Unexplained Gastrointestinal Bleeding Research Articles

Clinical characteristics and literature review of ectopic gastric mucosa in the small intestine

The study aims to summarize the clinical characteristics of patients with ectopic gastric mucosa in the small intestine, comparing clinical presentation differences between domestic and foreign patients through literature review. The clinical characteristics of cases diagnosed with ectopic gastric mucosa in the small intestine at Peking Union Medical College Hospital from January 2000 to January 2024 were retrospectively analyzed. By searching databanks, such as PubMed, EMBASE, the Cochrane Library, Wanfang, VIP, CNKI, and etc (the inclusion period was from the establishment of the database to January 1, 2024). The literature review was conducted on ectopic gastric mucosa in the small intestine. A total of 10 cases were included, all male, age [M (Q1, Q3)] was 27 (13-69) years old. Gastrointestinal bleeding was the first manifestation in most cases, with severe cases leading to hemorrhagic shock. Abdominal CT indicated local intestinal wall thickening and luminal narrowing in 3 cases. Four cases lesions were located at the beginning of the jejunum and 6 lesions were located in the end segment of ileum. All cases underwent local lesion resection, with postoperative pathology confirming ectopic gastric mucosa. Symptoms disappeared postoperatively, with a follow-up period of 0.5-3.0 years. Literature review indicates that the main clinical manifestation of gastric mucosa ectopia in the small intestine in China is gastrointestinal bleeding, while foreign patients are often complicated with intestinal duplication and intussusception, with abdominal pain and vomiting as the primary and main symptoms. The occurrence rate of intestinal obstruction in female patients, both domestically and abroad, is higher than that in male patients. The occurrence rate of ileal lesions with intestinal obstruction and small intestinal duplication is higher than that of duodenal lesions in both domestic and foreign patients. Local small intestine resection is an effective treatment method with generally good prognosis. Ectopic small intestinal mucosa is relatively rare, with symptoms of gastrointestinal bleeding and intestinal obstruction being common presentations, which can serve as one of the differential diagnoses for unexplained gastrointestinal bleeding.

Clinical, endoscopic and therapeutic features of bleeding Dieulafoy’s lesions: case series and literature review

ObjectiveDieulafoy’s lesions (DLs) are a rare but potentially life-threatening source of gastrointestinal (GI) haemorrhage. They are responsible for roughly 1%–6.5% of all cases of acute non-variceal GI bleeding.Here, we describe...

Recurrent Massive Gastrointestinal Bleeding as a first presentation of AL Amyloidosis in a 76-Year-Old Patient

Background: Light chain or AL amyloidosis is a systemic disease that occasionally involves the gastrointestinal tract, but very rarely presents as gastrointestinal bleeding without evidence of systemic involvement. In such cases recognition of amyloidosis as the cause of bleeding is essential in order to rapidly initiate effective treatment to stop the bleeding. Case presentation: We describe a 76-year-old patient who presented with recurrent massive gastrointestinal bleeding as the initial manifestation of AL amyloidosis. One episode necessitated emergency right colectomy, and histopathological analysis of the resected bowel revealed diffuse amyloid infiltration. This finding prompted further investigations, which demonstrated elevated plasma lambda light chain levels, and 10% monoclonal plasma cells in the bone marrow. Treatment with bortezomib, dexamethasone, and daratumumab was initiated and no further gastrointestinal bleeding occurred. Conclusion: The diagnosis of amyloidosis involving the gastrointestinal tract should be considered in adult patients with unexplained recurrent gastrointestinal bleeding.

Patient Preparation with Esomeprazole Is Comparable to Ranitidine in Meckel Diverticulum Scintigraphy.

