1. Obscure GI Bleeding Michael Rusche, MD.

3. Obscure GI Bleeding: Overview Definitions Definitions Epidemiology Epidemiology Cost Cost Etiology Etiology Evaluation Evaluation Conclusions Conclusions

4. GI Bleeding: Definitions I. Obscure Bleeding I. Obscure Bleeding Persistent or recurrent bleeding following negative GI tract evaluation (EGD, Colon, SB radiology Persistent or recurrent bleeding following negative GI tract evaluation (EGD, Colon, SB radiology Occult type: +FOBT and/or IDA Occult type: +FOBT and/or IDA Overt type: Visible bleeding Overt type: Visible bleeding

5. Obscure GI Bleeding: Epidemiology Represents 5-10% of all GI bleeding events (overt and occult) 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. Estimated that approx 5% of GI bleeding occurs between ligament of Treitz and IC valve. Katz LB. Semin Gastrointest. Dis 1999

6. Obscure GI Bleeding: Cost? Per patient (prior to diagnosis) Per patient (prior to diagnosis) Time: 2.7 years Time: 2.7 years > 7 diagnostic tests > 7 diagnostic tests > 5 hospitalizations > 5 hospitalizations Transfused 20-40 units PRBC Transfused 20-40 units PRBC Minimal cost (medicare) $34K Minimal cost (medicare) $34K (Excluding office visits, ER, Rx) (Excluding office visits, ER, Rx) Foutch et al. – GI Endo ‘90; Flickinger et al. – Am J Surg ‘89; Goldfarb et al. – Dis Manage ‘02

7. Obscure GI Bleeding: Etiologies Those <40 Those <40 Tumors Tumors Meckel’s Meckel’s Dieulafoy Dieulafoy Crohns Crohns Celiac Disease Celiac Disease Those >40 Those >40 Angioectasias Dieulafoy NSAIDs Celiac Disease Lymphoma Crohns Mid-gut (80%) Raju et al. – Gastro ‘07

8. Obscure GI Bleeding: Etiologies Uncommon Etiologies of SB Bleeding (<5%): Uncommon Etiologies of SB Bleeding (<5%): Hemobilia Hemobilia Hemosuccus pancreaticus Hemosuccus pancreaticus Aorto-enteric fistula Aorto-enteric fistula Ectopic varices Ectopic varices Strongyloides stercoralis infection Strongyloides stercoralis infection Pelvic radiotherapy Pelvic radiotherapy

9. Meckel’s Diverticulum Remnant of vitelline duct. At 50 ‐ 75 cm proximal from IC valve. Remnant of vitelline duct. At 50 ‐ 75 cm proximal from IC valve. Present in 0.3 –3% of population; Present in 0.3 –3% of population; 50% have ectopic gastric mucosa. 50% have ectopic gastric mucosa. In some, acid secretion causes ulcer and bleed; 85% with gastric mucosa are seen with Meckel scan; 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. May cause obstruction due to intussusception or intraperitoneal bands with volvulus, or diverticulitis. Presentation: Painless bleed (currant jelly, melena, or hematochezia) Presentation: Painless bleed (currant jelly, melena, or hematochezia) DX: DX: Meckel Scan: Technetium scan after H2 ‐ blocker, Meckel Scan: Technetium scan after H2 ‐ blocker, Capsule endoscopy, Capsule endoscopy, Enteroclysis Enteroclysis Balloon assisted enteroscopy Balloon assisted enteroscopy Treatment: surgery Treatment: surgery

10. Dieulafoy Lesion Definition: Aberrant submucosal artery, without ramification in gastric wall, which erodes the overlying epithelium in the absence of a primary ulcer. Definition: Aberrant submucosal artery, without ramification in gastric wall, which erodes the overlying epithelium in the absence of a primary ulcer. Causes less than 1 percent of cases of severe UGI hemorrhage 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). 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. 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. 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 Bleeding is often self ‐ limited, although it is usually recurrent and can be profuse Etiology is unknown, likely congenital. Etiology is unknown, likely congenital. Causes of bleeding are not well ‐ understood. Causes of bleeding are not well ‐ understood. Associations: cardiovascular disease, hypertension, chronic kidney disease, diabetes, or alcohol abuse. 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 Use of NSAIDs is common; NSAIDS may incite bleeding by causing mucosal atrophy and ischemic injury

