Case Series of Extended Upper Endoscopy Revealing Small Bowel Causes of Obscure Gastrointestinal Bleeding

Abstract

Purpose: Patients with obscure gastrointestinal bleeding (OGIB) are often difficult to diagnose and manage, particularly when the bleeding arises from small bowel (SB) lesions. Although OGIB accounts for approximately 5% of patients with gastrointestinal bleeding, the source is SB in 75% of the cases. Standard upper endoscopy involves examination extending up to the duodenum and can often miss up to 27% of more distal SB lesions necessitating further expensive investigations. Our study highlights the importance of careful, extended endoscopy in detecting SB lesions by advancing the upper endoscope beyond the distal duodenum further into the SB in cases with OGIB. Methods: We report four prospective cases of OGIB seen by the gastroenterology service over a one month period at our tertiary care academic hospital. Significant SB pathology was missed with initial upper and lower endoscopy. SB lesions were subsequently detected as the source of bleeding by advancing the upper endoscope beyond the conventional limit of the second part of the duodenum, further into the distal SB. Results: Extended upper endoscopy in our four cases revealed inflammation, ulceration and two cases with SB masses, which were not visualized previously. Pathology of these bleeding lesions showed jejunitis, distal duodenal ulceration, periampullary adenoma and metastatic non-small cell lung cancer respectively. Details of presentation and findings are discussed in the table below. All patients were white males presenting with melena and abdominal pain with a mean drop of 22% in hemoglobin from their baseline. Conclusion: Gross pathology may be missed at initial endoscopy, particularly in the SB. We recommend repeating endoscopy in cases with ongoing OGIB and advancing the scope further down the SB before considering referral for push enteroscopy, capsule endoscopy, and double balloon enteroscopy which are not only expensive but are also available at very limited U.S. centers. Our prospective case series highlights the importance of simply “extending the scope” of routine endoscopy technique to increase the yield and decrease patient care expenses when managing OGIB before considering costlier, alternative modalities.Table: Table. Case descriptions with endoscopic and histopathological findingsFigure