To localize ectopic gastric mucosa in patients with unexplained gastrointestinal bleeding and diagnose a Meckel diverticulum, 99mTc-pertechnetate imaging is the standard procedure. H2 inhibitor pretreatment enhances the sensitivity of the scan by reducing washout of 99mTc activity from the intestinal lumen. We aim to provide evidence of the effectiveness of the proton pump inhibitor esomeprazole as an ideal substitute for ranitidine. Methods: The scan quality for 142 patients who underwent a Meckel scan during a period of 10 y was evaluated. The patients were pretreated with ranitidine orally or intravenously before a switch to a proton pump inhibitor after ranitidine was no longer available. Good scan quality was characterized by the absence of 99mTc-pertechnetate activity in the gastrointestinal lumen. The effectiveness of esomeprazole to diminish 99mTc-pertechnetate release was compared with the standard treatment using ranitidine. Results: Pretreatment with intravenous esomeprazole resulted in 48% of scans with no 99mTc-pertechnetate release, 17% with release either in the intestine or in the duodenum, and 35% with 99mTc-pertechnetate activity both in the intestine and in the duodenum. Evaluation of scans obtained after oral ranitidine and intravenous ranitidine showed absence of activity in both intestine and duodenum in 16% and 23% of the cases, respectively. The indicated time to administer esomeprazole before starting the scan procedure was 30 min, but a delay of 15 min did not negatively influence the scan quality. Conclusion: This study confirms that esomeprazole, 40 mg, when administered intravenously 30 min before a Meckel scan, enhances the scan quality comparably to ranitidine. This procedure can be incorporated into protocols.

Small bowel intussusception caused by a serrated adenoma: a case report.

The case was a 17-year-old young woman with a one-year history of recurrent abdominal pain and discomfort. B-scan ultrasonography identified intussusception and contrast-enhanced computed tomography of the pelvis revealed volvulus. A laparoscopic procedure was planned to identify the reason for the intussusception and obstruction. Intraoperatively, the intussusception was found to be caused by a cauliflower-shaped polypoid tumor measuring approximately 4 × 3 cm. Postoperative pathological examination identified the tumor to be a traditional serrated adenoma of the small intestine, which is rare and has atypical clinical manifestations. If unexplained abdominal pain or gastrointestinal bleeding occurs and an abdominal mass cannot be accurately located, laparoscopic or open surgery should be performed immediately. Early surgery is the most effective and reliable way of securing a prompt diagnosis and a favorable prognosis.

Meckel diverticulum scintigraphy: technique, findings and diagnostic pitfalls.

Meckel diverticulum, the most common congenital anomaly of the gastrointestinal tract, results from the aberrant involution of the omphalomesenteric duct and accounts for more than 50% of unexplained lower gastrointestinal bleeding in the pediatric population. The most accurate imaging tool to identify a Meckel diverticulum containing ectopic gastric mucosa is the Technetium-99m pertechnetate Meckel scan, a scintigraphic study with a reported accuracy of 90% in the pediatric population. In addition to depicting a Meckel diverticulum with ectopic gastric mucosa, careful attention to the normal biodistribution of the radiotracer can lead to the identification of unexpected pathology with implications for patient management. This article serves to review the embryological origin and anatomical features of Meckel diverticulum, highlight the role of scintigraphy in evaluating Meckel diverticulum, and discuss the proper imaging technique when performing this test. We will focus on pitfalls that can lead to an erroneous diagnosis as well as incidental findings that can affect patient management.

Duodenal Dieulafoy lesion: a rare pathogeny of gastrointestinal bleeding in children

Dieulafoy lesion is a calibre persistent submucosal artery associated with a minuter mucosal defect. Dieulafoy lesion has been reported to account for 1-5.8% of acute nonvariceal upper gastrointestinal bleeding in adults, but it is rarely reported in children. Here we report a case of duodenal Dieulafoy lesion in a 13-year-old boy. After endoscopy and laparotomy, he still had no definite diagnosis and effective treatment. The duodenal Dieulafoy lesion was finally identified by selective angiography and was effectively treated by intravascular embolization. For unexplained upper gastrointestinal bleeding, the possibility of duodenal Dieulafoy lesion should be considered. A combination of multiple diagnosis and treatment methods can improve the success rate of diagnosis and treatment when a single test or treatment method cannot provide definitive diagnosis or effective treatment.

