Post on 31-Aug-2019
Obscure GI BleedingObscure GI Bleeding
Jerrod Keith MDJerrod Keith MDUniversity of Colorado Health SciencesUniversity of Colorado Health Sciences
General Surgery Grand RoundsGeneral Surgery Grand RoundsAugust 14, 2006August 14, 2006
OutlineOutline
Defining the problemDefining the problemDiagnostic approachDiagnostic approachRadiographic modalitiesRadiographic modalitiesEndoscopic modalitiesEndoscopic modalitiesSurgical modalitiesSurgical modalitiesCapsule endoscopy outcomesCapsule endoscopy outcomesCT scanCT scanConclusionsConclusions
Obscure GI BleedingObscure GI BleedingGastrointestinal bleeding of unknown origin that Gastrointestinal bleeding of unknown origin that persists or recurs after negative endoscopy of the persists or recurs after negative endoscopy of the upper and lower GI tractupper and lower GI tractOvertOvert
HematemesisHematemesisHematocheziaHematocheziaMelenaMelena
OccultOccultDrifting hematocrit Drifting hematocrit IronIron--deficiency anemiadeficiency anemiaBlood in stools not grossly apparentBlood in stools not grossly apparent
Gastrointestinal BleedingGastrointestinal Bleeding
GI bleeding GI bleeding –– 300,000 hospitalizations/year300,000 hospitalizations/year1010--20% no identifiable source (obscure)20% no identifiable source (obscure)5% recurrent bleeding5% recurrent bleeding
Sources of Obscure BleedingSources of Obscure BleedingVascularVascular
AngiodysplasiaAngiodysplasia (30 (30 -- 40%)40%)DieulafoyDieulafoy lesionlesion
Mass lesionsMass lesionsCarcinomaCarcinomaAdenomaAdenomaSmall bowel tumors (4%)Small bowel tumors (4%)
InflammationInflammationUlcersUlcersCameron lesionsCameron lesions
OtherOtherMeckelMeckel’’s s diverticulumdiverticulumDiverticulaDiverticula
Missed DiagnosisMissed Diagnosis
Stopped bleedingStopped bleedingSlow or intermittent bleedingSlow or intermittent bleedingAnemia and volume contractionAnemia and volume contraction
Lesions look less obviousLesions look less obvious
Lesions located in the small bowelLesions located in the small bowel27% of obscure bleeds have small bowel lesions27% of obscure bleeds have small bowel lesions
Small Bowel BleedingSmall Bowel Bleeding
Difficult to examineDifficult to examine6.7m in length6.7m in lengthEndoscopic visualizationEndoscopic visualization
Free Free intraperitonealintraperitoneal locationlocationActive contractilityActive contractility
Contrast studiesContrast studiesMultiple overlying loopsMultiple overlying loops
Approach to GI BleedApproach to GI Bleed
Localize the siteLocalize the siteHematemesis typically proximal to ligament of Hematemesis typically proximal to ligament of TreitzTreitzHematochezia typically left colon and distallyHematochezia typically left colon and distallyMelena typically right colon and proximalMelena typically right colon and proximal
Upper endoscopyUpper endoscopyLower endoscopyLower endoscopy
WorkWork--up for Obscure Bleedingup for Obscure Bleeding
Repeat upper endoscopyRepeat upper endoscopyDiagnostic yield 25% to 64%Diagnostic yield 25% to 64%
Repeat colonoscopyRepeat colonoscopyDiagnostic yield 6%Diagnostic yield 6%
Etiology still unclearEtiology still unclearFocus on small bowelFocus on small bowelLook for obscure bleedingLook for obscure bleeding
RadiographicRadiographicEndoscopicEndoscopicSurgicalSurgical
Radiographic ModalitiesRadiographic Modalities
Small bowel followSmall bowel follow--through (SBFT)through (SBFT)Diagnostic yield Diagnostic yield –– 8%8%
