Obscure Gastrointestinal Bleeding Research Articles

A 13-year time trend analysis of 3724 small bowel video capsule endoscopies and a forecast model during the financial crisis in Greece.

Since its introduction, small bowel video capsule endoscopy (VCE) use has evolved considerably. Evaluation of the temporal changes of small bowel VCE utilization in three tertiary centers in Greece in Era 1 (2002-2009) and Era 2 (2010-2014) and the development a forecast model for future VCE use during 2015-2017. Data from all small bowel VCE examinations were retrieved and analyzed in terms of the annual number of the performed examinations, their indications and the significance of their findings. Overall, we evaluated 3724 VCE examinations. The number of studies peaked in 2009 (n=595) and then decreased to reach 225 in 2014. Overall, more (53.8 vs. 51.4%) patients with iron-deficiency anemia and obscure gastrointestinal bleeding (IDA/OGIB) and fewer (10.7 vs. 14%) patients with chronic diarrhea were evaluated in Era 2 compared with Era 1 (P=0.046). In Era 2, there were more nondiagnostic examinations (39.5 vs. 29.3%, P<0.001), whereas the rate of cases with relevant findings decreased from 47.8 to 40.9%. According to the time trend analysis, we developed a forecast model with two scenarios: the pessimistic and the optimistic. Validation of the model with 2015 data showed that reality was close to the pessimistic scenario: the number of exams further decreased to 190, studies carried out for IDA/OGIB increased to 67%, and there were more negative than positive exams (40.7 vs. 39.2%). The number of VCE studies carried out after the emergence of the financial crisis decreased significantly and VCE indications were optimized. Our forecast model predicts lower numbers of VCE studies, with IDA/OGIB being the dominant indication. However, the predicted increase of negative exams requires further evaluation.

Historical analysis of experience with small bowel capsule endoscopy in a Spanish tertiary hospital

Abstract Introduction Capsule endoscopy was approved by the FDA in 2001. Gastrointestinal bleeding and inflammatory bowel disease are the main indications. It has been available in our hospital since 2004. Methods We retrospectively analysed data from patients who underwent small bowel capsule endoscopy in our hospital from October 2004 to April 2015. Indications were divided into: Obscure gastrointestinal bleeding (occult and overt), inflammatory bowel disease, and other indications. Findings were divided into: Vascular lesions, inflammatory lesions, other lesions, normal studies, and inconclusive studies. Results A total of 1027 out of 1291 small bowel studies were included. Mean patient age was 56.45 years; 471 were men and 556 women. The most common lesion observed was angiectasia, as an isolated finding or associated with other lesions. Findings were significant in up to 80% of studies when the indication was gastrointestinal bleeding, but in only 50% of studies in inflammatory bowel disease. Diagnostic yield was low in the group “other indications”. No major complications were reported. Discussion Small bowel capsule endoscopy has high diagnostic yield in patients with gastrointestinal bleeding, but yield is lower in patients with inflammatory bowel disease. Conclusions Our experience shows that capsule endoscopy is a safe and useful tool for the diagnosis of small bowel disease. The diagnostic yield of the technique in inflammatory bowel disease must be improved.

Abstract No. 457 - Eliminating the need for mesenteric angiography after negative CTA: negative predictive value of CTA in obscure GI bleeding

Abstract No. 457 - Eliminating the need for mesenteric angiography after negative CTA: negative predictive value of CTA in obscure GI bleeding

What is the Role of Double-Balloon Endoscopy in Patients Presenting with Obscure Gastrointestinal Bleeding?

What is the Role of Double-Balloon Endoscopy in Patients Presenting with Obscure Gastrointestinal Bleeding?

Assessment of multi-modality evaluations of obscure gastrointestinal bleeding.