11. Aorto-Enteric Fistula Rare cause of acute UGI bleeding, but associated with high mortality if undiagnosed and untreated. 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. Location: The third or fourth portion of the duodenum is the most common site for aortoenteric fistulas, followed by the jejunum and ileum. Presentation: Presentation: –Repetitive herald bleed with hematemesis and/or hematochezia; this may be followed by massive bleeding and exsanguination. –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. –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. –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. Pathophysiology—Aortoenteric fistulas arise from direct communication between the aorta and the gastrointestinal tract.

12. Aorto-Enteric Fistula Causes: Causes: 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. 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. 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: Diagnosis: A high index of suspicion. 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. 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 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. 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 Abdominal CT scan and aortography can be useful in confirming the diagnosis, but may be unreliable

13. Hemobilia Bleeding from the hepatobiliary tract; rare cause of acute UGI bleeding. 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: Should be considered in a patient with acute UGI bleeding and a recent history of: hepatic parenchymal or biliary tract injury, hepatic parenchymal or biliary tract injury, percutaneous and transjugular liver biopsy, percutaneous and transjugular liver biopsy, percutaneous transhepatic cholangiogram, percutaneous transhepatic cholangiogram, cholecystectomy, cholecystectomy, endoscopic biliary biopsies or stenting, endoscopic biliary biopsies or stenting, TIPS, TIPS, Angioembolization,or Angioembolization,or blunt abdominal trauma. blunt abdominal trauma. Other causes include gallstones, cholecystitis, hepatic or bile duct tumors, intrahepatic stents, hepatic artery aneurysms, and hepatic abscesses. Other causes include gallstones, cholecystitis, hepatic or bile duct tumors, intrahepatic stents, hepatic artery aneurysms, and hepatic abscesses.

14. Hemobilia Signs & Symptoms: Signs & Symptoms: Classic triad is biliary colic, obstructive jaundice, and occultor acute GI bleeding. Classic triad is biliary colic, obstructive jaundice, and occultor acute GI bleeding. Hemobilia can result in obstructive jaundice with or without biliary sepsis. Hemobilia can result in obstructive jaundice with or without biliary sepsis. Diagnosis: Diagnosis: Often overlooked in the absence of active bleeding. 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). 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 Technetium ‐ tagged red blood cell scan or Selective hepatic artery angiography to reveal the source of hemobilia and for treatment. Selective hepatic artery angiography to reveal the source of hemobilia and for treatment. Treatment: directed at the primary cause of bleeding; Treatment: directed at the primary cause of bleeding; embolization or surgical resection of a hepatic tumor, or embolization or surgical resection of a hepatic tumor, or arterial embolization following liver biopsy or PTC, arterial embolization following liver biopsy or PTC, laparoscopic cholecystectomy laparoscopic cholecystectomy

15. Hemosuccus Pancreaticus Definition: Bleeding from the pancreatic duct; rare cause of UGIbleeding. Definition: Bleeding from the pancreatic duct; rare cause of UGIbleeding. Causes: chronic pancreatitis, pancreatic pseudocysts, and pancreatic tumors. Causes: chronic pancreatitis, pancreatic pseudocysts, and pancreatic tumors. Pathogenesis: Pathogenesis: Pseudocyst or tumor erodes into a vessel, forming a direct communication between the pancreatic duct and a blood vessel. 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. 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. Diagnosis: confirmed by abdominal CT scan, ERCP, angiography, orintraoperative exploration. CT scan is performed first (least invasive). CT scan is performed first (least invasive). Treatment: Treatment: Mesenteric arteriography with coil embolization can control acute bleeding. Mesenteric arteriography with coil embolization can control acute bleeding. If bleeding persists or is massive: pancreaticoduodenectomy or pseudocyst resection and ligation of the bleeding vessel If bleeding persists or is massive: pancreaticoduodenectomy or pseudocyst resection and ligation of the bleeding vessel

