Specialist investigation of obscure gastrointestinal bleeding

Non-small-bowel lesions identification by capsule endoscopy: A single centre retrospective study

BACKGROUND

Capsule endoscopy has been considered the first-line approach for the investigation of obscure gastro-intestinal bleeding since its approval in 2001. Our study aims to evaluate the diagnostic yield of capsule endoscopy in the investigation of this condition. We also analyse the incidence of non-small-bowel lesions missed after conventional endoscopy and later detected by capsule endoscopy in patients with suspected obscure bleeding.

METHODS

A total of 290 patients with negative conventional endoscopy referred to our centre to undergo a capsule endoscopy examination for the investigation of obscure gastro-intestinal bleeding. We considered as non-small-bowel lesions those outside the tract between the second duodenal portion and the ileocecal valve. We also looked for actively bleeding lesions at the time of the exam.

RESULTS

Intestinal preparation was good, adequate or poor in 74.1%, 8.4%, and 17.5% of the tests, respectively. Caecum was reached in 92.4%. Capsule retention occurred in 0.7%. Mean small bowel transit time was 5hours and 13minutes. Diagnostic yield was 73.8%. An actively bleeding lesion was noticed in 39.3% of positive tests. Capsule endoscopy revealed clinically significant non-small-bowel lesions missed at gastroscopy or colonoscopy in 30.3% of patients, 43.2% of which were bleeding.

CONCLUSIONS

Capsule endoscopy has high diagnostic yield and safety in the investigation of obscure gastro-intestinal bleedings. Given the high percentage of non-small-bowel lesions detected, it may be appropriate to consider an endoscopic second look before performing a capsule endoscopy study.

Combined Use of Computed Tomography Enterography/Enteroclysis and Capsule Endoscopy Improves the Accuracy of Diagnosis of Small Bowel Bleeding

Objective CT enterography/enteroclysis (CTE) is listed in the clinical practice guidelines as a method for diagnosing small bowel bleeding, as is capsule endoscopy (CE), but there are no real-world data yet available on CTE in Japan. This study aimed to investigate the diagnostic ability of CTE and long-term prognosis after CTE in Japan. Patients We conducted a retrospective cohort study of patients suspected of having small bowel bleeding who underwent both CTE and CE within 30 days between April 2008 and March 2019. The number of patients free from rebleeding for up to 24 months was thus determined. Results Seventy-one patients were extracted from the database. The 43 patients (60.6%) with a definite and suspicious source of bleeding in the small bowel were detected by CTE. When the 31 patients with a definite source of bleeding in the small bowel were analyzed, the sensitivity of CTE was 19/31 (61.3%) and that of CE was 24/31 (77.4%), thus indicating no significant difference (p=0.332). However, the sensitivity when CTE and CE were used in combination was 30/31 (96.8%), which was significantly higher than that of CE alone (p=0.0412). No rebleeding was observed in the CTE and CE negative group (p=0.0965). Conclusion The combined use of CTE and CE increased the detection rate of small bowel bleeding. Therefore, in patients with suspected tumor/polyp lesions, not only CE, but also CTE should be performed. This study provides the first real-world data on the diagnostic accuracy of CTE for small bowel bleeding in Japan.

Obscure gastrointestinal bleeding resulting from small bowel neoplasia; A case series

•

Obscure GI bleeding can be a challenging diagnosis and is well acknowledged.

•

Perseverance is required to achieve the correct diagnosis in obscured GI bleeding.

•

Diagnostic overshadowing can halt investigations and delay diagnosis.

•

Multidisciplinary team input is important in the diagnosis of obscured GI bleeding.

Introduction

Undiagnosed gastrointestinal bleeding may originate in the small bowel. This presents a diagnostic challenge despite the advancement in contemporary imaging. We report two cases which highlight the limitations of routine investigation for obscure gastrointestinal bleeding.

Presentation of case

Patient A presented with a history of rectal bleeding, treated with interventional embolisation of caecal angiodysplasia. A diagnosis of neuroendocrine tumour (NET) was reached two years after presentation following intraoperative right hemicolectomy resection of a presumed recurrent angiodysplastic bleed. Patient B presented with recurrent melaena labelled as non-steroidal anti-inflammatory drug (NSAID) induced gastritis. After multiple endoscopic and radiological investigations, a 4.5 cm mass was visualised on imaging after three years, which was histologically proven as gastrointestinal stromal tumour (GIST) of the small bowel. Both patients experienced a delayed diagnosis despite multiple investigations and careful follow-up.