AIMTo determine the frequency of bleeding source detection in patients with obscure gastrointestinal bleeding (OGIB) who underwent double balloon enteroscopy (DBE) after pre-procedure imaging [multiphase computed tomography enterography (MPCTE), video capsule endoscopy (VCE), or both] and assess the impact of imaging on DBE diagnostic yield.METHODSRetrospective cohort study using a prospectively maintained database of all adult patients presenting with OGIB who underwent DBE from September 1st, 2002 to June 30th, 2013 at a single tertiary center.RESULTSFour hundred and ninety five patients (52% females; median age 68 years) underwent DBE for OGIB. AVCE and/or MPCTE performed within 1 year prior to DBE (in 441 patients) increased the diagnostic yield of DBE (67.1% with preceding imaging vs 59.5% without). Using DBE as the gold standard, VCE and MPCTE had a diagnostic yield of 72.7% and 32.5% respectively. There were no increased odds of finding a bleeding site at DBE compared to VCE (OR = 1.3, P = 0.150). There were increased odds of finding a bleeding site at DBE compared to MPCTE (OR = 5.9, P < 0.001). In inpatients with overt OGIB, diagnostic yield of DBE was not affected by preceding imaging.CONCLUSIONDBE is a safe and well-tolerated procedure for the diagnosis and treatment of OGIB, with a diagnostic yield that may be increased after obtaining a preceding VCE or MPCTE. However, inpatients with active ongoing bleeding may benefit from proceeding directly to antegrade DBE.

Implications of small-bowel transit time in the detection rate of capsule endoscopy: A multivariable multicenter study of patients with obscure gastrointestinal bleeding.

AIMTo define the role of small-bowel transit time in the detection rate of significant small-bowel lesions.METHODSSmall-bowel capsule endoscopy records, prospectively collected from 30 participating centers in the Lombardy Registry from October 2011 to December 2013, were included in the study if the clinical indication was obscure gastrointestinal bleeding and the capsule reached the cecum. Based on capsule findings, we created two groups: P2 (significant findings) and P0-1 (normal/negligible findings). Groups were compared for age, gender, small-bowel transit time, type of instrument, modality of capsule performance (outpatients vs inpatients), bowel cleanliness, and center volume.RESULTSWe retrieved and scrutinized 1,433 out of 2,295 capsule endoscopy records (62.4%) fulfilling the inclusion criteria. Patients were 67 ± 15 years old, and 815 (57%) were males. In comparison with patients in the P0-1 group, those in the P2 group (n = 776, 54%) were older (P < 0.0001), had a longer small-bowel transit time (P = 0.0015), and were more frequently examined in low-volume centers (P < 0.001). Age and small-bowel transit time were correlated (P < 0.001), with age as the sole independent predictor on multivariable analysis. Findings of the P2 group were artero-venous malformations (54.5%), inflammatory (23.6%) and protruding (10.4%) lesions, and luminal blood (11.5%).CONCLUSIONIn this selected, prospectively collected cohort of small-bowel capsule endoscopy performed for obscure gastrointestinal bleeding, a longer small-bowel transit time was associated with a higher detection rate of significant lesions, along with age and a low center volume, with age serving as an independent predictor.

Colonic lesions in patients undergoing small bowel capsule endoscopy: incidence, diagnostic and therapeutic impact.

Nowadays, capsule endoscopy is the first-line procedure to assess the small bowel. During small bowel procedures, other segments of the gastrointestinal tract may be visualized. The aim of the current study was to evaluate the incidence of colonic abnormalities in patients undergoing small bowel capsule and its impact on patient management. This study is a retrospective analysis of data from 526 consecutive capsule endoscopy procedures performed at a single tertiary-care centre between 2008 and 2011. Patients with incomplete procedures were excluded from the analysis. Patient baseline characteristics, colonic lesions, diagnosis and management before and after capsule endoscopy were recorded and a descriptive analysis was performed. Four hundred and sixty four patients were finally included in the analysis. Two hundred and ninety three patients were male (57.3%) and the mean age was 61.3 ± 20.03 years (18-86). Obscure gastrointestinal bleeding (59%) and inflammatory bowel disease (19%) were the main indications for the procedure. Colonic abnormalities were detected by capsule endoscopy in 47 (9%) of 464 patients. The most common types of missed lesions were vascular lesions (34%) and colonic ulcers (32%). This information had a clinical or diagnostic impact of 7.55% and a therapeutic impact of 6.03%. All images of the colon should be evaluated during small bowel capsule endoscopy as they may provide relevant information that may result in changes in patient management.

