Gastrointestinal Bleeding Of Unknown Origin Research Articles

Diagnosis and Treatment Options for Cirrhosis With Unexplained Upper Gastrointestinal Bleeding: An Observational Study Based on Endoscopic Ultrasonography.

To investigate the role of endoscopic ultrasonography (EUS) in the diagnosis and treatment of upper gastrointestinal bleeding of unknown origin in liver cirrhosis, focusing on patients with recurrent treatment of esophageal and gastric varices who failed to identify the bleeding site under direct endoscopy. Esophagogastric variceal bleeding is one of the severe complications of decompensated liver cirrhosis, and serial endoscopic therapy can improve the long-term quality of life of patients. Most acute bleeding can be detected under direct endoscopy with thrombus or active bleeding, but there are still some patients with recurrent bleeding after repeated treatments, and it is difficult to find the bleeding site, especially in gastric variceal bleeding. Therefore, it is of great significance to identify the bleeding site. A total of 88 patients with liver cirrhosis bleeding diagnosed and treated under EUS were collected in this study, including 26 patients who failed to identify the bleeding site under direct endoscopy. EUS was used to scan the bleeding site, and EUS-guided treatment was performed. The characteristics of the bleeding site under direct endoscopy and EUS and the follow-up results after surgery were analyzed. Among the 26 patients, 16 patients (16/26, 61.5%) showed red color signs of gastric fundus mucosa under direct endoscopy, 5 patients (5/26, 19.2%) showed punctate erosion, and the remaining 5 patients (5/26, 19.2%) showed no abnormal mucosal manifestations. All patients could find anechoic blood vessels under EUS, and blood flow signals could be detected within. Among them, 23 patients (23/26, 88.5%) chose EUS-guided treatment, and no rebleeding occurred after surgery. Another 3 patients (3/26, 11.5%) were given endoscopic variceal ligation due to small esophageal and gastric varices and inability to perform intravascular injection. The median follow-up time was 86 days. Adverse reactions included 5 cases of retrosternal pain (5/23, 21.7%), and 1 case of fever (1/23, 4.3%). EUS can detect submucosal varices in the gastric mucosa, and these bleeding sites may present as red color signs or punctate erosion under direct endoscopy.

Diagnostic and therapeutic possibilities of balloon-assisted enetroscopy in clinical practice

The aim. To evaluate the effectiveness of endoscopic techniques for gastrointestinal bleeding of unknown origin in the conditions of GBUZ “KKB No. 2” and to determine the most effective therapeutic tactics. Materials and methods. The basis for our study was the analysis of the results of treatment of 47 patients with suspected small intestine bleeding in the period 2018-2023 in the State Medical Institution “KKB No. 2” of the city of Krasnodar. The study group was dominated by men -25 patients (53%) compared with women - 27 patients (47%). The age of the patients ranged from 18 to 89 years. VCE was performed in 16 patients. In controversial and unconvincing cases, BAE-14 patients were performed. A comprehensive examination of VCE + BAE was performed in 17 patients. Results: The most rational method of endoscopic hemostasis in small intestine bleeding, according to our observation, is endoscopic clipping in combination with conservative therapy. Results. According to our observation, the most rational method of endoscopic hemostasis in small intestinal bleeding is endoscopic clipping in combination with conservative therapy. Conclusion. The capabilities of clinicians in the differential diagnosis of pathological conditions of the small intestine are enhanced by the availability of modern equipment in medical and preventive institutions, as well as to perform minimally invasive treatment, reducing the rehabilitation time due to the reduction of surgical trauma.

Blue rubber bleb nevus syndrome: a single-center case series in 12 years.

