Gastrointestinal bleeding: from overt to obscure

Position statement from the Indian Society of Gastroenterology, Cardiological Society of India, Indian Academy of Neurology and Vascular Society of India on gastrointestinal bleeding and endoscopic procedures in patients on antiplatelet and/or anticoagulant therapy

Antiplatelet and/or anticoagulant agents (collectively known as antithrombotic agents) are used to reduce the risk of thromboembolic events in patients with conditions such as atrial fibrillation, acute coronary syndrome, recurrent stroke prevention, deep vein thrombosis, hypercoagulable states and endoprostheses. Antithrombotic-associated gastrointestinal (GI) bleeding is an increasing burden due to the growing population of advanced age with multiple comorbidities and the expanding indications for the use of antiplatelet agents and anticoagulants. GI bleeding in antithrombotic users is associated with an increase in short-term and long-term mortality. In addition, in recent decades, there has been an exponential increase in the use of diagnostic and therapeutic GI endoscopic procedures. Since endoscopic procedures hold an inherent risk of bleeding that depends on the type of endoscopy and patients' comorbidities, in patients already on antithrombotic therapies, the risk of procedure-related bleeding is further increased. Interrupting or modifying doses of these agents prior to any invasive procedures put these patients at increased risk of thromboembolic events. Although many international GI societies have published guidelines for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures, no Indian guidelines exist that cater to Indian gastroenterologists and their patients. In this regard, the Indian Society of Gastroenterology (ISG), in association with the Cardiological Society of India (CSI), Indian Academy of Neurology (IAN) and Vascular Society of India (VSI), have developed a "Guidance Document" for the management of antithrombotic agents during an event of GI bleeding and during urgent and elective endoscopic procedures.

Clinical features predicting the detection of abnormalities by double balloon endoscopy in patients with suspected small bowel bleeding

BACKGROUND AND AIM

Although double balloon endoscopy (DBE) has demonstrated a high diagnostic yield in suspected small bowel bleeding, it is not known whether DBE is of equal value to all patients with suspected small bowel bleeding or of greater benefit in selected subgroups. We aimed to determine whether any clinical features predict an increased likelihood of finding a lesion in patients with suspected small bowel bleeding.

METHODS

We retrospectively analyzed clinical features of 43 consecutive patients (M : F = 26:17, age 13-82 years) who underwent DBE because of suspected small bowel bleeding. Data associated with DBE procedure were collected prospectively. Predictive factors for the detection of a lesion were determined by comparison of clinical features between patients with positive DBE findings and those with negative findings.

RESULTS

Potential bleeding sources were discovered in 30 patients (69.8%) out of 43. Duration of bleeding was longer in patients with positive DBE findings than in those with negative findings (195 +/- 311 vs 18 +/- 17 days, P = 0.015). Number of bleeding episodes was higher in patients with positive DBE findings (2.2 +/- 1.2 vs 1.3 +/- 0.5, P = 0.011). The odds ratio for the detection of bleeding focus on DBE for patients with two or more bleeding episodes, relative to those with only one current bleeding episode was 5.67 (95% CI: 1.12-28.81, P = 0.036) in multivariate analysis.

CONCLUSION

DBE may be the most useful in patients with suspected small bowel bleeding if they have a history of frequent bleeding episodes over a long period.

The patient with recidivent obscure gastrointestinal bleeding

Obscure gastrointestinal (GI) bleeding is defined as visible or invisible GI blood loss, the source of which can not be identified by standard endoscopy (oesophagogastroduodenoscopy and colonoscopy). Nowadays, GI bleeding is divided into upper, mid- and lower bleeding. Mid-GI bleeding covers the section from the Treitz ligament to the ileocaecal valve. The new diagnostic methods of capsule endoscopy and double balloon enteroscopy have revolutionised the diagnostic approach in recent years. As a result, previous radiological and nuclear medicine techniques (small bowel X-ray, scintigraphy and angiography), but also endoscopic techniques, such as the push enteroscopy and intraoperative endoscopy, are becoming less important. After standard endoscopy and persistent blood loss it is advisable to first have these procedures repeated by an experienced examiner under optimal conditions. Nevertheless, no source of bleeding is identified by this method in 5% of cases. It is then recommended to use capsule endoscopy and, depending on the findings, double balloon enteroscopy with the option of intervention. In patients with unstable circulation an invasive procedure (intraoperative endoscopy) may be required.