Transcript Obscure GI Bleeding

Obscure GI Bleeding
Michael Rusche, MD.
Obscure GI Bleeding: Overview
Definitions
 Epidemiology
 Cost
 Etiology
 Evaluation
 Conclusions
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GI Bleeding: Definitions
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I. Obscure Bleeding
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Persistent or recurrent bleeding following
negative GI tract evaluation (EGD, Colon, SB
radiology
 Occult
type: +FOBT and/or IDA
 Overt type: Visible bleeding
Obscure GI Bleeding:
Epidemiology
Represents 5-10% of all GI bleeding
events (overt and occult)
 Estimated that approx 5% of GI bleeding
occurs between ligament of Treitz and IC
valve.
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Katz LB. Semin Gastrointest. Dis 1999
Obscure GI Bleeding: Cost?
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Per patient (prior to diagnosis)
Time: 2.7 years
 > 7 diagnostic tests
 > 5 hospitalizations
 Transfused 20-40 units PRBC
 Minimal cost (medicare) $34K
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 (Excluding
office visits, ER, Rx)
Foutch et al. – GI Endo ‘90; Flickinger et al. – Am J Surg ‘89; Goldfarb et al. – Dis Manage ‘02
Obscure GI Bleeding: Etiologies
Mid-gut (80%)
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Those <40
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Tumors
Meckel’s
Dieulafoy
Crohns
Celiac Disease
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Those >40
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Raju et al. – Gastro ‘07
Angioectasias
Dieulafoy
NSAIDs
Celiac Disease
Lymphoma
Crohns
Obscure GI Bleeding: Etiologies
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Uncommon Etiologies of SB Bleeding
(<5%):
Hemobilia
 Hemosuccus pancreaticus
 Aorto-enteric fistula
 Ectopic varices
 Strongyloides stercoralis infection
 Pelvic radiotherapy
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Meckel’s Diverticulum
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Remnant of vitelline duct. At 50‐75 cm proximal from IC valve.
Present in 0.3 –3% of population;
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50% have ectopic gastric mucosa.
In some, acid secretion causes ulcer and bleed; 85% with gastric
mucosa are seen with Meckel scan;
 May cause obstruction due to intussusception or intraperitoneal bands
with volvulus, or diverticulitis.
Presentation: Painless bleed (currant jelly, melena, or hematochezia)
DX:
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Meckel Scan: Technetium scan after H2‐blocker,
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Capsule endoscopy,
Enteroclysis
Balloon assisted enteroscopy
Treatment: surgery
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Dieulafoy Lesion
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Definition: Aberrant submucosal artery, without ramification in gastric wall,
which erodes the overlying epithelium in the absence of a primary ulcer.
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Causes less than 1 percent of cases of severe UGI hemorrhage
Caliber of the artery is 1 to 3 mm (10‐times the caliber of mucosal capillaries).
Usually located in the upper stomach along the lesser curvature near
the gastro‐esophageal junction.
 May be found in all areas of the gastrointestinal tract, including the
esophagus and duodenum.
 Bleeding is often self‐limited, although it is usually recurrent and can be
profuse
Etiology is unknown, likely congenital.
Causes of bleeding are not well‐understood.
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Associations: cardiovascular disease, hypertension, chronic kidney disease, diabetes, or
alcohol abuse.
Use of NSAIDs is common; NSAIDS may incite bleeding by causing mucosal atrophy and
ischemic injury
Aorto-Enteric Fistula
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Rare cause of acute UGI bleeding, but associated with high mortality
if undiagnosed and untreated.
•Location: The third or fourth portion of the duodenum is the most
common site for aortoenteric fistulas, followed by the jejunum and
ileum .
•Presentation:
–Repetitive herald bleed with hematemesis and/or hematochezia;
this may be followed by massive bleeding and exsanguination.
–Intermittent bleeding can be seen if clot temporarily seals the
fistula.