BackgroundBlue rubber bleb nevus syndrome is a rare congenital disease characterized by multiple venous malformations in skin and gastrointestinal tract, not all patients have typical cutaneous lesions, refractory anemia may be the only clinical symptom, it is easy to miss diagnosis.MethodsA retrospective single center study was conducted on 8 patients with blue rubber bleb nevus syndrome from 2009 to 2021. Data were analyzed including clinical feature, diagnostic workup and results, gene detection, treatment and follow-up.ResultsFive children (62.5%) developed the disease in infancy, which initial symptoms were all cutaneous venous malformations. All children had chronic refractory anemia and gastrointestinal bleeding. Cutaneous lesions were observed in 87.5%, 1 child had multiorgan involvement. Gastrointestinal venous malformations were observed in 100%, lesions were more common in small intestine than in stomach or colon. No somatic mutation in TEK was found in our children. Diagnostic interval was on average 4.7 years. Eighty-seven-point-five percent children received at least one endoscopic or surgical intervention, however, those methods could not eradicate all the lesions and prevent relapse. Two children treated with sirolimus for more than 8 years, only 1 have satisfactory therapeutic effect. Besides, I child has growth retardation and emotional problems during follow-up.ConclusionsBlue rubber bleb nevus syndrome needs to be considered when find bluish nodular cutaneous lesions, chronic anemia or gastrointestinal bleeding of unknown origin. Capsule endoscopy is the most sensitive in diagnosing of this disease. Oral sirolimus at a relatively low dosage is effective, further comprehensively studies are required to evaluation of its efficacy, safety and the optimal dosage about the children.

Peritoneal dialysis catheter dysfunction due to fibrin clots following treatment with tranexamic acid: a clinical case

Chronic kidney disease patients experience not only more frequent arterial and venous thrombosis but also hemorrhagic episodes. Tranexamic acid is an anti-fibrinolytic molecule that inhibits plasmin activation. It is used in hemorrhage cases (post-traumatic, gynecologic, or gastrointestinal bleeding).
 We report on an original case of tranexamic acid (Exacyl®) use in a peritoneal dialysis patient for gastrointestinal bleeding of unknown origin. The use of tranexamic acid led to the Tenckhoff catheter dysfunction because of fibrin clots in the dialysate.
 The emergence of fibrin clots a few days after the start of tranexamic acid treatment, which never occurred again after the end of the treatment, and the anti-fibrinolytic function of tranexamic acid favors this treatment’s role in fibrin clot occurrence.

A prospective, multicentre study in acute non-cirrhotic, non-malignant portal vein thrombosis: comparison of medical and interventional treatment.

To evaluate medical versus interventional treatment (transjugular thrombus fragmentation, local thrombolysis with or without stent implantation) in patients with acute non-cirrhotic, non-malignant portal vein thrombosis (PVT). This prospective, observational study enrolled 65 patients with acute (<28days since begin of symptoms, no cavernoma) PVT in nine centres. Thirty patients received medical treatment and 35 patients received interventional treatment. PVT was graded into grade 1: short thrombosis and incomplete occlusion of the vessel lumen and grade 2: extended thrombosis or complete occlusion. Treatment response was classified as partial or complete, if thrombosis was reduced by one grade or to <25% of the vessel diameter respectively. Partial and complete response rates were 7% and 30% in the medical compared to 17% and 54% (P<0.001) in the interventional treatment group. In the multivariate analysis, interventional treatment showed a strong positive (OR 4.32, P<0.016) and a myeloproliferative aetiology a negative (OR 0.09, P=0.006) prediction of complete response. Complications were rare in the medical group and consisted of septicaemia and upper gastrointestinal bleeding of unknown origin in one patient each. Interventional treatment was accompanied by mild and self-limiting bleeding complications in nine patients, moderate intra-abdominal bleeding requiring transfusions (2 units) in one patient and peritoneal bleeding requiring surgical rescue in one patient. Four patients in each group developed intestinal gangrene requiring surgery. One patient died 52days after unsuccessful interventional treatment. Compared to medical treatment alone, interventional treatment doubled response rates at the cost of increased bleeding complications.

