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Christopher Robbins
BSN, RN, CGRN
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Slide 2
I have nothing to disclose.
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Review the definition and causes of obscure GI bleeding
Discuss standard methods for examining the small bowel.
Discuss new methods of examining the small bowel.
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Upper GI Bleeding◦ Proximal to papilla
Mid-gut (SB bleeding)◦ From second portion of duodenum to the terminal
ileum
Lower GI Bleeding◦ Colonic
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Obscure GI bleeding (OGIB) has been defined as bleeding of unknown origin that persists or recurs after an initial negative endoscopic evaluation, including colonoscopy and/or upper endoscopy (EGD).
5-10% of all GI bleeding events
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Slide 6
2.7 years
> 7 diagnostic tests
> 5 Hospitalizations
20-40 transfusions
Foutch et al. – GI Endo ‘90; Flickinger et al. – Am J Surg ‘89; Goldfarb et al. – Dis Manage ‘02
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Patient < 40 Patient > 40
Tumors *
Meckel’s Diverticulum
Dieulafoy*
Crohn’s disease
Celiac disease *
Vascular malformations
Angioectasias Dieulafoy* NSAIDs Celiac disease* Tumors (lymphoma)* Crohn’s disease
Raju et al. – Gastro ‘07
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• Meckel’s diverticulum> Remnant of vitelline duct in distal
ileum
> Prevalence of 1 – 3%
> Most common cause of small bowel bleeding in patients under the age of 25
> Ectopic gastric tissue causes ulceration
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Large, tortuous submucosalarteriole
Bleeds through a mucosal defect
75% in stomach
14% in duodenum
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Hemobilia
Hemosuccus pancreaticus
Aorto-enteric fistula
Ectopic varices
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Hemobilia◦ Neoplasm, vascular aneurysm,
liver abscess, trauma, liver biopsy
Hemosuccus pancreaticus◦ Pancreatic pseudocysts,
pancreatitis, neoplasms
◦ Erosion into a vessel with communication with PD
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Slide 13 Aorto-Enteric Fistula
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Upper GI Lower GI
Cameron’s ulcers
Gastric varices
PUD
GAVE
Agioectasias Neoplasms
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After APC
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Slide 18 Obscure Bleeding
Occult Overt
Capsule Endoscopy
Massive
+Further w/u needed
Specific mgmtMedical
RadiologicalEndoscopic
Surgery
Angiography
Observation Repeat studies
EGD, Colon
VCE, CTE
DBE, IOERecurrence
Need further w/uFollow-up Specific mgmt
Negative Positive
YesNo
-
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VCE First◦ Very good screening test
◦ Helps to determine further testing
Push enteroscopy
Deep enteroscopy
Surgery
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Visualizes all GI Tract
Non Invasive
Good yield
+/- Specificity
VCE
Raju et al. – Gastro ‘07
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Propelled via peristalsis
Captures ~ 60,000 images
Ambulatory office procedure
Naturally excreted
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1. Optical dome2. Lens holder3. Lens4. LEDs
(Light Source)5. Electronic Chip
converts Images to Radio Waves
6. (2) Battery7. Electronic
transmitter8. Antenna
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Slide 23
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Pennazio M, Santucci R, Rondonotti E, et al. Gastroenterology 2004; 126: 643-653
82.6 %Negative predictive
value
97.0 %Positive predictive
value
95.0 %Specificity
88.9 %Sensitivity
(Analysis of patients with verified final diagnosis, n = 56)
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Time efficient, patient friendly, sensitive method to visualize the small bowel
Disadvantages ◦ No therapeutics
◦ Unable to control movement
◦ Unable to clear bubbles and debris
ASGE
March 15, 2013
Oak Brook, IL
Capsule Endoscopy User’s Course
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Very low yield
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Time consuming
Diagnostic yield in average OGIB is ~25%
Location accuracy of bleed is ~30-50% of the time
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Slide 28 Infuse technetium-labeled RBC’s
Nuclear imaging obtained over 60 – 90 min
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Yield is ~ 25-30%
Good for bleeding and non-bleeding AVM’s
Bloomfeld et al. – Am J Gastro ‘00
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Active bleeding Coil embolization Post treatment
Kobayashi J Surg Rad 2011 Jan 1; 2 (1)
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Slide 31
Contrast injected into small bowel
X-rays obtained
Improved yield over small bowel series
Yield is poor:◦ 10%-25%
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Diagnostic tool in evaluating Small Bowel Disorders.
