1. Obscure GIT Bleeding Dr. Mohamed AlsenbesyBy
Dr. Mohamed Alsenbesy
Assistan Prof. of Internal Medicine

2. GIT Bleeding Definitions & Descriptions
Upper & Lowe GI bleeding:
ligament of Treitz.
Haematemesis & Melena.
Haematochesia: fresh blood per rectum.
Occult GI Bl.
positive fecal occult blood test (FOBT) and/or iron-deficiency anemia (IDA), with no evidence of visible blood loss to the patient or physician.

3. Obscure GI Bl
+ve occult bl. , recurrent Haematochezia or
unexplained Iron def. Anaemia with –ve upper & lower GI Endoscopy.
Acounts for 5% of all GIT bleeding (suryakanth 2006)
Obscure overt or occult.

7. Obscure GI Bleeding Small Intestinal Causes
Angiodysplasia.
Crohn's disease
Small bowel tumors.
Small bowel ulcers and erosions. NSAID
Small bowel diverticulosis/varices.
Lymphangioma.
Radiation enteritis.
Osler-Weber-Rendu syndrome.
Von Willebrand's disease.
Small bowel polyposis syndromes.
Aortoenteric fistula.
Amyloidosis.
Meckel's diverticulum.
Hemobilia.

9. Diagnosis Push enteroscopy . Conventional & CT Angiography.
Small bowel follow-through/enteroclysis
Intraoperative Enteroscopy.
Tagged red blood cell scan.
Capsule endoscopy.
Double Balloon Endoscopy.

10. Video Capsule Endoscopy
New method to evalute obscure bleeding.
FDA approved in 2001.
The system consists of:-
1. Capsule.(11x26mm)
2. Sensory Array.
3. Data Recorder.

13. Capsule Endoscopy
Angiodysplasia
Celiac
Crohn‘s

16. Double Balloon Enteroscopy
Developed by Yamamoto in 2001.
known as „Push – Pull Enteroscopy“.

17. Double Balloon Enteroscopy
Indications
Obscure GIT bleeding.
ERCP after gastric surgery with long afferent limbs

18. Double Balloon Enteroscopy
Advantages
Visualization of the entire small bowel.
Biopsy & intervention.
Disadvantages
Time consuming.

19. Double Balloon Enteroscopy
Normal Intestinal mucosa
Intestinal Polyp

20. Double Balloon (DB) versus Capsule Endoscopy (CE)
Average 72% diagnostic yields.
DB detected 2/3 of CE +ve lesions.
DB detected lesions in 1/3 of patients with –ve CE results.
DB and CE were comparable in detecting ulcers and Angiodysplasias.

21. Double Balloon (DB) versus Capsule Endoscopy (CE)
DB was more effective in detecting mucosal and submucosal polyps.
Average time: CE=44 min.
DB= 94min.

22. Summary 5% of GIT bleeding is obscure.
DB and CE are new promising diagnostic tools.
CE is less invasive but no intervention.
DB allows intervention but time consuming.
Initial workup should be the repeat of Upper&lower Endoscopy.

23. Thank You