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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 18  |  Issue : 4  |  Page : 255-259

Obscure gastrointestinal bleeding


Department of Gastroenterology, Institute of Gastrosciences and Liver, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India

Date of Submission06-Nov-2021
Date of Acceptance22-Nov-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Shivaraj Afzalpurkar
Department of Gastroenterology, Apollo Multispecialty Hospital, EM Bypass Road, Kadapara, Kolkata Pin - 700054 West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_129_21

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  Abstract 


The term “obscure gastrointestinal (GI) bleeding” is often replaced by “small bowel bleeding” by some authors. It accounts to 5%–10% of overall GI bleeding. We need to suspect obscure or small bowel bleeding when no source of bleeding is identified during routine standard endoscopy and colonoscopy. Video capsule endoscopy (VCE), balloon enteroscopy, spiral enteroscopy, etc., are some of the advances in small bowel evaluation that have improved the ability to detect the source of bleeding. The common causes in patients with 40 or more years of age are Angioectasia, Dieulafoy's lesions, Nonsteroidal anti-inflammatory drug-induced ulcers, and neoplasm. Black tarry stools with characteristic smell (melena) and/or passing of red blood from rectum (hematochezia) is the most common presentation. Routine performance of second look endoscopy is not always a cost-effective approach. The current available evidence is sufficient to suggest VCE as the first endoscopic investigation in diagnosis of obscure GI bleeding. In routine clinical practice the double balloon enteroscopy, single balloon enteroscopy, and spiral enteroscopy are the three different armamentariums available for evaluating small bowel. Motorized spiral enteroscopy (power spiral) is the new addition to it. Patients in whom the source of bleeding is not identified after appropriate small bowel evaluation should be initially managed conservatively with oral or intravenous iron therapy (strong recommendation). Medical management with iron supplements, somatostatin analogs, or antiangiogenic treatment should be administered to the patients with persistent and recurrent bleeding. The evaluation of small bowel in patients with obscure GI bleeding is a challenging task. There is a huge data on each of the modality involved in investigating small bowel. Systematic review of the topic is need of the hour to help understand the concept of diagnosis and management of obscure GI bleeding.

Keywords: Capsule endoscopy, enteroscopy, obscure, overt, small bowel bleeding


How to cite this article:
Afzalpurkar S, Goenka MK. Obscure gastrointestinal bleeding. Apollo Med 2021;18:255-9

How to cite this URL:
Afzalpurkar S, Goenka MK. Obscure gastrointestinal bleeding. Apollo Med [serial online] 2021 [cited 2022 Nov 28];18:255-9. Available from: https://apollomedicine.org/text.asp?2021/18/4/255/333599




  Introduction Top


  • The term “obscure gastrointestinal (GI) bleeding” is often replaced by “small bowel bleeding” by some authors.[1] It accounts to 5%–10% of overall GI bleeding.[2],[3] We need to suspect obscure or small bowel bleeding when no source of bleeding is identified during routine standard endoscopy and colonoscopy. Video capsule endoscopy (VCE), balloon enteroscopy, spiral enteroscopy, etc., are some of the advances in small bowel evaluation that have improved the ability to detect the source of bleeding.


Definition

  1. Traditional definition-When bleeding source is not identified after performing upper endoscopy, lower endoscopy and small bowel series
  2. Recent definition-When bleeding source is not identified after performing upper endoscopy, lower endoscopy, small bowel evaluation with VCE and/or deep enteroscopy and radiological imaging.[1]



  Etiology Top


The common causes in patients with 40 or more years of age are Angioectasia, Dieulafoy's lesions, Nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers and neoplasm. Inflammatory bowel disease, Dieulafoy's lesions, neoplasia and Meckel's diverticulum are more often causes of bleeding in younger patients.

Other rare causes of obscure bleeding are portal hypertensive enteropathy, small bowel varices, amyloidosis, Osler–Weber–Rendu syndrome, Kaposi's sarcoma with AIDS, blue rubber bleb nevus syndrome, pseudoxanthoma elasticum, Plummer–Vinson syndrome, inherited polyposis syndromes, and Ehlers–Danlos syndrome.


