Diagnosis Of Obscure Gastrointestinal Bleeding Research Articles

Jejunal gastrointestinal stromal tumor: a diagnostic challenge.

Gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors of the gastrointestinal tract and a rare cause of gastrointestinal bleeding. These tumors usually affect people over 50 years of age and they exhibit a wide range of clinical manifestations, including asymptomatic patients, nonspecific symptoms, obstruction or bleeding, which may delay diagnosis. Early diagnosis and treatment are crucial because GISTs can be aggressive and metastasize. This case highlights the importance of considering GISTs in the differential diagnosis of obscure gastrointestinal bleeding.

Diagnostic yield of small bowel capsule endoscopy in obscure gastrointestinal bleeding: a real-world prospective study

Small bowel capsule endoscopy (SBCE) visualizes the small bowel (SB) mucosa. Gastrointestinal (GI) bleeding from SB accounts for the majority of SBCE indications. We aimed to assess, in a “real-world” prospective study, the diagnostic yield of SBCE in a cohort of consecutive patients with obscure gastrointestinal bleeding (OGIB). Secondary end point was to assess the frequency of adverse events and the role of SBCE in determining the diagnostic work-up and clinical outcome. From 2016 to 2018, all patients referred for SBCE examination were enrolled. Indication for SBCE was re-assessed by 2 dedicated gastroenterologists. Inclusion criteria: (1) age ≥ 18 and ≤ 85 years; (2) diagnosis of OGIB; 3) non-diagnostic standard bidirectional endoscopy; (4) informed consent. Exclusion criteria: (1) deglutition impairment; (2) SBCE contraindications; (3) pregnancy. The cohort included 50 patients [males 18 (36%), age 68 (27–83)]. SBCE indication: patients with ongoing overt OGIB (Group A) (n = 11; 22%), previous overt OGIB (Group B) (n = 14; 28%), occult bleeding (with Iron Deficiency Anaemia) (Group C) (n = 25; 50%). SBCE detected clinically relevant lesions in 46 (92%) cases. Clinically relevant lesions were more frequent in Group C (24/25; 96%), followed by Group A (10/11; 91%) and Group B (12/14; 85.5%). After SBCE, treatment was medical (60%); endoscopic (14%), surgical (36%) or conservative (18%). Clinical follow-up showed complete resolution in 63.2%, partial/absent resolution in 18.4% of cases. In a prospective study, the high diagnostic yield of SBCE supports its role as first-line investigation in patients with OGIB. However, this achievement requires an accurate and timely assessment by dedicated gastroenterologists.

The role of early video capsule endoscopy in the diagnosis and prognosis of obscure gastrointestinal bleeding: A multi-center propensity score matching study.

Video capsule endoscopy (VCE) is a first-line procedure for the diagnosis of obscure gastrointestinal bleeding (OGIB). The opinions on the timing for such diagnostic evaluation remain unclear. We aimed to explore the role of early VCE in OGIB patients. A total of 997 patients that underwent VCE at Renji Hospital and Nagoya University from May 15, 2002, to December 28, 2016, were included in this study. We matched patients that underwent early VCE within 14days of bleeding (early group, n=678) to patients that did not (late group, n=319) via 1:1 propensity score matching (PSM). We then compared VCE diagnostic rates and the prevalence of post-VCE rebleeding in patients with initial negative VCE findings within 1year between these groups before and after PSM. Following PSM, early VCE was associated with a significantly higher rate of OGIB diagnosis (56.4% vs 45.5%, P=0.001) and with a significantly lower incidence of rebleeding within 1year following treatment (24.7% vs 36.7%, P=0.041). In univariate and multivariate analyses, VCE timing (odds ratio 0.648; 95% confidence interval 0.496-0.847, P=0.001 and odds ratio 0.666; 95% confidence interval 0.496-0.894, P=0.007, respectively) was found to be linked with a higher rate of positive findings. Early VCE can improve the reliability of OGIB diagnosis while also reducing rates of post-VCE rebleeding. This suggests that timely and accurate diagnosis can help to improve OGIB patient treatment and prognosis.