P1848Prevalence and outcomes in patients with Heyde syndrome after transcatheter aortic valve implantation, a single centre experience

Abstract Introduction Heyde syndrome is known as the association of severe aortic stenosis (AS) and recurrent gastrointestinal bleeding (GIB) from angiodysplasia. To date only few data exist regarding the prevalence of Heyde syndrome and results after transcatheter aortic valve implantation (TAVI) for the treatment of AS. Purpose We sought to evaluate the prevalence of Heyde syndrome in a routine clinical cohort of patients undergoing TAVI and analyze the effectiveness of treatment of AS regarding recurrent GIB in these patients. Methods We conducted a retrospective single-center analysis of 2545 consecutive patients who underwent TAVI for the treatment of AS in 2008–2017. Patients with a history of GIB were identified. The diagnosis of Heyde syndrome was defined as a clinical triad of presence of severe AS, a history of recurrent GIB, and an endoscopic diagnosis of angiodysplasia. GIB of unknown origin or related to other causes was defined as bleeding unrelated to angiodysplasia. Clinical outcomes of patients with Heyde syndrome were evaluated with emphasis on bleeding complications and recurrence of GIB. Results A history of GIB prior to TAVI was detected in 190 patients (7.5%) of the TAVI cohort. Among them, 143 patients had a GIB unrelated to angiodysplasia (5.6%) and 47 patients (1.8%) were diagnosed with Heyde syndrome. Median age and STS-PROM were 80.7 (75.3, 84.0) years and 4.7 (2.7, 9.0) respectively in Heyde patients. TAVI was successfully performed in all cases (66% endovascular access, 34% transapical access). The effective orifice areas increased from 0.8±0.1 cm2 to 2.1±0.5 cm2. Periprocedural major/life-threatening bleeding was found in 6 patients (12.8%), mainly access-related and none due to GIB. In 51% of Heyde-patients transfusion of 4.5±5.7 packed red blood cells was required during the index hospitalisation. During a mean follow-up of 12 months, recurrent GIB after TAVI was detected in 32% of patients with Heyde syndrome. In contrast only 18% of patients with GIB unrelated to angiodysplasia (Non-Heyde) had recurrent GIB after TAVI. In patients diagnosed with Heyde syndrome and recurrent GIB after TAVI the rate of residual mild or moderate paravalvular regurgitation was higher compared to those with an unremarkable course (73% vs. 37%, p=0.045). Figure 1. 1-year Follow-Up Conclusions A relevant number of patients presenting for treatment of AS can be diagnosed with Heyde syndrome. In these patients TAVI can be successfully performed with moderate incidence of periprocedural bleeding complications but significant transfusion rates. Regardless of successful treatment of AS, recurrent GIB was detected in a significant number of Heyde patients during follow-up. The possible association with residual paravalvular regurgitation requires further investigation to improve treatment options in patients with Heyde syndrome.

Covering the Cover

Covering the Cover

Obscure Gastrointestinal Bleeding: Capsule or Balloon?

