Obscure gastrointestinal bleeding: diagnosis and treatment

Hemangioendothelioma as a rare cause of lower gastrointestinal bleeding - a case report

INTRODUCTION AND IMPORTANCE

Gastrointestinal bleeding is a serious health threat, especially when it originates from the small intestine, often termed small bowel bleeding (SBB). Hemangioendothelioma, a rare vascular tumor, can be a significant yet uncommon cause of gastrointestinal bleeding. This case report highlights hemangioendothelioma's diagnostic challenges and clinical significance in SBB.

CASE PRESENTATION

A 16-year-old female experienced six months of intermittent massive rectorrhagia and melena, along with nausea, vomiting, loss of appetite, and abdominal pain. Initial endoscopic investigations, including colonoscopy and enteroscopy, did not identify the bleeding source. Imaging studies, including a CT scan and Meckel's scintigraphy, were also inconclusive. Persistent bleeding and a significant drop in hemoglobin levels led to exploratory laparotomy with intraoperative enteroscopy, which revealed a nodular lesion in the small intestine. Histopathological examination confirmed the lesion as hemangioendothelioma. Surgical resection of the lesion stopped the bleeding, and the patient recovered without complications, remaining asymptomatic during follow-ups at one and six months post-surgery.

CLINICAL DISCUSSION

Hemangioendothelioma is a rare, locally aggressive vascular tumor that can present with abdominal pain, bowel obstruction, anemia, and gastrointestinal bleeding. Due to its rarity and location, it often goes undetected in conventional endoscopy. The definitive diagnosis is made through histopathological examination, which shows characteristic endothelial cells and vascular structures. Surgical excision is the primary treatment, although there is a risk of recurrence and metastasis.

CONCLUSION

This case underscores hemangioendothelioma's diagnostic challenges and clinical relevance in obscure gastrointestinal bleeding. Intraoperative enteroscopy plays a crucial role in the diagnosis and management. Clinicians should consider hemangioendothelioma in similar cases to ensure appropriate treatment and management.

Small Intestinal Arteriovenous Malformation Treated by Double-balloon Endoscopy

A 42-year-old man was referred to our hospital because of anemia. The patient underwent gastroscopy and colonoscopy, but no bleeding site was detected. Abdominal contrast-enhanced computed tomography (CT) showed vascular dilatation along the wall of the small intestine. Small bowel capsule endoscopy and antegrade double-balloon endoscopy (DBE) were performed, and the patient was diagnosed with a small intestinal arteriovenous malformation (AVM). The AVM was clipped using DBE. After clipping, abdominal contrast-enhanced CT and small bowel angiography revealed the disappearance of the AVM. DBE may be a viable therapeutic option, helping avoid surgery and its associated risks.

Residual Recurrence of a Small Intestinal Capillary Hemangioma with Obscure Gastrointestinal Bleeding Treated by Double-Balloon Endoscopy: A Case Report and Literature Review

An 86-year-old man presented with anemia. He underwent abdominal contrast-enhanced computed tomography, gastroscopy, and colonoscopy without any bleeding detected. Small bowel capsule endoscopy (SBCE) revealed a reddish polypoid lesion with blood oozing into the jejunum. Antegrade double-balloon endoscopy (DBE) revealed a 5 mm sized protrusion into the jejunum. Endoscopic mucosal resection (EMR) was difficult; the lesion was snared and resected before energization. Clips prevented further bleeding and the lesion's position was marked with a tattoo. Histopathological examination of the lesion led to a diagnosis of capillary hemangioma. After 11 months, the patient was again anemic. A reddish polypoid lesion oozing blood near the tattoo was found by SBCE. Another antegrade DBE showed a 7 mm sized protrusion near the tattoo. The lesion was successfully treated by EMR. Histopathological examination revealed the residual recurrence of a small intestinal capillary hemangioma. The patient recovered from anemia after the EMR. Two months later, SBCE showed no findings around the tattoo. Hemangiomas account for 7-10% of benign small intestinal tumors; most are cavernous hemangiomas, and capillary hemangiomas are rare. We report a rare case of a recurring small intestinal capillary hemangioma detected by SBCE and treated using DBE. We also review the literature.

Capsule endoscopy: beyond the small bowel

Capsule endoscopy (CE) is considered the first-line for the investigation of OGIB after conventional non-diagnostic endoscopic examinations. A detection rate of lesions outside the small bowel segment has been reported to range from 3.5% to >30%. Our primary objective was to analyze the role of CE in identifying lesions outside the small bowel segment that were not identified on conventional endoscopy in patients suspected of OGIB. In our study, CE appears to be effective and safe in diagnosing OGIB, also proving to be a tool in identifying lesions outside the small intestine segment.

Small Bowel Variceal Bleeding in Patients with Liver Cirrhosis Treated with Transarterial Embolization: Case Series

Small bowel variceal bleeding is a rare cause of gastrointestinal hemorrhage, with clinical manifestations ranging from asymptomatic incidental findings to life-threatening conditions. The diagnosis and management of small bowel bleeding are challenging because of the localization of the lesion and the difficulty of the procedure. Trans-arterial embolization (TAE) is a secure and straightforward method for treating ectopic varices. On the other hand, there have been limited local studies on the outcomes of TAE for patients with small bowel variceal hemorrhage. This paper reports patients diagnosed with small bowel variceal bleeding and treated with TAE.

