1. Obscure gastrointestinal bleeding accounts for 1% of GI hemorrhage and remains undiagnosed in 25% of cases, mostly of lower GI origin. 2. Video capsule endoscopy has a high success rate of 90% for evaluating obscure GI bleeding and identifying sources such as small intestinal ulcers or colonic polyps. 3. For patients with transfusion-dependent obscure-occult bleeding, intraoperative endoscopy using a pediatric colonoscope introduced through the mouth, anus, or entereotomy can examine the whole bowel to locate bleeding sources.

2. Significance
Newer diagnostic modalities
New therapeutic interventions
Mortality still high
Better understanding needed
Potential to bring down mortality

3. Over last 20 years-
Rampant use of NSAIDs and SSRIs
Advent of newer PPIs
•Overall, the incidence of hospitalization for acute
gastrointestinal bleeding has fallen by a modest 4%
between years 1998 and 2006.*
*Ref:Sabiston,20th edition, page 1139

4. 1. Upper GI bleed
2. Lower GI bleed
3. Obscure GI bleed

5. Resuscitation – First priority
Attempts made at diagnosis – when
patient stable
Run parallel – when possible
Better revive the
patient before you
have to diagnose him
in AUTOPSY

6. Resuscitation
1. Securing airway
2. Maintaining Breathing

7. 3. Maintenance of circulation:
Crystalloids
Colloids
Blood & blood products

8. 4. Disability
5. Proper exposure
Ascites
Spider angioma
Caput medusae
Palmer erythema

9. Nasogastric tube insertion
Catheterisation

10. Empirical treatment: Blind
attempt at
arresting
the bleed1. Proton pump inhibitors –
Omeprazole, Pantoprazole,
Rabeprazole etc.
2. Stopping NSAIDs or SSRIs
3. Antifibrinolytics- Tranexamic acid

11. Differentiate between upper and lower GI bleeding
Further investigation- find out the exact cause
and location
Treatment according to cause

12. 1. Chief complaints
2. History
3. Physical
examination

13. Directly due to the
bleed-
1. Haematemesis
2. Haematochezia
3. Malena

14. As a Consequence of the blood loss
Signs of shock
Respiratory distress due to aspiration
As symptoms of underlying disease
Pain
Vomiting
In case of scanty blood loss
Only symptoms of anemia

15. •Detailed account of pain and vomiting
•Age
•Bowel habit & other personal histories
•History of medication and prior surgery
•History of past illnesses

16. 1. General survey
2. Examination of the oral cavity, nasopharynx
and oropharynx
3. Abdominal examination
4. Looking for signs (stigmata) of chronic liver
disease- such as jaundice, ascites, palmer
erythema, caput medusa etc.

17. History and physical
examination strongly suggests
Oesophagogastrodudenoscopy (preferably within first 24 hours)
Diagnostic
Treatment
Non-diagnostic
Slow haemorrhage
RBC scan
Massive haemorrhage
Angiography
Operation
Time is of paramount importance

19. Merits-
-Highly accurate
-helps in risk stratification
-Identify the underlying disease
-Therapeutic interventions
-Taking biopsy specimen

20. Duodenal ulcer
Gasric ulcer
Oesophagial
varices

21. Hemoclip applied to
bleeding varix
Band ligation of
ulcer
Therapeutic interventions
Fix the leak after
you’ve found it

22. Rockall classification

23. Forrest classification

24. When in
doubt,
perform EGD
to exclude
Upper GI
bleed
When history and physical
examination strongly suggests
Lower GI bleeding
Extent of
bleeding
Slow
haemorrhage
colonoscopy
Massive
haemorrhage
angiography
Diagnostic
Non-diagnostic
•RBC scan
•Capsule
endoscopy
•CT angiography

25. Lower gastrointestinal haemorrhage-
•Multiple sources (40% cases)
•Longer list of D/D
•More difficult to diagnose
•Intermittent
•commonly ceases spontaneously
•Less extensive
•lower mortality rates

26. Lower Gastrointestinal bleeding:
causes

27. - minimal to moderate bleeding
-within 24 hours, can be quite accurate
-Can identify :active bleeding site, clot adherent
to mucosa,diverticula, Polyps, cancers, and
inflammatory causes;
-therapeutic intervention
-collection of biopsy sample
-Ineffective in massive haemorrhage
-Risk of complications are high
-Needs expertise for performance

28. Crohn’s disease
Colorectal
carcinoma
Colonic
diverticula

29. RBC
scanning
Alternative investigations
Radionuclide (RBC) scanning:
Can be used in massive haemorrhage
Able to identify bleeding at a rate of 0.1mL/min
90% sensitive
Predicts outcome of angiography
Inaccurate

30. CT angiography
Sensitivity and specificity similar to radionuclide
scanning
More accurate in localizing the bleeding
CT angiograhy

31. Mesenteric artery angiography
Can only be used in ongoing haemorrhage
Can diagnose bleeding at a rate of 0.5-1.0mL/min
Best for diagnosing angiodysplasia and actively bleeding diverticula
Can be used therapeutically- vasopressors and embolization
High risk of complications
Selective
mesenteric
Mesenteric artery
angiography

32. Obscure GI bleeding
Obscure GI hemorrhage is defined as bleeding that persists or recurs after an initial
negative evaluation with EGD and colonoscopy.*
1. Obscure-overt bleeding: EGD and colonoscopy fail to localize the site but visible bleeding
present.
2. Obscure-occult bleeding: characterized by iron deficiency anemia or guaiac-positive stools
without visible bleeding.
*Sabiston, 20th edition, page 1155

33. Significance of obscure GI bleeding:
•Accounts for 1% of gastrointestinal haemorrhage
•Frustrating for both patient and doctors
•25% cases remain undiagnosed (mostly lower GI origin)
•High rate of rebleeding (33-50% within 3-5 years)
•Repeated blood transfusion needed

35. Repeated endoscopy:
Repeat esophagoduodenoscopy and colonoscopy
Identifies the lesion in 35% cases (most cases distal to ligament of Treitz)
Conventional imaging:
RBC scanning, angiography
Provocative tests
Small bowel enteroclysis (largely abandoned now)
Computed tomographic enterography
Meckel’s diverticulum scanning (especially in young patients)
Meckel’s scan
Small bowel enteroclysis

36. Small bowel enteroscopy
& sonde pull endoscopy, double balloon endoscopy
Push endoscopy uses paediatric colonoscope;
Can reach up to 50-70 cm beyond ligament of Treitz;
Success rate 40%
Double balloon endoscopy is successful in 85% cases of occult bleeding
(performed within 1 month);
if done within 72 hours, more successful than capsule endoscopy
Therapeutic intervention, biopsy possible

37. Video Capsule Endoscopy
•Well tolerated
•Has a high success rate of 90%
•Best for haemodynamically stable patients
having ongoing GI bleed
•Time consuming
•Warrants
continuous presence of a doctor
•Contraindicated
in intestinal obstruction and motility disorders

38. Intraoperative endoscopy
•In patients with
transfusion-dependent occult-obscure bleeding
•Paediatric colonoscope used
•Introduced through mouth/anus/entereotomy
•Whole bowel can be run
•Obscure bleeding sources identified
•Therapeutic intervention
Colonic polyp
Small intestinal
ulcer

39. Resuscitation first, and resuscitate fast
EGD within 24 hours: in upper GI bleed
Colonoscopy: in moderate lower GI bleed
Treat underlying disease: prevent rebleed
Newer modalities attempted only after EGD and colonoscopy fail
repeatedly.