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AGA Technical Review on the Evaluation and management of Occult and Obscure Gastrointestinal Bleeding Gastroenterology 200...
Bleeding Definitions (Ⅰ) <ul><li>Overt or visible bleeding: GI bleeding manifest as visible bright red or altered blood in...
Bleeding Definitions (Ⅱ) <ul><li>Obscure-occult bleeding: subcategory of obscure characterized by recurrent or persistent ...
Bedside Examination <ul><li>History: especially drug history( NSAID, Aspirin, KCl, anticoagulation) and family history. </...
Evaluation of Occult Bleeding(Ⅰ) <ul><li>Study design factors: The method of stool collection ( digital collection or spon...
Evaluation of Occult Bleeding(Ⅱ) <ul><li>Endoscopic evaluation: colonoscopy and upper endoscopy remain the cornerstones fo...
Evaluation of Occult Bleeding(Ⅲ) <ul><li>Bidirectional Endoscopy </li></ul><ul><li>-IDA and positive FOBT results are unac...
 
Evaluation of Occult Bleeding(Ⅳ) <ul><li>Radiographic Evaluation </li></ul><ul><li>- Single-column barium enemas: disconti...
Evaluation of Obscure Bleeding(Ⅰ) <ul><li>Small bowel </li></ul><ul><li>Repeat upper endoscopy and colonoscopy  </li></ul>...
Evaluation of Obscure Bleeding(Ⅱ) <ul><li>Small bowel biopsy: celiac sprue  </li></ul><ul><li>Peroral and transnasal enter...
 
Evaluation of Obscure Bleeding(Ⅲ) <ul><li>Retrograde enteroscopy: examination of the distal ileum at colonoscopy  </li></u...
Evaluation of Obscure Bleeding(Ⅳ) <ul><li>-IOE: the ability to identify potential bleeding lesions ranging from 70%-93% </...
 
Evaluation of Obscure Bleeding(Ⅴ) <ul><li>Small bowel x-ray series and enteroclysis  </li></ul><ul><li>-enteroclysis: high...
Evaluation of Obscure Bleeding(Ⅵ) <ul><li>Nuclear scans: technetium 99m-labeled red blood cell (TRBC)scan </li></ul><ul><l...
Evaluation of Obscure Bleeding(Ⅶ) <ul><li>Angiography </li></ul><ul><li>-active bleeding rate >=0.5 mL/min -> extravasatio...
Etiology(Ⅰ)
Etiology (Ⅱ)
Management <ul><li>Endoscopic therapy </li></ul><ul><li>Angiographic therapy </li></ul><ul><li>Pharmacotherapy </li></ul><...
Endoscopic Therapy <ul><li>Thermal contact probes, injection sclerotherapy, argon plasma coagulation,Nd:YAG laser </li></u...
Angiotherapy <ul><li>The number of patients successfully treated with vasopressin infusion or embolization for obscure-ove...
Pharmacotherapy <ul><li>Reserved for diffuse disease, lesion in area inaccessible endoscopic therapy, rebleeding with unkn...
Surgery <ul><li>Bleeding tumor, bleeding with high transfusion requirement, </li></ul><ul><li>angiographic localization of...
Nonspecific Measures <ul><li>Iron supplymentation: IDA with unknown bleeding source--anemia resolved in 83% with no recurr...
Outcomes <ul><li>The overall prognosis in occult bleeding is generally good , with no early mortality noted in prospective...
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AGA Technical Review on the Evaluation and management of Occult ...

