Occult Gastrointestinal Bleeding Research Articles

Application of a novel swallowable telemetric device for real-time luminal blood detection to guide timing of enteroscopy in a patient with occult GI bleeding: a case report

Application of a novel swallowable telemetric device for real-time luminal blood detection to guide timing of enteroscopy in a patient with occult GI bleeding: a case report

Plasma urea:creatinine ratio as a biomarker of gastrointestinal bleeding in dogs with anaemia.

Gastrointestinal bleeding is a cause of anaemia in dogs. A reliable, non-invasive biomarker to differentiate gastrointestinal bleeding from other causes of anaemia would be advantageous to direct clinical decisions in anaemic patients. Plasma urea:creatinine ratio is an accepted biomarker of upper gastrointestinal bleeding in human medicine. The objective of this study was to evaluate plasma urea:creatinine ratio as a biomarker of gastrointestinal bleeding in a population of dogs with anaemia. This was a prospective cross-sectional study of dogs with anaemia presenting to referral centres for the investigation of anaemia. Cases were categorised as having overt gastrointestinal bleeding (melena on presentation), occult gastrointestinal bleeding (historical and diagnostic findings consistent with gastrointestinal bleeding without melena at presentation) or anaemia of other cause (confident diagnosis other than gastrointestinal bleeding reached, normal diagnostic imaging of gastrointestinal tract). Urea:creatinine ratio at presentation was calculated by dividing urea (mg/dL) by creatinine (mg/dL). Ninety-five dogs were included. Plasma urea:creatinine ratio was not significantly different between dogs with overt or occult gastrointestinal bleeding or those with anaemia of other cause (median urea:creatinine ratio 25.8, 20.7 and 22.5, respectively). No significant difference in urea:creatinine ratio was found between dogs with upper and lower gastrointestinal bleeding (median urea:creatinine ratio 19.4 and 24.6, respectively). Plasma urea:creatinine ratio was not helpful in differentiating between dogs with anaemia resulting from gastrointestinal bleeding (overt or occult) and those with other causes of anaemia.

Intestinal cavernous hemangioma as a cause of anemic syndrome and gastrointestinal bleeding

There are multiple causes of non-variceal gastrointestinal bleeding, some more commonly diagnosed than others. Therefore, the finding of a cavernous hemangioma in the jejunum should make us consider patients who present with anemic syndrome due to occult gastrointestinal bleeding, once the more common pathologies have been ruled out, this after extensive studies, including upper endoscopy, colonoscopy, imaging studies and some cases endoscopic capsule. It is described that cavernous hemangiomas account for 0.05% of gastrointestinal neoplasms and up to 7-10% of benign tumors of the small intestine. They can also be found in up to 7.7% of patients with gastrointestinal bleeding.

Anemia in canine chronic kidney disease is multifactorial and associated with decreased erythroid precursor cells, gastrointestinal bleeding, and systemic inflammation.

Compare erythropoiesis-related factors between different stages of canine chronic kidney disease (CKD). 8 healthy adult dogs (controls), and 24 dogs with CKD, equally divided into 3 groups based on International Renal Interest Society-CKD Guidelines (stage 2, 3, and 4) were recruited between December 2012 and December 2014. The following were assessed in all dogs and then compared between groups: bone marrow cytology, CBC, reticulocyte count, urinalysis, serum biochemistry, blood pressure, occult gastrointestinal bleeding, and serum concentrations of parathyroid hormone (PTH), erythropoietin, interleukin-1β, interleukin-3, tumor necrosis factor-α (TNFα), and interferon-γ. Erythropoiesis inducing and suppressing factors and the results of the bone marrow cytology of dogs in stage 2 CKD did not differ from the control group. The presence of reticulocytosis in CKD stage 2 suggests that blood loss or erythrocyte destruction might be contributing to developing anemia. Anemia in dogs with progressive CKD was associated with increasing PTH and TNFα and with elevation of the ratio of myeloid to erythroid precursor cells caused by hypoplasia of the erythroid series. The latter was represented mainly by a decrease in the population of polychromatophilic rubricytes and metarubricytes. Increased PTH and TNFα seem to contribute to the reduced percentage of polychromatophilic rubricytes and erythroid population, thereby aggravating the anemia of dogs with advanced CKD. Gastrointestinal blood loss contributes to anemia in all canine CKD stages.