See “Roles of Capsule Endoscopy and Single-balloon Enteroscopy in Diagnosing Unexplained Gastrointestinal Bleeding” by Shohei Ooka, Kiyonori Kobayashi, Kana Kawagishi, et al., on page 56-60 Obscure gastrointestinal bleeding (OGIB) is defined as overt or obscure gastrointestinal bleeding of unknown origin despite an initial endoscopic evaluation including colonoscopy and esophagogastroduodenoscopy. The majority of patients with OGIB have a bleeding source in the small intestine. In past decades, the evaluation of the small bowel was extremely limited because of difficult intubation using conventional endoscopes. However, this limitation has been overcome by technical advances including capsule endoscopy (CE), balloon-assisted enteroscopy (BAE), and computed tomography or magnetic resonance enterography. The main strength of CE is noninvasive exploration of the entire small bowel. Complete small bowel evaluation can be performed in 79% to 90% of patients, and the diagnostic yield in patients with suspected small bowel bleeding is 38% to 83% [1]. BAE is distinguished by its diagnostic and therapeutic capabilities. Double-balloon enteroscopy (DBE) was described first and single-balloon enteroscopy (SBE) followed. The basic techniques and mechanisms of SBE are similar to those of DBE. Although DBE appeared to be superior to SBE in complete small bowel evaluation, diagnostic yield, ability to treat, and complication rates are similar between DBE and SBE [2]. In this issue of Clinical Endoscopy, Ooka et al. [3] reported that the rate of positive findings for OGIB was significantly higher with SBE (73.6%) than with CE (47.5%), and SBE may be more appropriate for overt OGIB. However, caution is required in the interpretation of the results of this report. CE was performed before SBE in 28.5% of the SBE group in this study. CE is useful for screening before performing BAE in patients with OGIB, and CE before BAE is known to increase the diagnostic and therapeutic yields [4]. In this study, CE might have improved the diagnostic yield in the SBE group, although CE was performed in a part of the SBE group. CE can also guide the insertion route of BAE. An oral approach is usually preferred when a lesion is located within the proximal two-thirds of the small bowel. In this issue of Clinical Endoscopy, it did not appear that a bidirectional approach was tried, because SBE was performed in 91 patients and the oral and anal approaches in 43 and 48, respectively. When an oral or anal approach fails to detect significant findings or reach the targeted lesion, the other route can be tried in practice. A 73.6% diagnostic yield by SBE in patients with OGIB is relatively surprising, even though only one route was tried in all cases. Diagnostic yield of CE and BAE for patients with overt bleeding is higher than that for patients with occult bleeding, and the diagnostic yield for patients with ongoing overt bleeding is higher than that for patients with previous overt bleeding. In Ooka’s study [3], the percentage of patients with overt bleeding was higher in the SBE group than in the CE group (80.8% vs. 58.4%), and ongoing overt bleeding was also more frequent (100.0% vs. 90.9%) in the SBE group. The results might have changed if the authors performed multivariate analyses according to the amount and timing of bleeding. Actually, CE and BAE are not competitive, but complementary. According to the American College of Gastroenterology guidelines, CE should be considered a first-line procedure for suspected small bowel bleeding, and BAE should be attempted if a small bowel lesion is strongly suspected based on clinical presentation and abnormal CE results [5]. However, the results of Ooka’s study do not seem to be sufficient to change current diagnostic guidelines for small bowel bleeding.

Utilidad de la enterotomografía en la hemorragia digestiva de origen oscuro

The aim of this article is to describe the imaging technique and CT enterography (CTE) findings in obscure gastrointestinal bleeding (OGIB). This condition is defined as the gastrointestinal bleeding of unknown origin that persists or recurs after having performed an upper endoscopy (UE) and a conventional colonoscopy (CC). Considering the presence or absence of visible bleeding in the stool, OGIB is classified as evident (OGIB–E) or occult (OGIB–O). In 40-70% of cases the bleeding source is found in the small bowel. The most common cause in young patients is neoplastic, while they are angiodysplasias in older patients.The CTE consists of previously administering an oral neutral contrast material, which distends the small and large bowel. Intravenous contrast allows the correct visualization and interpretation of mucosal and parietal lesions. The CTE diagnostic yield is approximately 40%.

An unusual case in which a perforated Meckel's diverticulum became trapped in a pericecal hernia: A rare complication of Meckel's diverticulum

