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CC BY-NC-ND 4.0 · Journal of Digestive Endoscopy 2013; 04(03): 061-070
DOI: 10.4103/0976-5042.129966
Review Article

Clinical approach to obscure GI bleeding - Diagnostic testing and management

Prashanth Prabakaran
1   Division of Gastroenterology & Hepatology, School of Medicine & Public Health Suite 4000, 1685 Highland Ave, Madison, Wisconsin, USA
,
Nalini Guda
2   Division of Gastroenterology & Hepatology University of Wisconsin GI Associates, St. Luke's Medical Center Milwaukee, Wisconsin, USA
,
Jacob Thomas
3   Department of Radiology and Diagnostic Imaging, School of Medicine & Public Health Suite 4000, 1685 Highland Ave, Madison, Wisconsin, USA
,
Charles Heise
4   Department of General Surgery, School of Medicine & Public Health Suite 4000, 1685 Highland Ave, Madison, Wisconsin, USA
,
Deepak Gopal
1   Division of Gastroenterology & Hepatology, School of Medicine & Public Health Suite 4000, 1685 Highland Ave, Madison, Wisconsin, USA
5   Medicine, University of Wisconsin - School of Medicine & Public Health Suite 4000, 1685 Highland Ave, Madison, Wisconsin, USA
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Abstract

Obscure gastrointestinal bleeding (OGIB) can present as a diagnostic dilemma and management can be challenging. The search for causes of OGIB is usually centered on visualizing the small bowel, and in the past decade, the technology to visualize the entire small bowel has significantly advanced. Moreover, small bowel endoscopic imaging has replaced, in many instances, prior radiographic evaluation for obscure GI bleeding. These new modalities, such as small bowel capsule endoscopy (CE), balloon-assisted deep enteroscopy [double balloon enteroscopy (DBE) and single balloon enteroscopy (SBE)], and overtube-assisted deep enteroscopy (spiral enteroscopy), are paving the way toward more accurately identifying and treating patients with OGIB. We will review the diagnostic modalities available in evaluating a patient with OGIB and also propose the management based on clinical and endoscopic findings.

Key words

Balloon-assisted enteroscopy - deep enteroscopy - magnetic resonance/computed tomography enterography - obscure gastrointestinal bleeding - small bowel capsule endoscopy


Publication History

Publication Date:
26 September 2019 (online)

© 2013. Thieme. All rights reserved.

