ObscureGIBleeding

8/3/2019 ObscureGIBleeding

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Obscure GI BleedingObscure GI BleedingKathy Bull-Henry, MDKathy Bull-Henry, MD

Georgetown University HospitalGeorgetown University HospitalDivision of GastroenterologyDivision of Gastroenterology



GI BleedingGI BleedingDefinitionsDefinitions



Obscure GI BleedingObscure GI BleedingDefinitionDefinition

Bleeding of unknown originBleeding of unknown origin that persists or that persists or

recurs after negative colonoscopy andrecurs after negative colonoscopy and

negative upper endoscopynegative upper endoscopy

Recurrent or persistent bleedingRecurrent or persistent bleeding FOBT positiveFOBT positive

IDAIDA

Visible bleedingVisible bleeding

Melena, hematemesis, hematochezia, coffeeMelena, hematemesis, hematochezia, coffee

groundsgrounds



Obscure-Occult GI BleedingObscure-Occult GI BleedingFrequencyFrequency



Obscure GI BleedingObscure GI BleedingFrequencyFrequency

10% - 20% of GI bleeding without10% - 20% of GI bleeding without

identifiable etiologyidentifiable etiology

5% GI bleeding recurrent without5% GI bleeding recurrent without

identifiable etiologyidentifiable etiology Majority have small bowel sourceMajority have small bowel source



Obscure GI BleedingObscure GI Bleeding

Small BowelSmall Bowel CausesCauses

Grouped by AgeGrouped by Age

Patient’s < 25 years oldPatient’s < 25 years old

Meckel’s DiverticulaMeckel’s DiverticulaPatient’s between 30 – 50 years oldPatient’s between 30 – 50 years old TumorsTumors

Patient’s > 50 years oldPatient’s > 50 years old Vascular ectasiasVascular ectasias



Small Bowel BleedingSmall Bowel Bleeding

CausesCauses

By EtiologyBy Etiology

Vascular LesionsVascular Lesions

NeoplasmsNeoplasmsInflammatory LesionsInflammatory Lesions

Other Other



Small Bowel BleedingSmall Bowel BleedingVascular LesionsVascular Lesions

Most common cause of small bowelMost common cause of small bowel

bleedingbleeding

Responsible for 70 -80% of small bowelResponsible for 70 -80% of small bowel

bleedingbleeding



Small Bowel BleedingSmall Bowel BleedingVascular LesionsVascular Lesions

Angioectasias Angioectasias

TelangiectasiasTelangiectasias Hereditary hemorrhagic telangiectasiaHereditary hemorrhagic telangiectasia Osler-Weber-Rendu SyndromeOsler-Weber-Rendu Syndrome

CREST SyndromeCREST Syndrome CCalcinosis,alcinosis, RReynaud’s,eynaud’s, EEsophageal dysmotilitysophageal dysmotility SSclerodactyl,clerodactyl,

TTelangiectasiaelangiectasia

Other Other Dieulafoy’s lesionDieulafoy’s lesion Aortoenteric fistula Aortoenteric fistula Small bowel varicesSmall bowel varices



Small Bowel BleedingSmall Bowel Bleeding Angiodysplasia Angiodysplasia

Dilated tortuous blood vessels with thinDilated tortuous blood vessels with thin

walls lined by endothelium with little or nowalls lined by endothelium with little or no

smooth musclesmooth muscle

Most common small bowel bleeding in theMost common small bowel bleeding in the

elderly (> 50 years old)elderly (> 50 years old)

May be associated with aging associatedMay be associated with aging associated

degeneration of vascular integritydegeneration of vascular integrity




TumorsTumors

Second most common cause of bleedingSecond most common cause of bleeding

One out of ten patients with obscure bleeding will have aOne out of ten patients with obscure bleeding will have asmall bowel tumor small bowel tumor

Most common cause in persons age 30 – 50 years of ageMost common cause in persons age 30 – 50 years of age

Malignant and BenignMalignant and Benign Adenocarcinoma, carcinoid, lymphoma, leiomyosarcoma, Adenocarcinoma, carcinoid, lymphoma, leiomyosarcoma, Leiomyoma, polyps (Peutz-Jeghers, familial polyposis), GISTLeiomyoma, polyps (Peutz-Jeghers, familial polyposis), GIST

