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Approach to occult bleeding
1.
2. DEFNITION
ο Occult gastrointestinal bleeding is defined as
gastrointestinal bleeding that is not visible to the
patient or physcian,resulting in either a positive fecal
occult blood test,or iron deficiency anemia with or
without a positive fecal occult blood test.
3. ο Obscure gi bleed = It refers to recurrent bleeding in which a source is
not identified after EGD, Colonoscopy, and small bowel radiography.
ο OBSCURE OCCULT= as manifested by recurrent IDA and / or
recurrent positive FOBT.
ο OBSCURE OVERT = recurrent passage of visible blood with
melena or hematochezia
4. CAUSES OF OCCULT GI BLEEDING
MASS LESIONS;
ο CARCINOMA( any site).
ο Large (>1.5 cm) adenoma (any site).
ο INFLAMMATION.
ο Erosive esophagitis
ο ulcer (any site)
ο Erosive gastritis
ο Cameron lesions ( linear erosions within a hiatus hernia).
ο Crohns disease
ο Celiac disease
ο Ulcerative colitis.
7. ETIOLOGY OF OCCULT BLEEDING
ο Age <40 years;
ο Small bowel tumors; M/C cause.
ο Celiac disease.
ο Crohns disease.
ο Age >40 years;
ο Vascular ectasia ,M/C cause
ο NSAID induced ulcers.
8.
9. HISTORY AND PHYSCIAL EXAM.
ο A targeted history and physcial exam. Should be
performed.
ο Abdominal pain with aspirin or other NSAID use
,suggests ulcerative mucosal injury.
ο Anticoagulants or antiplatelet medication may
precipitate bleeding in an undiagonised lesion.
ο Family history of GI bleeding may suggest HHT.
(associated with vascular lesions on lips tongue or
palms)
ο Blue rubber bleb navus syndrome(a syndrome with venous
malformations in the GIT,soft tissue and skin).
10. ο History of gastric bypass surgery ; may suggest impaired iron
absorption.
ο H/O stigmata of liver disease suggests portal hypertensive
gastropathy.
ο SKIN Signs;
ο Dermatitis herpetiformis > Celiac disease
ο Erythema Nodosum(painful erythematous nodules seen in
>Crohns disease.
ο Blue rubber bleb navus syndrome(a syndrome with venous
malformations in the GIT,soft tissue and skin).
ο Freckles on lips and in mouth (peutz jeghers syndrome).
ο Hyperextensible joints and ocular and dental abnormalities
>S/O Ehlers danlos syndrome.
11. DIAGNOSTIC STUDIES
ο Upper GI Bleeding (identified as source of bleeding
proximal to the ampulla of vater) can be dx.by EGD.
ο Proximal small bowel bleeding >can b detected by
push enteroscopy which reaches the proximal
jejunum.
ο Bleeding of mid and distal small bowel can be > can
be detected with Capsule endoscopy, Deep
enteroscopy and CT Enterography.
ο Lower GI Bleeding (Colonic bleeding) can be detected
with colonoscopy.
12. DIAGNOSTIC STUDIES
ο EGD and Colonoscopy > Bleeding source in 48-71 % pt.
ο In recurrent bleeding > repeat OGD and Colonoscopy
may find the missed lesion in 35% of those who had
negative initial findings.
ο Capsule endoscopy >dx.yield 63-74%.
ο In Meta analysis of 14 studies ;
ο Dx.yield of Capsule endoscopy was superior to push
enteroscopy (63 vs 28 %) and
ο Barium studies (42 vs 6 %).
13.
14. Fecal occult blood testing
ο Guaiac-based tests:
ο Uses a chemical indicator that shows a colour change in the presence of
blood in stool.
ο The pseudoperoxidase activity of hemoglobin turns the guaiac compound
blue in the presence of hydrogen peroxide.
ο IMMUNO CHEMICAL test ( FIT );
ο It is more specific ,detects only human hemoglobin,
ο ;uses antibodies directed against human hemoglobin to detect blood in the
stools.
ο Positive results indicate abnormal bleeding from lower intestine ,bcos blood
from lower sites is less degraded during transit
ο For FOBT + 2ml blood in stool is necessary.
ο Two samples of each of 3 consecuative (daily ) stools.
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20.
21. CAPSULE ENDOSCOPY.
ο Permits exam. 0f small intestinal mucosa using wireless image
capturing technology.
ο Noninvasive method to evaluate the entire length of small
bowel.
ο Can identify vascular ectasia ,ulcers and masses in small bowel.
ο CAPSULE= Size 2.6 cm,weight 3.5 g.
ο COMPARTMENTS=
ο Metal oxide silicon image sensor,
ο Light emitting diode (led)
ο Aerial belt with 8 aerials which collects signal from the capsule.
ο Software for analysis.
22. INDICATIONS OF CE.
ο Crohns disease
ο Celiac disease
ο Immunoproliferative small intestinal disease (IPSID)
ο Polyposis
ο Small intestinal tumor like carcinoid and lymphoma.
ο Recurrent abdominal pain with diarrhea.
ο Obscure GI BLEED (after negative EGD and
Colonoscopy )
ο Recurrent iron deficiency anemia.
23. CAPSULE ENDOSCOPY
ο ADVANTAGES;
ο Noninvasive
ο Disposable
ο DISADVANTAGES;
ο Cost
ο Inaccurate localization of the site of bleeding.
ο Capsule retension <1%.