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  • REFERENCES

  • 1 Liu K, Kaffes AJ. Review article: The diagnosis and investigation of obscure gastrointestinal bleeding. Aliment Pharmacol Ther 2011;34:416-23.
  • 2 ASGE Standards of Practice Committee, Fisher L, Lee Krinsky M, Anderson MA, Appalaneni V, Banerjee S, et al. The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc 2010;72:471-9.
  • 3 Kita H. Overview of deep small bowel enteroscopy. In: Howell DA, Travis AC, editors. UpToDate. Wolters Kluwer Health. Available from: http://www.uptodate.com [Last accessed on 2013 Oct 23].
  • 4 Cave D. Evaluation of obscure gastrointestinal bleeding. Saltzman JR, Travis AC Editors. UpToDate. Wolters Kluwer Health. Available from: http://www.uptodate.com [Last accessed on 2013 Nov 20].
  • 5 Goenka MK, Majumder S, Kumar S, Sethy PK, Goenka U. Single center experience of capsule endoscopy in patients with obscure gastrointestinal bleeding. World J Gastroenterol 2011;17;774-8.
  • 6 Graça BM, Freire PA, Brito JB, Ilharco JM, Carvalheiro VM, Caseiro-Alves F. Gastroenterologic and radiologic approach to obscure gastrointestinal bleeding: How, why, and when? Radiographics 2010;30:235-52.
  • 7 Raju GS, Gerson L, Das A, Lewis B, American Gastro-enterological Association. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 2007;133:1697-717.
  • 8 Rockey DC. Occult gastrointestinal bleeding. Gastroenterol Clin North Am 2005;34:699-718.
  • 9 Dubinsky M. Special issues in pediatric inflammatory bowel disease. World J Gastroenterol 2008;14:413-20.
  • 10 Huprich JE, Fletcher JG, Alexander JA, Fidler JL, Burton SS, McCullough CH. Obscure Gastrointestinal Bleeding: Evaluation with 64-Section Multiphase CT Enterography – Initial Experience. Radiology 2008;246;562-71.
  • 11 Maglinte DD, Sandrasegaran K, Lappas JC, Chiorean M. CT enteroclysis. Radiology 2007;245:661-71.
  • 12 Huprich JE. Multi-phase CT enterography in obscure GI bleeding. Abdom Imaging 2009;34:303-9.
  • 13 Filippone A, Cianci R, Milano A, Valeriano S, Di Mizio V, Storto ML. Oscure gastrointestinal bleeding and small bowel pathology: Comparison between wireless capsule endoscopy and multidetector-row CT enteroclysis. Abdom Imaging 2008;33:398-406.
  • 14 Hara AK, Walker FB, Silva AC, Leighton JA. Preliminary estimate of triphasic CT enterography performance in hemodynamicallystable patients with suspected gastrointestinal bleeding. AJR Am J Roentgenol 2009;193:1252-60.
  • 15 Zhang BL, Jiang LL, Chen CX, Zhong BS, Li YM. Diagnosis of obscure gastrointestinal hemorrhage with capsule endoscopy in combination with multiple-detector computed tomography. J Gastroenterol Hepatol 2010;25:75-9.
  • 16 Fidler JL, Guimaraes L, Einstein DM. MR imaging of the small bowel. Radiographics 2009;29:1811-25.
  • 17 Schmidt S, Lepori D, Meuwly JY, Duvoisin B, Meuli R, Michetti P, et al. Prospective comparison of MR enteroclysis with multidetector spiral-CT enteroclysis: Interobserver agreement and sensitivity by means of ‘’sign-bysign’’correlation. Eur Radiol 2003;13:1303-11.
  • 18 Soyer P, Boudiaf M, Fishman EK, Hoeffel C, Dray X, Manfredi R, et al. Imaging of malignant neoplasms of the mesenteric small bowel: New trends and perspectives. Crit Rev Oncol Hematol 2011;80:10-30.
  • 19 Zink SI, Ohki SK, Stein B, Zambuto DA, Rosenberg RJ, Choi JJ, et al. Noninvasive evaluation of active lower gastrointestinal bleeding: Comparison between contrast-enhanced MDCT and 99mTc-labeled RBC scintigraphy. AJR Am J Roentgenol 2008;191:1107-14.
  • 20 Mariani G, Pauwels EK, AlSharif A, Marchi S, Boni G, Barreca M, et al. Radionuclide evaluation of the lower gastrointestinal tract. J Nucl Med 2008;49:776-87.
  • 21 Wu LM, Xu JR, Yin Y, Qu XH. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: A meta-analysis. World J Gastroenterol 2010;16:3957-63.
  • 22 Howarth DM. The role of nuclear medicine in the detection of acute gastrointestinal bleeding. Semin Nucl Med 2006;36:133-46.
