Small Bowel Gastrointestinal Bleeding Research Articles

Patients on Antithrombotic Agents with Small Bowel Bleeding –Yield of Small Bowel Capsule Endoscopy and Subsequent Management

Background and AimsSmall bowel gastrointestinal bleeding (GIB) is associated with multiple blood transfusions, prolonged and/or multiple hospital admissions, utilization of significant healthcare resources, and negative effects on patient quality of life. There is a well-recognized association between antithrombotic medications and small bowel GIB. We aimed to identify the diagnostic yield of small bowel capsule endoscopy (SBCE) in patients on antithrombotic medications and the impact of SBCE on treatment course.MethodsThe electronic medical records of nineteen hundred eighty-six patients undergoing SBCE were retrospectively reviewed.ResultsThe diagnostic yield for detecting stigmata of recent bleeding and/or actively bleeding lesions in SBCE was higher in patients that were on antiplatelet agents (21.6%), patients on anticoagulation (22.5%), and in patients that had their SBCE performed while they were inpatient (21.8%), when compared to the patients not on antiplatelet agents (12.1%), patients not on anticoagulation (13.5%), and with patients that had their SBCE performed in the outpatient setting (12%). Of 318 patients who had stigmata of recent bleeding and/or actively bleeding lesion(s) identified on SBCE, SBCE findings prompted endoscopic evaluation (small bowel enteroscopy, esophagogastroduodenoscopy (EGD), and/or colonoscopy) in 25.2%, with endoscopic hemostasis attempted in 52.5%.ConclusionsOur study, the largest conducted to date, emphasizes the importance of performing SBCE as part of the evaluation for suspected small bowel bleeding, particularly in patients taking antithrombotic therapy, and especially during their inpatient hospital stay.

S3368 Bleeding From a Rare Omental Gastrointestinal Stromal Tumor Found on Capsule Endoscopy

Introduction: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors involving the gastrointestinal tract compromising approximately 1 -2 % of gastrointestinal cancers. They can arise from the bowel wall as a subepithelial neoplasm in the stomach and small intestine, and less than 5% of them arise as extragastrointestinal tumors in the retroperitoneum, mesentery and omentum. They occur in older adults aged 65 to 69 years old, and vary in their presentation depending on their location. We present a unusual case of small bowel gastrointestinal bleeding from a GIST adherent to the omentum. Case Description/Methods: 58 year old male with a history of diabetes mellitus type II, hypertension, recent prolonged hospitalization for disseminated nocardia infection on long term antibiotics and a Decadron taper presented with several days of epigastric pain, nausea and non-bloody diarrhea. He denied any signs of gastrointestinal bleeding such as melena or hematochezia. His labs were notable for a hemoglobin of 4.2 g/dL with a mean corpuscular volume of 78.5 fL that was previously noted to be within normal limits. Computed tomography of the abdomen and pelvis with contrast showed a 4 cm circumscribed, hyperdense enhancing exophytic solid mass arising from the small bowel in the left lower quadrant with adjacent hyperenhancement. The patient subsequently underwent capsule endoscopy which showed fresh blood in the mid jejunum with more active bleeding surrounding a possible small bowel tumor. Due to ongoing bleeding and anemia, the patient underwent laparoscopic small bowel resection and lymphadenectomy of a small bowel tumor adherent to the omentum with about 10 cm of proximal and distal margins. Pathology was consistent with a low-grade gastrointestinal stromal tumor approximately 3.0 x 3.0 x 2.3 cms with tumor free margins and no evidence of lymphovascular spread. Thereafter, the patient remained hemodynamically stable with improvement of his blood counts and was discharged home. (Figure) Discussion: While GISTS are common findings in the gastrointestinal tract, only a small percentage of them can cause gastrointestinal bleeding needing surgical intervention. Surgical resection remains the mainstay of treatment for localized, non-metastatic GISTs that present with bleeding as it can both stop the bleeding and resect the lesion. However, other modalities of treatment include endoscopic intervention depending on the location or transcatheter arterial embolization.Figure 1.: Top: CT Abdomen and Pelvis with contrast demonstrating a 4 cm circumscribed hyperdense enhancing exophytic solid mass arising from the small bowel in the left lower quadrant. Bottom: Capsule endoscopy showing a small bowel tumor.