16. Obscure GI Bleeding: Etiologies Overlooked Causes of GI Bleeding (10-20%): Upper GI tract: Upper GI tract: Cameron’s erosions Cameron’s erosions Fundic varices Fundic varices Peptic ulcer Peptic ulcer Angioectasias Angioectasias Dieulafoy’s Dieulafoy’s GAVE GAVE Lower GI tract: Lower GI tract: Angioectasias Angioectasias Neoplasms Neoplasms

17. Obscure/Occult GI Bleeding: Evaluation ? Missed occult source or new obscure? ? Missed occult source or new obscure? “2 nd look” endoscopies frequently + “2 nd look” endoscopies frequently + Cameron’s (DH) erosions Cameron’s (DH) erosions PUD PUD Vascular ectasias, angiodysplasias Vascular ectasias, angiodysplasias Neoplasias Neoplasias After negative bi-directional GI studies small intestine most likely source After negative bi-directional GI studies small intestine most likely source

18. Obscure GI Bleeding: Evaluation Diagnostic Techniques Diagnostic Techniques Bi-directional Endoscopy (“second look”) Bi-directional Endoscopy (“second look”) Nuclear (TRBC) scans Nuclear (TRBC) scans Angiography Angiography Meckel’s scan Meckel’s scan Small bowel biopsy Small bowel biopsy SBFT/Enteroclysis SBFT/Enteroclysis Enteroscopy Enteroscopy Per oral Per oral Transanal or retrograde Transanal or retrograde Interoperative Interoperative Capsule endoscopy Capsule endoscopy Exploratory laparotomy Exploratory laparotomy

19. Obscure GI Bleeding: Evaluation Diagnostic Techniques Diagnostic Techniques Bi-directional Endoscopy (“second look”) Bi-directional Endoscopy (“second look”) Nuclear (TRBC) scans Nuclear (TRBC) scans Angiography Angiography Small bowel biopsy Small bowel biopsy SBFT/Enteroclysis SBFT/Enteroclysis Enteroscopy Enteroscopy Per oral Per oral Transanal or retrograde Transanal or retrograde Interoperative Interoperative Capsule endoscopy Capsule endoscopy Exploratory laparotomy Exploratory laparotomy

20. Obscure GI Bleeding: Evaluation Diagnostic Techniques Diagnostic Techniques Bi-directional Endoscopy (“second look”) Bi-directional Endoscopy (“second look”) Nuclear (TRBC) scans Nuclear (TRBC) scans Angiography Angiography Small bowel biopsy Small bowel biopsy SBFT/Enteroclysis SBFT/Enteroclysis Enteroscopy Enteroscopy Per oral Per oral Transanal or retrograde Transanal or retrograde Interoperative Interoperative Capsule endoscopy Capsule endoscopy Deep endoscopy Deep endoscopy Exploratory laparotomy Exploratory laparotomy

21. Obscure GI Bleeding: TRBC scan Bleeding rate must be > 0.1-0.4ml/min (1unit per day) Bleeding rate must be > 0.1-0.4ml/min (1unit per day) Early scans (within 4 hours) with (+) more reliable than last (+) Early scans (within 4 hours) with (+) more reliable than last (+) Later scans show “pooled blood/isotope” Later scans show “pooled blood/isotope” Pre-requisite to angiography in most centers Pre-requisite to angiography in most centers Frequent false (+) and (-) Frequent false (+) and (-) Very little benefit in average OGIB: Very little benefit in average OGIB: Diganositic yield: 25% Diganositic yield: 25% Location accuracy: 30-50% Location accuracy: 30-50% Diagnostic yield in lower GI “overt” bleeding Diagnostic yield in lower GI “overt” bleeding Colorectal site found 45% (26-78%) Colorectal site found 45% (26-78%) Later positive scan verification studies: ~78% + lesion Later positive scan verification studies: ~78% + lesion

