Obscure Gastrointestinal Bleeding Research Articles

Minimal invasive management of proximal small bowel bleeding: A case report and reviewing the evidences

Objective: Gastrointestinal bleeding is one of the surgical emergencies that is routinely visited in emergency departments. Although most of these patients are managed with endoscopic modalities, some of them are managed with surgical interventions. Most of emergency surgical interventions are done via laparotomy. With evolution in minimal invasive surgery, the role of laparoscopic surgeries in emergency settings is on a rise. Case Presentation: In this report we describe a case of lower gastrointestinal bleeding that was presented with melena and during workups no bleeding lesion was detected in colon, stomach or duodenum. Further investigations revealed bleeding of proximal jejunum mass that was resected with the laparoscopic approach which is rarely used in the emergency management of patients with gastrointestinal bleedings. Also, resection and anastomosis of proximal jejunal loop was challenging in this case. Conclusion: This report is intended to describe the feasibility of laparoscopy in proximal small bowel lesion resection in emergency settings as well as the role of computed tomography (CT) angiography in detecting the source of obscure gastrointestinal bleeding.

Obscure-overt gastrointestinal bleeding: a review.

Obscure gastrointestinal (GI) bleeding (OGIB) is defined as small bowel bleeding of unknown etiology after negative endoscopic evaluation including esophagogastroduodenoscopy and colonoscopy with endoscopic evaluation of the terminal ileum. The presentation of OGIB may be either overt or occult. The former refers to persistent or recurrent visible GI bleeding (eg, melena and / or hematochezia, and rarely hematemesis), while the latter indicates the presence of persistently positive results of fecal oc-cult blood testing, iron deficiency anemia, or both, without evidence of visible GI bleeding. This review focuses exclusively on obscure‑overt GI bleeding and presents entities that should be considered as part of the differential diagnosis in patients with this type of bleeding, as well as details the role of endoscopic and radiographic techniques in the evaluation and treatment.

Small-Bowel Capsule Endoscopy: Indications and Results in Endoscopy Unit

Small-bowel capsule endoscopy (SBCE) is used widely because of its non-invasive and patient-friendly nature. SBCE can visualize entire small-intestinal mucosa and facilitate detection of small-intestinal abnormalities. Indications for SBCE are obscure gastrointestinal bleeding, Crohn’s disease, small-intestinal polyps, tumors and celiac disease. Materials and methods: We report a study from September 2018 to February 2022, including 59 patients who underwent SBCE type PillCam SB3®. All our patients previously had a normal endoscopic assessment (oesogastro-duodenal fibroscopy and ileo-colonoscopy). CT enterography and MR enterography realized in 54.2% of cases were normal. The preparation used is PEG (2l the day before and 0.5l after ingesting the capsule) with clear broth the day before the examination and 10 days off oral iron if taken. Results: The mean age was 53.9 years, with a female predominance (sex ratio: 0.52). 16.9% of the patients had a history of heart disease, 8.4% are chronic renal failure, 5% are followed for Crohn's disease and 3.3% for celiac disease. 10.1% of patients were on anticoagulants and 5% on antiplatelet agents. The indication for SBCE was Obscure gastrointestinal bleeding (OGIB) in 86,3%, Crohn's disease (CD) in 5%, celiac disease in 3,3%, chronic diarrhea in 3,3%, and unexplained edematoascites syndrome in 1,6%. SBCE found small bowel angiodysplasia lesions in 40.6% of patients, small bowel inflammatory lesions in 15% of patients, a submucosal tumor appearance in 6.7% of patients and active small bowel bleeding in 5% patients. The examination did not objectivate small bowel lesion in 25.4% of patients. Non-small bowel lesions have been demonstrated in the form of gastric (16.9% of cases) and cecal (10.1% of cases) angiodysplasia responsible for OGIB. Conclusion: In our study, SBCE showed lesions in 74,6% of cases; dominated by angiodysplasia followed by inflammatory lesions and submucosal tumors and whose indication was essentially OGIB. Enteroscopy with biopsies or with therapeutic gesture, remains essential in the management of these patients.