An Exceptional Presentation of “Watermelon Stomach” in a 30- Year-Old Cirrhotic Male

Gastric antral vascular ectasia (GAVE) is an unusual cause of chronic upper gastrointestinal bleeding commonly described in elderly females, with associated autoimmune diseases, and in cirrhotic males. The entity is characterized by angioectasia in the pyloric antrum, giving its classic streaky “watermelon stripe” appearance. This report highlights the rare presentation of a 30-year-old male with liver cirrhosis, who presented with anemia and fatigability. Diagnosis of GAVE was made using endoscopy, and trials of argon plasma coagulation were administered. Following this, an antrectomy was performed since there was a further drop in hemoglobin. The patient made a full recovery with no subsequent dependence on blood transfusions. GAVE can be mistakenly underdiagnosed as a treatable cause of occult gastrointestinal bleeding. This report mandates caution on endoscopy for younger patients with an upper gastrointestinal bleed while taking other more common causes of gastrointestinal bleeding (peptic ulcers, esophageal varices, and non-steroidal anti-inflammatory drugs [NSAID]-induced gastritis) into account.

A study of the risk factors and outcome in patients with upper gastrointestinal bleed presenting to a tertiary care center in Kumaon region of Uttarakhand

Background: Upper gastrointestinal (GI) bleeding refers to blood loss within the intraluminal GI tract from any location between the upper esophagi to the duodenum at the level of the ligament of Treitz. Bleeding from the upper GI tract may present as hematemesis, melena, hematochezia, occult GI bleeding, and anemia. Aims and Objectives: The aims of this study were to study the risk factors and outcome in upper GI bleed patients presenting to a tertiary care center in Kumaon region of Uttarakhand. The primary objective was to estimate the proportion of mortality in upper GI bleed patients attending a tertiary care center. The secondary objective was to study the risk factors associated with upper GI bleed and their effect on mortality. Materials and Methods: This was a hospital-based observational prospective clinical study, carried out in the Department of General medicine, Dr. Susheela Tiwari Memorial Hospital and associated Government Medical College, Haldwani, from January 2020 to September 2021 after obtaining ethical clearance from the Institutional Review Committee and informed consent from the patient or patient relatives. Statistical testing has been conducted with the Statistical Package for the Social Science software (SPSS version 20.0). Results: The factors associated with mortality using multivariate analysis were high international normalized ratio (INR), low albumin, raised serum glutamic oxaloacetic transaminas, high Child Pugh Score, and high model for end stage liver disease (MELD) score found to be significant. Conclusion: The mortality rate in our patients was 18% and factors associated with increased mortality were high INR, low Albumin, raised creatinine, high Child Pugh Score, high MELD score, and presence of spontaneous bacterial peritonitis.

Clinical characteristics of blue rubber bleb nevus syndrome in adults: systematic scoping review

Background Blue rubber bleb nevus syndrome (BRBNS) is a rare systemic vascular anomaly mainly affecting the skin, central nervous system and gastrointestinal tracts. Its clinical presentation and characteristics in adult patients are unclear. Aim To clarify the characteristics of BRBNS in adult patients with a focus on gastrointestinal symptoms. Methods Following the PRISMA Extension for Scoping Reviews, we searched MEDLINE and EMBASE for all peer-reviewed articles using keywords including ‘Blue rubber bleb nevus syndrome’ from their inception to 28 December 2021. Results Ninety-nine articles, including 3 observational studies and 101 cases from case reports and series, were included. Observational studies were consistently with small sample sizes, and there was only one prospective study to show the effectiveness of sirolimus in BRBNS. Common clinical presentations included anemia (50.5%) and melena (26.5%). While skin findings were known to be representative of BRBNS, only 57.4% had known vascular malformation. The diagnosis was primarily made clinically, with only 1% being diagnosed with BRBNS through genetic sequencing. Distribution of BRBNS-related lesions were variable, but predominantly oral (55.9%), followed by small bowel (49.5%), colorectal (35.6%) and stomach (26.7%) vascular malformations. Conclusion While it has been underrecognized, adult BRBNS could be a culprit for refractory microcytic anemia or occult gastrointestinal bleeding. Further studies are critical to establish a uniform understanding of diagnosis and treatment for those with adult BRBNS. The utility of genetic testing in adult BRBNS diagnosis and the patient characteristics that may benefit from sirolimus, a potentially curative agent, remain to be clarified.

