Obscure GI Bleeding (Bull-Henry)

Obscure GI Bleeding

Kathy Bull-Henry, MD

Georgetown University Hospital

Division of Gastroenterology

GI Bleeding Definitions

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

Obscure-Occult GI Bleeding Frequency

Obscure GI BleedingFrequency

10% - 20% of GI bleeding without

identifiable etiology

5% GI bleeding recurrent without

identifiable etiology

Majority have small bowel source

Obscure GI Bleeding

Small Bowel CausesGrouped 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

Small Bowel Bleeding

CausesBy Etiology

Vascular Lesions

Neoplasms

Inflammatory Lesions

Other

Small Bowel BleedingVascular Lesions

Most common cause of small bowel

bleeding

Responsible for 70 -80% of small bowel

bleeding

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

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


Tumors

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

Causes of Small Bowel Bleeding

Diverticula

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

Small Bowel BleedingInflammatory Lesions

Crohn’s Disease

Isolated ulcers

Idiopathic ulcers

Nonsteroidal antiinflammatory drugs

Ischemic

Other

Vasculitis, Zollinger-Ellison syndrome, Celiac

disease

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

Obscure GI BleedingSummary Causes

Obscure GI BleedingSmall Bowel Visualization

Difficult to visualize

Length (6.7 m)

Free intraperitoneal location

Vigorous contractility

Overlying loops


Diagnosis

UGI SBFT Enteroclysis

Push enteroscopy Double balloon enteroscopy

Intraoperative enteroscopy

CT scan CT enteroclysis

MRI

Video capsule endoscopy

Obscure BleedingSBFT and Enteroclysis

SBFT

0-5.6% diagnostic yield

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

Obscure GI BleedingNuclear Scans

Technetium (99mTc) sulfur colloid

Technetium 99m-labeled red blood cell scan (TRBC) Most commonly used method

Long half life allows for repeat scanning in 24 hours

Late pooled blood may not identify bleeding site

Requires bleeding rate of 0.1 to 0.4 mL/min

Positive in 45% all LGI bleeding Angiography verification highest (67%) when bleeding scan is

immediately positive

Data in obscure bleeding limited 15% false positive, 12-23% false negative

Need verification by angiography or endoscopy

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

Obscure 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

Obscure BleedingIntraoperative Enteroscopy

Transfusion dependent

Severe blood loss

Risk of continued bleeding outweigh the risk of laparotomy

Identifies bleeding source in 70 – 100%

Technically difficult Adhesions, luminal blood, infiltrating neoplasia

Complications (procedure and post op) Perforation, mucosal tears, mesenteric hemorrhage, prolonged

ileus, ischemia, wound infection, pneumonia

Mortality 11%

Obscure GI BleedingIntraoperative Enteroscopy

Obscure GI BleedingExploratory Laparotomy

Seldom without intraoperative enteroscopy

65% of 37 pt’s had lesion identified by

palpation or transillumination

1. The PillCam™ Capsule

2. SensorArray™ SB

3. Given® DataRecorder™

PillCam™ SB Exam Set

2

1

3

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

PillCam™ SBPatient 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

Pennazio M, Santucci R, Rondonotti E, et al. Gastroenterology 2004; 126: 643-653

82.6 %Negative predictive

value

97.0 %Positive predictive

value

95.0 %Specificity

88.9 %Sensitivity

(Analysis of patients with verified final diagnosis, n = 56)

Obscure GI BleedingPillCam™ SB

Obscure GI BleedingPillCamTM SB

CE results led to treatments resolving

the bleeding in 86.9% of patients

undergoing the procedure while actively

bleeding.

(12 – 25 month follow up)


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

Obscure GI Bleeding

Pennazio et al. 2004 Conclusion


Obscure GI Bleeding PillCamTM SB

StudySensitivity

(%)Specificity (%) PPV (%) NPV (%)

Pennazio et

al.

Gastro 2004

88.9 95 97 82.6

Delvaux et al.

Endoscopy

2004

94.4 100

Botelberge et

al.

ICCE 2005

91.6 86.3 88 90.4

Hartmann et

al.

GIE 2005

95 75 95 86

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 modalitiescombined1

Established as gold standard for diagnosis of disease of small intestine2

Now cleared in the US for pediatric populationfrom 10-18 years old

1. Internal data at Given Imaging Ltd. Reviewed by the FDA

2. 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

PillCam™ SBIndications

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 devices1.

In patients with swallowing disorders.

1 Leighton JA,, et al, SAFETY OF CAPSULE ENDOSCOPY IN PATIENTS WITH PACEMAKERS,

Gastrointest Endosc. 2004 Apr;59(4):567-9. 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.

PillCam™ SBContraindications


Causes Visualized by PillCamTM

Vascular Lesions

Angioectasias

Neoplasms

Inflammatory Lesions

Ulcers, Crohn’s Disease

Other

Diverticula, varices

PillCamTM SB Normal Esophagus

PillCamTM SB Normal Stomach

PillCamTM SBNormal

PillCamTM SBVascular Lesions

PillCamTM SBVascular Lesions

PillCam™ SBCrohn´s Disease

Strictured ulcer

A deep fissure can be seen in the

histological examination

Typical granulomas can be seen in

the wall of the small intestine

PillCamTM SBCeliac Image Spectrum

PillCam™ SBUlcers

PillCam™ SBPolyps and Masses

PillCam™ SBDiverticula

Wireless Capsule EndoscopySummary

Time efficient, patient friendly, sensitive

method to visualize the small bowel

Disadvantages

No therapeutics

Unable to control movement

Unable to clear bubbles and debris

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


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

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%)

Courtesy of Fujinon and Yamamoto H et al



Antegrade (oral) DBE Retrograde (anal) DBE


Contraindications

Non-cooperative patient

Prior intestinal perforation

AAA

Excessive deformity of cervical spine

Yield of Small Bowel Imaging

Modalities in Obscure GI Bleeding

Length of

Insertion

Yield

DBE Up to 100% 61 – 85%

PE 50 – 150 cm 15 – 50%

WCE 100% SB 45 – 75%

IOE Up to 100% 55 – 100%

Radiology 100% 5%

GIE 2005, 61:6:709-714

Obscure GI BleedingManagement

Resuscitation

Iron supplementation, correct coagulopathy and

platelet abnormalities, intermittent blood transfusions

Endoscopic treatment

Angiography

Pharmacotherapy

Estrogen therapy

Octreotide

Surgery

Obscure GI BleedingEvaluation

Repeat EGD and Colonoscopy (~ 35% yield)

If negative

Capsule Endoscopy (~ 60–70% yield)

If negative

Repeat Capsule Endoscopy (~ 35% yield)

If negative

Double Balloon Enteroscopy (~ 40% yield)

If negative

Intraoperative Enteroscopy in selected cases

GIE 2004;60:5:711-713

The FutureRobotics

The Magic Pill

Obscure GI BleedingEvaluation

Repeat EGD and Colonoscopy (~ 35% yield)

If negative

Capsule Endoscopy

If negative

Repeat Capsule Endoscopy

If negative


If negative

Intraoperative Enteroscopy in selected cases

GIE 2004;60:5:711-713

Obscure GI Bleeding (Bull-Henry)

Documents

gi bleeding recurrent

years oldtumorspatients

years of agemalignant

years oldmay

common cause of bleedingone

vascular aneurysm

liver abscess

identifiable etiologymajority