Case Of Obscure Gastrointestinal Bleeding Research Articles

Obscure gastrointestinal bleeding from a large jejunal lipoma treated using an endoscopic unroofing technique with double balloon enteroscopy: a case study.

Small intestinal lipomas are rare, but may cause obscure gastrointestinal bleeding. The endoscopic unroofing technique excises only the upper third of the lipoma and allows both histological confirmation and complete treatment with minimal risk of perforation. We present a rare case of obscure gastrointestinal bleeding caused by a jejunal lipoma. A 75-year-old man on antiplatelet therapy presented to our department with melena and anemia. Computed tomography revealed he had a 45-mm jejunal submucosal tumor with fat attenuation. Endoscopic resection using an endoscopic unroofing technique with double balloon enteroscopy was successfully performed. The tumor was confirmed to be a lipoma.

Clinical features of obscure gastrointestinal bleeding undergoing capsule endoscopy: A retrospective cohort study.

BackgroundCapsule endoscopy has been widely used to investigate obscure gastrointestinal bleeding (OGIB) in the small intestine since its approval in 2001. However, the clinical features of OGIB remain unclear.AimWe retrospectively examined the clinical features and risk factors of OGIB in patients who underwent capsule endoscopy in our hospital.MethodsWe included 420 of the 431 patients who underwent capsule endoscopy from June 2014 to May 2021, in whom the small intestine could be observed. We retrospectively compared the clinical features and treatment of OGIB cases, with or without active small bowel bleeding (n = 173), with other cases (n = 247). Patient sex, age, diabetes mellitus, and heart failure histories were matched for the analysis.ResultsThe male/female ratio was 247/173 and the average age was 51.54 years. In multivariate analysis, the use of direct oral anticoagulants was significant (P = 0.016), and vascular lesions (P = 0.018) were observed in OGIB cases. When OGIB cases with and without active small bowel bleeding were compared, serum albumin level was lower in cases with active bleeding (P = 0.031). When treatment of OGIB cases were compared, those without vascular lesions could be treated conservatively (P = 0.0047). In the 1:1 propensity score matching analysis, serum creatinine level was elevated in cases of active bleeding (P = 0.029), and cases without vascular lesions were treated conservatively (P = 0.010).ConclusionsUse of direct oral anticoagulants is frequently associated with OGIB. OGIB patients without vascular lesions may be treated conservatively.

Clinical Impact of Small Bowel Capsule Endoscopy in Obscure Gastrointestinal Bleeding.

Background and objectives: The most frequent indications for small bowel capsule endoscopy (SBCE) are obscure gastrointestinal bleeding (OGIB) and iron deficiency anemia (IDA). The aim of this study was to evaluate the diagnostic yield (DY) of SBCE in overt and occult OGIB, as well as its impact on the clinical outcome. Materials and Methods: This study retrospectively included all cases of OGIB investigated by SBCE in a tertiary care referral center, between 1st January 2016 and 31st December 2018. OGIB was defined by overt or occult gastrointestinal bleeding, with negative upper and lower endoscopy. Occult gastrointestinal bleeding was either proved by a fecal test or presumptively incriminated as a cause for IDA. DY was defined as the detection rate for what were thought to be clinically significant findings. DYs for overt and occult bleeding were assessed and compared. Gender, age, hemoglobin levels, NSAID consumption and the use of anticoagulants were recorded. Following SBCE results, individual therapeutic decisions were made, and follow-up data were recorded. Results: 224 SBCE examinations were performed for OGIB, of which 148 were for overt OGIB, and 76 for unexplained IDA. Positive findings were found in 139 patients, resulting in an overall DY for OGIB of 62%, higher in overt OGIB (75%) compared to IDA (37%). The most frequent findings were small bowel angioectasias (62.2% in overt OGIB and 78.5% in IDA). On multivariate logistic regression analysis, only hemoglobin level <10 g/dL and anticoagulants were the variables independently associated with positive findings. All patients received medical, endoscopic or surgical treatment and had good clinical outcome during follow-up. Conclusion: SBCE has a high diagnostic yield and a positive impact on management of patients with OGIB.