  • 23 Nusbaum M, Baum S, Blakemore WS. Clinical experience with the diagnosis and management of gastrointestinal hemorrhage by selective mesenteric catheterization. Ann Surg 1969;170:506-14.
  • 24 Liao Z, Gao R, Xu C, Li ZS. Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: A systematic review. Gastrointest Endosc 2010;71:280-6.
  • 25 Fireman Z, Kopelman Y. The role of video capsule endoscopy in the evaluation of iron deficiency anaemia. Dig Liver Dis 2004;36:97-102.
  • 26 Mazzarolo S, Brady P. Small bowel capsule endoscopy: A systematic review. South Med J 2007;100:274-80.
  • 27 Bresci G, Parisi G, Bertoni M, Tumino E, Capria A. The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: Usefulness of early use. J Gastroenterol 2005;40:256-9.
  • 28 May A, Wardak A, Nachbar L, Remke S, Ell C. Influence of patient selection on the outcome of capsule endoscopy in patients with chronic gastrointestinal bleeding. J Clin Gastroenterol 2005;39:684-8.
  • 29 Thomson M, Venkatesh K, Elmalik K, van der Veer W, Jaacobs M. Double balloon enteroscopy in children: Diagnosis, treatment, and safety. World J Gastroenterol 2010;16:56-62.
  • 30 van Gossum A, Francois E, Hittelet A, Schmit A, Devière J, et al. A prospective comparative study between push-enteroscopy and wireless video capsule in patients with obscure digestive bleeding. Gastroenterology 2003;125:276.
  • 31 Liangpunsakul S, Chadalawada V, Rex DK, Maglinte D, Lappas J. Wireless capsule endoscopy detects small bowel ulcers in patients with normal results from state of the art enteroclysis. Am J Gastroenterol 2003;98:1295-8.
  • 32 Cave D. Wireless video capsule endoscopy. In: Saltzman JR, Travis AC, editors. UpToDate. Wolters Kluwer Health. Available from: http://www.uptodate.com [Last accessed on 2013 Oct 30].
  • 33 Scapa E, Jacob H, Lewkowicz S, Migdal M, Gat D, Gluckhovski A, et al. Initial experience of wireless-capsule endoscopy for evaluating occult gastrointestinal bleeding and suspected small bowel pathology. Am J Gastroenterol 2002;97:2776-9.
  • 34 Cheifetz AS, Kornbluth AA, Legnani P, Schmelkin I, Brown A, Lichtiger S, et al. The risk of retention of the capsule endoscope in patients with known or suspected Crohn’s disease. Am J Gastroenterol 2006;101:2218-22.
  • 35 Chak A, Koehler MK, Sundaram SN, Cooper GS, Canto MI, Sivak MV Jr. Diagnostic and therapeutic impact of push enteroscopy: Analysis of factors associated with positive findings. Gastrointest Endosc 1998;47:18-22.
  • 36 Bandorski D, Keuchel M, Brück M, Hoeltgen R, Wieczorek M, Jakobs R. Capsule endoscopy in patients with cardiac pacemakers, implantable cardioverter defibrillators, and left heart devices: A review of the current literature. Diagn Ther Endosc 2011;2011:376053.
  • 37 Katsinelos P, Kountouras J, Chatzimavroudis G, Zavos C, Pilpilidis I, Fasoulas K, et al. Wireless capsule endoscopy in detecting small-intestinal polyps in familial adenomatous polyposis. World J Gastroenterol 2009;15:6075-9.
  • 38 Herrerias JM, Leighton JA, Costamagna G, Infantolino A, Eliakim R, Fischer D, et al. Agile patency system eliminates risk of capsule retention in patients with known intestinal strictures who undergo capsule endoscopy. Gastrointest Endosc 2008;67:902-9.
  • 39 Holden JP, Dureja P, Pfau PR, Schwartz DC, Reichelderfer M, Judd RH, et al. Endoscopic placement of the small-bowel video capsule by using a capsule endoscope delivery device. Gastrointest Endosc 2007;65:842-7.
  • 40 Gómez Rodríguez BJ, Ortiz Moyano C, Romero Castro R, Caunedo Alvarez A, Hernández Durán MD, Hergueta Delgado P, et al. Diagnostic yield of 335 push video-enteroscopies. Rev Esp Enferm Dig 2006;98:82-92.
  • 41 Schulz HJ, Schmidt H. Intraoperative enteroscopy. Gastrointest Endosc Clin N Am 2009;19:371-9.
  • 42 Raju GS, Gerson L, Das A, Lewis B, American Gastroenterological Association. American Gastroenterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding. Gastroenterology 2007;133:1694-6.
  • 43 Ghosh S, Watts D, Kinnear M. Management of gastrointestinal haemorrhage. Postgrad Med J 2002;78:4-14.