Discussion

Our case series discusses the benefits and limitations of investigation for gastrointestinal bleeding and suggests a need for continued multidisciplinary input in situations where the patient presumed diagnosis remains in question.

Conclusion

OGIB remains a diagnostic challenge and is attributable to small bowel pathology in 75% of cases. This suggests a need for continued investigation in situations where the patient presents multiple times despite adequate treatment for the presumed underlying condition.

Small intestinal diverticulum with bleeding: Case report and literature review

RATIONALE

Small intestinal diverticulum with bleeding is an important reason for obscure gastrointestinal bleeding (OGB) , in addition to tumor and vascular diseases. Small intestinal diverticulum with bleeding is difficult to detect by barium meal and angiographic methods and has been regarded as an important cause of obscure gastrointestinal tract bleeding in adolescents. Because of its complicated etiology and non-specific clinical manifestations, it is relatively difficult to detect small intestinal diverticulum with bleeding, especially in patients with a large amount of bleeding and hemodynamic instability.

PATIENT CONCERNS

This retrospective study collects clinical statistics of 19 patients admitted to our hospital from January 2010 to December 2016. Patients who had small intestinal diverticulum patients with bleeding were included in this study. Patients who were taking anticoagulants were excluded DIAGNOSES:: Small intestinal diverticulum patients with bleeding.

INTERVENTIONS

This retrospective study describes the clinical features of patients with small intestinal diverticulum whose main symptom was gastrointestinal bleeding and analyze the literature on this topic, with particular reference to the clinical characteristics, pathological features, and choice of examination methods.

LESSONS

Small intestinal diverticulum with bleeding is a common cause of obscure gastrointestinal bleeding, but it is difficult to detect using normal examination methods. For patients with repeated gastrointestinal bleeding and no positive results found on gastroscopy and colonoscopy, endoscopy of the small intestine and CTE with contrast can be considered as a diagnostic modality.

Review on gastrointestinal angiodysplasia throughout the gastrointestinal tract

Gastrointestinal angiodysplasia are rare but clinically important vascular aberrations found within the gastrointestinal mucosa and submucosa. Their clinical impact varies from being an asymptomatic incidental finding, to causing life threatening bleeding. In this review we critically appraise the key findings from the current literature on the pathology, clinical presentation and management of these lesions.

Obscure gastrointestinal bleeding: single centre experience of capsule endoscopy

The advent of capsule endoscopy (CE) has resulted in a paradigm shift in the approach to the diagnosis and management of patients with obscure gastrointestinal bleeding (OGIB). With increasing global availability of this diagnostic tool, it has now become an integral part of the diagnostic algorithm for OGIB in most parts of the world. However, there is scant data on optimum timing of CE for maximizing diagnostic yield. OGIB continues to be a challenge because of delay in diagnosis and consequent morbidity and mortality. We evaluated the diagnostic yield of CE in identifying the source of bleeding in patients with OGIB. We identified patients who underwent CE at our institution from May 2006 to May 2011. The patients' medical records were reviewed to determine the type of OGIB (occult, overt), CE results and complications, and timing of CE with respect to onset of bleeding. Out of 346 patients investigated for OGIB, 246 (71.1%) had some lesion detected by CE. In 206 patients (59.5%), definite lesions were detected that could unequivocally explain the OGIB. Small bowel angiodysplasia, ulcer/erosions secondary to Crohn's disease, non-steroidal anti-inflammatory agent use, and neoplasms were the commonest lesions detected. Visualization of the entire small bowel was achieved in 311 (89.9%) of cases. Capsule retention was noted in five patients (1.4%). In this study, CE was proven to be a safe, comfortable, and effective, with a high rate of accuracy for diagnosing OGIB.

