Overt Obscure Gastrointestinal Bleeding Research Articles

Video capsule endoscopy in overt and occult obscure gastrointestinal bleeding: Insights from a single-center, observational study in Japan.

This study aimed to evaluate the use of video capsule endoscopy (VCE) in patients with obscure gastrointestinal bleeding (OGIB), compare cases of overt and occult OGIB, assess the rates of balloon-assisted enteroscopy (BAE) interventions and rebleeding, and identify predictive markers of positive VCE findings. Medical records of 430 patients who underwent VCE for OGIB between 2004 and 2022 were analyzed. Occult OGIB was defined as IDA or positive fecal occult blood, whereas overt OGIB was defined as clinically imperceptible bleeding. We retrospectively analyzed demographics, VCE findings based on Saurin classification (P0, P1, and P2), outcome of BAE interventions, and rebleeding rates. A total of 253 patients with overt OGIB and 177 with occult OGIB were included. P1 findings were predominant in both groups, with a similar distribution. The percentage of patients receiving conservative therapy was higher in P1 than in P2 for both overt and occult OGIB. BAE was more frequently performed in P2 than in P1 VCE (83.0% vs. 35.3% in overt OGIB, 84.4% vs. 24.4% in occult OGIB). The percentage of positive findings and intervention in total BAE performed patients were comparable in P1 and P2 of overt OGIB, whereas these percentages in P2 were more than P1 of occult OGIB. VCE effectively identified OGIB lesions requiring intervention, particularly occult OGIB lesions, potentially reducing unnecessary BAE. Rebleeding rates varied according to the VCE findings, emphasizing the importance of follow-up in high-risk patients.

Early intervention with double balloon enteroscopy for higher yield for inpatient overt obscure gastrointestinal bleeding: A propensity matched analysis.

Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding. We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan-Meir survival curve showed GI bleed-free survival following initial bleed and was compared using the log rank test. A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity-score-matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed-free survival compared to those in the nonemergent group (P = 0.009). Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE.

A (Not So) Rare Cause of Obscure Gastrointestinal Bleed in Elderly

A 76-year-old woman presented with a 1-day history of bleeding per rectum and a syncopal episode. Her past medical history was notable for 2 episodes of melena in the previous 8 months, and evaluation by upper and lower endoscopy and computed tomography angiography had not identified a source of bleeding. The physical examination revealed pallor and there was maroon-colored stool on rectal examination. Her hemoglobin level was 6.3 g/dL at presentation. After resuscitation, urgent upper endoscopy and colonoscopy up to 10 cm of ileum followed by multidetector computed tomography angiography did not reveal any bleeding source. A videocapsule endoscopy showed blood in the ileum with no bleeding source. Novel motorized spiral enteroscopy revealed a solitary diverticulum in distal ileum, suggestive of Meckel diverticulum (Figure A). Meckel scan confirmed the presence of ectopic gastric mucosa. During laparoscopy a large wide-mouthed Meckel diverticulum was identified and excision with primary anastomosis was performed (Figures B and C). Gastrointestinal bleeding as a result of Meckel diverticulum should be considered as a differential diagnosis even in elderly patients. A high index of suspicion is necessary for diagnosis. Novel motorized spiral enteroscopy may be useful in the evaluation of patients with obscure overt gastrointestinal bleeding when a small bowel source is suspected. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkY2M1OWYyYWVmMWZmZTU5ZjVmNGNlMWU1MTA5NzNlOCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcyNTg3NzM0fQ.lP1rEC6Iy8N8YO69yqraGvWInBM0vPA8-AejgJRSFCKXA-pTgvJie207Rdn0R-68N90NO51Ea1845F0kkixsLijMM51V4a2rdoN_FqbD4xdGHUoRNKT2XXWQqN7v4UJWrK79sC0BXjJjKT-cxbihMb9dqe1WbUI9DqsxSPemQZzWFKw8btIQGv67-48gUxAH41tAIRcE_uJSjZwmGMi3gbexcnkMS2X7xnWGBfFq-p9M5SoF8Yf1JOWjRUy1fwI5_6oyc64R56mIKUR9335XdHehtHutczoyor132WSSLX6WabJhPfxP19b2m0dHqf5eRIpA929sByObeiVPEBAAAA Download .mp4 (5.38 MB) Help with .mp4 files Supplementary Video

Bedside Live-View Capsule Endoscopy in Evaluation of Overt Obscure Gastrointestinal Bleeding: A Pilot Point-of-Care Study