Intrahepatic Hematoma and Haemobilia after Percutaneous Liver Biopsy: A Clinical Case Report

Summary Assessing the severity of liver disease and predict the response to treatment in clinical practice requires the determination of the degree of inflammation progression and liver fibrosis. Percutaneous liver biopsy is the gold standard for grading and staging liver diseases. Complications are more common in the presence of vascular liver lesions, dilation of the bile ducts, ascites, or whether examination has been performed by less experienced physicians. Bleeding after liver biopsy is considered the most common cause of severe complications. Bleeding usually presents as a subcapsular or parenchymal hematoma, free intraperitoneal hemorrhage, hemobilia, or, rarely, hemothorax. The rarest of hemorrhagic complications is hemobilia, a term used to describe bleeding in the bile ducts. Hemobilia is usually suspected when there is a drop in hemoglobin after the procedure, pain in the upper right quadrant of the abdomen, hyperbilirubinemia, and unexplained gastrointestinal bleeding. The clinical manifestations range from chronic anemia to rapid, massive bleeding with hematemesis and/or melena.

HEMORRHAGIC SHOCK: WHERE IS THE BLEED?

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Meckel diverticulum(MD), characterized as a common congenital malformation and is well studied in the pediatric population but less so in adults. Our case emphasizes MD as one of the possible diagnoses of gastrointestinal bleeding in adults when CT scans and endoscopic evaluations are unremarkable. Also, if the suspicion is high, the technetium 99m pertechnetate is also not often adequate to exclude the diagnosis. CASE PRESENTATION: 28 year old male with a history of Inflammatory bowel syndrome presented to the emergency department with lightheadedness and palpitations. Soon after, he experienced a large melanotic stool and was transferred to the ICU with hypovolemic shock. His labs were notable for normocytic normochromic anemia for which he was transfused with packed red blood cells. CTA abdomen and pelvis demonstrated no evidence for active extravasation. The patient continued to have massive melenic bowel movements requiring repetitive blood transfusion for his hemorrhagic shock. Bedside double endoscopy showed non-bleeding internal hemorrhoids with no obvious source of bleeding. Subsequently, workup was broadened to a tagged RBC scan which was positive in the mid to distal small bowel prompting small ileal branch embolization. However, bleeding persisted for which Meckel's scan was ordered and found to be suggestive of Meckel's diverticulum. Subsequently, he had a laparoscopic small bowel resection which led to the resolution of symptoms. DISCUSSION: Meckel's Diverticulum is a rare entity in adults with only 17 cases reported in literature in the last year. It usually presents in childhood with more than half of the patients being less than 10 years old.MD usually presents with intestinal obstruction, hemorrhage and inflammation ofthe diverticulum with or without perforation. Bleeding usually occurs from an ulcer due to ectopic gastric mucosa producing acid and damaging the intestinal mucosa. Clinical features are comparable to any other inflammatory condition and can be confused with more prevalent conditions like acute appendicitis. Meckel's nuclear scan proves to be the standard test in case of high suspicion with a sensitivity of 89.6% and specificity of 97.1%. Other testing modalities include X-ray, CT scan or an MRI in case of an obstruction. Mesenteric arteriography in case of GI bleeding, double-balloon enteroscopy or capsule endoscopy can be used in order to directly visualize the MD, or abdominal exploration can be done as required if the diagnosis remains unclear with high index of suspicion.The standard of treatment in case of a symptomatic patient is surgical resection by performing a diverticulectomy that our patient underwent and was discharged to medical floor after stabilization. CONCLUSIONS: Meckel's Diverticulum remains a diagnosis associated with pediatric population although should not be forgotten in cases of adults with unexplained gastrointestinal bleeding. REFERENCE #1: Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A. Meckel's diverticulum in the adult. J Visc Surg. (2017) 154:253–9. 10.1016/j.jviscsurg.2017.06.006 [PubMed] [CrossRef] [Google Scholar] REFERENCE #2: Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC. The many faces of Meckel's diverticulum and its complications. J Med Imaging Radiat Oncol. (2017) 61:225–31. 10.1111/1754-9485.12505 [PubMed] [CrossRef] [Google Scholar] REFERENCE #3: Stone PA, Hofeldt MJ, Campbell JE, et al. Meckel diverticulum: ten-year experience in adults. South Med J 2004;97:1038-41. [PubMed] DISCLOSURES: No relevant relationships by Imama Ahmad, source=Web Response No relevant relationships by Anneris Estevez, source=Web Response No relevant relationships by Sneha Lakshman, source=Web Response

