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Finding Sources of Obscure Lower GI Bleeding Dr.P.Fallah Abed

Causes of Hematochezia COLONIC BLEEDING (95%) SMALL BOWEL BLEEDING (5%) Diverticular disease 30-40 Angiodysplasias Ischemia 5-10 Erosions or ulcers (K, NSAIDs) Anorectal disease 5-15 Crohn's disease Neoplasia 5-10 Radiation Infectious colitis 3-8 Meckel's diverticulum Postpolypectomy 3-7 Neoplasia IBD 3-4 Aortoenteric fistula Angiodysplasia 3 Radiation colitis/proctitis1-3 Other 1-5 Unknown 10-25

Causes of Hematochezia Diverticulosis Bleeding occurs in only 3-5% Left-sided source more common when diagnosed by colonoscopy Right-sided source more common when diagnosed by angiography Angiodysplasia Most common in cecum and ascending colon When in the small bowel, presents as iron deficiency anemia and rarely as hematochezia

Causes of Hematochezia Hemorrhoids Ischemic colitis Neoplasms NSAID-induced injury in terminal ileum and proximal colon IBD 10-15% of hematochezia caused by upper GI bleed

History NSAIDs & ASA strongly associated with lower GI bleeding just as with upper GI bleeding Stercoral ulcers caused by severe constipation Recent polypectomy Hypovolemia preceding bleed suggests ischemic colitis

Going Hunting

Going Hunting Bleeding source not found in 25% KUB to look for perforation or obstruction NG aspirate Colonoscopy No agreement over whether prep is needed because of increased risk of perforation with unpreped colon Radionuclide imaging Can detect slow bleeds at 0.1-0.5ml/min More sensitive but less specific than angiography

Going Hunting Angiography Small bowel evaluation Requires bleeding of at least 1ml/min Very specific but not very sensitive May cause bowel infarction, renal failure Small bowel evaluation Push enteroscopy can allow evaluation of the first 60cm of jejunum Video capsule to evaluate the remainder Meckel scan

Strategy with Lower GI bleeding If persistently unstable and major bleeding, proceed to surgery If colonic source, subtotal colectomy with ileorectal anastomosis If small bowel source, resection If no identified source, intraoperative enteroscopy followed by resection If stable and major bleeding Tagged red cell scan If positive, follow with angiography If negative, capsule endoscopy, enteroclysis, enteroscopy

Strategy with Lower GI bleeding If stable and minor bleeding Colonoscopy If negative, capsule endoscopy, enteroclysis, enteroscopy If all studies negative Colonoscopy if rebleeding

Don’t Forget In addition to basic labs (CBC, Chemistries, Coags), obtaining type and cross Two large bore peripheral IV’s Rectal exam as up to 40% of rectal cancers can be detected this way

Case Presentation A 41 year old AA male was admitted to the hospital after an acute episode of bleeding per rectum Admission hemoglobin = 6.2 g/dl The patient had a recent stay at a local private hospital for investigation of bleeding per rectum within the last 3 months and upper GI endoscopy, colonoscopy, small bowel contrast study were normal Following his last hospitalization, he was discharged on iron supplements

Case Presentation The gastrointestinal ROS: otherwise negative. He had had no abdominal pain, weight loss, or change in bowel function. Strong family history of PVD/MI PMH: CHF EF ~ 30% on last echo HTN DM PVD RA/GOUT Hx. AAA

Case presentation Meds: Metoprolol ASA Plavix Insulin Allopurinol Methotrexate 10 mg weekly Celebrex

Case presentation Routine laboratory: all normal except for initial hemoglobin level of 6.2 Coagulation, liver chemistries, blood urea nitrogen, and creatinine levels were normal Nasogastric aspirate produced bile-stained gastric contents but no blood Results of proctoscopy performed in the emergency department showed red blood but no source of bleeding The patient was admitted to the surgical intensive care unit (ICU)

Case presentation What is our DDX? What would you do for this patient?

