Recurrent Obscure Gastrointestinal Bleeding Research Articles

Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease.

Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.

Hemorragia digestiva de origen oscuro: “una causa no sospechada”

La hemorragia digestiva de origen oscuro se presenta en el 5 -10% del sangrado intestinal, con persistencia o recurrencia en el 50%, de los casos. Es ocasionado por varías etiologías, generando un desafío diagnóstico que requiere la realización de varios procedimientos endoscópicos. Entre las causas inusuales se encuentran las parasitosis intestinales por nematodos, siendo prevalentes en zonas tropicales y países en vía de desarrollo. Presentamos el caso de una paciente con hemorragia digestiva de origen oscuro manifiesto recurrente desencadenado por Ascaris lumbricoides, quien requirió varias hospitalizaciones, soporte transfusional y realización de un set de procedimientos endoscópicos previo al diagnóstico etiológico y posterior tratamiento planteando la necesidad de conocer la real costo efectividad de la desparasitación profiláctica en todo paciente con hemorragia intestinal y primera evaluación endoscópica estándar negativa, teniendo en cuenta la alta prevalencia de nematodos en nuestro país.

Continuing challenges in the diagnosis and management of obscure gastrointestinal bleeding.

The diagnosis and management of obscure gastrointestinal bleeding (OGIB) have changed dramatically since the introduction of video capsule endoscopy (VCE) followed by deep enteroscopy and other imaging technologies in the last decade. Significant advances have been made, yet there remains room for improvement in our diagnostic yield and treatment capabilities for recurrent OGIB. In this review, we will summarize the latest technologies for the diagnosis of OGIB, limitations of VCE, technological enhancement in VCE, and different management options for OGIB.

Long-Term Outcomes After Single-Balloon Enteroscopy: Are They Any Different from Double-Balloon Enteroscopy for Vascular Lesions?

Obscure GI bleeding is uncommon, accounting for approximately 5 % of all GI bleeding episodes [1]. With the advent of capsule endoscopy and introduction of balloon enteroscopy to the United States in 2004, endoscopic visualization of the small bowel has become feasible and successful. Double-balloon enteroscopy (DBE) is associated with diagnostic yields of approximately 50–60 %, which exceed 70 % in patients with obscure gastrointestinal bleeding (OGIB) [2]. Performance of video capsule endoscopy (VCE) prior to deep enteroscopy is associated with increased diagnostic yields. In an updated metaanalysis, the yield for DBE was 75 % when a prior VCE study was abnormal, but only 27 % after a negative VCE examination [3]. Single-balloon enteroscopy (SBE) was subsequently introduced into US clinical practice in 2008 in an effort to reduce time and complexity of the double-balloon procedure. Instead of using a second balloon on the distal end of the enteroscope as an anchor when the overtube is advanced, the tip of the enteroscope is deflected during the SBE procedure, creating a ‘‘hook’’ which functions similarly to the second balloon on the DBE enteroscope. Although less data have been published regarding SBE outcomes compared with DBE, initial studies reported somewhat lower diagnostic yields, potentially due to decreased rates of total enteroscopy [4, 5]. Higher total enteroscopy rates and therapeutic interventions with DBE compared to SBE were reported when the enteroscope balloon was removed from the Fujinon system [6]. Nevertheless, a subsequent randomized controlled trial did not confirm these results [7]. In this issue of Digestive Diseases and Sciences, Kushnir et al. [8] from Washington University School of Medicine performed a retrospective cohort study in order to determine long-term outcomes after SBE. While longterm outcomes studies have been performed for DBE and are discussed below [9, 10], this literature contribution is the first long-term outcomes assessment for SBE. Given the conflicting data regarding efficacy of SBE compared to DBE, the major question is whether recurrent bleeding rates differ post-SBE compared to published rates postDBE. In this study, the authors reviewed 147 SBE examinations performed for the evaluation of OGIB between 2008 and 2010, following 110 (75 %) patients for a mean of 24 months post-procedure. Patients who participated in the follow-up phone calls or visits were more likely to have undergone SBE with positive findings in the small bowel leading to endoscopic therapy compared with patients who were lost to follow-up post-enteroscopy (69 vs. 35 %, p 0.001). Seventy percent of the patients had undergone VCE studies before the enteroscopy examination. Significant lesions in the small bowel including vascular, ulcerative, and/or suspected neoplasms were detected in 91 % of the patients undergoing capsule endoscopy. A source of bleeding was identified in 95/147 (65 %) SBE examinations including vascular lesions in 54 %, ulcers or erosions in 5 %, and small bowel masses in 3 %. Endoscopic therapy was performed in 76 (52 %) patients, and an additional eight were referred to surgery. Recurrent OGIB occurred in 50/110 (45 %) patients available for follow-up. The authors were unable to find any risk factors associated with recurrent OGIB including Charlson co-morbidity index score, although the number of patients with valvular heart disease (22 %) was small. Recurrent bleeding occurred overall in 31/76 (41 %) of patients with a source found on SBE, and in 19/34 (56 %) of patients with normal L. B. Gerson (&) Stanford University School of Medicine, Stanford, CA, USA e-mail: lgersonmd@yahoo.com

