Standards of practiceThe role of endoscopy in the management of obscure GI bleeding
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. āāāā
- 2
We recommend urgent EGD in patients with active overt OGIB and a clinical presentation suggestive of upper GI bleeding. āāāā For those with signs or symptoms of lower GI bleeding, we suggest repeating colonoscopy. āāāā 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)
- et al.
Nonsteroidal anti-inflammatory drug-induced enteropathy: case discussion and review of the literature
Mayo Clin Proc
(1995) - et al.
Dieulafoy's lesion of the small bowel causing massive gastrointestinal bleeding: two case reports and literature review
Am J Gastroenterol
(2001) - et al.
Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a standard endoscope
Gastrointest Endosc
(1998) - et al.
Obscure gastrointestinal bleeding
Gastrointest Endosc
(2003) Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial
Gastrointest Endosc
(1999)- et al.
Non-small-bowel lesions detected by capsule endoscopy in patients with obscure GI bleeding
Gastrointest Endosc
(2005) - et al.
Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings
Gastrointest Endosc
(1998) - et al.
Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding?
Gastroenterology
(2007) - et al.
ASGE Technology Status Evaluation Report: wireless capsule endoscopy
Gastrointest Endosc
(2006) - et al.
A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding
Gastrointest Endosc
(2005)
Retention of the capsule endoscope: a single-center experience of 1000 capsule endoscopy procedures
Gastrointest Endosc
Endoscopy in patients with implanted electronic devices
Gastrointest Endosc
Negative capsule endoscopy in patients with obscure GI bleeding predicts low rebleeding rates
Gastrointest Endosc
Is there a role for second-look capsule endoscopy in patients with obscure GI bleeding after a nondiagnostic first test?
Gastrointest Endosc
Second capsule endoscopy for patients with severe iron deficiency anemia
Gastrointest Endosc
Total enteroscopy with a nonsurgical steerable double-balloon method
Gastrointest Endosc
Spiral enteroscopy: a novel method of enteroscopy by using the Endo-Ease Discovery SB overtube and a pediatric colonoscope
Gastrointest Endosc
Enteroscopes
Gastrointest Endosc
Diagnostic value of double balloon enteroscopy for small-intestinal disease: experience from China
Gastrointest Endosc
Diagnostic and therapeutic impact of double-balloon enteroscopy (DBE) in a series of 100 patients with suspected small bowel diseases
Dig Liver Dis
What is the learning curve associated with double-balloon enteroscopy?technical details and early experience in 6 u.s. tertiary care centers
Gastrointest Endosc
Double-balloon enteroscopy in patients with GI bleeding of obscure origin
Gastrointest Endosc
Outcome after enteroscopy for patients with obscure GI bleeding: diagnostic comparison between double-balloon endoscopy and videocapsule endoscopy
Gastrointest Endosc
Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis
Clin Gastroenterol Hepatol
Management of obscure occult gastrointestinal bleeding: a cost-minimization analysis
Clin Gastroenterol Hepatol
Cost-effectiveness analysis of management strategies for obscure GI bleeding
Gastrointest Endosc
Enteroscopy-enteroclysis: experience with a combined endoscopic-radiographic technique
Gastrointest Endosc
Intraoperative enteroscopyIndications and techniques
Gastrointest Endosc Clin N Am
Total peroral intraoperative enteroscopy for obscure GI bleeding using a dedicated push enteroscope: diagnostic yield and patient outcome
Gastrointest Endosc
Intraoperative enteroscopy for diagnosis and management of unexplained gastrointestinal bleeding
Am J Surg
Role of intraoperative enteroscopy in the management of obscure gastrointestinal bleeding at the time of video-capsule endoscopy
Am J Surg
ASGE guideline: the management of Antithrombotic agents for endoscopic procedures
Gastrointest Endosc
Double-balloon enteroscopy to facilitate retrograde PEG placement as access for therapeutic ERCP in patients with long-limb gastric bypass
Gastrointest Endosc
Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin
Am J Gastroenterol
Heparin provocation for endoscopic localization of recurrent obscure GI hemorrhage
Gastrointest Endosc
Push enteroscopic cauterization: long-term follow-up of 83 patients with bleeding small intestinal angiodysplasia
Gastrointest Endosc
Push enteroscopy and heater probe therapy for small bowel bleeding
Gastrointest Endosc
GRADE: an emerging consensus on rating quality of evidence and strength of recommendations
Br Med J
The role of surgery in occult gastrointestinal bleeding
Semin Gastrointest Dis
Angiodysplasia of the gastrointestinal tract
Am J Gastroenterol
Diaphragm disease: pathology of disease of the small intestine induced by non-steroidal anti-inflammatory drugs
J Clin Pathol
Small bowel tumours: yield of enteroscopy
Gut
The diagnosis of Meckel's diverticulum by small bowel enema in the investigation of obscure intestinal bleeding
Br J Surg
Detection of ectopic gastric mucosa using 99mTc pertechnetate: review of the literature
Ann Nucl Med
Massive bleeding from the ileum: a late complication of pelvic radiotherapy
Am J Gastroenterol
Hemosuccus pancreaticus as a source of obscure upper gastrointestinal bleeding: three cases and literature review
Am J Gastroenterol
Jejunal varices as a cause of massive gastrointestinal bleeding
Am J Gastroenterol
Variceal bleeding from ileum identified and treated by single balloon enteroscopy
World J Gastroenterol
Endoscopic characterization of the small bowel in patients with portal hypertension evaluated by double balloon endoscopy
J Gastroenterol
āMissedā upper gastrointestinal tract lesions may explain āoccultā bleeding
Endoscopy
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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.