Case presentation AVM Camerons lesion Dieulafoy Gastric or duodenal varices Neoplasm Aortoenteric fistula Hemobilia Hemosuccus pancreaticus Meckel’s IBD Celiac sprue NSAID enteropathy

Obscure GI BleedingDefinition Bleeding of unknown origin that persists or recurs after negative colonoscopy and negative upper endoscopy Recurrent or persistent bleeding FOBT positive IDA Visible bleeding Melena, hematemesis, hematochezia, coffee grounds

Obscure GI BleedingFrequency 10% - 20% of GI bleeding without identifiable etiology 5% GI bleeding recurrent without identifiable etiology Majority have small bowel source

Obscure GI BleedingSmall BowelCauses Grouped by Age Patient’s < 25 years old Meckel’s Diverticula Patient’s between 30 – 50 years old Tumors Patient’s > 50 years old Vascular ectasias

Small Bowel BleedingCauses By Etiology Vascular Lesions Neoplasms Inflammatory Lesions Other

Small Bowel BleedingVascular Lesions Angioectasias Telangiectasias Hereditary hemorrhagic telangiectasia Osler-Weber-Rendu Syndrome CREST Syndrome Calcinosis, Reynaud’s, Esophageal dysmotility Sclerodactyl, Telangiectasia Other Dieulafoy’s lesion Aortoenteric fistula Small bowel varices

Small Bowel BleedingAngiodysplasia Dilated tortuous blood vessels with thin walls lined by endothelium with little or no smooth muscle Most common small bowel bleeding in the elderly (> 50 years old) May be associated with aging associated degeneration of vascular integrity

Small Bowel BleedingTumors Second most common cause of bleeding One out of ten patients with obscure bleeding will have a small bowel tumor Most common cause in persons age 30 – 50 years of age Malignant and Benign Adenocarcinoma, carcinoid, lymphoma, leiomyosarcoma, Leiomyoma, polyps (Peutz-Jeghers, familial polyposis), GIST Metastatic Melanoma, breast, renal-cell, kaposi’s sarcoma, colon, ovarian

Causes of Small Bowel BleedingDiverticula Small bowel diverticula At the site of perforating blood vessels Meckel’s diverticulum Remnant of vitelline duct in distal ileum Most common cause of small bowel bleeding in patients under the age of 25 years old Ectopic gastric tissue causes ulceration Intussusception Inverted Meckel’s, angioectasias, submucosal tumors

Small Bowel BleedingInflammatory Lesions Crohn’s Disease Isolated ulcers Idiopathic ulcers Nonsteroidal antiinflammatory drugs Ischemic Other Vasculitis, Zollinger-Ellison syndrome, Celiac disease

Small Bowel BleedingRare Causes Hemobilia Neoplasm, vascular aneurysm, liver abscess, trauma, liver biopsy Hemosuccus pancreaticus Pancreatic pseudocysts, pancreatitis, neoplasms Erosion into a vessel with communication with PD Infections Cytomegalovirus, histoplasmosis, Tb

Small Bowel Bleeding Diagnosis UGI SBFT Enteroclysis Push enteroscopy Double balloon enteroscopy Intraoperative enteroscopy CT scan  ionizing radiation…. CT enteroclysis MRI  no ionizing radiation Video capsule endoscopy

Obscure BleedingSBFT and Enteroclysis SBFT 0-5.6% diagnostic yield Used for exclusion of structural lesion or fistula Enteroclysis Superior to SBFT Double contrast, Tube into proximal small bowel Inject barium, methylcellulose, air Performed with CT and MRI Only 10-21% diagnostic yield Use if capsule endoscopy or enteroscopy unavailable

Obscure GI BleedingAngiography Severe bleeding Bleeding rate of 0.5 mL/min Positive in 27-77% of acute LGI bleeding Positive in 61-72% if, Pt actively bleeding requiring transfusion Hemodynamic compromise TRBC scan shows an immediate blush Administer anticoagulants, vasodilators, clot-lysing agents to precipitate bleeding Increased diagnostic yield from 32 to 65% 17% complication rate including excessive bleeding

bscure BleedingEnteroscopy Pass scope beyond the ligament of Treitz Adult or pediatric colonoscope, SB enteroscope Diagnostic yield : 40-50% Angiodysplasia in 80% Advantage over capsule endoscopy Sample tissue Endoscopic therapy

Obscure GI BleedingExploratory Laparotomy Seldom without intraoperative enteroscopy 65% of 37 pt’s had lesion identified by palpation or transillumination

Wireless Capsule Endoscopy Patient Experience Sensors placed and attached to data recorder Easily ingested, painless procedure Progresses naturally through the GI tract via peristalsis Transmits images to data recorder