Background: Capsule endoscopy (CE) is an emerging tool in the diagnosis and management of occult bleeding and overt obscure gastrointestinal bleeding (OOGIB). Maximizing the efficiency of CE can lead to rapid bleeding localization and shorter time to therapy. We investigated whether a trained registered nurse (RN) can accurately interpret bleeding by observing the CE findings in real time by measuring inter-observer agreement between RN and physician interpretation. Methods: We conducted a prospective study of patients admitted for OOGIB who underwent live-view capsule endoscopy (LVCE) between December 2016 and November 2017. A matched control group who underwent standard CE was obtained through retrospective review. An RN received a 2-day training program for CE interpretation. RN bedside interpretation for bleeding was followed by interpretation by 2 gastrointestinal physicians blinded to LVCE findings. Outcomes were compared between groups using t-tests and χ² tests. Cohen’s kappa measured the agreement between the physicians and the RN. Results: Ten subjects were in the LVCE group, and 12 subjects were in the standard-of-care group. The agreement between the physicians and the RN was 9/10 (90%), with a kappa of 0.73 (95% CI: 0.26–1.00; p = 0.016). Patients in the LVCE group had shorter duration to physician interpretation (0.6 vs. 0.7 days [p = 0.50]), shorter duration to endoscopy (1.8 days vs. 3 days [p = 0.240]), and shorter length of stay (8.1 vs. 11.4 days [p = 0.26]) compared to the standard-of-care group. Conclusion: This study utilizing an RN for LVCE interpretation found inter-observer agreement between RN and physician findings. Larger studies are needed to assess whether this RN-physician team approach can translate to improved outcomes.

Clinical features of capsule endoscopy in young adults: A single-center retrospective study.

Background and AimCapsule endoscopy (CE) has been used in clinical examination among people of various ages, while few studies exclusively focused on the young. We aimed to explore its clinical features in young adults and those with obscure gastrointestinal bleeding (OGIB).MethodsA total of 479 young adults aged 18–44 years were analyzed, with median age of 33 years. Primary positive findings of patients were classified into four kinds of lesions, and potential risk of bleeding among patients with OGIB was assessed based on Saurin classification (P0‐2 lesions).ResultsThe overall completion rate and diagnostic yield of CE among young adults were 89.77 and 77.04%, respectively. Significant differences were found among overall completion rate/diagnostic yield and inpatient status/CE brand. Positive diagnostic yield among 157 patients with OGIB was 51.59% (P1‐2 lesions), and the significant risk of bleeding was 37.04% (P2 lesions). Among patients with OGIB in which 134 patients with a total of 216 lesions, ulceration was the commonest P2 lesions, followed by angioectasia and telangiectasia. Inpatient rate, completion rate, and diagnostic yield were higher among patients with overt OGIB, and disease categories of overt OGIB were different compared with occult OGIB.ConclusionCE is an optimal tool for discovering lesions in young adults and could play a role in evaluating the bleeding risk of young adults with OGIB.

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.

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

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

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

A guide for assessing the clinical relevance of findings in small bowel capsule endoscopy: analysis of 8064 answers of international experts to an illustrated script questionnaire

Background and aimAlthough recommended, the P-score used for assessing the pertinence / relevance of findings seen in small bowel (SB) capsule endoscopy (CE) is based on a low level of knowledge. The aim of this study was to evaluate the clinical relevance of the most frequent SBCE findings through an illustrated script questionnaire. Materials and MethodsSixteen types of SBCE findings were illustrated four times each in three different settings (occult and overt obscure gastrointestinal bleeding and suspected Crohn's disease), and with a variable number (n = 1/n = 2–5/n ≥ 6), thus providing a questionnaire with 192 scenarios and 576 illustrated questions. Fifteen international experts were asked to rate the finding's relevance for each question as very unlikely (−2) / unlikely (−1) / doubtful (0) / likely (+1) / very likely (+2). The median score (≤−0.75, between -0.75 and 0.75, or ≥0.75) obtained for each scenario determined a low (P0), intermediate (P1) or high (P2) relevance, respectively. Results8064 answers were analyzed. Participation and completion rates were 93% and 100%, respectively. In overt or occult OGIB, resultant P2 findings were 'typical angiectasia', 'deep ulceration', 'stenosis', and'blood', whatever their numbers, and 'superficial ulcerations' when multiple. While in suspected CD, consensus P2 lesions were 'deep ulceration' and 'stenosis' whatever their numbers, and 'aphthoid erosions' and 'superficial ulcerations' when multiple. ConclusionThis study establishes a guide for the evaluation of relevance of SBCE findings. It represents a step forward for SB-CE interpretation and is intended to be used as a tool for teaching and academic research.