The American Society for Gastrointestinal Endoscopy (ASGE) diagnostic algorithm for obscure gastrointestinal bleeding: eight burning questions from everyday clinical practice

The diagnosis and management of patients with obscure gastrointestinal bleeding are often long and challenging processes. Over the last 10 years the introduction in clinical practice of new diagnostic and therapeutic procedures (i.e. Capsule Endoscopy, Computed Tomographic Enterography, Magnetic Resonance Enterography, and Device Assisted Enteroscopy) has revolutionized the diagnostic/therapeutic work-up of these patients. Based on evidence published in the last 10 years, international scientific societies have proposed new practice guidelines for the management of obscure gastrointestinal bleeding, which include these techniques. However, although these algorithms (the most recent ones are endorsed by the American Society for Gastrointestinal Endoscopy - ASGE) allow the management of the large majority of patients, some issues still remain unsolved. The present paper reports the results of the discussion, based on the literature published up to September 2011, among a panel of experts and gastroenterologists, working with Capsule Endoscopy and with Device Assisted Enteroscopy, attending the 6th annual meeting of the Italian Club for Capsule Endoscopy and Enteroscopy. Eight unresolved issues were selected: each of them is presented as a "Burning question" and the "Answer" is the strategy proposed to manage it, according to both the available evidence and the discussion among participants.

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.

Multi-phase CT enterography in obscure GI bleeding

Multiphase CT enterography is a modification of conventional abdominal CT designed to optimize detection of abnormalities responsible for obscure GI bleeding. This imaging test appears to be complimentary to wireless capsule endoscopy in the evaluation of this difficult group of patients. A description of exam technique, findings, and discussion of results will be presented in this article.

Possible Role of Meckel's Scan Fused with SPECT CT Imaging: Unraveling the Cause of Abdominal Pain and Obscure-Overt Gastrointestinal Bleeding

A 27-year-old male presented with recurrent abdominal pain and high volume hematochezia despite undergoing extensive testing and a right hemicolectomy 3 years prior for a linear bleeding ulceration in the ascending colon. Studies at the University of Michigan included esophagogastroduodenoscopy (EGD), colonoscopy and video capsule endoscopy (VCE), revealing an arteriovenous malformation (AVM) in the terminal ileum. He was hospitalized for recurrent symptoms. His presentation suggested a small bowel source of obscure-overt GI bleeding based on prior non-diagnostic colonoscopy and EGD and a bilious nasogastric lavage. Tagged red blood cell scan localized bleeding to the right lower quadrant. Colonoscopy showed fresh blood in the terminal ileum without a clear source. Angiography showed no evidence of bleeding or terminal ileal AVM. A novel Meckel's scan fused with SPECT imaging showed focal uptake in the terminal ileum. The patient underwent Meckel's diverticulectomy with sparing of adjacent bowel and has remained asymptomatic for 19 months. This case illustrates that patients with obscure-overt GI bleeding require a step-wise multi-modality diagnostic work-up. Because Meckel's scans are false-positive in 28% of adults, Meckel's scan fused with SPECT imaging may offer an approach to refine diagnostic accuracy of either scan alone, but requires further investigation. Exploratory laparotomy should be reserved as a last option and is best performed with intraoperative endoscopy.

Impact of therapeutic interventions induced by capsule endoscopy on long term outcome in chronic obscure GI bleeding

BACKGROUND

The diagnostic yield and the clinical impact of capsule endoscopy (CE) in obscure gastrointestinal bleeding (OGIB) are well known. The aim of this study was to determine the impact of therapeutic interventions induced by CE findings on long term outcome.

PATIENTS AND METHODS

Patients with chronic OGIB referred to our center from September 2003 to June 2005 for CE were included. Treatment of intestinal lesions was prescribed according to the clinical characteristics of patients and the nature of the lesions.

RESULTS

Forty patients were included, 18 females and 22 males. Median age was 54 yrs (range: 5-87) with a median follow-up of 13 months (range: 6-22). The diagnostic yield of CE was 75% (30/40). From 30 patients with positive CE, 16 received treatment (Group I) and 14 did not (Group II). Thus clinical impact was 40%. Ten patients had negative CE (Group III). During follow-up, bleeding recurrence was observed in only 1 patient from Group I (6%), 5 from Group II (36%) and 1 from Group III (10%). There were only significant differences between Group I vs Group II (P=0.002).