Clinical characteristics of Dieulafoy's lesion in the small bowel diagnosed and treated by double-balloon endoscopy

BACKGROUND

Obscure gastrointestinal bleeding refers to bleeding for which the source cannot be ascertained even through balloon-assisted endoscopy. In certain instances, Dieulafoy's lesion in the small bowel is presumed to be the underlying cause.

AIM

This retrospective study aimed to elucidate the clinical characteristics of Dieulafoy's lesion in the small bowel as diagnosed via double-balloon endoscopy while also exploring the feasibility of predicting bleeding from Dieulafoy's lesion prior to endoscopy in cases of obscure gastrointestinal bleeding.

METHODS

A comprehensive analysis of our database was conducted, identifying 38 patients who received a diagnosis of Dieulafoy's lesion and subsequently underwent treatment via double-balloon endoscopy. The clinical background, diagnosis, and treatment details of patients with Dieulafoy's lesion were carefully examined.

RESULTS

The median age of the 38 patients was 72 years, and 50% of the patients were male. A total of 26 (68%) patients exhibited a high comorbidity index. The upper jejunum and lower ileum were the most frequently reported locations for the occurrence of Dieulafoy's lesion in the small bowel. The detected Dieulafoy's lesions exhibited active bleeding (n = 33) and an exposed vessel with plaque on the surface (n = 5). Rebleeding after endoscopic treatment occurred in 8 patients (21%, median period: 7 days, range: 1-366 days). We conducted an analysis to determine the definitive nature of the initial double-balloon endoscopy diagnosis. Multivariate analysis revealed that hematochezia of ≥ 2 episodes constituted the independent factor associated with ≥ 2 double-balloon endoscopy diagnoses. Additionally, we explored factors associated with rebleeding following endoscopic treatment. Although the number of hemoclips utilized displayed a likely association, multivariate analysis did not identify any independent factor associated with rebleeding.

CONCLUSION

If a patient encounters multiple instances of hematochezia, promptly scheduling balloon-assisted endoscopy, equipped with optional instruments without delay is advised, after standard endoscopic evaluation with esophagogastroduodenoscopy and colonoscopy is unrevealing.

Gastrointestinal Angiodysplasia in Patients with Severe Aortic Stenosis: The Endoscopic Features of Heyde's Syndrome

INTRODUCTION

Aortic stenosis (AS) is sometimes associated with gastrointestinal bleeding, and this phenomenon is known as Heyde's syndrome. Such bleeding is most often considered to originate from gastrointestinal angiodysplasias, but the frequency and endoscopic features of such bleeding remain unclear. This study aimed to determine the frequency and endoscopic features of gastrointestinal angiodysplasia in patients with severe AS.

PATIENTS AND METHODS

In this multicenter, retrospective study, we evaluated consecutive patients who underwent transcatheter aortic valve implantation (TAVI) with severe AS from May 2016 to December 2019. We extracted the data on the clinicopathological features according to the status of anemia, the proportion of patients who underwent gastrointestinal endoscopic examinations and demonstrated gastrointestinal angiodysplasia, and identified the endoscopic features associated with such patients.

RESULTS

In 325 patients, the rates of moderate/severe anemia (hemoglobin < 11 g/dL) were 52%. Regarding medicine, there were no significant differences between the patients with and without moderate/severe anemia. Patients were examined by esophagogastroduodenoscopy (21%), colonoscopy (12%), and balloon-assisted enteroscopy or small bowel capsule endoscopy (1.5%). Patients with moderate/severe anemia had significantly more angiodysplasia (38.3% vs. 7.7%; p < 0.0001) and active bleeding (23.4% vs. 0%; p < 0.01). Angiodysplasia was detected in 21 patients (stomach, n = 9; small intestine, n = 5, and colon, n = 10).

CONCLUSIONS

The results suggest, for the first time, that patients with severe AS who underwent TAVI and moderate/severe anemia frequently had gastrointestinal angiodysplasia and active bleeding throughout the entire gastrointestinal tract.

Early intervention with double balloon enteroscopy for higher yield for inpatient overt obscure gastrointestinal bleeding: A propensity matched analysis

Background and Aim

Overt obscure gastrointestinal bleeding (OOGIB) is defined as continued bleeding with unknown source despite esophagogastroduodenoscopy (EGD) and colonoscopy evaluation. Small bowel evaluation through video capsule endoscopy (VCE) or double balloon enteroscopy (DBE) is often warranted. We studied the timing of DBE in hospitalized OOGIB patients regarding diagnostic yield, therapeutic yield, and GI rebleeding.

Methods

We performed a retrospective review of DBEs performed at a tertiary medical center between November 2012 and December 2020. The inclusion criterion was first admission for OOGIB undergoing DBE. Those without previous EGD or colonoscopy were excluded. Patients were stratified into two groups: DBE performed within 72 h of OOGIB (emergent) and beyond 72 h of OOGIB (nonemergent). Propensity score matching was used to adjust for the difference in patients in the two groups. Logistic regression analysis was used to assess factors associated with diagnostic and therapeutic yield. Kaplan-Meir survival curve showed GI bleed-free survival following initial bleed and was compared using the log rank test.

Results

A total of 154 patients met the inclusion criterion, of which 62 had emergent DBE and 92 had nonemergent DBE. The propensity-score-matched sample consisted of 112 patients, with 56 patients each in the emergent and nonemergent groups. Univariate and multivariable logistic regression analysis showed a significant association between VCE and emergent DBE and diagnostic and therapeutic yield (P < 0.05). Emergent DBE patients had increased GI bleed-free survival compared to those in the nonemergent group (P = 0.009).