MetastaticMetastatic Melanoma, breast, renal-cell, kaposi’s sarcoma, colon, ovarianMelanoma, breast, renal-cell, kaposi’s sarcoma, colon, ovarian



Causes of Small Bowel BleedingCauses of Small Bowel Bleeding

DiverticulaDiverticula

Small bowel diverticulaSmall bowel diverticula At the site of perforating blood vessels At the site of perforating blood vessels

Meckel’s diverticulumMeckel’s diverticulum Remnant of vitelline duct in distal ileumRemnant of vitelline duct in distal ileum Most common cause of small bowel bleeding inMost common cause of small bowel bleeding in

patients under the age of 25 years oldpatients under the age of 25 years old

Ectopic gastric tissue causes ulcerationEctopic gastric tissue causes ulceration IntussusceptionIntussusception Inverted Meckel’s, angioectasias, submucosal tumorsInverted Meckel’s, angioectasias, submucosal tumors



Small Bowel BleedingSmall Bowel BleedingInflammatory LesionsInflammatory Lesions

Crohn’s DiseaseCrohn’s Disease

Isolated ulcersIsolated ulcers

Idiopathic ulcersIdiopathic ulcers Nonsteroidal antiinflammatory drugsNonsteroidal antiinflammatory drugs

IschemicIschemic

Other Other Vasculitis, Zollinger-Ellison syndrome, CeliacVasculitis, Zollinger-Ellison syndrome, Celiac

diseasedisease



Small Bowel BleedingSmall Bowel BleedingRare CausesRare Causes

HemobiliaHemobilia Neoplasm, vascular aneurysm, liver abscess, trauma,Neoplasm, vascular aneurysm, liver abscess, trauma,

liver biopsyliver biopsy

Hemosuccus pancreaticusHemosuccus pancreaticus Pancreatic pseudocysts, pancreatitis, neoplasmsPancreatic pseudocysts, pancreatitis, neoplasms

Erosion into a vessel with communication with PDErosion into a vessel with communication with PD

InfectionsInfections Cytomegalovirus, histoplasmosis, TbCytomegalovirus, histoplasmosis, Tb



Obscure GI BleedingObscure GI BleedingSummary CausesSummary Causes



Obscure GI BleedingObscure GI BleedingSmall Bowel VisualizationSmall Bowel Visualization

Difficult to visualizeDifficult to visualize

Length (6.7 m)Length (6.7 m)Free intraperitoneal locationFree intraperitoneal location

Vigorous contractilityVigorous contractility

Overlying loopsOverlying loops




DiagnosisDiagnosis

UGI SBFTUGI SBFT EnteroclysisEnteroclysis

Push enteroscopyPush enteroscopy Double balloon enteroscopyDouble balloon enteroscopy Intraoperative enteroscopyIntraoperative enteroscopy

CT scanCT scan CT enteroclysisCT enteroclysis

MRIMRI

Video capsule endoscopyVideo capsule endoscopy



Obscure BleedingObscure BleedingSBFT and EnteroclysisSBFT and Enteroclysis

SBFTSBFT 0-5.6% diagnostic yield0-5.6% diagnostic yield

EnteroclysisEnteroclysis Superior to SBFTSuperior to SBFT Double contrast, Tube into proximal small bowelDouble contrast, Tube into proximal small bowel

Inject barium, methylcellulose, air Inject barium, methylcellulose, air

Performed with CT and MRIPerformed with CT and MRI

Only 10-21% diagnostic yieldOnly 10-21% diagnostic yield

Use if capsule endoscopy or enteroscopy unavailableUse if capsule endoscopy or enteroscopy unavailable



Obscure GI BleedingObscure GI BleedingNuclear ScansNuclear Scans

Technetium (99mTc) sulfur colloidTechnetium (99mTc) sulfur colloid

Technetium 99m-labeled red blood cell scan (TRBC)Technetium 99m-labeled red blood cell scan (TRBC) Most commonly used methodMost commonly used method Long half life allows for repeat scanning in 24 hoursLong half life allows for repeat scanning in 24 hours Late pooled blood may not identify bleeding siteLate pooled blood may not identify bleeding site

Requires bleeding rate of 0.1 to 0.4 mL/minRequires bleeding rate of 0.1 to 0.4 mL/min

