Obscure GI Bleeding Michael Rusche, MD.. Obscure GI Bleeding: Overview Definitions Definitions...

Obscure GI BleedingObscure GI Bleeding

Michael Rusche, MD.Michael Rusche, MD.

Obscure GI Bleeding: OverviewObscure GI Bleeding: Overview

DefinitionsDefinitionsEpidemiologyEpidemiologyCostCostEtiologyEtiologyEvaluationEvaluationConclusionsConclusions

GI Bleeding: DefinitionsGI Bleeding: Definitions

I. Obscure BleedingI. Obscure BleedingPersistent or recurrent bleeding following Persistent or recurrent bleeding following

negative GI tract evaluation (EGD, Colon, SB negative GI tract evaluation (EGD, Colon, SB radiologyradiologyOccultOccult type: +FOBT and/or IDA type: +FOBT and/or IDA OvertOvert type: Visible bleeding type: Visible bleeding

Obscure GI Bleeding: EpidemiologyObscure GI Bleeding: Epidemiology

Represents 5-10% of all GI bleeding Represents 5-10% of all GI bleeding events (overt and occult)events (overt and occult)

Estimated that approx 5% of GI bleeding Estimated that approx 5% of GI bleeding occurs between ligament of Treitz and IC occurs between ligament of Treitz and IC valve.valve.

Katz LB. Semin Gastrointest. Dis 1999

Obscure GI Bleeding: Cost?Obscure GI Bleeding: Cost?

Per patient (prior to diagnosis)Per patient (prior to diagnosis)Time: 2.7 yearsTime: 2.7 years> 7 diagnostic tests> 7 diagnostic tests> 5 hospitalizations> 5 hospitalizationsTransfused 20-40 units PRBCTransfused 20-40 units PRBCMinimal cost (medicare) $34KMinimal cost (medicare) $34K

(Excluding office visits, ER, Rx)(Excluding office visits, ER, Rx)

Foutch et al. – GI Endo ‘90; Flickinger et al. – Am J Surg ‘89; Goldfarb et al. – Dis Manage ‘02

Obscure GI Bleeding: EtiologiesObscure GI Bleeding: Etiologies

Those <40Those <40 TumorsTumors MeckelMeckel’’ss DieulafoyDieulafoy CrohnsCrohns Celiac DiseaseCeliac Disease

Those >40Those >40 AngioectasiasAngioectasias DieulafoyDieulafoy NSAIDsNSAIDs Celiac DiseaseCeliac Disease LymphomaLymphoma CrohnsCrohns

Mid-gut (80%)

Raju et al. – Gastro ‘07


Uncommon Etiologies of SB Bleeding Uncommon Etiologies of SB Bleeding (<5%):(<5%):HemobiliaHemobiliaHemosuccus pancreaticusHemosuccus pancreaticusAorto-enteric fistulaAorto-enteric fistulaEctopic varicesEctopic varicesStrongyloides stercoralis infectionStrongyloides stercoralis infectionPelvic radiotherapyPelvic radiotherapy

MeckelMeckel’’s Diverticulums Diverticulum Remnant of vitelline duct. At 50‐75 cm proximal from IC valve.Remnant of vitelline duct. At 50‐75 cm proximal from IC valve. Present in 0.3 –3% of population; Present in 0.3 –3% of population;

50% have ectopic gastric mucosa. 50% have ectopic gastric mucosa.

In some, acid secretion causes ulcer and bleed; 85% with gastric In some, acid secretion causes ulcer and bleed; 85% with gastric mucosa are seen with Meckel scan; mucosa are seen with Meckel scan;

May cause obstruction due to intussusception or intraperitoneal bands May cause obstruction due to intussusception or intraperitoneal bands with volvulus, or diverticulitis.with volvulus, or diverticulitis.

Presentation: Painless bleed (currant jelly, melena, or hematochezia)Presentation: Painless bleed (currant jelly, melena, or hematochezia) DX: DX:

Meckel Scan: Technetium scan after H2‐blocker, Meckel Scan: Technetium scan after H2‐blocker,

Capsule endoscopy, Capsule endoscopy, EnteroclysisEnteroclysis Balloon assisted enteroscopyBalloon assisted enteroscopy Treatment: surgery Treatment: surgery

Dieulafoy LesionDieulafoy Lesion Definition: Aberrant submucosal artery, without ramification in gastric wall, Definition: Aberrant submucosal artery, without ramification in gastric wall,

which erodes the overlying epithelium in the absence of a primary ulcer. which erodes the overlying epithelium in the absence of a primary ulcer. Causes less than 1 percent of cases of severe UGI hemorrhageCauses 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). 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 Usually located in the upper stomach along the lesser curvature near the gastro‐esophageal junction. the gastro‐esophageal junction.