A practical approach for small bowel bleeding.

Gastrointestinal (GI) bleeding is one of the most common conditions among patients visiting emergency departments in Korea. GI bleeding is divided into upper and lower GI bleeding, according to the bleeding site. GI bleeding is also divided into overt and occult GI bleeding based on bleeding characteristics. In addition, obscure GI bleeding refers to recurrent or persistent GI bleeding from a source that cannot be identified after esophagogastroduodenoscopy or colonoscopy. The small intestine is the largest part of the alimentary tract. It extends from the pylorus to the cecum. The small intestine is difficult to access owing to its long length. Moreover, it is not fixed to the abdominal cavity. When hemorrhage occurs in the small intestine, the source cannot be found in many cases because of the characteristics of the small intestine. In practice, small-intestinal bleeding accounts for most of the obscure GI bleeding. Therefore, in this review, we introduce and describe systemic approaches and examination methods, including video capsule endoscopy and balloon enteroscopy, that can be performed in patients with suspected small bowel bleeding in clinical practice.

隐匿性消化道出血一例并文献复习

隐匿性消化道出血一例并文献复习

Radiologic Diagnosis of Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is not a single disease but a symptom and clinical manifestation of a broad spectrum of conditions in the GI tract. According to its clinical presentation, GI bleeding can be classified into overt, occult, and obscure types. Additionally, it can be divided into upper and lower GI bleeding based on the Treitz ligament. Variable disease entities, including vascular lesions, polyps, neoplasms, inflammation such as Crohn's disease, and heterotopic pancreatic or gastric tissue, can cause GI bleeding. CT and conventional angiographies and nuclear scintigraphy are all radiologic imaging modalities that can be used to evaluate overt bleeding. For the work-up of occult GI bleeding, CT enterography (CTE) can be the first imaging modality. For CTE, an adequate bowel distention is critical for obtaining acceptable diagnostic performance as well as minimizing false positives and negatives. Meckel's scintigraphy can be complementarily useful in cases where the diagnosis of CTE is suboptimal. For the evaluation of obscured GI bleeding, various imaging modalities can be used based on clinical status and providers' preferences.

Effect of small bowel transit time on accuracy of video capsule endoscopy in evaluating suspected small bowel bleeding.

Obscure small bowel bleeding is defined as gastrointestinal bleeding (GIB) that is unidentifiable with esophagogastroduodenoscopy and a colonoscopy with video capsule endoscopy (VCE) being the next gold standard step for evaluation. Small bowel transit time (SBTT) is a metric of a VCE study that is defined as the time the capsule takes to travel through the small intestine. To determine if SBTT within the VCE study, correlates to overall detection of obscure small bowel bleeds. Furthermore, we attempted to identify any existing correlation between SBTT and re-bleeding after a negative VCE study. This is a single center retrospective analysis of VCE studies performed for overt and occult GIB at Einstein Medical Center, Philadelphia, between 2015 and 2019. Inclusion criteria primarily consisted of patients 18 years or older who had a VCE study done as part of the workup for a GIB. Patients with incomplete VCEs, poor preparation, or with less than 6 mo of follow up were excluded. A re-bleeding event was defined either as overt or occult within a 6-mo timeframe. Overt re-bleeding was defined as Visible melena or hematochezia with > 2 gm/dL drop in hemoglobin defined an overt re-bleeding event; whereas an unexplained > 2 gm/dL drop in hemoglobin with no visible bleeding defined an occult re-bleed. Results indicated that there was a significant and positive point biserial correlation between SBTT of 220 min and detection of a bleeding focus with a statistically significant p value of 0.008. However, the area under the curve was negligible when trying to identify a threshold time for SBTT to discriminate between risk of re-bleeding events after a negative VCE. In terms of SBTT and association with accuracy of VCE finding a bleeding focus, 220 min was found to be adequate transit time to accurately find a bleeding focus, when present. It was found that no threshold SBTT could be identified to help predict re-bleeding after a negative VCE.

