OBSCURE GI BLEED

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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 - PowerPoint PPT Presentation

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  • OBSCURE GI BLEEDTalat Bessissow, MC CM, FRCPCAssistant Professor, Department of MedicineDivision of GastroenterologyMcGill University Health Center

  • DefinitionDefinition = 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

  • Fecal occult blood testing

    Guaiac-based tests: The pseudoperoxidase activity of hemoglobin turns the guaiac compound blue in the presence of hydrogen peroxide

  • Epidemiology300,000 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

  • Etiology of Obscure GI Bleeding5% 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;163:9092Br Med J (Clin Res Ed)1984;288:16631665.

  • Etiology of Obscure GI Bleeding

    Upper and lower GI bleedingoverlookedMid GI bleedingCamerons erosionsTumorsFundic varicesMeckels diverticulumPeptic ulcerDieulafoys lesionAngiectasiaCrohns diseaseDieulafoys lesionCeliac diseaseGAVEAngiectasiaNeoplasmsNSAID enteropathyErosive gastritisHemobiliaIschemic colitis/UCAortoenteric fistulaLarge polypsVasculitis

  • Etiology40% of OGIB - due to angiectasias (AVMs)Angiectasias : ectatic blood vessels made of thin wall with or without endothelial liningNatural history of angiectasias is not well knownOnly 10% of all patients with angioectasia will eventually bleedOnce a lesion has bled up to 50% will not rebleed --- predictors of rebleeding: multiple bleeding episodes, transfusion requirementBleeding angiectasias are associated with abnormal von Willebrands factor (vWF)

  • AVMConditions/diseases associated with angiodysplastic lesions:

    Elderly

    CRF

    Aortic valve disease (Heydes syndrome)

    Cirrhosis

    Collagen vascular disease

  • AVM

  • What is Heydes syndrome ?

    Heydes 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;17:272286.; Abdom Imaging (2009) 34:311319

  • Small Bowel BleedingEtiology depends on the age of the patient

    Young: small intestinal tumors, Meckels diverticulum, Dieulafoy lesion, Crohns disease

    Older: (>40) vascular lesions, NSAID-induced SB disease

    Uncommon: hemobilia, hemosuccus pancreaticus, aortoenteric fistula

  • History and Physical ExaminationThe nature of the exact presenting symptom is important in deciding a practical, efficient, and cost-effective evaluation planHematemesis indicate upper GI bleedMelena can be anywhere from the nose to the right colonHematochezia can be a lower GI bleed or a fast upper GI bleed

    History of medications (mainly OTC)

    Family history

    Skin signs

  • Hereditary hemorrhagic telangiectasia

  • Blue rubber bleb nevus syndrome

  • Dermatitis herpetiformis

  • PlummerVinson syndrome

  • Tylosis

  • Investigation optionsRepeat G & C

    CTE

    Capsule endoscopy

    Enteroscopy - push or SBE/DBE

    Angiography

    Tagged RBC scan

  • Common lesions that are overlooked

    EGD: Camerons erosions, fundic varices, PUD, angioectasias, Dieulafoy lesion, GAVE

    C-scope: angioectasias, neoplasms

  • InvestigationRepeat standard endoscopy, especially if anemia and overt GI bleeding:Overlooked lesions: fundus high lesser curvature antrum C loop of duodenum, posterior wall of duodenal bulbRandom 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;91:20992102

  • InvestigationConsider side-viewing scope if pancreatobiliary pathology is suspectedSmall 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;123:9991005

  • InvestigationCT 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

  • Investigation

    CT Enterography:

    Advantages: displays entire wall thickness examination of deep ileal loops mesentery & perienteric fat no need for NGT

  • CTE

  • Investigation

    Technetium-99mlabeled 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;23:591594

  • InvestigationEndoscopic imaging:

    Intraoperative enteroscopy; Terminal ileum can be reached in 90% of cases diagnostic yield 58-88% mortality up to 17%

  • Investigations

    Push enteroscopy:Length 220-250 cmusually limited to 150 cmdiagnostic yield up to 70%angioectasias in up to 60%some suggest push enteroscopy over repeat EGD as second look

  • Capsule endoscopy

    Size 11x26 mmObtains images and transmits the data via radiofrequency to a recording deviceThe capsule is disposableExamination takes at least 8 hours (57,600 images)Reading 60 120 minutes SB obstruction is a contraindication

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

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

    Diagnostic YieldObscure/Overt GI Bleeding36-92%Obscure/Occult GI Bleeding41-63%Unexplained Fe-def Anemia42-57%Yield Gain Over Push Enteroscopy+ 30%Yield Gain Over SB Barium Study+ 36%

  • Superior yield to other diagnostic modalities in both active and inactive obscure GI bleeds

    * Marmo, APT 2005, Triester, AJG 2005, Saperas AJG 2007

    StudySens (%)Spec (%)PPV (%)NPV (%)Pennazio 2004, Gastroenterol88.9959782.6Hartmann 2005, GIE95759586

  • Double Balloon Enteroscopy

    Double Balloon Enteroscopy (DBE)

    1st described in 2001

    200-cm enteroscope

    140-cm overtube

  • Double Balloon Enteroscopy (DBE)

    Antegrade approach: mean distance 240 +/- 100 cmmean time 72.5 +/- 23 min

    Retrograde approach: mean distance 140 +/- 90 cm mean time 75 +/- 28 min

  • How Effective is DBE?

    StudyDiagnostic Yield (%)Kaffes 2004, Clin Gastro Hep76Mehdizadeh 2006, GIE51Yamamoto 2006, Am J Gastro76Jacobs 2007, GIE75Tanaka 2008, GIE54Yadav 2010, abstract DDW52%

  • How Effective is DBE?

    StudyPatients (n)YieldMatsumoto 2005, Endo13EquivalentMay 2005, GIE52DBE betterHadithi 2006, Am J Gastro35CE betterMehdizadeh 2006, GIE115EquivalentOhmiya 2007, GIE74EquivalentKameda 2008, J Gastroenterol32EquivalentTeshima 2010, DDW (Meta-)1293CE favoured although nearly equivalent

  • Complications

    Perforation 0.3-1.1%

    Bleeding (post-polypectomy) 1.4-1.9%

    Pancreatitis 0.2-0.3%

    Melsink Endoscopy 2007, Gerson ACG 2008

  • Single Balloon EnteroscopyMuch more recentSimpler to set up, works with existing Olympus equipmentSame specifications as DBE without the second balloon on the endoscope

    Hartmann, Endoscopy 2007

  • Single Balloon EnteroscopyKawamura GIE 2008

  • SBE versus DBEEfthymiou, abstract 2010RCT involving 79 patients recruited for mainly OvGIB/ObGIBAbout half had SBEDepth 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

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