Obscure gastrointestinal bleeding: diagnostic and therapeutic approach

Diagnosis of Occult and Obscure Gastrointestinal Bleeding

Occult and obscure bleeding are challenging conditions to manage; however, recent advances in gastroenterology and endoscopy have improved our diagnostic and therapeutic capabilities. Obscure gastrointestinal (GI) bleeding is an umbrella category of bleeding of unknown origin that persists or recurs after endoscopic evaluation of the entire bowel fails to reveal a bleeding source. This review details the evaluation of patients with occult and obscure GI bleeding and offers diagnostic algorithms. The treatment of GI bleeding depends on the type and location of the bleeding lesion and an overview of how to manage these conditions is presented.

Value of multiphase computed tomography for gastrointestinal bleeding before endovascular treatment in hemodynamically unstable patients

BACKGROUND

There has been no practice-based study regarding the multiphase computed tomography (CT) before endovascular treatment in hemodynamically unstable gastrointestinal bleeding (GIB) and concerns exist regarding the time delay.

PURPOSE

To evaluate the clinical efficacy of multiphase CT before endovascular treatment in hemodynamically unstable GIB and to investigate the predictors of angiographic localization and recurrent bleeding.

MATERIAL AND METHODS

The multicenter retrospective study included 93 consecutive hemodynamically unstable patients who underwent conventional angiography for non-variceal GIB after failed endoscopic localization. Enrolled patients were divided into a CT group (n = 61) and a non-CT group (n = 32).

RESULTS

The clinical characteristics did not differ between the two groups except for the time to angiography (CT group, 14.8±15.1 h; non-CT group, 9.2±11.7 h, P = 0.022). The rate of angiographic localization was significantly higher in the CT group than in the non-CT group only for lower GIB (P = 0.049). Indirect sign was significantly more frequent in the CT group than in the non-CT group (P = 0.014). CT localization was positive predictor (odd ratio [OR] = 7.66; 95% confidence interval [CI] = 2.1-27.94; P = 0.002) and prolonged time to angiography was negative predictor (OR = 0.94; 95% CI = 0.9- 0.98; P = 0.001) for angiographic localization. A higher systolic blood pressure until index angiography (OR = 0.95; 95% CI = 0.91-1; P = 0.044) was associated with a reduced risk of recurrent bleeding.

CONCLUSION

In hemodynamically unstable patients, multiphase CT is particularly useful for angiographic localization of lower GIB. It should be considered immediately after failed endoscopic hemostasis to reduce time to angiography.

Positive Fecal Occult Blood Test is a Predictive Factor for Gastrointestinal Bleeding after Capsule Endoscopy in Patients with Unexplained Iron Deficiency Anemia: A Korean Multicenter CAPENTRY Study

BACKGROUND/AIMS

Capsule endoscopy (CE) is recommended as the primary method for the evaluation of unexplained anemia. This study aimed to assess the diagnostic yield of CE in patients with unexplained iron deficiency anemia (IDA) without overt bleeding, and to evaluate their long-term outcomes and related clinical factors.

METHODS

Data of patients who underwent CE for the evaluation of IDA were reviewed from a CE registry in Korea. Additional clinical data were collected by the involved investigators of each hospital through a review of medical records.

RESULTS

Among a total of 144 patients, the diagnostic yield of CE was 34%. Gastrointestinal (GI) bleeding was found in 6.3% (n=9) of the patients (occult bleeding in four patients and overt bleeding in five patients) during a mean follow-up of 17.8 months. Patients with a positive fecal occult blood test (FOBT) result at the initial diagnosis had a higher rate of GI bleeding after CE (p=0.004). In addition, a positive FOBT result was the only independent predictive factor for GI bleeding (hazard ratio, 5.30; 95% confidence interval, 1.41-19.85; p=0.013).

CONCLUSION

Positive FOBT is a predictive factor for GI bleeding during follow-up after CE in patients with unexplained IDA without overt bleeding. Thus, patients with positive FOBT need to be more closely followed up.

Diagnostic agreement between video capsule endoscopy and single and double balloon enteroscopy for small bowel bleeding at a tertiary care hospital in Bogota, Colombia

INTRODUCTION

Video capsule endoscopy and balloon-assisted enteroscopy are complementary diagnostic methods in the study of small bowel bleeding, and different factors can affect their diagnostic yield.