PillCam SB Patient Experience Liquid diet from lunch the day before Movie Prep the night before 12 hour fast the night before Capsule ingested in the morning Reglan or erythromycin for inpatients Liquid diet after 2 hours Light meal 4 hours after ingestion Disconnect after 8 hours

Obscure GI BleedingPillCamSB Capsule Endoscopy results led to treatments resolving the bleeding in 86.9% of patients undergoing the procedure while actively bleeding. Pennazio M, Santucci R, Rondonotti E, et al. Gastroenterology 2004; 126: 643-653

Obscure GI BleedingPennazio et al. 2004 Conclusion If done early in the course of the workup, PillCam endoscopy could: Shorten considerably the time to diagnosis Lead to definitive treatment in a relevant proportion of patients Spare a number of alternative investigations with low diagnostic yield Pennazio M, Santucci R, Rondonotti E, et al. Gastroenterology 2004; 126: 643-653

Obscure GI Bleeding PillCam SB

PillCam SB Indications First line diagnostic exam for visualization of small bowel mucosa. Clinical data reviewed 32 independent studies which indicate CE diagnostic yield of 71% vs. 41% diagnostic yield for all other modalitiescombined Established as gold standard for diagnosis of disease of small intestine Now cleared in the US for pediatric populationfrom 10-18 years old Rex, et. Al; WIRELESS CAPSULE ENDOSCOPY DETECTS SMALL BOWEL ULCERS IN PATIENTS WITH NORMAL RESULTS FROM STATE OF THE ART ENTEROCLYSIS The American Journal of Gastroenterology, Vol. 98, No. 6

PillCam SB Contraindications In patients with known or suspected gastrointestinal obstruction, strictures, or fistulas based on the clinical picture or pre-procedure testing and profile. In patients with cardiac pacemakers or other implanted electromedical devices. In patients with swallowing disorders. Leighton JA,, et al, SAFETY OF CAPSULE ENDOSCOPY IN PATIENTS WITH PACEMAKERS, Gastrointest Endosc. 2004 Apr;59(4):567-9. Concludes that capsule endoscopy appears to be safe in patients with cardiac pacemakers and does not appear to be associated with any significant adverse cardiac event. Pacemakers do not interfere with capsule imaging.

PillCam SB Vascular Lesions

PillCam SB

Wireless Capsule Endoscopy Summary Time efficient, patient friendly, sensitive method to visualize the small bowel Disadvantages No therapeutics Unable to control movement Unable to clear bubbles and debris

Double Balloon Enteroscopy First described by Yamamoto in 2001 Allows the diagnosis and treatment of disease along the entire length of the small bowel Entire SB visualized in 86% of patients (Yamamoto) Fujinon enteroscope overtube system 230 cm total length 200-cm working length 140-cm overtube 2.8 mm channel for biopsy and therapeutic intervention

Double Balloon Enteroscopy Also called “push-pull enteroscopy” Advanced antegrade or retrograde Patient Prep Antegrade: NPO 6-8 hrs Retrograde: Colo prep Moderate sedation, propofol, or general anesthesia

Double Balloon EnteroscopyComplications 2/178 procedures (1.1%) by Yamamoto Post procedure fever and abdominal pain Perforation 40/2362 procedures (1.7%) by Mensink 13/1728 diagnostic procedures (0.8%) 27/634 therapeutic procedures (4.3%) 12/364 post polypectomy bleeding (3.3%) 3/253 post APC perforation (1.2%) 2/70 post balloon dilations perforation (2.9%)

Courtesy of Fujinon and Yamamoto H et al

Courtesy of Fujinon and Yamamoto H et al

Double Balloon EnteroscopyContraindications Non-cooperative patient Prior intestinal perforation AAA Excessive deformity of cervical spine

Obscure GI BleedingManagement Resuscitation Iron supplementation, correct coagulopathy and platelet abnormalities, intermittent blood transfusions Endoscopic treatment Angiography Pharmacotherapy Estrogen therapy Octreotide Surgery

Obscure GI BleedingEvaluation Repeat EGD and Colonoscopy (~ 35% yield) If negative Capsule Endoscopy (~ 60–70% yield) Repeat Capsule Endoscopy (~ 35% yield) Double Balloon Enteroscopy (~ 40% yield) Intraoperative Enteroscopy in selected cases GIE 2004;60:5:711-713