Jejunal Dieulafoy's Lesion: A Systematic Review of Evaluation, Diagnosis, and Management.

Jejunal Dieulafoy’s lesion is an exceedingly rare but important cause of gastrointestinal bleeding. It frequently presents as a diagnostic and therapeutic conundrum due to the rare occurrence, intermittent bleeding symptoms often requiring prompt clinical action, variability in the detection and treatment methods, and the risk of rebleeding. We performed a systematic literature search of MEDLINE, Cochrane, Embase, and Scopus databases regarding jejunal Dieulafoy’s lesio from inception till June 2020. A total of 136 cases were retrieved from 76 articles. The mean age was 55 ± 24 years, with 55% of cases reported in males. Patients commonly presented with melena (33%), obscure-overt gastrointestinal bleeding (29%), and hemodynamic compromise (20%). Hypertension (26%), prior gastrointestinal surgery (14%), and valvular heart disease (13%) were the major underlying disorders. Conventional endoscopy often failed but single- and double-balloon enteroscopy identified the lesion in 96% and 98% of patients, respectively. There was no consensus on the treatment. Endoscopic therapy was instituted in 64% of patients. Combination therapy (34%) with two or more endoscopic modalities, was the preferred approach. With regard to endoscopic monotherapy, hemoclipping (19%) and argon plasma coagulation (4%) were frequently employed procedures. Furthermore, direct surgical intervention in 32% and angiographic embolization was performed in 4% of patients. The rebleeding rate was 13.4%, with a mean follow-up duration of 17.6 ± 21.98 months. The overall mortality rate was 4.4%. Jejunal Dieulafoy’s lesion is still difficult to diagnose and manage. Although the standard diagnostic and therapeutic modalities remain to be determined, device-assisted enteroscopy might yield promising outcomes.

Timing of enteroscopy in overt-obscure gastrointestinal bleeding: a systematic review and meta-analysis.

the impact of early enteroscopy on the outcome of overt-obscure gastrointestinal bleeding (OGIB) is still unclear. Our aim was to evaluate the impact of early enteroscopy on overt-OGIB. the PubMed-MEDLINE, Web of Science, and Scopus databases were systematically reviewed. Observational retrospective studies comparing early versus non-early enteroscopy in overt-OGIB were identified. Data on diagnosis, treatment, and rebleeding were extracted from each study, and a meta-analysis was performed. fifteen studies (comprising 1,907 patients) were included. Early enteroscopy was performed in 470 patients and non-early enteroscopy in 1,437 patients. Early enteroscopy was associated with a significantly higher diagnostic yield (odds ratio [OR] = 3.2, 95 % CI: 1.9-5.3; p = 0.002) and therapeutic yield (OR = 4.9, 95 % CI: 1.2-20.5; p = 0.03). However, moderate and high heterogeneity was observed in both analyses (DY I2 = 60.4 %; p = 0.002; TY I2 = 83.1 %; p < 0.001). When considering only studies where enteroscopy was performed during ongoing bleeding or within ≤ 24 h, ≤ 48 h, and ≤ 72 h of bleeding, heterogeneity was removed while the positive effect on diagnostic yield was maintained (OR = 4.7, 95 % CI: 3.4-6.6, p < 0.001, I2 = 0 %). Early enteroscopy did not significantly influence rebleeding rate (OR = 0.87, 95 % CI: 0.40-1.89, p = 0.72) in our analysis. in conclusion, early enteroscopy, especially when performed during ongoing bleeding or within 24 h, 48 h or 72 h of the bleeding episode, may increase diagnostic yield. Although an effect on therapeutic yield was observed, the value of early intervention has to be cautiously evaluated due to the high heterogeneity found among results. In our meta-analysis, early enteroscopy did not significantly influence rebleeding rate.