AIMS

To define the level of agreement between video capsule endoscopy and enteroscopy in small bowel bleeding, according to the type of lesion, in a cohort of patients at a tertiary care referral center.

MATERIALS AND METHODS

A retrospective study was conducted that included 428 capsule endoscopies performed within the time frame of 2011 and 2019 at our healthcare institution. Seventy-four video capsule endoscopies, followed by enteroscopy, in 71 patients suspected of presenting with small bowel bleeding, were analyzed.

RESULTS

Mean patient age was 63.9 ± 13.5 years and 42 patients were women. The two diagnostic procedures were performed. Overall diagnostic yield of positive findings between video capsule endoscopy and enteroscopy was 86.5% vs. 58.1%, respectively (p = 0.0527). Agreement between video capsule endoscopy and enteroscopy for positive pathologic findings was weak (Ik = 0.17, 95% CI: -0.0097-0.3543), but according to lesion type, it was good for inflammatory lesions (Ik = 0.71, 95% CI: 0.5182-0.9119) and moderate for angiectasias (Ik = 0.45, 95% CI: 0.2469-0.6538) and tumors (Ik = 0.40, 95% CI: 0.1217-0.6794). The results between the two methods differed in 38 patients (51.3%). There was complete intestinal capsule retention in one patient (1.4%) and active bleeding in 13 (17.6%).

CONCLUSIONS

The present study showed that the two techniques had a similar overall detection rate for small bowel lesions, but the type of lesion was the main factor that could modify diagnostic agreement.

Management of obscure gastrointestinal bleeding: Comparison of guidelines between Japan and other countries

Small-bowel bleeding accounts for the majority of obscure gastrointestinal bleeding, but it is caused by various types of small bowel disease, upper gastrointestinal disease, and colorectal disease. For the diagnosis, history taking and physical examination are required, leading to a determination of what diseases are involved. Next, cross-sectional imaging, such as computed tomography, should be carried out, followed by the latest enteroscopy such as small bowel capsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient condition. After a comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected. This article reviews recent advances in the endoscopic diagnosis of obscure gastrointestinal bleeding and compares perspectives of the management of obscure gastrointestinal bleeding in Japan with that in other countries.

Overview of small bowel angioectasias: clinical presentation and treatment options

Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.

Clinical Practice Guideline for Enteroscopy

Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed 'Clinical Practice Guidelines for Enteroscopy' in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease-based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.

Gastrointestinal Bleeding and Management

There is a broad clinical spectrum of gastrointestinal bleeding in children, ranging from subtle laboratory findings to dramatic clinical presentations. This review provides a framework for the evaluation and management of gastrointestinal hemorrhage for pediatricians. It outlines strategies for obtaining a tailored patient history and conducting a thorough physical examination that can shed light on the location, severity, and likely etiology of bleeding. It appraises blood tests, radiologic tools, and endoscopic modalities frequently used to identify and control a source of bleeding.

Role of computed tomography angiography on the management of overt obscure gastrointestinal bleeding

Background and aim

The role of computed tomography angiography (CTA) on the management of acute overt obscure gastrointestinal bleeding (OGIB) remains unclear. We designed a study to evaluate the impact of CTA before enteroscopy for acute overt OGIB.

Methods

All patients undergoing CTA followed by enteroscopy for acute overt OGIB were enrolled in this retrospective study. Clinical characteristics and diagnosis were compared between patients with positive and negative CTA findings. We evaluated the impact of CTA on subsequent enteroscopy.

Results

From February 2008 to March 2015, 71 patients including 25 patients with positive CTA findings and 46 patients with negative CTA findings, were enrolled. All 25 patients with positive CTA findings were confirmed to have mid GI lesions, a significantly higher proportion than among patients with negative CTA findings (100% vs. 52.2%, respectively; P <0.001). CTA had a higher diagnostic yield for bleeding from tumor origin than from non-tumor origin (80.0% vs. 23.7%, respectively; P <0.001). The diagnostic yield of CTA and enteroscopy was 35.2% and 73.2%, respectively. The lesions could be identified by the initial route of enteroscopy in more patients with positive CTA findings than in those with negative CTA findings (92.0% vs. 47.8%, respectively; P <0.001). Lesions could be identified in seven of the 25 patients (28.0%) with positive CTA findings by using only push enteroscopy instead of single-balloon enteroscopy (SBE), but all 46 patients with negative CTA findings needed SBE for deep small-bowel examination.

