Jonathan A. Leighton, MD, FACG
Occult and Overt Obscure Gastrointestinal Bleeding
Occult and Overt Obscure Gastrointestinal Bleeding
Jonathan A. Leighton, MDJonathan A. Leighton, MD
Obscure Gastrointestinal Bleeding
Scan, Scope or Surgery?
Obscure Gastrointestinal Bleeding
Scan, Scope or Surgery?
g ,Mayo Clinic in Arizona
ACG Regional CourseJanuary 2013
g ,Mayo Clinic in Arizona
ACG Regional CourseJanuary 2013
Case StudyCase Study
• 49 yr old woman• Intermittent mild iron deficiency
• 49 yr old woman• Intermittent mild iron deficiency• Intermittent mild iron-deficiency
anemia for 2 yr• 3 mo transfusion-dependent
anemia• Hg 4.7 g/dl, 5.7 g/dl, 7.6 g/dl
• Dark formed stool on iron
• Intermittent mild iron-deficiency anemia for 2 yr
• 3 mo transfusion-dependent anemia• Hg 4.7 g/dl, 5.7 g/dl, 7.6 g/dl
• Dark formed stool on ironDark formed stool on iron• EGD, push enteroscopy,
colonoscopy, SBFT normal
Dark formed stool on iron• EGD, push enteroscopy,
colonoscopy, SBFT normal
What next?
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1
Jonathan A. Leighton, MD, FACG
Obscure Gastrointestinal Bleeding (OGIB)Definition
Obscure Gastrointestinal Bleeding (OGIB)Definition
• Obscure bleeding - bleeding of unknown origin that persists or recurs
• Obscure overt (visible blood)
• Obscure occult (positive FOBT or IDA)
• Obscure bleeding - bleeding of unknown origin that persists or recurs
• Obscure overt (visible blood)
• Obscure occult (positive FOBT or IDA)Obscure occult (positive FOBT or IDA)
• Normal upper and lower endoscopy
Obscure occult (positive FOBT or IDA)
• Normal upper and lower endoscopy
Historical Challenges Related to the Evaluation of “Obscure GI Bleeding”Historical Challenges Related to the Evaluation of “Obscure GI Bleeding”
• High miss rate for lesions on initial upper and• High miss rate for lesions on initial upper and• High miss rate for lesions on initial upper and lower endoscopy
• The need for invasive intra-operative enteroscopy and exploratory laparotomy to adequately examine the small bowel
• Limited capacity of older diagnostic modalities to
• High miss rate for lesions on initial upper and lower endoscopy
• The need for invasive intra-operative enteroscopy and exploratory laparotomy to adequately examine the small bowel
• Limited capacity of older diagnostic modalities to• Limited capacity of older diagnostic modalities to adequately examine the small bowel
• Finding a lesion in the small bowel doesn’t always mean that is the source of the problem
• Limited capacity of older diagnostic modalities to adequately examine the small bowel
• Finding a lesion in the small bowel doesn’t always mean that is the source of the problem
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Jonathan A. Leighton, MD, FACG
The Challenge…..Is this the cause of bleeding?
The Challenge…..Is this the cause of bleeding?