Capsule endoscopy with PillCamSB2 versus PillCamSB3: has the improvement in technology resulted in a step forward?

To compare the findings and completion rate of PillCam® SB2 and SB3. This was a retrospective single-center study that included 357 consecutive small bowel capsule endoscopies (SBCE), 173 SB2 and 184 SB3. The data collected included age, gender, capsule type (PillCam® SB2 or SB3), quality of bowel preparation, completion of the examination, gastric and small bowel transit time, small bowel findings, findings in segments other than the small bowel and the detection of specific anatomical markers, such as the Z line and papilla. The mean age of the patients was 48 years and 66.9% were female. The two main indications were suspicion/staging of inflammatory bowel disease (IBD) and obscure gastrointestinal bleeding (OGIB) (43.7% and 40.3%, respectively). Endoscopic findings were reported in 76.2% of examinations and 53.5% were relevant findings. No significant differences were found between SB2 and SB3 with regard to completion rate (93.6% vs 96.2%, p = 0.27), overall endoscopic findings (73.4% vs 78.8%, p = 0.23), relevant findings (54.3% vs 52.7%, p = 0.76), first tertile findings (43.9% vs 48.9%, p = 0.35), extra-SB findings (23.7% vs 17.3%, p = 0.14), Z line and papilla detection rate (35.9% vs 35.7%, p = 0.97 and 27.1% vs 32.6%, p = 0.32, respectively). With regard to the patient subgroups with suspicion/staging of IBD, significant differences were found in relation to the detection of villous edema and the 3rd tertile findings, thus favoring SB3 (26.3% vs 43.8%, p = 0.02 and 47.4% vs 66.3%, p = 0.02, respectively). Mucosal atrophy was significantly more frequently diagnosed with the PillCam® SB3 in patients with anemia/OGIB (0% vs 8%, p = 0.03). Overall, PillCam® SB3 did not improve the diagnostic yield compared to SB2, although it improved the detection of villous atrophy and segmental edema.

Gastroduodenal lesions detected during small bowel capsule endoscopy: incidence, diagnostic and therapeutic impact.

Capsule endoscopy was primarily designed for the investigation of the small bowel. However, it may also identify lesions in other segments of the gastrointestinal tract. The aim of the current study was to evaluate the incidence of gastroduodenal abnormalities during small bowel capsule endoscopy and its impact on patient diagnosis and management. This study is a retrospective analysis of data from 2,217 consecutive capsule endoscopy procedures performed at a single tertiary-care center between January 2008 and February 2016. Patient baseline characteristics, gastroduodenal lesions, diagnosis and management before and after capsule endoscopy were recorded and a descriptive analysis was performed. Two thousands and two hundred seventeen patients were finally included in the analysis. One thousand and seventy patients were male (48.2%) and the mean age was 56.1 ± 19.5 years (range: 12-93). Obscure gastrointestinal bleeding (52.3%) and inflammatory bowel disease (18.3%) were the main procedure indications. Gastroduodenal abnormalities were detected by capsule endoscopy in 696 (31.4%) of 2,217 patients. The most common types of missed gastric and duodenal lesions found were gastric erosions (35.4%), findings suggestive of chronic gastritis (22.9%), duodenal erosions (28.1%) and duodenal erythema (23.5%). This information had a clinical or diagnostic impact of 26.2% and a therapeutic impact of 15.5%. Capsule endoscopy detects not only small bowel lesions but also some gastroduodenal lesions that may be overlooked during an initial gastroscopy. Therefore, all gastroduodenal images should be read during small bowel capsule endoscopy as it may provide relevant information that result in changes in patient management.