Intraoperative Fluoroscopy-Assisted Localization of Small Bowel Gastrointestinal Bleeding.

Intraoperative management of refractory small bowel gastrointestinal bleeding continues to present challenges to surgeons, specifically, in localizing the source of bleeding. The need for operative intervention has decreased significantly with improved percutaneous radiologic techniques for embolization with good success rates. When percutaneous treatment methods fail, the surgeon is left with a variety of suboptimal options for localization if the pathologic source is not obvious on external inspection of the small bowel. This report describes a novel method for localizing small bowel gastrointestinal bleeding in those patients who have had previous coil embolization attempts at controlling small bowel gastrointestinal bleeding.

Small Bowel Gastrointestinal Bleeding Diagnosis and Management-A Narrative Review.

Background: Small bowel bleeding accounts for 5–10% of all gastrointestinal bleeding. Despite advances in imaging, endoscopy and minimally invasive therapeutic techniques, its diagnosis and treatment remains a challenge and a standardized algorithm for approaching suspected small bowel bleeding remains elusive. Furthermore, the choice of investigation is subject to timing of presentation and accessibility to investigations. The aim of this study was to construct a narrative review of recent literature surrounding the diagnosis and management of small bowel bleeding.Methods: A literature review was conducted examining the database pubmed with the following key words and Boolean operators: occult GI bleed OR mesenteric bleed OR gastrointestinal hemorrhage OR GI hemorrhage AND management. Articles were selected and reviewed based on relevance to the research topic. Where necessary, the full text was sought to further assess relevance.Results: In overt GI bleeding, CT angiography and red cell scintigraphy are both feasible and reliable diagnostic imaging modalities if standard endoscopy is negative. Red cell scintigraphy may be advantageous through detection of lower bleeding rates but it is subject to availability. Overt bleeding and a positive CT angiogram or red cell scan improves the diagnostic yield of formal angiography ± embolization. Video capsule endoscopy or double balloon endoscopy can be considered in occult GI bleeding following normal upper and lower endoscopy.Conclusions: Small bowel bleeding remains a rare but significant diagnostic and therapeutic challenge. Technological advances in diagnostics have aided evaluation but have not broadened the range of therapeutic interventions.

Multidetector CT enterography of focal small bowel lesions: a radiological–pathological correlation

Focal small bowel lesions present a diagnostic challenge for both the radiologist and gastroenterologist. Both the detection and characterization of small bowel masses have greatly improved with the advent of multidetector CT enterography (MD-CTE). As such, MD-CTE is increasingly utilized in the workup of occult gastrointestinal bleeding. In this article, we review the spectrum of focal small bowel masses with pathologic correlation. Adenocarcinoma, the most common primary small bowel malignancy, presents as a focal irregular mass occasionally with circumferential extension leading to obstruction. Small bowel carcinoid tumors most commonly arise in the ileum and are characterized by avid enhancement and marked desmoplastic response of metastatic lesions. Aneurysmal dilatation of small bowel is pathognomonic for lymphoma and secondary findings of lymphadenopathy and splenomegaly should be sought. Benign small bowel masses such as leiomyoma and adenoma may be responsible for occult gastrointestinal bleeding. However, primary vascular lesions of the small bowel remain the most common cause for occult small bowel gastrointestinal bleeding. The arterial phase of contrast obtained with CTE aids in recognition of the vascular nature of these lesions. Systemic conditions such as Peutz-Jeghers syndrome and Crohn's disease may be suggested by the presence of multiple small bowel lesions. Lastly, potential pitfalls such as ingested material should be considered when faced with focal small bowel masses.

A rapid and accurate method to detect active small bowel gastrointestinal bleeding on video capsule endoscopy.