Dieulafoy's lesion in small intestine

Dieulafoy's lesion is a rare cause of gastrointestinal (GI) bleeding. It accounts for 0.3%–1.5% of major GI bleed. It is typically found in the stomach. Small intestinal Dieulafoy's lesion is very rare. In the small intestine, Dieulafoy's lesion is most commonly seen in the jejunum. Hereby, we present one such case. A 36-year-old female attended the department of gastrosurgery with complaints of pain abdomen and generalized weakness for 15 days. She also had on and off melena and hematochezia. She was admitted with a diagnosis of obscure GI bleeding and was taken up for laparotomy. On table, enterotomy and retrograde enteroscopy was performed. There was a lesion over the distal jejunum. That segment of the intestine was resected. The specimen was sent for histopathological examination. The luminal surface of the intestine showed a small, whitish nodule measuring 0.3 cm in diameter. This nodule was noted beneath the mucosa, in the subepithelium. The overlying mucosa was ulcerated. Histopathological examination established the lesion to be of Dieulafoy's. Awareness, careful endoscopy, and histopathological examination are essential to diagnose Dieulafoy's lesion.

PGI10 BUDGET IMPACT ANALYSIS OF INCORPORATING ENDOSCOPIC CAPSULE FOR DIAGNOSIS OF OBSCURE GASTROINTESTINAL BLEEDING IN THE BRAZILIAN PRIVATE HEALTHCARE SYSTEM

To simulate the financial impact of incorporating endoscopic capsule as a treatment option after non-confirmatory diagnosis of obscure gastrointestinal bleeding by high endoscopy and/or colonoscopy, for the Brazilian private healthcare system.

Exploratory laparoscopy combined with pathological examination in the diagnosis of obscure gastrointestinal bleeding in a child: a case report

BackgroundThe diagnosis of obscure gastrointestinal bleeding (OGIB) which is defined as bleeding of unknown origin of the small bowel by routine evaluation in childhood is a challenge.Case presentationHere we report a one-year-old Chinese girl who was suspected with idiopathic pulmonary haemosiderosis (IPH) and referred to our department for further diagnosis. Finally she was diagnosed with vascular malformations (VM) by exploratory laparoscopy combined with pathological examination.ConclusionsChildren OGIB could be easily misdiagnosed in the beginning, and OGIB children with active ongoing bleeding may benefit from proceeding directly to exploratory laparoscopy, followed by pathological confirmation of the diagnosis.

Diagnosis of Obscure Gastrointestinal Bleeding: Capsule Endoscopy or Double Balloon Enteroscopy?

The development of capsule endoscopy (CE) and double balloon enteroscopy (DBE) has significantly enhanced the visualization of the small bowel. CE and DBE have proven to be the choice of investigation for the diagnosis of small bowel disease and is an evident indication for obscure gastrointestinal bleeding (OGIB). CE or DBE respectively are frequent option of professionals for the diagnosis of obscure gastrointestinal bleeding. The purpose of this review is to provide an overview of studies focused on patients with obscure gastrointestinal bleeding with previous CE and/or DBE intervention. Studies show that CE and DBE have similar diagnostic yields for obscure gastrointestinal bleeding. Although with few chances for false negative results, most researches showed good concordance between CE and DBE. However due to its non-invasiveness, safety, patient tolerability and ability to view the entire small bowel, CE can be recommended as a first choice of investigation. DBE, despite being more invasive, is a necessary second choice, which has both diagnostic and therapeutic value, although skilled endoscopist and sedation are required and complications like bleeding, perforation, pancreatitis etc. may occur.

Training in Endoscopy: Enteroscopy.

The balloon-assisted enteroscope has been regarded as the standard device for direct visualization of deep small bowels and allows for the diagnosis and treatment of small bowel disease. At the beginning, its application was focused on the diagnosis of obscure gastrointestinal bleeding, inflammatory bowel disease, and small bowel tumor. However, the indications are being expanded to various therapeutic procedures, not only confined to bleeding control. With the expansion of the indications, the need to perform enteroscopy effectively and safely is increasing. Recent studies have been focused on the diagnostic yield, therapeutic yield, and long-term outcomes of the device. However, with the increasing number of procedures, procedural guidelines and quality indicators are also needed.