Hemobilia due to Ruptured Pseudoaneurysm of Accessory Right Hepatic Artery: A Rare Cause of upper Gastrointestinal Hemorrhage

Introduction: Anatomical variation of hepatic arteries are relatively common, but the occurence of pseudoaneurysm of hepatic arteries and its branches are rare,representing 0.01%-2% of all aneurysm. Method: We observed a case of 53 year old lady with the presentation of obscure-overt gastrointestinal bleeding associated with obstructive jaundice. Results: This patient had underwent computed tomography scan after repeated endoscopy failed to reveal the cause of bleeding, which has showed an arterially enhancing lesion at liver segment V with its supply from accessory right hepatic artery origin from superior mesenteric artery.This artery supplies segment V and segment VI of the liver. A subsequent digital substraction angiography demonstrated a large multilobulated pseudoaneurysm of this artery and successful embolization performed using gelfoam. A followup CT scan in 1 month later showed thrombosed pseudoaneurysm. Conclusions: This case has taught us that high suspicion of biliary disorder should be made when gastrointestinal bleeding is associated with jaundice. An early imaging should be considered when repeated endoscopy is unable to determine the cause of bleeding.Non operative management using transcatheter embolisation can be the treatment of choice in pseudoaneurysms to avoid potentially risky and difficult surgery.

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

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

Does urgent balloon-assisted enteroscopy impact rebleeding and short-term mortality in overt obscure gastrointestinal bleeding?

Background and aims The diagnostic yield (DY) and therapeutic yield (TY) of balloon-assisted enteroscopy (BAE) in overt obscure gastrointestinal bleeding (OGIB) is higher in the first 72 h. This study aimed to evaluate if this higher DY and TY after urgent BAE impacted the rebleeding rate, time to rebleed and short-term mortality. Methods Retrospective cohort-study, which consecutively included all patients submitted to BAE for overt OGIB, between 2010 and 2019. Patients were distributed in 2 groups: (1) Urgent BAE; (2) Non-urgent BAE. Rebleeding was defined as an Hb drop >2 g/dL, need for transfusional support or presence of melena/hematochezia. Results Fifty-four patients were included, of which 17 (31.5%) were submitted to BAE in the first 72 h. DY and TY of urgent BAE (DY 88.2%; n = 15; TY 94.1%; n = 16) was higher compared to non-urgent BAE (DY 59.5%; n = 22; TY 45.9%; n = 17) (DY p = .03) (TY p = .001). The rebleeding rate at 1, 2, and 5 years was 32.0%, 34.0%and 37.0%, respectively. Rebleeding was lower after urgent BAE (17.6%; n = 3) compared to non-urgent BAE (45.9%; n = 17) (p = .04). Rebleeding tended to occurr earlier in non-urgent BAE, being at 6-months (32.5%) and 36 months (41.3%) (p = .05). OGIB related 30-day mortality was 5.4% (n = 2) for non-urgent BAE and 0% for urgent BAE (p = .5). Conclusion Urgent BAE might be associated with higher DY and TY with lower rebleeding and trend toward higher rebleeding-free time.

Unusual Case of Massive Obscure Gastrointestinal Bleeding: Ectopic Varices in Jejunum Caused by Arteriovenous Malformation

Small bowel ectopic varices is a rare etiology for obscure gastrointestinal bleeding. Ectopic varices in the absence of portal hypertension can be caused by congenital or familial conditions (e.g. malformation of vessel). Bleeding caused by ectopic varices can be massive and life threatening. Single Balloon Enteroscopy (SBE) is one of diagnostic modalities for obscure gastrointestinal bleeding. We report one case of obscure overt gastrointestinal bleeding with sub-acute onset. Previous esophagogastroduodenoscopy and colonoscopy cannot found the source of bleeding. On the enteroscopy we found varices at proximal jejunum with active bleeding during procedure. We applied hemostatic powder to stop the bleeding and proceed to surgery. Surgery was performed by enteroscopy guide. The jejunum section with varices was resected and the pathology confirmed the malformation of arteriovenous. Currently there is no available guideline or randomized study for the treatment of ectopic varices. Treatment options include ligation, sclerotherapy, surgery and interventional radiology. In this patient we choose surgery because of massive gastrointestinal bleeding.

Low rate of recurrent bleeding after double-balloon endoscopy-guided therapy in patients with overt obscure gastrointestinal bleeding.