Is a Repeat Double Balloon Endoscopy in the Same Direction Useful in Patients With Recurrent Obscure Gastrointestinal Bleeding?

To evaluate the usefulness of repeat double balloon endoscopy (DBE) in obscure gastrointestinal bleeding (OGIB). OGIB recurs in 11% to 42% of patients after DBE. Little is known about the outcome of repeat DBE in recurrent OGIB after DBE. We reviewed clinical course of patients who underwent repeat DBE for recurrent OGIB in the same direction as in previous DBE. Diagnostic yield and therapeutic intervention of repeat DBE were analyzed. Thirty-five repeat DBEs were performed in 32 patients (M:F=15:17; age range, 36 to 85 y). The first DBE identified a probable bleeding source in 21 (65.6%) patients. Angiodysplasia was the most common and was found in 16 patients. The second DBEs were performed after a median of 30 weeks (range, 1 to 204 wk). Oral approach only was performed in 28 patients and anal approach only in 4. Probable bleeding sources were detected in 17 (53.1%) patients. Sixteen (94.1%) cases were angiodysplasia, of which 14 patients had angiodysplasia also at the first DBE. All detected bleeding sources were managed with endoscopic interventions such as argon plasma coagulation. Seventeen of 21 patients with positive first DBE showed bleeding source at the repeat DBE, whereas none of the 11 patients with negative first DBE did (81.0% vs. 0%; P<0.001). Three patients underwent the third DBE. Angiodysplasias were detected in 2 patients (66.7%). Repeat DBE in the same direction may detect bleeding sources in 53% of recurrent OGIB patients. The probability of bleeding source detection in repeat DBE is higher in patients with a prior positive DBE.

Diffuse Large B-Cell Lymphoma of the Small Bowel as an Unusual Cause for Recurrent Obscure Gastrointestinal Bleeding: Diagnosis by Video Capsule Endoscopy

R obscure gastrointestinal bleeding is a potentially life-threatening condition and accounts for 5% of all gastrointestinal bleeding episodes.1 In the majority of cases, the bleeding source is located in the small bowel. Diagnostic procedures typically comprise esophagogastroduodenoscopy and colonoscopy. In recent years, new endoscopic tools have been developed to further examine the small bowel. These tools include singleand double-balloon enteroscopy as well as video capsule endoscopy (VCE). A 51-year-old man was admitted to our department for further diagnostics of recurrent obscure gastrointestinal bleeding. At the time of admission, he presented with melena and weakness as bleeding symptoms. His hemoglobin level had dropped

Sa1738 Is a Repeated Double Balloon Endoscopy Through the Same Direction Useful in Patients With Recurrent Obscure Gastrointestinal Bleeding?

