Obscure GI Bleeding Diagnosis and Management
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Obscure GI Bleeding
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Obscure GI Bleeding Diagnosis and Management
- 1. PHONGTHORN TUNTIVARARUT POLICE GENERAL HOSPITAL, THAILAND
- 2. Obscure GI Bleeding Bleeding from the small intestine remains a relatively uncommon event ~5–10% of all patients presenting with GI bleeding Up to 90% of lesions responsible for GI bleeding are within the reach EGD and colonoscopy Am J Gastroenterol 2015; 110:1265–1287
- 3. Obscure GI Bleeding Small Bowel Bleeding Which one??
- 4. Obscure GI Bleeding Overt obscure bleeding refers to the presence of hematemesis, melena, or hematochezia Occult obscure bleeding occurs in the patients with positive fecal occult blood test with or without iron- deficiency anemia Schwartz's Principles of Surgery, 10ed
- 5. Common causes of small bowel bleeding Under age 40 years Inflammatory bowel disease Dieulafoy’s lesions Neoplasm Meckel’s diverticulum Polyposis syndrome Over age 40 years Angiodysplasia Dieulafoy’s lesions Neoplasm NSAID ulcers Am J Gastroenterol 2015; 110:1265–1287
- 6. Rare causes of small bowel bleeding Henoch-Schoenlein purpura Small bowel varices in patient with portal HT Amyloidosis Peutz-Jeghers syndrome Kaposi’s sarcoma in HIV patient Hemobilia Aorto-enteric fistula Am J Gastroenterol 2015; 110:1265–1287
- 7. Management of OGIB Initial assessment and resuscitation Localization of the bleeding point Definitive treatment Medication Endoscopic Intervention Surgery
- 8. Bleeding localization Second-look endoscopy or Repeated of EGD and Colonoscopy are recommended Missing lesion can be found ranging from 2 to 25% in repeated EGD and 6 to 23% on repeated colonoscopy Am J Gastroenterol 2015; 110:1265–1287
- 9. EGD and Colonoscopy During the colonoscopy, every effort should be made to intubate the terminal ileum Instead of repeating EGD, a push enteroscopy may be performed to examine the distal duodenum and proximal jejunum Schwartz's Principles of Surgery, 10ed
- 10. Push enteroscopy Push enteroscopy : Performed with a long endoscope such as a pediatric colonoscope or commercial scope Length of the scope is around 250 cm Commercial push enteroscope : 70 cm from ligament of treitz Colonoscopy : 45-60 cm distal to ligament of treitz Diagnostic yield : 3-70% Am J Gastroenterol 2015; 110:1265–1287
- 11. Subacute ongoing small bowel bleeding Massive small bowel bleeding Am J Gastroenterol 2015; 110:1265–1287
- 12. Am J Gastroenterol 2015; 110:1265–1287
- 13. Schwartz's Principles of Surgery, 10ed
- 14. Video Capsule Endoscopy (VCE) First clinical use in US in 2001 Capsule 26x11 mm with frame rate of 2 frames/sec Evaluation of the entire small bowel in 79-90% of patients Diagnostic yield in small bowel bleeding : 38-83% Duration of bleeding, time from bleeding, bleeding amount World J Gastroenterol 2007 December 14; 13(46): 6140-6149
- 15. VCE limitation Diagnostic tool Inability to control its movement Localization difficulty Miss duodenal lesion due to rapid transit False negative rate : 10-36% Cannot exclude SB lesion if negative Capsule retention Am J Gastroenterol 2015; 110:1265–1287
- 17. Deep Enteroscopy
- 18. Deep Enteroscopy First described in 2001 by Yamamoto Both diagnostic and therapeutic tool Diagnostic yield DBE : 60-80% SBE : 33% Complication : ileus, perforation (overall 1.2%) Am J Gastroenterol 2015; 110:1265–1287
- 20. Am J Gastroenterol 2015; 110:1265–1287
Editor's Notes
- In the past, if no source of bleeding was found after an upper and lower endoscopic evaluation, it is called “Obscure GI Bleeding”
- Prevalence : Vascular lesion 24% VS Inflammatory (crohn)16-18% VS Mass 11% Asian พบ neoplastic มากกว่า western ที่พบ angiodysplasia ดูจากการซักประวัติ พอบอกได้ Schwartz Angiodysplasia 75% Neoplasm 10% Meckel in children <30 yr
- ประวัติจะ guide ให้ ว่าคิดถึงอะไร
- ครั้งแรกอาจจะมีเลือดเยอะ
- intubate the terminal ileum to visualize the ileal mucosa and to inspect for blood coming from a more proximal location
- Video capsule endoscopy CT enterography
- Non-invasive ปัจจัยที่ทำให้ yield เพิ่ม ตรงไปตรงมา
- Miss duodenal lesion due to rapid transit ใส่ capsule 2 อัน ช่วย improve ได้ 60%
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