The magnetic resonance enterography imaging features of symptomatic Meckel's diverticulum in pediatric patients: a retrospective observational study of 31 cases.

BackgroundThe aim of this study was to explore the magnetic resonance enterography (MRE) imaging manifestations of a symptomatic Meckel’s diverticulum (MD) in pediatric patients in order to provide a reference for the diagnosis of the condition.MethodsThe medical records of 31 pediatric patients with MD from May 2014 to October 2020 were retrospectively analyzed. The inclusion criteria were patients with MD accompanied by unexplained gastrointestinal bleeding, anemia (except hematological diseases), chronic persistent abdominal pain, repeated intussusception, or intussusception in older pediatric patients during surgery. The clinical variables (age, sex, and hemoglobin) and imaging, surgical, and pathological findings were recorded.ResultsMD was definitively identified in 28 patients, with the following characteristics: a blind-ending fluid-filled and/or gas-filled structure (n=23), an elongated shape (n=1), a dumbbell shape (n=1), and a solid mass (n=3). The diverticula were located in the right lower quadrant (n=16), the right abdomen at the level of the umbilicus (n=3), the right upper quadrant (n=2), the left upper quadrant (n=2), and the midline lower abdomen (n=5). Supply arteries were visualized in nine cases. In all cases, mural enhancement was comparable to that of the adjacent small-bowel (SB). Extravasation of the intravascular contrast medium was seen in two cases. Peripheral structural abnormalities included mesenteric fat stranding (n=7), hemorrhage in the adjacent lumen (n=3), free intraperitoneal gas (n=1), abnormal fluid retention (n=2), intestinal obstruction (n=1), and lymph node enlargement (n=7). A normal appendix was identified in 18 cases.ConclusionsMRE is an appropriate method of diagnosing symptomatic MD in pediatric patients and is particularly useful in the assessment of complications.

Non-steroidal anti-inflammatory drug-induced enteropathy as a major risk factor for small bowel bleeding: a retrospective study

BackgroundSmall bowel (SB) bleeding accounts for 5% of all gastrointestinal (GI) bleeding cases and 80% of obscure GI bleeding cases. Although angioectasia is the common etiology of SB bleeding, nonsteroidal anti-inflammatory drug (NSAID)-induced SB lesions are also reported as a major cause in studies from Eastern countries. Herein, we assessed the frequency of occurrence of NSAID-induced SB lesions in Korean patients with obscure GI bleeding.MethodsWe retrospectively analyzed medical records of all consecutive patients aged ≥18 years who underwent capsule endoscopy from March 2018 to February 2019 at Ulsan University Hospital and Kosin University Gospel Hospital.ResultsOf the 83 subjects (all Korean; mean age ± standard deviation: 59 ± 18 years; age range: 18–84 years; men: n = 52; women: n = 31), 55 (66.2%) had stool with clear blood and 28 (33.8%) had normal stool with iron deficiency anemia. The detection rate of SB bleeding and lesions using capsule endoscopy was 72.3% (60 of 83 patients). A significantly higher frequency (40 of 51) of ulcerative/erosive lesions than other causes was observed in patients with inactive bleeding but visible SB lesions. As a result, NSAID-induced enteropathy accounted for 30.1% of 83 patients with obscure GI bleeding (25 of the all 60 SB bleeding cases).ConclusionsContrary to what is reported for patients in Western countries, this study in Korean patients showed an improved diagnostic yield of capsule endoscopy for obscure GI bleeding and that NSAID-induced enteropathy was the most common etiology of SB bleeding. Aggressive small intestine examination is required for patients with unexplained GI bleeding.

