Management of Small Intestinal Bleed

Management of Management of Small Intestinal Small Intestinal

BleedBleedDr Shamail Zafar Dr Shamail Zafar

Assistant Professor of MedicineAssistant Professor of Medicine

Lahore Medical & Dental College Lahore Medical & Dental College LahoreLahore

Bleeding from Small Bleeding from Small IntestineIntestine

CLASSIFICATION

Bleeding from Small Intestine can be Bleeding from Small Intestine can be classified as classified as

i) Overt Small Intestinal Bleed:

in which patient presents with in which patient presents with hematochezia or malena.hematochezia or malena.

ii) Occult Small Intestinal Bleed:

in which patient presents with iron in which patient presents with iron deficiency anemia and/or positive fecal deficiency anemia and/or positive fecal occult blood test.occult blood test.

ASGE Practice Committee Guideline on GI Bleed

GastroIntestinal Endoscopy 2003;58(5)650-55

Bleeding from Small Bleeding from Small IntestineIntestine

INCIDENCEINCIDENCE About ~5 % of Total GIT Bleed. Angiectasias account for about 50 % of

these cases.

Raju GS.Gastroenterology 2007;133(5):1697-1717

Concha R. J Clin Gastroenterol 2007;41(3):242-51

Bleeding from Small Bleeding from Small IntestineIntestine

CAUSES

Younger Younger than 40 than 40 years of years of ageage

Older than 40 Older than 40 years of ageyears of age

UncommonUncommon

Tumors Angiectasia Hemobilia

Meckel’s Diverticulum

NSAID Enteropathy

Hemosuccus Pancreaticus

Dieulafoy’s lesion

Celiac Disease Aortoenteric Fistula

Celiac Disease

Inflammatory Bowel Disease

Portal Hypertensive Vasculopathy

Inflammatory Bowel Disease

Tumors GAVE

AGA Institute Technical Review on Obscure GI Bleed

Gastroenterology 2007;133(5) 1697-1717

Bleeding from Small Bleeding from Small IntestineIntestine

DIAGNOSIS & MANAGEMENT

i)i) History & Clinical examinationHistory & Clinical examination

ii)ii) Laboratory AnalysisLaboratory Analysis

iii)iii) Emergency room managementEmergency room management

iv)iv) Non-Endoscopic managementNon-Endoscopic management

v)v) Endoscopic ManagementEndoscopic Management

vi)vi) Pharmacological ManagementPharmacological Management

Bleeding from Small Bleeding from Small IntestineIntestine

NON-ENDOSCOPIC MANAGEMENTi) Barium studies a) Small Bowel follow through

b) Enteroclysis

ii) Nuclear Scans a) Tagged Red Blood Cell Scan b) Meckel’s Scan

iii) CT Scan and MRIiv) Angiography

Bleeding from Small Bleeding from Small IntestineIntestine

ENDOSCOPIC MANAGEMENT

i) Enteroscopy a) Push Enteroscopy b) Double Balloon Enteroscopyii) Wireless Capsule endoscopyiii) Intraoperative enteroscopy

Barium StudiesBarium Studies Small Bowel follow through studies have

shown a low diagnostic yield (0% to 6%)1

Diagnosis is improved when combined with Enteroclysis which is a Biphasic examination using barium and methylcellulose as double contrast agent (10% to 20%)2

Even Enteroclysis fails to detect flat mucosal lesions like Angiodysplasia, thus use is limited to tumor and stricture detection.

1.Gastrointest Endosc.2003;57:418-420

2.Med Clin North Am 2002;86:1319-56

Radionuclide ScansRadionuclide Scans

Threshold bleeding rate is in the range Threshold bleeding rate is in the range of 0.1 to 0.4 ml/min.of 0.1 to 0.4 ml/min.

Technitium Tc 99m-lableled RBC’s stay Technitium Tc 99m-lableled RBC’s stay in the vascular space for 24 hours.in the vascular space for 24 hours.

Aid in localization of bleeding which Aid in localization of bleeding which can later verified endoscopically or can later verified endoscopically or angiographically.angiographically.

Surgical yield of early positive scan Surgical yield of early positive scan (1to 4 hr) is 70 to 80%.(1to 4 hr) is 70 to 80%.

Recent Advances in Small Intestinal Bleed

Kovacs TO. Med Clin North Am.2002;86:1319-56

AngiographyAngiography

Threshold bleeding rate is more than Threshold bleeding rate is more than 0.5ml/min0.5ml/min

Can detect both bleeding lesions of Can detect both bleeding lesions of tumors and AVM’s.tumors and AVM’s.

Therapy can be offered in the form of Therapy can be offered in the form of micro-coils, glue or drugs (vasopressin).micro-coils, glue or drugs (vasopressin).