Sa1738 Is a Repeated Double Balloon Endoscopy Through the Same Direction Useful in Patients With Recurrent Obscure Gastrointestinal Bleeding?

Sa1710 Long-Term Outcomes After Single Balloon Enteroscopy in Patients With Obscure Gastrointestinal Bleeding

The small bowel (SB) is the most common source of blood loss in patients with obscure gastrointestinal bleeding (OGIB). Without specific therapy 60-75% of patients with OGIB experience continued GI blood loss. The rate of recurrent OGIB after double balloon enteroscopy (DBE) has been reported to be 40% at 30 months of follow up. The impact of single balloon enteroscopy (SBE) on the long-term outcomes of patients with OGIB has not been established.

Long-Term Outcome of Patients Treated With Double Balloon Enteroscopy for Small Bowel Vascular Lesions

Early rebleeding rate after endoscopic therapy with double balloon enteroscopy (DBE) of hemorrhagic small bowel vascular lesions (SBVL) varies between 10 and 50%. In recent reports, long-term follow-up of patients have been described but rebleeding risk factors are still not well established. The aim of the current study was to identify long-term treatment success rate and rebleeding risk factors after DBE therapy in a large cohort. We conducted a single-center, retrospective cohort study in a large French tertiary-referral center between January 2004 and December 2007. Among 261 patients presenting with obscure gastrointestinal bleeding (OGIB), SBVL was present in 133 patients and was treated successfully in 129 (97%) using mainly argon plasma coagulation. Ninety-eight patients were followed up for a mean period of 22.6±13.9 months (range 1-52). Rebleeding rate was 46% (45/98 patients) at 36 months. On multivariate analysis, the total number of observed lesions (hazard ratio (HR): 1.15, 95% confidence interval (CI): 1.06-1.25, P=0.001) and the presence of a valvular and/or arrhythmic cardiac disease (HR: 2.50, 95% CI: 1.29-4.87, P=0.007) were significantly associated with the risk of rebleeding. Complication rate of therapeutic DBE was 2.3% with no mortality. Endoscopic therapy using DBE for SBVL in patients with recurrent OGIB allows a long-term remission in more than half of the patients. Independent rebleeding risk factors after a first endoscopic therapy are an increased number of SBVL and an associated valvular/arrhythmic heart disease.

Inverted Meckel’s diverticulum mimicking an ulcerated pedunculated polyp: detection by single-balloon enteroscopy

A 19-year-old woman was referred to our hospital because of recurrent obscure gastrointestinal bleeding. Abdominal computed tomography revealed one heterogeneous lesion with soft tissue and accumulation of fluid over the distal ileum ([Fig. 1]).

Recurrent Obscure Gastrointestinal Bleeding: Dilemmas and Success with Pharmacological Therapies. Case Series and Review

The present article describes three difficult cases of recurrent bleeding from obscure causes, followed by a review of the pitfalls and pharmacological management of obscure gastrointestinal bleeding. All three patients underwent multiple investigations. An intervening complicating diagnosis or antiplatelet drugs may have compounded longterm bleeding in two of the cases. A bleeding angiodysplasia was confirmed in one case but was aggravated by the need for anticoagulation. After multiple transfusions and several attempts at endoscopic management in some cases, long-acting octreotide was associated with decreased transfusion requirements and increased hemoglobin levels in all three cases, although other factors may have contributed in some. In the third case, however, the addition of low-dose thalidomide stopped bleeding for a period of at least 23 months.

