“THE HUNT FOR THE RED SPOT”Investigations and management of the obscure GI bleeder

Dr Georgina CameronEndoscopy Fellow, SVHMANZSPM Update Meeting

28th June 2013

Background

Obscure gastrointestinal bleeding (OGIB) represents occult or overt bleeding of unknown origin after normal gastroscopy and colonoscopy.

– Overt bleeding is characterised by haematemesis and/or melaena.

– Occult is not detectable by the patient

Background• 5% of all GI bleeding

occurs in the small bowel outside the intubation range of gastroscopy and colonoscopy.

• ~75% obscure GI bleeding arises from the small bowel (25% found on repeat upper and lower endoscopy)

Causes of obscure GI bleeding

Ulcer

GIST

Angioectasia

Diverticular disease

Varices

Endoscopic investigations for obscure GI bleeding

Repeat Gastroscopy, colonoscopy - 25% will detect aetiology of obscure GI bleeding

Push enteroscopy- Aiming to visualise proximal jejunum- Typically use a paediatric colonoscope and able to intubate 100cm into

small bowel

Capsule endoscopy- Benefit of complete small bowel visualisation- Fair localisation- Guides next best investigation- Not therapeutic

Endoscopic investigations for obscure GI bleeding

Double Balloon Enteroscopy

- Anterograde and retrograde allowing visualisation 75% small bowel - Allows therapeutic intervention such as polypectomy, cauterization, clipping - Ink tattooing allows localisation of pathology for surgeons

Intraoperative enteroscopy

Radiological investigations

CT Angiography (>0.3 mL/min)Good localisation, precursor to angiography

Labelled Red Cell Scan (>0.1mL/min)Poor localisation

Digital Subtraction Angiography (therapeutic)

Case 1 Mrs SM

• 70 year old lady from Warrnambool– Recurrent presentations with abdominal pain,

fever and melaena– Haemoglobin 60g/L requiring 3 units blood and

admission to intensive care– On aspirin for atrial fibrillation– Normal gastroscopy and colonoscopy

Case 1: Mrs SMCapsule endoscopy showed

bleeding from proximal small bowel CT showed

small bowel diverticula

Case 1: Mrs SM

• Transferred to St Vincent’s Hospital• Small amount of melaena with Haemoglobin

drop post arrival – transfused 3 units • CT angiogram – no focus of bleeding• Given capsule endoscopy findings, proceeded

to anterograde double balloon enteroscopy

Anterograde Double Balloon Enteroscopy

Fresh bleeding and clot within a small bowel diverticulum

Unable to achieve haemostasis

Site tattooed for surgical localisation

Case SM – “X” marks the spot

Laparotomy and 15cm small bowel resection with end to end anastamosis.

Case 2: Mrs EH• 73 year old• Several weeks of melaena• Hypotensive, dizzy and unable to mobilise • Hb 51g/L on admission and iron deficient• Past history of peptic ulcer disease,

rheumatoid arthritis, 2nd degree heart block• No non-steroidals anticoagulants/antiplatelets

on admission

Case 2: Mrs EH• Gastroscopy x2 – Chronic non-bleeding gastric ulcers

• Colonoscopy – Blood in colon and ileum

• CT angiogram – NAD

• Push enteroscopy to 90cm– NAD

• Red cell scan – bleeding in the proximal small bowel

Case EHCapsule endoscopy

Blood 2/3 into small bowel transit time

Capsule noted to be in the right iliac fossa on the 8-lead map

Case 2 Mrs EHAnterograde DBE – unremarkable

Retrograde DBE –ooze over a pulsating area of mucosa 100cm proximal to ileocaecal valve

This represented angioectasia, and was treated with Adrenaline, Argon Plasma Coagulation (APC), and clipping

Outcome

18 units PRBC in a 19 day admission

Haemostasis achieved at retrograde DBE

Patient discharged home 2 days later with no further bleeding

Prolonged overt obscure gastrointestinal bleeding – A “real world” experience

Prayman T Sattianayagam, Paul V Desmond, Andrew CF TaylorSubmitted to Digestive Diseases and Sciences 2013