Non-steroidal anti-inflammatory drug-induced enteropathy as a major risk factor for small bowel bleeding: a retrospective study

BackgroundSmall bowel (SB) bleeding accounts for 5% of all gastrointestinal (GI) bleeding cases and 80% of obscure GI bleeding cases. Although angioectasia is the common etiology of SB bleeding, nonsteroidal anti-inflammatory drug (NSAID)-induced SB lesions are also reported as a major cause in studies from Eastern countries. Herein, we assessed the frequency of occurrence of NSAID-induced SB lesions in Korean patients with obscure GI bleeding.MethodsWe retrospectively analyzed medical records of all consecutive patients aged ≥18 years who underwent capsule endoscopy from March 2018 to February 2019 at Ulsan University Hospital and Kosin University Gospel Hospital.ResultsOf the 83 subjects (all Korean; mean age ± standard deviation: 59 ± 18 years; age range: 18–84 years; men: n = 52; women: n = 31), 55 (66.2%) had stool with clear blood and 28 (33.8%) had normal stool with iron deficiency anemia. The detection rate of SB bleeding and lesions using capsule endoscopy was 72.3% (60 of 83 patients). A significantly higher frequency (40 of 51) of ulcerative/erosive lesions than other causes was observed in patients with inactive bleeding but visible SB lesions. As a result, NSAID-induced enteropathy accounted for 30.1% of 83 patients with obscure GI bleeding (25 of the all 60 SB bleeding cases).ConclusionsContrary to what is reported for patients in Western countries, this study in Korean patients showed an improved diagnostic yield of capsule endoscopy for obscure GI bleeding and that NSAID-induced enteropathy was the most common etiology of SB bleeding. Aggressive small intestine examination is required for patients with unexplained GI bleeding.

Successful Coil Embolization Without Balloon Occlusion of Mesocaval (Jejunal) Varices - a Case of Obscure Gastrointestinal Bleeding in a Patient with NASH Cirrhosis and Portal Hypertension

Successful Coil Embolization Without Balloon Occlusion of Mesocaval (Jejunal) Varices - a Case of Obscure Gastrointestinal Bleeding in a Patient with NASH Cirrhosis and Portal Hypertension

Comparison of Risk Factors Between Small Intestinal Ulcerative and Vascular Lesions in Occult Versus Overt Obscure Gastrointestinal Bleeding.

The detailed risk factors such as bleeding pattern, comorbidities, and medication usage of patients with obscure gastrointestinal bleeding (OGIB) are largely unknown. We evaluated the risk factors related to ulcerative and vascular lesions of the small intestine diagnosed by capsule endoscopy or balloon-assisted endoscopy in OGIB cases. We retrospectively evaluated 390 OGIB cases (occult, n = 101; overt, n = 289) in our hospital between January 2005 and March 2011 using univariate and multivariate logistic regression analyses to determine the related risk factors. In occult (n = 36) and overt (n = 120) OGIB cases, some lesions were detected in the small intestine. Ulcerative and vascular lesions were detected in both occult (n = 25, 69.4 %; n = 8, 22.2 %, respectively) and overt (n = 57, 47.5 %; n = 39, 32.5 %, respectively) cases. For ulcerative lesions, non-steroidal anti-inflammatory drugs were identified as a risk factor in overt cases [odds ratio (OR) 2.974, 95 % confidence interval (CI) 1.522-5.809, P = 0.001]. For vascular lesions, lowest hemoglobin level (OR 0.634, 95 % CI 0.422-0.953, P = 0.028) and hematologic disease (OR 8.575, 95 % CI 1.076-68.309, P = 0.042) were identified as risk factors in occult cases, whereas hemodialysis (OR 3.71, 95 % CI 1.315-10.467, P = 0.013) was identified in overt cases. Additionally, liver cirrhosis was noted as a risk factor in both occult (OR 7.453, 95 % CI 1.213-45.773, P = 0.013) and overt (OR 4.900, 95 % CI 2.099-11.443, P < 0.001) OGIB cases. There are differences in risk factors related to ulcerative versus vascular lesions in the small intestine in occult and overt OGIB cases. Differences were seen in both medication usage and comorbidities.