Small-Bowel Angioectasias: Are They Responsible for a Real Impact on Survival?

Introduction: This study aimed to evaluate the effect of small-bowel angioectasia on survival, given the hypothesis that angioectasia might be an independent risk factor of frailty and poor outcomes. Methods: In this retrospective cohort study, all patients undergoing small-bowel capsule endoscopy between 2010 and 2013 for obscure gastrointestinal bleeding from a Portuguese tertiary centre were included. Follow-up started after capsule endoscopy and ended upon death or end of the study (November 2020). Survival analysis was performed using a Cox proportional-hazards model, in order to analyse the effect of small-bowel angioectasia on survival as well as potentially confounding factors (age, vascular diseases and chronic kidney disease). Results: A total of 176 patients were included in this study (50.6% male), with a median age of 68.5 years (IQR 24). The median follow-up was 7 years (IQR 4), during which 67 (38.1%) patients died. Seventy-three (41.5%) patients had at least one small-bowel angioectasia on capsule endoscopy. On multivariate Cox regression analysis, only age, peripheral arterial disease, history of previous mesenteric ischaemia and chronic kidney disease were independent risk factors of death. The presence of small-bowel angioectasia did not affect survival in this analysis (HR 1.30; 95% CI 0.75–2.23; p = 0.35). Conclusion: In this retrospective cohort study, some comorbidities and age were independent predictors of poor survival. The presence of small-bowel angioectasia per se did not affect survival.

Evaluation by a Machine Learning System of Two Preparations for Small Bowel Capsule Endoscopy: The BUBS (Burst Unpleasant Bubbles with Simethicone) Study.

Background: Bubbles often mask the mucosa during capsule endoscopy (CE). Clinical scores assessing the cleanliness and the amount of bubbles in the small bowel (SB) are poorly reproducible unlike machine learning (ML) solutions. We aimed to measure the amount of bubbles with ML algorithms in SB CE recordings, and compare two polyethylene glycol (PEG)-based preparations, with and without simethicone, in patients with obscure gastro-intestinal bleeding (OGIB). Patients & Methods: All consecutive outpatients with OGIB from a tertiary care center received a PEG-based preparation, without or with simethicone, in two different periods. The primary outcome was a difference in the proportions (%) of frames with abundant bubbles (>10%) along the full-length video sequences between the two periods. SB CE recordings were analyzed by a validated computed algorithm based on a grey-level of co-occurrence matrix (GLCM), to assess the abundance of bubbles in each frame. Results: In total, 105 third generation SB CE recordings were analyzed (48 without simethicone and 57 with simethicone-added preparations). A significant association was shown between the use of a simethicone-added preparation and a lower abundance of bubbles along the SB (p = 0.04). A significantly lower proportion of “abundant in bubbles” frames was observed in the fourth quartile (30.5% vs. 20.6%, p = 0.02). There was no significant impact of the use of simethicone in terms of diagnostic yield, SB transit time and completion rate. Conclusion: An accurate and reproducible computed algorithm demonstrated significant decrease in the abundance of bubbles along SB CE recordings, with a marked effect in the last quartile, in patients for whom simethicone had been added in PEG-based preparations, compared to those without simethicone.

Diagnostic yield of inpatient capsule endoscopy

BackgroundCapsule endoscopy (CE) provides a novel approach to evaluate obscure gastrointestinal bleeding. Yet CE is not routinely utilized in the inpatient setting for a variety of reasons. We sought to identify factors that predict complete CE and diagnostically meaningful CE, as well as assess the impact of inpatient CE on further hospital management.1 na d2MethodsWe conducted a retrospective review of patients undergoing inpatient CE at a tertiary referral, academic center over a 3 year period. We analyzed data on patient demographics, medical history, endoscopic procedures, hospital course, and results of CE. The primary outcome was complete CE and the secondary outcome was positive findings of pathology on CE.Results131 patients were included (56.5% were men 43.5% women, median age of 71.0 years). Overall, CE was complete in 77.1% of patients. Complete CE was not related to motility risk factors, gender, or administration modality. Patients with incomplete CE tended to be older, have lower BMI, and Caucasian, however results did not reach statistical significance (p = 0.06; p = 0.06; p = 0.08 respectively). Positive CE was noted in 73.3% of patients, with 35.1% of all patients having active bleeding. Positive CE was not associated with AVM risk factors or medication use. 28.0% of patients underwent subsequent hospital procedures, among which 67.6% identified the same pathology seen on CE.ConclusionsContrary to previous studies, we found the majority of inpatient CEs were complete and positive for pathology. We found high rates of correlation between CE and subsequent procedures. The use of CE in the inpatient setting helps to guide the diagnosis and treatment of hospitalized patients with obscure gastrointestinal bleeding.

