1 / 46

OBSCURE GI BLEED

OBSCURE GI BLEED. Talat Bessissow , MC CM, FRCPC Assistant Professor, Department of Medicine Division of Gastroenterology McGill University Health Center. Definition. Definition = GI bleeding of uncertain etiology after EGD, C-scope, and small bowel radiography

etenia
Download Presentation

OBSCURE GI BLEED

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. OBSCURE GI BLEED TalatBessissow, MC CM, FRCPC Assistant Professor, Department of Medicine Division of Gastroenterology McGill University Health Center

  2. Definition • Definition = GI bleeding of uncertain etiology after EGD, C-scope, and small bowel radiography • Overt OGIB = hematochezia, melena, hematemesis or CG emesis • Occult OGIB = FOB + in abscence of visible blood, Iron deficiency Anemia

  3. Fecal occult blood testing • Guaiac-based tests: The pseudoperoxidase activity of hemoglobin turns the guaiac compound blue in the presence of hydrogen peroxide

  4. Epidemiology • 300,000 pts hospitalized/yr in US ... 5% of these will have normal EGD and C-scopes • Median time for diagnosis is 2 years • Average cost $33,630 per patient • Average 7.3 tests per patient • Paradigm shift since introduction of VCE and DBE

  5. Etiology of Obscure GI Bleeding • 5% of patients presenting with GI hemorrhage have no source found by upper endoscopy and colonoscopy. • Of these, 75% are 2ndry to small bowel lesions • Of these, 30-60% angiectasias Am J Surg 1992;163:90–92 Br Med J (Clin Res Ed)1984;288:1663–1665.

  6. Etiology of Obscure GI Bleeding

  7. Etiology • 40% of OGIB - due to angiectasias (AVMs) • Angiectasias : ectatic blood vessels made of thin wall with or without endothelial lining • Natural history of angiectasias is not well known • Only 10% of all patients with angioectasia will eventually bleed • Once a lesion has bled up to 50% will not rebleed --- predictors of rebleeding: multiple bleeding episodes, transfusion requirement • Bleeding angiectasias are associated with abnormal von Willebrand’s factor (vWF)

  8. AVM • Conditions/diseases associated with angiodysplastic lesions: • Elderly • CRF • Aortic valve disease (Heyde’s syndrome) • Cirrhosis • Collagen vascular disease

  9. AVM

  10. What is Heyde’s syndrome ? • Heyde’s syndrome: Bleeding from angiectasias in patients with AS. • Increased consumption of high-molecular-weight multimers of VWF due to shear stress of the abnormal valve which corrects after aortic valve replacement with decreased severity of bleeding Transfus Med Rev 2003;17:272–286.; Abdom Imaging (2009) 34:311–319

  11. Small Bowel Bleeding • Etiology depends on the age of the patient • Young: small intestinal tumors, Meckel’s diverticulum, Dieulafoy lesion, Crohn’s disease • Older: (>40) vascular lesions, NSAID-induced SB disease • Uncommon: hemobilia, hemosuccus pancreaticus, aortoenteric fistula

  12. History and Physical Examination • The nature of the exact presenting symptom is important in deciding a practical, efficient, and cost-effective evaluation plan • Hematemesis indicate upper GI bleed • Melena can be anywhere from the nose to the right colon • Hematochezia can be a lower GI bleed or a fast upper GI bleed • History of medications (mainly OTC) • Family history • Skin signs

  13. Hereditary hemorrhagic telangiectasia

  14. Blue rubber bleb nevus syndrome

  15. Dermatitis herpetiformis

  16. Plummer–Vinson syndrome

  17. Tylosis

  18. Investigation options • Repeat G & C • CTE • Capsule endoscopy • Enteroscopy - push or SBE/DBE • Angiography • Tagged RBC scan

  19. Common lesions that are overlooked • EGD: Cameron’s erosions, fundic varices, PUD, angioectasias, Dieulafoy lesion, GAVE • C-scope: angioectasias, neoplasms