Capsule Endoscopy Demonstrating Blood Sucking Hookworms as A Cause of Obscure Gastrointestinal Bleeding

Hookworm infestation will usually present with iron deficiency anemia. In this report we present a case of obscure overt gastrointestinal bleeding occuring from last two years in a young individual, requiring 50 units of blood transfusion. He was diagnosed with hookworm infection on a capsule endoscopy, which demonstrated dancing worms buried in the mucosa of small bowel and were actively sucking blood. He was treated with a short course of mebendazole and recovered completely. Capsule endoscopy can be useful in diagnosing hookworm infection if other modalities fail.

Assessment of serum angiogenic factors as a diagnostic aid for small bowel angiodysplasia in patients with obscure gastrointestinal bleeding and anaemia.

AIMTo assess the use of serum levels of angiopoietin-1 (Ang1), Ang2 and tumor necrosis factor-α (TNFα) as predictive factors for small bowel angiodysplasia (SBA).METHODSSerum samples were collected from patients undergoing capsule endoscopy for any cause of obscure gastrointestinal bleeding (OGIB) or anaemia. Based on small bowel findings patients were divided into 3 groups: (1) SBA; (2) other bleeding causes; and (3) normal, according to diagnosis. Using ELISA technique we measured serum levels of Ang1, Ang2 and TNFα and compared mean and median levels between the groups based on small bowel diagnosis. Using receiver operator curve analysis we determined whether any of the factors were predictive of SBA.RESULTSSerum samples were collected from a total of 120 patients undergoing capsule endoscopy for OGIB or anaemia: 40 with SBA, 40 with other causes of small bowel bleeding, and 40 with normal small bowel findings. Mean and median serum levels were measured and compared between groups; patients with SBA had significantly higher median serum levels of Ang2 (3759 pg/mL) compared to both other groups, with no significant differences in levels of Ang1 or TNFα based on diagnosis. There were no differences in Ang2 levels between the other bleeding causes (2261 pg/mL) and normal (2620 pg/mL) groups. Using Receiver Operator Curve analysis, an Ang2 level of > 2600 pg/mL was found to be predictive of SBA, with an area under the curve of 0.7. Neither Ang1 or TNFα were useful as predictive markers.CONCLUSIONElevations in serum Ang2 are specific for SBA and not driven by other causes of bleeding and anaemia. Further work will determine whether Ang2 is useful as a diagnostic or prognostic marker for SBA.

Does Intraoperative Endoscopy Still Apply in Obscure Gastrointestinal Bleeding Treatment? A Case Report and a Literature Review with a Diagnostic Algorithm Proposal

Background: Obscure gastrointestinal bleeding seems to be important problem affecting increasing group of patients. Due to its localization and mild symptoms investigation is difficult and usually requires advanced procedures. Unfortunately, it is often impossible to show precisely a source of bleeding what delays treatment and can cause severe bleeding. Methods: We describe a case report of the patient who refused surgical treatment despite proper bleeding localization by enteral capsule what caused serious bleeding few months later. Patient was operated on duty intraoperative endoscopy was necessary to perform. After treatment he left hospital in a good condition without any negative consequences. Discussion: Authors discussed investigation methods, a role of endoscopy performed intraoperatively and propose a scheme helpful during obscure bleeding investigation.

High short-term rebleeding rate in patients undergoing a second endoscopic therapy for small-bowel angioectasias after recurrent bleeding.

Angioectasias represents the most frequently found lesion in the small bowel by device-assisted enteroscopy for obscure gastrointestinal bleeding in Western countries. Recurrence of gastrointestinal bleeding after angioectasias therapy remains unclear and data regarding the efficacy of additional endoscopic therapeutic sessions to reduce the rebleeding rate is limited. To evaluate the rebleeding rate in small bowel angioectasias after a second endoscopic treatment with balloon-assisted enteroscopy after an initial bleed during the first endoscopic treatment. A retrospective double-center study of patients with small-bowel angioectasias undergoing a second enteroscopy treatment due to a first rebleeding episode. The endpoint was rebleeding, defined as the need for a blood transfusion, the presence of overt bleeding or a decrease in hemoglobin ≥ 2 g/dL. Fifteen of 37 (40.5%) patients with small-bowel angioectasias that underwent a second endoscopic therapy after a first rebleeding episode (n = 15) experienced a second rebleeding episode. Kaplan-Meier curve analysis showed that most rebleeding episodes occurred within the first 12 months of follow-up, resulting in a rebleeding rate of 33.1% at 6 months, 39.1% at 12 months and 52.6% at 24 months. Despite the high absolute short-term rebleeding rate, further endoscopic treatments may be beneficial due to the effective reduction of rebleeding in a subset of patients.