RHEMITT Score Predicts Rebleed After Capsule Endoscopy: First Validation at a U.S. Tertiary Care Center.

Patients with obscure gastrointestinal bleeding undergo small bowel capsule endoscopy (SBCE), but often return for recurrent bleeding or anemia. The RHEMITT score evaluates patients based on 7 variables (heart failure, chronic kidney disease, Saurin P1/P2 lesions, major bleeding, incomplete SBCE, smoking status, and endoscopic treatment) and seeks to predict the risk of rebleeding. This study aims to perform an external validation of the RHEMITT score in the United States. SBCEs performed to evaluate anemia or GI bleeding from a tertiary-care center's PillCam database between 1/22/2018 and 7/21/2020 were reviewed. Variables based on the RHEMITT score were collected. The primary outcome was rebleeding, defined as (1) melena or hematochezia or (2) hemoglobin drop of 2g/dL. Patient were categorized into low, intermediate, and high-risk categories based on RHEMITT score. The accuracy of the RHEMITT score for predicting rebleeding was assessed. A total of 361 SBCEs were included in the study. Age, indication for SBCE, endoscopic treatment, antiplatelet use, cirrhosis, heart failure, chronic kidney disease, and major bleeding were significantly associated with risk of rebleed (p < 0.05). Each increasing risk category for the RHEMITT score predicted increased probability of this study's primary outcome, rebleeding (p < 0.001). There was a significant association between RHEMITT risk category and rebleeding-free survival (log-rank p < 0.001). An area under the receiver operating characteristic curve for the RHEMITT score was 0.790 (p < 0.001). Our findings validate the RHEMITT score and confirm acceptable performance for predicting rebleeding at a tertiary referral center in the United States.

The Diagnostic Yield of Capsule Endoscopy in Egyptian Patients with Obscure Gastrointestinal Tract Bleeding

The Diagnostic Yield of Capsule Endoscopy in Egyptian Patients with Obscure Gastrointestinal Tract Bleeding

Indications, Detection, Completion and Retention Rates of Capsule Endoscopy in Two Decades of Use: A Systematic Review and Meta-Analysis.

Background: Capsule endoscopy (CE) has become a widespread modality for non-invasive evaluation of the gastrointestinal (GI) tract, with several CE models having been developed throughout the years. The aim of this systematic review and meta-analysis is to evaluate performance measures such as completion, detection and retention rates of CE. Methods: Literature through to August 2021 was screened for articles regarding all capsule types: small bowel, double-headed capsule for the colon or PillCam®Crohn’s capsule, magnetically-controlled capsule endoscopy, esophageal capsule and patency capsule. Primary outcomes included detection rate (DR), completion rate (CR) and capsule retention rate (RR). DR, CR and RR were also analyzed in relation to indications such as obscure GI bleeding (OGIB), known/suspected Crohn’s disease (CD), celiac disease (CeD), neoplastic lesions (NL) and clinical symptoms (CS). Results: 328 original articles involving 86,930 patients who underwent CE were included. OGIB was the most common indication (n = 44,750), followed by CS (n = 17,897), CD (n = 11,299), NL (n = 4989) and CeD (n = 947). The most used capsule type was small bowel CE in 236 studies. DR, CR and RR for all indications were 59%, 89.6% and 2%, respectively. According to specific indications: DR were 55%, 66%, 63%, 52% and 62%; CR were 90.6%, 86.5%, 78.2%, 94% and 92.8%; and RR were 2%, 4%, 1%, 6% and 2%. Conclusions: Pooled DR, CR and RR are acceptable for all capsule types. OGIB is the most common indication for CE. Technological advancements have expanded the scope of CE devices in detecting GI pathology with acceptable rates for a complete examination.

