CME Apollo Hospitals Bhubaneswar 16 Feb 2014 Obscure GI bleeding R.A.Sastry Krishna Institute of Medical Sciences Past President Indian association of Surgical Gastroenterology

Rhetorics as this have perhaps no role in scientific medicine Rhetorics as this have perhaps no role in scientific medicine. Nevertheless, operative intervention still represents the most definitive intervention and remains the final therapeutic option for many bleeding lesions of the upper GI tract. Of patients who develop UGIB, 3-15% still require a surgical procedure.

Case snippet 1 40 M Recurrent anemia – 2 yrs Lowest Hb: 4 gm% Was given blood transfusion twice UGI endoscopy Colonoscopy Capsule endoscopy CECT-CT angio Normal Normal

Enteroscopy

Case snippet 2 Hemophilia B Factor IX assay Inhibitor to FIX assay Recurrent rectal bleeding Colonooscopic polypectomy Post procedure bleed Argon beam coagulation Clips Suturing under GA Diversion colostomy Factor IX assay Inhibitor to FIX assay Hemophilia B Continued to bleed No other sites of bleed Coagulation profile grossly normal (APTT slight ) 18 units of blood and FFP in various hospitals Anterior resection Bleed recurred

Obscure GI Bleeding Bleeding from GI tract that persists or recurs without an obvious etiology after an initial evaluation using UGIE and colonoscopy and imaging with a small bowel radiograph

Types of OGIB Obscure overt Obscure occult Clinically perceptible Not apparent to patient or physician Presenting by Iron deficiency anemia or Positive fecal occult blood

General characteristics Always recurrent 5% of all GI Bleeds Majority due to lesions in small bowel Remaining Missed lesions on UGIE and colonoscopy

Etiology Vascular lesions Tumors Miscellaneous Angiodysplaia Vascular ectasia GAVE Dieulafoy etc Tumors GIST Carcinoma Carcinoid Miscellaneous Medication-related Infections (TB, Typhoid) Crohn’s Meckel’s Cameron lesion Vasculitis Radiation enteritis Jejunal diverticula Chronic mesenteric ischemia

Obscure gastrointestinal bleeding History and physical, UGIE, Colonoscopy Age Overt or Occult? Hematemesis, hematochezia or Malena? Any Bleeding Diathesis? Use of medications as NSAIDs H/o pancreatitis, liver trauma, PH Co-morbidities as valvular heart disease, vasculitis, Renal failure Radiation history Document objective evidence of OGIB Focus on signs and symp. that are likely to be overlooked Exclude other causes of anemia

Obscure gastrointestinal bleeding History and physical, UGIE, Colonoscopy Does Aspirin or Anticoagulants cause OGIB? Not true Fecal blood content in therapeutically anticoagulated patients is within normal limits Warfarin or Aspirin alone cause positive guaiac- based FOB tests 15 of 16 positive guaiac-based tests in anticoagulated patients had previously undiagnosed lesions 20% of which were malignant

Obscure gastrointestinal bleeding History and physical, UGIE, Colonoscopy Massive overt bleeding Enteroscopy Angiography Consider Surgery Second look endoscopy Definitive management Capsule endoscopy Enteroscopy

Double Balloon Enteroscopy

Small bowel studies in OGIB technique advantages Disadvantages Small‑bowel follow through Safe Radiation, insensitive, no therapy possible Enteroclysis Radiation, poor for mucosal lesions, no therapy possible Scintigraphy Safe active bleeding Localization only, no therapy possible Angiography Often helpful in active bleeding, therapy possible Unable to identify lesion, invasive Computed tomography Radiation, no therapy possible Push enteroscopy Wide experience, therapy possible Limited outcome data Capsule endoscopy Safe, improved sensitivity No therapy, limited outcome data Deep enteroscopy Improved sensitivity, therapy possible Limited experience and availability Surgery Highest potential for therapeutic efficacy Highly invasive

Detection rates for small‑bowel studies Technique occult bleeding with iron-deficiency anemia (%) obscure bleeding (%) Small‑bowel follow through 0–10 <5 Enteroclysis Scintigraphy NA Angiography 5–50 CT scan Push enteroscopy 20–25 30–40 Capsule endoscopy 30–50 50–80 Double‑balloon endoscopy 50–70 Single‑balloon enteroscopy 40–60 Spiral enteroscopy 40–50 Surgery (intraoperative enteroscopy) 70–100

CE or DBE Study Age Design Diagnostic yield: CE (%) Diagnostic yield: DBE (%) [Matsumoto et al. 2005] 48 Prospective 38 46 [Hadithi et al. 2006] 63 80 60 [Nakamura et al. 2006] 59 43 [Ohmiya et al. 2007] NA Retrospective 50 53 [Kaffes et al. 2007] 62 83 75 [Fujimori et al. 2007] 40 [Kamalaporn et al. 2008] 64 [Kameda et al. 2008] 72 66 [Arakawa et al. 2009] 54

Enteroscopy Type 1a Punctate erythema (<1mm) with or without oozing Type 1b Punctate erythema (a few mm) with or without oozing Type 2a Punctate lesions (<1mm) with pulsatile bleeder Type 2b Pulsatile red protrusions without surrounding venous dilatation Type 3 Pulsatile red protrusions with surrounding venous dilatation Type 4 Other lesions not classified into any of the above categories Case 1, a 58-year-old man with obscure GI bleeding (OGIB), represents a type 1a lesion, punctulate erythema ( < 1 mm), with or without oozing. Punctulate erythema with oozing was found at the distal jejunum. This lesion was very small. However, this was verified as the cause of the bleeding. Argon plasma coagulation (APC) was applied to the lesion.

