Obscure gastrointestinal (GI) bleeding is defined as bleeding into the GI tract that persists or ... and/or positive fecal occult blood test). Obscure GI bleeding.
Gastrointestinal Lesions Detected by Capsule Endoscopy and Double-Balloon Enteroscopy M Kopa´cˇova´, J Buresˇ, and I Tachecı´, Charles University Faculty of Medicine and University Teaching Hospital, Hradec Kra´love´, Czech Republic r 2013 Elsevier GmbH. Open access under CC BY-NC-ND license. Received 17 May 2012; Revision submitted 17 May 2012; Accepted 24 May 2012
Abstract The negative initial endoscopy investigations (gastroscopy and colonoscopy) are the basic conditions for the obscure gastrointestinal (GI) bleeding diagnosis. The bleeding source is mostly localized in the small bowel; in spite of this, there is still a large group of patients with upper GI lesions missed during initial gastroscopy. Therefore, the capsule endoscopy indicated as the first-line method can be valuable for the gastric and duodenal investigation, too. Some cases of missed upper GI lesions diagnosed by means of capsule endoscopy indicated for obscure GI bleeding are demonstrated. This article is part of an expert video encyclopedia.
Keywords Capsule endoscopy; Missed upper gastrointestinal lesions; Obscure gastrointestinal bleeding; Source of bleeding; Standard endoscopy; Video.
Video Related to this Article Video available to view or download at doi:10.1016/S22120971(13)70075-X
Materials
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Wireless capsule endoscopy: Given Imaging – Pillcam, Israel; Olympus – EndoCapsule, Tokyo, Japan. Double-balloon enteroscopy: Fujinon EN-450T5; Tokyo, Japan. Gastroscopy: Olympus GIF Q 180; Tokyo, Japan.
Background and Endoscopic Procedures Obscure gastrointestinal (GI) bleeding is defined as bleeding into the GI tract that persists or recurs without any evident source identified after initial endoscopy (gastroscopy and colonoscopy). Clinical presentation can be overt (melena and/ or hematochesia) or occult bleeding (iron-deficiency anemia and/or positive fecal occult blood test). Obscure GI bleeding may occur anywhere throughout the GI tract; the bleeding source is mostly localized in the small bowel.1,2 Many studies comparing wireless capsule endoscopy (WCE) to other imaging methods (endoscopic or radiologic) confirmed the highest diagnostic accuracy of WCE in patients with obscure GI bleeding.3–5 WCE is the first-line method in the standard algorithms followed by therapeutic enteroscopy, drug treatment, or surgery. In spite of this fact, substantial endoscopic miss rates have also been reported during initial standard gastroscopies.6–8 This article is part of an expert video encyclopedia. Click here for the full Table of Contents.
Video Journal and Encyclopedia of GI Endoscopy
There are two important questions in patients with obscure GI bleeding in this context. The first one is: When should we repeat gastroscopy before WCE? Risk factors associated with higher number of missed upper GI lesions are large hiatal hernias, hematemesis, and treatment by nonsteroidal antiinflammatory drugs (NSAIDs).9 In cases of obscure GI bleeding with negative initial gastroscopy, repeated standard endoscopy should be done in any doubt about the quality of first gastroscopy too (absence of video recording, retroversion or deep duodenal intubation, and large amount of gastric content with remnants of food or blood limiting investigation). The second question: Is there clinical ability of WCE in identifying the missed upper GI lesions? Although WCE is dedicated to explore the small bowel, it also provides quality images of the esophagus and stomach recorded before the passage through the pylorus. In retrospective analysis (published in cooperation with Belgian colleagues), 10 gastric lesions were observed in 37% (44/118) of patients undergoing WCE for obscure GI bleeding, and the lesions were considered as significant (potentially hemorrhagic) in 21% (25/118) of them. The identified pathology was subsequently considered as the only source of bleeding in 10% (12/118) of patients. Missed lesions in the upper GI tract included hemorrhagic erosions, portal gastropathy with blood, ulcers, angiectasias, Dieulafoy’s lesions, Cameron ulcer, and gastric antral vascular ectasias. Most of these lesions were described in the gastric body or in the antrum, confirming existing limits of WCE for evaluation of the fundus and cardia. On the contrary, the pylorus and prepyloric area were regularly observed in most cases.10 There were no statistically significant differences between the number of potentially hemorrhagic gastric lesions detected by means of WCE in patients with obscure overt (15/25) or occult (10/25) GI bleeding. There are some possible limits of WCE in these cases. The quick passage of the capsule through the esophagus limits the quality of visualization; usually only a few pictures from the distal part
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could be evaluated. Important factors limiting the visibility of the stomach are inability of insufflation and presence of gastric content despite adequate fasting. Another specific problem of WCE is poor visibility of periampular region with the risk of missing the lesions (important particularly in patients with inadequate duodenal intubation during initial gastroscopy). A video case of missed upper GI lesion during gastroscopy and identified by subsequent enteroscopy has been presented. A 73-year-old man with dual antiaggregation therapy was investigated because of recurrent GI bleeding requiring repeated blood transfusions (8 units during 3 months). Initial gastroscopy and colonoscopy were accomplished elsewhere with normal findings. Capsule endoscopy performed in the authors’ department identified a pedunculated tumor in the proximal small bowel. Double-balloon enteroscopy confirmed a fingerlike giant polyp growing from the distal duodenum and reaching the proximal jejunum. The length of the polyp was 12 and its diameter 2 cm. Because of the patient’s serious comorbidity, it was decided to remove the polyp endoscopically. The polyp was extracted for histology and the final diagnosis was vascular lipofibroma (angiolipofibroma). Gastroscopy and colonoscopy are the initial basic investigations in patients with GI bleeding from unknown origin. In the case of negative results, the source of bleeding in the small intestine is supposed. Capsule enteroscopy is the first-line method for detection of small intestinal pathology, although some missed lesions within reach of either gastroscopy or colonoscopy could be found as well.