Intraoperative endoscopy through enterotomy for overt obscure gastrointestinal bleeding: A retrospective cohort study

IntroductionOvert obscure gastrointestinal bleeding (OGIB) is challenging and often needs intraoperative endoscopy (IOE) with a high risk of morbidity and mortality. The study was to compare the different approaches to perform IOE for overt OGIB. Patients and methodsWe retrospectively reviewed the data of 98 patients who underwent trans-enterotomy IOE (IOE-E) or other approaches such as peroral IOE (IOE-oral), trans-anal IOE (IOE-anal), or combined route (IOE-combo). Patient characteristics, demographics, diagnostic tests, IOE findings, and follow-up outcomes were analyzed. ResultsAll 98 patients underwent IOE. There are 31 patients in the IOE-E group, 26 patients in the IOE-oral group, 23 patients in the IOE-anal group, and 18 patients in the IOE-combo group, respectively. Long-term follow-up information (>6 months) was successfully obtained in 72 patients. IOE-E has the lowest postoperative morbidity rate (16%, P < 0.05), the shortest time of operation (43.2 ± 17.4 min, P < 0.05) and shortest hospital length of stay (6.7 ± 5.1 days, P < 0.05), as compared to the other three approaches. ConclusionsIntraoperative endoscopy through enterotomy represents a safer and more ideal strategy in the management of overt OGIB.

Rebleeding Rate and Risk Factors for Rebleeding after Device-Assisted Enteroscopy in Patients with Obscure Gastrointestinal Bleeding: A KASID Multicenter Study.

Introduction: The impact of device-assisted enteroscopy (DAE) on long-term rebleeding in patients with obscure gastrointestinal bleeding (OGIB) exhibiting detectable small-bowel lesions remains unclear. We investigated the long-term rebleeding rate and predictive factors for DAE in patients with OGIB. Method: Patients with OGIB with small bowel lesions detected through DAE were enrolled at three Korean tertiary hospitals. Predictive risk factors associated with rebleeding were analyzed using the Cox regression analysis. Results: From April 2008 to April 2021, 141 patients were enrolled, including 38 patients (27.0%) with rebleeding. The rebleeding rates at 1, 2, and 3 years were 25.0%, 29.6%, and 31.1%, respectively. The Cox regression analysis revealed that multiple small-bowel lesions (hazard ratio [HR]: 2.551, 95% confidence interval [CI]: 1.157–5.627, p = 0.020), the need for more than five packed red blood cells (RBC) transfusions (HR: 2.704, 95% CI: 1.412–5.181, p = 0.003), and ulcerative lesions (HR: 1.992, 95% CI: 1.037–3.826, p = 0.039) were positively associated with rebleeding. Therapeutic interventions for patients with detectable lesions, overt bleeding (vs. occult bleeding), comorbidities, and medications were not associated with rebleeding. Conclusion: More than 25% of patients with OGIB having detectable small-bowel lesions had rebleeding. Patients with multiple lesions, a requirement of more than five packed RBC transfusions, and ulcerative lesions were associated with a higher risk of rebleeding.

Small bowel capsule endoscopy in obscure gastrointestinal bleeding: A matched cohort comparison of patients with normal vs surgically altered gastric anatomy

