Source Of Obscure Gastrointestinal Bleeding Research Articles

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

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

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

Obscure Gastrointestinal Bleeding – A Multimodal Imaging Approach

Gastrointestinal (GI) bleeding represents one of the most frequently encountered clinical case scenarios in the emergency department. In the United States, the annual rate of hospitalization for any type of GI hemorrhage accounts for 300/100,000 population, with more than 1,000,000 hospitalizations each year and an approximately mortality rate of 5%. Upper GI bleeding (UGIB) is more common than lower GI bleeding (LGIB), yet there are many sites and multiple lesions from which bleeding could occur and the source could remain unidentified after upper endoscopy or colonoscopy evaluation. The uncertain etiology of GI hemorrhage is traditionally defined as obscure GI bleeding (OGIB) and constitutes a diagnostic challenge, so accurate investigations are crucial. Even if the mainstay of initial evaluation consists of upper endoscopy, colonoscopy or contrast X-ray studies, current guidelines suggest that video capsule endoscopy, push enteroscopy, angiography and radionuclide imaging are best suited, allowing an appropriate examination of the entire small bowel, which represents the most common source of OGIB. Hence, the aim of this review is to provide a multimodal investigation approach and to highlight the most adequate imaging technique according to the leading cause of OGIB.

History of malignancy and relevant symptoms may predict a positive computed tomography enterography in obscure gastrointestinal bleeds.

This study aimed to assess the clinical utility of computed tomography enterography (CTE) and identify factors associated with a diagnostic CTE for patients with obscure gastrointestinal bleeding (OGIB). A retrospective observational study was performed at a Canadian tertiary care center from 2005 to 2015. A total of 138 patients underwent a CTE for OGIB. Univariate and multivariate logistic regressions were performed to determine factors associated with a diagnostic CTE. A highly sensitive clinical rule was then developed to help identify OGIB patients for whom a CTE may be beneficial in their clinical work-up. A possible bleeding source was identified in 30 (22%) cases. The presence of abdominal or constitutional symptoms as well as history of colorectal cancer was significantly associated with a positive CTE in univariate and multivariate analyses (P<0.05). A positive CTE could be predicted based on the presence of abdominal or constitutional symptoms and history of colorectal cancer with 90% sensitivity (95% CI 74-98%) in our population. CTE identified a possible source of OGIB in one in five cases. In patients with the presence of abdominal or constitutional symptoms and a personal history of colorectal cancer, CTE may contribute to their diagnostic work-up.

Does Size Matter? Cameron Lesions Associated With a Small Hiatal Hernia

Introduction: Cameron lesions are mucosal erosions or ulcers found at the level of the diaphragmatic hiatus within the hiatal hernia. Usually asymptomatic, Cameron lesions are found incidentally on upper endoscopy. However, they can be a source of obscure gastrointestinal bleeding. Cameron lesions have been reported to be associated mainly with large hiatus hernias and NSAIDs use. Here in, we present a unique case of gastrointestinal bleeding secondary to a Cameron ulcer associated with a small subcentimeter hiatus hernia. Case report: A 76-year-old woman with medical history of hypertension, sarcoidosis, prior cerebral vascular accidents, coronary artery disease presented with complaints of dark watery stools, multiple episodes of coffee ground emesis and mild epigastric abdominal pain. Physical examination revealed a soft abdomen with normal bowel sounds and mild tenderness in the epigastrium. Initial laboratory tests demonstrated hemoglobin of 10.3 g/dL, blood urea nitrogen and creatinine of 32 mg/dL and 1.5 mg/dL respectively. Esophagogastroduodenoscopy (EGD) revealed a small hiatal hernia with three linear clean based non-bleeding ulcers, consistent with Cameron ulcers (Figure 1&2). No gross lesions were noted in the remainder of the stomach or the duodenum.Figure: Small hiatal hernia (blue arrow) with three linear clean based non-bleeding ulcers (yellow arrow), consistent with Cameron ulcers.Figure: Small hiatal hernia (blue arrow) with three linear clean based non-bleeding ulcers (yellow arrow), consistent with Cameron ulcers.Discussion: Cameron lesions have a higher prevalence in cases of large hiatal hernias. An estimated 3.3-5% of individuals with hiatus hernias are said to have Cameron lesions. Prevalence however increases to 13.7% among patients with large (> 5cm) hiatus hernia. Cameron lesions are caused by a combination of various factors acting at the level of the diaphragmatic hiatus. Mechanical injury from the contractility of the respiratory diaphragm, mucosal damage from exposed esophageal mucosa to the caustic gastric acid and ischemia from mucosal erosions are thought to result in Cameron lesions. The treatment of Cameron lesions is mainly medical therapy with proton pump inhibitors. In patients with overt bleeding, there may be a need for endoscopic intervention with hemostasis clips coupled with medical therapy. Conclusion: Cameron lesions have a higher prevalence in large (>5cm) hiatus hernias. However, they can rarely be present in small sub-centimeter hiatus hernias and be a cause of an obscure GI bleeding. Therefore, a high index of suspicion for Cameron lesions is required at endoscopy- even in cases of small hiatus hernias in making a timely diagnosis and intervention.