Multifocal small-bowel carcinoid tumor causing obscure recurrent gastrointestinal bleeding diagnosed by capsule endoscopy

A 38-year-old woman presented to our hospital with a 2-day history of passing black tarry stools. She had a history of recurrent obscure gastrointestinal bleeding, manifested by hematochezia and iron-deficiency anemia for 2 years, and had had six negative upper endoscopies and six negative colonoscopies prior to this presentation. A small-bowel series and computed tomography of the abdomen were both negative. Because conventional studies failed to find a source of bleeding and because the bleeding persisted, the patient was referred for a small-bowel video capsule endoscopy (Given Imaging Ltd., Yoqneam, Israel). The study was limited due to prolonged retention of the capsule in the stomach but nevertheless it revealed multiple submucosal masses in the distal ileum, some of which were umbilicated and ulcerated, with stigmata of recent bleeding ([Fig. 1], Videos 1, 2).

Obscure gastrointestinal bleeding and calcific aortic stenosis (Heyde's syndrome)

The coexistence of calcific aortic valve stenosis and obscure gastrointestinal bleeding secondary to intestinal angiodysplasias usually of the cecum and the ascending colon constitutes Heyde's syndrome. The pathophysiologic link between both entities has remained unclear so far but newer studies suggest that it is the result of subtle alterations in plasma coagulation factors. Cessation of the bleeding has followed replacement of the aortic valve. We describe a patient with recurrent obscure gastrointestinal bleeding, calcific aortic stenosis and intestinal angiodysplasias, and discuss the current literature.

Use of Anticoagulation During Wireless Capsule Endoscopy for the Investigation of Recurrent Obscure Gastrointestinal Bleeding

Detecting the source of obscure gastrointestinal bleeding can be difficult. Capsule endoscopy is a promising diagnostic tool for investigating patients with this condition, although identifying the source of intermittent or low-grade bleeding remains a diagnostic challenge. We present case reports of two patients with obscure gastrointestinal bleeding, in whom the source of recurrent bleeding episodes was diagnosed by capsule endoscopy while they were on anticoagulation therapy. The first patient, an 81-year-old white woman, was on long-term oral anticoagulation because she had chronic atrial fibrillation. Capsule endoscopy demonstrated a bleeding tumor in the region of the terminal ileum. The second patient, a 59-year-old white man, underwent an initial capsule endoscopy, which was negative. After initiation of anticoagulation with heparin, a second capsule endoscopy procedure in this patient revealed several small bleeding lesions in the proximal small bowel. In both cases a gastrointestinal stromal tumor was identified as the bleeding source and was resected. These two cases demonstrate that provocation of bleeding during capsule endoscopy may increase its sensitivity.

Performing capsule endoscopy.

Small bowel bleeding is difficult to locate with current technology and costly to treat because of repeated diagnostic workups and hospitalizations. Some patients will eventually undergo intraoperative enteroscopy, the current gold standard. If the cause of bleeding is found, they may then have a bowel resection to treat their condition. Capsule endoscopy is a new technology that may greatly increase the ability to diagnose patients with recurrent obscure gastrointestinal bleeding and help reduce their treatment time and cost.

Recurrent obscure gastrointestinal bleeding caused by a jejunal stromal tumour

Upper gastrointestinal bleeding remains a common surgical emergency. Identification of the bleeding source determines the appropriate therapeutic strategy. Minimally invasive techniques may identify the bleeding source when traditional methods fail.

Provocative Angiography in Obscure Gastrointestinal Bleeding

Obscure gastrointestinal (GI) bleeding is relatively common but difficult to manage. By definition, diagnosis of a specific etiology is particularly challenging. We report the diagnostic use of provocative angiography in a patient with recurrent obscure GI bleeding. Although provocative angiography led to localization of bleeding and allowed specific treatment (placement of a 2-mm long, 0.010-inch diameter platinum coil, resulting in cessation of bleeding for 2 months), ultimately, the use of provocative angiography delayed specific diagnosis in our patient. We conclude that provocative angiography is a potentially powerful adjunct in the management of obscure GI bleeding, but that caution is required when using it. Provocative angiography should be reserved for patients who have had adequate imaging studies with negative results.