Obscure GI Bleeding

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Obscure GI Bleeding

• Kathy Bull-Henry, MD
• Georgetown University Hospital
• Division of Gastroenterology

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GI Bleeding Definitions
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Obscure GI BleedingDefinition

• Bleeding of unknown origin that persists or
  recurs after negative colonoscopy and negative
  upper endoscopy
• Recurrent or persistent bleeding
• FOBT positive
• IDA
• Visible bleeding
• Melena, hematemesis, hematochezia, coffee grounds

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Obscure-Occult GI Bleeding Frequency
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Obscure GI BleedingFrequency

• 10 - 20 of GI bleeding without identifiable
  etiology
• 5 GI bleeding recurrent without identifiable
  etiology
• Majority have small bowel source

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Obscure GI BleedingSmall Bowel CausesGrouped by
Age

• Patients lt 25 years old
• Meckels Diverticula
• Patients between 30 50 years old
• Tumors
• Patients gt 50 years old
• Vascular ectasias

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Small Bowel Bleeding CausesBy Etiology

• Vascular Lesions
• Neoplasms
• Inflammatory Lesions
• Other

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Small Bowel BleedingVascular Lesions

• Most common cause of small bowel bleeding
• Responsible for 70 -80 of small bowel bleeding

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Small Bowel BleedingVascular Lesions

• Angioectasias
• Telangiectasias
• Hereditary hemorrhagic telangiectasia
• Osler-Weber-Rendu Syndrome
• CREST Syndrome
• Calcinosis, Reynauds, Esophageal dysmotility
  Sclerodactyl, Telangiectasia
• Other
• Dieulafoys lesion
• Aortoenteric fistula
• Small bowel varices

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Small Bowel BleedingAngiodysplasia

• Dilated tortuous blood vessels with thin walls
  lined by endothelium with little or no smooth
  muscle
• Most common small bowel bleeding in the elderly
  (gt 50 years old)
• May be associated with aging associated
  degeneration of vascular integrity

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Small Bowel BleedingTumors

• Second most common cause of bleeding
• One out of ten patients with obscure bleeding
  will have a small bowel tumor
• Most common cause in persons age 30 50 years of
  age
• Malignant and Benign
• Adenocarcinoma, carcinoid, lymphoma,
  leiomyosarcoma,
• Leiomyoma, polyps (Peutz-Jeghers, familial
  polyposis), GIST
• Metastatic
• Melanoma, breast, renal-cell, kaposis sarcoma,
  colon, ovarian

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Causes of Small Bowel BleedingDiverticula

• Small bowel diverticula
• At the site of perforating blood vessels
• Meckels diverticulum
• Remnant of vitelline duct in distal ileum
• Most common cause of small bowel bleeding in
  patients under the age of 25 years old
• Ectopic gastric tissue causes ulceration
• Intussusception
• Inverted Meckels, angioectasias, submucosal
  tumors

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Small Bowel BleedingInflammatory Lesions

• Crohns Disease
• Isolated ulcers
• Idiopathic ulcers
• Nonsteroidal antiinflammatory drugs
• Ischemic
• Other
• Vasculitis, Zollinger-Ellison syndrome, Celiac
  disease

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Small Bowel BleedingRare Causes

• Hemobilia
• Neoplasm, vascular aneurysm, liver abscess,
  trauma, liver biopsy
• Hemosuccus pancreaticus
• Pancreatic pseudocysts, pancreatitis, neoplasms
• Erosion into a vessel with communication with PD
• Infections
• Cytomegalovirus, histoplasmosis, Tb

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Obscure GI BleedingSummary Causes
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Obscure GI BleedingSmall Bowel Visualization

• Difficult to visualize
• Length (6.7 m)
• Free intraperitoneal location
• Vigorous contractility
• Overlying loops

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Small Bowel Bleeding Diagnosis

• UGI SBFT
• Enteroclysis
• Push enteroscopy
• Double balloon enteroscopy
• Intraoperative enteroscopy
• CT scan
• CT enteroclysis
• MRI
• Video capsule endoscopy

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Obscure BleedingSBFT and Enteroclysis

• SBFT
• 0-5.6 diagnostic yield
• Enteroclysis
• Superior to SBFT
• Double contrast, Tube into proximal small bowel
• Inject barium, methylcellulose, air
• Performed with CT and MRI
• Only 10-21 diagnostic yield
• Use if capsule endoscopy or enteroscopy
  unavailable

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Obscure GI BleedingNuclear Scans

• Technetium (99mTc) sulfur colloid
• Technetium 99m-labeled red blood cell scan (TRBC)
• Most commonly used method
• Long half life allows for repeat scanning in 24
  hours
• Late pooled blood may not identify bleeding site
• Requires bleeding rate of 0.1 to 0.4 mL/min
• Positive in 45 all LGI bleeding
• Angiography verification highest (67) when
  bleeding scan is immediately positive
• Data in obscure bleeding limited
• 15 false positive, 12-23 false negative
• Need verification by angiography or endoscopy

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Obscure GI BleedingAngiography

• Severe bleeding
• Bleeding rate of 0.5 mL/min
• Positive in 27-77 of acute LGI bleeding
• Positive in 61-72 if,
• Pt actively bleeding requiring transfusion
• Hemodynamic compromise
• TRBC scan shows an immediate blush
• Administer anticoagulants, vasodilators,
  clot-lysing agents to precipitate bleeding
• Increased diagnostic yield from 32 to 65
• 17 complication rate including excessive
  bleeding

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Obscure BleedingEnteroscopy

• Pass scope beyond the ligament of Treitz
• Adult or pediatric colonoscope, SB enteroscope
• Diagnostic yield 40-50
• Angiodysplasia in 80
• Advantage over capsule endoscopy
• Sample tissue
• Endoscopic therapy

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Obscure BleedingIntraoperative Enteroscopy

• Transfusion dependent
• Severe blood loss
• Risk of continued bleeding outweigh the risk of
  laparotomy
• Identifies bleeding source in 70 100
• Technically difficult
• Adhesions, luminal blood, infiltrating neoplasia
• Complications (procedure and post op)
• Perforation, mucosal tears, mesenteric
  hemorrhage, prolonged ileus, ischemia, wound
  infection, pneumonia
• Mortality 11

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Obscure GI BleedingIntraoperative Enteroscopy
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Obscure GI BleedingExploratory Laparotomy

• Seldom without intraoperative enteroscopy
• 65 of 37 pts had lesion identified by palpation
  or transillumination

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PillCam SB Exam Set
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1. The PillCam Capsule 2. SensorArray SB 3.
Given DataRecorder
3
1
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Wireless Capsule Endoscopy Patient Experience

• Sensors placed and attached to data recorder
• Easily ingested, painless procedure
• Progresses naturally through the GI tract via
  peristalsis
• Transmits images to data recorder

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PillCam SB Patient Experience

• Liquid diet from lunch the day before
• Movie Prep the night before
• 12 hour fast the night before
• Capsule ingested in the morning
• Reglan or erythromycin for inpatients
• Liquid diet after 2 hours
• Light meal 4 hours after ingestion
• Disconnect after 8 hours

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Obscure GI BleedingPillCam SB
(Analysis of patients with verified final
diagnosis, n 56)
Pennazio M, Santucci R, Rondonotti E, et al.
Gastroenterology 2004 126 643-653
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Obscure GI BleedingPillCamTM SB

• CE results led to treatments resolving the
  bleeding in 86.9 of patients undergoing the
  procedure while actively bleeding.
• (12 25 month follow up)

Pennazio M, Santucci R, Rondonotti E, et al.
Gastroenterology 2004 126 643-653
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Obscure GI Bleeding Pennazio et al. 2004
Conclusion

• If done early in the course of the workup,
• PillCam endoscopy could
• Shorten considerably the time to diagnosis
• Lead to definitive treatment in a relevant
  proportion of patients
• Spare a number of alternative investigations with
  low diagnostic yield

Pennazio M, Santucci R, Rondonotti E, et al.
Gastroenterology 2004 126 643-653
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Obscure GI Bleeding PillCamTM SB
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PillCam SBIndications

• First line diagnostic exam for visualization of
  small bowel mucosa.
• Clinical data reviewed 32 independent studies
  which indicate CE diagnostic yield of 71 vs. 41
  diagnostic yield for all other modalities
  combined1
• Established as gold standard for diagnosis of
  disease of small intestine2
• Now cleared in the US for pediatric population
  from 10-18 years old

• Internal data at Given Imaging Ltd. Reviewed by
  the FDA
• Rex, et. Al WIRELESS CAPSULE ENDOSCOPY DETECTS
  SMALL BOWEL ULCERS IN PATIENTS WITH NORMAL
  RESULTS FROM STATE OF THE ART ENTEROCLYSIS The
  American Journal of Gastroenterology, Vol. 98,
  No. 6

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PillCam SBContraindications

• In patients with known or suspected
  gastrointestinal obstruction, strictures, or
  fistulas based on the clinical picture or
  pre-procedure testing and profile.
• In patients with cardiac pacemakers or other
  implanted electromedical devices1.
• In patients with swallowing disorders.