CONCLUSIONS

CE results had a favorable influence in patient outcome allowing for specific treatment as they showed significantly reduced recurrent bleeding.

Obscure gastrointestinal bleeding: diagnostic and therapeutic approach

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.

Increased diagnostic yield of small bowel tumors with capsule endoscopy

BACKGROUND

It is believed that cancers of the small intestine represent <2% of all malignant tumors of the gastrointestinal tract, although the accuracy of this estimate is unknown, because the current methodologies for examining the small bowel have proved inadequate. Capsule endoscopy allows a more detailed inspection of the small intestine and may improve the ability to diagnose small bowel tumors. The objective of this study was to evaluate the effectiveness of capsule endoscopy in diagnosing small bowel tumors and to help establish the true incidence of tumors in obscure gastrointestinal bleeding.

METHODS

A retrospective analysis of the charts of 562 patients who underwent capsule endoscopy from August 2001 to November 2003 for a variety of indications was performed. The indication for the procedure was bleeding (alone or in addition to another indication, such as abnormal imaging) in 443 patients.

RESULTS

A diagnosis was made by capsule endoscopy in 277 patients (49.3%). Of 562 patients who were included in the study, 50 patients (8.9%) were diagnosed with small bowel tumors. The types of tumor diagnosed by capsule endoscopy included 8 adenocarcinomas (1.4%), 10 carcinoids (1.8%), 4 gastrointestinal stromal tumors (0.7%), 5 lymphomas (0.9%), 3 inflammatory polyps, 1 lymphangioma, 1 lymphangioectasia,1 hemangioma, 1 hamartoma, and 1 tubular adenoma. Of the tumors diagnosed, 48% were malignant. It was observed that 9 of 67 patients (13%) younger than age 50 years who underwent capsule endoscopy for obscure bleeding had small bowel tumors. The pathology results were not available for 10 patients.

CONCLUSIONS

Capsule endoscopy diagnosed small bowel tumors in 8.9% of patients who underwent the procedure for a variety of reasons, establishing it as an effective diagnostic modality. This incidence of small bowel tumors suggests an important role for capsule endoscopy in the algorithm for the diagnostic work-up of patients with suspected small bowel lesions. Capsule endoscopy may lead to earlier detection and treatment of small bowel tumors and an improved prognosis for patients with these neoplasms.

Obscure gastrointestinal bleeding

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

Laparoscopy-Assisted Exploration of Obscure Gastrointestinal Bleeding After Capsule Endoscopy: The Korean Experience

BACKGROUND

Obscure gastrointestinal bleeding (OGB) is generally defined as recurrent acute or chronic bleeding for which no source has been identified by routine radiologic and endoscopic examination. The aim of this study was to report our early experiences detecting small bowel bleeding by capsule endoscopy (CE) and the results of laparoscopy assisted surgery for OGB.

MATERIALS AND METHODS

Seventy-five patients with OGB were examined by CE. Twelve of 24 patients in the active bleeding group underwent laparoscopic or laparoscopy assisted surgery and we carried out intraoperative enteroscopy to find the focus of the bleeding.

RESULTS

Laparoscopic localization of the lesion was successful for 4 patients-those with Meckel's diverticulum, gastrointestinal stromal tumor, lymphoma, and ischemic necrosis. In 3 cases in which there was no natural passage of the capsule endoscope, lesions were identified by small bowel exploration through simple palpation by hand. Intraoperative enteroscopy was performed extracorporeally in 5 cases through a minilaparotomy window using an extended incision of a port site less than 7 cm in length. The lesions that were identified by CE preoperatively were resected successfully, via laparoscopic or laparoscopy-assisted surgery. The gastrointestinal bleeding has not recurred during the postoperative follow-up period (mean, 10.6 months).

CONCLUSION

The laparoscopic approach can be chosen for surgical management of OGB patients with active bleeding whose lesions have been identified by CE. This approach allows minimally invasive surgical treatment for ongoing OGB.

