Investigating IDA (BSG Guideline)And

An overview of Obscure GI Bleed

Dr.D.GhoshGastroenterology Registrar

Anaemia: <10-11.5g/dl for women <12.5-13.8g/dl for men

Not known at what level of Hb Ix should be initiated. No reason why mild anaemia should be less indicative of important disease than severe anaemia

Iron deficiency: serum ferritin<12 MCV< 76

Transferrin sat<30%Bone marrow aspirationTherapeutic responseSr.transferrin receptor/ferritin ratio

Investigation

History - dietary,drugs and family hxExamination-abd mass/cutaneousGI evaluation:all with confirmed IDA unless non GI blood lossOrder of Ix in absence of symptoms-local availability OGD with small bowel bx : yield 30-50% Barium meal with coeliac serology if unable

Colonoscopy:unless OGD positive for Ca or coeliac ALL pts should have lower GI ixBa enema is a sufficent alternative with/without sigmoidoscopy (can omit in absence of

lower GI symptoms and a normal PR Exam)

FOB is of no benefit in the investigation of IDA –insensitive and nonspecific“The management of IDA is often suboptimal with most patients being incompletely

investigated if at all”

Iron treatment

• Different formulations• Vit c• Parental iron• Target: increase by 2 every 3wks• Replenish stores:3 more months• Monitor:3 monthly for a yr & then after one yr• Reassuring to know that IDA does not return in

most pts in whom no cause is found after ix

• Co-morbidity: appropriateness should be carefully considered and discussed with pts and carers.

• Pre-menopausal women:– 5-10% incidence in that group– Hx unreliable to quantify– Ix only if>45yrs – Ogd & SI bx if upper GI symptoms– But coeliac serology in all– Lower GI ix only if symptoms,family hx,refractory after correction

of potential cause• Post-gastrectomy:if refractory or occuring long after

Etiology of small-bowel bleeding

Classification of vascular malformations that cause gastrointestinal hemorrhage

Classification of vascular malformations that cause gastrointestinal hemorrhage Arteriovenous malformations (AVMs): Dilation of existing vascular structures Type I AVM (angiodysplasia, vascular ectasia of the colon, vascular dysplasia of the colon) Dilatation and ectasia of veins, venules, and capillaries in colonic mucosa and submucosa Important cause of lower gastrointestinal bleeding Majority of patients are older than 60 years of age 20%-25% have aortic stenosis Usually are multiple and occur mainly in the right colon Difficult to identify Type II AVM Rare, probably congenital Bleeding usually occurs before the age of 50 Small bowel is the most common location but may occur anywhere Larger than type I AVMs May be visible at laparotomy Type III AVM (hereditary hemorrhagic telangiectasia, Osler-Weber-Rendu syndrome) Rare Autosomal dominant Throughout the gastrointestinal tract Repeated bleeding episodes from nasopharynx and gastrointestinal tract Most have a positive family history Lesions readily visible on face, oral, and nasopharyngeal mucosa

Arteriovenous malformations in the gastrointestinal tract

Endoscopic views of small-bowel arteriovenous malformations

Endoscopic views of small-bowel arteriovenous malformations

Small-bowel arteriovenous malformations as the cause of gastrointestinal hemorrhage

Small-bowel tumors as the cause of gastrointestinal hemorrhage

Small-bowel tumors as the cause of gastrointestinal hemorrhage General Concepts of Small-Bowel Tumors: Represents only 1%-2% of gastrointestinal malignancies Except for adenocarcinoma, small-bowel tumors are more common distally Bleeding (overt or occult) is a prominent feature, being more common with benign than with malignant lesions. Among malignant tumors, leiomyosarcoma is most commonly associated with bleeding. Bleeding with adenocarcinoma is less frequent, and rarely occurs with carcinoid tumors. Sensitivity of barium studies depends on whether the calculation is made for any abnormality or only for the actual tumor. Thus, for malignant tumors the sensitivity for small-bowel follow-through when using the former criteria varies from 53% to 83% whereas it drops to 30% to 44% for visualization of the actual tumor. Enteroclysis, however, may increase these sensitivities up to 90% and 95%, respectively.

Gastrointestinal hemorrhage of obscure origin arising from small-bowel tumors

Diagnostic techniques available for evaluation of small-bowel bleeding Barium Contrast Radiologic Studies Small-bowel series Enteroclysis Nuclear Medicine Studies 99mTechnetium sulfur colloid scintigraphy 99mTechnetium-labeled erythrocyte scintigraphy 99mTechnetium sodium pertechnetate scan (Meckel's scan) Enteroscopy Push enteroscopy (jejunoscopy) Sonde enteroscopy Arteriography Wireless capsule endoscopy Exploratory Laparotomy Alone With intraoperative angiography With intraoperative scintigraphy With intraoperative enteroscopy

Barium studies in the evaluation of small-bowel bleeding

Barium studies in the evaluation of small-bowel bleeding Diagnostic yield Small-bowel series, % Enteroclysis, % Overall (all indications) 6.6-7.1 37 Bleeding

0-5.6 10 (Increased to 20%if done only after negative UGI/LGI work up)

Advantages Disadvantages Noninvasive Time-consuming Low complication rate, safe Operator dependent Low diagnostic yield Relatively easy to perform Requires duodenal intubation (enteroclysis) Should not be used in the presence of acute bleeding Lower cost than other options Fails to identify mucosal vascular abnormalities Incidental findings may be misleading (seen in 15%) Widely available May identify a lesion, but not necessarily the source of bleeding