  1. 1. AGA Technical Review on the Evaluation and management of Occult and Obscure Gastrointestinal Bleeding Gastroenterology 2000;118:201-221 Reporter :Intern 陳美舒 2002/10/28
  2. 2. Bleeding Definitions (Ⅰ) <ul><li>Overt or visible bleeding: GI bleeding manifest as visible bright red or altered blood in emesis or feces </li></ul><ul><li>Occult bleeding: initial present of IDA and/or positive FOBT; no visible blood in feces </li></ul><ul><li>Obscure bleeding: Recurrent or persistent IDA, positive FOBT ,or visible bleeding with no bleeding source found at original endoscopy </li></ul>
  3. 3. Bleeding Definitions (Ⅱ) <ul><li>Obscure-occult bleeding: subcategory of obscure characterized by recurrent or persistent IDA and/or positive FOBT with no source found at original endoscopy; no visible blood in feces </li></ul><ul><li>Obscure-overt bleeding: subcategory of obscure characterized by recurrent or persistent overt/visible bleeding with no source found at original endoscopy; bleeding manifest as visible blood in emesis or feces </li></ul>
  4. 4. Bedside Examination <ul><li>History: especially drug history( NSAID, Aspirin, KCl, anticoagulation) and family history. </li></ul><ul><li>Physical Examination: cutaneous manifestations VS. GI bleeding </li></ul><ul><li>It has been proposed that information on either upper or lower intestinal symptoms can direct the initial endoscopic approach to patients with occult bleeding. </li></ul>
  5. 5. Evaluation of Occult Bleeding(Ⅰ) <ul><li>Study design factors: The method of stool collection ( digital collection or spontaneously passed stool); dietary modification; Guaiac-based tests or immunochemical test for hemoglobin </li></ul>
  6. 6. Evaluation of Occult Bleeding(Ⅱ) <ul><li>Endoscopic evaluation: colonoscopy and upper endoscopy remain the cornerstones for investigation of occult blood loss. </li></ul><ul><li>Colon cancer screening trial: </li></ul><ul><li>78%-86% FOBT (+) p’ts performed colonoscopy: 2.2%-17% colon cancer; 16.7%-40% adenomatous polyps annual FOBT reduced mortality from colorectal cancer </li></ul>
  7. 7. Evaluation of Occult Bleeding(Ⅲ) <ul><li>Bidirectional Endoscopy </li></ul><ul><li>-IDA and positive FOBT results are unaccounted for in up to 52% of cases </li></ul><ul><li>-a lesion identified as responsible for occult blood loss was located in the upper GI tract (29%-56%) more than in the lower GI tract(20%-30%) </li></ul>
  8. 9. Evaluation of Occult Bleeding(Ⅳ) <ul><li>Radiographic Evaluation </li></ul><ul><li>- Single-column barium enemas: discontinued, 20% miss rate of colon cancer </li></ul><ul><li>- double-contrast enemas have been used primarily when results of colonoscopy are suboptimal </li></ul><ul><li>-air-contrast barium enemas preferably with flexible sigmoidoscopy: sensitivity of 98% for carcinoma and 99% for adenoma VS. ACBE alone missed 25% cancer and polyps in the rectosigmoid region </li></ul>
  9. 10. Evaluation of Obscure Bleeding(Ⅰ) <ul><li>Small bowel </li></ul><ul><li>Repeat upper endoscopy and colonoscopy </li></ul><ul><li>: 35% bleeding source identified (29% upper, 6% colonoscopy) </li></ul><ul><li>Upper GI tract: erosion of hiatal hernias, peptic ulcer, vascular ectasia </li></ul><ul><li>Colon: angiodysplasia and neoplasia </li></ul><ul><li>Enteroscopy in place of repeat upper endoscopy </li></ul>
  10. 11. Evaluation of Obscure Bleeding(Ⅱ) <ul><li>Small bowel biopsy: celiac sprue </li></ul><ul><li>Peroral and transnasal enteroscopy: </li></ul><ul><li>-push enteroscopy: standard approach to exam the proximal small bowel </li></ul><ul><li>-Sonde enteroscopy : potential for direct exam of the entire small bowel mucosa,but less popular. </li></ul>
  11. 13. Evaluation of Obscure Bleeding(Ⅲ) <ul><li>Retrograde enteroscopy: examination of the distal ileum at colonoscopy </li></ul><ul><li>-low diagnostic rate (2.7%) and should be reserved for instances in which other evidence indicates a potential source of blood loss in the terminal ileum </li></ul><ul><li>Intraoperative enteroscopy (IOE): apply in cases of transfusion dependent bleeding that is not localized in spite of extensive diagnostic evaluation. </li></ul>