An initial experience: using helical CT imaging to detect obscure gastrointestinal bleeding

Obscure gastrointestinal (GI) bleeding is a common but frustrating disease for clinicians because of its elusive nature despite extensive work-up. We evaluate the role of helical computed tomography (CT) imaging using rapid infusion of intravenous contrast and water as oral contrast in the work-up of patients who are actively bleeding. Helical CT may be a useful noninvasive, alternative study to consider when routine work-up fails to determine the cause of active GI bleeding. Our preliminary study shows that helical CT was able to identify a wide variety of causes of obscure GI bleeding.

Benign rectal ulcer: an underground cause of inpatient lower gastrointestinal bleeding

BACKGROUND

Although it is uncommon, significant bleeding per rectum presents one of the most difficult emergency problems. Bleeding from a rectal ulcer is not well recognized as a cause of such bleeding.

METHODS

From July 2000 through December 2000, 195 consecutive patients with significant blood loss per rectum were reviewed.

RESULTS

Forty-eight cases in whom significant gastrointestinal (GI) bleeding occurred following prior hospitalization were identified. Sources of bleeding were gastroduodenal in 38 cases (79%) and colorectal in 10 cases (21%). The causes of inpatient colorectal bleeding were benign rectal ulcer (n = 4), ischemic colitis (n = 3), neoplasia (n = 2), and diversion colitis (n = 1).

CONCLUSION

The differential diagnosis for inpatients who develop new inpatient GI bleeding differs from that of patients who develop outpatient GI bleeding. Careful examination of the rectum following rectal instrumentation is critical. In addition to the standard resuscitative measures, the identification and treatment of rectal ulcers in this group of patients is of paramount importance. The treatment options for bleeding rectal ulcer include conservative therapy, cauterization, embolization, banding, and local excision.

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.

Detection of bleeding due to small bowel cholesterol emboli using helical CT examination in gastrointestinal bleeding of obscure origin

Chronic, intermittent GI bleeding is defined as obscure when routine diagnostic examinations of the GI tract, including barium and endoscopic studies, fail to reveal the cause of bleeding. Our patient had significant bleeding and extensive evaluation including upper endoscopy, small bowel enteroscopy, enteroclysis, colonoscopy, and provocative angiography with urokinase, without the source of bleeding detected. This report describes a noninvasive novel approach using helical CT scanning with water as oral contrast and rapid injection of intravenous iodinated contrast material and thin slices obtained to diagnose the site of recurrent, obscure GI bleeding related to cholesterol crystal embolization to the small intestine.

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.

Gastrointestinal haemorrhage after abdominal aortic grafting

Images

Treatment of rectal hemorrhage by coil embolization

Four patients, aged 54-84 years, presenting with life-threatening rectal bleeding from the superior hemorrhoidal artery, underwent percutaneous fibered platinum coil embolization via coaxial catheters. Pre-procedure sigmoidoscopy had failed to identify the source of hemorrhage, because the rectum was filled with fresh blood. Embolization was technically and clinically successful in all four patients. Subsequent sigmoidoscopy confirmed the diagnoses in three patients as a solitary rectal ulcer, iatrogenic traumatic ulceration following manual evacuation, and a rectal Dieulafoy's lesion. The other case was angiographically seen to be due to a rectal angiodysplasia. Embolization is an effective procedure in life-threatening superior hemorrhoidal arterial bleeding when endoscopic treatment fails, and should be preferred to rectosigmoid resection.

Massive arterial bleeding from a single rectal vessel

We report a case of massive rectal haemorrhage arising from a single ectatic arterial vessel above the haemorrhoidal cushion in normal rectal mucosa. Use of an anal retractor enable identification of the bleeding vessel and avoided a major laparatomy.

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.

Diffuse microscopic angiodysplasia--a previously unreported variant of angiodysplasia. Report of a case

PURPOSE

The entity of diffuse microscopic angiodysplasia is described, and a patient with severe gastrointestinal hemorrhage because of this submucosal source of bleeding is reported.

METHOD

Case records of a patient with severe gastrointestinal hemorrhage were reviewed, and histologic findings were compared with colonoscopic and operative findings. The patient received 51 units of packed red blood cells over 3.5 months and remained undiagnosed, despite an exhaustive evaluation, until autopsy.