  20. Investigation • Repeat standard endoscopy, especially if anemia and overt GI bleeding: • Overlooked lesions: fundus • high lesser curvature antrum C loop of duodenum, posterior wall of duodenal bulb • Random SB Bx can be + for celiac disease in up to 12% • The yield of repeat colonoscopy is 6%, yield of repeat EGD is 29% (ASGE) Am J Gastroenterol 1996;91:2099–2102

  21. Investigation • Consider side-viewing scope if pancreatobiliary pathology is suspected • Small bowel series/SBFT: • When compared with capsule endoscopy • diagnostic yield 8% vs 67% • clinically significant finding 6% vs 42% (NNT 3) • Used if SB obstruction is suspected Gastroenterology 2002;123:999–1005

  22. Investigation • CT Enterography: • Thin sections and large volumes of enteric contrast material to better display the small bowel lumen and wall. • Neutral enteric contrast + IV contrast • 1.5 – 2 L of milk, PEG electrolytes or low-concentration barium

  23. Investigation • CT Enterography: • Advantages: displays entire wall thickness examination of deep ileal loops mesentery & perienteric fat no need for NGT

  24. CTE

  25. Investigation • Technetium-99m–labeled RBC scan: Limited value Blood loss of 0.1-0.4 ml/min (2U PRBCs /d) Poor localization of SB bleeding - not enough to direct operative therapy • Angiography: Useful in massive bleeding (>0.5ml/min) Diagnostic & therapeutic Nucl Med Commun 2002;23:591–594

  26. Investigation • Endoscopic imaging: • Intraoperativeenteroscopy; Terminal ileum can be reached in 90% of cases • diagnostic yield 58-88% • mortality up to 17%

  27. Investigations • Push enteroscopy: • Length 220-250 cm • usually limited to 150 cm • diagnostic yield up to 70% • angioectasias in up to 60% • some suggest push enteroscopy over repeat EGD as second look

  28. Capsule endoscopy • Size 11x26 mm • Obtains images and transmits the data via radiofrequency to a recording device • The capsule is disposable • Examination takes at least 8 hours (57,600 images) • Reading 60 – 120 minutes • SB obstruction is a contraindication

  29. Capsule endoscopy • Capsule endoscopy: yield 63% vs 23% for push enteroscopy Sensitivity 89 - 95% Specificity 75 – 95% +ve predictive value 97% -ve predictive value 86%

  30. Lin, GIE 2008 • Rastogi et al. GIE 2004 • Pennazio et al. Gastroenterol 2004 • Apostolopoulos et al. Endoscopy 2006 • Estevez et al. Eur J Gastro Hep 2006 • Delvaux et al. Endoscopy 2004

  31. Superior yield to other diagnostic modalities in both active and inactive obscure GI bleeds • * Marmo, APT 2005, Triester, AJG 2005, Saperas AJG 2007

  32. Double Balloon Enteroscopy • Double Balloon Enteroscopy (DBE) • 1stdescribed in 2001 • 200-cm enteroscope • 140-cm overtube

  33. Double Balloon Enteroscopy (DBE) • Antegradeapproach: mean distance  240 +/- 100 cm mean time  72.5 +/- 23 min • Retrograde approach: mean distance  140 +/- 90 cm mean time  75 +/- 28 min

  34. How Effective is DBE?

  35. How Effective is DBE?

  36. Complications • Perforation – 0.3-1.1% • Bleeding (post-polypectomy) – 1.4-1.9% • Pancreatitis – 0.2-0.3% Melsink Endoscopy 2007, Gerson ACG 2008

  37. Single Balloon Enteroscopy • Much more recent • Simpler to set up, works with existing Olympus equipment • Same specifications as DBE without the second balloon on the endoscope Hartmann, Endoscopy 2007

  38. Single Balloon Enteroscopy Kawamura GIE 2008

  39. SBE versus DBE • Efthymiou, abstract 2010 • RCT involving 79 patients recruited for mainly OvGIB/ObGIB • About half had SBE • Depth of insertion retrograde was identical (100 cm) • Depth of insertion orally favoured DBE (250 versus 205 cm but not significant) • Therapeutic yield was 54% DBE, 37% SBE (not significant) • Targetted biopsies or application of cautery or argon plasma

  40. Pennazio et al. Endoscopy 2005 & AGA Technical Insitute. Gastroenterol 2007

More Related