BackgroundLittle is known about small bowel capsule endoscopy (SBCE) outcomes in patients with surgically altered anatomy. AimsTo assess the feasibility and diagnostic yield of orally ingested SBCE to investigate obscure gastrointestinal bleeding (OGIB) in patients with surgically altered gastric anatomy, compared to native gastric anatomy. Methods207 patients with OGIB were selected from an open, multicenter, retrospective cohort (SAGA study) and match-paired according to age, gender and bleeding type (overt/occult) to 207 control patients from a randomized controlled trial (PREPINTEST). Primary outcomes were the diagnostic yield (P1 or P2 findings), completion rate, adverse events rate, and small bowel transit time (SBTT). ResultsThe diagnostic yield was not statistically different between groups (44.9% in SAGA vs 42.5% in control patients). Inflammatory/ulcerated lesions were significantly more frequent in patients with SAGA (43.0% vs 29.3%). The median SBTT was significantly longer in the SAGA group than in control patients (283 vs 206 minutes), with a significantly lower completion rate (82.6% vs 89.9%); Adverse events were scarce (0.5% vs 0.0%). ConclusionPatients with surgically altered gastric anatomy should benefit from SBCE investigation for OGIB as much as non-operated patients.

The Impact of Metabolic Risk Factors, Diabetes, Medications, and Comorbid Illness on Transit Time at Capsule Endoscopy: A Prospective Cohort Study

Background: Video capsule endoscopy (VCE) is a safe and effective way of investigating obscure gastrointestinal bleeding. One of the main limitations of VCE is suboptimal visualisation due to prolonged gastric transit time (GTT) or rapid small intestinal transit time (SITT). The role of metabolic risk factors, diabetes, and medications on transit times remains unclear. Aim: The aim of this study was to assess the impact of diabetes, obesity, medications, and metabolic syndrome on transit times at VCE. Method: The study performed was a single centre, observational study. Results: Significant predictors of decreased GTT were increasing age and use of beta blocker medication. No predictive factors for increased GTT were identified. Significant predictors of decreased SITT on univariate analysis were increased GTT, serum glucose &gt;5mmol/L, obesity, and diabetes. On multivariate analysis, increased GTT and glucose remained significant. Conclusions: Beta-blocker therapy reduces GTT. Hyperglycaemia at the time of VCE reduces SITT. These allow for possible therapeutic strategies to improve the diagnostic yield at VCE.

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.

A rare case of pseudoaneurysm of posterior inferior pancreaticoduodenal artery related with hemosuccus pancreaticus: a case report

Hemosuccus pancreaticus is a rare cause of obscure and intermittent upper GI bleeding, often life threatening. Usually seen in a patient with chronic alcoholic pancreatitis complicated with pseudoaneurysm of splenic artery in most of the cases. In the given case reports it was pseudoaneurysm of the posterior branch of inferior pancreaticoduodenal artery (IPDA) which accounts for less than 0.07% of total 10% of pseudoaneurysm of visceral arteries caused by hemosuccus pancreaticus. These patients usually present with an obscure moderate upper GI bleed. Early clinical, endoscopic and radiological diagnosis helps to determine the appropriate method of management. Most of the cases require the endovascular interventions like glue embolisation or metal coiling or beads, very few cases end up with explorative laparotomy. Here we report a rare case presentation of upper GI bleed due to pseudoaneurysm of IPDA in hemosuccus pancreaticus, it’s diagnosis and management.

A31 OUTCOMES OF PATIENTS UNDERGOING REPEAT VIDEOCAPSULE ENDOSCOPY (VCE) PRESENTING WITH OBSCURE GASTROINTESTINAL BLEEDING (OGIB)