Abstract An 11-year-old boy had previously been diagnosed with repeated Meckel's diverticulitis at another hospital. Emergency laparoscopy was performed under general anesthesia, and an inflammatory mass was seen in the ileocecal region of the mesentery. However, no Meckel's diverticulum (MD) was observed, and so the patient was diagnosed with lymphadenitis. Three days after the operation, he developed anemia and gastrointestinal bleeding of unknown origin. Thus, he was transferred to our hospital for further investigation and to have his gastrointestinal bleeding treated. Based on imaging scans obtained at the previous hospital, a paraduodenal hernia was suspected, but no paraduodenal hernia was detected during emergency surgery, despite the fact that the full length of the normal small intestine could be traced. However, an inflammatory mass was observed, and the ileum appeared to be incarcerated in a pericecal hernia. We could not identify which portion of the intestine had become entrapped or reduce the hernia due to adhesion. The inflammatory mass was removed by ileocecal resection, and a pathological examination revealed that the entrapped portion of the intestine was an MD that had branched off from the small intestine immediately proximal to the ileocecal valve. The MD had perforated in the hernia sac, which had caused the patient's bleeding.

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Enteroclysis uses contrast fluid distention of the small bowel through a jejunal catheter with flouroscopic imaging to identify abnormalities. Computed tomograpic enteroclysis (CT-E) adds cross-sectional imaging to identify small bowel pathology to include masses, gastrointestinal bleeding of unknown origin, and partial obstruction. Computed tomography-enteroclysis is being used more frequently in the assessment of patients with possible small bowel pathology. This study examines the applicability of CT-E and its superiority over conventional enteroclysis.A retrospective chart review was used to examine all CT-E and enteroclysis studies performed at our institution during a 24-month period (August 1997 to August 1999). All patients that had received CT-E or enteroclysis were divided into 3 categories; group I: small bowel mass, group II: gastrointestinal bleeding, and group III: partial small bowel obstruction (pSBO). All patients included had received other radiological procedures based on the indication for examination to include esophagogastroduodenoscopy, colonoscopy, CT, abdominal x-rays, barium enema, and upper gastrointestinal with small bowel follow-through.Forty-nine studies were performed, with enteroclysis or CT-E, used in 46 patients. Median age was 62 years (M:F, 1:1). In group 1 (n = 10), no masses were noted, but all patients identified as having a mass on previous studies (n = 6) were determined not to have a mass by CT-E (n = 1) and enteroclysis (n = 5). In group II (n = 19), 1 small bowel source (jejujunal arteriovenous malformation) was identified through CT-E, and all other studies in both categories were negative/normal. In group III (n = 20), 5 pSBO were identified through CT-E that had not been previously described.Enteroclysis and CT-E are both effective at disproving the presence of small bowel masses discovered through less-specific radiological methods. In terms of gastrointestinal bleeding, CT-E is as effective as enteroclysis at identifying source of bleeding and may have an added role through its ability to better identify anatomic relationships. Computed tomography-enteroclysis was able to determine the presence of pSBO in 5 patients that previously had been undiagnosed. In conclusion, enteroclysis remains an effective radiological study for examination of the small bowel. Computed tomography-enteroclysis matches that effectiveness with the added benefit on high-resolution anatomic images that serve it well as an additional diagnostic tool for the General Surgeon in patients with difficult to diagnose small bowel pathology.

A pedunculated polyp-shaped small-bowel lymphangioma causing gastrointestinal bleeding and treated by double-balloon enteroscopy

We report a rare case of a small-bowel lymphangioma causing massive gastrointestinal (GI) bleeding that we successfully diagnosed and treated using double-balloon enteroscopy (DBE). An 81-year-old woman suffering from repeated GI bleeding of unknown origin underwent a capsule endoscopy at a previous hospital. She was suspected of having bleeding from the jejunum, and was referred to our department for diagnosis and treatment. An oral DBE revealed a 20 mm × 10 mm, regularly surfaced, white to yellowish, elongated, pedunculated jejunal polyp with small erosions at 10 cm distal to the ligament of Treiz. Since no other source of bleeding was identified by endoscopy in the deep jejunum, an endoscopic polypectomy (EP) was performed for this lesion. A subsequent histopathological examination of the resected polyp showed clusters of lymphatic vessels with marked cystic dilatation in the submucosa and the deep layer of the lamina propria mucosae. These characteristics are consistent with the typical features of small-bowel lymphangioma with erosions. Although clipping hemostasis was performed during EP, re-bleeding occurred. Finally, a complete hemostasis was achieved by performing an additional argon plasma coagulation.