1 Leighton JA,, et al, SAFETY OF CAPSULE
ENDOSCOPY IN PATIENTS WITH PACEMAKERS,
Gastrointest Endosc. 2004 Apr59(4)567-9.
Concludes that capsule endoscopy appears to be
safe in patients with cardiac pacemakers and does
not appear to be associated with any significant
adverse cardiac event. Pacemakers do not
interfere with capsule imaging.
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Small Bowel Bleeding Causes Visualized by
PillCamTM

• Vascular Lesions
• Angioectasias
• Neoplasms
• Inflammatory Lesions
• Ulcers, Crohns Disease
• Other
• Diverticula, varices

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PillCamTM SB Normal Esophagus
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PillCamTM SB Normal Stomach
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PillCamTM SBNormal
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PillCamTM SBVascular Lesions
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PillCamTM SBVascular Lesions
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PillCam SBCrohns Disease
A deep fissure can be seen in the histological
examination
Strictured ulcer
Typical granulomas can be seen in the wall of the
small intestine
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PillCamTM SB Celiac Image Spectrum
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PillCam SBUlcers
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PillCam SBPolyps and Masses
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PillCam SBDiverticula
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Wireless Capsule EndoscopySummary

• Time efficient, patient friendly, sensitive
  method to visualize the small bowel
• Disadvantages
• No therapeutics
• Unable to control movement
• Unable to clear bubbles and debris

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Double Balloon Enteroscopy

• First described by Yamamoto in 2001
• Allows the diagnosis and treatment of disease
  along the entire length of the small bowel
• Entire SB visualized in 86 of patients
  (Yamamoto)
• Fujinon enteroscope overtube system
• 230 cm total length
• 200-cm working length
• 140-cm overtube
• 2.8 mm channel for biopsy and therapeutic
  intervention

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Double Balloon Enteroscopy

• Also called push-pull enteroscopy
• Advanced antegrade or retrograde
• Patient Prep
• Antegrade NPO 6-8 hrs
• Retrograde Colo prep
• Moderate sedation, propofol, or general anesthesia

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Double Balloon EnteroscopyComplications

• 2/178 procedures (1.1) by Yamamoto
• Post procedure fever and abdominal pain
• Perforation
• 40/2362 procedures (1.7) by Mensink
• 13/1728 diagnostic procedures (0.8)
• 27/634 therapeutic procedures (4.3)
• 12/364 post polypectomy bleeding (3.3)
• 3/253 post APC perforation (1.2)
• 2/70 post balloon dilations perforation (2.9)

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Courtesy of Fujinon and Yamamoto H et al
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Courtesy of Fujinon and Yamamoto H et al
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Courtesy of Fujinon and Yamamoto H et al
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Antegrade (oral) DBE
Retrograde (anal) DBE
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Double Balloon EnteroscopyContraindications

• Non-cooperative patient
• Prior intestinal perforation
• AAA
• Excessive deformity of cervical spine

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Yield of Small Bowel Imaging Modalities in
Obscure GI Bleeding
GIE 2005, 616709-714
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Obscure GI BleedingManagement

• Resuscitation
• Iron supplementation, correct coagulopathy and
  platelet abnormalities, intermittent blood
  transfusions
• Endoscopic treatment
• Angiography
• Pharmacotherapy
• Estrogen therapy
• Octreotide
• Surgery

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Obscure GI BleedingEvaluation
Repeat EGD and Colonoscopy ( 35 yield)
If negative
Capsule Endoscopy ( 6070 yield)
If negative
Repeat Capsule Endoscopy ( 35 yield)
If negative
Double Balloon Enteroscopy ( 40 yield)
If negative
Intraoperative Enteroscopy in selected cases
GIE 2004605711-713
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The FutureRobotics
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The Magic Pill
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Obscure GI BleedingEvaluation
Repeat EGD and Colonoscopy ( 35 yield)
If negative
Capsule Endoscopy
If negative
Repeat Capsule Endoscopy
If negative
Double Balloon Enteroscopy
If negative
Intraoperative Enteroscopy in selected cases
GIE 2004605711-713