Elsevier

Gastrointestinal Endoscopy

Volume 72, Issue 3, September 2010, Pages 471-479
Gastrointestinal Endoscopy

Standards of practice
The role of endoscopy in the management of obscure GI bleeding

https://doi.org/10.1016/j.gie.2010.04.032Get rights and content

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, we performed a search of the medical literature by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).1 The strength of individual recommendations is based both upon the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as ā€œwe suggest,ā€ whereas stronger recommendations are typically stated as ā€œwe recommend.ā€

This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Section snippets

Background

Obscure GI bleeding (OGIB) is defined as occult or overt bleeding of unknown origin that persists or recurs after an initial negative endoscopic evaluation including colonoscopy and EGD. Overt OGIB is defined as visible GI bleeding (eg, melena or hematochezia) and can be categorized further as active (ie, evidence of ongoing bleeding) versus inactive bleeding. Although there are no standard criteria for defining occult OGIB, for the purposes of this document, OGIB is designated as occult when

EGD and colonoscopy

EGD is indicated for the initial evaluation of a suspected upper GI source of bleeding. Early endoscopic intervention has been associated with lower hospital cost; however, optimal timing after an episode of bleeding and the impact of early endoscopy on diagnostic yield have not been rigorously studied.18 Repeat examination may yield a source even when the initial EGD is negative. For example, in studies of patients with OGIB that used small-bowel technologies, suspected sources of bleeding

Diagnostic approach to patients with OGIB

The diagnostic approach to patients with OGIB depends upon clinical factors, such as the age of the patient, quality of the prior endoscopic evaluation, and the overt or occult status of the bleeding. Clinical clues, such as nasogastric tube aspirates and the nature of the bleeding (eg, melena vs hematochezia) can help direct the choice of endoscopic tests. In addition, local availability of procedures, patient preferences, physician expertise, risks, and costs are also important determinants

Therapeutic approach to patients with OGIB

Therapy for OGIB depends on the etiology of the bleeding. Lesions found within the reach of a standard endoscope can be treated with appropriate therapy such as electrocautery, argon plasma coagulation, injection therapy, mechanical hemostasis (eg, hemoclips or bands), or a combination of these techniques. More distal vascular lesions, such as angiectasias, may be approached for therapy via PE or deep enteroscopy, depending upon location. There is evidence that treatment has a positive impact

Recommendations

  • 1

    After appropriate resuscitation, we recommend emergent endoscopy or angiography in patients with massive OGIB. āŠ•āŠ•ā—‹ā—‹

  • 2

    We recommend urgent EGD in patients with active overt OGIB and a clinical presentation suggestive of upper GI bleeding. āŠ•āŠ•āŠ•ā—‹ For those with signs or symptoms of lower GI bleeding, we suggest repeating colonoscopy. āŠ•āŠ•ā—‹ā—‹ Otherwise, recommended diagnostic options include PE, VCE, and tagged red blood cell scintigraphy.

  • 3

    For those patients with inactive overt OGIB, we suggest VCE, deep

References (106)

  • F. Li et al.

    Retention of the capsule endoscope: a single-center experience of 1000 capsule endoscopy procedures

    Gastrointest Endosc

    (2008)
  • B. Petersen et al.

    Endoscopy in patients with implanted electronic devices

    Gastrointest Endosc

    (2007)
  • J. Macdonald et al.

    Negative capsule endoscopy in patients with obscure GI bleeding predicts low rebleeding rates

    Gastrointest Endosc

    (2008)
  • N. Viazis et al.

    Is there a role for second-look capsule endoscopy in patients with obscure GI bleeding after a nondiagnostic first test?

    Gastrointest Endosc

    (2009)
  • S. Bar-Meir et al.

    Second capsule endoscopy for patients with severe iron deficiency anemia

    Gastrointest Endosc

    (2004)
  • H. Yamamoto et al.

    Total enteroscopy with a nonsurgical steerable double-balloon method

    Gastrointest Endosc

    (2001)
  • P. Akerman et al.

    Spiral enteroscopy: a novel method of enteroscopy by using the Endo-Ease Discovery SB overtube and a pediatric colonoscope

    Gastrointest Endosc

    (2009)
  • J. DiSario et al.

    Enteroscopes

    Gastrointest Endosc

    (2007)
  • F.-c Zhi et al.

    Diagnostic value of double balloon enteroscopy for small-intestinal disease: experience from China

    Gastrointest Endosc

    (2007)
  • I.A. Cazzato et al.

    Diagnostic and therapeutic impact of double-balloon enteroscopy (DBE) in a series of 100 patients with suspected small bowel diseases

    Dig Liver Dis

    (2007)
  • S. Mehdizadeh et al.

