Obscure gastrointestinal haemorrhage of small-bowel origin

Endovascular embolization for managing anastomotic bleeding after stapled digestive tract anastomosis

BACKGROUND

Anastomotic bleeding is an infrequent but life-threatening complication after stapled digestive tract anastomosis. Endovascular embolization is one of the available treatments, but precise clinical outcomes are yet to be evaluated.

PURPOSE

To evaluate the efficacy and safety of endovascular embolization for managing anastomotic bleeding after stapled digestive tract anastomosis.

MATERIAL AND METHODS

Twenty-eight patients were diagnosed with anastomotic bleeding after stapled digestive tract anastomosis by digital subtraction angiography (DSA). Curative effect was summed for analysis.

RESULTS

All bleeding arteries were located in the stoma and were identified by contrast agent spillover by DSA. The offending arteries were superselectively catheterized and embolized with microcoils and/or gelatin sponge particles. Laboratory examinations showed normal hemoglobin and red blood cell counts when the patients' abdominal cavity drainage tubes stopped draining blood. The follow-up period was 3.2-84.7 months (median, 19.7 months). Four patients died during this time, of which two had cholangiocarcinoma, one had gastric cancer with tumor recurrence and multiple organ failure, and the final patient had a subarachnoid hemorrhage 4 months after embolization. In the surviving patients, no rebleeding occurred after embolization and no additional intervention or surgery was required.

CONCLUSION

Endovascular embolization is safe and effective for managing anastomotic bleeding after stapled digestive tract anastomosis.

Capsule Endoscopy in the Assessment of Obscure Gastrointestinal Bleeding: An Economic Analysis

BACKGROUND

Small-bowel capsule endoscopy is a tool used to visualize the small bowel to identify the location of bleeds in obscure gastrointestinal bleeding (OGIB). Capsule endoscopy is currently funded in Ontario in cases where there has been a failure to identify a source of bleeding via conventional diagnostic procedures. In Ontario, capsule endoscopy is a diagnostic option for patients whose findings on esophagogastroduodenoscopy, colonoscopy, and push enteroscopy have been negative (i.e., the source of bleeding was not found).

OBJECTIVES

This economic analysis aims to estimate the budget impact of different rates of capsule endoscopy use as a complement to push enteroscopy procedures in patients aged 18 years and older.

DATA SOURCES

Population-based administrative databases for Ontario were used to identify patients receiving push enteroscopy and small-bowel capsule endoscopy in the fiscal years 2008 to 2012.

REVIEW METHODS

A systematic literature search was performed to identify economic evaluations of capsule endoscopy for the investigation of OGIB. Studies were assessed for their methodological quality and their applicability to the Ontarian setting. An original budget impact analysis was performed using data from Ontarian administrative sources and published literature. The budget impact was estimated for different levels of use of capsule endoscopy as a complement to push enteroscopy due to the uncertain clinical utility of the capsule based on current clinical evidence. The analysis was conducted from the provincial public payer perspective.

RESULTS

With varying rates of capsule endoscopy use, the budgetary impact spans from savings of $510,000, when no (0%) push enteroscopy procedures are complemented with capsule endoscopy, to $2,036,000, when all (100%) push enteroscopy procedures are complemented with capsule endoscopy. A scenario where 50% of push enteroscopy procedures are complemented with capsule endoscopy (expected use based on expert opinion) would result in additional expenditure of about $763,000.

LIMITATIONS

In the literature on OGIB, estimates of rebleeding rates after endoscopic procedures or spontaneous cessation rates are unreliable, with a lack of data. Rough estimates from expert consultation can provide an indication of expected additional use of capsule endoscopy; however, a wide range of capsule uses was explored.

CONCLUSIONS

The budgetary impact in the first year in Ontario of capsule endoscopy use to complement push enteroscopy procedures ranges from $510,000 in savings to an additional expenditure of $2,036,000 (at 0% and 100% push enteroscopy procedures complemented, respectively). The expected scenario of 50% of push enteroscopy procedures likely to benefit from the use of capsule endoscopy, based on expert opinion, would result in additional expenditures of $763,000 in the first year.

Efficacy of video capsule endoscopy with flexible spectral imaging color enhancement at setting 3 for differential diagnosis of red spots in the small bowel

BACKGROUND

Red spots on the small bowel mucosa are observed in patients with angioectasia and enteritis. The present study investigated the effectiveness of capsule endoscopy (CE)-flexible spectral imaging color enhancement (FICE) as a method for differential diagnosis of the two conditions.