Small bowel tumors Small bowel tumors –– 83%83%CrohnCrohn’’s disease s disease –– >90%>90%
EnteroclysisEnteroclysisDoubleDouble--contrast infused under pressure into distal contrast infused under pressure into distal duodenum or proximal jejunumduodenum or proximal jejunumDiagnostic yield Diagnostic yield –– 10% to 21%10% to 21%
Small bowel tumors Small bowel tumors –– 93%93%CrohnCrohn’’s disease s disease –– 93% to 100%93% to 100%
Radiographic ModalitiesRadiographic ModalitiesTechnitiumTechnitium--labeled nuclear scanlabeled nuclear scan
Tagged RBC scanTagged RBC scanActive bleeding, rate of 0.1 Active bleeding, rate of 0.1 mLmL/min/minDiagnostic yield Diagnostic yield –– 15% to 70%15% to 70%
Higher in overt bleedingHigher in overt bleeding
Poor localizationPoor localization
AngiographyAngiographyActive bleeding, rate of 0.5 Active bleeding, rate of 0.5 mLmL/min/minDiagnostic yield Diagnostic yield –– 40% to 53%40% to 53%Identify vascular patterns as wellIdentify vascular patterns as wellProvocative angiographyProvocative angiographyTreatment optionsTreatment options
Vasopressin, Vasopressin, embolizationembolization
Mesenteric angiography yield Mesenteric angiography yield –– 53% to 60%53% to 60%
Radiographic ModalitiesRadiographic ModalitiesMeckelMeckel’’s scans scan
Technetium Technetium pertechnetatepertechnetateIdentifies heterotopic gastric mucosaIdentifies heterotopic gastric mucosa
50% of GI bleeding in patients <3 years of age50% of GI bleeding in patients <3 years of ageSensitivity in pediatric patients Sensitivity in pediatric patients –– 81% to 90%81% to 90%
Helical CT angiogramHelical CT angiogramBleeding rates of 0.5 to 6 Bleeding rates of 0.5 to 6 mLmL/min/minDiagnostic yield Diagnostic yield –– 72%72%
MRIMRIVisualize changes in the bowelVisualize changes in the bowel
Mucosal thickening, strictures, ulcerationsMucosal thickening, strictures, ulcerations
Endoscopic ModalitiesEndoscopic Modalities
Routine endoscopyRoutine endoscopyRepeat upper endoscopy yield Repeat upper endoscopy yield –– 25% to 64%25% to 64%Repeat colonoscopy yield Repeat colonoscopy yield –– 6%6%
Endoscopic ModalitiesEndoscopic Modalities
EnteroscopyEnteroscopyPush enteroscopyPush enteroscopy
120cm past ligament of 120cm past ligament of TreitzTreitzDiagnostic yield Diagnostic yield –– 28%28%
SondeSonde enteroscopyenteroscopyRarely usedRarely used
Double balloon enteroscopyDouble balloon enteroscopyInvasiveInvasiveNewer technologyNewer technologyDiagnostic yield Diagnostic yield –– 76%76%
Endoscopic ModalitiesEndoscopic ModalitiesCapsule endoscopyCapsule endoscopy
FDA approval in 2001FDA approval in 2001Diagnostic yield Diagnostic yield –– 40% to 70%40% to 70%Clinical impact unclearClinical impact unclear
Abnormalities seen in 23% of healthy patientsAbnormalities seen in 23% of healthy patientsPoor localizationPoor localizationPoor visualizationPoor visualization
Bowel prepBowel prepRapid or delayed bowel transitRapid or delayed bowel transitOrientation of cameraOrientation of camera
Inability to treat lesionsInability to treat lesions
Surgical ModalitiesSurgical Modalities
Exploratory laparotomyExploratory laparotomyAloneAlone
Diagnostic yield Diagnostic yield –– 31% to 65%31% to 65%
Combined with Combined with intraoperativeintraoperative enteroscopyenteroscopyDiagnostic yield increased Diagnostic yield increased –– 50% to 100%50% to 100%
Modality OverviewModality OverviewInvasiveInvasive Diagnostic YieldDiagnostic Yield TherapeuticTherapeutic