S3614 Gastric Linitis Plastica - An Easily Missed Diagnosis

Introduction: Gastric cancer remains one of the most common malignancies worldwide, with large variations based on genetic, ethnic, geographic, and socioeconomic factors. Patients can present with nonspecific abdominal pain, weight loss, early satiety, or anemia from occult gastrointestinal bleeding. Gastric linitis plastica, a diffuse type of gastric adenocarcinoma, results in proliferation of fibrous tissue in the submucosa and muscle layers of the stomach wall. Biopsy will show classic signet ring cells or poorly differentiated tumor cells. Case Description/Methods: A 54-year-old Caucasian male with a past medical history of end stage renal disease, hypertension, type II diabetes mellitus presented to the hospital for fatigue and melena. His hemoglobin was 7.3 g/dL, which was approximately 3g lower than his most recent hospitalization two weeks prior. He underwent upper endoscopy, which revealed a well-demarcated region of severely congested, erythematous, and friable mucosa with a reticular appearance localized to the gastric cardia, fundus, and body (Figure A and B). Histopathology revealed intramucosal adenocarcinoma with high-grade signet ring features (Figure C), consistent with gastric linitis plastica. Staining for Helicobacter pylori was negative. He was treated with acid suppression. The patient had a prolonged hospital course complicated by hypoxic respiratory failure and eventual cardiac arrest resulting in his death. Discussion: We present here a case of gastric linitis plastica. This is a diffuse type of gastric adenocarcinoma that involves the deeper layers of the stomach wall, making the stomach firm and non-distensible. It is not associated with Helicobacter pylori infection. Diagnostic upper endoscopy remains the gold standard for evaluation, however such malignancies that spare the mucosa can be easily missed on endoscopy or histopathology. The lack of mucosal involvement decreases the yield of endoscopy and biopsy, and findings on computed tomography imaging of the abdomen lack specificity. Early diagnosis remains challenging, as endoscopic findings are less sensitive. Clinicians should maintain a high index of suspicion for this condition with findings of localized congested-appearing gastric mucosa, especially with distinct demarcation and regional non-distensibility of the gastric lumen. Deeper biopsies using “bite-on-bite” technique or endoscopic ultrasound guided fine needle biopsy should be considered.Figure 1.: A and B. Reticular appearance of gastric mucosa in linitis plastica. Figure C. Pathology of gastric biopsy demonstrating the classic appearance of signet ring cells in linitis plastica.

S1754 Late Metastatic Recurrence of Renal Cell Cancer to the Pancreas Presenting With Occult Gastrointestinal Bleeding and Symptomatic Anemia

S1754 Late Metastatic Recurrence of Renal Cell Cancer to the Pancreas Presenting With Occult Gastrointestinal Bleeding and Symptomatic Anemia

S3739 An Elusive Diagnosis: Primary Gastric Melanoma With Metastatic Disease Presenting as Occult Gastrointestinal Bleed

S3739 An Elusive Diagnosis: Primary Gastric Melanoma With Metastatic Disease Presenting as Occult Gastrointestinal Bleed

Which model of small bowel capsule endoscopy has a better diagnostic yield? A systematic review and meta-analysis.