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

immediately positiveimmediately positiveData in obscure bleeding limitedData in obscure bleeding limited 15% false positive, 12-23% false negative15% false positive, 12-23% false negative Need verification by angiography or endoscopyNeed verification by angiography or endoscopy



Obscure GI BleedingObscure GI Bleeding Angiography Angiography

Severe bleedingSevere bleeding

Bleeding rate of 0.5 mL/minBleeding rate of 0.5 mL/min

Positive in 27-77% of acute LGI bleedingPositive in 27-77% of acute LGI bleeding

Positive in 61-72% if,Positive in 61-72% if, Pt actively bleeding requiring transfusionPt actively bleeding requiring transfusion Hemodynamic compromiseHemodynamic compromise TRBC scan shows an immediate blushTRBC scan shows an immediate blush

Administer anticoagulants, vasodilators, clot- Administer anticoagulants, vasodilators, clot-lysing agents to precipitate bleedinglysing agents to precipitate bleeding Increased diagnostic yield from 32 to 65%Increased diagnostic yield from 32 to 65% 17% complication rate including excessive bleeding17% complication rate including excessive bleeding



Obscure BleedingObscure BleedingEnteroscopyEnteroscopy

Pass scope beyond the ligament of TreitzPass scope beyond the ligament of Treitz Adult or pediatric colonoscope, SB Adult or pediatric colonoscope, SB

enteroscopeenteroscope

Diagnostic yield : 40-50%Diagnostic yield : 40-50%

Angiodysplasia in 80% Angiodysplasia in 80%

Advantage over capsule endoscopy Advantage over capsule endoscopy Sample tissueSample tissue

Endoscopic therapyEndoscopic therapy



Obscure BleedingObscure BleedingIntraoperative EnteroscopyIntraoperative Enteroscopy

Transfusion dependentTransfusion dependent

Severe blood lossSevere blood loss

Risk of continued bleeding outweigh the risk of Risk of continued bleeding outweigh the risk of laparotomylaparotomy

Identifies bleeding source in 70 – 100%Identifies bleeding source in 70 – 100%

Technically difficultTechnically difficult Adhesions, luminal blood, infiltrating neoplasia Adhesions, luminal blood, infiltrating neoplasia

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

ileus, ischemia, wound infection, pneumoniaileus, ischemia, wound infection, pneumonia Mortality 11%Mortality 11%



Obscure GI BleedingObscure GI BleedingIntraoperative EnteroscopyIntraoperative Enteroscopy



Obscure GI BleedingObscure GI BleedingExploratory LaparotomyExploratory Laparotomy

Seldom without intraoperative enteroscopySeldom without intraoperative enteroscopy65% of 37 pt’s had lesion identified by65% of 37 pt’s had lesion identified by

palpation or transilluminationpalpation or transillumination



1. The PillCam™ Capsule

2. SensorArray™ SB

3. Given® DataRecorder™

PillCam™ SB Exam SetPillCam™ SB Exam Set

2

1

3



Wireless Capsule EndoscopyWireless Capsule EndoscopyPatient ExperiencePatient Experience

Sensors placed andSensors placed andattached to dataattached to datarecorder recorder

Easily ingested,Easily ingested,painless procedurepainless procedure

Progresses naturallyProgresses naturallythrough the GI tractthrough the GI tract

via peristalsisvia peristalsisTransmits images toTransmits images todata recorder data recorder



PillCam™ SBPillCam™ SB Patient ExperiencePatient Experience

Liquid diet from lunch the day beforeLiquid diet from lunch the day before

Movie Prep the night beforeMovie Prep the night before

12 hour fast the night before12 hour fast the night beforeCapsule ingested in the morningCapsule ingested in the morning

Reglan or erythromycin for inpatientsReglan or erythromycin for inpatients

Liquid diet after 2 hoursLiquid diet after 2 hoursLight meal 4 hours after ingestionLight meal 4 hours after ingestion

Disconnect after 8 hoursDisconnect after 8 hours

Ob GI Bl diOb GI Bl di



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

82.6 %82.6 %Negative predictiveNegative predictivevaluevalue

97.0 %97.0 %Positive predictivePositive predictive

valuevalue

95.0 %95.0 %

SpecificitySpecificity

88.9 %88.9 %SensitivitySensitivity

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

Obscure GI BleedingObscure GI BleedingPillCam™ SBPillCam™ SB




PillCamPillCamTMTM

SBSB

CE results led to treatments resolvingCE results led to treatments resolving

thethe bleeding in 86.9% of patientsbleeding in 86.9% of patients

undergoing the procedure while activelyundergoing the procedure while activelybleeding.bleeding.