Conclusion

Our data demonstrate that emergent DBE during inpatient OOGIB can impact the overall diagnostic yield, therapeutic yield, and GI rebleeding post DBE.

Application of validated bleeding risk scores for atrial fibrillation in obscure gastrointestinal bleeding patients increases videocapsule endoscopy's diagnostic yield: a retrospective monocentric study

BACKGROUND

Videocapsule endoscopy (VCE) is considered the gold standard for overt and obscure gastrointestinal bleeding (OGIB), after negative upper and lower endoscopy. Nonetheless, VCE's diagnostic yield is suboptimal, and it represents a costly, time-consuming, and often not easily available technique. In order to evaluate bleeding risk in patients with atrial fibrillation, several scoring systems have been proposed, but their utilization outside the original clinical setting has rarely been explored. The aim of the study is to evaluate potential role of bleeding risk scoring systems in predicting the occurrence of positive findings at VCE examination, and therefore in increasing VCE diagnostic yield.

METHODS

Data from consecutive patients undergoing VCE between April 2015 and June 2020 were retrospectively retrieved, and clinical and demographic characteristics were collected. HAS-BLED, ATRIA, and ORBIT scores were calculated, and patients were considered at low or high risk of bleeding accordingly. Discriminative ability of the scores for positive VCE findings has been evaluated by area under receiver operator characteristic curve (AUC) calculation. Diagnostic yield of scores in high- and low-risk patients was calculated.

RESULTS

A total of 413 patients underwent VCE examination, among which 368 (89%) for OGIB. Positive findings were observed in 246 patients (67%), with angiodysplasias being the most frequent lesion (92%). The three scores displayed similar consistent discriminative ability for positive VCE findings (mean AUC = 0.69), and identified high-risk group of patients in which VCE has a higher diagnostic yield.

CONCLUSIONS

In the present retrospective study, bleeding scores accurately discriminated patients with higher probability of positive findings at VCE examination. Bleeding scores utilization may help in the management of patients with OGIB, with a potential consistent resource optimization and cost-saving.

Clinical characteristics and risk factors for rebleeding in uremic patients with obscure gastrointestinal bleeding undergoing deep enteroscopy: A multi-center retrospective study in Taiwan

BACKGROUND/PURPOSE

Recurrent obscure gastrointestinal bleeding (OGIB) in patients with chronic kidney disease is a challenge often faced by physicians, given the need for repeated hospitalizations, multiple extensive examinations, limited treatment options, and high medical costs. The purpose of this study was to identify the clinical characteristics of uremic patients undergoing deep enteroscopy for OGIB and analyze the risk factors for rebleeding in these patients after undergoing single-balloon enteroscopy (SBE).

METHODS

Out of 765 patients with OGIB who underwent 1004 procedures of SBE in four teaching hospitals, 78 uremic patients with OGIB were enrolled. Clinical characteristics and endoscopic findings were collected, and multiple variables were analyzed to determine the risk of rebleeding after SBE.

RESULTS

The diagnostic yield was 75.6%, and the rebleeding rate was 29.5% in the enrolled uremic patients. The most common etiology was angiodysplasia (74.6%) and the most common site was the jejunum (50.8%). The endoscopic intervention rate was 62.8% and most patients were treated with argon plasma coagulation (75.6%). Among the eight patients with valvular heart disease (VHD), four (50%) had severe aortic stenosis, and the remaining had non-aortic stenosis-VHD. VHD (p < 0.05) and angiodysplasia (p < 0.05) were both associated with a higher rebleeding rate.

CONCLUSION

VHD may be an independent risk factor associated with rebleeding after SBE in uremic patients with OGIB. Moreover, uremic patients with angiodysplasia-related bleeding appear to have a higher rebleeding rate than those with alternative causes of bleeding.

Diagnostic yield of proximal jejunal lesions with third-generation capsule endoscopy

Objectives

Capsule endoscopy (CE) has been shown to have poor diagnostic performance when the capsule passes quickly through the small bowel, especially the proximal jejunum. This study aimed to evaluate the diagnostic yield of proximal jejunal lesions with third-generation CE technology.

Methods

We retrospectively examined 138 consecutive patients, 76 (55.0%) of whom were men. The patients' median age was 70 years, and proximal jejunal lesions were detected by CE and/or double-balloon endoscopy at Hiroshima University Hospital between January 2011 and June 2021. We analyzed the diagnostic accuracy of CE for proximal jejunal lesions and compared the characteristics of the discrepancy between the use of CE and double-balloon endoscopy with Pillcam SB 2 (SB2) and Pillcam SB 3 (SB3).

Results

SB2 and SB3 were used in 48 (35%) and 90 (65%) patients, respectively. There was no difference in baseline characteristics between these groups. Small-bowel lesions in the proximal jejunum comprised 75 tumors (54%), 50 vascular lesions (36%), and 13 inflammatory lesions (9%). The diagnostic rate was significantly higher in the SB3 group than in the SB2 group for tumors (91% vs. 72%, p < 0.05) and vascular lesions (97% vs. 69%, p < 0.01). For vascular lesions, in particular, the diagnostic rate of angioectasia improved in the SB3 group (100%) compared with that in the SB2 group (69%).

Conclusions

SB3 use improved the detection of proximal jejunal tumors and vascular lesions compared with SB2 use.

Single-centre empirical analysis of double-balloon enteroscopy in the diagnosis and treatment of small bowel diseases: A retrospective study of 466 cases

BACKGROUND AND OBJECTIVE

The diagnosis and treatment of small bowel diseases (SBDs) has always been a challenge. The purpose of this study was to evaluate the value of double-balloon enteroscopy (DBE) in the diagnosis and treatment of small bowel diseases.

