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OBSCURE GI BLEED Talat Bessissow, MC CM, FRCPC Assistant Professor, Department of Medicine Division of Gastroenterology McGill University Health Center.

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Presentation on theme: "OBSCURE GI BLEED Talat Bessissow, MC CM, FRCPC Assistant Professor, Department of Medicine Division of Gastroenterology McGill University Health Center."— Presentation transcript:

1 OBSCURE GI BLEED Talat Bessissow, MC CM, FRCPC Assistant Professor, Department of Medicine Division of Gastroenterology McGill University Health Center

2 Definition Definition = GI bleeding of uncertain etiology after EGD, C-scope, and small bowel radiography Overt OGIB = hematochezia, melena, hematemesis or CG emesis Occult OGIB = FOB + in abscence of visible blood, Iron deficiency Anemia

3 Fecal occult blood testing Guaiac-based tests: The pseudoperoxidase activity of hemoglobin turns the guaiac compound blue in the presence of hydrogen peroxide

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5 Epidemiology  300,000 pts hospitalized/yr in US... 5% of these will have normal EGD and C-scopes  Median time for diagnosis is 2 years  Average cost $33,630 per patient  Average 7.3 tests per patient  Paradigm shift since introduction of VCE and DBE

6 Etiology of Obscure GI Bleeding  5% of patients presenting with GI hemorrhage have no source found by upper endoscopy and colonoscopy.  Of these, 75% are 2 ndry to small bowel lesions  Of these, 30-60% angiectasias Am J Surg 1992;163:90–92 Br Med J (Clin Res Ed)1984;288:1663–1665.

7 Etiology of Obscure GI Bleeding Upper and lower GI bleeding overlooked Mid GI bleeding Cameron’s erosionsTumors Fundic varicesMeckel’s diverticulum Peptic ulcerDieulafoy’s lesion AngiectasiaCrohn’s disease Dieulafoy’s lesionCeliac disease GAVEAngiectasia NeoplasmsNSAID enteropathy Erosive gastritisHemobilia Ischemic colitis/UCAortoenteric fistula Large polypsVasculitis

8 Etiology 40% of OGIB - due to angiectasias (AVMs)  A ngiectasias : ectatic blood vessels made of thin wall with or without endothelial lining o Natural history of angiectasias is not well known o Only 10% of all patients with angioectasia will eventually bleed o Once a lesion has bled up to 50% will not rebleed --- predictors of rebleeding: multiple bleeding episodes, transfusion requirement o Bleeding angiectasias are associated with abnormal von Willebrand ’ s factor (vWF)

9 AVM Conditions/diseases associated with angiodysplastic lesions: Elderly CRF Aortic valve disease (Heyde ’ s syndrome) Cirrhosis Collagen vascular disease

10 AVM

11 What is Heyde ’ s syndrome ?  Heyde ’ s syndrome: Bleeding from angiectasias in patients with AS. o Increased consumption of high-molecular-weight multimers of VWF due to shear stress of the abnormal valve which corrects after aortic valve replacement with decreased severity of bleeding Transfus Med Rev 2003;17:272–286.; Abdom Imaging (2009) 34:311–319

12 Small Bowel Bleeding Etiology depends on the age of the patient Young: small intestinal tumors, Meckel ’ s diverticulum, Dieulafoy lesion, Crohn ’ s disease Older: (>40) vascular lesions, NSAID-induced SB disease Uncommon: hemobilia, hemosuccus pancreaticus, aortoenteric fistula

13 History and Physical Examination  The nature of the exact presenting symptom is important in deciding a practical, efficient, and cost-effective evaluation plan  Hematemesis indicate upper GI bleed  Melena can be anywhere from the nose to the right colon  Hematochezia can be a lower GI bleed or a fast upper GI bleed  History of medications (mainly OTC)  Family history  Skin signs

14 Hereditary hemorrhagic telangiectasia

15 Blue rubber bleb nevus syndrome

16 Dermatitis herpetiformis

17 Plummer–Vinson syndrome

18 Tylosis

19 Investigation options I. Repeat G & C II. CTE III. Capsule endoscopy IV. Enteroscopy - push or SBE/DBE V. Angiography VI. Tagged RBC scan

20 Common lesions that are overlooked EGD: Cameron ’ s erosions, fundic varices, PUD, angioectasias, Dieulafoy lesion, GAVE C-scope: angioectasias, neoplasms

21 Investigation  Repeat standard endoscopy, especially if anemia and overt GI bleeding: o Overlooked lesions: fundus o high lesser curvature antrum C loop of duodenum, posterior wall of duodenal bulb  Random SB Bx can be + for celiac disease in up to 12%  The yield of repeat colonoscopy is 6%, yield of repeat EGD is 29% (ASGE) Am J Gastroenterol 1996;91:2099–2102

