Regular Article
Obscure digestive bleeding

https://doi.org/10.1053/bega.2000.0161Get rights and content

Abstract

Obscure digestive bleeding is defined as recurrent bleeding for which no definite source has been identified by routine endoscopic or barium studies. Mucosal vascular abnormality or ‘angioectasia’ is the most common course of obscure bleeding, especially in elderly patients. Small bowel tumours are more frequent in patients younger than 50 years. However, missed or underestimated upper and lower gastrointestinal lesions at the initial endoscopic investigation may be the source of a so-called obscure intestinal bleeding.

The various radiological procedures, including enteroclysis, visceral angiography and CT scan as well as radioisotope bleeding scans have limitations in the case of obscure gastrointestinal bleeding. Recent developments in magnetic resonance imaging are promising. The different methods of enteroscopy have a similar diagnostic yield, reaching approximately 40–65%. Endoscopic cauterization of small bowel angioectasias seems to be efficacious but randomized trials are needed. Efficacy of hormonal therapy is very controversial.

The extent of diagnostic and therapeutic strategies must be based on a number of factors including the patient's parameters, bleeding characteristics and also the result of previous work-up.

References (87)

  • A Zaman et al.

    Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a standard endoscope

    Gastrointestinal Endoscopy

    (1998)
  • A Cameron et al.

    Linear gastric erosion

    Gastroenterology

    (1986)
  • D Rex et al.

    Enteroclysis in the evaluation of suspected small intestinal bleeding

    Gastroenterology

    (1989)
  • J Willis et al.

    Enteroscopy-enteroclysis with a combined endoscopic-radiographic technique

    Gastrointestinal Endoscopy

    (1997)
  • A Chak et al.

    Diagnostic and therapeutic impact of push-enteroscopy

    Gastrointestinal Endoscopy

    (1998)
  • CJ Gostout

    Improving the withdrawal phase of sonde enteroscopy with the ‘push-away’ method

    Gastrointestinal Endoscopy

    (1993)
  • A Ress et al.

    Efficacy of intraoperative enteroscopy in diagnosis and prevention of recurrent, occult gastrointestinal bleeding

    American Journal of Surgery

    (1992)
  • A Zaman et al.

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

    Gastrointestinal Endoscopy

    (1999)
  • E Flickinger et al.

    Intraoperative panendoscopy for diagnosing sites of chronic intestinal bleeding

    American Journal of Surgery

    (1989)
  • M Askin et al.

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

    Gastrointestinal Endoscopy

    (1996)
  • AJ Morris et al.

    Push-enteroscopy and heater probe therapy for small bowel bleeding

    Gastrointestinal Endoscopy

    (1996)
  • E Van Cutsem et al.

    Treatment of bleeding gastrointestinal vascular malformations with oestrogen-progesterone

    Lancet

    (1990)
  • J Barkin et al.

    Medical therapy for chronic gastrointestinal bleeding of obscure origin

    American Journal of Gastroenterology

    (1998)
  • G Zuckerman et al.

    AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding

    Gastroenterology

    (2000)
  • T Rockall et al.

    Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom

    British Medical Journal

    (1995)
  • C Descamps et al.

    ‘Missed’ upper gastrointestinal tract lesions may explain ‘occult’ bleeding

    Endoscopy

    (1999)
  • R Clouse

    Vascular lesions: ectasias, tumors, and malformations

  • PG Foutch

    Angiodysplasia of the gastrointestinal tract

    American Journal of Gastroenterology

    (1993)
  • S Marchuard et al.

    Gastrointestinal angiodysplasia in renal failure

    Journal of Clinical Gastroenterology

    (1988)
  • C Gostout et al.

    Is angiodysplasia associated with von Willebrand's disease?

    Gastroenterology

    (1990)
  • B Lewis et al.

    The correlation of endoscopically identified vascular lesions to their pathologic diagnosis

    Gastrointestinal Endoscopy

    (1993)
  • A Schmit et al.

