Occult and Overt Obscure Gastrointestinal Bleedings3.gi.org/wp-content/uploads/2013/01/13ACG_Western_Regional_0008.pdfJonathan A. Leighton, MD, FACG Occult and Overt Obscure Gastrointestinal

Jonathan A. Leighton, MD, FACG

Occult and Overt Obscure Gastrointestinal Bleeding

Occult and Overt Obscure Gastrointestinal Bleeding

Jonathan A. Leighton, MDJonathan A. Leighton, MD

Obscure Gastrointestinal Bleeding

Scan, Scope or Surgery?

Obscure Gastrointestinal Bleeding

Scan, Scope or Surgery?

g ,Mayo Clinic in Arizona

[email protected]

ACG Regional CourseJanuary 2013

g ,Mayo Clinic in Arizona

[email protected]

ACG Regional CourseJanuary 2013

Case StudyCase Study

• 49 yr old woman• Intermittent mild iron deficiency

• 49 yr old woman• Intermittent mild iron deficiency• Intermittent mild iron-deficiency

anemia for 2 yr• 3 mo transfusion-dependent

anemia• Hg 4.7 g/dl, 5.7 g/dl, 7.6 g/dl

• Dark formed stool on iron

• Intermittent mild iron-deficiency anemia for 2 yr

• 3 mo transfusion-dependent anemia• Hg 4.7 g/dl, 5.7 g/dl, 7.6 g/dl

• Dark formed stool on ironDark formed stool on iron• EGD, push enteroscopy,

colonoscopy, SBFT normal

Dark formed stool on iron• EGD, push enteroscopy,

colonoscopy, SBFT normal

What next?

ACG Regional Postgraduate Course - Los Angeles, CA Copyright 2013 American College of Gastroenterology

1


Obscure Gastrointestinal Bleeding (OGIB)Definition

Obscure Gastrointestinal Bleeding (OGIB)Definition

• Obscure bleeding - bleeding of unknown origin that persists or recurs

• Obscure overt (visible blood)

• Obscure occult (positive FOBT or IDA)

• Obscure bleeding - bleeding of unknown origin that persists or recurs

• Obscure overt (visible blood)

• Obscure occult (positive FOBT or IDA)Obscure occult (positive FOBT or IDA)

• Normal upper and lower endoscopy

Obscure occult (positive FOBT or IDA)

• Normal upper and lower endoscopy

Historical Challenges Related to the Evaluation of “Obscure GI Bleeding”Historical Challenges Related to the Evaluation of “Obscure GI Bleeding”

• High miss rate for lesions on initial upper and• High miss rate for lesions on initial upper and• High miss rate for lesions on initial upper and lower endoscopy

• The need for invasive intra-operative enteroscopy and exploratory laparotomy to adequately examine the small bowel

• Limited capacity of older diagnostic modalities to

• High miss rate for lesions on initial upper and lower endoscopy

• The need for invasive intra-operative enteroscopy and exploratory laparotomy to adequately examine the small bowel

• Limited capacity of older diagnostic modalities to• Limited capacity of older diagnostic modalities to adequately examine the small bowel

• Finding a lesion in the small bowel doesn’t always mean that is the source of the problem

• Limited capacity of older diagnostic modalities to adequately examine the small bowel

• Finding a lesion in the small bowel doesn’t always mean that is the source of the problem


2


The Challenge…..Is this the cause of bleeding?

The Challenge…..Is this the cause of bleeding?

Pasha et al: Clin Gastro Hep 2008;6:671Ragu et al: Gastro 2007;133;1697Gerson: GIE 2008;68:920

Pasha et al: Clin Gastro Hep 2008;6:671Ragu et al: Gastro 2007;133;1697Gerson: GIE 2008;68:920

Uncertainty whether angiodysplasia detection and ablation affect long-term outcome because most angiodysplasia not actively bleeding when detected

Bleeding source found in up to 80%, but rebleeding occurs in as many as 30%

Small Intestine (SI) BleedingSmall Intestine (SI) Bleeding

Dieulafoy’s lesion


3


Diagnostic Approach in Patients with “Obscure GI Bleeding”

Diagnostic Approach in Patients with “Obscure GI Bleeding”

• Document objective evidence of gastrointestinal bleeding

• Exclude hematologic causes for anemia• Exclude malabsorption

• Sufficiently rule out an upper and lower

• Document objective evidence of gastrointestinal bleeding

• Exclude hematologic causes for anemia• Exclude malabsorption

• Sufficiently rule out an upper and lower y ppgastrointestinal tract bleeding source with second-look endoscopy as indicated