Computed tomography versus digital subtraction angiography for the diagnosis of obscure gastrointestinal bleeding

PurposeThe diagnostic yield of computed tomography angiography (CTA) compared to digital subtraction angiography (DSA) for major obscure gastrointestinal bleeding (OGIB) is not known. Aim of the study was to prospectively evaluate the diagnostic yield of CTA versus DSA for the diagnosis of major OGIB. Material and methodsThe institutional review board approved the study and informed consent was obtained from each patient. Patients with major OGIB were prospectively enrolled to undergo both CTA and DSA. Two blinded radiologists each reviewed the CTA and DSA images retrospectively and independently. Contrast material extravasation into the gastrointestinal lumen was considered diagnostic for active bleeding. Primary end point of the study was the diagnostic yield, defined as the frequency a technique identified an active bleeding or a potential bleeding lesion. The diagnostic yield of CTA and DSA were compared by McNemar's test. Results24 consecutive patients (11 men; median age 64 years) were included. CTA and DSA identified an active bleeding or a potential bleeding lesion in 92% (22 of 24 patients; 95% CI 72%–99%) and 29% (7 of 24 patients; 95% CI 12%–49%) of patients, respectively (p<0.001). CTA and DSA identified an active bleeding in 42% (10 of 24; 95% CI 22%–63%) and 21% (5 of 24; 95% CI 7%–42%) of patients, respectively (p=0.06). ConclusionDue to the lower invasiveness and higher diagnostic yield CTA should be favored over DSA for the diagnosis of major OGIB.

The role of capsule endoscopy in the diagnosis and treatment of obscure gastrointestinal bleeding in older individuals.

Capsule endoscopy (CE) is currently recommended as the first-line diagnostic modality for the investigation of obscure gastrointestinal bleeding (OGIB). This study aimed to evaluate the diagnostic efficacy of CE and to determine the subsequent impacts on the treatment of the OGIB episode in older individuals. Eight hundred and fifty-three patients who underwent CE for the indication of OGIB were investigated in a single center between January 2004 and December 2015. Patients were divided into two groups: those 65 years of age and older and those younger than 65 years of age. There were no significant differences between older patients and younger patients with respect to the CE completion rate. The diagnostic yield was significantly higher in older patients than in younger patients (55.1 vs. 46.6%, P=0.021). Vascular lesions were the main cause of bleeding in the elderly, whereas ulcerated/erosive lesions were found most frequently in younger patients. Furthermore, 56.0% of older patients with positive CE results had relevant changes in their management plans and received specific treatment on the basis of CE findings. Our study confirmed the important role of CE in the diagnosis of OGIB and its huge impact on decision making in the management plan for older patients.

A comparison between capsule endoscopy and double balloon enteroscopy using propensity score-matching analysis in patients with previous obscure gastrointestinal bleeding

Background: Recently, diagnosis of obscure gastrointestinal bleeding (OGIB) has improved greatly due to introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE). However, the efficacy of CE over DBE in patients with previous OGIB remains unclear. This study aimed to compare, in terms of diagnostic yield, the efficacy of DBE with that of CE in patients with previous OGIB.Patients and methods: We enrolled 223 consecutive patients with previous OGIB who were treated between May 2007 and March 2012. We retrospectively evaluated the respective diagnostic yields of CE and DBE in patients with previous OGIB using propensity score-matching analysis. We compared the diagnostic yield of CE with that of DBE.Results: The diagnostic yields were 41.9% in DBE group and 11.6% in CE group, respectively (p < .01). On logistic regression analysis, DBE was significantly superior to CE after matching (Odds ratio [OR], 4.25; 95% confidence interval [CI], 1.43–12.6; p < .01), even after adjustment for propensity score (OR, 5.65; 95% CI, 1.56?20.5; p < .01).Conclusions: Our results indicate that DBE might be more useful and perhaps safer than CE in achieving a positive diagnosis in patients with previous OGIB.

The Role of Dynamic Contrast-enhanced Multidetector-row Computed Tomography in Diagnosis of Obscure Gastrointestinal Bleeding

The Role of Dynamic Contrast-enhanced Multidetector-row Computed Tomography in Diagnosis of Obscure Gastrointestinal Bleeding

What is the impact of capsule endoscopy in the long term period?