    Diagnostic efficacy of push-enteroscopy and long-term follow-up of patients with small bowel angiodysplasias

    Digestive Diseases and Sciences

    (1996)
  • P Foutch et al.

    Prevalence and natural history of colonic angiodysplasia among healthy asymptomatic people

    American Journal of Gastroenterology

    (1995)
  • B Lewis et al.

    Does hormonal therapy have any benefit for bleeding angiodysplasia?

    Journal of Clinical Gastroenterology

    (1992)
  • P Reilly et al.

    Clinical manifestations of hereditary hemorrhagic telengiectasia

    American Journal of Gastroenterology

    (1984)
  • K McAllister et al.

    Endoglin, a TGF-beta binding protein of endothelial cells, is the gene for hereditary hemorrhagic telengiectasia type 1

    Nature Genetics

    (1994)
  • P Ramanujam et al.

    Hemangioma of the small intestine: case report and literature review

    American Journal of Gastroenterology

    (1995)
  • N Dy et al.

    Bleeding from the endoscopically-identified Dieulafoy lesion of the proximal small intestine and colon

    American Journal of Gastroenterology

    (1995)
  • D Blanchard et al.

    Tumors of the small intestine

    World Journal of Surgery

    (2000)
  • R Scully et al.

    Case records of the Massachussets General Hospital

    New England Journal of Medicine

    (1999)
  • B Lewis et al.

    Small bowel tumors: the yield of enteroscopy

    Gut

    (1991)
  • J Martin et al.

    Meckel's diverticulum

    American Family Physician

    (2000)
  • P Regan et al.

    A reappraisal of clinical roentographic and endoscopic features of the Zollinger Ellison syndrome

    Mayo Clinic Proceedings

    (1978)
  • Cited by (62)

    • Intraoperative Enteroscopy: Is There Still a Role?

      2017, Gastrointestinal Endoscopy Clinics of North America
      Citation Excerpt :

      According to the previously published data (see Table 2), a site-specific source of bleeding was detected in 371 patients (79.27%), confirming that the source of bleeding in OGIB is often located in the small bowel. The predominant lesions responsible for OGIB and identified by IOE were vascular lesions, which represented 61% (n = 227) of findings, as described previously.24,25 The remaining lesion types were as follows: benign ulcers in 19% (n = 70), tumors in 10% (n = 36), and diverticula in 4.0% (n = 15).

    • Intraoperative enteroscopy in the management of obscure gastrointestinal bleeding

      2013, Digestive and Liver Disease
      Citation Excerpt :

      These results confirm that the source of bleeding is often located in the small bowel. As it has been previously reported for small bowel lesions in obscure gastrointestinal bleeding patients [1,59], the predominant documented lesions responsible for obscure gastrointestinal bleeding in the 15 studies are vascular lesions, which represent 61% (n = 217). The remaining lesion types are as follows: benign ulcers are 18.5% (n = 66), tumours are 10.1% (n = 36), and diverticula are 4.2% (n = 15).

    • Video capsule endoscopy: What is the future?

      2010, Gastroenterology Clinics of North America
      Citation Excerpt :

      Arteriovenous malformations or angioectasias account for most of the lesions, followed by SB tumors, drug-related lesions, and CD.18,21 Several factors have been identified for selecting patients with OGIB in whom the risk of detecting a lesion is high: a serum hemoglobin level less than 10 g/dL, an ongoing overt bleeding (within 15 days), the presence of anemia or recurrent bleeding for more than 6 months, the occurrence of more than 1 episode of bleeding, the coexistence of renal insufficiency, and an occult bleeding with continuous positive FOBT results.18,19,21–23 Should all patients with an OGIB be investigated?

    • Digestive bleeding with atypical cause

      2007, Revista Clinica Espanola
    • Identification of ectopic pancreas in the ileum by capsule endoscopy

      2007, Journal of the Formosan Medical Association
    View all citing articles on Scopus
    View full text