Pasha et al: Clin Gastro Hep 2008;6:671Ragu et al: Gastro 2007;133;1697Gerson: GIE 2008;68:920
Pasha et al: Clin Gastro Hep 2008;6:671Ragu et al: Gastro 2007;133;1697Gerson: GIE 2008;68:920
Uncertainty whether angiodysplasia detection and ablation affect long-term outcome because most angiodysplasia not actively bleeding when detected
Bleeding source found in up to 80%, but rebleeding occurs in as many as 30%
Small Intestine (SI) BleedingSmall Intestine (SI) Bleeding
Dieulafoy’s lesion
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Jonathan A. Leighton, MD, FACG
Diagnostic Approach in Patients with “Obscure GI Bleeding”
Diagnostic Approach in Patients with “Obscure GI Bleeding”
• Document objective evidence of gastrointestinal bleeding
• Exclude hematologic causes for anemia• Exclude malabsorption
• Sufficiently rule out an upper and lower
• Document objective evidence of gastrointestinal bleeding
• Exclude hematologic causes for anemia• Exclude malabsorption
• Sufficiently rule out an upper and lower y ppgastrointestinal tract bleeding source with second-look endoscopy as indicated
• Then proceed with a small bowel evaluation
y ppgastrointestinal tract bleeding source with second-look endoscopy as indicated
• Then proceed with a small bowel evaluation
Etiology of Obscure GI BleedingEtiology of Obscure GI Bleeding
Vascular
Angiodysplasia
Vascular
Angiodysplasia
Inflammatory
Inflammatory bowel
Inflammatory
Inflammatory bowel
Neoplastic
Carcinoid
Neoplastic
CarcinoidAngiodysplasia
Hemangioma
Dieulafoy lesion
Portal hypertensive enteropathy
Varices
Angiodysplasia
Hemangioma
Dieulafoy lesion
Portal hypertensive enteropathy
Varices
Inflammatory bowel disease
NSAID enteropathy
Celiac disease
Autoimmune enteropathy
Inflammatory bowel disease
NSAID enteropathy
Celiac disease
Autoimmune enteropathy
Carcinoid
GIST
Adenocarcinoma
Lymphoma
Metastases
Carcinoid
GIST
Adenocarcinoma
Lymphoma
Metastases
Obscure Gastrointestinal BleedingNot Obscure Anymore
Obscure Gastrointestinal BleedingNot Obscure AnymoreTruly Obscure Etiologies
• Hemobilia • Hemosuccus pancreaticus • Vasculitis
Truly Obscure Etiologies• Hemobilia • Hemosuccus pancreaticus • Vasculitis
Radiation enteritisRadiation enteritis
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Jonathan A. Leighton, MD, FACG
Vascular
Angiodysplasia
Vascular
Angiodysplasia
Inflammatory
Inflammatory bowel
Inflammatory
Inflammatory bowel
Neoplastic
Carcinoid
Neoplastic
Carcinoid
Etiology of Suspected SI BleedingEtiology of Suspected SI Bleeding
Angiodysplasia
Hemangioma
Dieulafoy lesion
Portal hypertensive enteropathy
Varices
Angiodysplasia
Hemangioma
Dieulafoy lesion
Portal hypertensive enteropathy
Varices
Inflammatory bowel disease
NSAID enteropathy
Celiac disease
Autoimmune enteropathy
Inflammatory bowel disease
NSAID enteropathy
Celiac disease
Autoimmune enteropathy
Carcinoid
GIST
Adenocarcinoma
Lymphoma
Metastases
Carcinoid
GIST
Adenocarcinoma
Lymphoma
Metastases
Obscure Gastrointestinal BleedingNot Obscure Anymore
Obscure Gastrointestinal BleedingNot Obscure AnymoreTruly Obscure Etiologies
• Hemobilia • Hemosuccus pancreaticus • Vasculitis
Truly Obscure Etiologies• Hemobilia • Hemosuccus pancreaticus • Vasculitis
Radiation enteritisRadiation enteritis
Obscure GI BleedingObscure GI Bleeding
Management of Suspected SI BleedingManagement of Suspected SI Bleeding
Obscure GI BleedingObscure GI Bleeding
Repeat EGD and colonoscopyRepeat EGD and colonoscopy
Push enteroscopyll b l t l i
Push enteroscopyll b l t l i
AngiogramIntraoperative Endoscopy
AngiogramIntraoperative Endoscopy
small bowel x-ray or enteroclysissmall bowel x-ray or enteroclysis