Wireless capsule endoscopy of the small intestine in children.

Wireless capsule endoscopy (CE) for the diagnosis of small-bowel disease has been in clinical use for more than a decade, and is no longer an emerging technology, but rather one that has reached fruition. This noninvasive technology has been readily embraced by both physicians and patients. Used in the diagnosis of inflammatory bowel disease, for locating sources of obscure gastrointestinal bleeding, and for assessing small-bowel polyp burden in polyposis syndromes as well as for less common indications, CE has transformed the diagnostic algorithms of small-bowel investigations. Although already in widespread use, the technology incorporated into the various CE platforms continues to improve and expand. Here, we briefly review the indications, limitations, and advances in video capsule technology, with an emphasis on its use in pediatrics.

CT enterography: technical and interpretive pitfalls.

CT enterography is a first-line test at many institutions to investigate potential small bowel disorders. While numerous articles have focused on the ability of CT enterography to diagnose and stage Crohn's disease, small bowel neoplasia, and malabsorptive or vascular disorders, this article reviews CT enterography limitations, technical and interpretive pitfalls, image review tactics, and complementary radiologic and endoscopic examinations to improve diagnostic accuracy. CT enterography limitations include its inability to demonstrate isolated mucosal abnormalities such as aphthous ulcers and its use of ionizing radiation. The most common technical pitfall of CT enterography is inadequate small bowel distention resulting from inadequate ingestion, gastric retention, or rapid small bowel transit of a large volume of neutral enteric contrast material. Additionally, segments of jejunum are frequently collapsed. Interpretive pitfalls commonly result from peristaltic contractions, transient intussusception and opaque intraluminal debris. Opaque debris is especially problematic during multiphasic CT enterography performed to identify potential small bowel sources of obscure gastrointestinal bleeding. False-negative examinations may result from inadequate radiation dose. Examinations complementary to CT enterography include small bowel follow through, enteroclysis, CT enteroclysis, MR enterography, MR enteroclysis, capsule endoscopy, and balloon-assisted endoscopy. Properly performed and accurately interpreted CT enterography contributes to the diagnosis and management of small bowel disease by itself and as a complement to other radiologic and optical small bowel imaging examinations.

