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.