCLUSIONS Endoscopic thermal ablation effectively controls acute bleeding and reduces transfusion requirements in most patients with upper-GI vascular ectasias. Patients with gastric antral vascular ectasia require significantly more treatment sessions to achieve this effect.
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Affiliation(s)
- Darren A Pavey
- Department of Gastroenterology, St George Hospital, Sydney, Australia
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24
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Affiliation(s)
- Shou-jiang Tang
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael's Hospital, University of Toronto, 600 Sherbourne Street, Suite 611, Toronto, Ontario, M4X 1W4, Canada
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