Approach to occult bleeding
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- 1. DEFNITION Occult gastrointestinal bleeding is defined as gastrointestinal bleeding that is not visible to the patient or physcian,resulting in either a positive fecal occult blood test,or iron deficiency anemia with or without a positive fecal occult blood test.
- 2. Obscure gi bleed = It refers to recurrent bleeding in which a source is not identified after EGD, Colonoscopy, and small bowel radiography. OBSCURE OCCULT= as manifested by recurrent IDA and / or recurrent positive FOBT. OBSCURE OVERT = recurrent passage of visible blood with melena or hematochezia
- 3. CAUSES OF OCCULT GI BLEEDING MASS LESIONS; CARCINOMA( any site). Large (>1.5 cm) adenoma (any site). INFLAMMATION. Erosive esophagitis ulcer (any site) Erosive gastritis Cameron lesions ( linear erosions within a hiatus hernia). Crohns disease Celiac disease Ulcerative colitis.
- 4. VASCULAR DISORDERS Vascular ectasia (any site) P0rtal hypertensive gastropathy Gastric antral vascular ectasia Hemangiomas Dieulafoys vascular malformations. INFECTIOUS DISEASES; Worm infestations Tuberculous enterocolitis Amoebiasis
- 5. Surreptitious bleeding Haemoptysis Oropharyngeal bleeding. OTHER CAUSES Haemosuccus pancreaticus Haemobilia Long distance running.
- 6. ETIOLOGY OF OCCULT BLEEDING Age 40 years; Vascular ectasia ,M/C cause NSAID induced ulcers.
- 7. HISTORY AND PHYSCIAL EXAM. A targeted history and physcial exam. Should be performed. Abdominal pain with aspirin or other NSAID use ,suggests ulcerative mucosal injury. Anticoagulants or antiplatelet medication may precipitate bleeding in an undiagonised lesion. Family history of GI bleeding may suggest HHT. (associated with vascular lesions on lips tongue or palms) Blue rubber bleb navus syndrome(a syndrome with venous malformations in the GIT,soft tissue and skin).
- 8. History of gastric bypass surgery ; may suggest impaired iron absorption. H/O stigmata of liver disease suggests portal hypertensive gastropathy. SKIN Signs; Dermatitis herpetiformis > Celiac disease Erythema Nodosum(painful erythematous nodules seen in >Crohns disease. Blue rubber bleb navus syndrome(a syndrome with venous malformations in the GIT,soft tissue and skin). Freckles on lips and in mouth (peutz jeghers syndrome). Hyperextensible joints and ocular and dental abnormalities >S/O Ehlers danlos syndrome.
- 9. DIAGNOSTIC STUDIES Upper GI Bleeding (identified as source of bleeding proximal to the ampulla of vater) can be dx.by EGD. Proximal small bowel bleeding >can b detected by push enteroscopy which reaches the proximal jejunum. Bleeding of mid and distal small bowel can be > can be detected with Capsule endoscopy, Deep enteroscopy and CT Enterography. Lower GI Bleeding (Colonic bleeding) can be detected with colonoscopy.
- 10. DIAGNOSTIC STUDIES EGD and Colonoscopy > Bleeding source in 48-71 % pt. In recurrent bleeding > repeat OGD and Colonoscopy may find the missed lesion in 35% of those who had negative initial findings. Capsule endoscopy >dx.yield 63-74%. In Meta analysis of 14 studies ; Dx.yield of Capsule endoscopy was superior to push enteroscopy (63 vs 28 %) and Barium studies (42 vs 6 %).
- 11. Fecal occult blood testing Guaiac-based tests: Uses a chemical indicator that shows a colour change in the presence of blood in stool. The pseudoperoxidase activity of hemoglobin turns the guaiac compound blue in the presence of hydrogen peroxide. IMMUNO CHEMICAL test ( FIT ); It is more specific ,detects only human hemoglobin, ;uses antibodies directed against human hemoglobin to detect blood in the stools. Positive results indicate abnormal bleeding from lower intestine ,bcos blood from lower sites is less degraded during transit For FOBT + 2ml blood in stool is necessary. Two samples of each of 3 consecuative (daily ) stools.
- 12. CAPSULE ENDOSCOPY. Permits exam. 0f small intestinal mucosa using wireless image capturing technology. Noninvasive method to evaluate the entire length of small bowel. Can identify vascular ectasia ,ulcers and masses in small bowel. CAPSULE= Size 2.6 cm,weight 3.5 g. COMPARTMENTS= Metal oxide silicon image sensor, Light emitting diode (led) Aerial belt with 8 aerials which collects signal from the capsule. Software for analysis.
- 13. INDICATIONS OF CE. Crohns disease Celiac disease Immunoproliferative small intestinal disease (IPSID) Polyposis Small intestinal tumor like carcinoid and lymphoma. Recurrent abdominal pain with diarrhea. Obscure GI BLEED (after negative EGD and Colonoscopy ) Recurrent iron deficiency anemia.
- 14. CAPSULE ENDOSCOPY ADVANTAGES; Noninvasive Disposable DISADVANTAGES; Cost Inaccurate localization of the site of bleeding. Capsule retension
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