May be found in all areas of the gastrointestinal tract, including the May be found in all areas of the gastrointestinal tract, including the esophagus and duodenum.esophagus and duodenum.

Bleeding is often self‐limited, although it is usually recurrent and can be Bleeding is often self‐limited, although it is usually recurrent and can be profuseprofuse

Etiology is unknown, likely congenital. Etiology is unknown, likely congenital. Causes of bleeding are not well‐understood. Causes of bleeding are not well‐understood.

Associations: cardiovascular disease, hypertension, chronic kidney disease, diabetes, or Associations: cardiovascular disease, hypertension, chronic kidney disease, diabetes, or alcohol abuse. alcohol abuse.

Use of NSAIDs is common; NSAIDS may incite bleeding by causing mucosal atrophy and Use of NSAIDs is common; NSAIDS may incite bleeding by causing mucosal atrophy and ischemic injuryischemic injury

Aorto-Enteric FistulaAorto-Enteric Fistula Rare cause of acute UGI bleeding, but associated with high mortality if Rare cause of acute UGI bleeding, but associated with high mortality if

undiagnosed and untreated. undiagnosed and untreated. ••Location: The third or fourth portion of the duodenum is the most Location: The third or fourth portion of the duodenum is the most

common site for aortoenteric fistulas, followed by the jejunum and common site for aortoenteric fistulas, followed by the jejunum and ileum .ileum .

••Presentation: Presentation: ––Repetitive herald bleed with hematemesis and/or hematochezia; this Repetitive herald bleed with hematemesis and/or hematochezia; this

may be followed by massive bleeding and exsanguination. may be followed by massive bleeding and exsanguination. ––Intermittent bleeding can be seen if clot temporarily seals the fistula. Intermittent bleeding can be seen if clot temporarily seals the fistula. ––Other signs and symptoms may include abdominal or back pain, fever, Other signs and symptoms may include abdominal or back pain, fever,

and sepsis. Infrequently, an abdominal mass is palpable or an and sepsis. Infrequently, an abdominal mass is palpable or an abdominal bruit is heard.abdominal bruit is heard.

••Pathophysiology—Aortoenteric fistulas arise from direct communication Pathophysiology—Aortoenteric fistulas arise from direct communication between the aorta and the gastrointestinal tract.between the aorta and the gastrointestinal tract.

Aorto-Enteric FistulaAorto-Enteric Fistula Causes: Causes:

Primary A‐E fistula in USA are due to atherosclerotic aortic aneurysm. In other parts of the world are 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. infectious aortitis due to syphilis or tuberculosis.

Secondary A‐E fistula due to prosthetic abdominal aortic vascular graft. Secondary A‐E fistula due to prosthetic abdominal aortic vascular graft. Mayhave pressure necrosis or graft infection causing the fistula. Other Mayhave pressure necrosis or graft infection causing the fistula. Other secondarycauses include penetrating ulcers, tumor invasion, trauma, radiation secondarycauses include penetrating ulcers, tumor invasion, trauma, radiation therapy, and foreign body perforation.therapy, and foreign body perforation.

Diagnosis: Diagnosis: A high index of suspicion. A high index of suspicion. Should be considered in all patients with massive or repetitive UGI bleeding and a history of a thoracic 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.or abdominal aortic aneurysm, or prosthetic vascular graft.

Endoscopy is the procedure of choice for diagnosis and exclusionof other Endoscopy is the procedure of choice for diagnosis and exclusionof other causes of acute UGI bleeding. causes of acute UGI bleeding.

Endoscopy with an enteroscope or side‐viewing endoscope may reveal a graft, 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 an ulcer or erosion at the adherent clot, or an extrinsic pulsatile mass in the distal duodenum or esophagus.distal duodenum or esophagus.