–Other signs and symptoms may include abdominal or back pain,
fever, and sepsis. Infrequently, an abdominal mass is palpable or an
abdominal bruit is heard.
•Pathophysiology—Aortoenteric fistulas arise from direct
communication between the aorta and the gastrointestinal tract.
Aorto-Enteric Fistula
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Causes:
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Primary A‐E fistula in USA are due to atherosclerotic aortic aneurysm. In other parts of the
world are infectious aortitis due to syphilis or tuberculosis.
Secondary A‐E fistula due to prosthetic abdominal aortic vascular graft.
Mayhave pressure necrosis or graft infection causing the fistula. Other
secondarycauses include penetrating ulcers, tumor invasion, trauma,
radiation therapy, and foreign body perforation.
Diagnosis:
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A high index of suspicion.
Should be considered in all patients with massive or repetitive UGI bleeding and a history of
a thoracic or abdominal aortic aneurysm, or prosthetic vascular graft.
Endoscopy is the procedure of choice for diagnosis and exclusionof
other causes of acute UGI bleeding.
Endoscopy with an enteroscope or side‐viewing endoscope may reveal
a graft, an ulcer or erosion at the adherent clot, or an extrinsic pulsatile
mass in the distal duodenum or esophagus.
Abdominal CT scan and aortography can be useful in confirming the
diagnosis, but may be unreliable
Hemobilia
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Bleeding from the hepatobiliary tract; rare cause of acute UGI bleeding.
Should be considered in a patient with acute UGI bleeding and a recent
history of:
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hepatic parenchymal or biliary tract injury,
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percutaneous and transjugular liver biopsy,
percutaneous transhepatic cholangiogram,
cholecystectomy,
endoscopic biliary biopsies or stenting,
TIPS,
Angioembolization,or
blunt abdominal trauma .
Other causes include gallstones, cholecystitis, hepatic or bile duct
tumors, intrahepatic stents, hepatic artery aneurysms, and hepatic
abscesses.
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Hemobilia
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Signs & Symptoms:
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Classic triad is biliary colic, obstructive jaundice, and occultor acute GI bleeding.
Hemobilia can result in obstructive jaundice with or without biliary
sepsis.
Diagnosis:
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Often overlooked in the absence of active bleeding.
A side‐viewing duodenoscope is helpful for visualizing the ampulla or for performing
diagnostic endoscopic retrograde cholangiography (ERCP).
Technetium‐tagged red blood cell scan or
 Selective hepatic artery angiography to reveal the source of hemobilia
and for treatment.
Treatment: directed at the primary cause of bleeding;
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embolization or surgical resection of a hepatic tumor, or
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arterial embolization following liver biopsy or PTC,
laparoscopic cholecystectomy
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Hemosuccus Pancreaticus
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Definition: Bleeding from the pancreatic duct; rare cause of UGIbleeding.
Causes: chronic pancreatitis, pancreatic pseudocysts, and pancreatic
tumors.
Pathogenesis:
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Pseudocyst or tumor erodes into a vessel, forming a direct communication between the
pancreatic duct and a blood vessel.
May be seen after therapeutic endoscopy of the pancreas or pancreatic
duct, including pancreatic stone removal, pancreatic duct
sphincterotomy, pseudocyst drainage, or pancreatic duct stenting.
Diagnosis: confirmed by abdominal CT scan, ERCP, angiography,
orintraoperative exploration.
CT scan is performed first (least invasive).
Treatment:
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Mesenteric arteriography with coil embolization can control acute bleeding.
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If bleeding persists or is massive: pancreaticoduodenectomy or
pseudocyst resection and ligation of the bleeding vessel
Obscure GI Bleeding: Etiologies
Overlooked Causes of GI Bleeding (10-20%):
 Upper GI tract:
 Cameron’s erosions
 Fundic varices
 Peptic ulcer
 Angioectasias
 Dieulafoy’s
 GAVE
 Lower GI tract:
 Angioectasias
 Neoplasms
Obscure/Occult GI Bleeding:
Evaluation
? Missed occult source or new obscure?