-- 8%8%
21%21%
53%53%
70%70%
72%72%
64%64%
28%28%
76%76%
70%70%
Near 100%Near 100%
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--
--
++
--
--
++
++
++
--
++
--
++
++
++
Double Balloon enteroscopyDouble Balloon enteroscopy ++
++
--
++++
SBFTSBFT
EnteroclysisEnteroclysis
AngiographyAngiography
Tagged RBC scanTagged RBC scan
CT angiogramCT angiogram
Repeat upper endoscopyRepeat upper endoscopy
Push enteroscopyPush enteroscopy
Capsule endoscopyCapsule endoscopy
IntraoperativeIntraoperative endoscopyendoscopy
Double Balloon EnteroscopyDouble Balloon Enteroscopy
InvasiveInvasiveDiagnostic yield near that of capsule endoscopyDiagnostic yield near that of capsule endoscopy2 prospective trials compared DBE with CE2 prospective trials compared DBE with CE
Slightly higher diagnostic yield in capsule endoscopySlightly higher diagnostic yield in capsule endoscopy
Capsule EndoscopyCapsule EndoscopyAbsolute contraindicationsAbsolute contraindications
Known small bowel stricture or obstructionKnown small bowel stricture or obstructionIleusIleus
Relative contraindicationsRelative contraindicationsGI motility disorderGI motility disorderPrior abdominal surgeries or radiationPrior abdominal surgeries or radiationDysphagiaDysphagia or swallowing disorderor swallowing disorderDiverticuliDiverticuliPatients requiring MR imagingPatients requiring MR imagingCardiac pacemaker or defibrillatorCardiac pacemaker or defibrillatorPregnancyPregnancy
MetaMeta--AnalysisAnalysis14 studies comparing CE with push enteroscopy14 studies comparing CE with push enteroscopy
Yield for CE Yield for CE –– 63%63%Yield for push enteroscopy Yield for push enteroscopy –– 28%28%
3 studies compared CE to barium radiography3 studies compared CE to barium radiographyYield for CE Yield for CE –– 67%67%Yield for small bowel barium radiography Yield for small bowel barium radiography –– 8%8%
1 prospective study compared CE to mesenteric 1 prospective study compared CE to mesenteric angiographyangiography
CE yield CE yield –– 47%47%Angiography yield Angiography yield –– 53%53%No significant differenceNo significant difference
TriesterTriester S, et al. A metaS, et al. A meta--analysis of the yield of capsule endoscopy compared to other diaanalysis of the yield of capsule endoscopy compared to other diagnostic gnostic modalities in patients with obscure gastrointestinal bleeding. modalities in patients with obscure gastrointestinal bleeding. Am J Am J GastroenterolGastroenterol.. 2005;100:24072005;100:2407--2418.2418.
Clinical OutcomesClinical OutcomesRetrospective reviewRetrospective reviewFollowFollow--up 6.7 monthsup 6.7 months44 consecutive capsule endoscopies44 consecutive capsule endoscopies
Negative EGD, colonoscopy, barium studyNegative EGD, colonoscopy, barium studyOvert bleeding Overt bleeding –– 51%51%Occult bleeding Occult bleeding –– 42%42%
Diagnostic yield Diagnostic yield –– 42% (18 of 43)42% (18 of 43)AngiodysplasiasAngiodysplasias most commonmost common12 ( 28%) patients underwent intervention or change in 12 ( 28%) patients underwent intervention or change in managementmanagement7 (16%) positive clinical outcome7 (16%) positive clinical outcome
RostagiRostagi A, et al. Diagnostic and clinical outcomes of capsule endoscopA, et al. Diagnostic and clinical outcomes of capsule endoscopy. y. Gastrointestinal Gastrointestinal Endoscopy.Endoscopy. 2004; 60:9592004; 60:959--963.963.