BackgroundVideocapsule Endoscopy (VCE) as well as balloon-assisted enteroscopy (BAE) are useful tools in the diagnosis and management of obscure gastrointestinal bleeding (OGIB). There is limited data assessing the diagnostic yield of VCE in subjects with OGIB according to different subtypes: 1) obscure overt 2) inactive overt and 3) active overt.AimsWe evaluated the diagnostic yield and outcomes of patients undergoing a second VCE in OGIB.MethodsThis is a retrospective analysis of all patients who underwent more than one VCE completed at the University of Alberta from January 1, 2015 to August 31, 2021. Demographic and background information was collected including previous endoscopy results, cross-sectional imaging, and subsequent interventions. Patient data was analyzed according to subtype of OGIB at presentation.ResultsDuring the study period, there were 59 subjects who met inclusion criteria. The indication for VCE was recurrent iron deficiency anemia (IDA), active OGIB, and/or inactive OGIB in 38 subjects. The median time to VCE after initial endoscopic evaluation was 61 days. Median age of cases was 61.5 years and 49% were female.Initial VCE had clinically significant positive findings in 68% of cases (Table 1). The diagnostic yield was 75%, 56% and 74% in active OGIB, inactive OGIB, and IDA, respectively. Active bleeding or fresh blood was present in 33% of VCEs for active OGIB compared to 11% of inactive OGIB and 13% of subjects with IDA.At second VCE investigation, there were positive findings in 42% of cases. Findings on second VCE differed from initial VCE in 17 of 38 cases. Findings that changed clinical management were found in 76% of patients after first and second VCE.BAEs were performed in 20 subjects after VCE, with therapeutics applied in 75%. The most common findings were arteriovenous malformations (AVMs) (65%) and erosions/ulcers (15%).ConclusionsThe diagnostic yield of VCE is high in appropriately selected patients and did not significantly differ in patients with IDA, active, and inactive OGIB. Serial VCE is appropriate for the investigation of suspected recurrent small bowel bleeding when initial workup is nondiagnostic.Table 1: Comparison of findings after 1st and 2nd VCEActive OGIB (n=12)Inactive OGIB (n=9)IDA (n=23)1st VCEComplete100%78%91%Source identified755674AVM253348Erosions/ulcers421117Mass114Fresh blood331113BAE505648BAE with treatment2533262nd VCEComplete8389100Negative findings427843AVM252243Erosions/ulcers89BAE83335BAE with treatment229Funding AgenciesNone

A116 CLINICAL OUTCOMES OF PATIENTS UNDERGOING BALLOON-ASSISTED ENDOSCOPY FOR SUSPECTED SMALL BOWEL BLEEDING

Abstract Background Obscure gastrointestinal bleeding (OGIB) accounts for approximately 50% of all GI bleeds. This refers to bleeding from an unknown etiology despite initial investigations with upper endoscopy and colonoscopy, of which 75–80% is attributed to a small bowel source, also termed as small bowel bleeding. Various diagnostic and therapeutic modalities have been used to investigate sources of OGIB. Balloon-assisted enteroscopy (BAE) is a useful procedure for managing small bowel bleeding, with reported diagnostic and therapeutic rates up to 87% and 80%, respectively. Aims The aims of this study are to evaluate the outcomes of patients with OGIB who have undergone BAE, as well as to explore correlations between the timing of BAE and clinical outcomes. Methods We performed a retrospective review of 342 patients who underwent BAE at a tertiary referral centre between 2016 to 2021, of which 116 underwent evaluation for OGIB. Aside from gender and age, preprocedural variables including endoscopy indication, timing from video capsule endoscopy (VCE) and overt GI bleed were collected to allow for further stratification of data. Endoscopic variables including modality, findings, and therapeutic interventions were used to calculate diagnostic and therapeutic yields. Furthermore, the association between timing of BAE after VCE and clinical outcomes including rebleeding rate, diagnostics and therapeutic yields were assessed. All data analyses were performed with SPSS. Results The overall diagnostic yield was 70.3%. Patients with active overt bleeding were found to have a higher yield compared to those with occult and inactive overt bleeding (78.6% vs 72.5% vs 64.6%, respectively). Amongst all OGIB presentations, the most common findings were vascular lesions including angiodysplasia, arteriovenous malformations, and dieulafoy lesions. The majority of lesions were found within the proximal jejunum. Subgroup analysis did not show a statistically significant difference in diagnostic yields between BAE with and without prior VCE (75.9% vs 77.8, P = 0.605). The therapeutic yield was 51.1% with a higher yield found in those presenting with active overt bleeds compared to occult and inactive overt cases. Compared to BAE performed after 30 days of overt GI bleeding, those completed within 30 days was found to have a higher diagnostic and therapeutic rate (80.0% vs 60.0%, 70.0 vs 30.0%, respectively). Conclusions Balloon-assisted enteroscopy continues to be an effective diagnostic and therapeutic modality for the investigation of obscure gastrointestinal bleeding. Our retrospective study shows a higher diagnostic and therapeutic rate in those presenting with active overt GI bleed as well as those who underwent BAE within 30 days of overt GI bleeding Funding Agencies None