PATIENTS AND METHODS

The subjects were 30 patients who underwent CE and double-balloon endoscopy at Dokkyo Medical University Hospital between February 2007 and January 2013. Of these 30 patients, those diagnosed with angioectasia were assigned to Group A (n = 13) and those diagnosed with enteritis were assigned to Group E (n = 17).

RESULTS

Using FICE at setting 3 and comparing the color intensity of the red spots on a four-step scale (0-3), no statistically significant (P = 0.712) difference was found between the twogroups (Group A: 2.69 ± 0.48, Group E: 2.76 ± 0.56). Subjects were considered to show a positive blue sign when areas of blue were observed against the yellow-green background and surrounding the red spots. A comparison of the ratio of positive blue sign for both groups (Group A: 15.4% ± 37.6%, Group E: 94.1% ± 24.2%) showed a statistically significant increase in the ratio in Group E (P < 0.001).

CONCLUSION

The results of the present study suggest that blue sign may be effective in the differential diagnosis of angioectasia and enteritis in patients with red spots.

Diagnostic evaluation and management of obscure gastrointestinal bleeding: a changing paradigm

Obscure gastrointestinal bleeding (OGIB) is defined as bleeding from the gastrointestinal tract that persists or recurs after a negative initial evaluation using bidirectional endoscopy and radiologic imaging with small-bowel radiograph. The main challenges related to evaluation of OGIB include the high miss rate for lesions on initial evaluation with standard endoscopy and the limited capacity of older diagnostic modalities to effectively examine the small bowel. The introduction of capsule endoscopy, balloon-assisted enteroscopy, spiral enteroscopy, and computed tomography (CT) enterography have served to overcome the limitations of older diagnostic tests. Capsule endoscopy is currently recommended as the third test of choice in the evaluation of patients with OGIB, after a negative bidirectional endoscopy. Balloon-assisted enteroscopy is useful for both the diagnosis and endoscopic management of OGIB. CT enterography is superior to small-bowel radiograph for luminal and extraluminal small-bowel examination. These advances in small-bowel diagnostics and the capacity to successfully perform endoscopic therapeutics have largely replaced surgical procedures and resulted in a trend toward noninvasive evaluation and endoscopic management of OGIB.

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.

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.

Malignant tumors of the small intestine

Malignant tumors of the small bowel are unusual and account for only 1% to 5% of all gastrointestinal tract malignancies. Thirteen cases of malignant tumors of the small bowel identified at the VAMC in Puerto Rico from January 1999 to September 2001 and a review of the literature are presented. The mean age of our cases was 67 (range: 45-78). Vague abdominal pain, nausea, vomiting, and melena were the most frequently reported symptoms. The average time from first symptoms to diagnosis was 3.2 months. A positive test for occult blood or hypochromic microcytic anemia was invariably present. Hyperbilirubinemia and increased alkaline phosphatase were warning signs that allowed earlier diagnosis in patients with duodenal tumors. Fifty-four percent of the lesions were detected by endoscopic examination while 46% relied on radiographic studies. Eleven had carcinomas and two malignant gastrointestinal stromal tumors. Neither carcinoids nor lymphomas were identified. Our report of thirteen cases of malignant small bowel tumors is unusual and exhibits differences with the previously reported data. The cases were identified in a limited Hispanic population in a short period of time. Aggressive evaluation and a high suspicion of these malignancies should be entertained whenever subtle symptoms and unexplained gastrointestinal blood loss are assessed.

Review article: The advent of capsule endoscopy--a not-so-futuristic approach to obscure gastrointestinal bleeding

Capsule endoscopy is a new, wireless, endoscopic examination of the small intestine. To date, two small clinical trials have been reported utilizing capsule endoscopy in patients with obscure gastrointestinal bleeding, and have shown its superiority to push enteroscopy in diagnosing the cause of blood loss. No outcome studies have been reported. This paper proposes a change in practice guidelines for obscure bleeding. It is our opinion that, in the future, with the advent of wireless capsule endoscopy, the evaluation of patients with obscure gastrointestinal bleeding will be very different from the practice of medicine today. We believe that capsule endoscopy will become the first-line method for the evaluation of patients with obscure bleeding, once upper endoscopy and colonoscopy have been shown to be negative. In patients with active bleeding, capsule endoscopy will confirm the small bowel as the site of bleeding, providing a location, or, if the study is negative for the small intestine, may indicate that the bleeding is either colonic or gastric in origin. In a patient with active bleeding within the small intestine, the capsule will guide further evaluation and therapy. A patient with a small bowel tumour detected by capsule endoscopy will proceed directly to laparoscopic surgery. If the site of bleeding is identified in the proximal small bowel and there is no mass, push enteroscopy will be used to re-identify the site and cauterize it. A distal small bowel site will require surgical intervention, coupled with intra-operative enteroscopy. Should the patient be too sick to undergo surgery, medical therapy utilizing hormonal agents will be considered. A colonic site will be evaluated by colonoscopy. In patients with a more occult or intermittent type of bleeding and in those whose upper endoscopies and colonoscopies are negative, capsule endoscopy will be used similarly to identify a bleeding lesion and thereby direct subsequent testing or treatment.