Gastric Diverticuli as a Cause of Obscure Gastrointestinal Bleeding

Introduction: Gastric diverticuli are a rare but life-threatening source of obscure gastrointestinal bleeding. Their insidious and sometimes catastrophic presentation underlies the need for increased awareness and prompt management. A 75-year-old white male presented with symptoms of pre-syncope and dyspnea on exertion after multiple episodes of melena. He denied hematemesis, abdominal pain, dysphagia, or NSAID use. His co-morbidities included hypertension, diabetes mellitus, and atrial fibrillation. On admission, he was hemodynamically unstable with a tachycardia of 120 beats/minute and systolic BP of 60 mm of Hg. His physical examination was remarkable for melena on digital rectal examination. Laboratory tests revealed a Hb of 6.2, INR of 5.7, and an elevated BUN of 71. He was administered intravenous fluids, large-volume blood and plasma transfusions, and started on a pantoprazole infusion. On transfer to the ICU, he underwent an emergent upper endoscopy (EGD) with a large amount of retained blood and no obvious source of bleeding seen. The fundus was not adequately visualized due to an inability to clear the blood clots. An emergent Nuclear Medicine bleeding scan did not reveal active blood loss. He remained transfusiondependent and subsequently underwent a second EGD. This revealed the presence of a gastric fundal diverticulum (Figure 1 a,b), about 1 cm in diameter, with no other source of bleeding identified. The patient was referred for surgical evaluation; however, his clinical status gradually improved and he was discharged to the medical floor. Due to an often dramatic and potentially fatal presentation, gastrointestinal bleeding secondary to gastric diverticuli (GD) requires a high index of suspicion. Some reports have indicated vague symptoms of burning sub sternal pain or nonspecific abdominal discomfort preceding the presentation; however, patients are mostly symptom free. Prevalence ranges from 0.04% on barium contrast studies to 0.01-0.11% on endoscopy. Surgical resection is advocated in the presence of persistent symptoms or with complications such as persistent bleeding or a perforation.Figure 1

Does the CT Enterography Really Lead to Better Improvement of Diagnostic Yield Than Conventional CT in Obscure Gastrointestinal Bleeding?

Introduction: The aim of the present study was to evaluate the diagnostic performance of conventional computed tomographic (CT) and CT enterography in identifying the source of obscure gastrointestinal bleeding (OGIB) and to investigate the types of diseases that CT enterography can detect better if CT enterography shows higher diagnostic yield than conventional CT. Methods: We retrospectively included 170 patients with OGIB who received conventional CT (126 patients) or CT enterography (44 patients). The median age of the patients was 57 years, and 57.6% of patients were male. The median hospital day was 13 days. Overt bleeding was 74.7%, and occult bleeding was 25.3%. Results: Based on all performed examinations, a definitive diagnosis was made for 141 patients (82.9%): ulcer in 45 (26.4%) patients, tumor in 29 (17%), angiodysplasia in 28 (16.4%), and Crohn’s disease in 20 (11.7%). The overall diagnostic yield of conventional CT and CT enterography was 29.6% and 45.4%. (OR= 2.25; 95% CI 1.106-4.595; p=0.02). The CT enterography had better diagnostic yield than conventional CT in all etiology mentioned above, but there was no statistically significant difference. Conclusion: CT enterography showed higher diagnostic yield in patients with OGIB than conventional CT. Therefore, we need further studies with more patients to identify who will benefit from the examinations.

PTH-185 Capsule Endoscopy and Obscure Gastrointestinal Bleeding: Experience from a Tertiary Centre

IntroductionCapsule endoscopy (CE) is the first line modality to investigate the small bowel (SB) in patients with obscure gastrointestinal bleeding (OGB). We investigated the largest cohort of patients to date...

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

Limited data exists on the long-term outcomes of patients with obscure gastrointestinal bleeding (OGIB) following single-balloon enteroscopy (SBE). To examine the long-term outcomes of patients undergoing SBE for OGIB. Consecutive patients undergoing SBE for OGIB at a tertiary care center between 2008 and 2010 were retrospectively identified. Clinical data and SBE findings were extracted from the medical record. Recurrence of OGIB during follow-up through 2012 was assessed by a combination of chart review and telephone interviews. One hundred and forty-seven patients were included in the study. The overall diagnostic yield of SBE was 64.6% (95/147 patients). Findings of SBE included vascular lesions (VLs, 53.7%), small bowel neoplasm (2.7%), inflammatory lesions (4.8%), and normal SBE (35.4%). One hundred and ten patients (56.4% female, mean age 70.6±11.3 years) were followed for an average 23.9 months after initial SBE. During follow-up, OGIB recurred in 39.5% of patients in whom a source of OGIB was identified on SBE and 55.9% of patients with normal findings on SBE. OGIB recurred in 47.6% of patients in whom small bowel VLs were treated endoscopically. None of the 13 patients in whom a non-VL lesion was identified as the source of bleeding on SBE experienced recurrent bleeding (p=0.019). SBE is a safe and valuable method for managing patients with OGIB. More than 50% of patients experienced no recurrent bleeding during 2 years of follow-up after SBE. The long-term management of OGIB due to small bowel VLs remains challenging.