22. Obscure GI Bleeding: Angiography Yield: Yield: When active bleeding as high as: 61-72% When active bleeding as high as: 61-72% Overall: 27-77% (mean 40%) Overall: 27-77% (mean 40%) Requires > 0.5 ml/min bleeding rate 1ml/h (3 Units/day) Requires > 0.5 ml/min bleeding rate 1ml/h (3 Units/day) Reasonable in patient with hemodynamic instability or ongoing transfusion need Reasonable in patient with hemodynamic instability or ongoing transfusion need Study first SMA (50-80% of bleeds, then IMV, and then celiac axis 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) 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 Provocative angiography (anticoagulation or thrombolytic) can increase yield but lead to uncontrollable bleed

23. Obscure GI Bleeding: SBFT/Enterocolysis Occult bleeding patient diagnostic yields Occult bleeding patient diagnostic yields SBFT 0-4% reported in multiple studies SBFT 0-4% reported in multiple studies Enteroclysis 0% in multiple studies Enteroclysis 0% in multiple studies Obscure patient diagnostic yields Obscure patient diagnostic yields SBFT 0-5.6% reported SBFT 0-5.6% reported Enteroclysis 10-21% seen Enteroclysis 10-21% seen

24. Obscure GI Bleeding: Push enteroscopy Extended upper endoscopy Extended upper endoscopy Typically involves pediatric colonoscope or dedicated enteroscope Typically involves pediatric colonoscope or dedicated enteroscope Distance reached in SB anywhere from 40-90 cm (at most 40 cm beyond ligament of Treitz) Distance reached in SB anywhere from 40-90 cm (at most 40 cm beyond ligament of Treitz) Yield Yield Average of 35% (3-78%) Average of 35% (3-78%) Picks up previously missed proximal lesions Picks up previously missed proximal lesions Up to 64% of lesions identified with a push enteroscope were within reach of a standard endoscope Up to 64% of lesions identified with a push enteroscope were within reach of a standard endoscope Increased yield in overt bleeding situations Increased yield in overt bleeding situations

25. Obscure GI Bleeding: Capsule Endoscopy Approved since 2001 Approved since 2001 Most sensitive non-invasive test for obscure GI bleeding Most sensitive non-invasive test for obscure GI bleeding Excellent for screening who needs more invasive procedures Excellent for screening who needs more invasive procedures High negative predictive value High negative predictive value

26. Obscure GI Bleeding: Capsule Endoscopy 2 images/second during 8 hours study 2 images/second during 8 hours study 65,000-80,000 images 65,000-80,000 images Streaming video Streaming video Reading time of roughly one hour Reading time of roughly one hour

27. Obscure GI Bleeding: Capsule Endoscopy Needs good Small Bowel Prep. Needs good Small Bowel Prep. Reading rate </= 15 frames/sec Reading rate </= 15 frames/sec Experimental Yield: Dedicated Enteroscope vs. Capsule Enteroscopy Experimental Yield: Dedicated Enteroscope vs. Capsule Enteroscopy Bleeds at reach of enteroscope: 94% vs 53% Bleeds at reach of enteroscope: 94% vs 53% Bleeds in all small bowel: 37% vs 64% Bleeds in all small bowel: 37% vs 64% Clinical Yield of Capsule: Clinical Yield of Capsule: Ongoing obscure ‐ overtbleed within 2 weeks: 92% Ongoing obscure ‐ overtbleed within 2 weeks: 92% Ongoing obscure ‐ overtbleed after 2 weeks: 34% Ongoing obscure ‐ overtbleed after 2 weeks: 34% Obscure ‐ overtbleed in past year: 13% Obscure ‐ overtbleed in past year: 13% Obscure ‐ occult bleed: 44% Obscure ‐ occult bleed: 44%

28. Obscure GI Bleeding: Capsule Endoscopy Predictors of (+) capsule finding: Predictors of (+) capsule finding: Through Hb < 10 g, Through Hb < 10 g, more than 1 bleeding episode, or more than 1 bleeding episode, or bleeding persisting > 6 months bleeding persisting > 6 months Capsule vs Intraop Endoscopy: Capsule vs Intraop Endoscopy: yield 74 vs 76.6%, yield 74 vs 76.6%, Capsule: sensitivity = 95%, specificity = 75%, PPV = 95%, NPV = 86% Capsule: sensitivity = 95%, specificity = 75%, PPV = 95%, NPV = 86% Management change: 37 to 66%; this led to resolution of bleeding in 65% Management change: 37 to 66%; this led to resolution of bleeding in 65%