METHOD

The clinical data of 466 patients who underwent double-balloon enteroscopy (DBE) in the Endoscope Center of Gastroenterology Department of the First People's Hospital of Yunnan Province from Jan. 2015 to Dec. 2020 were analysed retrospectively. The factors included age, sex, indications, endoscopic treatment results, pathological results, discharge diagnosis and so on.

RESULTS

A total of 370 patients underwent 466 double-balloon enteroscopies, among whom 274 underwent one examination and 96 received two-way examinations (oral and transanal approaches). Abnormalities were detected in 299 cases, with a detection rate of 80.81% (299/370). The common indications were occult gastrointestinal bleeding (OGIB) (30.8%, 114/370) and abdominal pain (28.3%, 105/370). The diagnosis rates were 64.9% and 77.1%, respectively. The common positive findings included nonspecific inflammation/erosion (60 cases), ulcers (34 cases), diverticulum (32 cases), polyps (26 cases) and Crohn's disease (CD) (24 cases). The common tumours were lymphoma(12 cases), adenocarcinoma(11 cases) and stromal tumour(8 cases). Lymphoma was mostly located in the ileum, while stromal tumours and adenocarcinoma were mostly located in the duodenum and jejunum. The main endoscopic intervention measures were haemostasis and polypectomy, including haemostatic clip, argon plasma coagulation (APC), endoscopic mucosal resection (EMR), endoscopic trap resection, endoscopic foreign body extraction and other operations, without serious complications.

CONCLUSION

DBE has a high success rate in the diagnosis and treatment of some SBDs, and it is a safe and effective management method.

Factors Affecting Route Selection of Balloon-Assisted Enteroscopy in Patients with Obscure Gastrointestinal Bleeding: A KASID Multicenter Study

Balloon-assisted enteroscopy (BAE) is an important diagnostic modality for ongoing obscure gastrointestinal bleeding (OGIB). However, it is difficult to determine the optimal insertion route. We retrospectively analyzed the records of patients with OGIB contained in a multicenter enteroscopy database of 1108 balloon-assisted enteroscopy (BAE) procedures (875 patients) to find out factors affecting BAE route selection in patients with OGIB. A total of 603 BAE procedures in 512 patients were investigated: there were 392 (65.0%) bidirectional and 211 (35.0%) unidirectional procedures. Overt OGIB was more frequent in the latter group (p = 0.024). Computed tomography (CT) was more frequently performed in the unidirectional group (p < 0.001). Capsule endoscopy and a small bowel barium study were performed more frequently in the bidirectional group (p < 0.001 and p = 0.039, respectively). Multivariate analysis showed that occult OGIB, capsule endoscopy and a small bowel barium study were independently associated with use of the bidirectional approach (p = 0.011, p = 0.013 and p = 0.046, respectively). Conversely, CT was associated with use of the unidirectional approach (p < 0.001). Conclusion: CT can aid the selection of an optimal insertion route in OGIB patients. However, capsule endoscopy and small bowel barium study are unhelpful.

Risk factors for rebleeding in patients with obscure gastrointestinal bleeding from southern China

Background

To identify the risk factors associated with rebleeding in obscure gastrointestinal bleeding (OGIB) patients from southern China.

Methods

This retrospective study involved 229 patients who underwent small bowel endoscopy in our hospital between 1 January 2018 and 1 December 2020. The clinical characteristics and risk factors related to rebleeding were retrospectively evaluated.

Results

Rebleeding patients were significantly older than non-rebleeding patients (53.0 ± 15.9 vs. 46.2 ± 17.8 years), had lower hemoglobin concentrations (89.2 ± 28.1 vs. 126.2 ± 25.1 g/L), and higher blood urea nitrogen concentrations (5.4 ± 2.6 vs. 4.5 ± 2.2 µmol/L), respectively. A higher percentage of rebleeding patients had diabetes mellitus (13.9% vs. 2.9%) and overt bleeding (70.4% vs. 38.6%), and required blood transfusions (43.1% vs. 8.0%), compared with non-rebleeding patients, respectively. Multivariate logistic analysis indicated that drinking alcohol (odds ratio (OR): 9.27; 95% confidence interval (CI) = 1.35–63.78), anemia (OR: 17.38; 95% CI = 5.48–55.10), and blood transfusion (OR: 3.76; 95% CI = 1.04–13.56) increased the risk of rebleeding in OGIB patients.

Conclusion

Our data suggested that OGIB patients who drink alcohol, have anemia, and require blood transfusion have an increased risk of rebleeding.

Factitious Gastrointestinal Bleeding: A Case Series and Review

Factitious gastrointestinal bleeding (GIB) is a manifestation of factitious disorder (FD) wherein patients feign GIB in the absence of external gain. As it can be a challenging diagnosis to make, factitious GIB often leads to multiple tests, exposure to contrast agents and radiation, invasive endoscopic and surgical procedures, an increased risk of iatrogenic complications, and increased healthcare costs. Patients who feign GIB often demonstrate characteristic behaviors that may go unnoticed unless they are explicitly addressed. We report a series of patients admitted to our institution for further evaluation of obscure overt GIB with an eventual diagnosis of factitious GIB and review of the epidemiology and development of FD, a diagnostic approach to factitious GIB, and current management strategies.