Evaluation of Transcatheter Arterial Embolization in Treating Gastrointestinal Bleeding Due to Angiodysplasia: A Retrospective Study on Twelve Cases

Background: Angiodysplasia (AD) is a common cause of otherwise unexplained gastrointestinal bleeding and anemia and it increases in frequency with aging. Objectives: To investigate the safety and efficacy of transcatheter arterial embolization (TAE) in treating gastrointestinal bleeding caused by angiodysplasia. Patients and Methods: A total of 12 patients (five men, seven women; mean age: 50 ± 18 years; range: 31 - 82 years) with gastrointestinal bleeding, who had failed after endoscopic therapy and were not eligible for surgery, were treated via TAE. The presentations of patients included hematemesis (n = 2), melena (n = 7), and hematochezia (n = 5). The details of procedures and follow-up records were reviewed. Results: The procedures of TAE were performed using poly vinyl alcohol particles and/or coils. The procedures were achieved and the hemorrhage was controlled in all cases. In three patients, the small AD lesions were not found during the first session of angiography, but were instead detected on the repeated angiography conducted one week later. All the patients were discharged without any severe complications. No rebleeding occurred within 30 days following the embolization. Hemorrhage recurred in two patients within one year after hospital discharge. TAE procedures were performed once more using microcoils, and the bleeding was controlled. Conclusion: For the patients with refractory and repeated gastrointestinal hemorrhage due to angiodysplasia, TAE seems to be an effective alternative option when endoscopic examination and treatment do not work.

Clinical value of capsule endoscopy in small intestinal diseases

Objective: To analyze the clinical value of capsule endoscopy (CE) in small intestinal diseases and to explore the correlation between the diagnosis and clinical characteristics. Methods: From June 2016 to April 2019, a total of 194 patients receiving CE were enrolled in the Department of Gastroenterology, Shanxi People's Hospital, including 68 patients with obscure gastrointestinal bleeding, 104 with chronic abdominal pain and 22 with diarrhea. Results: The detection rate of small intestinal lesions by CE was 53.6%(104/194), of which gastrointestinal bleeding was 66.2% (45/68), chronic abdominal pain was 53.8%(56/104), and diarrhea was 13.6%(3/22). The first three positive diagnostic criteria of CE for gastrointestinal bleeding were non-specific inflammation, small intestinal ulcer and vascular malformation. CE findings in patients with abdominal pain were non-specific inflammation, small intestinal ulcer and Crohn's disease; while the major endoscopic presentations in patients with diarrhea were small intestinal ulcer and non-specific inflammation. Logistic regression analysis suggested that the clinical manifestations and gender were correlated with positive diagnosis by CE (P<0.05), and the positive diagnostic rate of CE in female patients was significantly lower than that in male patients [31.6%(25/79) vs. 51.3%(59/115), P<0.05]. The diagnostic rates of CE in patients with gastrointestinal bleeding and chronic abdominal pain were similar [55.9%(38/68) vs. 41.4%(43/104)], which was significantly higher than those with diarrhea [9.1%(2/22), P<0.05]. Conclusions: Capsule endoscopy has a high detection rate for small intestinal diseases, which could be the first choice in patients with unexplained gastrointestinal bleeding. Male patients and gastrointestinal bleeding are predictors of positive findings by CE.

Meckel's diverticulum: clinical features, diagnosis and management.