Abdominal CT scan and aortography can be useful in confirming the diagnosis, Abdominal CT scan and aortography can be useful in confirming the diagnosis, but may be unreliablebut may be unreliable

HemobiliaHemobilia Bleeding from the hepatobiliary tract; rare cause of acute UGI bleeding. Bleeding from the hepatobiliary tract; rare cause of acute UGI bleeding. Should be considered in a patient with acute UGI bleeding and a recent Should be considered in a patient with acute UGI bleeding and a recent

history of:history of: hepatic parenchymal or biliary tract injury, hepatic parenchymal or biliary tract injury,

percutaneous and transjugular liver biopsy,percutaneous and transjugular liver biopsy, percutaneous transhepatic cholangiogram, percutaneous transhepatic cholangiogram, cholecystectomy, cholecystectomy, endoscopic biliary biopsies or stenting, endoscopic biliary biopsies or stenting, TIPS, TIPS, Angioembolization,or Angioembolization,or blunt abdominal trauma . blunt abdominal trauma . Other causes include gallstones, cholecystitis, hepatic or bile duct Other causes include gallstones, cholecystitis, hepatic or bile duct

tumors, intrahepatic stents, hepatic artery aneurysms, and hepatic tumors, intrahepatic stents, hepatic artery aneurysms, and hepatic abscesses.abscesses.

HemobiliaHemobilia Signs & Symptoms: Signs & Symptoms:

Classic triad is biliary colic, obstructive jaundice, and occultor acute GI bleeding.Classic triad is biliary colic, obstructive jaundice, and occultor acute GI bleeding.

Hemobilia can result in obstructive jaundice with or without biliary Hemobilia can result in obstructive jaundice with or without biliary sepsis.sepsis.

Diagnosis: Diagnosis: Often overlooked in the absence of active bleeding. Often overlooked in the absence of active bleeding. A side‐viewing duodenoscope is helpful for visualizing the ampulla or for performing A side‐viewing duodenoscope is helpful for visualizing the ampulla or for performing

diagnostic endoscopic retrograde cholangiography (ERCP). diagnostic endoscopic retrograde cholangiography (ERCP).

Technetium‐tagged red blood cell scan or Technetium‐tagged red blood cell scan or Selective hepatic artery angiography to reveal the source of hemobilia Selective hepatic artery angiography to reveal the source of hemobilia

and for treatment.and for treatment. Treatment: directed at the primary cause of bleeding; Treatment: directed at the primary cause of bleeding;

embolization or surgical resection of a hepatic tumor, or embolization or surgical resection of a hepatic tumor, or

arterial embolization following liver biopsy or PTC, arterial embolization following liver biopsy or PTC, laparoscopic cholecystectomylaparoscopic cholecystectomy

Hemosuccus PancreaticusHemosuccus Pancreaticus Definition: Bleeding from the pancreatic duct; rare cause of UGIbleeding. Definition: Bleeding from the pancreatic duct; rare cause of UGIbleeding. Causes: chronic pancreatitis, pancreatic pseudocysts, and pancreatic tumors. Causes: chronic pancreatitis, pancreatic pseudocysts, and pancreatic tumors. Pathogenesis: Pathogenesis:

Pseudocyst or tumor erodes into a vessel, forming a direct communication between the Pseudocyst or tumor erodes into a vessel, forming a direct communication between the pancreatic duct and a blood vessel. pancreatic duct and a blood vessel.

May be seen after therapeutic endoscopy of the pancreas or pancreatic May be seen after therapeutic endoscopy of the pancreas or pancreatic duct, including pancreatic stone removal, pancreatic duct sphincterotomy, duct, including pancreatic stone removal, pancreatic duct sphincterotomy, pseudocyst drainage, or pancreatic duct stenting.pseudocyst drainage, or pancreatic duct stenting.

Diagnosis: confirmed by abdominal CT scan, ERCP, angiography, Diagnosis: confirmed by abdominal CT scan, ERCP, angiography, orintraoperative exploration. orintraoperative exploration.

CT scan is performed first (least invasive). CT scan is performed first (least invasive). Treatment: Treatment:

Mesenteric arteriography with coil embolization can control acute bleeding. Mesenteric arteriography with coil embolization can control acute bleeding.