Obscure Gastrointestinal Bleeding in a Pancreas and Kidney Transplant Patient

Purpose: Case: A 48-yr-old female presented with melena and symptomatic anemia. She had been hospitalized multiple times with similar symptoms in the past 5 months, requiring multiple blood transfusions. Two EGDs and 2 colonoscopies during this time period did not reveal a cause of her gastrointestinal (GI) bleeding. Past medical history included type 1 Diabetes, and a combined cadaveric pancreas and kidney transplant 2 yrs ago. A video capsule endoscopy (VCE) performed at this point showed a mucosal polypoid lesion about 1 hr and 25 minutes post pylorus without active bleeding (Figure 1). Patient subsequently underwent an antegrade double balloon enteroscopy (DBE) based on the VCE findings. This exam showed a heaped up, friable area at the anastomosis between the donor duodenum and the recipient jejunum. Hemostasis was achieved with injection of epinephrine and application of one endoclip. Patient has presented on 2 more occasions with similar symptoms since then, and successful hemostatsis has been achieved with antegrade DBE guided therapy with epinephrine, endoclips, and Argon Photo Coagulation (APC) (Figure 2). Discussion: Localizing the source of obscure GI bleeding in pancreatic transplant patients can be challenging. Potential source may include anastomotic ulcerations due to ischemia, opportunistic infections, NSAIDs or post-transplant lymphoproliferative disease. Surgical intervention may carry high morbidity. This case highlights the potential role of VCE and DBE in the management of obscure GI bleeding in pancreas transplant patients.Figure: Video capsule study showing a polypoid lesion at the anastomosis betweeen donor duodenum and recepient jejunum.Figure: Double balloon endoscopy images with heaped up and friable area at anastomosis; hemostasis achieved with epineprine injection, APC, and endoclips.

Obscure Gastrointestinal Bleeding: Diagnostic Performance of Multidetector CT Enterography

To evaluate the diagnostic performance of computed tomographic (CT) enterography in identifying the source of obscure gastrointestinal bleeding and to determine clinical features associated with a higher diagnostic yield of CT enterography. The institutional review board approved this study, with waiver of informed consent. CT enterographic images in 65 patients (46 men [mean age, 54 years; range, 18-85 years] and 19 women [mean age, 62.1 years; range, 33-79 years]) who presented with obscure gastrointestinal bleeding between August 2005 and July 2007 were reviewed retrospectively and independently by two radiologists. The diagnostic performance of CT enterography was assessed by using the results of endoscopic and other imaging examinations, surgery, and clinical follow-up as the reference standard. Differences in the diagnostic yield of CT enterography according to patient demographic and clinical features, including age, sex, type and episode of bleeding (occult, initial overt, and recurrent overt), occurrence of recent bleeding, and history of massive bleeding, were evaluated by using univariate and multivariate logistic regression analyses. CT enterography helped identify the source of obscure gastrointestinal bleeding in 16 (24.6%) of 65 patients. The sensitivity, specificity, positive predictive value, and negative predictive value of CT enterography were 55.2% (16 of 29), 100% (32 of 32), 100% (16 of 16), and 71.1% (32 of 45), respectively. Among patients' clinical features, a history of massive bleeding (diagnostic yield, 58.3% [seven of 12]; adjusted odds ratio, 7.2; P = .01) was independently associated with a higher diagnostic yield for CT enterography. CT enterography has a potential role in the evaluation of obscure gastrointestinal bleeding. Despite the limited sensitivity of CT enterography, positive CT enterographic findings can reliably indicate the true source of obscure gastrointestinal bleeding. CT enterography is particularly effective in helping identify the source of bleeding in patients with a history of massive bleeding. http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11101936/-/DC1.