Meckel's diverticulum is the most common anomalous development of the gastrointestinal system that results from an incomplete vitelline canal. A diagnosis is usually made during the clinical examination of presentations such as unexplained gastrointestinal bleeding, obstruction, inflammation or perforation. The purpose of this review is to provide an adequate level of knowledge of the clinical and diagnostic features as well as the management of Meckel's diverticulum. Diagnosis of Meckel's diverticulum may be challenging as the condition remains asymptomatic or may mimic various diseases and obscure the clinical picture. Life-threatening complications include bleeding, obstruction, inflammation and perforation. Therefore, it is essential that anatomical and pathophysiological characteristics are known in detail in order to prevent complications which will result in morbidity and mortality.

Laparoscopic resection for Meckel's diverticulum causing intestinal obstruction.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal system with an estimated incidence of approximately 2% of the population. Although most cases are asymptomatic, it has the potential to create complications, such as hemorrhage, inflammation, intestinal obstruction, perforation, and intussusception. Meckel's diverticulum is generally diagnosed incidentally or upon investigation of unexplained gastrointestinal bleeding, perforation, inflammation, or obstruction for both pediatric and adult patients. Complications are often present as surgical emergencies and require resection of the diseased intestinal segment. In doubtful cases, laparoscopy should be the surgical method for both diagnosing and treating MD. Here we present a case of MD causing intestinal obstruction and that was treated by laparoscopic resection.

Clinical Characteristics and Prognostic Factors of Small Intestine Angiosarcoma: a Retrospective Clinical Analysis of 66 Cases

Background/Aims: Primary angiosarcoma of the small intestine is a rare neoplasia, and there are limited data from systematic analyses. The aim of this study is to describe the clinical and pathological characteristics in addition to the prognostic factors for this rare neoplasia. Methods: We retrospectively collected the clinical records and prognostic information of 66 patients with small intestine angiosarcoma reported between 1970 and 2017. We used the Chi-square test, the log-rank test, and Cox regression analyses to evaluate the data. Results: There were 66 patients diagnosed with small intestine angiosarcoma. The onset age ranged from 24–92 years old. There were 24 patients diagnosed before the year 2000, and 42 patients were diagnosed after 2000. The data indicated that 49 cases were diagnosed as primary disease, and the remaining 15 cases were secondary disease. The main clinical symptoms were nonspecific and included gastrointestinal (GI) bleeding and abdominal pain. Additionally, we found multi-center foci were one of the characteristics of this disease. Radiation-induced small intestine angiosarcoma (RSIA) is a special type of disease with a similar prognosis. This type was more frequent in females and decreased after the year 2000. We also found that GI bleeding was less common in RSIA cases. The log-rank test results revealed that old-age, poor differentiation, and GI bleeding were associated with worse prognosis. Surgical treatment showed a trend toward a prolonged survival time. However, the result was not statistically significant. Our results show treatment with adjuvant therapy improved prognosis. The multivariate Cox analysis demonstrated adjuvant therapy was an independent indicator of a favorable outcome in small intestine angiosarcoma patients. Conclusion: Pay attention to the unexplained gastrointestinal bleeding could lead to a faster diagnosis and control of small intestine angiosarcoma. Furthermore, treatments including adjuvant therapy can effectively improve the prognosis.

MR enterography for the diagnosis of symptomatic Meckel diverticulum in pediatric patients

