AGA Technical Review on the Evaluation and management of Occult and Obscure Gastrointestinal Bleeding - PowerPoint PPT Presentation

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AGA Technical Review on the Evaluation and management of Occult and Obscure Gastrointestinal Bleeding

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Title: AGA Technical Review on the Evaluation and management of Occult and Obscure Gastrointestinal Bleeding


1
AGA Technical Review on the Evaluation and
management of Occult and Obscure Gastrointestinal
Bleeding
  • Gastroenterology 2000118201-221
  • Reporter Intern ???
  • 2002/10/28

2
Bleeding Definitions (?)
  • Overt or visible bleeding GI bleeding manifest
    as visible bright red or altered blood in emesis
    or feces
  • Occult bleeding initial present of IDA and/or
    positive FOBT no visible blood in feces
  • Obscure bleeding Recurrent or persistent IDA,
    positive FOBT ,or visible bleeding with no
    bleeding source found at original endoscopy

3
Bleeding Definitions (?)
  • Obscure-occult bleeding subcategory of obscure
    characterized by recurrent or persistent IDA
    and/or positive FOBT with no source found at
    original endoscopy no visible blood in feces
  • Obscure-overt bleeding subcategory of obscure
    characterized by recurrent or persistent
    overt/visible bleeding with no source found at
    original endoscopy bleeding manifest as visible
    blood in emesis or feces

4
Bedside Examination
  • History especially drug history( NSAID, Aspirin,
    KCl, anticoagulation) and family history.
  • Physical Examination cutaneous manifestations
    VS. GI bleeding
  • It has been proposed that information on either
    upper or lower intestinal symptoms can direct the
    initial endoscopic approach to patients with
    occult bleeding.

5
Evaluation of Occult Bleeding(?)
  • Study design factors The method of stool
    collection ( digital collection or spontaneously
    passed stool) dietary modification Guaiac-based
    tests or immunochemical test for hemoglobin

6
Evaluation of Occult Bleeding(?)
  • Endoscopic evaluation colonoscopy and upper
    endoscopy remain the cornerstones for
    investigation of occult blood loss.
  • Colon cancer screening trial
  • 78-86 FOBT () pts performed colonoscopy
    2.2-17 colon cancer 16.7-40 adenomatous
    polyps annual FOBT reduced mortality from
    colorectal cancer

7
Evaluation of Occult Bleeding(?)
  • Bidirectional Endoscopy
  • -IDA and positive FOBT results are unaccounted
    for in up to 52 of cases
  • -a lesion identified as responsible for occult
    blood loss was located in the upper GI tract
    (29-56) more than in the lower GI tract(20-30)

8
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9
Evaluation of Occult Bleeding(?)
  • Radiographic Evaluation
  • - Single-column barium enemas discontinued, 20
    miss rate of colon cancer
  • - double-contrast enemas have been used
    primarily when results of colonoscopy are
    suboptimal
  • -air-contrast barium enemas preferably with
    flexible sigmoidoscopy sensitivity of 98 for
    carcinoma and 99 for adenoma VS. ACBE alone
    missed 25 cancer and polyps in the rectosigmoid
    region

10
Evaluation of Obscure Bleeding(?)
  • Small bowel
  • Repeat upper endoscopy and colonoscopy
  • 35 bleeding source identified (29 upper,
    6 colonoscopy)
  • Upper GI tract erosion of hiatal hernias,
    peptic ulcer, vascular ectasia
  • Colon angiodysplasia and neoplasia
  • Enteroscopy in place of repeat upper endoscopy

11
Evaluation of Obscure Bleeding(?)
  • Small bowel biopsy celiac sprue
  • Peroral and transnasal enteroscopy
  • -push enteroscopy standard approach to exam
    the proximal small bowel
  • -Sonde enteroscopy potential for direct exam
    of the entire small bowel mucosa,but less
    popular.