Zuckerman et al: AGA position statement and review, Gastroenterology 2000; 118;197, 201Zuckerman et al: AGA position statement and review, Gastroenterology 2000; 118;197, 201
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Jonathan A. Leighton, MD, FACG
Obscure GI BleedingObscure GI Bleeding
Management of Suspected SI BleedingManagement of Suspected SI Bleeding
Obscure GI BleedingObscure GI Bleeding
Repeat EGD and colonoscopyRepeat EGD and colonoscopy
Push enteroscopyll b l t l i
Push enteroscopyll b l t l i
AngiogramIntraoperative Endoscopy
AngiogramIntraoperative Endoscopy
small bowel x-ray or enteroclysissmall bowel x-ray or enteroclysis
Zuckerman et al: AGA position statement and review, Gastroenterology 2000; 118;197, 201Zuckerman et al: AGA position statement and review, Gastroenterology 2000; 118;197, 201
Middle GI Tract BleedingMiddle GI Tract Bleeding
TodayToday
Upper GIUpper GI Upper GIUpper GI
Middle GIMiddle GI
Ell et al: Endoscopy 2006;38:73; Raju et al: Gastroenterology 2007;133:1697Ell et al: Endoscopy 2006;38:73; Raju et al: Gastroenterology 2007;133:1697
Lower GILower GI Lower GILower GI
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Jonathan A. Leighton, MD, FACG
Our Case: Suspected SI Bleeding49 yo female with transfusion dependent
recurrent IDA
Our Case: Suspected SI Bleeding49 yo female with transfusion dependent
recurrent IDA
• Single bleeding nodule
• 30% of small bowel transit
• Single bleeding nodule
• 30% of small bowel transitWhat Next?
Case StudyCase Study
Antegrade Deep Enteroscopy
• 200cm beyond pylorus
• Mid to distal jejunum
• Bleeding nodule: hemangioma?
Antegrade Deep Enteroscopy
• 200cm beyond pylorus
• Mid to distal jejunum
• Bleeding nodule: hemangioma?
• APC hemostasis• APC hemostasis
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Jonathan A. Leighton, MD, FACG
Capsule EndoscopyCapsule Endoscopy
Hartmann D et al: Endoscopy 39:1041-1045, 2007Cave D et al: GI Endoscopy 68:487-494, 2008Hartmann D et al: Endoscopy 39:1041-1045, 2007Cave D et al: GI Endoscopy 68:487-494, 2008
Yield of CE Compared to Other Modalities
Yield of CE Compared to Other Modalities
• Range: 45-83%• Range: 45-83%
• Entire small bowel seen in 80-90%
• CE had an incremental yield of 30% and 36% compared to Push Enteroscopy and SBFT, respectively
• Main utility of CE lies in its high positive predictive value (94-97%) and its high negative
• Entire small bowel seen in 80-90%
• CE had an incremental yield of 30% and 36% compared to Push Enteroscopy and SBFT, respectively
• Main utility of CE lies in its high positive predictive value (94-97%) and its high negativepredictive value (94-97%) and its high negative predictive value (83-100%)
• It can identify a bleeding lesion and help direct further therapeutic intervention and/or surgery
predictive value (94-97%) and its high negative predictive value (83-100%)
• It can identify a bleeding lesion and help direct further therapeutic intervention and/or surgery
Triester SL et al: Am J Gastro 2005;100:2407-18Pennazio M et al: Gastro 2004;126643-53Delvaux M et al: Endoscopy 2004;36:1067-73
Triester SL et al: Am J Gastro 2005;100:2407-18Pennazio M et al: Gastro 2004;126643-53Delvaux M et al: Endoscopy 2004;36:1067-73
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Jonathan A. Leighton, MD, FACG
“Deep Enteroscopy”Tube or Balloon Assisted Enteroscopy
“Deep Enteroscopy”Tube or Balloon Assisted Enteroscopy
Double-Balloon Enteroscopy (DBE)
Double-Balloon Enteroscopy (DBE)
Single-Balloon Enteroscopy (SBE)
Single-Balloon Enteroscopy (SBE)
Spiral Overtube Enteroscopy
Spiral Overtube Enteroscopy
