1. به نام خدا

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

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

6. 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

7. 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

8. 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

9. Going Hunting

10. 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 ml/min
More sensitive but less specific than angiography

11. 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

12. 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

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

15. 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

18. 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

19. 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

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

22. 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)

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

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

26. 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

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

29. 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

30. Small Bowel BleedingCauses By Etiology
Vascular Lesions
Neoplasms
Inflammatory Lesions
Other

32. 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

33. 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

34. 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

35. 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

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

37. 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

39. 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

40. 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

43. 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

45. 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

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

48. 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

49. 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

51. 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:

52. 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:

53. Obscure GI Bleeding PillCam SB

54. 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 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

55. 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 Apr;59(4): 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.

56. PillCam SB Vascular Lesions

57. PillCam SB

59. 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

60. 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

61. 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

62. 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%)

64. Courtesy of Fujinon and Yamamoto H et al

65. Courtesy of Fujinon and Yamamoto H et al

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

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

69. 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: