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Obscure GI Bleeding

Obscure GI Bleeding

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Obscure GI Bleeding

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  1. Obscure GI Bleeding Homayon Iraninezhad September 2010 Plaza medical center

  2. 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

  6. 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)

  7. 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 • Meckel’s • IBD • Celiac sprue • NSAID enteropathy

  9. GI Bleeding Definitions

  10. 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

  11. Obscure-Occult GI Bleeding Frequency In Rockey et al. anemia resolved in 83% of patients with no source of bleeding!

  12. Obscure GI BleedingFrequency • 10% - 20% of GI bleeding without identifiable etiology • 5% GI bleeding recurrent without identifiable etiology • Majority have small bowel source

  13. Obscure GI BleedingSmall BowelCauses Grouped by Age • Patient’s < 25 years old • Meckel’s Diverticula • Patient’s between 30 – 50 years old • Tumors • Patient’s > 50 years old • Vascular ectasias

  14. Small Bowel BleedingCauses By Etiology • Vascular Lesions • Neoplasms • Inflammatory Lesions • Other

  15. Small Bowel BleedingVascular Lesions • Most common cause of small bowel bleeding • Responsible for 70 -80% of small bowel bleeding

  16. Small Bowel BleedingVascular Lesions • Angioectasias • Telangiectasias • Hereditary hemorrhagic telangiectasia • Osler-Weber-Rendu Syndrome • CREST Syndrome • Calcinosis, Reynaud’s, Esophageal dysmotility Sclerodactyl, Telangiectasia • Other • Dieulafoy’s lesion • Aortoenteric fistula • Small bowel varices

  17. 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 (> 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, kaposi’s sarcoma, colon, ovarian

  19. Causes of Small Bowel BleedingDiverticula • Small bowel diverticula • At the site of perforating blood vessels • Meckel’s 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 Meckel’s, angioectasias, submucosal tumors

  20. Small Bowel BleedingInflammatory Lesions • Crohn’s Disease • Isolated ulcers • Idiopathic ulcers • Nonsteroidal antiinflammatory drugs • Ischemic • Other • Vasculitis, Zollinger-Ellison syndrome, Celiac disease

  21. 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

  22. Obscure GI BleedingSummary Causes

  23. 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

  24. 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

  25. 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

  26. 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

  27. Obscure GI BleedingAngiography

  28. 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

  29. Obscure GI BleedingExploratory Laparotomy • Seldom without intraoperative enteroscopy • 65% of 37 pt’s had lesion identified by palpation or transillumination

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

  31. 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

  32. PillCam SBPatient 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

  33. Sensitivity 88.9 % Specificity 95.0 % Positive predictive value 97.0 % Negative predictive value 82.6 % 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

  34. Obscure GI BleedingPillCamSB • 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

  35. Obscure GI BleedingPennazio 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

  36. Obscure GI Bleeding PillCam SB

  37. 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 modalitiescombined • Established as gold standard for diagnosis of disease of small intestine • Now cleared in the US for pediatric populationfrom 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

  38. 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 Apr;59(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.

  39. PillCam SBVascular Lesions

  40. PillCam SB A deep fissure can be seen in the histological examination Stricturedulcer Typical granulomas can be seen in the wall of the small intestine

  41. PillCam SB

  42. 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

  43. 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

  44. 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

  45. 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%)

  46. Courtesy of Fujinon and Yamamoto H et al

  47. Courtesy of Fujinon and Yamamoto H et al

  48. Antegrade (oral) DBE Retrograde (anal) DBE

  49. Double Balloon EnteroscopyContraindications • Non-cooperative patient • Prior intestinal perforation • AAA • Excessive deformity of cervical spine