Forcep channel allows biopsy and therapyForcep channel allows biopsy and therapy
Deep EnteroscopyDeep Enteroscopy
• Overall diagnostic yield: ~ 60% ( 41%-80%)• Overall diagnostic yield: ~ 60% ( 41%-80%)
• Channel allows therapeutic interventions
• Total enteroscopy is possible using both routes in ~ 50-70% of cases
• More invasive and often requires anesthesia with MAC or general endotracheal
• Channel allows therapeutic interventions
• Total enteroscopy is possible using both routes in ~ 50-70% of cases
• More invasive and often requires anesthesia with MAC or general endotracheal
• Resource utilization is high with procedure duration >60min and need for assistants, anesthesia, fluoroscopy
• Complications low at 1-3% but do occur
• Resource utilization is high with procedure duration >60min and need for assistants, anesthesia, fluoroscopy
• Complications low at 1-3% but do occur
Gerson: Clin Gastr Hep 2009;7:828Ragu et al: Gastro 2007;133;1697Gerson: Clin Gastr Hep 2009;7:828Ragu et al: Gastro 2007;133;1697
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Jonathan A. Leighton, MD, FACG
Comparing Deep Enteroscopy Methods
Comparing Deep Enteroscopy Methods
• All f l t h i• All f l t h i• All are useful techniques• Similar yield, safety, learning curve• Spiral may allow faster intubation
• Overtubes and balloons• DBE has latex (allergy); others don’t
O t b ti i il t
• All are useful techniques• Similar yield, safety, learning curve• Spiral may allow faster intubation
• Overtubes and balloons• DBE has latex (allergy); others don’t
O t b ti i il t• Overtubes: one-time use, similar cost
• Altered anatomy (Billroth, gastric bypass)• All can reach bypassed stomach• All allow successful ERCP
• Overtubes: one-time use, similar cost
• Altered anatomy (Billroth, gastric bypass)• All can reach bypassed stomach• All allow successful ERCP
• No difference in overall yield between CE and DBE• No difference in overall yield between CE and DBE
Meta-Analysis of CE vs DBE8 Studies
Meta-Analysis of CE vs DBE8 Studies
No difference in overall yield between CE and DBE (OR 1.21 [95%CI:0.64-2.29])
• However, CE had a higher yield compared to DBE using a single approach (OR 1.61 [95%CI:1.07-2.43])
• But CE had a significantly lower yield compared to DBE using a combined approach (OR 0.12 [95%CI:0 03-0 52])
No difference in overall yield between CE and DBE (OR 1.21 [95%CI:0.64-2.29])
• However, CE had a higher yield compared to DBE using a single approach (OR 1.61 [95%CI:1.07-2.43])
• But CE had a significantly lower yield compared to DBE using a combined approach (OR 0.12 [95%CI:0 03-0 52])[95%CI:0.03-0.52])[95%CI:0.03-0.52])
Chen X et al: World J Gastro 2007;13:4372-8Chen X et al: World J Gastro 2007;13:4372-8
This reinforces the importance of total enteroscopy with DBEin patients with a high clinical suspicion for a SI lesion
This reinforces the importance of total enteroscopy with DBEin patients with a high clinical suspicion for a SI lesion
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Jonathan A. Leighton, MD, FACG
Case Study Case Study
35 yr old man
• A t GI h h
35 yr old man
• A t GI h h• Acute GI hemorrhage• Maroon stools, 6 units transfusion
• Negative EGD, push enteroscopy, colonoscopy, SBFT, CT, Meckel’s scan
Capsule endoscopy
• Blood in mid small intestine
• Acute GI hemorrhage• Maroon stools, 6 units transfusion
• Negative EGD, push enteroscopy, colonoscopy, SBFT, CT, Meckel’s scan
Capsule endoscopy
• Blood in mid small intestine• Blood in mid small intestine, source not seen
• Nodular mucosa: unsure if normal lymphoid tissue (vs lesion)
• Blood in mid small intestine, source not seen