12
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13
Evaluation of Obscure Bleeding(?)
  • Retrograde enteroscopy examination of the distal
    ileum at colonoscopy
  • -low diagnostic rate (2.7) and should be
    reserved for instances in which other evidence
    indicates a potential source of blood loss in the
    terminal ileum
  • Intraoperative enteroscopy (IOE) apply in cases
    of transfusion dependent bleeding that is not
    localized in spite of extensive diagnostic
    evaluation.

14
Evaluation of Obscure Bleeding(?)
  • -IOE the ability to identify potential
    bleeding lesions ranging from 70-93
  • -Laparotomy has been coupled with the passage
    of an endoscope orally, per rectum, transnasally,
    or through enterotomy
  • -IOE through an enterotomy decreased
    intestinal dead space and decreased trauma to the
    bowel.

15
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16
Evaluation of Obscure Bleeding(?)
  • Small bowel x-ray series and enteroclysis
  • -enteroclysis higher radiation exposure and
    discomfort higher diagnostic yield, sensitivity,
    shorter procedure time.
  • -enteroclysis the radiological study of
    choice for the investigation of suspected gross
    disorder of the small bowel. (diagnostic rate of
    neoplasia of 95)

17
Evaluation of Obscure Bleeding(?)
  • Nuclear scans technetium 99m-labeled red blood
    cell (TRBC)scan
  • -long half-life , bleeding rate0.1-0.4 mL/min
  • -significant false localization and miss rate
    ?alternate test angiography or endoscopy before
    an invasive therapeutic procedure

18
Evaluation of Obscure Bleeding(?)
  • Angiography
  • -active bleeding rate gt0.5 mL/min ?
    extravasation of contrast may be found
  • - diagnostic rate27-77 in acute lower
    intestine bleeding
  • -repeat angiography increased diagnostic rate
    from 43 to 54 in patient with no initial
    diagnosis.
  • Exploratory laparotomy

19
Etiology(?)
20
Etiology (?)
21
Management
  • Endoscopic therapy
  • Angiographic therapy
  • Pharmacotherapy
  • Surgery
  • Nonspecific therapy

22
Endoscopic Therapy
  • Thermal contact probes, injection sclerotherapy,
    argon plasma coagulation,NdYAG laser
  • decrease the requirement for blood transfusion
    requirement
  • slightly higher rebleeding rates( up to 34) have
    been reported with the use of thermal contact
    devices

23
Angiotherapy
  • The number of patients successfully treated with
    vasopressin infusion or embolization for
    obscure-overt small bowel bleeding is limited.
  • Vessopressin- cardiovascular complications rate
    up to 9-21
  • embolization-complication rate 17
  • Embolozation may have utility in patients with
    coronary disease or other disorders wherein
    vasopressin infusion is relatively
    contraindicated or as an alternative to surgery.

24
Pharmacotherapy
  • Reserved for diffuse disease, lesion in area
    inaccessible endoscopic therapy, rebleeding with
    unknown source
  • estrogen-progesteron combination therapy
  • octreotide
  • danazol and desmopressin

25
Surgery
  • Bleeding tumor, bleeding with high transfusion
    requirement,
  • angiographic localization of the bleeding source
    assisted resection the lowest rebleeding rates
    after bowel resection for bleeding angiodysplasia

26
Nonspecific Measures
  • Iron supplymentation IDA with unknown bleeding
    source--anemia resolved in 83 with no recurrence
    over a mean F/U period of 20 months
  • obs. and intermittent transfusion 54had no
    rebleeding episodes during a 3-year follow-up
    period
  • elderly patient, slowly blood loss rate,risk for
    further diagnostic evaluation

27
Outcomes
  • The overall prognosis in occult bleeding is
    generally good , with no early mortality noted in
    prospective studies.
  • There appears to be no single efficient
    diagnostic approach or therapeutic panacea in the
    management of obscure bleeding.
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