Double-balloon endoscopy (DBE) provides both diagnosis and treatment in overt obscure gastrointestinal bleeding (OGIB). The aim of this study was to evaluate the rebleeding rate after DBE. This retrospective review was conducted between January 2006 and July 2018, 166 patients with overt OGIB who underwent DBE were enrolled. Therapeutic intervention was defined as endoscopic treatment, embolization, or surgery. Primary outcome was rebleeding rate after DBE. The patients were divided into 3 groups based on their DBE; (1) positive DBE requiring therapeutic intervention (G1), (2) positive DBE without therapeutic intervention required (G2) and (3) negative DBE (G3). Cumulative incidence of rebleeding was estimated using the Kaplan-Meier method. Cox regression was used to assess the association of DBE with rebleeding risk. This study was approved by our Institutional Review Board. Sixty-eight patients (41%) were categorized in G1, 34 patients (20%) in G2 and 64 patients (39%) in G3. Overall rebleeding occurred in 24 patients (15%). The cumulative incidence of rebleeding for G1 was the lowest. The 1-year and 2-year cumulative probability of developing rebleeding after DBE in G1 were 3.5% and 3.5%, 8.2% and 14.0% in G2, and 18.2% and 20.6% in G3, respectively (p = 0.02). After adjusting for bleeding severity and comorbidities, patients with positive DBE requiring therapeutic intervention had a significantly lower rate of rebleeding when compared with patients who did not receive intervention (hazard ratio 0.17; 95% CI 0.03-0.90). DBE-guided therapeutic intervention was associated with a lower risk of rebleeding when compared with those with negative and positive DBE without therapeutic intervention. One-fifth of patients with overt OGIB had false negative after DBE.

Clinical Utility of Emergency Capsule Endoscopy for Diagnosing the Source and Nature of Ongoing Overt Obscure Gastrointestinal Bleeding.

Background and Aims In patients with ongoing overt obscure gastrointestinal bleeding (OGIB), prompt detection of the bleeding source is crucial to treatment success. However, there is no consensus on the optimal timing of diagnostic capsule endoscopy (CE). We investigated the clinical utility of emergency CE for detecting the source of ongoing overt OGIB. Methods We retrospectively evaluated 146 consecutive patients who, between February 2009 and July 2018, underwent emergency CE at Hiroshima University Hospital to detect the source of ongoing overt OGIB. Patients with a bleeding source located outside the small bowel were excluded. The remaining 127 patients were stratified according to the timing of CE relative to the onset of bleeding: patients in group A (n = 15, 12 men; mean age: 75 years; age range: 62–83 years) underwent CE within 48 hours of bleeding onset, whereas patients in group B (n = 112, 73 men; mean age: 65 years; age range: 17–88 years) underwent CE at >48 hours after bleeding onset. All patients underwent double-balloon endoscopy, and the final diagnosis was compared against the CE findings. Results The CE lesion detection rate was significantly higher in group A (12/15 patients, 80%) than in group B (53/112 patients, 47%) (p = 0.0174). There was no significant difference between the two groups regarding the patients' background characteristics. Vascular lesions were the most frequent finding in both groups. The diagnostic concordance rate between emergency CE and double-balloon endoscopy was 100% in group A and 92.9% in group B. Rebleeding after endoscopic treatment was confirmed in only one patient in group B. Conclusions Emergency CE represents a useful diagnostic modality in patients with ongoing overt OGIB, potentially improving detection rates and reducing rebleeding risk.

2612 Gastrointestinal Stromal Tumor Causing Obscure Gastrointestinal Bleeding: An Uncommon Way of Diagnosing an Uncommon Disease

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are neoplasms which arise from the tissue of the gastrointestinal tract or, rarely, from other intra-abdominal tissues. CT angiography can be utilized as an alternative imaging study when endoscopic and colonoscopy results are non-diagnostic. We report a case of a 59 year-old-female who presented with recurrent episodes of obscure overt gastrointestinal bleeding and was found to have a GIST. CASE DESCRIPTION/METHODS: A 59-year old woman with history of gastro-esophageal reflux disease presented to the emergency room with bright red blood per rectum and lower abdominal pain for one month. She reported one episode of melenic stool. Physical examination was unremarkable. Laboratory findings revealed a hemoglobin of 9.4 g/dL and a positive fecal occult blood test. Esophagogastroduodenoscopy (EGD) was non-diagnostic. Colonoscopy revealed fresh blood with clots at the terminal ileum, but no evident source of bleeding was identified. As the source of bleeding could not be accurately diagnosed with routine colonoscopy and EGD, an abdominal computed tomography angiography (CTA) was obtained. Abdominal CTA revealed a large exophytic, necrotic mass with hypervascularity to the right of the uterine fundus along with extensive vessels within the bowel wall. The mass, distal portion of the distal jejunum, portion of the terminal ileum were resected. Postoperative pathological examination revealed gastrointestinal stromal tumor (high grade, spindle cell variant). The patient is doing well at a four-month follow-up. DISCUSSION: Patients with GISTs can often be asymptomatic leading to a missed initial diagnosis. When symptomatic, patients often present with bleeding, anemia, mucosal ulceration or mass effect, depending on location. Occasionally they are discovered as incidental findings in radiologic imaging or as incidental findings during surgery or autopsy. Bleeding is the most common presenting symptom and is attributed to the erosion of the gastrointestinal tract lumen with tumor invasion, resulting in hematemesis, melena or anemia. This case offers a unique perspective of GIST diagnosis. In cases where a colonoscopy and EGD along with abdominal series is undiagnostic and capsule endoscopy/balloon enteroscopy are not available - CT angiography can be considered an alternative imaging procedure for the management of GIST tumors. In our case, CT angiography provided exact tumor location preoperatively allowing for appropriate surgical resection.