• Nodular mucosa: unsure if normal lymphoid tissue (vs lesion)
Antegrade DBE performed and negative
Lower DBE: 100 cm proximal to ileocecal valveLower DBE: 100 cm proximal to ileocecal valve
Case StudyCase Study
Meckel’s Diverticulum with UlcerMeckel’s Diverticulum with Ulcer
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Jonathan A. Leighton, MD, FACG
Case StudyMeckel’s Diverticulum with Ulcer
Case StudyMeckel’s Diverticulum with Ulcer
View inside diverticulum; View inside diverticulum; light, raised mucosa was light, raised mucosa was gastricgastric--type mucosa on type mucosa on
biopsybiopsy
Opening of diverticulum Opening of diverticulum with healing ulcerwith healing ulcer
Newer Radiologic ProceduresNewer Radiologic Procedures
Cross-sectional imaging (CTE, CTA, MRE)Cross-sectional imaging (CTE, CTA, MRE)
• May identify SI angiodysplasia, tumors, inflammation
• Diagnostic yield 10-40% (vs 50-80% CE)
• Consider before capsule if concern for obstruction
• May identify SI angiodysplasia, tumors, inflammation
• Diagnostic yield 10-40% (vs 50-80% CE)
• Consider before capsule if concern for obstruction
Pasha et al: Gasto Hep 2009;12:839; Triester: AJG 2005;100:2407Pasha et al: Clin Gastro Hep 2008;6:671; Ragu et al: Gastro 2007;133;1697Gerson: GIE 2008;68:920
Pasha et al: Gasto Hep 2009;12:839; Triester: AJG 2005;100:2407Pasha et al: Clin Gastro Hep 2008;6:671; Ragu et al: Gastro 2007;133;1697Gerson: GIE 2008;68:920
• Consider if ongoing bleeding despite negative capsule or deep enteroscopy, especially if IBD or tumor suspected
• Consider if ongoing bleeding despite negative capsule or deep enteroscopy, especially if IBD or tumor suspected
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Jonathan A. Leighton, MD, FACG
CE Compared to Angiography forAcute Overt Obscure GI BleedingCE Compared to Angiography forAcute Overt Obscure GI Bleeding
• 60 patients with melena or hematochezia and nondiagnostic upper and lower endoscopy
• Randomized to CE vs Angiography and then folllowed for up to 5 years
• Results:• Diagnostic yield CE vs Angio:
• 60 patients with melena or hematochezia and nondiagnostic upper and lower endoscopy
• Randomized to CE vs Angiography and then folllowed for up to 5 years
• Results:• Diagnostic yield CE vs Angio:Diagnostic yield CE vs Angio:
• 53.3% vs 20.0%, p=0.016• Rebleeding risk CE vs Angio:
• 33.3% vs 16.7%, p=0.10• Long-term outcomes no different
Diagnostic yield CE vs Angio: • 53.3% vs 20.0%, p=0.016
• Rebleeding risk CE vs Angio: • 33.3% vs 16.7%, p=0.10
• Long-term outcomes no different
Leung WK et al. AJG 2012;107:1370-1376Leung WK et al. AJG 2012;107:1370-1376
CE as a Screening Tool Prior to Deep Enteroscopy
CE as a Screening Tool Prior to Deep Enteroscopy
• CE transit times are useful: • CE transit times are useful: • Antegrade approach for lesions within the
proximal 75% based on transit time• Retrograde for more distal lesions
• Increases both the diagnostic (73-93%) and therapeutic (57-73%) yield
• Antegrade approach for lesions within the proximal 75% based on transit time
• Retrograde for more distal lesions
• Increases both the diagnostic (73-93%) and therapeutic (57-73%) yield
Gay G et al: Endoscopy 2006;38:49-58Kaffes Aj et al: GIE 2007;66:304-9Hendel JW et al: Scan J Gastro 2008;43:363-7
Gay G et al: Endoscopy 2006;38:49-58Kaffes Aj et al: GIE 2007;66:304-9Hendel JW et al: Scan J Gastro 2008;43:363-7
• A negative CE allows for the avoidance of Deep Enteroscopy in patients with a low pre-test probability for SI findings
• A negative CE allows for the avoidance of Deep Enteroscopy in patients with a low pre-test probability for SI findings