Obscure Gastrointestinal Bleeding in a Patient With Neurofibromatosis Type 1

Neurofibromatosis Type 1 (NF1) is an autosomal dominant disorder affecting approximately 1 in 3000, with well-known skin, ocular, and CNS manifestations. Gastrointestinal (GI) abnormalities are reported in 5-25% of cases of NF1. They may, however, go unrecognized as only 5% of these abnormalities are symptomatic. In particular, gastrointestinal stromal tumors (GIST) appear associated with NF1. GIST tumors account for less than 1-3% of all GI malignancies, but are the most common GI manifestation of NF1. We report a case of obscure GI bleeding for 7 years with eventual discovery of a small bowel GIST in a patient with NF1. A 39-year-old male with NF1 was transferred to our hospital with melena and hematochezia. He reported several episodes of GI bleeding since 2007 and required previous transfusions for chronic anemia. Extensive workup had been negative, including CT enterography, Meckel's scan, colonoscopy, EGD and capsule endoscopy. On admission, his hemoglobin was 6.0g/L, yet he was hemodynamically stable. Physical examination revealed mild epigastric pain and neurofibromas of his back. He was admitted to the ICU on a pantoprazole drip and received RBC transfusions. A tagged RBC scan localized bleeding in the duodenum/jejunum. Subsequent small bowel enteroscopy located a 4 cm ulcerated submucosal mass in the proximal jejunum with active bleeding. He then underwent partial small bowel resection with primary anastomosis. Pathology was positive for a low grade GIST (stage T3), characterized by a low mitotic index, with negative margins and lymph nodes. The patient did well post-operatively and his hemoglobin stabilized at 9.0g/L by discharge. He was then lost to follow-up. In NF1, mutation of the NF1 tumor suppressor gene on chromosome 17 leads to loss of tumor suppressor function and subsequent development of benign and malignant tumors. NF1-associated GI findings include neurogenic neoplasms, neuroendocrine tumors, and most commonly GIST. The majority of NF1-associated GISTs are small asymptomatic lesions with low malignant potential, often noted incidentally on imaging. Intermittent GI bleeding and anemia over several years are the most common presentations. Treatment for NF1 GIST includes surgical excision of localized tumor with good prognosis. For large tumor burden, few studies have reported cytoreduction with tyrosine kinase inhibition prior to surgical excision, but describe variable results.

Should Capsule Endoscopy Be the First Test for Every Obscure Gastrointestinal Bleeding?

Obscure gastrointestinal bleeding (OGIB) refers to gastrointestinal (GI) bleeding of unclear origin that persists or recurs after negative findings on esophagogastroduodenoscopy and colonoscopy. OGIB accounts for approximately 5% of all types of GI bleeding. More than 80% of OGIB cases originate in the small bowel. The ability to detect OGIB in the small bowel has significantly advanced and been revolutionized since the introduction of the capsule endoscopy and double-balloon enteroscopy techniques in 2000 and 2001, respectively. With these new methods for small-bowel evaluation, new guidelines have been proposed for the diagnosis and management of OGIB. However, some issues remain unsolved. The purpose of this article is to review the various modalities used for evaluating OGIB, including capsule endoscopy and double-balloon enteroscopy, and to help guide clinicians in their decisions on which modality will be the most effective.

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

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

Sa1644 Differences in Clinical Features and the Related Risk Factors Between Occult and Overt Cases of Obscure Gastrointestinal Bleeding

Sa1644 Differences in Clinical Features and the Related Risk Factors Between Occult and Overt Cases of Obscure Gastrointestinal Bleeding

A Case of a Jejunal Ectopic Pancreas Presenting as Obscure Gastrointestinal Bleeding

A jejunal ectopic pancreas, where pancreatic tissue is found outside of the usual anatomical location, is a rare submucosal tumor that may cause obscure gastrointestinal (GI) bleeding. After initial negative endoscopic evaluation of the obscure GI bleeding, including colonoscopy and/or upper endoscopy, it is reasonable to proceed with further evaluation of the small bowel. Diagnostic options for the evaluation of the small bowel may include capsule endoscopy, push enteroscopy, or barium contrast small bowel studies. Here, we report a case of obscure GI bleeding caused by a jejunal ectopic pancreas, diagnosed through capsule endoscopy and barium contrast small bowel studies, which was treated successfully with single incision access laparoscopy.

QuickView in small-bowel capsule endoscopy is useful in certain clinical settings, but QuickView with Blue Mode is of no additional benefit