To assess the clinical impact of capsule endoscopy (CE) in the long-term follow-up period in patients with obscure gastrointestinal bleeding (OGIB). One hundred and forty-one patients who applied CE for OGIB between 2009 and 2012 were retrospectively analyzed, and this cohort was then questioned prospectively. Demographic data of the patients were determined via the presence of comorbid diseases, use of non-steroidal anti-inflammatory drugs anticoagulant-antiaggregant agents, previous diagnostic tests for bleeding episodes, CE findings, laboratory tests and outcomes. CE was performed on 141 patients because of OGIB. The capsule was retained in the upper gastrointestinal (GI) system in two of the patients, thus video monitoring was not achieved. There were 139 patients [62% male, median age: 72 years (range: 13-93 years) and a median follow-up duration: 32 mo (range: 6-82 mo)]. The overall diagnostic yield of CE was 84.9%. Rebleeding was determined in 40.3% (56/139) of the patients. The rebleeding rates of patients with positive and negative capsule results at the end of the follow-up were 46.6% (55/118) and 4.8% (1/21), respectively. In the multivariate analysis, usage of NSAIDs, anticoagulant-antiaggregant therapies (OR = 5.8; 95%CI: 1.86-18.27) and vascular ectasia (OR = 6.02; 95%CI: 2.568-14.146) in CE were detected as independent predictors of rebleeding. In the univariate analysis, advanced age, comorbidity, and overt bleeding were detected as predictors of rebleeding. CE is a reliable method in the diagnosis of obscure GI bleeding. Negative CE correlated with a significantly lower rebleeding risk in the long-term follow-up period.

Recurrent Obscure Gastrointestinal Bleeding: Intestinal Lymphangiohemangioma

Obscure gastrointestinal bleeding (OGIB) is thought to be a diagnostic and therapeutic challenge for the clinicians and radiologists. A 46-year-old woman complaining of intermittent melena for 3 months was admitted. After extensive investigations, a vascular lesion located in the ileum, diagnosed as intestinal lymphangiohemangioma pathologically, was found by CT angiography (CTA) and selective arterial angiography. The value of CTA to the diagnosis of OGIB is showed.

Complimentary Imaging Modalities for Investigating Obscure Gastrointestinal Bleeding: Capsule Endoscopy, Double-Balloon Enteroscopy, and Computed Tomographic Enterography.

Objectives. The complimentary value of computed tomographic enterography (CTE) and double-balloon enteroscopy (DBE) combined with capsule endoscopy (CE) was evaluated in the diagnosis of obscure gastrointestinal bleeding (OGIB). Methods. Patients who received CE examinations at Ruijin Hospital between July 2007 and July 2014 with the indication of OGIB were identified, and those who also underwent DBE and/or CTE were included. Their clinical information was retrieved, and results from each test were compared with findings from the other two examinations. Results. The overall diagnostic yield of CE was comparable with DBE (73.9% versus 60.9%) but was significantly higher than the yield of CTE (87% versus 25%, p < 0.001). The diagnostic yield of angiodysplasia at CE was significantly higher than CTE (73% versus 8%, p < 0.001) and DBE (39.1% versus 17.4%, p = 0.013), while no significant difference was found between the three approaches for small bowel tumors. DBE and CTE identified small bowel diseases undetected or undetermined by CE. Conversely, CE improved diagnosis in the cases with negative CTE and DBE, and findings at initial CE directed further diagnosis made by DBE. Conclusions. Combination of the three diagnostic platforms provides complementary value in the diagnosis of OGIB.

Mo1603 Capsule Endoscopy in Patients With Left Ventricular Assist Devices Is Safe and Effective

Capsule endoscopy (CE) is a well-established modality for diagnosis of obscure gastrointestinal bleeding (GIB). Obscure GIB in patients with left ventricular assist devices (LVAD) is not unusual. The safety and efficacy of CE in patients with LVAD are unknown. The aims of this study are to define the safety and efficacy of CE in patients with LVAD.

Hemobilia: A Fatal Cause of Obscure Gastrointestinal Bleeding Diagnosed by Abdominal Computed Tomography

Hemobilia is characterized by hemorrhage into the biliary system and is an unusual cause of obscure gastrointestinal bleeding. At endoscopy, active bleeding or blood clots can be observed at the papilla of Vater, but diagnosis can be difficult if the hemorrhage has ceased. Here, we report a 67-year-old man who was admitted to our emergency department for evaluation of obscure gastrointestinal bleeding. He had been admitted to another hospital for obscure gastrointestinal hemorrhage three times during the previous month. Repeat endoscopic examinations were inconclusive. Emergency abdominal CT disclosed active contrast extravasations from the gallbladder with blood clots in the common bile duct. A diagnosis of hemobilia was made. The patient rapidly developed hypovolemic shock and died 12 hours after admission. This case illustrated that abdominal CT may be useful for diagnosis of obscure gastrointestinal bleeding in an emergency setting. Clinicians should be reminded that hemobilia is a possible cause of bleeding when jaundice and abdominal pain are associated with gastrointestinal bleeding.