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Jonathan A. Leighton, MD, FACG
CE Before Deep EnteroscopyCE Before Deep Enteroscopy
62 yo male presented with a hemoglobin of 2: colonoscopy negative and upper endoscopy showed
62 yo male presented with a hemoglobin of 2: colonoscopy negative and upper endoscopy showedcolonoscopy negative and upper endoscopy showed
angioectasia in the stomachcolonoscopy negative and upper endoscopy showed
angioectasia in the stomach
CE-Guided Deep EnteroscopyMay Not Always Be ApplicableCE-Guided Deep EnteroscopyMay Not Always Be Applicable
• CE has been found to have a false negative rate of 11% for all SI findings and 19% for neoplasms
• There are reports of neoplasms missed on CE and diagnosed on Deep Enteroscopy
• Th f i ti t ith ti CE b t
• CE has been found to have a false negative rate of 11% for all SI findings and 19% for neoplasms
• There are reports of neoplasms missed on CE and diagnosed on Deep Enteroscopy
• Th f i ti t ith ti CE b t• Therefore, in patients with a negative CE but a high clinical suspicion, CTE and/or total enteroscopy should be pursued
• Therefore, in patients with a negative CE but a high clinical suspicion, CTE and/or total enteroscopy should be pursued
Kamalaporn P et al: Can J Gastro 2008;22:491-5Jones BH et al: Am J Gastro 2005;100:1058-64Ross A et al: Dig Dis Sci 2008;53:2140-3Postgate A et al: GIE 2008;68:1209-14Pasha SF et al: Nat Clin Pract GastroHep 2008;5:490-1
Kamalaporn P et al: Can J Gastro 2008;22:491-5Jones BH et al: Am J Gastro 2005;100:1058-64Ross A et al: Dig Dis Sci 2008;53:2140-3Postgate A et al: GIE 2008;68:1209-14Pasha SF et al: Nat Clin Pract GastroHep 2008;5:490-1
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Jonathan A. Leighton, MD, FACG
Surgery for Suspected SI BleedingSurgery for Suspected SI Bleeding
• In most cases, can be avoided except for• In most cases, can be avoided except forIn most cases, can be avoided except for tumor resection
• Indicated for patients who continue to bleed and have had negative endoscopic and radiologic workups, and are operative candidates.
In most cases, can be avoided except for tumor resection
• Indicated for patients who continue to bleed and have had negative endoscopic and radiologic workups, and are operative candidates.
• Laparoscopy combined with deep enteroscopy may be helpful in a subset of patients
• Laparoscopy combined with deep enteroscopy may be helpful in a subset of patients
Zuckerman GR et al: Gastro 118:201-221, 2000; Ress AM et al: Am J Surg 163:94-98, 1992; Szold A et al: Am J Surg 163:90-92, 1992Zuckerman GR et al: Gastro 118:201-221, 2000; Ress AM et al: Am J Surg 163:94-98, 1992; Szold A et al: Am J Surg 163:90-92, 1992
Reasonable Approach to SI Bleeding
Reasonable Approach to SI Bleeding
• Individualize based on clinical presentation
• Intermittent overt/occult CE
• Acute ongoing overt BAE
• Obstructive symptoms CTE/MRE
• Individualize based on clinical presentation
• Intermittent overt/occult CE
• Acute ongoing overt BAE
• Obstructive symptoms CTE/MRE• Obstructive symptoms CTE/MRE
• Controlled prospective clinical studies are needed to substantiate these recommendations
• Obstructive symptoms CTE/MRE
• Controlled prospective clinical studies are needed to substantiate these recommendations
Das A, Leighton J: Nat Clin Pract Gastro Hep 4(3):120Das A, Leighton J: Nat Clin Pract Gastro Hep 4(3):120--1, Mar 2007 1, Mar 2007
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Jonathan A. Leighton, MD, FACG
Case StudyCase Study
• 73 yo female with end stage liver disease presents with hematochezia. History of esophageal varices without stigmata of bleeding.