29. Obscure GI Bleeding: Capsule Endoscopy

34. Obscure GI Bleeding: Intraoperative enteroscopy Yield: 58 ‐ 88% of small bowel lesions. 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”. IOE: Examination done “anterograde”, with dedicated enteroscope, with dimmed OR light. Lesions are marked when seen in the “way in”. TI reached in > 90% TI reached in > 90% Therapy given in 64%. Therapy given in 64%. Recurrent bleed: 12.5 ‐ 60% Recurrent bleed: 12.5 ‐ 60% Mortality: up to 17% Mortality: up to 17% May cause lacerations, perforations, bowel ischemia, pancreatitis, and prolonged ileus. May cause lacerations, perforations, bowel ischemia, pancreatitis, and prolonged ileus. Should be done only when DBE is limited for adhesions or other anatomic factors. Should be done only when DBE is limited for adhesions or other anatomic factors.

35. Deep Enteroscopy Double-Balloon Enteroscopy Double-Balloon Enteroscopy Single-Balloon Enteroscopy Single-Balloon Enteroscopy Spiral Enteroscopy Spiral Enteroscopy Therapeutic as well as diagnostic capabilities

36. Obscure GI Bleeding: Deep Enteroscopy Yield: 41 ‐ 80% of small bowel lesions. Yield: 41 ‐ 80% of small bowel lesions. DBE: uses anterograde + retrograde approach DBE: uses anterograde + retrograde approach Time: anterograde 72 ‐ 95 min, retrograde 75 ‐ 102 min. Each exam done in separate days. Time: anterograde 72 ‐ 95 min, retrograde 75 ‐ 102 min. Each exam done in separate days. Outcomes: Outcomes: Diagnostic yield 65%, Diagnostic yield 65%, Diagnostic/treatment success 64%, Diagnostic/treatment success 64%, Total SB exam 29% (tattoo), Total SB exam 29% (tattoo), Miss rates 28% (vs 20% for capsule) Miss rates 28% (vs 20% for capsule)

37. Obscure GI Bleeding: Deep Enteroscopy Findings: Findings: Angioectasia 31%, Angioectasia 31%, Ulcers (including IBD) 13%, Ulcers (including IBD) 13%, Malignancies 8%, Malignancies 8%, Other 6%, Other 6%, Negative exam 40% Negative exam 40% May cause lacerations, perforations, bleeding, and pancreatitis. May cause lacerations, perforations, bleeding, and pancreatitis. Ante ‐ grade approach recommended when lesion is in initial 2/3. Retrograde approach when distal 1/3. Ante ‐ grade approach recommended when lesion is in initial 2/3. Retrograde approach when distal 1/3.

38. For Now…DBE primarily therapeutic Time, labor, personnel and cost intensive Time, labor, personnel and cost intensive Complications risk: Initially ≈ 1%, upcoming data likely to show less Complications risk: Initially ≈ 1%, upcoming data likely to show less Diagnostic and therapeutic yield ↑if pre-screening done Diagnostic and therapeutic yield ↑if pre-screening done May be cost-effective as initial approach in patients with ongoing overt bleeding May be cost-effective as initial approach in patients with ongoing overt bleeding However, VCE before DE will reduce the number of procedures and ↓ complications  better long-term outcomes However, VCE before DE will reduce the number of procedures and ↓ complications  better long-term outcomes

53. REDUCTION

69. Obscure GI Bleeding: Algorithim

70. Obscure GI Bleeding: Conclusions GI bleeding is a significant pathologic condition which is growing due to the aging patient population and increasing use of antiplatelets/anticoagulants. 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 are number of pathologies which can range from the common to the rare. There is a significant societal cost to this. There is a significant societal cost to this. No single efficient diagnostic approach or therapeutic panacea. No single efficient diagnostic approach or therapeutic panacea. Must individualize approach and Rx. Must individualize approach and Rx. Second look endoscopies by a GI MD are the intial test of choice 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. 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.