Non-small-bowel lesions identification by capsule endoscopy: A single centre retrospective study

BACKGROUND

Capsule endoscopy has been considered the first-line approach for the investigation of obscure gastro-intestinal bleeding since its approval in 2001. Our study aims to evaluate the diagnostic yield of capsule endoscopy in the investigation of this condition. We also analyse the incidence of non-small-bowel lesions missed after conventional endoscopy and later detected by capsule endoscopy in patients with suspected obscure bleeding.

METHODS

A total of 290 patients with negative conventional endoscopy referred to our centre to undergo a capsule endoscopy examination for the investigation of obscure gastro-intestinal bleeding. We considered as non-small-bowel lesions those outside the tract between the second duodenal portion and the ileocecal valve. We also looked for actively bleeding lesions at the time of the exam.

RESULTS

Intestinal preparation was good, adequate or poor in 74.1%, 8.4%, and 17.5% of the tests, respectively. Caecum was reached in 92.4%. Capsule retention occurred in 0.7%. Mean small bowel transit time was 5hours and 13minutes. Diagnostic yield was 73.8%. An actively bleeding lesion was noticed in 39.3% of positive tests. Capsule endoscopy revealed clinically significant non-small-bowel lesions missed at gastroscopy or colonoscopy in 30.3% of patients, 43.2% of which were bleeding.

CONCLUSIONS

Capsule endoscopy has high diagnostic yield and safety in the investigation of obscure gastro-intestinal bleedings. Given the high percentage of non-small-bowel lesions detected, it may be appropriate to consider an endoscopic second look before performing a capsule endoscopy study.

PREDICTIVE FACTORS FOR COMPLETE AND INCOMPLETE EVALUATION OF SMALL INTESTINE BY ENDOSCOPIC CAPSULE

Background:

The small-bowel is the most difficult segment to be visualized by traditional endoscopic methods. The need for its exploration led to the development of capsule endoscopy. The percentage of the complete examination varies and still remains uncertain the factors that influence the complete and incomplete examination.

Aim:

Evaluate the factors that interfere with the completeness of the endoscopic evaluation by the capsule.

Methods:

A prospective study in which were included 939 patients divided into two groups: complete group (CG) and incomplete group (IG). The studied variables that could interfere were: age, gender, comorbidities, diagnosis of Crohn’s disease, previous abdominal surgery, inadequate preparation to compare the groups reached and did not reach the cecum.

Results:

Of the 939 patients included 879 (93.3%) reached the cecum (CG) and 63 (6.7%) IG no. The IG was composed of 29 (46.0%) men and 34 (54.0%) women with a mean age of 49.7 years; comorbidities this group accounted for 46% of which 15.9% was Crohn’s disease, previous abdominal surgery 22.2% and 17.5% inadequate preparation.

Conclusion:

Factors associated with complete or incomplete outcome of the examination with capsule endoscopy were: associated comorbidities, Crohn’s disease, previous abdominal surgery and inadequate preparation.

Roles of Capsule Endoscopy and Balloon-Assisted Enteroscopy in the Optimal Management of Small Bowel Bleeding

The small bowel had long been considered a dark unapproachable tunnel until the invention of capsule endoscopy and doubleballoon enteroscopy in the 21st century, which revolutionized the diagnosis and management of small bowel diseases, including bleeding. Various imaging modalities such as computed tomographic enterography, angiography, capsule endoscopy, and balloonassisted enteroscopy play vital roles in the diagnosis and management of small bowel bleeding. The choice of modality to use and timing of application differ according to the availability of the modalities, patient’s history, and physician’s experience. Small bowel bleeding is managed using different strategies as exemplified by medical treatment, interventional radiology, endoscopic therapy, or surgical intervention. Balloon-assisted enteroscopy enables endoscopic interventions to control small bowel bleeding, including electrocautery, argon plasma coagulation, clip application, and tattooing as a prelude to surgery. In this article, we clarify the recent approaches to the optimal diagnosis and management of patients with small bowel bleeding.

The diagnostic value of video capsule endoscopy for Meckel's diverticulum in children

BACKGROUND

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract and is also an important cause of bloody stool and anemia in children. However, there are few data about video capsule endoscopy (VCE) for MD in children. This study aimed to evaluate the diagnostic value of VCE for MD in children.

MATERIALS AND METHODS

children who underwent VCE for obscure gastrointestinal bleeding from October 1st 2015 to August 31st 2019 at the Children's Hospital of Fudan University were included in this retrospective study. Medical data, VCE data and Meckel's scans, etc. were collected for each patient.

RESULTS

sixteen patients were diagnosed with MD by VCE, including 13 males and 3 females. The age of the patients ranged from 4 years to 13 years, with an average of 7.8 ± 2.7 years. Lower gastrointestinal tract bleeding was the main symptom for patients with MD, including hematochezia (75 %) and melena (25 %). Of the VCE findings, 14 patients had double lumen signs and 2 showed protruding lesions. Among the 16 patients diagnosed with MD by VCE, 14 patients were diagnosed with MD by Meckel's scan, 3 with MD by abdominal enhanced CT and 14 patients were diagnosed with MD by surgery. During the follow-up, bleeding occurred sporadically in patient 12 and the reason is still unknown.

CONCLUSIONS

VCE is useful for the diagnosis of MD and should be used as a valuable and less invasive examination to confirm or establish a diagnosis.