Types of nuclear medicine studies for the evaluation of small-bowel bleeding

Types of nuclear medicine studies for the evaluation of small-bowel bleeding 99MTc Sulfur Colloid 99MTc-Labeled RBC By 12-15 minutes, most activity is cleared from the intravascular space Remains in intravascular space for up to 24 hours Useful for the acute ongoing bleeding

Useful for intermittent bleeding

Advantages Disadvantages Detects slow bleeding rates (0.1 mL/min) Background activity in esophagus, stomach, duodenum, spleen, and

liver Readily available techniques Limited use in the upper gastrointestinal tract Lower complication rate Delayed films may be misleading for correct anatomic location Relative low cost Poor positive and negative predictive value Noninvasive Regarded as screening procedure only Safe

Diagnostic yield of nuclear medicine studies for small-bowel bleeding

Diagnostic yield of nuclear medicine studies for small-bowel bleeding Overall yield for all gastrointestinal bleedings

25%-64%

(patients with positive scan/total patients)

Overall correct localization confirmed by other means

41%-95%

(positive scans in which confirmation attempted)

Yield for small-bowel Bleeding

55% (0%-100%)

Correct localization of small-bowel bleeding site

47% (10%-100%)

Diagnostic value of Meckel's scan in the adult population

Diagnostic value of Meckel's scan in the adult population Sensitivity Specificity Accuracy PPV 62.5% 9% 46% 60% PPV=positive predictive value Causes of false-negative scans Causes of false-positive scans Absent/insufficient (> 1.8 cm2 required []) or necrotic ectopic gastric mucosa

Ectopic gastric mucosa in absence of diverticulum

Inflammatory reactions Bad technique or failure in interpretation Neoplastic conditions Dye washout (rapid bleeding) Renal abnormalities Vascular compromise Vascular lesions Yield of Meckel's Scan in the bleeding patient: 55%

Arteriography in the diagnosis of small-bowel bleedingArteriography in the diagnosis of small-bowel bleeding Advantages Accurately identifies the anatomic location of bleeding May allow hemostatic therapy Disadvantages and complications Invasive High cost Requires invasive radiologist and special equipment Major complications (< 2%): Formation of false aneurysm Occlusion of the artery at the site of catheter insertion Contrast-related allergic reactions; acute renal failure Complications specific to therapeutic methods used Reasons for false-negative results (overall) Bleeding stopped Insufficient contrast Short period of observation Very slow active bleeding (< 0.5-1 mL/min) Failure to include the bleeding site on the film Early termination because of patient's clinical deterioration The bleeding vessel may be overlooked or not selectively opacified Unfavorable anatomy (stenosis, anomalies, aneurysms, tortuous arteries) May be difficult to differentiate from normal mucosal blush if bleeding is diffuse Dilution of contrast in the venous phase may prevent visualization from varices

Arteriography in gastrointestinal bleeding

Arteriography in gastrointestinal bleeding Overall diagnostic yield: 57.6% Yield for small-bowel bleeding: 61.3% Sensitivity, % Specificity, % PPV, % NPV, % Chronic occult bleeding 40 100 100 75 Recurrent acute bleeding 30 100 100 46 Acute bleeding 47 100 100 11 Overall 37.5 100 100 47 Based on 58 patients with gastrointestinal bleeding undergoing 62 arteriographic examinations []

Enteroscopy in the diagnosis and management of small-bowel hemorrhage

Enteroscopy in the diagnosis and management of small-bowel hemorrhage Push enteroscopy (jejunoscopy) Sonde enteroscopy Instruments Adult or Pediatric Colonoscope or Prototypes

(ie, Olympus XSIF-10.5, SIF-100 [Olympus America, Inc., Lake Success, NY])

Different Prototypes (Olympus SIF-VI KAI, SSIF-VI KAI, XSIF-VI KAI3, SIF-SW, SSIF-VII, Pentax ESI-2000 [Pentax Precision Instruments Corp., Orangeburg, NY])

Maximum depth of insertion Jejunum Terminal ileum Special operator skills Not needed Desirable Procedure time Short Long Therapeutic capability Yes No Complete mucosal visualization possible Yes No

Yield of jejunoscopy for small-bowel bleeding

Treatment options for small-bowel bleeding lesions

Treatment options for small-bowel bleeding lesions Options Useful in these circumstances Applications Limitations Medical 1. Chronic slow bleeding Diffuse arteriovenous

malformations (AVMs) Temporary

Iron Supplementation 2. Patient unfit for invasive diagnostic work-up

Metastatic disease Bleeding recurs if therapy stops

Blood Transfusion 3. Patient unfit for surgery Estrogen/Progesterone 4. After rebleeding despite other

therapies

Endoscopic 1. Active bleeding discovered during endoscopy

AVMs Endoscopic skills needed

Heater Probe 2. When multiple lesions are diffuse and therefore not suitable for surgical therapy

Ulcers Persistent/recurrent bleeding

Electrocoagulation Laser Radiographic 1. Active bleeding discovered

during angiography Ulcers Temporary

Vasopressin 2. Patient unfit for surgery Tumors Recurrence Embolization 3. Widespread metastasis AVMs Invasive Surgical 1. Bleeding uncontrolled by other

modalities Tumors Invasive

Excision 2. Isolated bleeding lesion Meckel's diverticulum Persistent/recurrent bleeding Local Resection 3. Suspected malignancy Isolated AVMs Segmental Resection

Evaluation and management of acute hemorrhage

Evaluation and management of chronic gastrointestinal bleeding of obscure origin

Thank you