Lower Gastrointestinal Bleeding of Unknown Origin: Tricks of the Trade

Lower Gastrointestinal Bleeding of Unknown Origin: Tricks of the Trade

Laparoscopic Resection of a Small Bowel Lipoma with Incidental Intussusception

Small bowel tumors are rare entities that often present with nonspecific symptoms. The diagnosis is more likely in patients with occult gastrointestinal bleeding of unknown origin or in adults with small bowel intussusception. Even with exhaustive diagnostic testing, small bowel tumors are often not diagnosed preoperatively. Because 60% to 70% of small bowel tumors are malignant, surgical excision is always recommended. We report the case of a 73-year-old man with occult gastrointestinal bleeding. A small bowel tumor was discovered only after video capsule endoscopy, computed tomography, and multiple endoscopies were performed. The patient underwent laparoscopic exploration. An incidental intussusception made the tumor simple to identify. By extending the umbilical port, the tumor was easily removed. The final pathology demonstrated a submucosal lipoma. Small bowel lipomas can cause intussusception and gastrointestinal bleeding. When diagnosed preoperatively, laparoscopic resection is feasible.

Detection of ectopic gastric mucosa using 99mTc pertechnetate: review of the literature

Technetium-99m ((99m)Tc) pertechnetate scintigraphy in a child with acute gastrointestinal bleeding of unknown origin suggests ectopic gastric mucosa caused by Meckel's diverticulum or gastrointestinal duplication cysts. Our objective was to define the patterns of scintigraphic findings likely to be encountered in patients with ectopic gastric mucosa with illustrative cases and to review the literature. Fifty children (age 1 year to 14 years) were evaluated for ectopic gastric mucosa using (99m)Tc pertechnetate scintigraphy. Functioning ectopic gastric mucosa was detected in eight patients with Meckel's diverticula and three patients with bowel duplication. Three patients showed atypical findings on scintigraphy which were perforated appendix, calyceal stasis, and regional enteritis. Ectopic functioning gastric mucosa in Meckel's diverticulum is visualized simultaneously with the stomach, whereas in intestinal duplications tracer activity can be visualized in the dynamic sequence or before gastric tracer visualization in an irregular pattern. A variety of scintigraphic patterns can be found in patients with ectopic gastric mucosa undergoing (99m)Tc pertechnetate scintigraphy depending on the location and size of the ectopic tissue. Also, acquisition of delayed images is useful when the initial images are equivocal in children.

Acquired Jejunoileal Diverticulosis and Its Complications: A Review of the Literature

Jejunoileal diverticulosis is a rare entity. Jejunoileal diverticulosis is not a disease that surgeons see often in clinical practice; however, it should remain on the differential diagnosis for any patient with an acute abdomen or gastrointestinal bleeding of unknown origin. It can present with a wide range of clinical scenarios and when patients experience chronic symptoms such as bloating, abdominal pain, nausea, bacterial overgrowth, or malabsorption, medical therapy is successful in most patients. However, when patients present with acute symptoms of bleeding, inflammation, perforation, or obstruction, surgical resection and primary anastomosis is often the treatment of choice. If patients are asymptomatic, they are better left alone, even when discovered incidentally in the operating room. In closing, the possibility of a patient having jejunal diverticular disease should be suspected whenever the symptoms of obscure abdominal pain, anemia, dilated jejunal loops on abdominal radiographs, a history of colonic diverticuli, and a history of acute appendicitis.