Conclusions

CTA is useful in the diagnosis of acute overt OGIB, especially in patients with bleeding from tumors. In addition, it also can show the precise location of bleeding, and guide subsequent enteroscopic management.

Intraoperative transillumination with water-filling of lumen for localizing lesions in occult small bowel bleeding: Case report

RATIONALE

Occult small bowel bleeding is always difficult to locate by either radiological examination or endoscopy. When the site of bleeding cannot be found by nonsurgical measures, exploratory laparotomy becomes necessary.

PATIENT CONCERNS

A 63-year-old woman with a half-month history of occult gastrointestinal bleeding failed to many conservative therapies.

INTERVENTIONS

Intraoperative transillumination with water-filling of lumen was performed.

DIAGNOSES

Small bowel bleeding was diagnosed intraoperatively.

OUTCOMES

Segmental resection of the diseased small bowel with side-to-side anastomosis was performed while the histology showed no significant abnormality.

LESSONS

The technique of intraoperative transillumination with water-filling of lumen allows simple, accurate, and rapid localization of lesions in occult small bowel bleeding and facilitates precise and definitive surgery.

[Obscure gastrointestinal bleeding due to gastrointestinal stromal tumors]

BACKGROUND

The gastrointestinal stromal tumours (GIST) are the most common soft tissue sarcomas of the digestive tract. They are usually found in the stomach (60-70%) and small intestine (25-30%) and, less commonly, in the oesophagus, mesentery, colon, or rectum. The symptoms present at diagnosis are, gastrointestinal bleeding, abdominal pain, abdominal mass, or intestinal obstruction. The type of symptomatology will depend on the location and size of the tumour. The definitive diagnosis is histopathological, with 95% of the tumours being positive for CD117.

CLINICAL CASES

This is an observational and descriptive study of 5cases of small intestinal GIST that presented with gastrointestinal bleeding as the main symptom. The period from the initial symptom to the diagnosis varied from 1 to 84 months. The endoscopy was inconclusive in all of the patients, and the diagnosis was made using computed tomography and angiography. Treatment included resection in all patients. The histopathological results are also described.

CONCLUSION

GIST can have multiple clinical pictures and unusual symptoms, such as obscure gastrointestinal bleeding. The use of computed tomography and angiography has shown to be an important tool in the diagnosis with patients with small intestine GISTs.

Length of endoscopic workup in gastrointestinal bleeding

BACKGROUND

The number of procedures utilized in the general management of gastrointestinal bleeding (GIB) has not been investigated previously. We used the National Endoscopic Database of the Clinical Outcomes Research Initiative for an observational study to analyze the average length of workup in GIB.

METHODS

The electronic database was queried for all patients aged 18 years and older who underwent an endoscopic evaluation for any bleeding indication between 2000 and 2014. Data were stratified by indication, type, and number of endoscopies per patient, and length of workup.

RESULTS

A total of 603 807 endoscopic procedures among 451 470 individual patients were used in the workup of GIB, with 152 337 procedures among 113 030 patients (25%) being performed as a secondary procedure. The average length was 2.4±0.9 procedures per workup in procedural sequences involving multiple endoscopies. The length of workup was independent of the initial type of GIB. An esophago-gastro-duodenoscopy (EGD), followed by a colonoscopy or a colonoscopy, followed by an EGD were the most frequent combinations. In another substantial fraction of two consecutive procedures, the first and the second procedure were identical. This pattern applied not only to EGD and colonoscopy but also to flexible sigmoidoscopy, enteroscopy, and video capsule endoscopy.

CONCLUSION

The majority of patients with GIB require only one type of endoscopy to manage their bleeding. However, in a quarter of patients, on average, 2.4 procedures are needed. Previous trials assessing the outcomes of individual types of endoscopy may have exaggerated their overall success rates in diagnosing and treating GIB.