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.

Hemorragia gastrointestinal de origen oscuro por tumores de estroma gastrointestinal

BackgroundThe gastrointestinal stromal tumours (GIST) are the most common soft tissue sarcomas of the digestive tract. They are usually found in the stomach (60-70%) and small intestine (25-30%) and, less commonly, in the oesophagus, mesentery, colon, or rectum.The symptoms present at diagnosis are, gastrointestinal bleeding, abdominal pain, abdominal mass, or intestinal obstruction. The type of symptomatology will depend on the location and size of the tumour. The definitive diagnosis is histopathological, with 95% of the tumours being positive for CD117. Clinical casesThis is an observational and descriptive study of 5cases of small intestinal GIST that presented with gastrointestinal bleeding as the main symptom. The period from the initial symptom to the diagnosis varied from 1 to 84 months. The endoscopy was inconclusive in all of the patients, and the diagnosis was made using computed tomography and angiography. Treatment included resection in all patients. The histopathological results are also described. ConclusionGIST can have multiple clinical pictures and unusual symptoms, such as obscure gastrointestinal bleeding. The use of computed tomography and angiography has shown to be an important tool in the diagnosis with patients with small intestine GISTs.

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.

Double balloon enteroscopy in children: diagnosis, treatment, and safety.

To assess the feasibility and utility of double balloon enteroscopy (DBE) in the management of small bowel diseases in children. Fourteen patients (10 males) with a median age of 12.9 years (range 8.1-16.7) underwent DBE; 5 for Peutz-Jeghers syndrome (PJ syndrome), 2 for chronic abdominal pain, 4 for obscure gastrointestinal (GI) bleeding, 2 with angiomatous malformations (1 blue rubber bleb nevus syndrome) having persistent GI bleeding, and 1 with Cowden's syndrome with multiple polyps and previous intussusception. Eleven procedures were performed under general anesthesia and 3 with deep sedation. The entire small bowel was examined in 6 patients, and a length between 200 cm and 320 cm distal to pylorus in the remaining 8. Seven patients had both antegrade (trans-oral) and retrograde (trans-anal and via ileostomy) examinations. One patient underwent DBE with planned laparoscopic assistance. The remaining 6 had trans-oral examination only. The median examination time was 118 min (range 95-195). No complications were encountered. Polyps were detected and successfully removed in all 5 patients with PJ syndrome, in a patient with tubulo-villous adenoma of the duodenum, in a patient with significant anemia and occult bleeding, and in a patient with Cowden's syndrome. A diagnosis was made in a patient with multiple angiomata not amenable to endotherapy, and in 1 with a discrete angioma which was treated with argon plasma coagulation. The source of bleeding was identified in a further patient with varices. DBE was normal or revealed minor mucosal friability in the remaining 3 patients. Hence a diagnostic yield of 11/14 with therapeutic success in 9/14 was achieved. Double balloon enteroscopy can be a useful diagnostic and therapeutic tool for small bowel disease in children, allowing endo-therapeutic intervention beyond the reach of the conventional endoscope.

Double-balloon enteroscopy in small bowel diseases: Eight years single-center experience in China.