  12. 14. Evaluation of Obscure Bleeding(Ⅳ) <ul><li>-IOE: the ability to identify potential bleeding lesions ranging from 70%-93% </li></ul><ul><li>-Laparotomy has been coupled with the passage of an endoscope orally, per rectum, transnasally, or through enterotomy </li></ul><ul><li>-IOE through an enterotomy: decreased intestinal dead space and decreased trauma to the bowel. </li></ul>
  13. 16. Evaluation of Obscure Bleeding(Ⅴ) <ul><li>Small bowel x-ray series and enteroclysis </li></ul><ul><li>-enteroclysis: higher radiation exposure and discomfort; higher diagnostic yield, sensitivity, shorter procedure time. </li></ul><ul><li>-enteroclysis: the radiological study of choice for the investigation of suspected gross disorder of the small bowel. (diagnostic rate of neoplasia of 95%) </li></ul>
  14. 17. Evaluation of Obscure Bleeding(Ⅵ) <ul><li>Nuclear scans: technetium 99m-labeled red blood cell (TRBC)scan </li></ul><ul><li>-long half-life , bleeding rate:0.1-0.4 mL/min </li></ul><ul><li>-significant false localization and miss rate ->alternate test: angiography or endoscopy before an invasive therapeutic procedure </li></ul>
  15. 18. Evaluation of Obscure Bleeding(Ⅶ) <ul><li>Angiography </li></ul><ul><li>-active bleeding rate >=0.5 mL/min -> extravasation of contrast may be found </li></ul><ul><li>- diagnostic rate:27%-77% in acute lower intestine bleeding </li></ul><ul><li>-repeat angiography: increased diagnostic rate from 43% to 54% in patient with no initial diagnosis. </li></ul><ul><li>Exploratory laparotomy </li></ul>
  16. 19. Etiology(Ⅰ)
  17. 20. Etiology (Ⅱ)
  18. 21. Management <ul><li>Endoscopic therapy </li></ul><ul><li>Angiographic therapy </li></ul><ul><li>Pharmacotherapy </li></ul><ul><li>Surgery </li></ul><ul><li>Nonspecific therapy </li></ul>
  19. 22. Endoscopic Therapy <ul><li>Thermal contact probes, injection sclerotherapy, argon plasma coagulation,Nd:YAG laser </li></ul><ul><li>decrease the requirement for blood transfusion requirement </li></ul><ul><li>slightly higher rebleeding rates( up to 34%) have been reported with the use of thermal contact devices </li></ul>
  20. 23. Angiotherapy <ul><li>The number of patients successfully treated with vasopressin infusion or embolization for obscure-overt small bowel bleeding is limited. </li></ul><ul><li>Vessopressin- cardiovascular complications rate up to 9%-21% </li></ul><ul><li>embolization-complication rate: 17% </li></ul><ul><li>Embolozation may have utility in patients with coronary disease or other disorders wherein vasopressin infusion is relatively contraindicated or as an alternative to surgery. </li></ul>
  21. 24. Pharmacotherapy <ul><li>Reserved for diffuse disease, lesion in area inaccessible endoscopic therapy, rebleeding with unknown source </li></ul><ul><li>estrogen-progesteron combination therapy </li></ul><ul><li>octreotide </li></ul><ul><li>danazol and desmopressin </li></ul>
  22. 25. Surgery <ul><li>Bleeding tumor, bleeding with high transfusion requirement, </li></ul><ul><li>angiographic localization of the bleeding source assisted resection: the lowest rebleeding rates after bowel resection for bleeding angiodysplasia </li></ul>
  23. 26. Nonspecific Measures <ul><li>Iron supplymentation: IDA with unknown bleeding source--anemia resolved in 83% with no recurrence over a mean F/U period of 20 months </li></ul><ul><li>obs. and intermittent transfusion :54%had no rebleeding episodes during a 3-year follow-up period </li></ul><ul><li>elderly patient, slowly blood loss rate,risk for further diagnostic evaluation </li></ul>
  24. 27. Outcomes <ul><li>The overall prognosis in occult bleeding is generally good , with no early mortality noted in prospective studies. </li></ul><ul><li>There appears to be no single efficient diagnostic approach or therapeutic panacea in the management of obscure bleeding. </li></ul>

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