Diagnostic yield varies between 12- 70 %.Diagnostic yield varies between 12- 70 %. CT Angiography is better than CT Angiography is better than

conventional Angiography.conventional Angiography.

Concha R. Obscure GI Bleed. J Clin Gastroenterol 2007;41(3):242-51

Cross Sectional Imaging Cross Sectional Imaging TechniquesTechniques

CT SCAN , CT ENTEROCLYSIS, MRECT SCAN , CT ENTEROCLYSIS, MRE It provides non-superimposed views of all

small bowel loops as well as of any mesenteric or extra intestinal lesions. or extra intestinal lesions.

CTE requires distension of bowel lumen CTE requires distension of bowel lumen with 1200-1500 cc of low density, with 1200-1500 cc of low density, negative oral contrast agent like water or negative oral contrast agent like water or barium sulphate suspension.barium sulphate suspension.

MRE provides better soft tissue MRE provides better soft tissue discrimination.discrimination.

Horton KM.MDCT of small bowel neoplasms. J CAT 2004;28:106-116

Cross Sectional Imaging Cross Sectional Imaging TechniquesTechniques

Both CTE and MRE are novel techniques of accurate diagnosis of inflammatory, vascular and neoplastic lesions of small intestine.

Push EnteroscopyPush Enteroscopy

Proximal part of small intestine can be Proximal part of small intestine can be directly visualized using extended directly visualized using extended length enteroscope or pediatric length enteroscope or pediatric Colonoscope.Colonoscope.

Accessories like Biopsy forceps or APC Accessories like Biopsy forceps or APC probes enable to perform diagnostic probes enable to perform diagnostic and therapeutic procedures.and therapeutic procedures.

50 % of small Bowel is accessible50 % of small Bowel is accessible Diagnostic Yield 40-65%.Diagnostic Yield 40-65%.

Waye JD. Enteroscopy.Gastrointest Endosc 1997;46:247-56

O’Mahony S. Push Enteroscopy. QJM 1996;89:685-90

Double Balloon Double Balloon EnteroscopyEnteroscopy

It allows complete It allows complete examination of examination of small intestinesmall intestine

Scope has got a Scope has got a balloon at its tip balloon at its tip and a soft overtube and a soft overtube with another with another balloon at the balloon at the distal end are used distal end are used together.together.

Double Balloon Double Balloon EnteroscopyEnteroscopy

Accessory channel enables interventions Accessory channel enables interventions like biopsies, balloon dilatation, stent like biopsies, balloon dilatation, stent placement, polypectomy and endoscopic placement, polypectomy and endoscopic mucosal resection.mucosal resection.

Overall Diagnostic yield is 43-80 %Overall Diagnostic yield is 43-80 % DBE can be performed in antegrade DBE can be performed in antegrade

and /or retrograde fashion; insertion and /or retrograde fashion; insertion route is chosen according to the route is chosen according to the suspected lesion location.suspected lesion location.

Nakamura M.Which route to select in DBE.Gastrointest Endosc2008;687(3)577-8

Sidhu R. Guidelines on small bowel enteroscopy. GUT2008;67(1)125-36

Double Balloon Double Balloon EnteroscopyEnteroscopy

Endoscopic Coagulation Heated probe or lasers such as Nd:YAG and Heated probe or lasers such as Nd:YAG and

argon argon Argon laser treatment is recommended for Argon laser treatment is recommended for

mucosal or superficial lesions because the mucosal or superficial lesions because the energy penetrates only 1 mm.energy penetrates only 1 mm.

Nd:YAG lasers are more useful for deeper Nd:YAG lasers are more useful for deeper lesions because they penetrate 3-4 mm .lesions because they penetrate 3-4 mm .

Absolute alcohol, Ethanolamine and sodium Absolute alcohol, Ethanolamine and sodium tetradecyl sulfate can be used for tetradecyl sulfate can be used for sclerotherapy.sclerotherapy.

Capsule EndoscopyCapsule Endoscopy

Procedure Consists of three Procedure Consists of three stepssteps

1. Ingest the video capsule.

2. Capsule transmits images to Data Recorder. 3. Images are reviewed using RAPID software, and physician makes diagnosis.

Capsule EndoscopyCapsule Endoscopy Capsule includes a miniature color video

camera, a light, a battery and transmitter Weighs 3.7 g and measures 11 mm × 26 mm Image features include a 140° field of view, 1:8

magnification, 1 to 30 mm depth of view, and a minimum size of detection of about 0.1 mm

The camera takes two pictures every second for eight hours

Capsule cost: Pack of 1 for $500 Capsule endoscopy not a substitute for

regular endoscopy

AVM

Bleeding Lesion Polyp

Sprue

Intra-operative Intra-operative EnteroscopyEnteroscopy

Intra-operative Enteroscopy is the Intra-operative Enteroscopy is the traditional Gold standard in small traditional Gold standard in small bowel visualization.bowel visualization.