 “2nd look” endoscopies frequently +
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Cameron’s (DH) erosions
 PUD
 Vascular ectasias, angiodysplasias
 Neoplasias
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After negative bi-directional GI studies
small intestine most likely source
Obscure GI Bleeding: Evaluation
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Diagnostic Techniques
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Bi-directional Endoscopy (“second look”)
Nuclear (TRBC) scans
Angiography
Meckel’s scan
Small bowel biopsy
SBFT/Enteroclysis
Enteroscopy
 Per oral
 Transanal or retrograde
 Interoperative
 Capsule endoscopy
Exploratory laparotomy
Obscure GI Bleeding: Evaluation
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Diagnostic Techniques
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Bi-directional Endoscopy (“second look”)
Nuclear (TRBC) scans
Angiography
Small bowel biopsy
SBFT/Enteroclysis
Enteroscopy
 Per oral
 Transanal or retrograde
 Interoperative
 Capsule endoscopy
Exploratory laparotomy
Obscure GI Bleeding: Evaluation
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Diagnostic Techniques
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Bi-directional Endoscopy (“second look”)
Nuclear (TRBC) scans
Angiography
Small bowel biopsy
SBFT/Enteroclysis
Enteroscopy
 Per oral
 Transanal or retrograde
 Interoperative
 Capsule endoscopy
 Deep endoscopy
Exploratory laparotomy
Obscure GI Bleeding: TRBC scan
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Bleeding rate must be > 0.1-0.4ml/min (1unit per
day)
Early scans (within 4 hours) with (+) more
reliable than last (+)
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Pre-requisite to angiography in most centers
Frequent false (+) and (-)
Very little benefit in average OGIB:
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Later scans show “pooled blood/isotope”
Diganositic yield: 25%
Location accuracy: 30-50%
Diagnostic yield in lower GI “overt” bleeding
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Colorectal site found 45% (26-78%)
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Later positive scan verification studies: ~78% + lesion
Obscure GI Bleeding: Angiography
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Yield:
 When active bleeding as high as: 61-72%
 Overall: 27-77% (mean 40%)
Requires > 0.5 ml/min bleeding rate 1ml/h (3 Units/day)
 Reasonable in patient with hemodynamic instability or ongoing
transfusion need
Study first SMA (50-80% of bleeds, then IMV, and then celiac axis
Can control bleeding with vasopressin (90% efficacy) or coil
embolization (riskier; 20% infarct)
Provocative angiography (anticoagulation or thrombolytic) can
increase yield but lead to uncontrollable bleed
Obscure GI Bleeding:
SBFT/Enterocolysis
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Occult bleeding patient diagnostic yields
SBFT 0-4% reported in multiple studies
 Enteroclysis 0% in multiple studies
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Obscure patient diagnostic yields
SBFT 0-5.6% reported
 Enteroclysis 10-21% seen
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Obscure GI Bleeding: Push
enteroscopy
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Extended upper endoscopy
Typically involves pediatric colonoscope or
dedicated enteroscope
Distance reached in SB anywhere from 40-90
cm (at most 40 cm beyond ligament of Treitz)
Yield
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Average of 35% (3-78%)
Picks up previously missed proximal lesions
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Up to 64% of lesions identified with a push enteroscope were
within reach of a standard endoscope
Increased yield in overt bleeding situations
Obscure GI Bleeding: Capsule
Endoscopy
Approved since 2001
 Most sensitive non-invasive test for
obscure GI bleeding
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Excellent for screening who needs more
invasive procedures
 High negative predictive value
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Obscure GI Bleeding: Capsule
Endoscopy
2 images/second during 8 hours
study
 65,000-80,000 images
 Streaming video
 Reading time of roughly one
hour
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Obscure GI Bleeding: Capsule
Endoscopy
Needs
good Small Bowel Prep.