A Retrospective Analysis Comparing Small Bowel Follow-Through With Wireless Capsule Endoscopy in the Evaluation of Obscure Gastrointestinal Bleeding

A comparative retrospective study was conducted to evaluate diagnostic findings between small bowel follow-through (SBFT) and wireless capsule endoscopy in the presence of obscure gastrointestinal bleeding. A convenience sample of 31 patients with previous negative upper and lower endoscopy was included in the study. Wireless capsule endoscopy established a significant source of obscure gastrointestinal bleeding 53% of the time. The diagnostic capacity of radiographic SBFT was measured at 17% as compared with that of the wireless capsule endoscopy. The clinical findings along with the digital images obtained from the wireless capsule endoscopy was found to be the optimum diagnostic tool in the evaluation of obscure gastrointestinal bleeding in the small bowel.

Endoscopic observation of Meckel's diverticulum by double balloon endoscopy: Report of five cases

Most cases of Meckel's diverticula are asymptomatic, however, some cases presented with gastrointestinal (GI) bleeding. It is often difficult to determine whether Meckel's diverticulum is a source of obscure GI bleeding. Double balloon endoscopy allows endoscopic access to the entire small intestine. The aim of this study was to compare endoscopic findings of three hemorrhagic and two non-hemorrhagic Meckel's diverticula in patients with obscure GI bleeding using this novel technique. Between September 2000 and April 2005, 354 enteroscopies, including 162 anterograde and 192 retrograde procedures, were performed on 217 patients at the Jichi Medical University Hospital, Japan, using the double balloon endoscopy system. Five consecutive patients where Meckel's diverticulum was endoscopically observed were selected and analyzed. Double balloon endoscopy enabled direct observation of Meckel's diverticula in all five patients. Surgical procedures were indicated for three patients where double balloon endoscopy discovered ulcers. By contrast, double balloon endoscopy detected other sources of bleeding in the remaining two patients where no ulcers were found in the Meckel's diverticula. Endoscopic observation of the ulcers in Meckel's diverticula was important evidence of bleeding in patients with obscure GI bleeding. Other sources of bleeding should be considered when no ulcers are found in the Meckel's diverticula.

Hemorrhoids can be a Source of Obscure Gastrointestinal Bleeding that Requires Transfusion: Report of Five Patients

Hemorrhoids have been rarely reported to be a source of transfusion-dependent, obscure gastrointestinal bleeding. We report the diagnosis and management of a series of patients in whom hemorrhoids were the source of obscure gastrointestinal bleeding that was severe enough to require transfusion. Five patients, who presented with severe hematochezia or obscure gastrointestinal bleeding, during a 24-month period had had an extensive workup for gastrointestinal bleeding. All had required transfusion of 2 units or more of blood. In the absence of other causes of bleeding, the five patients had unprepared flexible sigmoidoscopy on the same day that they reported hematochezia to exclude a proximal source of bleeding. All were found to have internal hemorrhoids as a likely source of bleeding, which was confirmed at exploration under anesthesia, and were treated by surgical hemorrhoidectomy. The five patients underwent surgical, Ferguson-type, hemorrhoidectomy. One patient required 1 unit of blood immediately postoperatively, but none have required further transfusion or reported hematochezia in more than three months of follow-up. We have shown that hemorrhoids can be a source of transfusion-dependent, obscure gastrointestinal bleeding. This aspect of the common problem of hemorrhoidal bleeding has not been previously reported, which reflects underreporting or missed diagnosis.

