approach to occult gastrointestinal bleed

2. DEFNITION
 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.  Obscure gi bleed = It refers to recurrent bleeding in which a source is
not identified after EGD, Colonoscopy, and small bowel radiography.
 OBSCURE OCCULT= as manifested by recurrent IDA and / or
recurrent positive FOBT.
 OBSCURE OVERT = recurrent passage of visible blood with
melena or hematochezia

4. CAUSES OF OCCULT GI BLEEDING
MASS LESIONS;
 CARCINOMA( any site).
 Large (>1.5 cm) adenoma (any site).
 INFLAMMATION.
 Erosive esophagitis
 ulcer (any site)
 Erosive gastritis
 Cameron lesions ( linear erosions within a hiatus hernia).
 Crohns disease
 Celiac disease
 Ulcerative colitis.

5.  VASCULAR DISORDERS
 Vascular ectasia (any site)
 P0rtal hypertensive gastropathy
 Gastric antral vascular ectasia
 Hemangiomas
 Dieulafoys vascular malformations.
 INFECTIOUS DISEASES;
 Worm infestations
 Tuberculous enterocolitis
 Amoebiasis

6.  Surreptitious bleeding
 Haemoptysis
 Oropharyngeal bleeding.
 OTHER CAUSES
 Haemosuccus pancreaticus
 Haemobilia
 Long distance running.

7. ETIOLOGY OF OCCULT BLEEDING
 Age <40 years;
 Small bowel tumors; M/C cause.
 Celiac disease.
 Crohns disease.
 Age >40 years;
 Vascular ectasia ,M/C cause
 NSAID induced ulcers.

9. HISTORY AND PHYSCIAL EXAM.
 A targeted history and physcial exam. Should be
performed.
 Abdominal pain with aspirin or other NSAID use
,suggests ulcerative mucosal injury.
 Anticoagulants or antiplatelet medication may
precipitate bleeding in an undiagonised lesion.
 Family history of GI bleeding may suggest HHT.
(associated with vascular lesions on lips tongue or
palms)
 Blue rubber bleb navus syndrome(a syndrome with venous
malformations in the GIT,soft tissue and skin).

10.  History of gastric bypass surgery ; may suggest impaired iron
absorption.
 H/O stigmata of liver disease suggests portal hypertensive
gastropathy.
 SKIN Signs;
 Dermatitis herpetiformis > Celiac disease
 Erythema Nodosum(painful erythematous nodules seen in
>Crohns disease.
 Blue rubber bleb navus syndrome(a syndrome with venous
malformations in the GIT,soft tissue and skin).
 Freckles on lips and in mouth (peutz jeghers syndrome).
 Hyperextensible joints and ocular and dental abnormalities
>S/O Ehlers danlos syndrome.

11. DIAGNOSTIC STUDIES
 Upper GI Bleeding (identified as source of bleeding
proximal to the ampulla of vater) can be dx.by EGD.
 Proximal small bowel bleeding >can b detected by
push enteroscopy which reaches the proximal
jejunum.
 Bleeding of mid and distal small bowel can be > can
be detected with Capsule endoscopy, Deep
enteroscopy and CT Enterography.
 Lower GI Bleeding (Colonic bleeding) can be detected
with colonoscopy.

12. DIAGNOSTIC STUDIES
 EGD and Colonoscopy > Bleeding source in 48-71 % pt.
 In recurrent bleeding > repeat OGD and Colonoscopy
may find the missed lesion in 35% of those who had
negative initial findings.
 Capsule endoscopy >dx.yield 63-74%.
 In Meta analysis of 14 studies ;
 Dx.yield of Capsule endoscopy was superior to push
enteroscopy (63 vs 28 %) and
 Barium studies (42 vs 6 %).

14. Fecal occult blood testing
 Guaiac-based tests:
 Uses a chemical indicator that shows a colour change in the presence of
blood in stool.
 The pseudoperoxidase activity of hemoglobin turns the guaiac compound
blue in the presence of hydrogen peroxide.
 IMMUNO CHEMICAL test ( FIT );
 It is more specific ,detects only human hemoglobin,
 ;uses antibodies directed against human hemoglobin to detect blood in the
stools.
 Positive results indicate abnormal bleeding from lower intestine ,bcos blood
from lower sites is less degraded during transit
 For FOBT + 2ml blood in stool is necessary.
 Two samples of each of 3 consecuative (daily ) stools.

21. CAPSULE ENDOSCOPY.
 Permits exam. 0f small intestinal mucosa using wireless image
capturing technology.
 Noninvasive method to evaluate the entire length of small
bowel.
 Can identify vascular ectasia ,ulcers and masses in small bowel.
 CAPSULE= Size 2.6 cm,weight 3.5 g.
 COMPARTMENTS=
 Metal oxide silicon image sensor,
 Light emitting diode (led)
 Aerial belt with 8 aerials which collects signal from the capsule.
 Software for analysis.

22. INDICATIONS OF CE.
 Crohns disease
 Celiac disease
 Immunoproliferative small intestinal disease (IPSID)
 Polyposis
 Small intestinal tumor like carcinoid and lymphoma.
 Recurrent abdominal pain with diarrhea.
 Obscure GI BLEED (after negative EGD and
Colonoscopy )
 Recurrent iron deficiency anemia.

23. CAPSULE ENDOSCOPY
 ADVANTAGES;
 Noninvasive
 Disposable
 DISADVANTAGES;
 Cost
 Inaccurate localization of the site of bleeding.
 Capsule retension <1%.

33. Deep Enteroscopy
 Double-Balloon
Enteroscopy
 Single-Balloon
Enteroscopy
 Spiral Enteroscopy
Therapeutic as well as
diagnostic capabilities