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Obscure GI Bleeding

Obscure GI Bleeding. Michael Rusche, MD. Obscure GI Bleeding: Overview. Definitions Epidemiology Cost Etiology Evaluation Conclusions. GI Bleeding: Definitions. I. Obscure Bleeding Persistent or recurrent bleeding following negative GI tract evaluation (EGD, Colon, SB radiology

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Obscure GI Bleeding

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  1. Obscure GI Bleeding Michael Rusche, MD.

  2. Obscure GI Bleeding: Overview • Definitions • Epidemiology • Cost • Etiology • Evaluation • Conclusions

  3. GI Bleeding: Definitions • I. Obscure Bleeding • Persistent or recurrent bleeding following negative GI tract evaluation (EGD, Colon, SB radiology • Occult type: +FOBT and/or IDA • Overt type: Visible bleeding

  4. Obscure GI Bleeding: Epidemiology • Represents 5-10% of all GI bleeding events (overt and occult) • Estimated that approx 5% of GI bleeding occurs between ligament of Treitz and IC valve. Katz LB. Semin Gastrointest. Dis 1999

  5. Obscure GI Bleeding: Cost? • Per patient (prior to diagnosis) • Time: 2.7 years • > 7 diagnostic tests • > 5 hospitalizations • Transfused 20-40 units PRBC • Minimal cost (medicare) $34K • (Excluding office visits, ER, Rx) Foutch et al. – GI Endo ‘90; Flickinger et al. – Am J Surg ‘89; Goldfarb et al. – Dis Manage ‘02

  6. Those <40 Tumors Meckel’s Dieulafoy Crohns Celiac Disease Those >40 Angioectasias Dieulafoy NSAIDs Celiac Disease Lymphoma Crohns Obscure GI Bleeding: Etiologies Mid-gut (80%) Raju et al. – Gastro ‘07

  7. Obscure GI Bleeding: Etiologies • Uncommon Etiologies of SB Bleeding (<5%): • Hemobilia • Hemosuccus pancreaticus • Aorto-enteric fistula • Ectopic varices • Strongyloides stercoralis infection • Pelvic radiotherapy

  8. Meckel’s Diverticulum • Remnant of vitelline duct. At 50‐75 cm proximal from IC valve. • Present in 0.3 –3% of population; • 50% have ectopic gastric mucosa. • In some, acid secretion causes ulcer and bleed; 85% with gastric mucosa are seen with Meckel scan; • May cause obstruction due to intussusception or intraperitoneal bands with volvulus, or diverticulitis. • Presentation: Painless bleed (currant jelly, melena, or hematochezia) • DX: • Meckel Scan: Technetium scan after H2‐blocker, • Capsule endoscopy, • Enteroclysis • Balloon assisted enteroscopy • Treatment: surgery

  9. Dieulafoy Lesion • Definition: Aberrant submucosal artery, without ramification in gastric wall, which erodes the overlying epithelium in the absence of a primary ulcer. • Causes less than 1 percent of cases of severe UGI hemorrhage • Caliber of the artery is 1 to 3 mm (10‐times the caliber of mucosal capillaries). • Usually located in the upper stomach along the lesser curvature near the gastro‐esophageal junction. • May be found in all areas of the gastrointestinal tract, including the esophagus and duodenum. • Bleeding is often self‐limited, although it is usually recurrent and can be profuse • Etiology is unknown, likely congenital. • Causes of bleeding are not well‐understood. • Associations: cardiovascular disease, hypertension, chronic kidney disease, diabetes, or alcohol abuse. • Use of NSAIDs is common; NSAIDS may incite bleeding by causing mucosal atrophy and ischemic injury

  10. Aorto-Enteric Fistula • Rare cause of acute UGI bleeding, but associated with high mortality if undiagnosed and untreated. • •Location: The third or fourth portion of the duodenum is the most common site for aortoenteric fistulas, followed by the jejunum and ileum . • •Presentation: • –Repetitive herald bleed with hematemesis and/or hematochezia; this may be followed by massive bleeding and exsanguination. • –Intermittent bleeding can be seen if clot temporarily seals the fistula. • –Other signs and symptoms may include abdominal or back pain, fever, and sepsis. Infrequently, an abdominal mass is palpable or an abdominal bruit is heard. • •Pathophysiology—Aortoenteric fistulas arise from direct communication between the aorta and the gastrointestinal tract.

