Obscure GI Bleeding

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Obscure GI Bleeding

• Homayon Iraninezhad
• September 2010
• Plaza medical center

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Case Presentation

• A 41 year old AA male was admitted to the
  hospital after an acute episode of bleeding per
  rectum
• Admission hemoglobin 6.2 g/dl
• The patient had a recent stay at a local private
  hospital for investigation of bleeding per rectum
  within the last 3 months and upper GI endoscopy,
  colonoscopy, small bowel contrast study were
  normal
• Following his last hospitalization, he was
  discharged on iron supplements

3
Case Presentation

• The gastrointestinal ROS otherwise negative. He
  had had no abdominal pain, weight loss, or change
  in bowel function. Strong family history of
  PVD/MI
• PMH
• CHF EF 30 on last echo
• HTN
• DM
• PVD
• RA/GOUT
• Hx. AAA

4
Case presentation

• Meds
• Metoprolol
• ASA
• Plavix
• Insulin
• Allopurinol
• Methotrexate 10 mg weekly
• Celebrex

5
Case Presentation

• Physical exam
• BP 105/70 lying 95/69 standing HR 95 bpm
  lying, 101 bpm standing
• Gen AxOx3, NAD
• Skin and extremities normal
• No jaundice or stigmata of chronic liver disease
  Lungs Normal
• Cardiac Tachycardia, no R/C/G
• GI No TTP, mass, or organomegaly
• Digital rectal examination no mass or
  tenderness, good sphincter tone but old dark
  blood noted on glove

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Case presentation

• Routine laboratory all normal except for initial
  hemoglobin level of 6.2
• Coagulation, liver chemistries, blood urea
  nitrogen, and creatinine levels were normal
• Nasogastric aspirate produced bile-stained
  gastric contents but no blood
• Results of proctoscopy performed in the emergency
  department showed red blood but no source of
  bleeding
• The patient was admitted to the surgical
  intensive care unit (ICU)

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Case presentation

• What is our DDX?
• What would you do for this patient?

8
Case presentation

• AVM
• Camerons lesion
• Dieulafoy
• Gastric or duodenal varices
• Neoplasm
• Aortoenteric fistula
• Hemobilia
• Hemosuccus pancreaticus

• Meckels
• IBD
• Celiac sprue
• NSAID enteropathy

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GI Bleeding Definitions
Term Definition
Overt or visible bleeding GI bleeding manifest as visible bright red or altered blood in emesis or feces
Occult bleeding Initial presentation of IDA and/or positive FOBT no visible blood in feces
Obscure bleeding Recurrent of persistent IDA, positive FOBT, or visible bleeding with no bleeding source found on original endoscopy
Obscure-occult bleeding Subcat. Of obscure bleeding with recurrent or persistent IDA and/or positive FOBT with no source found on original endoscopy, no visible blood in feces
Obscure-overt bleeding Subcategory of obscure bleeding characterized by recurrent or persistant overt/visible bleeding with no source found at original endoscopy, bleeding manifest as visible blood in emesis or feces
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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
In Rockey et al. anemia resolved in 83 of
patients with no source of bleeding!
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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 Causes Grouped 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 Causes By 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

18
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
Causes within reach of upper endoscope Causes beyond reach of upper endoscope
Erosions within hiatal hernia (Camerons erosions) Angiodysplasia
Esophagitis Small bowel tumor
Angiodysplasia Small bowel ulcers and erosions, including NSAIDS/other drug-induced lesions
Esophageal varices Crohns disease
PUD Celiac sprue
Gastritis Small bowel tics
Gastric polyps small bowel varices
GAVE Lympagioma
Blue rubber blue nevus syndrome Radiation enteritis
Osler weber rendue Blue rubber bleb nevus syndrome
Dieulofoys Osler weber rendu
Celiac sprue VWB,, gardners, aortoenteric fistula, amyloidosis, Meckels, hemosuccus pancreaticus, hemobilia
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Small Bowel Bleeding Diagnosis

• UGI SBFT
• Enteroclysis
• Push enteroscopy
• Double balloon enteroscopy
• Intraoperative enteroscopy
• CT scan ? ionizing radiation.
• CT enteroclysis
• MRI ? no ionizing radiation
• Video capsule endoscopy

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Obscure BleedingSBFT and Enteroclysis

• SBFT
• 0-5.6 diagnostic yield
• Used for exclusion of structural lesion or
  fistula
• 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 GI BleedingAngiography
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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 GI BleedingExploratory Laparotomy

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

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PillCam Exam Set
2
1. The PillCam Capsule 2. Sensor Array SB 3.
Given Data Recorder
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 BleedingPillCam SB

• Capsule Endoscopy results led to treatments
  resolving the bleeding in 86.9 of patients
  undergoing the procedure while actively bleeding.

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 PillCam SB
Study Sensitivity () Specificity () PPV () NPV ()
Pennazio et al. Gastro 2004 88.9 95 97 82.6
Botelberge et al. ICCE 2005 91.6 86.3 88 90.4
Hartmann et al. GIE 2005 95 75 95 86
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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
  combined
• Established as gold standard for diagnosis of
  disease of small intestine
• Now cleared in the US for pediatric population
  from 10-18 years old

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 devices.
• In patients with swallowing disorders.

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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PillCam SBVascular Lesions
40
PillCam SB
A deep fissure can be seen in the histological
examination
Strictured ulcer
Typical granulomas can be seen in the wall of the
small intestine
41
PillCam SB
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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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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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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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