22 Investigation  Consider side-viewing scope if pancreatobiliary pathology is suspected  Small bowel series/SBFT: o When compared with capsule endoscopy diagnostic yield 8% vs 67% clinically significant finding 6% vs 42% (NNT 3) o Used if SB obstruction is suspected Gastroenterology 2002;123:999–1005

23 Investigation  CT Enterography: o Thin sections and large volumes of enteric contrast material to better display the small bowel lumen and wall. o Neutral enteric contrast + IV contrast o 1.5 – 2 L of milk, PEG electrolytes or low-concentration barium

24 Investigation  CT Enterography: o Advantages: displays entire wall thickness examination of deep ileal loops mesentery & perienteric fat no need for NGT

25 CTE

26 Investigation  Technetium-99m–labeled RBC scan: Limited value Blood loss of 0.1-0.4 ml/min (2U PRBCs /d) Poor localization of SB bleeding - not enough to direct operative therapy  Angiography: Useful in massive bleeding (>0.5ml/min) Diagnostic & therapeutic Nucl Med Commun 2002;23:591–594

27 Investigation  Endoscopic imaging: o Intraoperative enteroscopy; Terminal ileum can be reached in 90% of cases diagnostic yield 58-88% mortality up to 17%

28 Investigations  Push enteroscopy:  Length 220-250 cm  usually limited to 150 cm  diagnostic yield up to 70%  angioectasias in up to 60%  some suggest push enteroscopy over repeat EGD as second look

29 Capsule endoscopy o Size 11x26 mm o Obtains images and transmits the data via radiofrequency to a recording device o The capsule is disposable o Examination takes at least 8 hours (57,600 images) o Reading 60 – 120 minutes o SB obstruction is a contraindication

30 Capsule endoscopy  Capsule endoscopy: yield 63% vs 23% for push enteroscopy Sensitivity 89 - 95% Specificity 75 – 95% +ve predictive value 97% -ve predictive value 86%

31 Lin, GIE 2008 Rastogi et al. GIE 2004 Pennazio et al. Gastroenterol 2004 Apostolopoulos et al. Endoscopy 2006 Estevez et al. Eur J Gastro Hep 2006 Delvaux et al. Endoscopy 2004 Diagnostic Yield Obscure/Overt GI Bleeding 36-92% Obscure/Occult GI Bleeding 41-63% Unexplained Fe-def Anemia 42-57% Yield Gain Over Push Enteroscopy + 30% Yield Gain Over SB Barium Study + 36%

32 Superior yield to other diagnostic modalities in both active and inactive obscure GI bleeds StudySens (%)Spec (%)PPV (%)NPV (%) Pennazio 2004, Gastroenterol 88.9959782.6 Hartmann 2005, GIE 95759586 * Marmo, APT 2005, Triester, AJG 2005, Saperas AJG 2007

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36 Double Balloon Enteroscopy  Double Balloon Enteroscopy (DBE) o 1 st described in 2001 o 200-cm enteroscope o 140-cm overtube

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39 Double Balloon Enteroscopy (DBE) o Antegrade approach: mean distance  240 +/- 100 cm mean time  72.5 +/- 23 min Retrograde approach: mean distance  140 +/- 90 cm mean time  75 +/- 28 min

40 How Effective is DBE? StudyDiagnostic Yield (%) Kaffes 2004, Clin Gastro Hep76 Mehdizadeh 2006, GIE51 Yamamoto 2006, Am J Gastro76 Jacobs 2007, GIE75 Tanaka 2008, GIE54 Yadav 2010, abstract DDW52%

41 How Effective is DBE? StudyPatients (n)Yield Matsumoto 2005, Endo 13Equivalent May 2005, GIE 52DBE better Hadithi 2006, Am J Gastro 35CE better Mehdizadeh 2006, GIE 115Equivalent Ohmiya 2007, GIE 74Equivalent Kameda 2008, J Gastroenterol 32Equivalent Teshima 2010, DDW (Meta-)1293CE favoured although nearly equivalent

42 Complications -Perforation – 0.3-1.1% -Bleeding (post-polypectomy) – 1.4-1.9% - Pancreatitis – 0.2-0.3% Melsink Endoscopy 2007, Gerson ACG 2008

43 Single Balloon Enteroscopy -Much more recent -Simpler to set up, works with existing Olympus equipment -Same specifications as DBE without the second balloon on the endoscope Hartmann, Endoscopy 2007

44 Single Balloon Enteroscopy Kawamura GIE 2008

45 SBE versus DBE Efthymiou, abstract 2010 RCT involving 79 patients recruited for mainly OvGIB/ObGIB About half had SBE Depth of insertion retrograde was identical (100 cm) Depth of insertion orally favoured DBE (250 versus 205 cm but not significant) Therapeutic yield was 54% DBE, 37% SBE (not significant) Targetted biopsies or application of cautery or argon plasma

46 Pennazio et al. Endoscopy 2005 & AGA Technical Insitute. Gastroenterol 2007


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