    What is the learning curve associated with double-balloon enteroscopy?technical details and early experience in 6 u.s. tertiary care centers

    Gastrointest Endosc

    (2006)
  • N. Manabe et al.

    Double-balloon enteroscopy in patients with GI bleeding of obscure origin

    Gastrointest Endosc

    (2006)
  • D. Arakawa et al.

    Outcome after enteroscopy for patients with obscure GI bleeding: diagnostic comparison between double-balloon endoscopy and videocapsule endoscopy

    Gastrointest Endosc

    (2009)
  • S. Pasha et al.

    Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis

    Clin Gastroenterol Hepatol

    (2008)
  • M. Somsouk et al.

    Management of obscure occult gastrointestinal bleeding: a cost-minimization analysis

    Clin Gastroenterol Hepatol

    (2008)
  • L. Gerson et al.

    Cost-effectiveness analysis of management strategies for obscure GI bleeding

    Gastrointest Endosc

    (2008)
  • J.R. Willis et al.

    Enteroscopy-enteroclysis: experience with a combined endoscopic-radiographic technique

    Gastrointest Endosc

    (1997)
  • D.R. Cave et al.

    Intraoperative enteroscopyIndications and techniques

    Gastrointest Endosc Clin N Am

    (1996)
  • A. Zaman et al.

    Total peroral intraoperative enteroscopy for obscure GI bleeding using a dedicated push enteroscope: diagnostic yield and patient outcome

    Gastrointest Endosc

    (1999)
  • R. Douard et al.

    Intraoperative enteroscopy for diagnosis and management of unexplained gastrointestinal bleeding

    Am J Surg

    (2000)
  • R. Douard et al.

    Role of intraoperative enteroscopy in the management of obscure gastrointestinal bleeding at the time of video-capsule endoscopy

    Am J Surg

    (2009)
  • M.A. Anderson et al.

    ASGE guideline: the management of Antithrombotic agents for endoscopic procedures

    Gastrointest Endosc

    (2009)
  • T. Baron

    Double-balloon enteroscopy to facilitate retrograde PEG placement as access for therapeutic ERCP in patients with long-limb gastric bypass

    Gastrointest Endosc

    (2006)
  • R.S. Bloomfeld et al.

    Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin

    Am J Gastroenterol

    (2000)
  • C. Berkelhammer et al.

    Heparin provocation for endoscopic localization of recurrent obscure GI hemorrhage

    Gastrointest Endosc

    (2000)
  • M.P. Askin et al.

    Push enteroscopic cauterization: long-term follow-up of 83 patients with bleeding small intestinal angiodysplasia

    Gastrointest Endosc

    (1996)
  • A.J. Morris et al.

    Push enteroscopy and heater probe therapy for small bowel bleeding

    Gastrointest Endosc

    (1996)
  • G. Guyatt et al.

    GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

    Br Med J

    (2008)
  • L.B. Katz

    The role of surgery in occult gastrointestinal bleeding

    Semin Gastrointest Dis

    (1999)
  • P.G. Foutch

    Angiodysplasia of the gastrointestinal tract

    Am J Gastroenterol

    (1993)
  • J. Lang et al.

    Diaphragm disease: pathology of disease of the small intestine induced by non-steroidal anti-inflammatory drugs

    J Clin Pathol

    (1988)
  • B.S. Lewis et al.

    Small bowel tumours: yield of enteroscopy

    Gut

    (1991)
  • C.I. Bartram et al.

    The diagnosis of Meckel's diverticulum by small bowel enema in the investigation of obscure intestinal bleeding

    Br J Surg

    (1980)
  • P. Kiratli et al.

    Detection of ectopic gastric mucosa using 99mTc pertechnetate: review of the literature

    Ann Nucl Med

    (2009)
  • D. Taverner et al.

    Massive bleeding from the ileum: a late complication of pelvic radiotherapy

    Am J Gastroenterol

    (1982)
  • B. Risti et al.

    Hemosuccus pancreaticus as a source of obscure upper gastrointestinal bleeding: three cases and literature review

    Am J Gastroenterol

    (1995)
  • N. Yuki et al.

    Jejunal varices as a cause of massive gastrointestinal bleeding

    Am J Gastroenterol

    (1992)
  • M. Traina et al.

    Variceal bleeding from ileum identified and treated by single balloon enteroscopy

    World J Gastroenterol

    (2009)
  • M. Kodama et al.

    Endoscopic characterization of the small bowel in patients with portal hypertension evaluated by double balloon endoscopy

    J Gastroenterol

    (2008)
  • C. Descamps et al.

    ā€œMissedā€ upper gastrointestinal tract lesions may explain ā€œoccultā€ bleeding

    Endoscopy

    (1999)
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    This document is a product of the Standards of Practice Committee. This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

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