Predictive Factors for Rebleeding after Negative Capsule Endoscopy among Patients with Overt Obscure Gastrointestinal Bleeding

Background: Although capsule endoscopy (CE) is useful to evaluate obscure gastrointestinal bleeding (OGIB), CE does not always identify the responsible lesions in patients with overt OGIB. Objectives: To identify factors predictive of rebleeding after negative CE in patients with overt OGIB. Methods: We retrospectively analyzed the clinical data of 221 patients who underwent CE for overt OGIB. Among 120 patients with negative CE findings, clinical course of 112 patients after CE was followed-up. Clinical factors associated with rebleeding after negative CE and lesions responsible for rebleeding were investigated. Results: Rebleeding was identified in 37 patients (33.0%) during follow-up after negative CE, and 36 patients (32.1%) developed rebleeding within 24 months after negative CE. Multivariate analyses showed that ongoing overt OGIB (OR 2.67; 95% CI 1.07–5.80; p = 0.036) and severe anemia at the initial CE examination (OR 2.54; 95% CI 1.33–4.96; p = 0.005) were independent factors ­associated with rebleeding. Rebleeding source was detected in 13 patients. Conclusions: Rebleeding is not a rare condition among patients with overt OGIB after negative CE. Patients with ongoing overt OGIB or severe anemia at the initial CE examination seem to have a higher risk of rebleeding.

Outcomes in Patients with Left Ventricular Assist Devices, Pacemakers, and Implantable Cardioverter Defibrillators Undergoing Single Balloon Enteroscopy

Obscure overt gastrointestinal bleeding can be challenging to evaluate in patients with electronic cardiac devices such as continuous flow left ventricular assist devices (LVADs), pacemakers (PPMs), and implantable cardioverter defibrillators (ICDs). Limited data exist on the utility and safety of single balloon enteroscopy (SBE) in patients with cardiac devices. We aimed to evaluate the safety, efficacy, diagnostic, and therapeutic outcomes of the aforementioned devices in patients undergoing SBE. A retrospective study was performed using the medical records of 57 patients undergoing SBE at our institution from 2010 to 2014. Patients were divided into two groups: those with cardiac devices and those without. Data on comorbidities, complications, findings, diagnostic, and therapeutic yield were compared. t Test and logistic regression assessed the association between dependent and independent variables. For continuous data, the results were summarized as mean difference and standard deviation. For dichotomous data, the results were summarized as odds ratio and 95% confidence intervals. The overall age in patients with cardiac devices was 67.89 ± 6.96 versus 66.03 ± 11.95 years in the control. The cardiac device group was composed of 42.1% women; the control comprised 21.1% women. There were 19 patients with cardiac devices; 8 (LVAD + ICD), 1 (LVAD + PPM + ICD), 2 (PPM + ICD), 6 (PPM), 2 (ICD); 38 patients were in the control group. Patients with cardiac devices were hospitalized more often than patients without devices; this finding was not statistically significant (odds ratio 1.826, 95% confidence interval 0.544-6.128, P = 0.389). Procedure times were longer in the cardiac device group, 65.16 ± 49.92 minutes, when compared with the control, 57.40 ± 20.42, but it also did not reach statistical significance (mean difference 7.758, 95% confidence interval -11.360 to 26.876, P = 0.049). There was no statistically significant difference in major or minor events between patients with cardiac devices and the control group. Diagnostic and therapeutic yield and rebleeding rates were similar across both groups. Patients in the cardiac device group did not appear to be at any more significant risk than those without cardiac devices. Furthermore, diagnostic and therapeutic yield and rebleeding rates appear to be similar across both groups. Clinicians may perform SBE in these patients safely and effectively, with good overall outcomes.