Rebleeding rate after interventional therapy directed by capsule endoscopy in patients with obscure gastrointestinal bleeding

BackgroundThe precise role of capsule endoscopy in the diagnostic algorithm of obscure gastrointestinal bleeding has yet to be determined. Despite the higher diagnostic yield of capsule endoscopy, the actual impact on clinical outcome remains poorly defined. The aim of this study was to evaluate the follow-up results of patients with obscure gastrointestinal bleeding to determine which management strategies after capsule endoscopy reduced rebleeding.MethodsAll patients in whom the cause of obscure gastrointestinal bleeding was investigated between May 2004 and March 2007 were studied retrospectively. We evaluated the clinical outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy using the rebleeding rate as the primary outcome.ResultsSeventy-seven patients with obscure gastrointestinal bleeding underwent capsule endoscopy. Capsule endoscopy identified clinically significant findings that were thought to be the sources of obscure gastrointestinal bleeding in 58.4% of the patients. The overall rebleeding rate was 36.4%. The rebleeding rate was significantly higher among patients with insignificant findings than among those with significant findings (p = 0.036). Among the patients in whom capsule endoscopy produced significant findings, the rebleeding rate of the patients who underwent therapeutic interventions was significantly lower than that in those who did not undergo intervention (9.5% vs 40.0%, p = 0.046).ConclusionFollow-up and further aggressive interventions are necessary for patients with obscure gastrointestinal bleeding and significant capsule endoscopy findings to reduce the chance of rebleeding.

Obscure Gastrointestinal Bleeding Caused by Small Bowel Lipoma

Obscure gastrointestinal bleeding is a very rare entity which accounts for less than 5% of all gastrointestinal bleeding cases. Small bowel tumors are rare but a serious source of obscure gastrointestinal bleeding. Lipomas are the second most common benign tumors in the small bowel and can produce many complications, including gastrointestinal bleeding. Herein, we describe a case of obscure gastrointestinal bleeding caused by a small bowel tumor which was detected by capsule endoscopy and double-balloon enteroscopy preoperatively. Finally, the tumor was surgically confirmed to be a lipoma.

Capsule endoscopy was superior to push enteroscopy for identifying sources of obscure gastrointestinal bleeding

Source Citation de Leusse A, Vahedi K, Edery J, et al. Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding? Gastroenterology. 2007;132:855-62. 17324401

Small-bowel masses found and missed on capsule endoscopy for obscure bleeding

Objective. Data on the nature of small-bowel tumors found or missed by capsule endoscopy (CE) are limited. The aim of this study was to review the CE findings in patients with small-bowel tumors presenting as obscure gastrointestinal (GI) bleeding. Material and methods. We retrospectively reviewed the medical records of the first 300 patients who underwent CE for obscure bleeding (non-diagnostic EGD and colonoscopy) at our institution. Results. Ten (3%) confirmed small-bowel masses were found in 9 patients. CE findings included distinct mass (n=4), focal irregular (ulcerated or nodular) mucosa (n=2), focal blood without clear lesion (n=1), proximal angiodysplasia with obscuring distal melena (n=1), incomplete distal examination with normal proximal images (n=1), and normal findings (n=1). Most (80%) of the lesions were potentially malignant: adenocarcinoma (n=4), neuroendocrine carcinoma (n=1), leiomyosarcoma (n=1), and GI stroma cell tumors (GISTs) (n=2). Benign lesions included inflammatory fibroid polyp (n=1) and lipoma (n=1). Three duodenal masses were missed on a previous EGD; one was missed by CE as well. CE findings led directly to tumor diagnosis in 7 of the 10 cases. Capsule retention occurred in 2 of the 10 cases, with one patient requiring urgent surgery for acute obstruction. Conclusions. Small-bowel tumors are a rare but serious source of obscure GI bleeding. Our large single-center experience shows that most lesions are of malignant potential. Tumors can have an atypical appearance including focal ulceration, nodularity, or active bleeding without a clear lesion. Mass lesions in the duodenum are particularly elusive and can be missed by both EGD and CE.