The health economic evaluation of surgical treatment for obscure gastrointestinal bleeding under the guidance of double–balloon enteroscopy

Objective To evaluate the double–balloon enteroscopy(DBE) for obscure gastrointestinal bleeding(OGIB) and evaluate the health economics under the guidance of DBE for surgical treatment of obscure gastrointestinal bleeding. Methods A total of 114 patients, whose hemorrhage etiology could not be determined by conventional gastroscopy, enteroscopy and gastroenterography, underwent DBE. With pathological results as diagnostic criteria, the value of double–balloon enteroscopy for obscure gastrointestinal bleeding diagnosis was studied. Results The sensitivity, specificity and accuracy of DBE for OGIB were 85.86%, 63.63%, 81.57%, respectively. The positive likelihood ratio was 2.36 and the negative likelihood ratio was 0.22. The total days of hospitalization, hospital costs, cost of hospital drugs were lower in the DBE group than in the control group(27.2±11.8 days VS 16.4±5.3 days, 35 690.2±3 466.5 Yuan VS 19 409.3±9 253.2 Yuan, 17 805.8±2 145.5 Yuan VS 9 133.0±4 664.9 Yuan)(all P<0.05). Conclusion DBE plays an important role in diagnosis of OGIB. It has significance in clinic, health economics, and social benefits. Key words: Double–balloon enteroseopy; Obscure gastrointestinal bleeding; Etiology; Diagnosis; Health economic evaluation

Guidelines for video capsule endoscopy: emphasis on Crohn's disease.

Video capsule endoscopy (VCE) is an ingestible video camera that transmits high-quality images of the small intestinal mucosa. This makes the small intestine more readily accessible to physicians investigating the presence of small bowel disorders, such as Crohn's disease (CD). Although VCE is frequently performed in Korea, there are no evidence-based guidelines on the appropriate use of VCE in the diagnosis of CD. To provide accurate information and suggest correct testing approaches for small bowel diseases, the Korean Gut Image Study Group, part of the Korean Society of Gastrointestinal Endoscopy, developed guidelines on VCE. Teams were set up to develop guidelines on VCE. Four areas were selected: diagnosis of obscure gastrointestinal bleeding, small bowel preparation for VCE, diagnosis of CD, and diagnosis of small bowel tumors. Three key questions were selected regarding the role of VCE in CD. In preparing these guidelines, a systematic literature search, evaluation, selection, and meta-analysis were performed. After writing a draft of the guidelines, the opinions of various experts were solicited before producing the final document. These guidelines are expected to play a role in the diagnosis of CD. They will need to be updated as new data and evidence become available.

Role of Double Balloon Enteroscopy in the Diagnosis of Obscure Gastrointestinal Bleeding

Obscure gastrointestinal bleeding (OGIB) is bleeding in the digestive tract which persist or recur and with unclear aetiology. OGIB is one of the important problems in the gastrointestinal field due to difficulty in diagnosing the aetiology and determining the source of digestive tract bleeding in patients. In diagnosing the cause of OGIB, clinical approach through history taking and physical examination still have important roles. Most of the sources of bleeding in OGIB is from the small intestine, which cannot be reached by esophagogastroduodenoscopy (EGD) or colonoscopy. Therefore, role of diagnostic tool which is able to perform total enteroscopy becomes important in diagnosing the cause of OGIB.Double balloon enteroscopy (DBE) technique is a safe endoscopy procedure which may use oral or even rectal approach. In finding the cause of OGIB, where most of the lesions is found in the proximal region of the small intestine, oral approach is more beneficial. When bleeding is not found after conventional endoscopy is performed, it needs to be suspected that the source might come from the small intestine. Currently, the two main modalities which can be used in the evaluation are video capsule endoscopy (VCE) and DBE. However, based on cost effectiveness DBE without prior VCE has benefit because it can also administer therapy in the abnormalities being found. Keywords: obscure gastrointestinal bleeding, endoscopy, diagnosis, double balloon enteroscopy