Small bowel ulcers and bleeding: An overlooked yet critical clinical challenge

Pediatric Jejunal Gastrointestinal Stromal Tumor Diagnosed by Wireless Capsule Endoscopy

Initial Capsule Endoscopy or Angiography in Patients with Obscure Gastrointestinal Bleeding?

Therapeutic Double Balloon Enteroscopy Reduces Transfusion Requirements in the Management of Occult or Obscure Gastrointestinal Bleeding

Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases

Small intestine, hitherto an obscure area for endoscopists before 2000, is now easily evaluated non-invasively using capsule endoscopy and invasively by device-assisted enteroscopies. Major advances in understanding the causes and management of small bowel diseases have been in obscure gastrointestinal (GI) bleed, currently re-named as small bowel bleed, after the discovery of capsule endoscopy. The current article is a narrative review of the technology of capsule endoscopy, its advantages and limitations, future perspective and Indian studies on its utility in patients with small bowel bleed. Till date, eight large series reporting 2319 patients with obscure GI bleed (1554 overt and 765 occult) undergoing capsule endoscopy have been reported from India. Overall yield of capsule endoscopy to detect lesions in these studies varied from 43.5% to 90%. The major causes detected in various studies for small bowel bleed include vascular malformation, portal hypertensive enteropathy, ulcer, stricture, tumor, polyps, etc. Hookworm can cause both occult as well as overt small bowel bleed as shown mainly from India. Capsule endoscopy has also been quite safe in patients with small bowel bleed as despite 0.6% to15% retention of imaging capsule in Indian studies, development of clinically evident small bowel obstruction has rarely been reported. The major limitations of capsule endoscopy include lack of maneuvrability and therapeutic capability. Research is in progress to overcome some of the limitations of the current capsule endoscopy system. It is concluded that discovery of capsule endoscopy has brought a new paradigm in GI endoscopy and explored a hitherto unexplored area of GI tract, i.e. small bowel that continued to be a black box for the endoscopists.

Wireless capsule endoscopy for obscure small-bowel disorders: Final results of the first pediatric controlled trial

Gastrointestinal stromal tumors (GISTs) account for 1-3% of all GI malignancies and, of these, 20-25% occur in the small intestine. Although small bowel GISTs are rare, GI bleeding is a frequent presentation of symptomatic GISTs.1 We present a case of overt GI bleeding due to a jejunal GIST. A previously healthy 61-year-old woman was admitted for a syncope initially attributed to bradycardia until, after another syncopal episode, the patient had melena and a drop in hemoglobin from 11.4 to 7.9 g/dL. Initial EGD was unremarkable and colonoscopy was planned for the next day as she was hemodynamically stable. Overnight, she became hypotensive with a transient vasopressor requirement, and could not tolerate bowel preparation. In light of her continued melena and elevated BUN/creatinine ratio, a more distal GI bleed was suspected. A push enteroscopy was performed at which time adherent clot was visualized distal to the furthest extent of the colonoscope. Examination with an enteroscope demonstrated a large (3-5 cm) serpiginous, pulsatile mass with an overlying ulceration. No active bleeding was seen and the site was tattooed at either extent of the lesion. Biopsies were not performed due to concern for inciting significant bleeding. A CT angiogram demonstrated a 58 x 72 mm hypervascular right pelvic mass adjacent to a loop of small bowel. She underwent exploratory laparoscopy with resection of a segment of the jejunum and the adjacent 9 cm mass. Pathology demonstrated an intermediate to high risk GIST (pT3N0) and the patient was started on adjuvant imatinib. Although small bowel GISTs are rare and the small bowel is an uncommon source of GI bleeding, GISTs may be overrepresented as a cause of small bowel bleeding. In a case series of capsule endoscopy for diagnosis of small bowel bleeding, GISTs accounted for 18.75% of bleeding among 40 to 64 year olds, second only to vascular lesions.2 This underscores the importance of keeping this otherwise rare entity on the differential in small bowel bleeding, particularly in this age group. GISTs are primarily extraintestinal and cross-sectional imaging may be beneficial as in this case.1965_A Figure 1. Endoscopic image of the jejunum with a large (3-5 cm) serpiginous, pulsatile mass with overlying ulceration.1965_B Figure 2. CT Angiogram demonstrating a 58 x 72 mm hypervascular right pelvic mass adjacent to a loop of small bowel1965_C Figure 3. Exploratory laparoscopy revealed a 9cm GIST adjacent to the jejunum