Analysis of small-bowel capsule endoscopy (SBCE) is time-consuming. QuickView (QV) has been added to the RAPID software to reduce the reading times. However, its validity is still under intense review. Recently, we have shown that Blue Mode (BM) provides improvements in images for most lesion categories. To assess the validity of QuickView with white light (QVWL) and QuickView with Blue Mode (QVBM) reading, in a group of patients who underwent SBCE in our centre, by comparing it with the standard video sequence review (used as reference) by experienced SBCE readers. This was a retrospective study; all SBCE (August 2008-November 2011), performed with PillCam SB, with complete small-bowel visualization were included. A clinician with previous SBCE experience, unaware of the SBCE reports, reviewed prospectively the video streams on RAPID platform using QVWL and QVBM. All SBCE had been reported previously using the standard mode; these reports were considered as the reference. There were 106 cases of obscure gastrointestinal bleeding (OGIB), 81 cases of known or suspected Crohn's disease (CD) and 10 cases of polyposis syndromes. The mean small-bowel evaluation was 475 (± 270) s and 450 (± 156) s for QVWL and QVBM, respectively. In the OGIB (n=106; 21 overt/85 occult), with QVWL, 54 [P0 (28), P1 (18), P2 (8)] lesions were detected, 63 [P0 (48), P1 (13), P2 (2)] with QVBM, as compared with 98 [P0 (67), P1 (23), P2 (8)] by standard (reference) reporting. For P1+P2 lesions, the sensitivity, specificity, positive predictive value and negative predictive value for QVWL (as compared with reference reporting) were 92.3, 96.3, 96 and 92.8%, respectively. For QVBM, the above values were 91, 96, 96.2 and 90.6%, respectively. Eighty-one (n=81) patients underwent SBCE for small-bowel evaluation on the basis of a clinical history of suspected or known CD. With QVWL, 71 mucosal ulcers were detected, 68 with QVBM, as compared with 155 mucosal ulcers with reference reading. Finally, in the polyposis category with QVWL and QVBM, four polypoid lesions were detected compared with seven with standard (reference) review. QV can be used confidently in OGIB in an urgent inpatient setting and in outpatients with occult OGIB or suspected CD. Furthermore, BM does not confer any additional advantage in the QV setting. Standard review settings should be used in all other cases.

Capsule endoscopy and double balloon enteroscopy for obscure gastrointestinal bleeding: Which is better?

See article in J. Gastroenterol. Hepatol. 2011; 26: 796–801.

Small Bowel Lymphangiectasia and Angiodysplasia

Small bowel angiodysplasia accounts for 30 to 40% of cases of obscure gastrointestinal bleeding and is associated with significant morbidity and mortality. Identifying lesions can be difficult. Small bowel capsule endoscopy (SBCE) is a significant advance on earlier diagnostic techniques. The cause of angiodysplasia is unknown and the natural history poorly understood. Many lesions are thought to arise from a degenerative process associated with ageing, local vascular anomalies, and tissue hypoxia. Nonpathologic lymphangiectasias are commonly seen throughout the small bowel and are considered a normal finding. To determine whether there is an association between lymphangiectasias, angiodysplasia, and atherosclerosis related conditions. Relevant information was collected from a dedicated SBCE database. Logistic regression analysis was used to examine associations between angiodysplasia, lymphangiectasia, patient demographics, and comorbidity. In all, 180 patients underwent SBCE during the study period, 46 (25%) had angiodysplasia and 47 (26%) lymphangiectasia. Lymphangiectasia were seen in 24 (52%) of 46 with angiodysplasia, in 16 (19%) of 84 with obscure gastrointestinal bleeding without angiodysplasia and in 7 (14%) of 50 without gastrointestinal bleeding. Logistic regression analysis confirmed a strong positive association between angiodysplasia and lymphangiectasia; odds ratio 4.42, P<0.003. Angiodysplasias were also associated with increasing age; odds ratio 1.1. There was no correlation with any other patient characteristic. Lymphangiectasia are strongly associated with the presence of small intestinal angiodysplasia and may represent a useful clinical marker for this condition. Angiodysplasia are also associated with increasing age. Conditions associated with systemic atherosclerosis did not increase the risk of angiodysplasia.

Combined capillary hemangioma and angiodysplasia of the ileum: an unusual cause of obscure gastrointestinal bleeding with preoperative localization by double-balloon endoscopy

Vascular lesions in the small bowel with bleeding complications are usually difficult to diagnose and localize preoperatively. With the increased use of either capsule endoscopy or enteroscopy, there have been more reports of preoperative diagnosis from such lesions. The authors report a rare case of obscure gastrointestinal bleeding from a combined hemangioma and angiodysplasia identified by double-balloon enteroscopy. To the authors' knowledge, this is the first report of such combined lesions.

