Title: AGA Technical Review on the Evaluation and management of Occult and Obscure Gastrointestinal Bleeding
1AGA Technical Review on the Evaluation and
management of Occult and Obscure Gastrointestinal
Bleeding
- Gastroenterology 2000118201-221
- Reporter Intern ???
- 2002/10/28
2Bleeding 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
3Bleeding 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
4Bedside 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.
5Evaluation 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
6Evaluation 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
7Evaluation 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)
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9Evaluation 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
10Evaluation 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
11Evaluation 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.
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13Evaluation 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.
14Evaluation 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.
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16Evaluation 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)
17Evaluation 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
18Evaluation 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
-
19Etiology(?)
20Etiology (?)
21Management
- Endoscopic therapy
- Angiographic therapy
- Pharmacotherapy
- Surgery
- Nonspecific therapy
22Endoscopic 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
23Angiotherapy
- 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.
24Pharmacotherapy
- Reserved for diffuse disease, lesion in area
inaccessible endoscopic therapy, rebleeding with
unknown source - estrogen-progesteron combination therapy
- octreotide
- danazol and desmopressin
25Surgery
- 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
26Nonspecific 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
27Outcomes
- 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.