  Diagnosis Top


Black tarry stools with characteristic smell (melena) and/or passing of red blood from rectum (hematochezia) are the most common presentation. Other presentations include abdominal pain, lethargy, easy fatigability, angina, dyspnea on exertion, and syncope. Anatomic and vascular causes of bleeding present with painless passage of large volume of blood. Diarrhea with or without bloodstain and abdominal pain are the usual presentations of inflammatory causes of bleeding. History of preexisting diseases such as bleeding diathesis, chronic liver/kidney disease, coronary artery disease, abdominal surgeries, abdominal aortic aneurysm, bowel stenosis/stricture, and peptic ulcer are important.

Diagnostic modalities

The various diagnostic modalities which help in identifying the bleeding source in obscure GI bleeding are as follows:

  1. Routine investigations
  2. Endoscopic procedures


    • Second look endoscopy (upper GI endoscopy, lower GI endoscopy, push enteroscopy)
    • VCE
    • Device-assisted endoscopy.


      • Single balloon enteroscopy (SBE)
      • Double-balloon enteroscopy (DBE)
      • Spiral enteroscopy (manual and motorized)
      • Intraoperative enteroscopy.


  3. Radiologic procedures


    1. Conventional radiology


      • Barium meal follow-through
      • Enteroclysis.


    2. Computed tomography (CT) enterography (with angiography)
    3. Conventional Angiography (CA)
    4. Nuclear scans.


Routine investigations

Blood tests

  • Routine blood investigations such as complete hemogram, liver biochemistry, coagulation profile, and kidney function tests should be ordered as soon as the patient reaches the hospital
  • Blood for crossmatching of packed red cells should be on top priority
  • It takes 24–72 h to equilibrate vascular space with extracellular fluid. Hence, hematocrit values may not reflect blood loss if obtained immediately after the onset of bleeding
  • Thrombocytopenia and/or elevated prothrombin time contributes to the severity of GI bleeding and also denotes the possibility of underlying coagulation disorder or liver disease
  • Mean corpuscular volume-value <0 fl denotes iron deficiency anaemia and/or chronic blood loss. Higher value (>100 fl) is typically seen in folate or Vit B12 deficiency and chronic liver disease.


Endoscopy procedures

There is a contradicting data related to the second look endoscopy before going for capsule endoscopy. Routine performance of second-look endoscopy is not always a cost-effective approach. Selby reported that in 92 patients of obscure GI bleed there is no difference in localization of lesions in VCE whether the patient has undergone only one or multiple preceding endoscopic procedures.[4] In another study by Gilbert et al., the likely cause of bleeding was detected on repeat upper GI endoscopy in only 4% (2/50) but no additional source was identified on repeat colonoscopy.[5] In a retrospective analysis of VCE (after preceding normal upper and lower Gu endoscopy) by Vlachogiannakos et al.[6] it was found that 3.5% patients had bleeding source in the stomach or the cecum Performing second look endoscopy routinely prior to VCE is not recommended by the European Society of GI Endoscopy (ESGE). However, it recommends to decide on a case-by-case basis in regards to performance of second look endoscopy in such patients (strong recommendation and low-quality evidence).[7] Common lesions which are detected on second look endoscopy include Cameron's ulcers, Dieulafoy's lesion, small gastric ulcers, hemosuccus pancreaticus, and hemobilia.

Video capsule endoscopy

The current available evidence is sufficient to suggest VCE as the first endoscopic investigation in diagnosis of obscure GI bleeding. In obscure GI bleeding, VCE is recommended as first-line investigation before consideration of device-assisted enteroscopy (strong recommendation, moderate-quality evidence) and small bowel radiographic studies or mesenteric angiography (strong recommendation, high-quality evidence). ESGE recommends VCE as the first-line investigation in patients of obscure GI bleeding (strong recommendation, moderate quality of evidence).[7] The pooled diagnostic yield of VCE according to a meta-analysis is 61.7% (95% confidence interval [CI] 47.3–76.1).[8] Liao et al. reported the detection rate of VCE in obscure GI bleeding as 60.5% (95% CI 57.2–63.9).[9] Similar diagnostic yields have been reported by previously published meta-analyses.[10],[11],[12] VCE has been considered to be better diagnostic modality than small bowel barium studies due to its comparatively high diagnostic yield (30% vs. 7%).[13] Timing of VCE-Several retrospective studies have reported that the diagnostic yield of VCE in obscure GI bleeding increases if it is done as soon as possible after bleeding episode.[14],[15] In India, Goenka e al.[16] reported that in patients with obscure GI bleeding who underwent VCE, 74% (284/385) had some lesion identified. VCE had the greatest yield if it is done within 48–72 h of suspected overt small bowel bleeding (87% vs. 68%). In order to maximize the diagnostic yield, ESGE recommends performing VCE ideally within 14 days of bleeding episode (strong recommendation, moderate quality evidence).[7] Katsinelos et al.[17] and Bresci et al.[18] have reported a diagnostic yield of 87.5% and 92% in patients who underwent VCE within 10 and 15 days of bleeding episode, respectively. The diagnostic yield was only 1/9 (11.1%) and 34% for those who had VCE after 10 and 15 days of bleeding episode respectively. VCE has an excellent safety profile in obscure GI bleeding with a retention rate of 1.2% and overall pooled retention rate of 1.4%.[9]

Indian studies on capsule endoscopy in obscure GI bleed [Table 1]: Gupta et al.[19] in 2006 reported the diagnostic yield of 52% with NSAID-induced lesions (15%) followed by angiodysplasias (14%) being the most common lesions identified. In a study by UC Ghoshal et al.[20] in 2011, vascular malformations with or without fresh bleeding (37.5%), and small bowel tumors (18.8%) were most common lesions with a diagnostic yield of 74.4%. Goenka MK et al.[16] in the same year reported the diagnostic yield of 78% and noted Ulcers/Erosions (74%) and tumors (22%) most commonly. In another study by Pandey V et al.[21] in 2016, the diagnostic yield was 65% and angiodysplasia (23%) was the most common lesion identified.
Table 1: Indian studies on capsule endoscopy in obscure gastrointestinal bleeding

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Device-assisted enteroscopy

In routine clinical practice the DBE, SBE, and spiral enteroscopy are the three different armamentariums available for evaluating small bowel. Motorized spiral enteroscopy (power spiral) is the new addition to it. The choice of device depends on the indication, experience of the endoscopist, availability in the institution. Baniya et al.[22] in their systematic review reported no significant difference between conventional enteroscopy and balloon-assisted enteroscopy in terms of depth of insertion, adverse events, diagnostic and therapeutic yield. ESGE recommends device-assisted enteroscopy in patients with positive findings at small-bowel capsule endoscopy to confirm and possibly treat those lesions (strong recommendation, high-quality evidence).[7] Teshima et al.[8] noted the pooled diagnostic yield of DBE in patients with previously positive VCE of 75% (95% CI 60.1%–90%) and in previously negative VCE of 27.5% (95% CI 16.7%–37.8%). Several studies have demonstrated improved outcomes and change in patient management following device-assisted enteroscopy.[23],[24],[25],[26],[27],[28] Motorized spiral enteroscope (MSE) has multiple novel features such as ability of self-propulsion, shorter length, larger channel, and better irrigation. Recently, Ramchandani et al. have reported the therapeutic success of 93.4%. In a study by Goenka et al., the indication for the device assisted procedure was obscure GI bleeding in 129 (71.66%) and the most common finding obtained during evaluation of small bowel endoscopy was ulcer (25%) followed by stricture 4.44% and both ulcers and strictures (3.33%).[29]

Intraoperative enteroscopy

It has a high diagnostic yield which ranges from 58% to 88%.[30] It is very reliable method for a complete evaluation of small bowel but it is highly invasive. It is recommended that intraoperative enteroscopy should be used only in certain situations like intestinal adhesions (strong recommendation, low level of evidence).[1]


  Radiologic Procedures Top


Conventional imaging

In cases of suspected small bowel bleeding barium examinations have yields of only 3%–17%.[31],[32],[33] According to ACG guidelines, barium studies should not be used as a diagnostic modality in patients with obscure GI bleeding (strong recommendation, high level evidence). The performance of routine cross-sectional imaging of the abdomen can be increased by large volume contrast ingestion (enterography) or by administration of contrast through nasoenteric tube (enteroclysis).[34] The yields of imaging are higher in overt bleeding in comparison to occult bleeding.