Variability in Diagnostic YieldVariability in Diagnostic YieldMulticenterMulticenter, prospective study, prospective study100 consecutive patients with obscure GI bleed 100 consecutive patients with obscure GI bleed and previous negative workupand previous negative workupCapsule retention in 5 patient, 4 requiring surgeryCapsule retention in 5 patient, 4 requiring surgeryOverall diagnostic yield Overall diagnostic yield –– 47%47%
Overt bleedingOvert bleeding92.3%92.3%
Previous overt bleedingPrevious overt bleeding12.9%12.9%The shorter the interval, the higher the yieldThe shorter the interval, the higher the yield
Occult bleedingOccult bleeding44.2%44.2%
Subsequent management dictated by capsule Subsequent management dictated by capsule endoscopy findingsendoscopy findingsResolution of bleedingResolution of bleeding
Mean followMean follow--up 18 monthsup 18 monthsOvert bleedingOvert bleeding
86.9%86.9%Previous overt bleedingPrevious overt bleeding
41.4%41.4%Occult bleedingOccult bleeding
69.2%69.2%PennazioPennazio M, et al. Outcome of patients with obscure gastrointestinal blM, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule eeding after capsule endoscopy: report of 100 consecutive cases. endoscopy: report of 100 consecutive cases. GastroenterologyGastroenterology 2004; 126:6432004; 126:643--653.653.
Clinical Outcomes: Classified by Clinical Outcomes: Classified by BleedingBleeding
Clinical Outcomes: Classified by FindingsClinical Outcomes: Classified by Findings
96 patients, prospective96 patients, prospectiveMedian followMedian follow--up 14 monthsup 14 monthsPrior endoscopy, barium studies and push enteroscopyPrior endoscopy, barium studies and push enteroscopyCapsule endoscopy findings classificationCapsule endoscopy findings classification
Positive Positive –– 41.7%41.7%Explained symptoms, helped management, confirmed findingsExplained symptoms, helped management, confirmed findings
Uncertain significance Uncertain significance –– 20.8%20.8%Failed to completely explain symptomsFailed to completely explain symptoms
Negative Negative –– 37.5%37.5%
ViazisViazis N, et al. Impact of capsule endoscopy in obscure small bowel bN, et al. Impact of capsule endoscopy in obscure small bowel bleeding: defining strict diagnostic leeding: defining strict diagnostic criteria for favorable outcome. criteria for favorable outcome. GastrointestGastrointest EndoscEndosc. 2005;62: 717. 2005;62: 717--22.22.
Resolution of BleedingResolution of Bleeding
Based upon positive findings Based upon positive findings (p = 0.009)(p = 0.009)
Positive CE Positive CE –– 68.4%68.4%Uncertain or negative CE Uncertain or negative CE –– 40.8%40.8%
Based upon any CE findingBased upon any CE findingPositive and uncertain CE vs. negative CEPositive and uncertain CE vs. negative CENo significant difference (p = 0.198)No significant difference (p = 0.198)
ViazisViazis N, et al. Impact of capsule endoscopy in obscure small bowel bN, et al. Impact of capsule endoscopy in obscure small bowel bleeding: leeding: defining strict diagnostic criteria for favorable outcome. defining strict diagnostic criteria for favorable outcome. GastrointestGastrointest EndoscEndosc. . 2005;62: 7172005;62: 717--22.22.