If bleeding persists or is massive: pancreaticoduodenectomy or If bleeding persists or is massive: pancreaticoduodenectomy or pseudocyst resection and ligation of the bleeding vesselpseudocyst resection and ligation of the bleeding vessel


Overlooked Causes of GI Bleeding (10-20%):Overlooked Causes of GI Bleeding (10-20%): Upper GI tractUpper GI tract:: CameronCameron’’s erosionss erosions Fundic varicesFundic varices Peptic ulcerPeptic ulcer AngioectasiasAngioectasias DieulafoyDieulafoy’’ss GAVEGAVE Lower GI tractLower GI tract:: AngioectasiasAngioectasias NeoplasmsNeoplasms

Obscure/Occult GI Bleeding: Obscure/Occult GI Bleeding: EvaluationEvaluation

? Missed occult source or new obscure?? Missed occult source or new obscure? ““22ndnd look look”” endoscopies frequently + endoscopies frequently +

CameronCameron’’s (DH) erosionss (DH) erosionsPUDPUDVascular ectasias, angiodysplasiasVascular ectasias, angiodysplasiasNeoplasiasNeoplasias

After negative bi-directional GI studies After negative bi-directional GI studies small intestine most likely sourcesmall intestine most likely source

Obscure GI Bleeding: EvaluationObscure GI Bleeding: Evaluation

Diagnostic TechniquesDiagnostic Techniques Bi-directional Endoscopy (Bi-directional Endoscopy (““second looksecond look””)) Nuclear (TRBC) scansNuclear (TRBC) scans AngiographyAngiography MeckelMeckel’’s scans scan Small bowel biopsySmall bowel biopsy SBFT/EnteroclysisSBFT/Enteroclysis EnteroscopyEnteroscopy

Per oralPer oralTransanal or retrogradeTransanal or retrogradeInteroperativeInteroperativeCapsule endoscopyCapsule endoscopy

Exploratory laparotomyExploratory laparotomy


Diagnostic TechniquesDiagnostic Techniques Bi-directional Endoscopy (Bi-directional Endoscopy (““second looksecond look””)) Nuclear (TRBC) scansNuclear (TRBC) scans AngiographyAngiography Small bowel biopsySmall bowel biopsy SBFT/EnteroclysisSBFT/Enteroclysis EnteroscopyEnteroscopy

Per oralPer oralTransanal or retrogradeTransanal or retrogradeInteroperativeInteroperativeCapsule endoscopyCapsule endoscopy



Diagnostic TechniquesDiagnostic Techniques Bi-directional Endoscopy (Bi-directional Endoscopy (““second looksecond look””)) Nuclear (TRBC) scansNuclear (TRBC) scans AngiographyAngiography Small bowel biopsySmall bowel biopsy SBFT/EnteroclysisSBFT/Enteroclysis EnteroscopyEnteroscopy

Per oralPer oral Transanal or retrogradeTransanal or retrograde InteroperativeInteroperative Capsule endoscopyCapsule endoscopy Deep endoscopyDeep endoscopy


Obscure GI Bleeding: TRBC scanObscure GI Bleeding: TRBC scan

Bleeding rate must be Bleeding rate must be >> 0.1-0.4ml/min (1unit per day) 0.1-0.4ml/min (1unit per day) Early scans (within 4 hours) with (+) more reliable Early scans (within 4 hours) with (+) more reliable

than last (+)than last (+) Later scans show Later scans show ““pooled blood/isotopepooled blood/isotope””

Pre-requisite to angiography in most centersPre-requisite to angiography in most centers Frequent false (+) and (-)Frequent false (+) and (-) Very little benefit in average OGIB:Very little benefit in average OGIB:

Diganositic yield: 25%Diganositic yield: 25% Location accuracy: 30-50%Location accuracy: 30-50%

Diagnostic yield in lower GI Diagnostic yield in lower GI ““overtovert”” bleeding bleeding Colorectal site found 45% (26-78%)Colorectal site found 45% (26-78%)

Later positive scan verification studies: ~78% + lesionLater positive scan verification studies: ~78% + lesion

Obscure GI Bleeding: AngiographyObscure GI Bleeding: Angiography

Yield:Yield: When active bleeding as high as: 61-72%When active bleeding as high as: 61-72% Overall: 27-77% (mean 40%)Overall: 27-77% (mean 40%)

Requires Requires >> 0.5 ml/min bleeding rate 1ml/h (3 Units/day) 0.5 ml/min bleeding rate 1ml/h (3 Units/day) Reasonable in patient with hemodynamic instability or ongoing Reasonable in patient with hemodynamic instability or ongoing

transfusion needtransfusion need Study first SMA (50-80% of bleeds, then IMV, and then celiac axisStudy first SMA (50-80% of bleeds, then IMV, and then celiac axis Can control bleeding with vasopressin (90% efficacy) or coil Can control bleeding with vasopressin (90% efficacy) or coil

embolization (riskier; 20% infarct)embolization (riskier; 20% infarct) Provocative angiography (anticoagulation or thrombolytic) can Provocative angiography (anticoagulation or thrombolytic) can

increase yield but lead to uncontrollable bleedincrease yield but lead to uncontrollable bleed