• Then proceed with a small bowel evaluation

y ppgastrointestinal tract bleeding source with second-look endoscopy as indicated

• Then proceed with a small bowel evaluation

Etiology of Obscure GI BleedingEtiology of Obscure GI Bleeding

Vascular

Angiodysplasia

Vascular

Angiodysplasia

Inflammatory

Inflammatory bowel

Inflammatory

Inflammatory bowel

Neoplastic

Carcinoid

Neoplastic

CarcinoidAngiodysplasia

Hemangioma

Dieulafoy lesion

Portal hypertensive enteropathy

Varices

Angiodysplasia

Hemangioma

Dieulafoy lesion


Varices

Inflammatory bowel disease

NSAID enteropathy

Celiac disease

Autoimmune enteropathy


NSAID enteropathy

Celiac disease


Carcinoid

GIST

Adenocarcinoma

Lymphoma

Metastases

Carcinoid

GIST

Adenocarcinoma

Lymphoma

Metastases

Obscure Gastrointestinal BleedingNot Obscure Anymore

Obscure Gastrointestinal BleedingNot Obscure AnymoreTruly Obscure Etiologies

• Hemobilia • Hemosuccus pancreaticus • Vasculitis

Truly Obscure Etiologies• Hemobilia • Hemosuccus pancreaticus • Vasculitis

Radiation enteritisRadiation enteritis


4


Vascular

Angiodysplasia

Vascular

Angiodysplasia

Inflammatory

Inflammatory bowel

Inflammatory

Inflammatory bowel

Neoplastic

Carcinoid

Neoplastic

Carcinoid

Etiology of Suspected SI BleedingEtiology of Suspected SI Bleeding

Angiodysplasia

Hemangioma

Dieulafoy lesion


Varices

Angiodysplasia

Hemangioma

Dieulafoy lesion


Varices


NSAID enteropathy

Celiac disease



NSAID enteropathy

Celiac disease


Carcinoid

GIST

Adenocarcinoma

Lymphoma

Metastases

Carcinoid

GIST

Adenocarcinoma

Lymphoma

Metastases

Obscure Gastrointestinal BleedingNot Obscure Anymore

Obscure Gastrointestinal BleedingNot Obscure AnymoreTruly Obscure Etiologies

• Hemobilia • Hemosuccus pancreaticus • Vasculitis

Truly Obscure Etiologies• Hemobilia • Hemosuccus pancreaticus • Vasculitis

Radiation enteritisRadiation enteritis

Obscure GI BleedingObscure GI Bleeding

Management of Suspected SI BleedingManagement of Suspected SI Bleeding


Repeat EGD and colonoscopyRepeat EGD and colonoscopy

Push enteroscopyll b l t l i


AngiogramIntraoperative Endoscopy


small bowel x-ray or enteroclysissmall bowel x-ray or enteroclysis

Zuckerman et al: AGA position statement and review, Gastroenterology 2000; 118;197, 201Zuckerman et al: AGA position statement and review, Gastroenterology 2000; 118;197, 201


5



Management of Suspected SI BleedingManagement of Suspected SI Bleeding


Repeat EGD and colonoscopyRepeat EGD and colonoscopy





small bowel x-ray or enteroclysissmall bowel x-ray or enteroclysis

Zuckerman et al: AGA position statement and review, Gastroenterology 2000; 118;197, 201Zuckerman et al: AGA position statement and review, Gastroenterology 2000; 118;197, 201

Middle GI Tract BleedingMiddle GI Tract Bleeding

TodayToday

Upper GIUpper GI Upper GIUpper GI

Middle GIMiddle GI

Ell et al: Endoscopy 2006;38:73; Raju et al: Gastroenterology 2007;133:1697Ell et al: Endoscopy 2006;38:73; Raju et al: Gastroenterology 2007;133:1697

Lower GILower GI Lower GILower GI


6


Our Case: Suspected SI Bleeding49 yo female with transfusion dependent

recurrent IDA

Our Case: Suspected SI Bleeding49 yo female with transfusion dependent

recurrent IDA

• Single bleeding nodule

• 30% of small bowel transit

• Single bleeding nodule

• 30% of small bowel transitWhat Next?


Antegrade Deep Enteroscopy

• 200cm beyond pylorus

• Mid to distal jejunum

• Bleeding nodule: hemangioma?

Antegrade Deep Enteroscopy

• 200cm beyond pylorus

• Mid to distal jejunum

• Bleeding nodule: hemangioma?