Management of obscure gastrointestinal bleeding: Comparison of guidelines between Japan and other countries

Small-bowel bleeding accounts for the majority of obscure gastrointestinal bleeding, but it is caused by various types of small bowel disease, upper gastrointestinal disease, and colorectal disease. For the diagnosis, history taking and physical examination are required, leading to a determination of what diseases are involved. Next, cross-sectional imaging, such as computed tomography, should be carried out, followed by the latest enteroscopy such as small bowel capsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient condition. After a comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected. This article reviews recent advances in the endoscopic diagnosis of obscure gastrointestinal bleeding and compares perspectives of the management of obscure gastrointestinal bleeding in Japan with that in other countries.

Multiple intestinal stromal tumors in a young patient with acute gastrointestinal hemorrhage: A case report and literature review

BACKGROUND

Acute small intestinal bleeding in clinical diagnosis and treatment is not specific, and the diagnosis of small intestinal bleeding is still a major clinical challenge because of its high mobility, tortuosity, and difficulty in endoscopic examination.

CASE SUMMARY

This case is a young patient with multiple stromal tumors of the small intestine complicated with acute massive hemorrhage of the digestive tract. After correction of shock, abdominal computed tomography (CT) and emergency enteroscopy were performed, followed by multi-disciplinary team discussion to develop a reasonable and standardized treatment plan and subsequent therapy to save the patient¡¯s life and maximize the benefits of the patient.

CONCLUSION

Small intestinal stromal tumor has an insidious onset and lacks specific clinical manifestations. According to the characteristics of this disease, B-mode ultrasound, CT, magnetic resonance imaging, digital subtraction angiography, gastrointestinal endoscopy, capsule endoscopy, and other examinations should be used to make a preoperative diagnosis and conduct accurate clinical staging. Multidisciplinary discussion is helpful to develop standardized treatment options to improve the prognosis of patients.

Transcatheter embolization effectively controls acute lower gastrointestinal bleeding without localizing bleeding site prior to angiography

BACKGROUND AND AIMS

Colonoscopy is preferred for treatment of lower gastrointestinal bleeding (LGIB). However, several conditions such as poor bowel preparation can cause endoscopic failure, leading to surgery or transcatheter therapy as alternative options. We aimed to assess the efficacy and safety of transcatheter arterial embolization (TAE) for LGIB in patients with endoscopic failure.

METHODS

Between January 2005 and June 2015, 93 consecutive patients with acute LGIB underwent visceral angiography at three academic hospitals. Among them, a total of 52 patients were treated with TAE for LGIB and analyzed. Technical success, complications and 30-day rebleeding and mortality after TAE were investigated retrospectively in patients with and without localization of LGIB.

RESULTS

Technical success of TAE was achieved in all patients. After TAE, 30-day rebleeding and mortality rate were 27% (14/52) and 29% (15/52), respectively. TAE was performed without localizing bleeding site in 32 of 52 patients (62%). Between patients with and without localized bleeding site, there were no significant differences in 30-day rebleeding rate (25% vs. 28%) and mortality rate (15% vs. 38%). Causes of death were mostly unrelated to bleeding. Only two cases of bowel infarction occurred after TAE in patients without bleeding site localization. Rebleeding could be predicted if the patient received more than six units of packed red blood cell transfusion before TAE in multivariate analysis.

CONCLUSIONS

TAE can be an effective treatment for LGIB even without localizing bleeding site.

Acute Small Bowel Perforation Caused by Obstruction of a Novel Tag-Less AgileTM Patency Capsule

A 74-year-old man visited our hospital complaining of abdominal pain. An abdominal computed tomography scan showed multiple wall thickness of the small bowel. Capsule endoscopy was recommended for further evaluation, and patency capsule examination was performed. Eighteen hours after patency capsule ingestion, he experienced small bowel perforation with severe peritonitis caused by intestinal pressure rising because of the patency capsule trapped in his terminal ileum. An ileocolic resection was performed, including the removal of the sclerotic ileum as an emergency surgery. A pathological examination showed transmural inflammation and multiple ulcers with perforation of the small intestine, consistent with Crohn's disease. Here, we report a rare and valuable case of novel tag-less Agile^TM patency capsule (Given Imaging Ltd., Yoqneam, Israel) retention leading to small bowel perforation.

Case of Bleeding Ileal Varices after a Colectomy Diagnosed by Capsule Endoscopy

We report a case of bleeding ileal varices associated with intra-abdominal adhesions after colectomy which was successfully diagnosed using capsule endoscopy. A 77-year-old woman visited the emergency department for several episodes of melena. She had a medical history of neoadjuvant chemo-radiation therapy and subsequent surgery for rectal cancer 6 years previously. Conventional diagnostic examinations including upper endoscopy, colonoscopy, and abdominal computed tomography could not detect any bleeding focus, however, following capsule endoscopy revealed venous dilatations with some fresh blood in the distal ileum, indicating bleeding ileal varices. The patient underwent exploratory laparotomy and the affected ileum was successfully resected. No further gastrointestinal bleeding occurred during the 6 months follow-up. Small intestinal varices are important differential for obscure gastrointestinal bleeding especially in patients with a history of abdominal surgery in the absence of liver cirrhosis, and capsule endoscopy can be a good option for diagnosing small intestinal varices.

Accuracy of Computed Tomographic Enterography for Obscure Gastrointestinal Bleeding: A Diagnostic Meta-analysis

RATIONALE AND OBJECTIVES

Obscure gastrointestinal bleeding (OGIB) is the bleeding from the gastrointestinal tract without definite source that persists and recurs after a negative endoscopic evaluation. The study aimed to systematically evaluate the diagnostic accuracy of computed tomography enterography on OGIB detection by meta-analysis.