Enteroscopy Type 1a Punctate erythema (<1mm) with or without oozing Type 1b Punctate erythema (a few mm) with or without oozing Type 2a Punctate lesions (<1mm) with pulsatile bleeder Type 2b Pulsatile red protrusions without surrounding venous dilatation Type 3 Pulsatile red protrusions with surrounding venous dilatation Type 4 Other lesions not classified into any of the above categories Case 2, a 68-year-old man with OGIB, represents a type 1b lesion, patchy erythema (a few mm), with or without oozing. APC was applied to a 5-mm erythema located at the proximal jejunum. Bleeding started during the application of APC and was successfully stopped by conscientious application of additional APC after an epinephrine injection.

Enteroscopy Type 1a Punctate erythema (<1mm) with or without oozing Type 1b Punctate erythema (a few mm) with or without oozing Type 2a Punctate lesions (<1mm) with pulsatile bleeder Type 2b Pulsatile red protrusions without surrounding venous dilatation Type 3 Pulsatile red protrusions with surrounding venous dilatation Type 4 Other lesions not classified into any of the above categories Case 3, a 72-year-old woman with OGIB, represents a type 2a lesion, punctulate lesion ( < 1 mm), with pulsatile bleeding. A punctulate lesion with pulsatile bleeding was found at the proximal jejunum. For accurate identification of the bleeding point, observation in water infused through the accessory channel was useful; in the water, the bleeding was clearly observed as a red flame-like shape. Hemostasis was achieved by clip placements.

Enteroscopy Type 1a Punctate erythema (<1mm) with or without oozing Type 1b Punctate erythema (a few mm) with or without oozing Type 2a Punctate lesions (<1mm) with pulsatile bleeder Type 2b Pulsatile red protrusions without surrounding venous dilatation Type 3 Pulsatile red protrusions with surrounding venous dilatation Type 4 Other lesions not classified into any of the above categories Case 4, a 56-year-old man with OGIB, represents a type 2b lesion, pulsatile red protrusion, without surrounding venous dilatation. A reddish protruding lesion with a whitish clot was found at the jejunoileal junction. The pulsatile lesion was about 4 mm in diameter. Pulsatile bleeding started after placing a clip on the lesion. The bleeding was successfully stopped with 4 clips. Complete hemostasis was confirmed by observation under water.

Enteroscopy Type 1a Punctate erythema (<1mm) with or without oozing Type 1b Punctate erythema (a few mm) with or without oozing Type 2a Punctate lesions (<1mm) with pulsatile bleeder Type 2b Pulsatile red protrusions without surrounding venous dilatation Type 3 Pulsatile red protrusions with surrounding venous dilatation Type 4 Other lesions not classified into any of the above categories Case 5, a 71-year-old woman with OGIB, represents a type 3 lesion, pulsatile red protrusion, with surrounding venous dilatation. A reddish pulsatile protrusion, with surrounding venous dilatation, was found at the distal ileum. An EUS revealed the presence of abnormal vessels. A total of 6 clips were placed to collapse the lesion

Enteroscopy Type 1a Punctate erythema (<1mm) with or without oozing Type 1b Punctate erythema (a few mm) with or without oozing Type 2a Punctate lesions (<1mm) with pulsatile bleeder Type 2b Pulsatile red protrusions without surrounding venous dilatation Type 3 Pulsatile red protrusions with surrounding venous dilatation Type 4 Other lesions not classified into any of the above categories Case 6, a 24-year-old man with OGIB, represents a type 4 lesion, other lesions not classified into any of the above categories. A 10-mm submucosal tumor, with ulceration and coagula, was found in the distal jejunum. Tattooing with a submucosal injection of India ink was useful for locating the lesion during surgery. This lesion was pathologically diagnosed as an angiodysplasia after laparoscopically assisted surgery.

Adeno ca on DBE

Obscure gastrointestinal bleeding Definitive management Capsule endoscopy Oral DAE Second look endoscopy Massive overt bleeding Enteroscopy Angiography Consider Surgery Obscure gastrointestinal bleeding History and physical, UGIE, Colonoscopy Definitive Management Conservative treatment Medical treatment Embolisation Endoscopic therapy Consider Surgery +ve -ve Observe + Medical treatment No Ongoing Bleeding? Consider repeat routine scopes Consider repeat CE Consider Enteroscopy Consider Meckel’s scan Consider haematology referral Yes Recurrence? Follow up No -ve +ve

Operative Enteroscopy Intra-op enteroscopy Operative Enteroscopy

Operative Enteroscopy

Operative Enteroscopy

Lower GI Bleed due to Koch’s

Young girl with Angiodysplasia

Obscure G I Bleed due to GIST

Lower GI Bleed - Leiomyoma

Meckles with bleed

Post Whipple’s obscure GI bleed Large lower GI bleed one year after Whipple’s for periampullary Ca UGIE and colonoscopy – normal Bleeding stopped spontaneously Recurred after one month Rpt. UGIE and colonoscopy not informative

Obscure gastrointestinal bleeding Definitive management Capsule endoscopy Oral DAE Second look endoscopy Massive overt bleeding Enteroscopy Angiography Consider Surgery Obscure gastrointestinal bleeding History and physical, UGIE, Colonoscopy Definitive Management Conservative treatment Medical treatment Embolisation Endoscopic therapy Consider Surgery +ve -ve Observe + Medical treatment No Ongoing Bleeding? Consider repeat routine scopes Consider repeat CE Consider Enteroscopy Consider Meckel’s scan Consider haematology referral Yes Recurrence? Follow up No -ve +ve