Obscure GI Bleeding: Obscure GI Bleeding: SBFT/EnterocolysisSBFT/Enterocolysis

Occult bleeding patient diagnostic yieldsOccult bleeding patient diagnostic yieldsSBFT 0-4% reported in multiple studiesSBFT 0-4% reported in multiple studiesEnteroclysis 0% in multiple studiesEnteroclysis 0% in multiple studies

Obscure patient diagnostic yieldsObscure patient diagnostic yieldsSBFT 0-5.6% reportedSBFT 0-5.6% reportedEnteroclysis 10-21% seenEnteroclysis 10-21% seen

Obscure GI Bleeding: Push Obscure GI Bleeding: Push enteroscopyenteroscopy

Extended upper endoscopyExtended upper endoscopy Typically involves pediatric colonoscope or Typically involves pediatric colonoscope or

dedicated enteroscopededicated enteroscope Distance reached in SB anywhere from 40-90 Distance reached in SB anywhere from 40-90

cm (at most 40 cm beyond ligament of Treitz)cm (at most 40 cm beyond ligament of Treitz) Yield Yield

Average of 35% (3-78%)Average of 35% (3-78%) Picks up previously missed proximal lesionsPicks up previously missed proximal lesions

Up to 64% of lesions identified with a push enteroscope were Up to 64% of lesions identified with a push enteroscope were within reach of a standard endoscopewithin reach of a standard endoscope

Increased yield in overt bleeding situationsIncreased yield in overt bleeding situations

Obscure GI Bleeding: Capsule Obscure GI Bleeding: Capsule EndoscopyEndoscopy

Approved since 2001Approved since 2001Most sensitive non-invasive test for Most sensitive non-invasive test for

obscure GI bleedingobscure GI bleedingExcellent for screening who needs more Excellent for screening who needs more

invasive proceduresinvasive proceduresHigh negative predictive valueHigh negative predictive value


2 images/second during 8 hours 2 images/second during 8 hours studystudy

65,000-80,000 images65,000-80,000 imagesStreaming videoStreaming videoReading time of roughly one Reading time of roughly one

hourhour


Needs good Small Bowel Prep.Needs good Small Bowel Prep.Reading rate </= 15 frames/secReading rate </= 15 frames/secExperimental Yield: Dedicated Enteroscope vs. Capsule Experimental Yield: Dedicated Enteroscope vs. Capsule EnteroscopyEnteroscopy

Bleeds at reach of enteroscope: 94% vs 53%Bleeds at reach of enteroscope: 94% vs 53%

Bleeds in all small bowel: 37% vs 64%Bleeds in all small bowel: 37% vs 64%Clinical Yield of Capsule:Clinical Yield of Capsule:

Ongoing obscure‐Ongoing obscure‐overtovertbleed within 2 weeks: 92%bleed within 2 weeks: 92% Ongoing obscure‐Ongoing obscure‐overtovertbleed after 2 weeks: 34%bleed after 2 weeks: 34% Obscure‐Obscure‐overtovertbleed in past year: 13%bleed in past year: 13% Obscure‐Obscure‐occult occult bleed: 44%bleed: 44%


Predictors of (+) capsule finding: Predictors of (+) capsule finding: Through Hb < 10 g, Through Hb < 10 g, more than 1 bleeding episode, or more than 1 bleeding episode, or bleeding persisting > 6 monthsbleeding persisting > 6 months

Capsule vs Intraop Endoscopy: Capsule vs Intraop Endoscopy: yield 74 vs 76.6%, yield 74 vs 76.6%, Capsule: sensitivity = 95%, specificity = 75%, PPV = Capsule: sensitivity = 95%, specificity = 75%, PPV =

95%, NPV = 86%95%, NPV = 86% Management change: 37 to 66%; this led to resolution of Management change: 37 to 66%; this led to resolution of

bleeding in 65% bleeding in 65%

Obscure GI Bleeding: Obscure GI Bleeding: Intraoperative enteroscopyIntraoperative enteroscopy

Yield: 58‐88% of small bowel lesions.Yield: 58‐88% of small bowel lesions. IOE: Examination done IOE: Examination done ““anterogradeanterograde””, with dedicated , with dedicated

enteroscope, with dimmed OR light. Lesions are marked enteroscope, with dimmed OR light. Lesions are marked when seen in the when seen in the ““way inway in””..

