1. “THE HUNT FOR THE RED SPOT” Investigations and management of the obscure GI bleeder Dr Georgina Cameron Endoscopy Fellow, SVHM ANZSPM Update Meeting 28 th June 2013

2. Background Obscure gastrointestinal bleeding (OGIB) represents occult or overt bleeding of unknown origin after normal gastroscopy and colonoscopy. – Overt bleeding is characterised by haematemesis and/or melaena. – Occult is not detectable by the patient

3. Background 5% of all GI bleeding occurs in the small bowel outside the intubation range of gastroscopy and colonoscopy. ~75% obscure GI bleeding arises from the small bowel (25% found on repeat upper and lower endoscopy)

4. Causes of obscure GI bleeding Ulcer GIST Angioectasia Diverticular disease Varices

5. Endoscopic investigations for obscure GI bleeding Repeat Gastroscopy, colonoscopy -25% will detect aetiology of obscure GI bleeding Push enteroscopy -Aiming to visualise proximal jejunum -Typically use a paediatric colonoscope and able to intubate 100cm into small bowel Capsule endoscopy -Benefit of complete small bowel visualisation -Fair localisation -Guides next best investigation -Not therapeutic

6. Endoscopic investigations for obscure GI bleeding Double Balloon Enteroscopy -Anterograde and retrograde allowing visualisation 75% small bowel -Allows therapeutic intervention such as polypectomy, cauterization, clipping -Ink tattooing allows localisation of pathology for surgeons

7. Intraoperative enteroscopy

8. Radiological investigations CT Angiography (>0.3 mL/min) Good localisation, precursor to angiography Labelled Red Cell Scan (>0.1mL/min) Poor localisation Digital Subtraction Angiography (therapeutic)

9. Case 1 Mrs SM 70 year old lady from Warrnambool – Recurrent presentations with abdominal pain, fever and melaena – Haemoglobin 60g/L requiring 3 units blood and admission to intensive care – On aspirin for atrial fibrillation – Normal gastroscopy and colonoscopy

10. Case 1: Mrs SM Capsule endoscopy showed bleeding from proximal small bowel CT showed small bowel diverticula

11. Case 1: Mrs SM Transferred to St Vincent’s Hospital Small amount of melaena with Haemoglobin drop post arrival – transfused 3 units CT angiogram – no focus of bleeding Given capsule endoscopy findings, proceeded to anterograde double balloon enteroscopy

12. Anterograde Double Balloon Enteroscopy Fresh bleeding and clot within a small bowel diverticulum Unable to achieve haemostasis Site tattooed for surgical localisation

13. Case SM – “X” marks the spot Laparotomy and 15cm small bowel resection with end to end anastamosis.

14. Case 2: Mrs EH 73 year old Several weeks of melaena Hypotensive, dizzy and unable to mobilise Hb 51g/L on admission and iron deficient Past history of peptic ulcer disease, rheumatoid arthritis, 2nd degree heart block No non-steroidals anticoagulants/antiplatelets on admission

15. Case 2: Mrs EH Gastroscopy x2 – Chronic non-bleeding gastric ulcers Colonoscopy – Blood in colon and ileum CT angiogram – NAD Push enteroscopy to 90cm– NAD Red cell scan – bleeding in the proximal small bowel

16. Case EH Capsule endoscopy Blood 2/3 into small bowel transit time Capsule noted to be in the right iliac fossa on the 8-lead map

17. Case 2 Mrs EH Anterograde DBE – unremarkable Retrograde DBE – ooze over a pulsating area of mucosa 100cm proximal to ileocaecal valve This represented angioectasia, and was treated with Adrenaline, Argon Plasma Coagulation (APC), and clipping

18. Outcome 18 units PRBC in a 19 day admission Haemostasis achieved at retrograde DBE Patient discharged home 2 days later with no further bleeding

19. Prolonged overt obscure gastrointestinal bleeding – A “real world” experience Prayman T Sattianayagam, Paul V Desmond, Andrew CF Taylor Submitted to Digestive Diseases and Sciences 2013

20. Aims To assess – the final diagnosis and outcomes in patients with overt obscure GI bleeding – clinical features of the patients that may point to the diagnosis – diagnostic yield of the battery of investigations used for this group of patients

21. Methods: Over a ten-year period between 2002 and 2012 twenty-eight patients who fulfilled the following inclusion criteria were included in the study: 1)overt GI haemorrhage 2)anaemia requiring transfusion 3)an initial negative gastroscopy and colonoscopy 4)at least one inpatient hospital stay of ≥7 days because of persistent GI bleeding

22. Recorded Measurements The clinical presentation, transfusion requirements and investigations of each patient were recorded -until diagnosis and treatment, or -until death or census in September 2012 (in those who had undiagnosed OGIB)

23. Results: 28 patients (14 male) Median age at presentation = 68 years (18-88) Median follow-up in the entire cohort was 3 years (0.1-9.4) Drugs potentiating GI bleeding (present in 76% of those >60yo) – 10 on aspirin – 3 on clopidogrel – 4 on warfarin Median time from presentation to treatment 5.3 months (0.3 - 48) Median number of units of blood transfused per patient 29 (10 - 86) units

24. Causative Pathologies DiagnosesNo.Ages of patients (yrs) Small intestinal angioectasia666,67,67,67,68,84 Large intestinal angioectasia278,86 Small intestinal varices418,39,50, 58 Small intestinal gastrointestinal stromal tumour270,79 Small intestinal carcinoid333,76,78 Jejunal diverticula269,80 Colonic diverticula173 Pancreaticoduodenal artery aneurysm188 Small intestinal anastomotic bleeding233,48 Infected aortoenteric fistula174 No diagnoses431,32,61,74

25. Yield of endoscopic investigations in overt OGIB TestNo. of patientsNo. of tests Positive diagnostic yield Positive therapeutic yield Repeat Gastroscopy19363% Repeat colonoscopy14284% Capsule endoscopy203253%0% Push enteroscopy111217% Antegrade double balloon enteroscopy 131631%13% Retrograde double balloon enteroscopy 670%

26. Yield of radiological investigations in overt OGIB Test No. of patients No. of tests Positive diagnostic yield Positive therapeutic yield Radionuclide red cell scan 234151%0% CT angiography 172730%0% Angiography 132133%29%

27. Surgical outcomes in overt OGIB TestNo. of patientsNo. of tests Positive diagnostic yield Positive therapeutic yield Surgery overall131560% -Clear lesion identified prior to surgery 7786% -Non-specific finding prior to surgery 682 (25%)25% Enteroscopy performed in addition to surgery 552 (40%)

28. Summary Repeat gastroscopy/colonoscopy allowed treatment of angioectasias in two elderly patients Radionuclide red cell scans had the highest radiological diagnostic yield but were beneficial only in conjunction with other tests such as CT angiography, which was a useful precursor test to angiographic embolisation Capsule endoscopy had the highest endoscopic diagnostic yield Anterograde double balloon enteroscopy had the best endoscopic diagnostic and therapeutic yield Surgery had a diagnostic and therapeutic yield of 60%, which was better if a definite lesion had been identified previously

29. Conclusions: Overt OGIB is difficult to manage Angioectasias are the commonest cause of overt OGIB in patients over 65 who are often on antiplatelet/anticoagulant therapy Capsule endoscopy is best first-line test, which can guide enteroscopy Nuclear medicine labelled red cell scan helpful but poor localisation CT angiography can guide angiographic embolisation but this requires more rapid rate of bleeding Surgery is often curative if you can localise the site of bleeding prior “Management should be individualised with consideration for repeating investigations”