“THE HUNT FOR THE RED SPOT”
Investigations and management of
the obscure GI bleeder
Dr Georgina Cameron
Endoscopy Fellow, SVHM
ANZSPM Update Meeting
28th June 2013
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
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)
Causes of obscure GI bleeding
Ulcer
Angioectasia
Varices
GIST
Diverticular disease
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
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
Intraoperative enteroscopy
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)
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
Case 1: Mrs SM
Capsule endoscopy showed
bleeding from proximal small bowel
CT showed
small bowel diverticula
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
Anterograde
Double Balloon Enteroscopy
Fresh bleeding
and clot within a
small bowel
diverticulum
Unable to achieve
haemostasis
Site tattooed for
surgical
localisation
Case SM – “X” marks the spot
Laparotomy and 15cm small bowel resection with end to end anastamosis.
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
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
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
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
Outcome
18 units PRBC in a 19 day admission
Haemostasis achieved at retrograde DBE
Patient discharged home 2 days later with no
further bleeding
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
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
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)
2)
3)
4)
overt GI haemorrhage
anaemia requiring transfusion
an initial negative gastroscopy and colonoscopy
at least one inpatient hospital stay of ≥7 days
because of persistent GI bleeding
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)
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
Causative Pathologies
Diagnoses
No.
Ages of patients (yrs)
Small intestinal angioectasia
6
66,67,67,67,68,84
Large intestinal angioectasia
2
78,86
Small intestinal varices
4
18,39,50, 58
Small intestinal gastrointestinal stromal tumour
2
70,79
Small intestinal carcinoid
3
33,76,78
Jejunal diverticula
2
69,80
Colonic diverticula
1
73
Pancreaticoduodenal artery aneurysm
1
88
Small intestinal anastomotic bleeding
2
33,48
Infected aortoenteric fistula
1
74
No diagnoses
4
31,32,61,74
Yield of endoscopic investigations in
overt OGIB
Test
No. of patients
No. of tests
Positive
Positive
diagnostic yield therapeutic
yield
Repeat Gastroscopy
19
36
3%
3%
Repeat colonoscopy
14
28
4%
4%
Capsule endoscopy
20
32
53%
0%
Push enteroscopy
11
12
17%
17%
Antegrade double
balloon enteroscopy
13
16
31%
13%
Retrograde double
balloon enteroscopy
6
7
0%
0%
Yield of radiological investigations in
overt OGIB
Test
No. of
patients
No. of
tests
Positive
diagnostic
yield
Positive
therapeutic
yield
Radionuclide red
cell scan
23
41
51%
0%
CT angiography
17
27
30%
0%
Angiography
13
21
33%
29%
Surgical outcomes in overt OGIB
Test
No. of patients
No. of tests
Positive
diagnostic yield
Surgery overall
13
15
Positive
therapeutic
yield
60%
86%
-
Clear lesion identified 7
prior to surgery
7
-
Non-specific finding
prior to surgery
6
8
2 (25%)
Enteroscopy performed
in addition to surgery
5
5
2 (40%)
25%
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
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”