The aim of the study was to evaluate the diagnostic and therapeutic value of double-balloon entoroscopy (DBE) in small bowel diseases (SBDs) in China.A retrospective review of 674 consecutive patients who underwent DBE between January 2007 and November 2015 was conducted. Patients were divided into 3 groups by age, young group (<45 years), middle-aged group (45–65 years), and elderly group (>65 years). Data were collected with regard to demographics, clinical, endoscopic findings, complications, diagnostic yield, and management.A total of 729 DBE procedures were performed successfully in our series. More than 20 types of SBDs were found with the detection rate of 70.9%(517/729). The majority of patients were Crohn's disease (33.4%,225/674), followed by tumor (18.8%,127/674) and angioectasia (7.9%, 53/674). Endoscopic treatment was performed in 60 patients in which hemostasis (17,28.3%) and polypectomy (15,25%) were the predominant form of intervention used. Adverse events occurred in 6 patients (0.96%,6/729) including perforation, hemorrhage, aspiration pneumonia. No acute pancreatitis or other major complications occurred. Adenocarcinoma, GIST, and lymphoma were the most common tumor detected, the majority of tumors located in the jejunum (56.7%), The detection rate of angioectasia was also higher in the jejunum (54.7%),77.8% of Crohn's disease was located in the ileum. The positive rate of DBE in small bowel tumor and Crohn's disease were significantly higher than that of angioectasia (P<0.05). In young cohort, Crohn's disease (48.1%) was the most commonly diseases followed by tumor (10.4%) and nonspecific enteritis (7.1%). Yet in the elderly group, the majority of patients were tumor (27.6%); angioectasia (21.3%) was also detected frequently. The positive rate of capsule endoscopy was 75.44 %(202/268) which was a little high than DBE (67.9%, 182/268) (P > 0.05). The obscure gastrointestinal bleeding (OGIB) was the most common indication, and the diagnostic yield was 71.8%.DBE is a useful diagnostic and therapeutic tool with high clinical practice value for the investigation of SBDs. With growing experience of endoscopist, we believe that DBE must be kept in mind as the first-line modality for suspected SBDs.

ReFUSE to Give Up; A Case of Recurrent GI Bleeding Solved with Full Spectrum Endoscopy

Full-spectrum endoscopy (FUSE®) is a novel technology developed to enhance detection of adenomatous polyps during colonoscopy. While research has shown FUSE® to be superior to standard forward-viewing colonoscopy for adenomatous polyp detection, it has not been studied in the setting of gastrointestinal (GI) bleeding. We present a case of recurrent GI bleeding solved utilizing FUSE®. A 75 year old female with a history of hepatitis c, hypertension, and right hemicolectomy presented in June of 2015 with recurrent melena for one year. Prior to her presentation, she underwent a workup at another institution which included upper endoscopy, push enteroscopy, colonoscopy and video capsule endoscopy (VCE) without identifying a source of bleeding. Upon her initial presentation to our institution, exam was notable for melena on rectal exam and laboratory workup for hemoglobin 7.0 g/dL, hematocrit 21.5%, platelet count 136 K/UL, and an MCV 79.3FL. Over the next six months, the patient required three hospitalizations for overt, obscure GI bleeding during which she underwent three colonoscopies, two endoscopies, two single balloon enteroscopies, and three VCEs. Initial colonoscopy revealed blood 40cm into the terminal ileum without a source. Subsequently, VCE revealed red blood starting at the distal-jejunum. A follow up small bowel enteroscopy was unremarkable. The bleeding resolved and the patient was discharged home. The patient presented one month later and underwent colonoscopy, enteroscopy and capsule endoscopy without a source. The distal and proximal extents reached within the small bowel were tattooed. Once again, the bleeding resolved. During the third hospitalization, a discussion to perform surgical assisted enteroscopy occurred but a final VCE was performed and demonstrated a possible lesion at the ileocolonic anastomosis (Figure 1). The decision was made to perform a final colonoscopy using FUSE®, which demonstrated a large, non-bleeding angiodysplastic lesion distal to the ileocolonic anastomosis on the right sided camera (Figure 2) between two folds. Argon plasma coagulation was performed and three hemostatic clips were placed. Since the procedure one year ago, the patient has not experienced further bleeding. In conclusion, FUSE® has been studied for adenoma detection in colon cancer prevention; however this case highlights a possible additional use of FUSE® in diagnosing the etiology of overt, obscure GI bleeding.Figure 1Figure 2