TI reached in > 90%TI reached in > 90% Therapy given in 64%.Therapy given in 64%. Recurrent bleed: 12.5‐60%Recurrent bleed: 12.5‐60% Mortality: up to 17%Mortality: up to 17% May cause lacerations, perforations, bowel ischemia, May cause lacerations, perforations, bowel ischemia,

pancreatitis, and prolonged ileus.pancreatitis, and prolonged ileus. Should be done only when DBE is limited for adhesions Should be done only when DBE is limited for adhesions

or other anatomic factors.or other anatomic factors.

Deep EnteroscopyDeep Enteroscopy Double-Balloon Double-Balloon

EnteroscopyEnteroscopy Single-Balloon Single-Balloon

EnteroscopyEnteroscopy Spiral EnteroscopySpiral Enteroscopy

Therapeutic as well as Therapeutic as well as diagnostic capabilitiesdiagnostic capabilities

Obscure GI Bleeding: Deep Obscure GI Bleeding: Deep EnteroscopyEnteroscopy

Yield: 41‐80% of small bowel lesions.Yield: 41‐80% of small bowel lesions. DBE: uses anterograde + retrograde approachDBE: uses anterograde + retrograde approach Time: anterograde 72‐95 min, retrograde 75‐102 min. Time: anterograde 72‐95 min, retrograde 75‐102 min.

Each exam done in separate days.Each exam done in separate days. Outcomes: Outcomes:

Diagnostic yield 65%,Diagnostic yield 65%, Diagnostic/treatment success 64%, Diagnostic/treatment success 64%, Total SB exam 29% (tattoo), Total SB exam 29% (tattoo), Miss rates 28% (vs 20% for capsule)Miss rates 28% (vs 20% for capsule)

Obscure GI Bleeding: Deep Obscure GI Bleeding: Deep EnteroscopyEnteroscopy

Findings: Findings: Angioectasia 31%, Angioectasia 31%,

Ulcers (including IBD) 13%, Ulcers (including IBD) 13%, Malignancies 8%, Malignancies 8%, Other 6%, Other 6%, Negative exam 40%Negative exam 40%

May cause lacerations, perforations, bleeding, and May cause lacerations, perforations, bleeding, and pancreatitis.pancreatitis.

Ante‐grade approach recommended when lesion is in Ante‐grade approach recommended when lesion is in initial 2/3. Retrograde approach when distal 1/3.initial 2/3. Retrograde approach when distal 1/3.

For Now…DBE primarily For Now…DBE primarily therapeutictherapeutic

Time, labor, personnel and cost intensiveTime, labor, personnel and cost intensive

Complications risk: Initially ≈ 1%, upcoming data likely to Complications risk: Initially ≈ 1%, upcoming data likely to show lessshow less

Diagnostic and therapeutic yield ↑if pre-screening done Diagnostic and therapeutic yield ↑if pre-screening done

May be cost-effective as initial approach in patients with May be cost-effective as initial approach in patients with ongoing overt bleedingongoing overt bleeding

However, VCE before DE will reduce the number of However, VCE before DE will reduce the number of procedures and ↓ complications procedures and ↓ complications better long-term better long-term outcomesoutcomes

REDUCTION

Obscure GI Bleeding: AlgorithimObscure GI Bleeding: Algorithim

Obscure GI Bleeding: ConclusionsObscure GI Bleeding: Conclusions

GI bleeding is a significant pathologic condition which is GI bleeding is a significant pathologic condition which is growing due to the aging patient population and increasing growing due to the aging patient population and increasing use of antiplatelets/anticoagulants.use of antiplatelets/anticoagulants.

There are number of pathologies which can range from the There are number of pathologies which can range from the common to the rare.common to the rare.

There is a significant societal cost to this.There is a significant societal cost to this. No single efficient diagnostic approach or therapeutic No single efficient diagnostic approach or therapeutic

panacea.panacea. Must individualize approach and Rx.Must individualize approach and Rx. Second look endoscopies by a GI MD are the intial test of Second look endoscopies by a GI MD are the intial test of

choice choice While radiography offers diagnostic and therapeutic While radiography offers diagnostic and therapeutic

capabilities and should be utilized, once a small bowel capabilities and should be utilized, once a small bowel etiology is noted the role of capsule endoscopy and deep etiology is noted the role of capsule endoscopy and deep enteroscopy offers distinct advantages.enteroscopy offers distinct advantages.

Obscure GI Bleeding Michael Rusche, MD.. Obscure GI Bleeding: Overview Definitions Definitions...

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