The Role of Capsule Endoscopy in Patients with Obscure Gastrointestinal Bleeding

Obscure gastrointestinal bleeding (OGIB) accounts for 5% of all gastrointestinal (GI) bleeding cases and is often caused by small bowel lesions. Capsule endoscopy (CE), which allows non-invasive visualization of the small bowel mucosa, has revolutionized the evaluation of OGIB. CE is preferred by both patients and physicians mainly because of its non-invasiveness, and is widely used as the first-line diagnostic modality for OGIB. The diagnostic yield of CE in OGIB has been reported to be in the range of 32% to 83%. Although no direct comparison has been made, a meta-analysis showed similar diagnostic yields between CE and double-balloon enteroscopy (DBE) for OGIB. However, CE could enhance the yield of subsequent DBE and serve as a guide for optimizing the insertion route for DBE. Even after negative CE, selected patients could benefit from second-look CE for OGIB. In terms of outcomes, a favorable clinical impact after CE has been reported in several studies. However, observations indicate that CE might not influence clinical outcomes directly, but rather play a role in selecting patients with OGIB who are likely to benefit from subsequent evaluation and intervention.

Lower Gastrointestinal Bleeding in Children

This article provides an overview of the evaluation and management of lower gastrointestinal bleeding (LGIB) in children. The common etiologies at different ages are reviewed. Conditions with endoscopic importance for diagnosis or therapy include solitary rectal ulcer syndrome, polyps, vascular lesions, and colonic inflammation and ulceration. Diagnostic modalities for identifying causes of LGIB in children include endoscopy and colonoscopy, cross-sectional and nuclear medicine imaging, video capsule endoscopy, and enteroscopy. Pre-endoscopic preparation and decision-making unique to pediatrics is highlighted. The authors conclude with a summary of current and emerging therapeutic hemostatic techniques that can be used in pediatric patients.

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.

Obscure gastrointestinal bleeding: diagnosis and treatment

Small-bowel bleeding comprises a majority of obscure gastrointestinal bleeding, but is caused by various kinds of diseases. For its diagnosis, history-taking and physical examination is requisite, leading to a suspicion of what diseases are involved. Next, cross-sectional imaging such as computed tomography should be done, followed by the latest enteroscopy, videocapsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient conditions. After comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected.

Evaluation and outcomes of patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is defined as recurrent or persistent bleeding or presence of iron deficiency anaemia after evaluation with a negative bidirectional endoscopy. OGIB accounts for 5% of gastrointestinal bleeding and presents a diagnostic challenge. Current modalities available for the investigation of OGIB include capsule endoscopy, balloon assisted enteroscopy, spiral enteroscopy and computed tomography enterography. These modalities overcome the limitations of previous techniques. Following a negative bidirectional endoscopy, capsule endoscopy and double balloon enteroscopy remain the cornerstone of investigation in OGIB given their high diagnostic yield. Long-term outcome data in patients with OGIB is limited, but is most promising for capsule endoscopy. This article reviews the current literature and provides an overview of the clinical evaluation of patients with OGIB, available diagnostic and therapeutic modalities and long-term clinical outcomes.

Sarcomatoid carcinoma of the jejunum presenting as obscure gastrointestinal bleeding in a patient with a history of gliosarcoma

Small bowel malignant tumors are rare and sarcomatoid carcinomas have rarely been reported at this site. We report a 56-year-old woman, with history of an excised gliosarcoma, who presented with recurrent obscure gastrointestinal bleeding. She underwent endoscopy and colonoscopy, which failed to identify the cause of the bleeding. The abdominal computed tomography scan located a tumor in the small bowel. Pathology revealed a jejunal sarcomatoid carcinoma. She developed tumor recurrence and multiple liver metastases shortly after surgery. Immunohistochemistry is required for accurate diagnosis. Sarcomatoid carcinoma is a rare cause of obscure gastrointestinal bleeding, which is associated with a poor prognosis.

Frequency of rebleeding events in obscure gastrointestinal bleeding with negative capsule endoscopy

BACKGROUND AND AIMS

Although capsule endoscopy (CE) is widely used as a first-line diagnostic modality for obscure gastrointestinal bleeding (OGIB), the rebleeding rate after negative CE varies according to different studies. We tried to elucidate the outcomes after negative CE for OGIB and to determine the risk factors associated with rebleeding.

METHODS

We retrospectively reviewed data from 125 patients who had received CE for OGIB.

