Obscure Gastrointestinal Bleeding
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Transcript of Obscure Gastrointestinal Bleeding
Evaluation of Obscure Gastrointestinal Bleed
Omar Badrin Masters of Surgery
Definitionbleeding from the GI tract that persists / recur without obvious cause after initial endoscopic evaluation
Occult : non visible bleeding, positive for FOBT and anaemia (iron deficiency anemia)
Overt : visible bleeding presenting as melena or hematochezia
Overt can be active or inactive bleed.
how much do we miss?
• Endoscopy during or immediately after an acute bleed misses the source in 35 - 75% (Chen RY Anz J Surg 2002)
• Half missed upper GI lesions are in the fundus (Decamps C Endoscopy 2009)
• With early endoscopy & good bowel preparation, still 3 - 5% bleeding source undetected (Leighton J Gastrointestinal Endoscopy 2003)
how much do we miss?
• 25% of these are due to missed lesions in the upper and lower GI tract (Tee H P World J Gastroenterology 2010)
• 75% are from small bowel, majority of which are vascular abnormalities. (Tee H P World J Gastroenterology 2010)
why do we miss the bleed?
• no active bleed on endoscopy
• lesions are obscured by blood and clot
• hypovolaemia and anemia
• untrained eye
what we missUpper GI Lower GI
Fundal varices Cameron’s ulcer
Mallory Weiss tear Gastric antral vascular ectasia
Dieulafoy’s lesion Hemobilia
Meckel’s diverticulum Angiodysplasias
IBD Aortoenteric fistula
common causes
< 40 years
IBD
Meckel’s
Dieulafoy’s lesion
Small bowel tutors
> 40 years
vascular lesions
drug related erosions / ulcer
tumors
Fundal varix
Cameron’s ulcer
Mallory Weiss tear
GAVE
Dieulafoy’s lesion
Angiodysplasia
Meckel’s diverticulum
Aorto-entertic fistula
Evaluation• localizing source of bleed [ upper vs lower ]
• exclude non GI sources [ENT bleeds]
• surgical history [AAA repair]
• drug history
• family history:
colorectal or endometrial malignancy [FAP & Lynch syndrome]
neurofibromatosis
Peutz Jagher Syndrome
Kaposi sarcoma
Repeat Upper & Lower endoscope
• 1st step in most centres & practices
• detection rate after initial assessment ranges between 2.8 - 4.8% in upper endoscopy studies (ASGE Fischer J Gastrointestinal Endoscopy 2010)
• rescoping detection rate 3.5% of 174 patients prior to capsule endoscopy (Vlachogiannakos J Dig Dis Sci. 2011)
• missed lesions are: Cameron’s ulcer, peptic ulcers / erosions, GAVE & Dieulafoy’s lesions
• not economical
• based on centres
Video Capsule Endoscopy (VCE)
• non invasive, examination of entire small bowel, safe & diagnostic yield
• no biopsy or therapeutic capability, small bowel folds, unable to locate lesion & risk of retention
• detection of clinically significant lesion by VCE 56% vs PE 26% vs small bowel study 6% (ASGE Fischer J Gastrointestinal Endoscopy 2010)
• 2nd VCE after -ve initial VCE study, detection rate 49% (ASGE Fischer J Gastrointestinal Endoscopy 2010)
VCE• VCE in detecting overt % occult bleed: 100% vs
67% (Hartmann D et al Gastrointest Endosc. 2005)
• VCE vs PE as first line study: detection rate 50% vs 24%, missed lesion 8% vs 24% (lesions detected on standard endoscopy) (de Leusse A Gastroenterology. 2007)
• VCE vs small bowel study: detection rate 20% vs 5%, diagnostic / therapeutic intervention 26% vs 21%. concluded - detection rate is improved, outcome is still the same. (Laine L, Sahota A, Shah A Gastroenterology. 2010)
Enteroscopy• after -ve VCE study
• Types: Push, Deep (single/double balloon, spiral) & intra-operative
• based on design of an over-tube
• diagnostic and therapeutic
• invasive, discomfort
• detection rate 70% (ASGE Fischer J Gastrointestinal Endoscopy 2010)
• most common detected lesion: angiodysplasia, erosions
• most lesions are within reach of standard endoscope
Intra-operative enteroscopy• either through an enterotomy, or upper / lower
endoscope (telescoping)
• examination of 90% of bowel length
• detection rate up 60 - 88% (ASGE Fischer J Gastrointestinal Endoscopy 2010)
• morbidity: serosal tear, hematoma, ileus, ischemia & perforation
• for recurrent overt bleed, high transfusion requirement
• 41 cases 1995 - 2005
• 12 cases angiodysplasias, 8 cases of Crohn’s, 5 with carcinoid, 5 with hamartomas, 4 with lipomas and others
• described procedure as:
1. midline laparotomy
2. examination of small bowel
3. circular stay suture for enterotomy of the proximal bowel
4. introduction of enteroscope, telescoping through small bowel
5. distal bowel clamping for insufflation (prevent over inflation)
Imaging
Small bowel study
1. low detection rate 0 - 5.6% (ASGE Fischer J Gastrointestinal Endoscopy 2010)
2. large luminal / fungating lesion
3. unable to detect flat mucosal lesion
4. contrast may mask active bleed for endoscopy
Radionuclide scan• overt GI bleed
• bleed rate 0.1 - 0.4 cc/min
• RBC tagged with technetium 99m
• poor with localising small bowel lesions
• also Meckel’s scanning in children and young adult with obscure GI bleed
CT mesenteric angiogram
• non invasive
• small bowel IBD
• recent multiphasic CT enterography can detect small vascular lesion [44% of 22 patients, 3 of which were missed on VCE] (Huprich J, Fletcher J, Alexander J, et al. Obscure gastrointestinal bleed- ing: evaluation with 64-section multiphase CT enterography: initial ex- perience. Radiology 2008)
•
Selective angiography• bleeding rate 0.5 cc/min
• better at localising
• detection rate 22 - 77% (Zuckerman GR Gastrointest Endosc 1998)
• selective embolisation (Tan K-K World J Surg 2008)
•
Managementovert occult
stableunstable
resus
repeat scope
CT angiograpgy angiogram
Laparotomy IO scope
repeat scope
VCE
VCE or PE or CT enterography
Deep enteroscopy
-ve
-ve
-ve
-ve
-ve
-ve
take home• careful endoscopy is essential
• VCE as first line in occult bleed
• type of enteroscopy will depend on level of bleed
• intraoperative enteroscopy is not without complications