Multiple jejunal angiodysplasia detected by enema-helical CT

The small bowel angiodysplasia is a rare entity that causes lower intestinal bleeding; the diagnosis is difficult and based on selective angiogram. In our case, an 85-year-old woman was hospitalized after frequent episodes of melena. We performed an enema-helical CT abdominal examination before and after contrast medium administration per venam, detecting some increased intensity areas that surgery confirmed to be a vascular dysplasia on the jejunal first loop. We found the source of hemorrhage without performing an angiographic examination.

AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics committee. The paper was approved by the committee on May 16, 1999, and by the AGA governing board on July 18, 1999.

Enteroscopic identification of an adenocarcinoma of the small bowel in a patient with previously unrecognized hereditary nonpolyposis colorectal cancer syndrome

Tumors of the small bowel are uncommon and seldom suspected on a clinical basis. Together with the relative inaccessibility of the small bowel to endoscopic investigation, the rarity of these tumors undoubtedly delays their diagnosis. The case reported is of a patient with an adenocarcinoma of the jejunum presenting as gastrointestinal bleeding of obscure origin. Diagnosis was by push enteroscopy, after several years of unsuccessful radiological and upper and lower endoscopic evaluation. The patient's family fulfilled the Amsterdam criteria for hereditary nonpolyposis colorectal cancer syndrome, which was previously unrecognized. This report emphasizes the value of push enteroscopy and the limits of radiography of the small bowel when investigating patients with obscure GI bleeding. It also underlines the importance of a careful evaluation of the pedigree (concerning history of colorectal and extracolonic cancer) of all patients, including those who present with adenocarcinoma of the small bowel; it is similarly important to consider the possibility of small bowel cancer in members of families with hereditary nonpolyposis colorectal cancer (HNPCC) syndrome.

Two way push videoenteroscopy in investigation of small bowel disease

AIMS

To evaluate the diagnostic yield and safety of a new push type videoenteroscope (PVE) for diagnosis of small bowel disease.

METHODS

Three hundred and thirteen patients were referred for one or two way PVE from December 1993 to June 1996. Indications for PVE were: an unexplained iron deficiency anaemia with or without clinically evident gastrointestinal bleeding; or a complementary investigation for suspected small bowel disease, after a small bowel barium follow through (SBBFT) considered as normal or abnormal, but without a definite diagnosis.

RESULTS

A jejunoscopy and a retrograde ileoscopy were carried out in 306 and 234 patients, respectively. In patients with isolated anaemia (n = 131) and those with clinically evident gastrointestinal bleeding associated anaemia (n = 72), PVE provided a diagnosis in 26 (19.8%) and 22 (30.5%) cases, respectively. Lesions found were located in the jejunoileum in 30 (14.7%) patients and in the gastroduodenum or the colon in 18 (8.8%) patients--that is, within the reach of the conventional gastroscope/colonoscope. In patients with normal (n = 54) or abnormal (n = 56) SBBFT, PVE provided a diagnosis in 17 (31%) and 27 (48%) cases, respectively. In 25% of cases, the abnormal appearance of SBBFT was not confirmed. The site of the radiological abnormality was not reached in 27% of cases. Lesions were located at the jejunum and the ileum in 59 (64%) and 33 (36%) cases, respectively.

CONCLUSIONS

PVE is useful in around 30% of cases of unexplained anaemia or after an SBBFT which failed to provide an accurate aetiological diagnosis. Use of retrograde videoenteroscopy increases diagnostic yield by one third.

Push enteroscopy and heater probe therapy for small bowel bleeding

BACKGROUND

Blood loss from the small bowel is a significant cause of obscure gastrointestinal bleeding. Small bowel angiodysplasia may be the source of bleeding in 30% to 40% of patients with this problem. In other areas of the bowel, angiodysplasia has been effectively treated by endoscopic methods.