RESULTS

PillCam SB capsules were used for 92 patients (73.6%) and SB2 capsules for the other 33 (26.4%). The complete visualization of the small bowel was achieved in 93 patients (74.4%). Of the 63 patients (50.4%) who showed negative CE results, 60 patients did not receive any further specific treatment for OGIB, and were analyzed for the rebleeding rate and risk factors for rebleeding. Of the 60 patients, rebleeding episodes were observed in 16 patients (26.7%), and the cumulative rebleeding rates after 6, 12, 24, and 36 months were 12.4%, 14.3%, 28.7%, and 35.9%, respectively. Substantial rebleeding events were observed with similar frequency both after negative CE without subsequent treatment (26.7%) and after positive CE without specific treatment (21.2%) (P = 0.496).

CONCLUSIONS

Considerable rebleeding episodes were observed after negative CE result for OGIB. Further complementary diagnostic work-ups and close follow-up are needed to be considered for patients with OGIB and negative CE results.

In the workup of patients with obscure gastrointestinal bleed, does 64-slice MDCT have a role?

Purpose:

The purpose was to prospectively determine the sensitivity of 64-slice MDCT in detecting and diagnosing the cause of obscure gastrointestinal bleed (OGIB).

Materials and Methods:

Our study included 50 patients (male 30, female 20) in the age range of 3–82 years (average age: 58.52 years) who were referred to our radiology department as part of their workup for clinically evident gastrointestinal (GI) bleed or as part of workup for anemia (with and without positive fecal occult blood test). All patients underwent conventional upper endoscopy and colonoscopy before undergoing CT scan. Following a noncontrast scan, all patients underwent triple-phase contrast CT scan using a 64-slice CT scan system. The diagnostic performance of 64-slice MDCT was compared to the results of capsule endoscopy, 99m-technetium-labeled red blood cell scintigraphy (99mTc-RBC scintigraphy), digital subtraction angiography, and surgery whenever available.

Results:

CT scan showed positive findings in 32 of 50 patients. The sensitivity, specificity, positive predictive value, and negative predictive values of MDCT for detection of bleed were 72.2%, 42.8%, 81.2%, and 44.4%, respectively. Capsule endoscopy was done in 15 patients and was positive in 10 patients; it had a sensitivity of 71.4%. Eleven patients had undergone 99mTc-RBC scintigraphy prior to CT scan, and the result was positive in seven patients (sensitivity 70%). Digital subtraction angiography was performed in only eight patients and among them all except one patient showed findings consistent with the lesions detected on MDCT.

Conclusion:

MDCT is a sensitive and noninvasive tool that allows rapid detection and localization of OGIB. It can be used as the first-line investigation in patients with negative endoscopy and colonoscopy studies. MDCT and capsule endoscopy have complementary roles in the evaluation of OGIB.

Use of Conjugated Estrogens in Life-Threatening Gastrointestinal Bleeding in Hemodialysis Patients—A Review

Hormonal agents (estrogen and progesterone) are being studied for their use in bleeding. This observance was initially explored in a patient with hereditary hemorrhagic telangiectasia (HHT) with epistaxis had variation in bleeding depending on her menstrual cycles.1 Thus, hormonal therapy was initially used in patients with HHT to control episodes of epistaxis.2 The literature on hormonal therapy in patients with life-threatening bleeding from gastrointestinal (GI) lesions is very limited. There are a few clinical trials in patients with chronic bleeds. However, no definite guidelines exist on their use in life-threatening GI bleeding in patients with uremia. Here, we describe a case with a life-threatening GI bleeding requiring multiple endoscopies and intensive care unit stay that responded to conjugated estrogens. We have done extensive research on English medical literature on PubMed and Google Scholar on the use of hormonal therapy for GI bleeding in patients with renal failure, and here we present the data as a review.

An intelligent electronic capsule system for automated detection of gastrointestinal bleeding

In clinical practice, examination of the hemorrhagic spot (HS) remains difficult. In this paper, we describe a remote controlled capsule (RCC) micro-system with an automated, color-based sensor to identify and localize the HS of the gastrointestinal (GI) tract. In vitro testing of the detecting sensor demonstrated that it was capable of discriminating mimetic intestinal fluid (MIF) with and without the hemoglobin (Hb) when the concentration of Hb in MIF was above 0.05 g/ml. Therefore, this RCC system is able to detect the relatively accurate location of the HS in the GI tract.

Primary balloon-assisted enteroscopy in patients with obscure gastrointestinal bleeding: findings and outcome of therapy

GOALS

The aim of this study was to evaluate the diagnostic and therapeutic outcome of a primary balloon-assisted enteroscopy (BAE) approach in obscure gastrointestinal bleeding (OGIB) patients.

BACKGROUND

In the diagnostic approach of OGIB, both wireless capsule endoscopy (WCE) and BAE are used. The advantage of the primary wireless capsule endoscopy approach is its noninvasiveness. The main advantage of the primary BAE approach is the excellent diagnostic accuracy and the possibility to perform treatment during the same procedure.

STUDY

A retrospective analysis of our BAE database with patients evaluated for OGIB was performed. BAE data, findings, and follow-up were obtained and evaluated.

RESULTS

One hundred and thirty-two patients (81 male, mean age 62 (11-88) years) were included. In 60 (45%) patients with follow-up, a likely cause for OGIB was found in the small bowel during BAE: angiodysplasia or vascular malformations in 42 (70%), ulcerative lesions in 7 (12%), tumors in 3 (5%), and other findings in 8 (13%) patients. Follow-up was available in 118 (89%) patients; mean time of follow-up was 18 (1-47) months. Thirty-eight (76%) patients with findings at BAE received endoscopic treatment, 27 (71%) of them improved, but anemia also improved spontaneously in 34 patients (63%) with normal findings during BAE. The total number of angiodysplasia per patient was not related to the outcome after treatment.

CONCLUSIONS

The primary BAE approach in OGIB patients has an acceptable diagnostic yield. Therapy seems successful at mid-term follow-up. A high frequency of spontaneous resolution of anemia in patients with normal findings during BAE was observed.

Negative capsule endoscopy without subsequent enteroscopy does not predict lower long-term rebleeding rates in patients with obscure GI bleeding

BACKGROUND

Capsule endoscopy (CE) is now widely accepted as a first-line diagnostic modality for obscure GI bleeding (OGIB). However, the clinical implications of negative results of CE studies remain unclear.

OBJECTIVE

To investigate long-term (>1 year) outcomes for patients undergoing CE for OGIB and to identify risk factors associated with rebleeding.

DESIGN AND SETTING

Retrospective study in a tertiary care hospital.

METHODS

A total of 57 consecutive patients who had undergone CE for OGIB were enrolled and their pre- and post-CE clinical data were collected. Specific treatments were defined as treatments directly aimed at presumed bleeding causes including hemostasis and disease-specific medical therapy, whereas nonspecific treatments were defined as symptomatic treatments for anemia.

RESULTS

Of the 57 patients, the indication for CE was obscure-overt bleeding in 46 patients and obscure-occult bleeding in 11 patients. Among 51 patients for whom long-term data were available, significant (P2) lesions were found in 23 (45.1%) patients. The overall rebleeding rate was 35.3% during a median follow-up duration of 31.7 months (range 12.8-58.0 months). There was no statistically significant difference in the cumulative rebleeding rate between patients with positive and negative CE results (34.8% vs 35.7%, respectively; P = .989). However, specific treatments after CE (hazard ratio, 0.111; 95% CI, 0.013-0.980; P = .043) significantly decreased rebleeding.

LIMITATIONS

Small number of patients, retrospective study design.

CONCLUSIONS

The rebleeding rate for patients with OGIB and negative CE results was substantial, indicating that these patients should be closely observed. However, specific treatment after CE significantly reduced the incidence of recurrent bleeding.

Angiographically negative acute arterial upper and lower gastrointestinal bleeding: incidence, predictive factors, and clinical outcomes

OBJECTIVE

To evaluate the incidence, predictive factors, and clinical outcomes of angiographically negative acute arterial upper and lower gastrointestinal (GI) bleeding.

MATERIALS AND METHODS

From 2001 to 2008, 143 consecutive patients who underwent an angiography for acute arterial upper or lower GI bleeding were examined.