  11. Aorto-Enteric Fistula • Causes: • Primary A‐E fistula in USA are due to atherosclerotic aortic aneurysm. In other parts of the world are infectious aortitis due to syphilis or tuberculosis. • Secondary A‐E fistula due to prosthetic abdominal aortic vascular graft. Mayhave pressure necrosis or graft infection causing the fistula. Other secondarycauses include penetrating ulcers, tumor invasion, trauma, radiation therapy, and foreign body perforation. • Diagnosis: • A high index of suspicion. • Should be considered in all patients with massive or repetitive UGI bleeding and a history of a thoracic or abdominal aortic aneurysm, or prosthetic vascular graft. • Endoscopy is the procedure of choice for diagnosis and exclusionof other causes of acute UGI bleeding. • Endoscopy with an enteroscope or side‐viewing endoscope may reveal a graft, an ulcer or erosion at the adherent clot, or an extrinsic pulsatile mass in the distal duodenum or esophagus. • Abdominal CT scan and aortography can be useful in confirming the diagnosis, but may be unreliable

  12. Hemobilia • Bleeding from the hepatobiliary tract; rare cause of acute UGI bleeding. • Should be considered in a patient with acute UGI bleeding and a recent history of: • hepatic parenchymal or biliary tract injury, • percutaneous and transjugular liver biopsy, • percutaneous transhepaticcholangiogram, • cholecystectomy, • endoscopic biliary biopsies or stenting, • TIPS, • Angioembolization,or • blunt abdominal trauma . • Other causes include gallstones, cholecystitis, hepatic or bile duct tumors, intrahepatic stents, hepatic artery aneurysms, and hepatic abscesses.

  13. Hemobilia • Signs & Symptoms: • Classic triad is biliary colic, obstructive jaundice, and occultor acute GI bleeding. • Hemobilia can result in obstructive jaundice with or without biliary sepsis. • Diagnosis: • Often overlooked in the absence of active bleeding. • A side‐viewing duodenoscope is helpful for visualizing the ampulla or for performing diagnostic endoscopic retrograde cholangiography (ERCP). • Technetium‐tagged red blood cell scan or • Selective hepatic artery angiography to reveal the source of hemobilia and for treatment. • Treatment: directed at the primary cause of bleeding; • embolization or surgical resection of a hepatic tumor, or • arterial embolization following liver biopsy or PTC, • laparoscopic cholecystectomy

  14. Hemosuccus Pancreaticus • Definition: Bleeding from the pancreatic duct; rare cause of UGIbleeding. • Causes: chronic pancreatitis, pancreatic pseudocysts, and pancreatic tumors. • Pathogenesis: • Pseudocystor tumor erodes into a vessel, forming a direct communication between the pancreatic duct and a blood vessel. • May be seen after therapeutic endoscopy of the pancreas or pancreatic duct, including pancreatic stone removal, pancreatic duct sphincterotomy, pseudocyst drainage, or pancreatic duct stenting. • Diagnosis: confirmed by abdominal CT scan, ERCP, angiography, orintraoperative exploration. • CT scan is performed first (least invasive). • Treatment: • Mesenteric arteriography with coil embolization can control acute bleeding. • If bleeding persists or is massive: pancreaticoduodenectomy or pseudocyst resection and ligation of the bleeding vessel

  15. Obscure GI Bleeding: Etiologies Overlooked Causes of GI Bleeding (10-20%): • Upper GI tract: • Cameron’s erosions • Fundic varices • Peptic ulcer • Angioectasias • Dieulafoy’s • GAVE • Lower GI tract: • Angioectasias • Neoplasms

  16. Obscure/Occult GI Bleeding: Evaluation • ? Missed occult source or new obscure? • “2nd look” endoscopies frequently + • Cameron’s (DH) erosions • PUD • Vascular ectasias, angiodysplasias • Neoplasias • After negative bi-directional GI studies small intestine most likely source

  17. Obscure GI Bleeding: Evaluation • Diagnostic Techniques • Bi-directional Endoscopy (“second look”) • Nuclear (TRBC) scans • Angiography • Meckel’s scan • Small bowel biopsy • SBFT/Enteroclysis • Enteroscopy • Per oral • Transanal or retrograde • Interoperative • Capsule endoscopy • Exploratory laparotomy

  18. Obscure GI Bleeding: Evaluation • Diagnostic Techniques • Bi-directional Endoscopy (“second look”) • Nuclear (TRBC) scans • Angiography • Small bowel biopsy • SBFT/Enteroclysis • Enteroscopy • Per oral • Transanal or retrograde • Interoperative • Capsule endoscopy • Exploratory laparotomy

  19. Obscure GI Bleeding: Evaluation • Diagnostic Techniques • Bi-directional Endoscopy (“second look”) • Nuclear (TRBC) scans • Angiography • Small bowel biopsy • SBFT/Enteroclysis • Enteroscopy • Per oral • Transanal or retrograde • Interoperative • Capsule endoscopy • Deep endoscopy • Exploratory laparotomy

  20. Obscure GI Bleeding: TRBC scan • Bleeding rate must be > 0.1-0.4ml/min (1unit per day) • Early scans (within 4 hours) with (+) more reliable than last (+) • Later scans show “pooled blood/isotope” • Pre-requisite to angiography in most centers • Frequent false (+) and (-) • Very little benefit in average OGIB: • Diganositic yield: 25% • Location accuracy: 30-50% • Diagnostic yield in lower GI “overt” bleeding • Colorectal site found 45% (26-78%) • Later positive scan verification studies: ~78% + lesion