Application of Laparoscopy in the Management of Obscure Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is considered obscure when it persists or recurs after negative endoscopy. Small bowel lesions account for approximately 1-fourth of cases of obscure GI bleeding. These lack specific clinical symtoms and signs, and tend to be inaccessible to routine examinations. The management of patients with intermittent obscure GI bleeding poses both diagnostic and therapeutic challenges. The aim of this study was to report the importance of laparoscopy in diagnosing and treating small bowel lesions responsible for obscure bleeding in 5 patients with subacute presentations. Data were collected from 2 hospitals' in-patient records and a prospective database. All patients underwent laparoscopic exploration. After the identification of the diseased segments, laparoscopy-assisted segmental resection of the small bowel and enteroentorostomy were carried out in all cases. This approach enabled a successful minimally invasive treatment of the obscure GI bleeding. The overall procedure was safe and our results were satisfactory.

Ectopic Varices Causing Recurrent Obscure Gastrointestinal Bleeding

Purpose: To present an unusual case of obscure gastrointestinal bleeding. Methods: A 53-year old male with a history of hepatitis C and a gun-shot wound to the abdomen requiring unknown surgical interventions initially presented to our institution for melena, hematochezia, and a hemoglobin of 6.5 g/dL. Initial evaluation included an EGD which showed no source for bleeding and no endoscopic findings suggestive of portal hypertensive related complications. Colonoscopy (which included evaluation of the terminal ileum) was also negative for source. Neither abdominal imaging nor laboratory investigations were suggestive of advanced liver disease. As the patient manifested no other signs or symptoms of continued bleeding, he was subsequently discharged with instructions to have an outpatient wireless capsule endoscopy. He did not get the capsule endoscopy but presented similiarly to the hospital four more times. At each time, a variety of investigative techniques (EGD, enteroscopy, tagged RBC scan) were unrevealing for source. Due to the inability to obtain a capsule endoscopy, the patient was ultimately referred for a double balloon enteroscopy at a neighboring institution. Results: The double balloon enteroscopy revealed large, non-bleeding ileal varices which are the presumed source to the recurrent obscure GI bleeding. No endoscopic therapy was performed. The patient was initiated on a non-selective beta blocker and referred for surgical evaluation. Conclusion: Ectopic varices are an unusual and challenging cause of gastrointestinal bleeding. Unfortunately, there are no clear evidence-based guidelines to direct their management. Management of this challenging clinical entity should therefore employ a multidisciplinary approach between the gastroenterologist, the surgeon, and the interventional radiologist to define an optimal approach. In this case, we believe that the ileal varices are complications of the prior abdominal surgery rather than intrinsic liver disease.Figure: Large ileal varices identifed at double balloon enteroscopy.

The Self-administered Capsule Endoscopy is Useful for the Obscure Gastrointestinal Bleeding Cases

The Self-administered Capsule Endoscopy is Useful for the Obscure Gastrointestinal Bleeding Cases

A case of obscure gastrointestinal bleeding in a teenager

In this report, we discuss a case of obscure gastrointestinal bleeding (OGIB) in an 18-year-old man, where oesophagogastroduodenoscopy (OGD) and colonoscopy proved inconclusive in determining a source of bleeding. On day 14 of admission, a laparoscopy was performed, identifying a mass 2 feet from the ileocaecal junction. This was thought initially to be a Meckel's diverticulum and the patient underwent a laparotomy and a small bowel resection. Surprisingly, the histology revealed a benign gastrointestinal stromal tumour (GIST) of the ileum, rare in such a young person. Given the diagnostic delay, we propose a simple algorithm for the diagnostic management of a teenager presenting with a significant ongoing gastrointestinal bleed.

Long-acting somatostatin analogue therapy in obscure-overt gastrointestinal bleeding in noncirrhotic portal hypertension: a case report and literature review

We describe a case of obscure gastrointestinal bleeding in a male with noncirrhotic portal hypertension who required multiple admissions and repeated blood transfusions over a 5-month period. Upper and lower gastrointestinal endoscopy failed to establish a cause for bleeding which was eventually ascribed to universal portal hypertensive stigmata in stomach, small bowel and colon, which were not amenable to endoscopic therapy. On account of extensive venous thrombosis, neither surgical shunting nor interventional radiology was an option. Initial management with prothrombotic agents failed. Our patient was successfully stabilized on long-acting somatostatin (SMS) analogue therapy using lanreotide, resulting in avoidance of further admissions and blood transfusion and restoration of his independence and quality of life. The use of short-acting SMS analogues is recognised in acute variceal haemorrhage secondary to portal hypertension in cirrhosis, and long-acting SMS analogue therapy has been described in obscure gastrointestinal bleeding though secondary to angiodysplasia. However, the potential role of long-term SMS analogues in noncirrhotic portal hypertensive bleeding of this type has not been reported earlier. This case supports its use in this scenario in the absence of surgical options and when only palliative approaches are available.