Computed tomography enterography

A meta-analysis has shown that CTE has a lower pooled yield in comparison to VCE (40% vs. 53%).[35] However, it has got improved detection of mural-based small bowel lesions. If suspicion of small bowel source of bleeding is high then CTE should be performed despite doing prior standard CT abdomen and negative VCE.[1] In comparison to MR imaging, CTE is preferred for the evaluation of suspected small bowel bleeding (conditional recommendation).[1]

Computed tomography angiography

CTA is used to detect active bleeding in patients with acute overt bleeding and can detect bleeding even at a rate of 0.3 ml/min.[1] It can be used to triage the patients presenting with acute overt GI bleeding The pooled sensitivity and specificity in detecting the source of acute GI bleeding is 89% and 85%, respectively.[36] Hemodynamically unstable acute overt GI bleeding patients should be subjected to CA (strong recommendation, low level of evidence). On the other hand, in hemodynamically stable patients multiphasic CTA should be performed for the identification of the site of bleeding (strong recommendation, moderate level of evidence), before planning a CA. The advantage of CA is the ability to perform therapeutic intervention in the form of transarterial embolization at the time of diagnosis. CA should not be used as a diagnostic test in patients without overt GI bleeding. Some of the limitations are the lesions can be detected only if the patient is bleeding at the time of scan. In elderly patients, administration of contrast agent may increase the risk of renal impairment.

Scintigraphy

99mTc tagged RBC scintigraphy can detect bleeding even at a rate of 0.2 ml/min. It helps in detection of delayed bleeding by performing delayed imaging. Wide range of diagnostic yields (26%–87%), localization accuracy (19%–100%), sensitivity (33%–93%) and specificity (30%–95%) has been reported in the literature. Due to these large variations, there is considerable controversy in using scintigraphy in diagnosing acute overt GI bleeding. Limitations-Inability to characterize the source of bleeding, difficult to localize the foregut lesions are few of the limitations. The authors do not support the use of 99mTc tagged RBC scintigraphy. Meckel scan (Technetium-99 m pertechnetate scintigraphy) should be performed in younger patients with normal VCE and ongoing overt bleeding to detect Meckel diverticulum.[1]


  Treatment Top


If a patient presents with brisk or massive bleeding then hemodynamic stabilization with fluid resuscitation and blood transfusion should be done followed by CT angiography [Figure 1]. If the bleeding source is identified then angioembolization of bleeding vessel(s) can be done to control the bleeding. On the other hand, if the patient presents with subacute ongoing bleeding then after initial hemodynamic stabilization, he/she should be considered for VCE and CT enterography. If a lesion is identified on capsule endoscopy or CT enterography then device assisted enterosocpy can be done to control the bleeding and/or obtain the tissue for histopathological examination.
Figure 1: Algorithm for the management of suspected small bowel bleeding

Click here to view


Recommendations

Patients with significant anemia or ongoing bleeding should be managed with endoscopic therapy if bleeding source is identified by VCE and/or enteroscopy (strong recommendation, low level of evidence). Patients in whom the source of bleeding is not identified after appropriate small bowel evaluation should be initially managed conservatively with oral or intravenous iron therapy (strong recommendation). Medical management with iron supplements, somatostatin analogs, or antiangiogenic treatment should be administered to the patients with persistent and recurrent bleeding. In patients with massive small bowel bleeding surgical intervention is useful after presurgical localization and marking of the lesion with a tattoo (strong recommendation).

A major limitation of this review is the management of obscure GI bleeding is not discussed in detail.


  Conclusion Top


“Obscure GI bleeding” often replaced by “small bowel bleeding” by some authors accounts to 5%–10% of overall GI bleeding. VCE, balloon enteroscopy, spiral enteroscopy, etc., are some of the advances in small bowel evaluation that have improved the ability to detect the source of bleeding. Patients in whom the source of bleeding is not identified after appropriate small bowel evaluation should be initially managed conservatively with oral or intravenous iron therapy (strong recommendation). Medical management with iron supplements, somatostatin analogs, or antiangiogenic treatment should be administered to the patients with persistent and recurrent bleeding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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