Video capsule endoscopy (VCE) is indicated to evaluate for suspected small bowel bleeding, but "standard view" (SV) evaluation is time-consuming. Rapid Reader 6.0 software (Given Imaging, Duluth GA) contains two computer algorithmic systems: (1) "Quickview" (QV) which automatically skips similar images and (2) a pixel analysis program that identifies suspected blood (SBI). Combining the two modalities (QV + SBI) may provide a faster modality to assess for active small bowel bleeding. This study was designed to assess the accuracy of QV + SBI for small bowel bleeding compared to SV findings. This is a retrospective, case-control study at a single tertiary care referral hospital including all patients with VCE performed for suspected small bowel bleeding from 4/2007 to 3/2011. All studies were previously read using SV by one of two experienced faculty (CS, DR). The primary outcome was diagnostic accuracy of QV + SBI in assessing for active small bowel bleeding compared to SV. A total of 116 VCE were included, 28 with active small bowel bleeding identified by original SV. Using QV + SBI, all 28 VCEs with active small bowel bleeding were identified. The sensitivity of QV + SBI to detect active bleeding was 100%, while the specificity was 93-94%. The mean time to identify landmarks and read the entire study was 3 min 20 s. The QV + SBI reading format of VCE is an efficient, highly sensitive modality to assess for potential small bowel bleeding.

A New and Improved Version of a Novel Algorithm of Automatic Lesion Detection and Its Impact on the Diagnostic Yield of Capsule Endoscopy in Patients With Small Bowel Gastrointestinal Bleeding

A New and Improved Version of a Novel Algorithm of Automatic Lesion Detection and Its Impact on the Diagnostic Yield of Capsule Endoscopy in Patients With Small Bowel Gastrointestinal Bleeding

Balloon Enteroscopy for Diagnosis and Treatment of Cytomegalovirus-Induced Small Bowel Gastrointestinal Bleeding After Whole-Organ Pancreas Transplantation

Balloon Enteroscopy for Diagnosis and Treatment of Cytomegalovirus-Induced Small Bowel Gastrointestinal Bleeding After Whole-Organ Pancreas Transplantation

Small Bowel Diseases in the Elderly

Small bowel diseases in the elderly are discussed including small bowel gastrointestinal bleeding and malabsorption syndromes such as celiac disease. Crohn's disease and nonsteroidal enteropathy also cause considerable morbidity in the elderly population and are reviewed. Finally, a brief discussion of malignancies of the small bowel (adenocarcinoma, carcinoid, and so forth) occurring in the elderly is presented.

Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings

Background: Push enteroscopy is indicated in patients with suspected small bowel gastrointestinal bleeding or small bowel mucosal disease. Our aim was to determine the diagnostic yield of enteroscopy, identify clinical predictors associated with findings, and measure frequency of management changes made on the basis of results. Methods: Endoscopy reports, office charts, and hospital charts were reviewed for 164 patients who had enteroscopy performed, primarily with a video enteroscope, during a period of 2 years. Data extraction included details of comorbid illnesses, associated risk factors, and previous endoscopies. Results: Indications for enteroscopy were suspected occult bleeding in 65, overt bleeding in 64, diarrhea in 20, and suspected mucosal disease in 15 patients. Diagnostic lesions, identified in 92 patients (56%), included 57 jejunal lesions (35%). In patients with overt bleeding, upper tract lesions were present more commonly in patients receiving nonsteroidal medication (54% versus 27%, p < 0.05). Jejunal vascular ectasia occurred more frequently in patients with documented vascular ectasias elsewhere in the gastrointestinal tract (34% versus 15%, p < 0.01). Missed lesions on previous upper endoscopy included large hiatal hernias with erosions in 10, peptic ulcers in 10, and vascular ectasias in 9 patients. Therapeutic interventions, made in 67 of 92 patients (73%) with diagnostic lesions, included small bowel resection in 12 (8%), endoscopic therapy in 21 (14%), and changes in medical regimen in 34 patients (22%). Conclusions: Push enteroscopy with video enteroscopes has a moderate diagnostic yield. Positive findings frequently lead to therapy changes. Large hiatal hernias remain an underrecognized etiology of anemia. Repeat upper endoscopy should be considered before enteroscopy in patients taking nonsteroidals who develop overt bleeding. (Gastrointest Endosc 1998;47:18-22.)