Small-bowel capsule endoscopy (SBCE) is a safe and efficient method for diagnosis of small-bowel diseases. Since its development, different models have appeared. The aim of this study was to analyze which of the different models of SBCE has the best diagnostic yield. Extensive medical literature research was reviewed, using MESH terms, searching studies comparing different SBCE types. We analyzed the diagnostic yield of all the comparisons and when there were 2 or more studies that compared the same model of SBCEs, a meta-analysis was performed. Ten eligible studies including 1065 SBCEs procedures were identified. The main indication was occult gastrointestinal bleeding in 9/10 studies. Two of them included anemia, chronic diarrhea and/or chronic abdominal pain. The indication in one article was celiac disease. In 9 studies, different types of SBCEs (MiroCam, Endocapsule, OMOM and CapsoCam) were compared with PillCam (SB, SB2 and SB3). Three studies compared MiroCam vs PillCam and CapsoCam vs PillCam, while two studies contrast Endocapsule vs PillCam. None of the SBCEs show superiority over PillCam [OR 0.78 (95%CI;0.60-1.01)]. One study compared SBCEs other than Pillcam (MiroCam vs Endocapsule). Nine studies did not find statistical differences between SBCEs, one showed better diagnostic yield of Mirocam compared with PillCam SB3 (p=0.02). The difference between these SBCE was not replayed in the metaanalysis [OR 0.77 (95%CI;0.49-1.21)]. Despite the appearance of new SBCE models, there are no differences in diagnostic yield; therefore, SBCE endoscopist's performance should be based on experience and availability.

Single-Balloon-Assisted Enteroscopy With Endoscopic Mucosal Resection of a Bleeding Jejunal Lymphangioma.

CASE REPORT Lymphangiomas are rare tumors with <1% found in the jejunum or ileum.1 Typically asymptomatic, lymphangiomas can cause gastrointestinal bleeding, intussusception, or protein-losing gastroenteropathy.1–3 We present a case of occult gastrointestinal bleeding caused by a lymphangioma, successfully removed by endoscopic mucosal resection by an upper single-balloon-assisted enteroscopy. A healthy, asymptomatic 75-year-old man had routine tests that revealed a new normocytic anemia: hemoglobin 12.9 g/dL, previously 15 g/dL. Upper endoscopy and colonoscopy were normal. Over 6 months, he developed weakness, worsened microcytic anemia (hemoglobin 8.5 g/dL), and iron deficiency. Celiac disease serology was negative. Video capsule endoscopy captured a white-speckled lesion with fresh blood at 25% of the small bowel transit (Figure 1). An upper single-balloon-assisted enteroscopy localized the polyp in the proximal jejunum (Figure 2). The polyp was lifted with hetastarch-epinephrine-methylene blue, and en bloc endoscopic mucosal resection was performed (Figure 3). Pathology confirmed a lymphangioma (Figure 4). The patient's hemoglobin normalized and symptoms resolved.Figure 1.: A submucosal polypoid lesion with a white and red speckled surface was captured in 1 single image.Figure 2.: An upper single-balloon-assisted enteroscopy localized a 12 mm white-speckled, bleeding, sessile polyp in the proximal jejunum.Figure 3.: The polyp submucosa was injected with a long-lasting lifting agent and resected en bloc using snare cautery endoscopic mucosal resection.Figure 4.: Pathology revealed dilated lymphatic vessels (stars) in the lamina propria consistent with a lymphangioma.Bleeding from lymphangioma is proposed by lymphatic obstruction, increasing lymphatic-venous pressures.4 Surgical resection is the standard for the management of symptomatic jejunal and ileal lymphangiomas.1,2 Similarly, there are only 2 other reported cases of endoscopically treated small bowel lymphangiomas,4,5 demonstrating that endoscopic management is feasible with experienced endoscopists. DISCLOSURES Author contributions: J. Trieu and A. Dua wrote the original manuscript. N. Gupta, RP Venu, and M. Venu critically reviewed the manuscript before submission. Mukund Venu is the article guarantor. Financial disclosure: None to report. Previous presentation: The case was submitted to Digestive Disease Week 2021 but not presented. It received an honorable mention from the ASGE. DDW 2021 was a virtual conference held on May 21-24. Informed consent was obtained for this case report.

Efficacy and safety of capsule endoscopy in octogenarian patients: a retrospective study.