Aims

• To assess – the final diagnosis and outcomes in patients with

overt obscure GI bleeding– clinical features of the patients that may point to

the diagnosis– diagnostic yield of the battery of investigations

used for this group of patients

Methods:

Over a ten-year period between 2002 and 2012 twenty-eight patients who fulfilled the following inclusion criteria were included in the study:

1) overt GI haemorrhage2) anaemia requiring transfusion 3) an initial negative gastroscopy and colonoscopy 4) at least one inpatient hospital stay of ≥7 days

because of persistent GI bleeding

Recorded Measurements

The clinical presentation, transfusion requirements and investigations of each patient were recorded - until diagnosis and treatment, or - until death or census in September 2012 (in those who had undiagnosed OGIB)

Results:• 28 patients (14 male)

• Median age at presentation = 68 years (18-88)

• Median follow-up in the entire cohort was 3 years (0.1-9.4)

• Drugs potentiating GI bleeding (present in 76% of those >60yo)– 10 on aspirin– 3 on clopidogrel – 4 on warfarin

• Median time from presentation to treatment 5.3 months (0.3 - 48)

• Median number of units of blood transfused per patient 29 (10 - 86) units

Causative PathologiesDiagnoses No. Ages of patients (yrs)Small intestinal angioectasia 6 66,67,67,67,68,84

Large intestinal angioectasia 2 78,86

Small intestinal varices 4 18,39,50, 58

Small intestinal gastrointestinal stromal tumour 2 70,79

Small intestinal carcinoid 3 33,76,78

Jejunal diverticula 2 69,80

Colonic diverticula 1 73

Pancreaticoduodenal artery aneurysm 1 88

Small intestinal anastomotic bleeding 2 33,48

Infected aortoenteric fistula 1 74

No diagnoses 4 31,32,61,74

Yield of endoscopic investigations in overt OGIB

Test No. of patients No. of tests Positive diagnostic yield

Positive therapeutic yield

Repeat Gastroscopy 19 36 3% 3%

Repeat colonoscopy 14 28 4% 4%

Capsule endoscopy 20 32 53% 0%

Push enteroscopy 11 12 17% 17%

Antegrade double balloon enteroscopy

13 16 31% 13%

Retrograde double balloon enteroscopy

6 7 0% 0%

Yield of radiological investigations in overt OGIB

Test No. of patients

No. of tests

Positive diagnostic yield

Positive therapeutic yield

Radionuclide red cell scan

23 41 51% 0%

CT angiography 17 27 30% 0%

Angiography 13 21 33% 29%

Surgical outcomes in overt OGIBTest No. of patients No. of tests Positive

diagnostic yieldPositive therapeutic yield

Surgery overall 13 15 60%

- Clear lesion identified prior to surgery

7 7 86%

- Non-specific finding prior to surgery

6 8 2 (25%) 25%

Enteroscopy performed in addition to surgery

5 5 2 (40%)

Summary• Repeat gastroscopy/colonoscopy allowed treatment of angioectasias in two

elderly patients

• Radionuclide red cell scans had the highest radiological diagnostic yield but were beneficial only in conjunction with other tests such as CT angiography, which was a useful precursor test to angiographic embolisation

• Capsule endoscopy had the highest endoscopic diagnostic yield

• Anterograde double balloon enteroscopy had the best endoscopic diagnostic and therapeutic yield

• Surgery had a diagnostic and therapeutic yield of 60%, which was better if a definite lesion had been identified previously

Conclusions:• Overt OGIB is difficult to manage

• Angioectasias are the commonest cause of overt OGIB in patients over 65 who are often on antiplatelet/anticoagulant therapy

• Capsule endoscopy is best first-line test, which can guide enteroscopy

• Nuclear medicine labelled red cell scan helpful but poor localisation

• CT angiography can guide angiographic embolisation but this requires more rapid rate of bleeding

• Surgery is often curative if you can localise the site of bleeding prior

• “Management should be individualised with consideration for repeating investigations”