Objective To retrospectively investigate the value of MR enterography(MRE) for detecting symptomatic Meckel diverticulum(MD) in pediatric patients. Methods We retrospectively selected 16 patients from our MR database patients who underwent MRE between June 2014 and September 2015. They were referred for MRE because of suspected MD after negative or inconclusive upper sonography or scintigraphy or for exclusion diagnosis. There were 13 males and 3 females, with a median age of 2.2 years of age ranging from 0.4 to 8.2 years old. The first symptom included unexplained gastrointestinal bleeding, abdominal pain, small-bowel obstruction, intussusception, vomiting and fever. Two experienced radiologists determined the diverticulum's location, shape, contents and peripheral structural abnormalities. Results MD were diagnosed by MRE in all children. A total of 13 MD and 3 intestinal duplication cysts were pathologically confirmed. The diverticulum's location included: the right lower quadrant in 2 cases, around the navel in 4 cases, the left lower quadrant in 4 cases, the middle quadrant in 2 cases and pelvic cavity in 1 case. The diverticulum's presented as a blind-ending fluid-filled or gas-filled structure in 11 cases and a solid-appearing mass in 2 cases. The wall of the diverticulum showed restricted diffusion, increased mural enhancement comparable with that of adjacent small bowel in 12 cases, and interruption of the wall continuity in 1 case. Hemorrhage in diverticulum appeared as hyperintensity on T1WI images and/or hypointensity on T2WI images in 2 cases. Extravasation of intravascular contrast medium into the gastrointestinal tract due to active bleeding from a Meckel diverticulum was detected in 2 cases. Peripheral structural abnormalities included soft-tissue stranding, adjacent mesenteric stranding and enhancement, free fluid, small-bowel obstruction and enlarged lymph nodes. Conclusion MRE may play an important role in the diagnosis of suspected symptomatic Meckel diverticula, particularly given its lack of ionizing radiation. Key words: Meckel diverticulum; Child; Magnetic resonance imaging

Roles of Capsule Endoscopy and Single-Balloon Enteroscopy in Diagnosing Unexplained Gastrointestinal Bleeding.

Background/Aims:The diagnostic algorithms used for selecting patients with obscure gastrointestinal bleeding (OGIB) for capsule endoscopy (CE) or balloon-assisted enteroscopy (BE) vary among facilities. We aimed to demonstrate the appropriate selection criteria of CE and single balloon-assisted enteroscopy (SBE) for patients with OGIB according to their conditions, by retrospectively comparing the diagnostic performances of CE and BE for detecting the source of the OGIB. Methods:We investigated 194 patients who underwent CE and/or BE. The rate of positive findings, details of the findings, accidental symptoms, and hemostasis methods were examined and analyzed.Results:CE and SBE were performed in 103 and 91 patients, respectively, and 26 patients underwent both examinations. The rate of positive findings was significantly higher with SBE (73.6%) than with CE (47.5%, p<0.01). The rate of positive findings was higher in overt bleeding cases than in occult bleeding cases for both BE and SBE. Among the overt bleeding cases, the rate was significantly higher in ongoing bleeding cases than in previous bleeding cases. Conclusions:Both CE and SBE are useful to diagnose OGIB. For overt bleeding cases and ongoing bleeding cases, SBE may be more appropriate than CE because endoscopic diagnosis and treatment can be completed simultaneously.

Obscure Gastrointestinal Bleeding: Capsule or Balloon?