The price of surgery for weight reduction – gastrointestinal bleeding of unknown origin

The price of surgery for weight reduction – gastrointestinal bleeding of unknown origin

Transfusion requirements in patients with gastrointestinal bleeding: a study in a Blood Unit at a referral hospital

1. To study transfusion requirements in the Department of Gastroenterology of a Tertiary Referral Hospital, and their evolution over the last seven years. 2. To analyze risk factors associated with greater erythrocyte transfusion requirements. erythrocyte transfusion requirements were compared for patients admitted to the Department of Gastroenterology at Hospital Virgen del Rocío, Seville, from 1999 to 2005. Clinical data of interest have been analyzed in order to determine factors associated with greater transfusion requirements. 1,611 patients with a mean age of 60.45 years (59.7-61.2) were included in this study; 76.41% were males. Gastric ulcers were the cause of bleeding in 18.4% of cases (with 69% requiring transfusions); duodenal ulcers caused 22.2% of cases (with 52.9% requiring transfusions), and portal hypertension caused 33.6% of cases (with 90.2% requiring transfusions). Upper and lower gastrointestinal bleeding of unknown origin requires transfusions in 88.9 and 96.2% of cases, respectively.A multivariate logistic regression analysis showed that clinical presentations such as hematemesis (odds ratio = 3.12), hematochezia (odds ratio = 33.17), gastrointestinal hemorrhage of unknown origin (odds ratio = 6.57), and hemorrhage as a result of portal hypertension (odds ratio = 3.43) were associated with greater transfusion requirements for erythrocyte concentrates. No significant differences were observed between the percentages of patients who received transfusions from 1999 to 2005. 1. No differences have been observed between the percentages of patients who received transfusions over the last seven years at our Department of Gastroenterology. 2. Patients presenting with hematemesis or hematochezia, in addition to those with bleeding of unknown origin or from portal hypertension, are prone to have greater transfusion requirements.

Pro/con debate: Octreotide has an important role in the treatment of gastrointestinal bleeding of unknown origin?

Whether it is the primary reason for admission or a complication of critical illness, upper gastrointestinal bleeding is commonly encountered in the intensive care unit. In this setting, in the absence of endoscopy, intensivists generally provide supportive care (transfusion of blood products) and acid suppression (such as proton pump inhibitors). More recently, octreotide (a somatostatin analogue) has been used in such patients. However, its precise role in patients with upper gastrointestinal bleeding is not necessarily clear and the drug is associated with significant costs. In this issue of Critical Care, two expert teams debate the merits of using octreotide in non-variceal upper gastrointestinal bleeding.

Real Time Capsule Endoscopy in the Evaluation of Acute Unstable Gastrointestinal Bleeding

Endoscopic evaluation of the small bowel has traditionally been an area of difficulty, particularly in the patient with active gastrointestinal (GI) bleeding of obscure origin. Capsule endoscopy allows inspection of the small bowel to rule out pathology when upper endoscopy and colonoscopy fail to identify a source. Patients who undergo capsule endoscopy are typically having chronic GI bleeding of unknown origin. We report a case of a patient with a history of obscure GI bleeding who presented with acute upper GI bleeding. The source of bleeding was identified with a novel technique, real time capsule endoscopy. The patient is an 83 year-old with a history of recurrent gastrointestinal bleeding. Three prior upper endoscopies as well as a colonoscopy were negative for a source. He presented with melena and became unstable immediately upon arrival to the emergency room. During the resuscitation, a capsule endoscopy was performed in “real time” utilizing two recording devices. The goal was to obtain an early diagnosis by analyzing the capsule images urgently rather than waiting the typical 6–8 hours for a “down-load.” Each recording device was exchanged every 15–30 minutes to download and view the images. Images revealed a bleeding arteriovenous malformation (AVM) in the proximal jejunum. This allowed a targeted therapeutic enteroscopy when the patient's hemodynamic status improved. The bleeding AVM was successfully ablated. This case demonstrates a role of real time capsule endoscopy in an unstable patient with active GI bleeding of unknown origin. Rather than waiting the usual 8-hour transit time before downloading images from the recording device, the two-device exchange technique allows for a “real-time” diagnostic evaluation in patients who are currently unstable for endoscopy.