METHODS

We used a 1.7 meter push enteroscope and heater probe ablation to examine and treat 11 transfusion-dependent patients with significant bleeding from small bowel angiodysplasia. Patients had push enteroscopy to target all lesions identified and had follow-up hemoglobin and fecal occult blood tests for a minimum of 6 months after final enteroscopy.

RESULTS

There were a median of 2 (range 1 to 7) small bowel lesions per patient. Patients required a median of 1 (range 1 to 5) examination to treat lesions identified at enteroscopy. Following therapy, hemoglobin levels rose significantly from a median of 8.5 (range 5.3 to 10.6) gm/dL) to a median of 13.5 (range 7.6 to 16.5) gm/dL (p < 0.01 Wilcoxon matched pair signed rank test).

CONCLUSION

Push enteroscopy and heater probe ablation offer potential therapy for bleeding from small bowel angiodysplasia and result in reduction of blood loss and transfusion requirements along with a significant improvement in levels of hemoglobin.

Jejunal angiodysplasia confirmed by intravascular injection technique in vitro. Report of a case and review of the literature

Angiodysplasia of the small intestine is a rare but important cause of gastrointestinal bleeding. We present a 64-year-old man with repeated melena in whom the diagnosis of multiple angiodysplasia of the jejunum was suggested by angiography. The affected segment of the small intestine, in which reddish patches were detected by intraoperative endoscopy, was removed. The combined technique of injecting a dye and a water-soluble contrast medium into the resected specimen revealed areas of dilated vessels, which were diagnosed histologically as angiodysplasia. This case suggests that angiodysplasia of the small intestine can be recognized clinically before the operation and that the intravascular injection technique is useful in confirming the diagnosis in the resected specimen in vitro. We describe this case in detail and review other cases of small intestinal angiodysplasia reported in the English literature.

Upper-gastrointestinal bleeding from angiodysplasia of the minor papilla

Angiodysplasia is an often unrecognized cause of upper-gastrointestinal bleeding, most commonly found in the antrum of the stomach but also in the duodenum and rarely in the esophagus. Small-intestinal angiodysplasia is the source of gastrointestinal bleeding of obscure origin in 30-40% of cases. The diagnosis is usually made by esophagogastroduodenoscopy, push enteroscopy, or selective angiography. We report the first case of angiodysplasia of the minor papilla diagnosed by side-viewing duodenoscopy.

Value of laparotomy in the diagnosis of obscure gastrointestinal haemorrhage

Over a nine year period a total of 137 patients were investigated for obscure gastrointestinal bleeding on one surgical unit. In 20 patients visceral angiography strongly suggested the presence of caecal or right colonic angiodysplasia. These patients were treated by an appropriate colectomy and they are not considered further in this study. Similarly lesions of the small bowel detected by preoperative investigations are not considered here. Fifty five patients were offered diagnostic laparotomy after the failure of other investigations to establish a diagnosis. Two patients refused. A diagnostic laparotomy was performed in the remaining 53. At operation if no visible lesion was seen an on table enteroscopy was performed using a colonoscope passed per oram and, if necessary, per anum. In nine (17%) patients no cause for bleeding was found. In 18 (34%) patients there was a small bowel vascular anomaly, in 14 (26%) a small bowel tumour, in four (7.5%) a bleeding Meckel's diverticulum, and in eight (15%) other miscellaneous lesions. Laparotomy, with on table enteroscopy where indicated, elucidated the cause of bleeding in 44 patients (83%). It was associated, however, with a postoperative death rate of 7.5% (four patients). After seemingly appropriate surgery, rebleeding occurred in 14 patients (26%). Of 18 patients with small bowel vascular anomalies seven rebled (39%), at an average follow up interval of 32 months.

Small intestinal bleeding

Bleeding from the small intestine may be difficult to diagnose, because of the organ's length and free intraperitoneal location. Although there is a variety of causes of intestinal bleeding, angiodysplasia is the most common. Several different tests can be used to identify the bleeding site preoperatively or intraoperatively, including enteroscopy.