Highly sensitive and specific for Crohn'sdisease
Fistulizing Crohn disease in a 36-year-old woman
with a long-standing history of intermittent diarrhea,
hematochezia, and nocturnal stools.
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Visualized to Proximal SB
Invasive
Yield is fair (operator dependent)
Very specific
Average + yield ~35%
Better yield in overt bleeding and AVM’s
Push Enteroscopy
Raju et al. – Gastro ‘07
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Slide 35
Double-balloon Enteroscopy (2001)
Single-balloon Enteroscopy (2007)
Rotational Enteroscopy (2006)
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Three divisions Duodenum Jejunum Ileum
Average length ~ 22 feet or 670 cm
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Overtube with double balloons
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Rotational Enteroscopy usually requires < 15 minutes to reach maximum depth
Physicians report easier controlled withdrawal compared to balloon endoscopy
Scope removal without position loss
Procedures are well tolerated with few reported complications
The short time required allows for upper and lower exams in the same setting
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Slide 46
Avg. Time to Max. Depth 25 minutes
Avg. Total Procedure Time 45 minutes (all procedures)
35 minutes (diagnostic without therapy)
Avg. Depth 247 cm
65% Diagnostic Yield
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Slide 47
Comparative Performance
DeviceAverage Procedure
TimeDepth Therapy Source
Rotational Enteroscopy
45 min 250 Yes National Independent Study 2008
Double Balloon
73 min 233 YesASGE Technology Status Report-
Enteroscopes: 2007
Single Balloon 77 min 239 YesMeta-analysis of 5 published studies
2007-2008
Pill Camera8 hrs. to record
30-120 min. to readAll No
ASGE Technology Status Report –Wireless Capsule: 2006
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Slide 48
Rotational Enteroscopyhelps facilitate deep enteroscopy and ERCP in altered anatomy patients◦ Roux-en-Y
Aids insertion
Provides high level of control and stabilization
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Slide 49 ◦ 14 patients with altered anatomy
7 patients had Roux-en-Y gastric bypass
Excluded stomach reached in 5/7 (71%)
1 successful ERCP
Remaining seven had either small bowel resections, choledochojejunostomy, or a Whipple procedure
All deep enteroscopies successful
Baylor University Medical Center 2008
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Slide 50
All PatientsDouble Balloon
ERCPDiscovery SB
ERCP
Number of Patients 13 12 3
Number of Procedures 21 18 3
Cannulation Success 12/21 (57.1%) 10/18 (55.6%) 3/3 (100%)Number of Procedures where Intervention Indicated
20 17 3
Therapeutic Success 12/20 (60%) 10/17 (58.8%) 3/3 (100%)Mean total procedure time (min)
84.3 +/- 39.4 79.2 +/- 34.1 116.7 +/- 59
May facilitate pancreatico-biliary intervention in patients that fail DB ERCP
Although these procedures are time consuming, the development of better accessories may improve efficacy of these procedures
Fox-Chase Cancer Center 2007 – 2008
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◦ 7 patients with Roux-en-Y anatomy
◦ Spiral allowed deep small bowel access in a reasonable amount of time
◦ Allowed for therapy that was previously only available by intra-operative enteroscopy or laparotomy
◦ Was successful after failure of the single balloon
University of Texas Southwestern
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Slide 52
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Fits over standard endoscopes and pediatric colonoscopes◦ 11.1mm-11.6mm OD
100cm overall length / 18mm OD
5.5mm spiral height
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Slide 54
Aids insertion & advancement of the endoscope and helps reduce the colon.
Allows scope to be pushed into the ileum while stabilizing the colon.
Standard reduction maneuvers are performed to inspect the ileum.
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