MATERIALS AND METHODS

Studies were searched in relevant databases. With predefined inclusion criteria, eligible studies were included, followed by quality assessment using the Quality Assessment of Diagnostic Accuracy Studies scoring system. The Meta-DiSc software was used to implement the meta-analysis, and sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio with their 95% confidence intervals (CIs) were used as the effect size. Publication bias was determined by Egger test.

RESULTS

A set of nine studies was included in this meta-analysis, having a relatively high quality. Under the random effects model, the pooled sensitivity and specificity were 0.724 (95% CI: 0.651-0.789) and 0.752 (95% CI: 0.691-0.807), respectively. Under the fixed effects model, the pooled positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 2.949 (95% CI: 2.259-3.850), 0.393 (95% CI: 0.310-0.497), and 9.452 (95% CI: 5.693-15.692), respectively. The area under curve of the summary receiver operating characteristic curve was 0.7916 (95% CI: 0.723-0.860). No obvious publication bias was detected (t = 1.62, P = .181).

CONCLUSIONS

Computed tomography enterography might be used as a complementary to video capsule endoscopy instead of an alternative for the detection of OGIB.

Laparoscopic treatment of hemorrhagic Meckel diverticulum after diagnosis with wireless capsule endoscopy and double-balloon enteroscopy

Meckel diverticulum (MD) is a common small intestinal malformation. The difficulty of MD with hemorrhage treatment lies in preoperative diagnosis. Wireless capsule endoscopy (WCE) and double-balloon enteroscopy (DBE) have been widely used to diagnose and treat diseases of the small intestine, but only rarely have they been used in combination to diagnose and treat bleeding MD. We successfully diagnosed and treated a patient with MD with hemorrhage with a combination of WCE, DBE, and laparoscopy. A 17-year-old man presented to the emergency room with hematochezia and was admitted for testing. Abdominal computed tomography, gastroscopy, and colonoscopy did not reveal hemorrhage, but WCE showed MD combined with ulceration. DBE was conducted to confirm the presence of the lesion and showed MD combined with ulceration 1 m proximal to the ileocecal valve. The patient underwent emergency laparoscopic surgery, which confirmed MD. The patient recovered well after the operation.MD with hemorrhage poses diagnostic and therapeutic challenges and can be missed on examination using standard modalities. Laparoscopy combined with WCE and DBE can be efficacious in the treatment of MD with hemorrhage.

Neurofibromatosis tipo 1 y sangrado de intestino delgado. Reporte de caso

La neurofibromatosis tipo 1, o enfermedad de von Recklinghausen, es un desorden neurocutáneo hereditario con compromiso gastrointestinal en el 5-25% de los pacientes, siendo sintomático solo el 5%; se presenta posterior a las manifestaciones cutáneas y afecta en su mayoría el yeyuno. Los síntomas de esta enfermedad son dolor abdominal, obstrucción intestinal, perforación, diarrea, masa palpable y sangrado gastrointestinal alto o bajo.A continuación se reporta el caso de una mujer con sangrado gastrointestinal manifiesto secundario a neurofibromas plexiformes en yeyuno y se realiza una breve revisión de la literatura sobre compromiso gastrointestinal.

Clinical Practice Guideline for Enteroscopy

Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed 'Clinical Practice Guidelines for Enteroscopy' in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease-based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.

Role of computed tomography angiography on the management of overt obscure gastrointestinal bleeding

Background and aim

The role of computed tomography angiography (CTA) on the management of acute overt obscure gastrointestinal bleeding (OGIB) remains unclear. We designed a study to evaluate the impact of CTA before enteroscopy for acute overt OGIB.

Methods

All patients undergoing CTA followed by enteroscopy for acute overt OGIB were enrolled in this retrospective study. Clinical characteristics and diagnosis were compared between patients with positive and negative CTA findings. We evaluated the impact of CTA on subsequent enteroscopy.

Results

From February 2008 to March 2015, 71 patients including 25 patients with positive CTA findings and 46 patients with negative CTA findings, were enrolled. All 25 patients with positive CTA findings were confirmed to have mid GI lesions, a significantly higher proportion than among patients with negative CTA findings (100% vs. 52.2%, respectively; P <0.001). CTA had a higher diagnostic yield for bleeding from tumor origin than from non-tumor origin (80.0% vs. 23.7%, respectively; P <0.001). The diagnostic yield of CTA and enteroscopy was 35.2% and 73.2%, respectively. The lesions could be identified by the initial route of enteroscopy in more patients with positive CTA findings than in those with negative CTA findings (92.0% vs. 47.8%, respectively; P <0.001). Lesions could be identified in seven of the 25 patients (28.0%) with positive CTA findings by using only push enteroscopy instead of single-balloon enteroscopy (SBE), but all 46 patients with negative CTA findings needed SBE for deep small-bowel examination.

Conclusions

CTA is useful in the diagnosis of acute overt OGIB, especially in patients with bleeding from tumors. In addition, it also can show the precise location of bleeding, and guide subsequent enteroscopic management.

Duodenal plexiform fibromyxoma as a cause of obscure upper gastrointestinal bleeding: A case report

RATIONALE

We are reporting the first-to our knowledge-case of duodenal Plexiform Fibromyxoma causing obscure upper gastrointestinal bleeding.

PATIENT CONCERNS

Plexiform fibromyxoma triggered recurrent upper gastrointestinal bleeding episodes in a 63-year-old man who remained undiagnosed, despite multiple hospitalizations, extensive diagnostic workups and surgical interventions (including gastrectomies), for almost 17 years.