Gastrointestinal stromal tumors (GISTs) are a rare variety of tumors of mesenchymal origin found in the gastrointestinal (GI) tract forming about 1% of all GI tumors. These originate from the interstitial cells of Cajal. Small bowel GISTs have been shown to present as obscure GI bleeding, obstruction and perforation in literature. We report a 57 years old female patient presenting with pain abdomen, fever and vomiting and palpable right iliac fossa (RIF) mass diagnosed as an appendicular mass and managed conservatively. She was planned interval appendicectomy and was discovered to have a jejunal GIST at laparotomy treated with resection and anastomosis. There are case reports of small bowel GISTs presenting as sources of obscure or overt GI bleeding and luminal or extra luminal mass causing small bowel obstruction. Surgery is mainstay of treatment with imatinib for adjuvant or neoadjuvant therapy. This case highlights an unusual presentation of a jejunal GIST with a sealed off perforation mimicking an appendicular mass in the RIF treated by surgical resection followed by adjuvant Imatinib therapy. GIST being an uncommon tumor with varied presentations can lead to misdiagnosis and delays in treatment. This differential should be kept in mind while evaluating small bowel pathologies to aid a timely diagnosis.

Performance Characteristics of the Suspected Blood Indicator Feature in Capsule Endoscopy According to Indication for Study

58-Year-Old Woman With Melena

Use and Misuse of Small Bowel Video Capsule Endoscopy in Clinical Practice

The coexistence of gastrointestinal (GI) stromal tumors (GISTs) and other malignancies, both synchronous or metachronous, has been discussed extensively in literature. It has also been described that the frequency of malignancies among patients with GIST is significantly higher than that in the general population. We present a case report of a patient with synchronous occurrence of myelodysplastic syndrome (MDS) and a GIST who presented with chronic fatigue and an episode of syncope and was found to have obscure GI bleed. Laboratory investigations revealed severe anemia, marrow picture was suggestive of MDS, and magnetic resonance imaging of the abdomen revealed a proximal small bowel neoplasm. She underwent resection of the diseased segment and anastomosis. The histopathology of the specimen confirmed the diagnosis of a GIST arising from the jejunum. She was started on imatinib on postoperative day 21 and is presently well preserved and on regular follow-up. The possibility of small bowel neoplasm, especially GIST, must be considered in patients diagnosed with chronic anemia secondary to obscure GI bleed and the possibility of a synchronous GIST, although uncommon must be considered in patients with myeloproliferative disorders and leukemia.

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

17 - Middle Gastrointestinal Bleeding

INTRODUCTION: Approximately 5% of gastrointestinal bleeding presentations are due to suspected small bowel bleeding or obscure gastrointestinal bleeding (OGIB). Small bowel capsule endoscopy (SBCE) and CT/MR enterography are common modalities used to evaluate the small bowel for possible lesions. The miss rate of SBCE for small bowel tumors has been reported as high as 25%. Due to a concern for possible missed small bowel lesion, CTE/MRE is often performed after SBCE in patients with obscure GI bleeding, however the diagnostic yield of these studies is unknown. The primary aim of this study was to investigate the diagnostic yield of CTE/MRE performed after SBCE in patients with obscure GI bleeding. METHODS: A retrospective chart review was performed of patients who underwent both SBCE and CT or MR enterography for evaluation of obscure GI bleeding – both occult and overt. The capsule endoscopy database at a single tertiary academic medical center was reviewed for studies performed from 1/2010-4/2019. Only cases with clinical suspicion of small bowel bleeding were included. Charts were reviewed to determine whether patients had a subsequent CT or MR enterography. Exclusion criteria included more than 6 months between SBCE and enterography, incomplete SBCE and IBD diagnosis. Descriptive statistics were performed. RESULTS: A total of n = 11 were included. The indications of the studies were evaluation of anemia and occult blood loss in the setting of unrevealing endoscopies in 72.7% of patients and evaluation of overt bleeding without source on endoscopy for 22.3% of patients. There were five (45.5%) significant small bowel findings on SBCE. There were no small bowel lesions identified by enterography. In the patients with overt bleeding, SBCE identified possible culprit lesions in 66.7% of patients and enterography didn't show any culprit lesions. In patients with occult blood loss, SBCE identified potential culprit lesions in 50% of the patients, while enterography didn't identify any. All patients with a negative SBCE also had a negative enterography study. CONCLUSION: These findings suggest that there may be no additional diagnostic yield from enterography performed after SBCE in patients with suspicion of GI bleeding from a small bowel source. SBCE seems to have a high negative predictive value for significant small bowel lesions. Larger studies need to be performed to evaluate the utility of performing enterography after SBCE in the evaluation of suspected small bowel bleeding, both occult and overt.