Diffuse hemangiolymphangioma of small bowel-rare cause of obscure gastrointestinal bleeding

Hemangiolymphangioma (HL) is a rare benign tumor, commonly present in pediatric age group that involves the head and neck. Small bowel HL has been reported as solitary or segmental involvement. Here we report a case of diffuse small bowel HL, presented as chronic anemia, fatigability and obscure gastrointestinal (GI) bleeding. A 42-year male presented with 15 years history of bleeding per rectum, anemia, and fatigability, received multiple blood transfusions. The exact cause could not be identified. His complete hemogram parameters were low requiring further imaging studies. Imaging and intraoperative enteroscopy showed multiple nodular lesions in mesentry as well as in the mucosa of the entire small bowel. Bleeding points were noted in a proximal jejunal lesion which was resected. Histopathological study confirmed as benign HL. HL are rare tumors of gastrointestinal tract. To the best of our knowledge diffuse HL of the small bowel have not been reported in the medical literature. With this case scenario, one should consider these tumors in the differential diagnosis of obscure lower GI bleed and chronic anemia, as well as explore definitive management options for these benign symptomatic tumors.

Video Capsule Endoscopy Optimal Timing in Overt Obscure Gastrointestinal Bleeding.

Video capsule endoscopy (VCE) has become the noninvasive diagnostic standard in the investigation of overt obscure gastrointestinal bleeding (OGIB), with a high positive and negative predictive value. However, the diagnostic yield of the VCE is thought to depend on when it was performed. We evaluate the optimal timing performing VCE relative to overt OGIB to improve the diagnostic yield. A total 271 patients had admitted and underwent VCE for overt OGIB between 2007 and 2016 in Samsung Medical Center, Seoul, Korea. To evaluate the diagnostic yield of VCE for overt OGIB with respect to timing of the intervention, diagnostic yield was analyzed according to the times after latest bleeding. The finding of VCE was classified into P0 or P1 (no potential for bleeding or uncertain hemorrhagic potential) and P2 (high potential for bleeding, such as active bleeding, typical angiodysplasia, large ulcerations or tumors). The P2 lesion was found in 106 patients and diagnostic yield of was 39.1% for overt OGIB. Diagnostic yield of VCE to detect P2 lesion was higher when it is performed closer to the time of latest bleeding (timing of VCE between the VCE and latest bleeding: <24 h, 43/63 (68.3%); 1 days, 16/43 (34.9%); 2 days, 18/52 (34.6%); 3 days, 13/43 (30.2%); 4 days, 7/28 (25.0%); 5–7 days, 6/24 (25.0%), and ≥8 days, 4/18 (22.2%); ptrend < 0.001). The interval between the VCE and latest bleeding were categorized into <24 h (n = 63), 1–2 days (n = 95), 3–7 days (n = 95) and ≥8 days (n = 18). Multivariable analyses showed the odds ratio for P2 lesion detection was 4.99 (95% confidence interval, 1.47–16.89) in <24 h group, compared with ≥8 days group (p < 0.010). The overall re-bleeding rate for those with P2 lesion was higher than for those with P0 or P1 lesion at the end of mean follow up of 2.5 years. The proportion of patients who underwent therapeutic intervention including surgery, endoscopic intervention and embolization was higher when VCE is performed closer to the time of latest bleeding (p = 0.010). Early deployment of VCE within 24 h of the latest GI bleeding results in a higher diagnostic yield for patients with overt OGIB and consequently resulted in a higher therapeutic intervention rate

A wrong path

Background and Aim: Obscure GI bleed in patients with cirrhosis is usually due to portal hypertension. Bleeding resulting from extrahepatic arterioportal fistulas (APFs) is extremely rare. We present a case of Obscure GI bleed secondary to APF and portal vein thrombosis successfully managed with coil embolization.