RESULTS

The angiographies revealed a negative bleeding focus in 75 of 143 (52%) patients. The incidence of an angiographically negative outcome was significantly higher in patients with a stable hemodynamic status (p < 0.001), or in patients with lower GI bleeding (p = 0.032). A follow-up of the 75 patients (range: 0-72 months, mean: 8 +/- 14 months) revealed that 60 of the 75 (80%) patients with a negative bleeding focus underwent conservative management only, and acute bleeding was controlled without rebleeding. Three of the 75 (4%) patients underwent exploratory surgery due to prolonged bleeding; however, no bleeding focus was detected. Rebleeding occurred in 12 of 75 (16%) patients. Of these, six patients experienced massive rebleeding and died of disseminated intravascular coagulation within four to nine hours after the rebleeding episode. Four of the 16 patients underwent a repeat angiography and the two remaining patients underwent a surgical intervention to control the bleeding.

CONCLUSION

Angiographically negative results are relatively common in patients with acute GI bleeding, especially in patients with a stable hemodynamic status or lower GI bleeding. Most patients with a negative bleeding focus have experienced spontaneous resolution of their condition.

Role of videocapsule endoscopy for gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is defined as bleeding of an unknown origin that persists or recurs after negative initial upper and lower endoscopies. Several techniques, such as endoscopy, arteriography, scintigraphy and barium radiology are helpful for recognizing the bleeding source; nevertheless, in about 5%-10% of cases the bleeding lesion cannot be determined. The development of videocapsule endoscopy (VCE) has permitted a direct visualization of the small intestine mucosa. We will analyze those techniques in more detail. The diagnostic yield of CE for OGIB varies from 38% to 93%, being in the higher range in those cases with obscure-overt bleeding.

Is there a role for second-look capsule endoscopy in patients with obscure GI bleeding after a nondiagnostic first test?

BACKGROUND

Long-term follow-up data on patients with obscure GI bleeding subjected to capsule endoscopy (CE) are missing.

OBJECTIVE

Our purpose was to follow up patients with a nondiagnostic test and determine whether a second-look CE would be beneficial.

PATIENTS

We enrolled 293 subjects. CE studies were classified as diagnostic (positive findings) or nondiagnostic (findings of uncertain significance/no findings). Patients were followed up for a mean (SD) 24.8 (5.2) months. Outcome was defined as continued or complete resolution of bleeding.

INTERVENTIONS

Patients with a nondiagnostic test were subjected to a repeat CE if they manifested a new bleeding episode or a drop in hemoglobin >or=2 g/dL.

RESULTS

Positive findings, findings of uncertain significance, and no findings were identified in 41.6%, 16.0%, and 42.3% of our patients, respectively. Therapeutic intervention was possible in 72.1% of those with positive findings and in 30% of those with findings of uncertain significance. Complete resolution of bleeding occurred more often in patients with a diagnostic test (65.2%) compared with those with a nondiagnostic test (35.4%, P < .001). Second-look CE was performed in a subgroup of our patients (n = 76) and was diagnostic in those whose presentation changed from occult to overt or those whose hemoglobin dropped >or=4 g/dL.

CONCLUSIONS

In patients with obscure GI bleeding, a diagnostic CE leads to therapeutic interventions and a favorable outcome. Patients with a nondiagnostic test would definitely benefit from a second-look CE if the bleeding presentation changes from occult to overt or if the hemoglobin value drops >or=4 g/dL.

Diagnostic value of digital subtraction angiography in small intestinal bleeding

Due to lack of specific clinical symptoms of small intestinal bleeding and the limitation of its conventional examination methods, diagnosis of small intestinal bleeding is in a great dilemma. The purpose of this paper is to review the value of digital subtraction angiography (DSA) in the diagnosis of small intestinal bleeding and hope to instruct clinical diagnosis and therapy sufficiently.

Small bowel enteroscopy: territory conquered, future horizons

PURPOSE OF REVIEW

To review recent advances in small bowel enteroscopy, focusing on indications, modifications to improve imaging and techniques, pitfalls, and clinical applications.

RECENT FINDINGS

The need for endoscopic access to improve diagnosis and treatment of small bowel disease has led to the development of novel technologies, video capsule, and double balloon endoscopy. Newer devices, single balloon and spiral endoscopy, are just entering clinical use. With new technologies come the trials and tribulations of learning new endoscopic skills and determining their role in the diagnosis and treatment of small bowel disease. Identification of small bowel lesions has dramatically improved. However, small bowel angulations, peristalsis, and bilious fluid in the lumen can result in false readings or missed lesions. Studies are underway to determine the best strategy to apply new enteroscopy technologies for the diagnosis and management of small bowel disease, particularly bleeding.