Life expectancy and the number of ultra-octogenarians increased significantly, thus making crucial the appropriateness of several endoscopic procedures in elderly patients. The aim of our study was to provide a retrospective analysis of the efficacy and safety of capsule endoscopy (CE) in patients aged over 80 years. In this single-centre study, 900 patients underwent capsule endoscopy between 2002 and 2015 for different indications; of these 106 patients aged ≥80 years (group A) and 99 patients aged 40-60 years (control group B) were retrospectively selected. Occult gastrointestinal bleeding accounted for 62.1% of all indications for capsule endoscopy in group B, compared to 95.2% in group A (P<0.001). Although not statistically significant, the diagnostic yield was higher in group A (71%) vs. group B (62%). The percentages of reaching the cecum and the median gastric transit time were uniform within the two groups. In contrast, small bowel transit time was longer in group A vs. B. Small bowel preparation was similar in the two groups. The exam was generally well tolerated in both groups, with capsule aspiration being one of the main adverse events, which occurred in two elderly patients. Our data expand previous findings confirming that capsule endoscopy can be performed safely even in very old patients and show that the diagnostic yield is similar to that of younger patients.

Prolonged Intestinal Transit Time and Its Relation with Capsule Endoscopy Diagnostic Yield.

Capsule endoscopy is a gold standard diagnostic method for small bowel lesions. There is scarce evidence regarding vari- ables that may increase the odds of identifying small bowel lesions with this endoscopic method. The aim of this work is to describe variables associated with a higher probability of finding small bowel lesions on capsule endoscopy. Cross-sectional study was performed using our Department's adult patients' capsule endoscopy database. The presence of any small bowel mucosal lesion was registered. Other variables were examined: age, gender, reason for referral, quality of bowel cleans- ing, and intestinal transit time. These variables were compared between those patients showing at least 1 lesion versus those without lesions. Univariate and multivariate analysis was performed to determine variables significantly associated with the presence of bowel lesions. In total, 140 studies were analyzed; 90% were performed due to occult gastrointestinal bleeding. Median age was 69 years (60-75); 54.29% were males. Bowel cleansing was adequate in 94.29%; 68.57% showed at least 1 lesion. Non-significant difference was observed in terms of age between groups of comparison (70 [61-76] vs 63 [59-74], P = .07). No difference was found comparing bowel cleansing, gender, or reason for referral. Intestinal transit time was significantly longer among those patients with a bowel lesion (359 minutes [257-427] vs 279 minutes [200-333], P = .05). On multivariate analysis, age and intestinal time were significantly associ- ated with the presence of at least one small bowel lesion (odds ratio 1.02 [1-1.06] and 1.09 [1.03-1.12], respectively). Age and intestinal transit time were significantly associated with the presence of abnormal findings on capsule endoscopy.

Helminth Infections in Children.

Helminth Infections in Children.

Utility of video capsule endoscopy in clinical practice, experience at King Faisal Specialist Hospital and Research Center, Riyadh

Background: Video capsule endoscopy (VCE) is a valuable diagnostic tool for the evaluation of the small intestine. Evidence shows that it is effective in the diagnosis of occult bleeding and superficial lesions that are not radiographically observed. We evaluated the efficacy and safety of the capsule endoscopy in the diagnosis and management of the common gastrointestinal disorders.Methods: A retrospective chart review of a total of 326 candidates who have met the inclusion criteria and who underwent VCE from the period from January 2006 till December 2018.Results: The main indication for Video Capsule Endoscopy was small bowel overt gastrointestinal bleeding with 106 cases (32.6%) followed by iron deficiency anemia with 104 cases (32%). Capsule retention rate was observed in 11 cases (3.4%) 4 of which were crohn’s disease patients (22.2%). Overall diagnostic yield was 36%, 64% for overt gastrointestinal bleeding and 41% for occult gastrointestinal bleeding. The most common reported positive finding was Angiodysplasia in 19.9% of cases, followed by ulcers in 13.8% of cases, followed by polyps in 8.3% of cases and erosions in 8% of cases.Conclusions: Video capsule endoscopy proved to be an essential diagnostic tool in gastrointestinal bleeding. Advantages of VCE include; less labor, higher resolution examination of mucosa, relative safety, and noninvasiveness. On the other hand, it does not offer intervention capabilities when compared with enteroscopy and its interpretation was sometimes difficult and time consuming. Risk of capsule retention remains significant especially in patients suffering from crohn’s disease.