• APC hemostasis• APC hemostasis


7


Capsule EndoscopyCapsule Endoscopy

Hartmann D et al: Endoscopy 39:1041-1045, 2007Cave D et al: GI Endoscopy 68:487-494, 2008Hartmann D et al: Endoscopy 39:1041-1045, 2007Cave D et al: GI Endoscopy 68:487-494, 2008

Yield of CE Compared to Other Modalities

Yield of CE Compared to Other Modalities

• Range: 45-83%• Range: 45-83%

• Entire small bowel seen in 80-90%

• CE had an incremental yield of 30% and 36% compared to Push Enteroscopy and SBFT, respectively

• Main utility of CE lies in its high positive predictive value (94-97%) and its high negative

• Entire small bowel seen in 80-90%

• CE had an incremental yield of 30% and 36% compared to Push Enteroscopy and SBFT, respectively

• Main utility of CE lies in its high positive predictive value (94-97%) and its high negativepredictive value (94-97%) and its high negative predictive value (83-100%)

• It can identify a bleeding lesion and help direct further therapeutic intervention and/or surgery

predictive value (94-97%) and its high negative predictive value (83-100%)

• It can identify a bleeding lesion and help direct further therapeutic intervention and/or surgery

Triester SL et al: Am J Gastro 2005;100:2407-18Pennazio M et al: Gastro 2004;126643-53Delvaux M et al: Endoscopy 2004;36:1067-73

Triester SL et al: Am J Gastro 2005;100:2407-18Pennazio M et al: Gastro 2004;126643-53Delvaux M et al: Endoscopy 2004;36:1067-73


8


“Deep Enteroscopy”Tube or Balloon Assisted Enteroscopy

“Deep Enteroscopy”Tube or Balloon Assisted Enteroscopy

Double-Balloon Enteroscopy (DBE)

Double-Balloon Enteroscopy (DBE)

Single-Balloon Enteroscopy (SBE)

Single-Balloon Enteroscopy (SBE)

Spiral Overtube Enteroscopy

Spiral Overtube Enteroscopy

Forcep channel allows biopsy and therapyForcep channel allows biopsy and therapy

Deep EnteroscopyDeep Enteroscopy

• Overall diagnostic yield: ~ 60% ( 41%-80%)• Overall diagnostic yield: ~ 60% ( 41%-80%)

• Channel allows therapeutic interventions

• Total enteroscopy is possible using both routes in ~ 50-70% of cases

• More invasive and often requires anesthesia with MAC or general endotracheal

• Channel allows therapeutic interventions

• Total enteroscopy is possible using both routes in ~ 50-70% of cases

• More invasive and often requires anesthesia with MAC or general endotracheal

• Resource utilization is high with procedure duration >60min and need for assistants, anesthesia, fluoroscopy

• Complications low at 1-3% but do occur

• Resource utilization is high with procedure duration >60min and need for assistants, anesthesia, fluoroscopy

• Complications low at 1-3% but do occur

Gerson: Clin Gastr Hep 2009;7:828Ragu et al: Gastro 2007;133;1697Gerson: Clin Gastr Hep 2009;7:828Ragu et al: Gastro 2007;133;1697


9


Comparing Deep Enteroscopy Methods

Comparing Deep Enteroscopy Methods

• All f l t h i• All f l t h i• All are useful techniques• Similar yield, safety, learning curve• Spiral may allow faster intubation

• Overtubes and balloons• DBE has latex (allergy); others don’t

O t b ti i il t

• All are useful techniques• Similar yield, safety, learning curve• Spiral may allow faster intubation

• Overtubes and balloons• DBE has latex (allergy); others don’t

O t b ti i il t• Overtubes: one-time use, similar cost

• Altered anatomy (Billroth, gastric bypass)• All can reach bypassed stomach• All allow successful ERCP

• Overtubes: one-time use, similar cost

• Altered anatomy (Billroth, gastric bypass)• All can reach bypassed stomach• All allow successful ERCP

• No difference in overall yield between CE and DBE• No difference in overall yield between CE and DBE

Meta-Analysis of CE vs DBE8 Studies

Meta-Analysis of CE vs DBE8 Studies

No difference in overall yield between CE and DBE (OR 1.21 [95%CI:0.64-2.29])

• However, CE had a higher yield compared to DBE using a single approach (OR 1.61 [95%CI:1.07-2.43])

• But CE had a significantly lower yield compared to DBE using a combined approach (OR 0.12 [95%CI:0 03-0 52])