If facilities of DBE are not available or If facilities of DBE are not available or it cannot be performed due to it cannot be performed due to abdominal adhesions, IOE still remains abdominal adhesions, IOE still remains the procedure of choice especially in the procedure of choice especially in transfusion dependant patients.transfusion dependant patients.

Diagnostic yield is 58-88%.Diagnostic yield is 58-88%.Hartmann D.Comparing CE with IOE in OGIB. Gastrointest Endosc 2005;61(7):826-32

Diagnostic Yield of IOEDiagnostic Yield of IOE

AGA Institute Technical Review on Obscure GI Bleed

Gastroenterology 2007;133(5) 1697-1717

Push Enteroscopy vs Capsule Push Enteroscopy vs Capsule EndoscopyEndoscopy

Barium Radiography vs Capsule Barium Radiography vs Capsule EndoscopyEndoscopy

Pharmacological TherapyPharmacological Therapy Pharmacotherapy should be considered Pharmacotherapy should be considered

whenever endoscopic therapy, surgical whenever endoscopic therapy, surgical intervention or angiographic therapy is intervention or angiographic therapy is either not available or effective.either not available or effective.

It includes supportive therapy withIt includes supportive therapy with1. Blood transfusions2. Epoetin alpha3. Iron replacement 4. Hormonal therapy5. Octreotide 6. Avoidance of Anticoagulants, aspirin and NSAID’s

Hormonal TherapyHormonal Therapy

Discordant results have been Discordant results have been obtained regarding efficacy of obtained regarding efficacy of Hormonal therapy for suspected Hormonal therapy for suspected Angiodysplasia bleeding.Angiodysplasia bleeding.

Combined hormonal therapies with Combined hormonal therapies with estrogen-progesterone significantly estrogen-progesterone significantly reduces blood transfusions and reduces blood transfusions and rebleeding.rebleeding.

Van Custem E. Treatment of vascular malformations with estrogen progeterone. Lancet 1990;335:953-5

Hormonal therapy in GI angiodysplasia.Gastroenterology 2001;121(5):1073-79

Octreotide AcetateOctreotide Acetate

Potential benefit of reducing Potential benefit of reducing Angiodysplastic bleeding.Angiodysplastic bleeding.

20% reduction in bleeding can be 20% reduction in bleeding can be obtained over a 1-2 year period.obtained over a 1-2 year period.

Junquera F. Longterm efficacy of Octreotide in recurrent GI Bleeding

Am J Gastroenterol 2007;102(2):254-70

Nardone G. Efficacy of Octreotide in GI Bleeding. Aliment Pharmacol Ther 1999;13(11) 1429-36)

ThalidomideThalidomide

It is proven to have anti It is proven to have anti inflammatory activity in patients of inflammatory activity in patients of Crohn’s disease.Crohn’s disease.

It also displays anti-angiogenic It also displays anti-angiogenic activityactivity

Perez-Ecinas. Is thalidomide effective for management of GI Bleeding. Haematologica 2002;87:ELT 34

Anti Fibrinolytic AgentsAnti Fibrinolytic Agents

Tranexamic acid and Epsilon-Tranexamic acid and Epsilon-Aminocaproic acid.Aminocaproic acid.

They inhibit the process of They inhibit the process of Fibrinolysis in Telangiectasia walls, Fibrinolysis in Telangiectasia walls, which enables fibrin deposits to seal which enables fibrin deposits to seal the bleeding site.the bleeding site.

Korzenik JR. Treatment of bleeding in HHT with aminocaproic acid. NEJM 1994;331:1236

ConclusionsConclusions

Push Enteroscopy is better than Push Enteroscopy is better than barium studies.barium studies.

Help should be taken radionuclide Help should be taken radionuclide scans and mesenteric Angiography scans and mesenteric Angiography to localize the lesions.to localize the lesions.

Intra-operative Enteroscopy still Intra-operative Enteroscopy still remains the Gold standard.remains the Gold standard.

Thank you

PE vs PPEPE vs PPE Insertion depth of push enteroscopy is limited to

the proximal jejunum. The diagnostic yield of push

enteroscopy can be estimated on approximately 40%. With the new method of push-and-pull enteroscopy in

double-balloon technique also deeper parts of the small bowel can be reached.

Push-and-pull enteroscopy is superior to push enteroscopy both with regard to the length of small bowel visualized and to the diagnostic yield.