(12 – 25 month follow up)(12 – 25 month follow up)




If done early in the course of the workup,If done early in the course of the workup,

PillCamPillCam™™ endoscopy could:endoscopy could:

Shorten considerably the time to diagnosisShorten considerably the time to diagnosisLead to definitive treatment in a relevantLead to definitive treatment in a relevant

proportion of patientsproportion of patients

Spare a number Spare a number of alternative investigations withof alternative investigations with

low diagnostic yieldlow diagnostic yield


Pennazio et al. 2004 ConclusionPennazio et al. 2004 Conclusion




Obscure GI BleedingObscure GI BleedingPillCamPillCamTMTM SBSB

StudyStudy SensitivitySensitivity (%)(%)

Specificity (%)Specificity (%) PPVPPV (%)(%) NPV (%)NPV (%)

Pennazio etPennazio etal.al.

Gastro 2004Gastro 2004

88.988.9 9595 9797 82.682.6

Delvaux et al.Delvaux et al.Endoscopy Endoscopy 20042004

94.494.4 100100

Botelberge etBotelberge et

al.al.ICCE 2005 ICCE 2005

91.691.6 86.386.3 8888 90.490.4

Hartmann etHartmann etal.al.GIE 2005 GIE 2005

9595 7575 9595 8686



First line diagnostic exam for visualization of First line diagnostic exam for visualization of small bowel mucosa.small bowel mucosa.

Clinical data reviewed 32 independent studiesClinical data reviewed 32 independent studieswhich indicate CE diagnostic yield of 71% vs.which indicate CE diagnostic yield of 71% vs.

41% diagnostic yield for all other modalities41% diagnostic yield for all other modalities combinedcombined11

Established as gold standard for diagnosis of Established as gold standard for diagnosis of disease of small intestinedisease of small intestine22

Now cleared in the US for pediatric populationNow cleared in the US for pediatric population from 10-18 years oldfrom 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™ SBPillCam™ SBIndicationsIndications



In patients with known or suspected gastrointestinalIn patients with known or suspected gastrointestinal

obstruction, strictures, or fistulas based on theobstruction, strictures, or fistulas based on the

clinical picture or pre-procedure testing and profile.clinical picture or pre-procedure testing and profile.

In patients with cardiac pacemakers or other In patients with cardiac pacemakers or other

implanted electromedical devicesimplanted electromedical devices11..

In patients with swallowing disorders.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™ SBPillCam™ SBContraindicationsContraindications




CausesCauses Visualized by PillCamVisualized by PillCamTMTM

Vascular LesionsVascular Lesions Angioectasias Angioectasias

NeoplasmsNeoplasms

Inflammatory LesionsInflammatory Lesions

Ulcers, Crohn’s DiseaseUlcers, Crohn’s DiseaseOther Other Diverticula, varicesDiverticula, varices



PillCamPillCamTMTM SBSBNormal EsophagusNormal Esophagus



PillCamPillCamTMTM SBSBNormal StomachNormal Stomach



PillCamPillCamTMTM SBSBNormalNormal



PillCamPillCamTMTM SBSBVascular LesionsVascular Lesions



PillCamPillCamTMTM SBSBVascular LesionsVascular Lesions



PillCam™ SBPillCam™ SBCrohn´s DiseaseCrohn´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



PillCamPillCamTMTM SBSB Celiac Image SpectrumCeliac Image Spectrum



PillCam™ SBPillCam™ SBUlcersUlcers



PillCam™ SBPillCam™ SBPolyps and MassesPolyps and Masses



PillCam™ SBPillCam™ SBDiverticulaDiverticula



Wireless Capsule EndoscopyWireless Capsule EndoscopySummarySummary

Time efficient, patient friendly, sensitiveTime efficient, patient friendly, sensitive

method to visualize the small bowelmethod to visualize the small bowel

DisadvantagesDisadvantages No therapeuticsNo therapeutics

Unable to control movementUnable to control movement

Unable to clear bubbles and debrisUnable to clear bubbles and debris

D bl B ll E tD bl B ll E t



Double Balloon EnteroscopyDouble Balloon Enteroscopy

First described by Yamamoto in 2001First described by Yamamoto in 2001

Allows the diagnosis and treatment of disease Allows the diagnosis and treatment of disease

along the entire length of the small bowelalong the entire length of the small bowel