• Two EGDs, two colonoscopies, nuclear RBC scan negative
• 73 yo female with end stage liver disease presents with hematochezia. History of esophageal varices without stigmata of bleeding.
• Two EGDs, two colonoscopies, nuclear RBC scan negativeRBC scan negative.
• At Mayo, SB enteroscopy negative and bleeding continued.
• Retrograde BAE performed….
RBC scan negative.
• At Mayo, SB enteroscopy negative and bleeding continued.
• Retrograde BAE performed….
Retrograde BAE 150cm Proximal to IC Valve
Retrograde BAE 150cm Proximal to IC Valve
Jejunal Varix
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Jonathan A. Leighton, MD, FACG
What To Do In Clinical PracticeWhat To Do In Clinical Practice
Bringing it together
Integrating Capsule and Deep
Bringing it together
Integrating Capsule and DeepIntegrating Capsule and Deep Enteroscopy in suspected SI bleeding
Integrating Capsule and Deep Enteroscopy in suspected SI bleeding
Perform Capsule Endoscopy after Negative EGD and Colonoscopy (and perhaps second look endoscopy)
Review of Capsule EndoscopyAre findings equivocal and clinical suspicion low?
Consider repeat CE vs Cross-Sectional Imaging vs Observation
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Jonathan A. Leighton, MD, FACG
Perform Capsule Endoscopy after Negative EGD and Colonoscopy (and perhaps second look endoscopy)
Review of Capsule EndoscopyDefinite submucosal tumor with bleeding
Should patient go directly to surgery?If not, then Deep Enteroscopy should be planned
If Surgery Not Planned, Review of Capsule Endoscopy
Estimate Location to Plan Deep Enteroscopy Approach
If Surgery Not Planned, Review of Capsule Endoscopy
Estimate Location to Plan Deep Enteroscopy Approach
0% - 75%Start with Oral Approach0% - 75%Start with Oral Approach
0% Small Bowel Transit 0% Small Bowel Transit
75% - 100%Start with Anal Approach 75% - 100%Start with Anal Approach
Start with Oral Approach Start with Oral Approach
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Jonathan A. Leighton, MD, FACG
Positive Capsule
Approach to Possible SI LesionApproach to Possible SI Lesion
Suggests Vascular Suggests Tumor or
D E t if
Suggests Vascular Lesion
Treat Those in Reach with Push Enteroscopy
even if not bleeding
Suggests Tumor or Inflammation
Cross-Sectional
Consider Push Enteroscopy or
colonoscopy if in reach
Negative Capsule
If Serious Problem or
Mild Anemia or Low Suspicion – Observe
with Iron Therapy
Deep Enteroscopy if Symptoms Persist
For Mild Anemia, few angiodysplasia, observe with iron therapy, stop antiplatelet therapy if
possible
Otherwise proceed with Deep Enteroscopy if
findings might prevent surgery
Cross Sectional Imaging is considered
complimentary and often very helpful
If Serious Problem or Suspicion High, then proceed with Deep Enteroscopy and/or
Cross sectional Imaging
Suspected SI BleedingImportant Points to Remember
Suspected SI BleedingImportant Points to Remember
U i CE d D E t di tiU i CE d D E t di ti• Using CE and Deep Enteroscopy, diagnostic yield is 40-80%
• Overlooked upper or lower GI source common; consider second look endoscopy
• Capsule Endoscopy is next best test - Yield higher if done soon after overt bleeding
• Using CE and Deep Enteroscopy, diagnostic yield is 40-80%
• Overlooked upper or lower GI source common; consider second look endoscopy
• Capsule Endoscopy is next best test - Yield higher if done soon after overt bleeding
• Deep Enteroscopy and cross-sectional imaging are complimentary for detecting bleeding, tumors or inflammation
• Evaluate patient as close to bleeding episode as possible
• Deep Enteroscopy and cross-sectional imaging are complimentary for detecting bleeding, tumors or inflammation
• Evaluate patient as close to bleeding episode as possible
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