RESULTS

Ectatic veins, venules, and capillaries were present within the submucosa in virtually every section of the small and large intestine examined (79 of 86 sections). Histologic evidence of bleeding from these submucosal vessels was identified in three sites (colon, jejunum, and ileum). The absence of endoscopically visible lesions was explained by findings that vessels did not traverse the muscularis mucosa and that mucosal depth was normal. This case of diffuse microscopic angiodysplasia, therefore, represents a unique variant, because the vascular findings were so diffuse and the mucosa remained histologically and endoscopically uninvolved, despite severe bleeding.

CONCLUSION

Gastrointestinal bleeding from angiodysplasia is generally assumed to arise from endoscopically recognizable vascular ectasia within the mucosa. Thus, this case helps provide an explanation for some cases in which occult or massive bleeding is assumed to be secondary to angiodysplasia, even when endoscopic verification is not possible. Recognition of this disease process may require segmental resection or deep biopsy of endoscopically normal intestine.

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.

Iron deficiency anaemia--how far to investigate?

Since 1980 investigations, by this group, of patients with iron deficiency anaemia and no obvious cause, have been limited to upper gastrointestinal endoscopy, with small bowel biopsy, and barium enema. This study attempted to follow up 93 consecutive patients whose anaemia remained obscure after these investigations to determine the outcome and assess the safety of this limited approach. In 1991/92 questionnaires were sent to the general practitioners. Eighty three completed questionnaires were received. Ten patients had died all unrelated to the iron deficiency anaemia. The mean follow up of the 73 living patients was six years (range 4-12). Sixty five (89%) had a normal haemoglobin concentration and only 15 were still taking oral iron. Possible causes for the anaemia were found in 17-non-steroidal anti-inflammatory drug use in 10, menstruation in two, gastrectomy in three, poor nutrition in two. No other cause emerged. It is concluded that this limited investigative approach is safe.

Laparoscopic diagnosis and treatment of Meckel's diverticulum complicated by gastrointestinal bleeding

Laparoscopy has been utilized for many gynecological and surgical procedures that previously required laparotomy. Its use in the diagnosis and treatment of Meckel's diverticulum complicated by gastrointestinal bleeding is described.

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.

Evaluation of HemoQuant test and enteroclysis in estimating the sites of obscure gastrointestinal bleeding

The HemoQuant test includes the measurement of total fecal hemoglobin (Hb) or porphyrin derived from heme, and of intestinal converted fraction (ICF) which is the performed porphyrin probably by bacteria during enterocolic transit. The mean +/- SD of HemoQuant in 31 healthy subjects was 0.57 +/- 0.49 mg Hb/g stool, values above 2 mg Hb/g stool are considered to be positive. In patients with upper GI bleeding (n = 44), small bowel bleeding (n = 11) and large bowel bleeding (n = 16), the ICF ranged 0.03-23%, 0.09-20.20% and 0.35-11.0%, respectively. There was major overlap in individual ICF due to some influencing factors such as the quantity of fecal blood and the enterocolic transit. We conclude that HemoQuant is a sensitive assay for detection of fecal occult blood, but ICF is not helpful in estimating the anatomic site of bleeding. Seventy-one patients with GI bleeding of obscure origin underwent enteroclysis. The results showed 77.5% had definite lesions in the small bowel, but 22.5% still were undefined. It is suggested that enteroclysis should be performed without delay if upper and lower GI endoscopic studies 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.

Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin

Push-enteroscopy using a disinfected colonoscope was performed on 39 patients with gastrointestinal bleeding of obscure origin. Our results show that: (1) A high percentage of patients (38%) have pathological lesions responsible for bleeding located in the distal duodenum and proximal jejunum, which are readily detected by push-enteroscopy. (2) Duodeno-jejunal arteriovenous malformations (AVMs) are the most common cause for bleeding, and these lesions can be conveniently cauterized through the endoscope. (3) An efficient sequence of steps for diagnosis of patients with this problem includes push-enteroscopy when the initial EGD and colonoscopy are normal followed by small bowel radiography. Mesenteric angiography and intraoperative enteroscopy can be reserved for patients with severe bleeding when push-enteroscopy and small bowel radiography are negative. We conclude that push-enteroscopy has an important role to play in the early assessment of patients with gastrointestinal bleeding of obscure origin.