Entire SB visualized in 86% of patients (Yamamoto)Entire SB visualized in 86% of patients (Yamamoto)

Fujinon enteroscope overtube systemFujinon enteroscope overtube system 230 cm total length230 cm total length

200-cm working length200-cm working length

140-cm overtube140-cm overtube

2.8 mm channel for biopsy and therapeutic intervention2.8 mm channel for biopsy and therapeutic intervention

D bl B ll E




Also called “push-pull enteroscopy” Also called “push-pull enteroscopy”

Advanced antegrade or retrograde Advanced antegrade or retrograde

Patient PrepPatient Prep Antegrade: NPO 6-8 hrs Antegrade: NPO 6-8 hrs

Retrograde: Colo prepRetrograde: Colo prep

Moderate sedation, propofol, or generalModerate sedation, propofol, or generalanesthesiaanesthesia



Double Balloon EnteroscopyDouble Balloon EnteroscopyComplicationsComplications

2/178 procedures (1.1%) by Yamamoto2/178 procedures (1.1%) by Yamamoto Post procedure fever and abdominal painPost procedure fever and abdominal pain

PerforationPerforation

40/2362 procedures (1.7%) by Mensink40/2362 procedures (1.7%) by Mensink 13/1728 diagnostic procedures (0.8%)13/1728 diagnostic procedures (0.8%)

27/634 therapeutic procedures (4.3%)27/634 therapeutic procedures (4.3%)

12/364 post polypectomy bleeding (3.3%)12/364 post polypectomy bleeding (3.3%)

3/253 post APC perforation (1.2%)3/253 post APC perforation (1.2%)

2/70 post balloon dilations perforation (2.9%)2/70 post balloon dilations perforation (2.9%)



Courtesy of Fujinon and Yamamoto H et al









Antegrade (oral) DBE Retrograde (anal) DBE

D bl B ll E tD bl B ll E t




ContraindicationsContraindications

Non-cooperative patientNon-cooperative patient

Prior intestinal perforationPrior intestinal perforation AAA AAA

Excessive deformity of cervical spineExcessive deformity of cervical spine

Yi ld f S ll B l I iYi ld f S ll B l I i



Yield of Small Bowel ImagingYield of Small Bowel Imaging

Modalities in Obscure GI BleedingModalities in Obscure GI Bleeding

Length of Length of InsertionInsertion

YieldYield

DBEDBE Up to 100%Up to 100% 61 – 85%61 – 85%

PEPE 50 – 150 cm50 – 150 cm 15 – 50%15 – 50%

WCEWCE 100% SB100% SB 45 – 75%45 – 75%

IOEIOE Up to 100%Up to 100% 55 – 100%55 – 100%

RadiologyRadiology 100%100% 5%5%

GIE 2005, 61:6:709-714

Ob GI Bl di



Obscure GI BleedingObscure GI BleedingManagementManagement

ResuscitationResuscitation Iron supplementation, correct coagulopathy andIron supplementation, correct coagulopathy and

platelet abnormalities, intermittent blood transfusionsplatelet abnormalities, intermittent blood transfusions

Endoscopic treatmentEndoscopic treatment Angiography Angiography

PharmacotherapyPharmacotherapy Estrogen therapyEstrogen therapy

OctreotideOctreotide

SurgerySurgery




Obscure GI BleedingObscure GI BleedingEvaluationEvaluation

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



Th F tTh F t



The FutureThe FutureRoboticsRobotics





The Magic PillThe Magic Pill




Obscure GI BleedingObscure GI BleedingEvaluationEvaluation

Repeat EGD and Colonoscopy (~ 35% yield)

If negative

Capsule Endoscopy

If negative

Repeat Capsule Endoscopy

If negative

Double Balloon Enteroscopy

If negative

Intraoperative Enteroscopy in selected cases

GIE 2004;60:5:711 713

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ObscureGIBleeding