DIAGNOSES-INTERVENTIONS

During hospitalization for the last bleeding episode, an upper gastrointestinal endoscopy revealed an intestinal hemorrhagic nodule. The lesion was deemed unresectable by endoscopic means. An abdominal computerized tomography disclosed no further lesions and surgery was decided. The lesion at operation was found near the edge of the duodenal stump and treated with pancreas-preserving duodenectomy (1st and 2nd portion).

OUTCOMES

Postoperative recovery was mainly uneventful and a 20-month follow-up finds the patient in good health with no need for blood transfusions.Plexiform fibromyxomas stand for a rare and widely unknown mesenchymal entity. Despite the fact that they closely resemble other gastrointestinal tumors, they distinctly vary in clinical management as well as the histopathology. Clinical awareness and further research are compulsory to elucidate its clinical course and prognosis.

Emergency surgery for hemorrhagic shock caused by a gastrointestinal stromal tumor of the ileum: A case report

In this report, a case of hemorrhagic shock caused by a gastrointestinal stromal tumor (GIST) of the ileum, which was successfully treated by emergency surgery, is presented. A 67-year-old male patient presented to the Ibaraki Medical Center, Tokyo Medical University (Ami, Japan) in July 18, 2014, with dizziness and blood in the stool. Upper endoscopy and colonoscopy failed to reveal the source of the hemorrhage, although abdominal contrast-enhanced computed tomography revealed extravasation of the contrast medium into the small intestine. The patient developed hemorrhagic shock; thus, double-balloon enteroscopy (DBE) was performed, which revealed a Meckel's diverticulum and a submucosal tumor with excessive bleeding at 60 and 100 cm proximal to the ileocecal valve, respectively. Subsequent emergency partial resection of the ileum, including the tumor and the Meckel's diverticulum, was performed in July 20, 2014. Histological examination of the excised tumor revealed proliferation of spindle-shaped cells, and immunohistochemical staining of the tumor was positive for CD34, KIT and α-smooth muscle actin, but negative for S-100 protein. These immunohistological results supported the diagnosis of GIST of the ileum. The patient had an uneventful recovery and has been monitored at our outpatient clinic for 14 months after surgery. This case demonstrated the efficacy of DBE for the diagnosis of small intestinal bleeding, and immediate emergency surgery should be considered for cases of small intestinal GISTs with excessive bleeding.

Clinical usefulness of transabdominal ultrasonography prior to patency capsule for suspected small-bowel strictures

OBJECTIVE

Patency capsule (PC) examination has made it possible to perform capsule endoscopy (CE) in patients with a suspected small-bowel stricture. However, PC has some drawbacks, so we assessed the usefulness of transabdominal ultrasonography (TUS) prior to PC in patients with suspected small-bowel strictures to avoid unnecessary PC examination.

PATIENTS AND METHODS

Fifty-two patients who underwent TUS prior to PC were enrolled in this study. TUS findings were classified as follows: intestinal narrowing and distension at the oral side (Type A); extensive bowel wall thickening (Type B); focal bowel wall thickening (Type C) or no abnormality detected (Type D). We evaluated the TUS and PC findings for the detection of small-bowel strictures.

RESULTS

Double-balloon endoscopy (DBE) revealed small-bowel strictures in 13 of 50 patients (26%). TUS yielded Type B or C findings in 12 of 13 patients (92%), while PC revealed strictures in all 13 patients. In Crohn's disease (CD) patients with Type B TUS findings, 8 of 9 (89%) had small-bowel strictures on DBE. However, only two of six non-CD patients (33%) with Type B TUS findings had small-bowel strictures. The incidence of Type B strictures was significantly higher in CD patients.

CONCLUSIONS

CD patients with Type B TUS findings should not undergo PC or CE because of the high rate of small-bowel strictures. Non-CD patients diagnosed with Type B TUS strictures, as well as patients diagnosed with Type C or D strictures should undergo CE after confirming small-bowel patency using PC.

The Role of Emergency Endoscopy in Small Bowel Bleeding: A Review

There is no consensus on the timing and management of emergency overt obscure gastrointestinal bleeding. Emergency capsule endoscopy and balloon-assisted enteroscopy have a high diagnostic and therapeutic yield in these situations. Most lesions detected by small bowel endoscopy are amenable to endoscopic haemostasis, although some lesions still require surgery or interventional radiology. The management of these patients is varied, and doubt persists about which technique should be preferred as first-line treatment. This narrative review analyses the usefulness and impact of small bowel endoscopic techniques in the emergency setting for severe overt obscure gastrointestinal bleeding.

Diagnosis of Obscure Gastrointestinal Bleeding

Obscure gastrointestinal bleeding (OGIB) is defined as gastrointestinal bleeding from a source that cannot be identified on upper or lower gastrointestinal endoscopy. OGIB is considered an important indication for capsule endoscopy (CE). CE is particularly useful for the detection of vascular and small ulcerative lesions, conditions frequently associated with OGIB, particularly in Western countries. On the other hand, balloon enteroscopy (BE) can facilitate the diagnosis of lesions presenting with minimal changes of the mucosal surface, such as submucosal tumors, and can be used not only for diagnosis, but also for treatment, including endoscopic hemostasis. In other words, the complementary use of both CE and BE enables OGIB to be more efficiently diagnosed and treated. However, rebleeding can occur even in patients with negative results of CE, and such patients require repeat CE or BE. It is essential to effectively use both CE and BE based on a thorough understanding of the strong points and weak points of these procedures. Further advances and developments in virtual endoscopy incorporating computed tomography and magnetic resonance imaging are expected in the future.