  • 44 Pérez Roldán F, González Carro P, Legaz Huidobro ML, Roncero García-Escribano O, Ynfante Ferrús M, Aoufi S, et al. E-cacy of pediatric colonoscopy used as push enteroscopy in the management of capsule endoscopy findings. Rev Esp Enferm Dig 2009;101:468-76.
  • 45 Ress AM, Benacci JC, Sarr MG. E-cacy of intraoperative enteroscopy in diagnosis and prevention of recurrent, occult gastrointestinal bleeding. Am J Surg 1992;163:94-8.
  • 46 Bowden TA Jr, Hooks VH 3rd, Mansberger AR Jr. Intraoperative gastrointestinal endoscopy. Ann Surg 1980;191:680-7.
  • 47 May A, Färber M, Aschmoneit I, Pohl J, Manner H, Lotterer E, et al. Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol 2010;105:575-81.
  • 48 Moreels TG, Pelckmans PA. Comparison between double-balloon and single-balloon enteroscopy in therapeutic ERC after Roux-en-Y entero-enteric anastomosis. World J Gastrointest Endosc 2010;2:314-7.
  • 49 Raju GS, Gerson L, Das A, Lewis B. American Gastro-enterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding. Gastroenterology 2007;133:1694-96.
  • 50 Yamamoto H, Kita H, Sunada K, Hayashi Y, Sato H, Yano T, et al. Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol 2004;2:1010-6.
  • 51 Ell C, May A, Nachbar L, Cellier C, Landi B, di Caro S, et al. Push-and-pull enteroscopy in the small bowel using the double-balloon technique: Results of a prospective European multicenter study. Endoscopy 2005;37:613-6.
  • 52 Gerson LB, Batenic MA, Newsom SL, Ross A, Semrad CE. Long-term outcomes after double-balloon enteroscopy for obscure gastrointestinal bleeding. Clin Gastroenterol Hepatol 2009;7:664-9.
  • 53 Mensink PB, Haringsma J, Kucharzik T, Cellier C, Pérez-Cuadrado E, Mönkemüller K, et al. Complications of double balloon enteroscopy: A multicenter survey. Endoscopy 2007;39:613-5.
  • 54 Pasha SF, Leighton JA, Das A, Harrison ME, Decker GA, Fleischer DE, et al. Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: A meta-analysis. Clin Gastroenterol Hepatol 2008;6:671-6.
  • 55 Mehdizadeh S, Han NJ, Cheng DW, Chen GC, Lo SK, et al. Success rate of retrograde double-balloon enteroscopy. Gastrointest Endosc 2007;65:633-9.
  • 56 May A, Manner H, Aschmoneit I, Ell C. Prospective, cross-over, single-center trial comparing oral double-balloon enteroscopy and oral spiralenteroscopy in patients with suspected small-bowel vascular malformations. Endoscopy 2011;43:477-83.
  • 57 Amaro R, Barkin JS. Diagnostic and therapeutic options in obscure gastrointestinal blood loss. Curr Gastroenterol Rep 2000;2:395-8.
  • 58 Mergener K, Ponchon T, Gralnek I, Pennazio M, Gay G, Selby W, et al. Literature review and recommendations for clinical application of small-bowel capsule endoscopy, based on a panel discussion by international experts. Consensus statements for small-bowel capsule endoscopy, 2006/2007. Endoscopy 2007;39:895-909.
  • 59 Albert JG, Nachtigall F, Wiedbrauck F, Dollinger MM, Gittinger FS, Hollerbach S, et al. Minimizing procedural cost in diagnosing small bowel bleeding: Comparison of a strategy on initial capsule endoscopy versus initial double-balloon enteroscopy. Eur J Gastroenterol Hepatol 2010;22:679-88.
  • 60 Westerhof J, Weersma RK, Koornstra JJ. Investigating obscure gastrointestinal bleeding: Capsule endoscopy or double balloon enteroscopy? Neth J Med 2009;67:260-5.
  • 61 Bar-Meir S. Video capsule endoscopy or double-balloon enteroscopy: Are they equivalent? Gastrointest Endosc 2009;69:875-6.
  • 62 Lopez MJ, Cooley JS, Petros JG, Sullivan JG, Cave DR. Complete intraoperative small-bowel endoscopy in the evaluation of occult gastrointestinal bleeding using the Sonde enteroscope. Arch Surg 1996;131:272-7.
  • 63 Goldfarb NI, Phillips A, Conn M, Lewis BS, Nash DB. Economic and health outcomes of capsule endoscopy: Opportunities for improved management of the diagnostic process for obscure gastrointestinal bleeding. School of Population Health Faculty Papers. Dis Manage 2002;5:123-35.