See “Roles of Capsule Endoscopy and Single-balloon Enteroscopy in Diagnosing Unexplained Gastrointestinal Bleeding” by Shohei Ooka, Kiyonori Kobayashi, Kana Kawagishi, et al., on page 56-60 Obscure gastrointestinal bleeding (OGIB) is defined as overt or obscure gastrointestinal bleeding of unknown origin despite an initial endoscopic evaluation including colonoscopy and esophagogastroduodenoscopy. The majority of patients with OGIB have a bleeding source in the small intestine. In past decades, the evaluation of the small bowel was extremely limited because of difficult intubation using conventional endoscopes. However, this limitation has been overcome by technical advances including capsule endoscopy (CE), balloon-assisted enteroscopy (BAE), and computed tomography or magnetic resonance enterography. The main strength of CE is noninvasive exploration of the entire small bowel. Complete small bowel evaluation can be performed in 79% to 90% of patients, and the diagnostic yield in patients with suspected small bowel bleeding is 38% to 83% [1]. BAE is distinguished by its diagnostic and therapeutic capabilities. Double-balloon enteroscopy (DBE) was described first and single-balloon enteroscopy (SBE) followed. The basic techniques and mechanisms of SBE are similar to those of DBE. Although DBE appeared to be superior to SBE in complete small bowel evaluation, diagnostic yield, ability to treat, and complication rates are similar between DBE and SBE [2]. In this issue of Clinical Endoscopy, Ooka et al. [3] reported that the rate of positive findings for OGIB was significantly higher with SBE (73.6%) than with CE (47.5%), and SBE may be more appropriate for overt OGIB. However, caution is required in the interpretation of the results of this report. CE was performed before SBE in 28.5% of the SBE group in this study. CE is useful for screening before performing BAE in patients with OGIB, and CE before BAE is known to increase the diagnostic and therapeutic yields [4]. In this study, CE might have improved the diagnostic yield in the SBE group, although CE was performed in a part of the SBE group. CE can also guide the insertion route of BAE. An oral approach is usually preferred when a lesion is located within the proximal two-thirds of the small bowel. In this issue of Clinical Endoscopy, it did not appear that a bidirectional approach was tried, because SBE was performed in 91 patients and the oral and anal approaches in 43 and 48, respectively. When an oral or anal approach fails to detect significant findings or reach the targeted lesion, the other route can be tried in practice. A 73.6% diagnostic yield by SBE in patients with OGIB is relatively surprising, even though only one route was tried in all cases. Diagnostic yield of CE and BAE for patients with overt bleeding is higher than that for patients with occult bleeding, and the diagnostic yield for patients with ongoing overt bleeding is higher than that for patients with previous overt bleeding. In Ooka’s study [3], the percentage of patients with overt bleeding was higher in the SBE group than in the CE group (80.8% vs. 58.4%), and ongoing overt bleeding was also more frequent (100.0% vs. 90.9%) in the SBE group. The results might have changed if the authors performed multivariate analyses according to the amount and timing of bleeding. Actually, CE and BAE are not competitive, but complementary. According to the American College of Gastroenterology guidelines, CE should be considered a first-line procedure for suspected small bowel bleeding, and BAE should be attempted if a small bowel lesion is strongly suspected based on clinical presentation and abnormal CE results [5]. However, the results of Ooka’s study do not seem to be sufficient to change current diagnostic guidelines for small bowel bleeding.

The outcome and role of drugs in patients with unexplained gastrointestinal bleeding

Objective. Studies on unexplained gastrointestinal bleeding (GIB) are lacking. We aimed to study the clinical outcomes of patients with unexplained GIB and to determine the incidence of obscure GIB. Material and methods. A population-based study on all patients undergoing endoscopy at the National University Hospital of Iceland in 2010. Indications, results of endoscopies and drug history were prospectively registered with a follow-up of 3 years. A national pharmaceutical database containing prescription data was utilized. Patients were categorized into unexplained overt and occult GIB and obscure GIB. Patients undergoing endoscopy and without GIB acted as controls. Results. Of 2471 patients undergoing endoscopy, 11% had unexplained GIB. Of those, 46% had unexplained overt GIB, 44% had unexplained occult GIB and 11% had obscure GIB. Multivariate analysis showed that patients with unexplained GIB and unexplained overt GIB had greater odds of NSAID use than controls, OR 1.8 (CI 1.03–3.03) and OR 2.0 (CI 1.01–3.77), respectively. Warfarin was strongly associated with all bleeder groups, OR 4–4.8. The incidence of obscure GIB was 10/100,000 inhabitants annually. Two (0.8%) patients were diagnosed with colon cancer 16 and 30 months after the index colonoscopy. Of patients with unexplained overt, unexplained occult GIB and controls, 5%, 6% and 3.5% (NS) had another overt bleeding episode, during the study period. Conclusions.NSAIDs and warfarin seem to play an important role in unexplained GIB. The incidence of obscure GIB is low and missed cancers are very rare. The probability of a repeat bleeding episode is similar to that of controls.