SUMMARY

Complete enteroscopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and therapeutic maneuvers require patience and significant skill. Prospective randomized studies are needed to guide diagnostic testing and therapy with these new endoscopic techniques.

Small bowel haemorrhage associated with partial midgut malrotation in a middle-aged man

We describe a case of life-threatening small bowel haemorrhage in a 56 year old man, who was found to have partial midgut malrotation at laparotomy. An association between congenital malrotation and gastrointestinal haemorrhage has not previously been reported in this age group. We discuss the association between gut malrotation and small intestinal pathology and describe the principles of management in these patients.

Role of videocapsule endoscopy for gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is defined as bleeding of an unknown origin that persists or recurs after negative initial upper and lower endoscopies. Several techniques, such as endoscopy, arteriography, scintigraphy and barium radiology are helpful for recognizing the bleeding source; nevertheless, in about 5%-10% of cases the bleeding lesion cannot be determined. The development of videocapsule endoscopy (VCE) has permitted a direct visualization of the small intestine mucosa. We will analyze those techniques in more detail. The diagnostic yield of CE for OGIB varies from 38% to 93%, being in the higher range in those cases with obscure-overt bleeding.

How useful is capsule endoscopy for the selection of patients for double-balloon enteroscopy?

Although double-balloon enteroscopy (DBE) is useful for the diagnosis and management of patients with obscure gastrointestinal bleeding, the technique is fairly invasive, has several limitations, and can be associated with complications. It is, therefore, important to identify those patients who will benefit most from DBE, and those in whom the procedure should be avoided. In this Practice Point commentary, we discuss the findings and limitations of a retrospective study conducted by Hendel and colleagues that evaluated the utility of capsule endoscopy screening for the selection of patients with obscure gastrointestinal bleeding who would benefit from DBE. The results suggest that capsule endoscopy screening is useful to predict the diagnostic yield of DBE, guide the route of DBE, influence sedation choices, and avoid the performance of unnecessary procedures. This commentary highlights the issues to consider when interpreting and generalizing these results in clinical practice.

Capsule endoscopy in Crohn's disease - Indications and reservations 2008

Capsule endoscopy (CE) was found to be an effective tool in diagnosis of small bowel pathology. This review will focus on its role in Crohn's disease. Its role in patients with suspected Crohn's disease (CD) is described. CE has an established role for diagnosing CD when other tests are negative, though it is not a first line investigative tool in these patients. Over diagnosis is of concern. Its use in established CD remains an open question. It can provide exact mapping of small bowel disease before surgery, and might have impact on the treatment of the disease. It may have role in monitoring mucosal healing, which is becoming a target of therapy, and may help establish the exact diagnosis in a limited group of patients with indeterminate colitis. Retention of CE might occur. It is of low rate in patients with suspected CD and higher in patients with known CD but clinical obstruction is extremely rare. Economic considerations are a limit to a wider application of the CE.

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.

Double balloon endoscopy associated pancreatitis: A description of six cases

AIM: To perform a single-center analysis of all double balloon endoscopy (DBE) related cases of pancreatitis identified prospectively from a recorded DBE-complication database.

METHODS: From November 2003 until January 2007, 603 DBE procedures were performed on 412 patients, with data on complications recorded in a database. The setting was a tertiary care center offering DBE. DBE was performed from the antegrade or retrograde route. Outcome measurements included age, gender, medication, indication, DBE-endoscope type, insertion depth, procedure duration, findings, interventions, post-procedural abdominal pain, and post-procedural hospitalization.

RESULTS: This is the largest single-center study reporting on post-DBE pancreatitis prospectively. Six patients (1.0%) developed post-DBE pancreatitis, all after antegrade DBE. There was no association with gender, duration of the procedure or type of endoscope. The mean age was 51.9 years (range 25-78). Four patients had severe pancreatitis. Of these, two had inflammatory signs in the body-tail region, one had pancreatitis in the tail region, and the total pancreas was involved in one.

CONCLUSION: The incidence of post-DBE pancreatitis in our series is higher than previously reported. We found no relation with DBE-endoscope type. The inflammatory changes occurred in the body-tail region of the pancreas, suggesting that post-DBE pancreatitis is caused by repetitive mechanical strain on the pancreas.