Radiological appearances of small intestinal leiomyomas

During a 5 year period we have identified leiomyomas of the small intestine in six patients using enteroclysis. Gastrointestinal bleeding were the presenting symptoms in five and partial small bowel obstruction in one. The time interval between the onset of symptoms and radiological diagnosis ranged between 3 months and 5 years. All patients had previously been investigated by a number of endoscopic and barium radiology examinations and one had undergone a nondiagnostic laparotomy. The jejunum was the site of involvement in one patient and the ileum in five. The growth was intraluminal in two cases, extraluminal in three and bidirectional (dumb-bell) in one. Radiological appearances included round or broad-based semilunar intraluminal filling defects with encroachment of the lumen, or intussusception, displacement and/or indentation of the intestinal wall with effacement of the overlying mucosa or an ulcer crater, tenting deformity and mass effect on neighbouring loops. All six patients came to operation. Pre-operative radiological diagnosis was correct in five and suggestive in one. There was excellent correlation between the radiological appearances and morphology of the pathology specimens.

A solitary jejunal vascular abnormality: a source of massive rectal bleeding

Haemorrhage of small bowel origin may prove to be a clinical and diagnostic challenge, particularly when the bleeding is massive and continuous. Such a case is described where the source of blood loss was a jejunal vascular abnormality.

Small bowel tumours: yield of enteroscopy

A total of 258 patients with obscure gastrointestinal bleeding were referred for small bowel enteroscopy, a procedure which allows endoscopic evaluation of most of the small intestine. A small bowel tumour was found in 5% of patients. In 50% of patients no diagnosis could be made, but when the cause of obscure bleeding was discovered small bowel tumours were the single most common lesion in patients younger than 50 years. Small bowel tumours causing gastrointestinal bleeding may remain undetected despite extensive diagnostic evaluation. We conclude that small bowel tumours are the most common cause of obscure gastrointestinal bleeding in patients less than 50 years of age. Small bowel enteroscopy is diagnostic of small bowel tumours even when all previous diagnostic studies, including enteroclysis and angiography, are negative.

Role of intraoperative enteroscopy in obscure gastrointestinal bleeding of small bowel origin

Intraoperative enteroscopy was performed in 12 patients (median age 68 years) with obscure gastrointestinal bleeding probably of small bowel origin, six of whom were men. All the patients were evaluated by routine haematological, coagulation and biochemical profiles, upper and lower gastrointestinal endoscopies, visceral angiography and/or isotope scanning. All the patients were anaemic. Visceral angiography was useful on three of the 12 occasions on which it was used and isotope scanning was valuable on eight of the 11 occasions it was used. Nine patients had undergone previous laparotomy. Enteroscopy was performed successfully in all cases, with fresh blood and discrete vascular lesions being the chief findings (10 of 12 cases). Segmental resections (n = 8) and local resections (n = 2) were performed in ten patients, with two patients having more than one laparotomy for rebleeding. Five patients developed postoperative complications and there was an operative death and one late death. Three of the ten surviving patients experienced further rebleeding. Intraoperative enteroscopy is now an essential adjunct to laparotomy for gastrointestinal bleeding which has been localized to the small bowel before operation.

Cavernous haemangioma of the jejunum. Long-standing anaemia in a child

A 15-year-old boy who had been examined for almost lifelong iron deficiency anaemia caused by occult gastrointestinal bleeding was eventually, by abdominal surgery, found to have a cavernous haemangioma of the jejunum. A diagnostic approach is described and the importance of systematic evaluation and subsequent diagnosis in such patients is stressed.

Rare case of obscure haemorrhage in the upper digestive tract (epiglottis)

An exceptional case of obscure bleeding in the upper digestive tract caused by an arteriovenous haemangioma of the epiglottis is presented. The clinical details and surgical findings are described.

Laser treatment of intestinal vascular abnormalities

Mucosal vascular abnormalities, including haemangioma, angiodysplasia and telangiectasia, are thought to be responsible for one third of chronic lower gastrointestinal blood loss. One hundred and ninety-one patients were referred for endoscopic diagnosis and treatment of acute or chronic blood loss. In 24 (13%) of patients no bleeding source could be found, in 23 (12%) laser treatment was not indicated and in another 23 (12%) follow-up was insufficient. Of 121 evaluable patients, 107 had angiodysplasia with colonic localisation in 54, 9 had telangiectasia diffusely within the digestive tract, and 5 haemangioma with colonic location in 3. In angiodysplasia effective haemostasis was obtained in 78% with a recurrence rate of 34% at prolonged follow-up, which responded to treatment in 82%. In patients with Rendu-Osler-Weber disease the haemostasis rate was 56%, with recurrence occurring in 33% and a retreatment response in 21%. Colonic haemangioma responded in 67% of cases but there was a high recurrence rate of 67% and a low retreatment response (33%). There were five major complications and all occurred with colonic angiodysplasia (5/54, 9.3%). These included serosal irritation (2), CO2 distension (1) and posttreatment bleeding (2). Minor complications consisted of CO2 retention in one case treated for angiodysplasia, and fever (1) and posttreatment bleeding (2) in haemangioma. Effective and safe haemostasis can be obtained by Neodymium-YAG laser-photocoagulation in often difficult circumstances without perforation or mortality. The method has proven to be indispensible for elderly and inoperable patients with intestinal vascular abnormalities.