Reading rate </= 15 frames/sec
Experimental Yield: Dedicated Enteroscope vs. Capsule
Enteroscopy
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Bleeds at reach of enteroscope: 94% vs 53%
Bleeds in all small bowel: 37% vs 64%
Clinical Yield of Capsule:
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Ongoing obscure‐overtbleed within 2 weeks: 92%
Ongoing obscure‐overtbleed after 2 weeks: 34%
Obscure‐overtbleed in past year: 13%
Obscure‐occult bleed: 44%
Obscure GI Bleeding: Capsule
Endoscopy
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Predictors of (+) capsule finding:
 Through Hb < 10 g,
 more than 1 bleeding episode, or
 bleeding persisting > 6 months
Capsule vs Intraop Endoscopy:
 yield 74 vs 76.6%,
 Capsule: sensitivity = 95%, specificity = 75%, PPV =
95%, NPV = 86%
Management change: 37 to 66%; this led to resolution of
bleeding in 65%
Obscure GI Bleeding: Capsule
Endoscopy
Obscure GI Bleeding: Capsule
Endoscopy
Obscure GI Bleeding: Capsule
Endoscopy
Obscure GI Bleeding: Capsule
Endoscopy
Obscure GI Bleeding: Capsule
Endoscopy
Obscure GI Bleeding:
Intraoperative enteroscopy
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Yield: 58‐88% of small bowel lesions.
IOE: Examination done “anterograde”, with dedicated
enteroscope, with dimmed OR light. Lesions are marked
when seen in the “way in”.
TI reached in > 90%
Therapy given in 64%.
Recurrent bleed: 12.5‐60%
Mortality: up to 17%
May cause lacerations, perforations, bowel ischemia,
pancreatitis, and prolonged ileus.
Should be done only when DBE is limited for
adhesions or other anatomic factors.
Deep Enteroscopy
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Double-Balloon
Enteroscopy
Single-Balloon
Enteroscopy
Spiral Enteroscopy
Therapeutic as well as
diagnostic capabilities
Obscure GI Bleeding: Deep
Enteroscopy
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Yield: 41‐80% of small bowel lesions.
DBE: uses anterograde + retrograde approach
Time: anterograde 72‐95 min, retrograde 75‐102 min.
Each exam done in separate days.
Outcomes:
 Diagnostic yield 65%,
 Diagnostic/treatment success 64%,
 Total SB exam 29% (tattoo),
 Miss rates 28% (vs 20% for capsule)
Obscure GI Bleeding: Deep
Enteroscopy
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Findings:
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Ulcers (including IBD) 13%,
 Malignancies 8%,
 Other 6%,
 Negative exam 40%
May cause lacerations, perforations, bleeding, and
pancreatitis.
Ante‐grade approach recommended when lesion is in
initial 2/3. Retrograde approach when distal 1/3.
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Angioectasia 31%,
For Now…DBE primarily
therapeutic
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Time, labor, personnel and cost intensive
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Complications risk: Initially ≈ 1%, upcoming data likely to
show less
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Diagnostic and therapeutic yield ↑if pre-screening done
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May be cost-effective as initial approach in patients with
ongoing overt bleeding
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However, VCE before DE will reduce the number of
procedures and ↓ complications  better long-term
outcomes
REDUCTION
REDUCTION
REDUCTION
REDUCTIO
N
REDUCTION
REDUCTION
Obscure GI Bleeding: Algorithim
Obscure GI Bleeding: Conclusions
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GI bleeding is a significant pathologic condition which is
growing due to the aging patient population and
increasing use of antiplatelets/anticoagulants.
There are number of pathologies which can range from
the common to the rare.
There is a significant societal cost to this.
No single efficient diagnostic approach or therapeutic
panacea.
Must individualize approach and Rx.
Second look endoscopies by a GI MD are the intial test
of choice
While radiography offers diagnostic and therapeutic
capabilities and should be utilized, once a small bowel
etiology is noted the role of capsule endoscopy and deep
enteroscopy offers distinct advantages.