No difference in overall yield between CE and DBE (OR 1.21 [95%CI:0.64-2.29])

• However, CE had a higher yield compared to DBE using a single approach (OR 1.61 [95%CI:1.07-2.43])

• But CE had a significantly lower yield compared to DBE using a combined approach (OR 0.12 [95%CI:0 03-0 52])[95%CI:0.03-0.52])[95%CI:0.03-0.52])

Chen X et al: World J Gastro 2007;13:4372-8Chen X et al: World J Gastro 2007;13:4372-8

This reinforces the importance of total enteroscopy with DBEin patients with a high clinical suspicion for a SI lesion

This reinforces the importance of total enteroscopy with DBEin patients with a high clinical suspicion for a SI lesion


10


Case Study Case Study

35 yr old man

• A t GI h h

35 yr old man

• A t GI h h• Acute GI hemorrhage• Maroon stools, 6 units transfusion

• Negative EGD, push enteroscopy, colonoscopy, SBFT, CT, Meckel’s scan

Capsule endoscopy

• Blood in mid small intestine

• Acute GI hemorrhage• Maroon stools, 6 units transfusion

• Negative EGD, push enteroscopy, colonoscopy, SBFT, CT, Meckel’s scan

Capsule endoscopy

• Blood in mid small intestine• Blood in mid small intestine, source not seen

• Nodular mucosa: unsure if normal lymphoid tissue (vs lesion)

• Blood in mid small intestine, source not seen

• Nodular mucosa: unsure if normal lymphoid tissue (vs lesion)

Antegrade DBE performed and negative

Lower DBE: 100 cm proximal to ileocecal valveLower DBE: 100 cm proximal to ileocecal valve


Meckel’s Diverticulum with UlcerMeckel’s Diverticulum with Ulcer


11


Case StudyMeckel’s Diverticulum with Ulcer

Case StudyMeckel’s Diverticulum with Ulcer

View inside diverticulum; View inside diverticulum; light, raised mucosa was light, raised mucosa was gastricgastric--type mucosa on type mucosa on

biopsybiopsy

Opening of diverticulum Opening of diverticulum with healing ulcerwith healing ulcer

Newer Radiologic ProceduresNewer Radiologic Procedures

Cross-sectional imaging (CTE, CTA, MRE)Cross-sectional imaging (CTE, CTA, MRE)

• May identify SI angiodysplasia, tumors, inflammation

• Diagnostic yield 10-40% (vs 50-80% CE)

• Consider before capsule if concern for obstruction

• May identify SI angiodysplasia, tumors, inflammation

• Diagnostic yield 10-40% (vs 50-80% CE)

• Consider before capsule if concern for obstruction

Pasha et al: Gasto Hep 2009;12:839; Triester: AJG 2005;100:2407Pasha et al: Clin Gastro Hep 2008;6:671; Ragu et al: Gastro 2007;133;1697Gerson: GIE 2008;68:920

Pasha et al: Gasto Hep 2009;12:839; Triester: AJG 2005;100:2407Pasha et al: Clin Gastro Hep 2008;6:671; Ragu et al: Gastro 2007;133;1697Gerson: GIE 2008;68:920

• Consider if ongoing bleeding despite negative capsule or deep enteroscopy, especially if IBD or tumor suspected

• Consider if ongoing bleeding despite negative capsule or deep enteroscopy, especially if IBD or tumor suspected


12


CE Compared to Angiography forAcute Overt Obscure GI BleedingCE Compared to Angiography forAcute Overt Obscure GI Bleeding

• 60 patients with melena or hematochezia and nondiagnostic upper and lower endoscopy

• Randomized to CE vs Angiography and then folllowed for up to 5 years

• Results:• Diagnostic yield CE vs Angio:

• 60 patients with melena or hematochezia and nondiagnostic upper and lower endoscopy

• Randomized to CE vs Angiography and then folllowed for up to 5 years

• Results:• Diagnostic yield CE vs Angio:Diagnostic yield CE vs Angio:

• 53.3% vs 20.0%, p=0.016• Rebleeding risk CE vs Angio:

• 33.3% vs 16.7%, p=0.10• Long-term outcomes no different

Diagnostic yield CE vs Angio: • 53.3% vs 20.0%, p=0.016

• Rebleeding risk CE vs Angio: • 33.3% vs 16.7%, p=0.10

• Long-term outcomes no different

Leung WK et al. AJG 2012;107:1370-1376Leung WK et al. AJG 2012;107:1370-1376

CE as a Screening Tool Prior to Deep Enteroscopy

CE as a Screening Tool Prior to Deep Enteroscopy

• CE transit times are useful: • CE transit times are useful: • Antegrade approach for lesions within the

proximal 75% based on transit time• Retrograde for more distal lesions

• Increases both the diagnostic (73-93%) and therapeutic (57-73%) yield

• Antegrade approach for lesions within the proximal 75% based on transit time

• Retrograde for more distal lesions

• Increases both the diagnostic (73-93%) and therapeutic (57-73%) yield

Gay G et al: Endoscopy 2006;38:49-58Kaffes Aj et al: GIE 2007;66:304-9Hendel JW et al: Scan J Gastro 2008;43:363-7

Gay G et al: Endoscopy 2006;38:49-58Kaffes Aj et al: GIE 2007;66:304-9Hendel JW et al: Scan J Gastro 2008;43:363-7

• A negative CE allows for the avoidance of Deep Enteroscopy in patients with a low pre-test probability for SI findings

• A negative CE allows for the avoidance of Deep Enteroscopy in patients with a low pre-test probability for SI findings


13


CE Before Deep EnteroscopyCE Before Deep Enteroscopy

62 yo male presented with a hemoglobin of 2: colonoscopy negative and upper endoscopy showed

62 yo male presented with a hemoglobin of 2: colonoscopy negative and upper endoscopy showedcolonoscopy negative and upper endoscopy showed

angioectasia in the stomachcolonoscopy negative and upper endoscopy showed

angioectasia in the stomach

CE-Guided Deep EnteroscopyMay Not Always Be ApplicableCE-Guided Deep EnteroscopyMay Not Always Be Applicable

• CE has been found to have a false negative rate of 11% for all SI findings and 19% for neoplasms

• There are reports of neoplasms missed on CE and diagnosed on Deep Enteroscopy

• Th f i ti t ith ti CE b t

• CE has been found to have a false negative rate of 11% for all SI findings and 19% for neoplasms

• There are reports of neoplasms missed on CE and diagnosed on Deep Enteroscopy

• Th f i ti t ith ti CE b t• Therefore, in patients with a negative CE but a high clinical suspicion, CTE and/or total enteroscopy should be pursued

• Therefore, in patients with a negative CE but a high clinical suspicion, CTE and/or total enteroscopy should be pursued

Kamalaporn P et al: Can J Gastro 2008;22:491-5Jones BH et al: Am J Gastro 2005;100:1058-64Ross A et al: Dig Dis Sci 2008;53:2140-3Postgate A et al: GIE 2008;68:1209-14Pasha SF et al: Nat Clin Pract GastroHep 2008;5:490-1

Kamalaporn P et al: Can J Gastro 2008;22:491-5Jones BH et al: Am J Gastro 2005;100:1058-64Ross A et al: Dig Dis Sci 2008;53:2140-3Postgate A et al: GIE 2008;68:1209-14Pasha SF et al: Nat Clin Pract GastroHep 2008;5:490-1


14


Surgery for Suspected SI BleedingSurgery for Suspected SI Bleeding

• In most cases, can be avoided except for• In most cases, can be avoided except forIn most cases, can be avoided except for tumor resection

• Indicated for patients who continue to bleed and have had negative endoscopic and radiologic workups, and are operative candidates.

In most cases, can be avoided except for tumor resection

• Indicated for patients who continue to bleed and have had negative endoscopic and radiologic workups, and are operative candidates.

• Laparoscopy combined with deep enteroscopy may be helpful in a subset of patients

• Laparoscopy combined with deep enteroscopy may be helpful in a subset of patients

Zuckerman GR et al: Gastro 118:201-221, 2000; Ress AM et al: Am J Surg 163:94-98, 1992; Szold A et al: Am J Surg 163:90-92, 1992Zuckerman GR et al: Gastro 118:201-221, 2000; Ress AM et al: Am J Surg 163:94-98, 1992; Szold A et al: Am J Surg 163:90-92, 1992

Reasonable Approach to SI Bleeding

Reasonable Approach to SI Bleeding

• Individualize based on clinical presentation

• Intermittent overt/occult CE

• Acute ongoing overt BAE

• Obstructive symptoms CTE/MRE

• Individualize based on clinical presentation

• Intermittent overt/occult CE

• Acute ongoing overt BAE

• Obstructive symptoms CTE/MRE• Obstructive symptoms CTE/MRE

• Controlled prospective clinical studies are needed to substantiate these recommendations

• Obstructive symptoms CTE/MRE

• Controlled prospective clinical studies are needed to substantiate these recommendations

Das A, Leighton J: Nat Clin Pract Gastro Hep 4(3):120Das A, Leighton J: Nat Clin Pract Gastro Hep 4(3):120--1, Mar 2007 1, Mar 2007


15



• 73 yo female with end stage liver disease presents with hematochezia. History of esophageal varices without stigmata of bleeding.