  21. Obscure GI Bleeding: Angiography • Yield: • When active bleeding as high as: 61-72% • Overall: 27-77% (mean 40%) • Requires > 0.5 ml/min bleeding rate 1ml/h (3 Units/day) • Reasonable in patient with hemodynamic instability or ongoing transfusion need • Study first SMA (50-80% of bleeds, then IMV, and then celiac axis • Can control bleeding with vasopressin (90% efficacy) or coil embolization (riskier; 20% infarct) • Provocative angiography (anticoagulation or thrombolytic) can increase yield but lead to uncontrollable bleed

  22. Obscure GI Bleeding: SBFT/Enterocolysis • Occult bleeding patient diagnostic yields • SBFT 0-4% reported in multiple studies • Enteroclysis 0% in multiple studies • Obscure patient diagnostic yields • SBFT 0-5.6% reported • Enteroclysis 10-21% seen

  23. Obscure GI Bleeding: Push enteroscopy • Extended upper endoscopy • Typically involves pediatric colonoscope or dedicated enteroscope • Distance reached in SB anywhere from 40-90 cm (at most 40 cm beyond ligament of Treitz) • Yield • Average of 35% (3-78%) • Picks up previously missed proximal lesions • Up to 64% of lesions identified with a push enteroscope were within reach of a standard endoscope • Increased yield in overt bleeding situations

  24. Obscure GI Bleeding: Capsule Endoscopy • Approved since 2001 • Most sensitive non-invasive test for obscure GI bleeding • Excellent for screening who needs more invasive procedures • High negative predictive value

  25. Obscure GI Bleeding: Capsule Endoscopy • 2 images/second during 8 hours study • 65,000-80,000 images • Streaming video • Reading time of roughly one hour

  26. Obscure GI Bleeding: Capsule Endoscopy • Needs good Small Bowel Prep. • Reading rate </= 15 frames/sec • Experimental Yield: Dedicated Enteroscope vs. Capsule Enteroscopy • Bleeds at reach of enteroscope: 94% vs 53% • Bleeds in all small bowel: 37% vs 64% • Clinical Yield of Capsule: • Ongoing obscure‐overtbleed within 2 weeks: 92% • Ongoing obscure‐overtbleed after 2 weeks: 34% • Obscure‐overtbleed in past year: 13% • Obscure‐occult bleed: 44%

  27. Obscure GI Bleeding: Capsule Endoscopy • Predictors of (+) capsule finding: • Through Hb < 10 g, • more than 1 bleeding episode, or • bleeding persisting > 6 months • Capsule vs Intraop Endoscopy: • yield 74 vs 76.6%, • Capsule: sensitivity = 95%, specificity = 75%, PPV = 95%, NPV = 86% • Management change: 37 to 66%; this led to resolution of bleeding in 65%

  28. Obscure GI Bleeding: Capsule Endoscopy

  29. Obscure GI Bleeding: Capsule Endoscopy

  30. Obscure GI Bleeding: Capsule Endoscopy

  31. Obscure GI Bleeding: Capsule Endoscopy

  32. Obscure GI Bleeding: Capsule Endoscopy

  33. Obscure GI Bleeding: Intraoperative enteroscopy • Yield: 58‐88% of small bowel lesions. • IOE: Examination done “anterograde”, with dedicated enteroscope, with dimmed OR light. Lesions are marked when seen in the “way in”. • TI reached in > 90% • Therapy given in 64%. • Recurrent bleed: 12.5‐60% • Mortality: up to 17% • May cause lacerations, perforations, bowel ischemia, pancreatitis, and prolonged ileus. • Should be done only when DBE is limited for adhesions or other anatomic factors.

  34. Deep Enteroscopy • Double-Balloon Enteroscopy • Single-Balloon Enteroscopy • Spiral Enteroscopy Therapeutic as well as diagnostic capabilities

  35. Obscure GI Bleeding: Deep Enteroscopy • Yield: 41‐80% of small bowel lesions. • DBE: uses anterograde + retrograde approach • Time: anterograde 72‐95 min, retrograde 75‐102 min. Each exam done in separate days. • Outcomes: • Diagnostic yield 65%, • Diagnostic/treatment success 64%, • Total SB exam 29% (tattoo), • Miss rates 28% (vs 20% for capsule)

  36. Obscure GI Bleeding: Deep Enteroscopy • Findings: • Angioectasia 31%, • Ulcers (including IBD) 13%, • Malignancies 8%, • Other 6%, • Negative exam 40% • May cause lacerations, perforations, bleeding, and pancreatitis. • Ante‐grade approach recommended when lesion is in initial 2/3. Retrograde approach when distal 1/3.

  37. For Now…DBE primarily therapeutic • Time, labor, personnel and cost intensive • Complications risk: Initially ≈ 1%, upcoming data likely to show less • Diagnostic and therapeutic yield ↑if pre-screening done • May be cost-effective as initial approach in patients with ongoing overt bleeding • However, VCE before DE will reduce the number of procedures and ↓ complications  better long-term outcomes

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