Clinical managementObscure-Overt Gastrointestinal Bleeding
Section snippets
Clinical Case
A 65-year-old man was admitted for recurrent gastrointestinal (GI) bleeding. The patient, passing dark red blood per rectum, was hospitalized 2 months previously at an outside hospital. He required 2 units of packed red blood cells (RBCs), and there was no further evidence of bleeding by the second day of hospitalization. Upper endoscopy, colonoscopy, and upper GI series with small-bowel follow-through (SBFT) radiography were unrevealing. The patient was discharged home on oral iron therapy and
Background
Obscure GI bleeding is defined as bleeding from an unknown source that persists or recurs after negative diagnostic evaluation.1, 2 A negative diagnostic evaluation is commonly agreed on as consisting of a negative upper endoscopy and colonoscopy, perhaps with the addition of small-bowel radiographic evaluation (eg, SBFT or enteroclysis). For patients who present with persistent or recurrent hematemesis, a rare presentation of obscure GI bleeding, colonoscopy is not part of the initial
Potential Management Strategies
To evaluate patients with obscure-overt GI bleeding, several endoscopic, radiographic, and surgical diagnostic modalities are available to the practicing gastroenterologist.
Recommended Management Strategy
A recommended management strategy for this case is summarized in Figure 1. The patient in the case outlined previously has now been readmitted to the hospital with recurrent overt GI bleeding and has required repeat blood transfusions. The findings from the previous esophagogastroduodenoscopy, colonoscopy, and SBFT were reviewed. At the time of previous colonoscopy, there was a moderate amount of liquid brown stool in the cecum and ascending colon that limited visibility, and there was no
Evolution of the Case
During hospitalization, the patient underwent push enteroscopy with a dedicated 220-cm small-bowel videoenteroscope to approximately 90 cm beyond the ligament of Treitz. The examination, including careful evaluation of the GI tract proximal to the ligament of Treitz, did not identify any etiology for recurrent hemorrhage. The patient also underwent repeat colonoscopy with retrograde examination of the terminal ileum, which was normal. No blood was found in the colon or terminal ileum. The
Conclusions
Obscure GI bleeding is defined as bleeding from an unknown source that persists or recurs after negative diagnostic evaluation and may be further subcategorized as occult or overt. It is estimated that up to 5% of patients with overt GI hemorrhage will have negative upper endoscopy and colonoscopy and therefore be suspected of a small-bowel source for their bleeding. As compared with obscure-occult GI bleeding, patients with obscure-overt GI bleeding are more likely to harbor a significant
References (21)
- et al.
AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding
Gastroenterology
(2000) - et al.
Severe GI bleeding of obscure origin
Gastrointest Endosc Clin North Am
(2004) - et al.
Recent advances in the endoscopic diagnosis and therapy of upper gastrointestinal, small intestinal and colonic bleeding
Med Clin North Am
(2002) - et al.
Enteroscopy
Gastrointest Endosc
(2001) - et al.
Diagnostic and therapeutic impact of push enteroscopyanalysis of factors associated with positive findings
Gastrointest Endosc
(1998) - et al.
A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease
Gastroenterology
(2002) - et al.
Capsule endoscopy in the evaluation of patients with suspected small intestinal bleedingresults of a pilot study
Gastrointest Endosc
(2002) - et al.
A prospective comparison of capsule endoscopy and push enteroscopy in patients with GI bleeding of obscure origin
Gastrointest Endosc
(2004) - et al.
Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopyreport of 100 consecutive cases
Gastroenterology
(2004) - et al.
A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small-bowel lesions
Gastroenterology
(2000)
Cited by (60)
Novel capsules for potential theranostics of obscure gastrointestinal bleedings
2016, Medical HypothesesCitation Excerpt :Intraoperative enteroscopy has been utilized in obscure small intestinal bleedings as the golden standard for a period of time and this method enables 50–100% rate of diagnosis for the GI bleedings. This enteroscopic method offers opportunities for the treatment, however, it is an invasive method [16]. Its complication rates are reported 12–33% [17] or 8% [18].
The role of deep enteroscopy in the management of small-bowel disorders
2015, Gastrointestinal EndoscopyCitation Excerpt :OGIB is defined as occult or overt bleeding of unknown origin that persists or reoccurs after an initial negative endoscopic evaluation including upper endoscopy and colonoscopy.51 OGIB occurs in approximately 5% of all patients who present with GI hemorrhage.52 VCE is frequently the initial diagnostic test in patients with suspected OGIB, because it is minimally invasive and can visualize the entire small bowel.
Small bowel diagnostics: Current place of small bowel endoscopy
2012, Best Practice and Research: Clinical GastroenterologyCitation Excerpt :OGIB is defined as occult or overt bleeding of unknown origin that persists or reoccurs after an initial negative endoscopic evaluation including upper endoscopy and colonoscopy, the latter both often repeatedly performed. OGIB has been shown to be defined to occur in approximately 5% of all patients who present with gastrointestinal haemorrhage [44]. In the evaluation and treatment of OGIB, capsule endoscopy and DAE are considered complementary procedures [45,46].
Gastrointestinal bleeding: The role of radiology
2011, Radiologia