Helical CTHelical CTProspective studyProspective study
18 patients with obscure GI bleeding18 patients with obscure GI bleeding
CT bleeding protocolCT bleeding protocol1 liter H1 liter H22O POO POUnenhancedUnenhanced imagesimagesEnhanced images, IV contrastEnhanced images, IV contrast
Arterial and venous phasesArterial and venous phases
Control population of 20 patientsControl population of 20 patientsNo known history of GI bleedingNo known history of GI bleeding
ResultsResults
11 of 18 patients11 of 18 patients12 causes of bleeding confirmed12 causes of bleeding confirmedCT correctly diagnosed 10/12CT correctly diagnosed 10/12
5 of remaining 75 of remaining 7+ findings on CT+ findings on CTBleeding unconfirmedBleeding unconfirmed
Angiodysplasia
ResultsResults
All casesAll cases14/18, + findings on CT14/18, + findings on CTDiagnostic yield Diagnostic yield –– 78%78%
Confirmed bleedingConfirmed bleeding10/12 diagnosed by CT10/12 diagnosed by CTDiagnostic yield Diagnostic yield –– 83%83%
Miller FH, Hwang CM. An initial experience: using helical CT imMiller FH, Hwang CM. An initial experience: using helical CT imaging to aging to detect obscure gastrointestinal bleeding. detect obscure gastrointestinal bleeding. ClinClin Imaging.Imaging. 2004;28(4):2452004;28(4):245--51.51.
ConclusionsConclusions
11stst –– begin with repeat upper endoscopybegin with repeat upper endoscopy22ndnd –– use minimallyuse minimally--invasive tests with high invasive tests with high diagnostic yieldsdiagnostic yields
Capsule endoscopyCapsule endoscopyCT scanCT scan
GI bleeding protocolGI bleeding protocol
ConclusionsConclusions
Capsule endoscopyCapsule endoscopyNot appropriate for all patientsNot appropriate for all patientsTimeTime--consumingconsumingHigh diagnostic yieldHigh diagnostic yieldClinical relevance is unclearClinical relevance is unclear
Limited to overt bleeding and strictly positive findingsLimited to overt bleeding and strictly positive findings
Not therapeuticNot therapeutic
ConclusionsConclusions
CT scanCT scanRapid, nonRapid, non--invasive evaluationinvasive evaluationHigh diagnostic yieldHigh diagnostic yieldClinically relevant findingsClinically relevant findings
Double balloon enteroscopy Double balloon enteroscopy InvasiveInvasiveHigh diagnostic yieldHigh diagnostic yieldTherapeutic optionsTherapeutic optionsImpact remains to be seenImpact remains to be seen
Angiodysplasia
Angiodysplasia
Angiodysplasia
ReferencesReferencesLin S, Lin S, RockeyRockey D. Obscure Gastrointestinal Bleeding. D. Obscure Gastrointestinal Bleeding. GastroenterolGastroenterol ClinClin N Am.N Am.2005;34:6792005;34:679--98.98.TriesterTriester S, et al. A metaS, et al. A meta--analysis of the yield of capsule endoscopy compared to other analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal diagnostic modalities in patients with obscure gastrointestinal bleeding. bleeding. Am J Am J GastroenterolGastroenterol.. 2005;100:24072005;100:2407--2418.2418.RostagiRostagi A, et al. Diagnostic and clinical outcomes of capsule endoscopA, et al. Diagnostic and clinical outcomes of capsule endoscopy. y. Gastrointestinal Endoscopy.Gastrointestinal Endoscopy. 2004; 60:9592004; 60:959--963.963.PennazioPennazio M, et al. Outcome of patients with obscure gastrointestinal blM, et al. Outcome of patients with obscure gastrointestinal bleeding after eeding after capsule endoscopy: report of 100 consecutive cases. capsule endoscopy: report of 100 consecutive cases. GastroenterologyGastroenterology 2004; 126:6432004; 126:643--653.653.ViazisViazis N, et al. Impact of capsule endoscopy in obscure small bowel bN, et al. Impact of capsule endoscopy in obscure small bowel bleeding: leeding: defining strict diagnostic criteria for favorable outcome. defining strict diagnostic criteria for favorable outcome. GastrointestGastrointest EndoscEndosc. 2005;62: . 2005;62: 717717--22.22.Miller FH, Hwang CM. An initial experience: using helical CT imMiller FH, Hwang CM. An initial experience: using helical CT imaging to detect aging to detect obscure gastrointestinal bleeding. obscure gastrointestinal bleeding. ClinClin Imaging.Imaging. 2004;28(4):2452004;28(4):245--51.51.