• Two EGDs, two colonoscopies, nuclear RBC scan negative

• 73 yo female with end stage liver disease presents with hematochezia. History of esophageal varices without stigmata of bleeding.

• Two EGDs, two colonoscopies, nuclear RBC scan negativeRBC scan negative.

• At Mayo, SB enteroscopy negative and bleeding continued.

• Retrograde BAE performed….

RBC scan negative.

• At Mayo, SB enteroscopy negative and bleeding continued.

• Retrograde BAE performed….

Retrograde BAE 150cm Proximal to IC Valve

Retrograde BAE 150cm Proximal to IC Valve

Jejunal Varix


16


What To Do In Clinical PracticeWhat To Do In Clinical Practice

Bringing it together

Integrating Capsule and Deep

Bringing it together

Integrating Capsule and DeepIntegrating Capsule and Deep Enteroscopy in suspected SI bleeding

Integrating Capsule and Deep Enteroscopy in suspected SI bleeding

Perform Capsule Endoscopy after Negative EGD and Colonoscopy (and perhaps second look endoscopy)

Review of Capsule EndoscopyAre findings equivocal and clinical suspicion low?

Consider repeat CE vs Cross-Sectional Imaging vs Observation


17


Perform Capsule Endoscopy after Negative EGD and Colonoscopy (and perhaps second look endoscopy)

Review of Capsule EndoscopyDefinite submucosal tumor with bleeding

Should patient go directly to surgery?If not, then Deep Enteroscopy should be planned

If Surgery Not Planned, Review of Capsule Endoscopy

Estimate Location to Plan Deep Enteroscopy Approach

If Surgery Not Planned, Review of Capsule Endoscopy

Estimate Location to Plan Deep Enteroscopy Approach

0% - 75%Start with Oral Approach0% - 75%Start with Oral Approach

0% Small Bowel Transit 0% Small Bowel Transit

75% - 100%Start with Anal Approach 75% - 100%Start with Anal Approach

Start with Oral Approach Start with Oral Approach


18


Positive Capsule

Approach to Possible SI LesionApproach to Possible SI Lesion

Suggests Vascular Suggests Tumor or

D E t if

Suggests Vascular Lesion

Treat Those in Reach with Push Enteroscopy

even if not bleeding

Suggests Tumor or Inflammation

Cross-Sectional

Consider Push Enteroscopy or

colonoscopy if in reach

Negative Capsule

If Serious Problem or

Mild Anemia or Low Suspicion – Observe

with Iron Therapy

Deep Enteroscopy if Symptoms Persist

For Mild Anemia, few angiodysplasia, observe with iron therapy, stop antiplatelet therapy if

possible

Otherwise proceed with Deep Enteroscopy if

findings might prevent surgery

Cross Sectional Imaging is considered

complimentary and often very helpful

If Serious Problem or Suspicion High, then proceed with Deep Enteroscopy and/or

Cross sectional Imaging

Suspected SI BleedingImportant Points to Remember

Suspected SI BleedingImportant Points to Remember

U i CE d D E t di tiU i CE d D E t di ti• Using CE and Deep Enteroscopy, diagnostic yield is 40-80%

• Overlooked upper or lower GI source common; consider second look endoscopy

• Capsule Endoscopy is next best test - Yield higher if done soon after overt bleeding

• Using CE and Deep Enteroscopy, diagnostic yield is 40-80%

• Overlooked upper or lower GI source common; consider second look endoscopy

• Capsule Endoscopy is next best test - Yield higher if done soon after overt bleeding

• Deep Enteroscopy and cross-sectional imaging are complimentary for detecting bleeding, tumors or inflammation

• Evaluate patient as close to bleeding episode as possible

• Deep Enteroscopy and cross-sectional imaging are complimentary for detecting bleeding, tumors or inflammation

• Evaluate patient as close to bleeding episode as possible


19

Documents

Occult and Overt Obscure Gastrointestinal Bleedings3.gi.org/wp-content/uploads/2013/01/13ACG_Western_Regional_0008.pdfJonathan A. Leighton, MD, FACG Occult and Overt Obscure Gastrointestinal