Selective visceral angiography in obscure postoperative gastrointestinal bleeding

Postoperative gastrointestinal bleeding may be difficult to diagnose and treat. Selective visceral angiography localised the bleeding site in seven out of ten episodes of obscure postoperative gastrointestinal haemorrhage, and in two cases radiological embolisation was used successfully to control the bleeding. Angiography, preferably during an episode of haemorrhage, is recommended whenever possible for patients with undiagnosed postoperative gastrointestinal bleeding.

Gastrointestinal haemorrhage from a second source in patients with colonic angiodysplasia

Angiodysplasia of the colon is increasingly recognized as a cause of obscure gastrointestinal haemorrhage. On review of 71 patients with angiodysplasia, 40 came to surgery. Of these, nine (22.5 per cent) were also found to have small bowel lesions, either at the original laparotomy (7) or later when further investigations were performed for recurrent bleeding. Angiodysplasia can only be confidently diagnosed as the source of blood loss if seen to be actively bleeding. If a synchronous small bowel lesion is seen, we recommend that it should be removed at the same time as the colectomy.

Specialist investigation of obscure gastrointestinal bleeding

The investigation and treatment of 131 patients with 'obscure' gastrointestinal bleeding has been reviewed. One hundred and six patients were assessed electively for recurrent haemorrhage, 25 presented as emergencies. The major presenting feature was melaena (55 patients), anaemia (35), rectal bleeding (34), haematemesis (six) and ileostomy bleeding (one). The lesions responsible for haemorrhage were colonic angiodysplasia (52 patients), small bowel vascular anomalies (16), Meckel's diverticula (nine), small bowel smooth muscle tumours (seven), gastric vascular anomalies (four), chronic pancreatitis (three), colonic diverticular disease (three) and 16 other miscellaneous lesions. No lesion was found in 21 cases. Lesions were first shown by visceral angiography (69 patients), at laparotomy (23), on endoscopy (11), on gastrointestinal contrast radiological studies (four), and at ERCP (three). Lesions which were undetectable at operation increased markedly with age (p less than 0.0001). Expert visceral angiography is strongly recommended before surgery in patients over 45 years of age and after laparotomy when no cause has been found. Exploratory laparotomy is recommended at an early stage for younger patients, and for older patients after non-diagnostic angiography.

The importance of laparotomy in the diagnosis and management of intestinal bleeding of obscure origin

Thirty-seven patients who had had either a colonoscopy or a selective mesenteric angiogram while being investigated for severe or persistent gastrointestinal bleeding of obscure origin were reviewed. Failure to make a prompt diagnosis was partly responsible for the 16% hospital mortality in the series. Colonoscopy was diagnostic on 6 out of 38 examinations but detected 43% of lesions in the colon. Angiography achieved only 3 diagnoses in 17 examinations. Fourteen patients had an exploratory laparotomy which was diagnostic in 9. We believe that early laparotomy still has an important place in the diagnosis and treatment of intestinal bleeding of obscure origin.

Melaena caused by small bowel metastases of colorectal cancer in presence of anastomotic recurrence

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Acute stress ulceration

Stress ulceration is usually considered a mucosal abnormality of the oesophagus, stomach or duodenum in the critically ill. It is found to a varying degree in all such patients. Only about one-quarter of lesions are associated with blood loss and less than 5% need resuscitation and treatment. However, because treatment of established bleeding is unsatisfactory, and associated with a high mortality, prophylactic measures are usually employed. These include optimising gastric mucosal blood flow and oxygen delivery, correcting coagulation abnormalities and treating underlying infection. Enteral feeding should also be employed whenever possible. Other prophylactic measures currently used involve raising gastric pH above 4, with either antacids or H2 receptor antagonists. This is best achieved by measuring the gastric pH hourly and titrating it against an appropriate dose of either type of drug or a combination of both. Newer drugs, such as omeprazole, sucralfate and prostaglandins, are proving very successful in the treatment and prevention of gastric and duodenal ulcers and may prove even more effective than currently available agents.