Key Learning Points/Tips and Tricks
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The prevalence of upper GI lesions in patients with obscure GI bleeding is relatively high (especially in patients with axial hiatal hernia, hematemesis, and NSAID therapy). Reevaluate the quality of the initial gastroscopy and read the ‘upper’ part of the WCE.
00:52–01:10
The presence of digested blood, or clots in the stomach at capsule endoscopy, confirms the suspicion of an overlooked gastric lesion. In this patient, the gastric angiectasia was the source of obscure bleeding.
01:10–01:24
An example of intermittent bleeding pathology localized in the duodenum is this Dieulafoy’s lesion, treated by means of bipolar electrocoagulation during the second gastroscopy.
01:24–01:36
Small lesions, like this ulcerated gastrointestinal stromal tumor, can be missed due to intestinal content (e.g., bile or bubbles) in the duodenal area.
01:40–02:15
We present a video case of upper gastrointestinal lesion missed at initial gastroscopy, identified by subsequent enteroscopy methods. A 73-year-old man with dual antiaggregation therapy was investigated due to recurrent gastrointestinal bleeding and repeated blood transfusions. The initial gastroscopy and colonoscopy were accomplished elsewhere with normal findings. Wireless capsule endoscopy identified an abnormal fold in the duodenum (on 6 and 4 h) and a suspected polyp, with abnormal mucosa, on the frozen picture here on 11 h.
02:17–02:37
The double-balloon enteroscopy confirmed a finger-like giant polyp growing from the duodenum. The length of the polyp was 12 cm and its diameter 2 cm, the tip, with oedematous mucosa, was localized in the proximal jejunum.
03:06–03:36
Because of the patient’s comorbidity, we decided to remove the polyp endoscopically. Risk of serious bleeding was expected, so we set an endoloop and hemoclips on the polyp base. The snare polypectomy time was unusually long and we observed intensive bleeding from the polyp stump.
03:41–04:07
The bleeding was controlled by means of argon plasmacoagulation of the whole area.
04:08–04:17
The polyp was extracted for histology, and the final diagnosis was angiolipofibroma.
04:19–04:29
Control endoscopies 24 h and 9 day after polypectomy confirmed uncomplicated healing of the polyp stump.
Scripted Voiceover Time (min:sec)
Voiceover text
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The topic of our video presentation are upper gastrointestinal lesions detected by capsule endoscopy in patients with obscure gastrointestinal bleeding. We present some examples of missed lesions in the upper gastrointestinal tract identified by means of wireless capsule endoscopy. This is a typical picture of portal hypertensive gastropathy in the gastric body with characteristic mosaic-like pattern and red spots.
00:30–00:40
In another patient, the source of bleeding was identified as several hemorrhagic erosions localized in the gastric antrum.
00:40–00:52
The small linear antral ulcer was found by capsule endoscopy in a patient treated with nonsteroidal anti-inflammatory drugs.
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5. Saperas, E.; Dot, J.; Videla, S.; et al. Capsule Endoscopy Versus Computed Tomographic or Standard Angiography for the Diagnosis of Obscure Gastrointestinal Bleeding. Am. J. Gastroenterol. 2007, 102, 731–737. 6. Zaman, A.; Katon, R. M. Push Enteroscopy for Obscure Gastrointestinal Bleeding Yields a High Incidence of Proximal Lesions Within Reach of a Standard Endoscope. Gastrointest. Endosc. 1998, 47, 372–376. 7. Sidhu, R.; Sanders, D. S.; McAlindon, M. E. Does Capsule Endoscopy Recognise Gastric Antral Vascular Ectasia More Frequently than Conventional Endoscopy? J. Gastrointest. Liver Dis. 2006, 15, 375–377. 8. Fry, L. C.; Bellutti, M.; Neumann, H.; Malfertheiner, P.; Mo¨nkemu¨ller, K. Incidence of Bleeding Lesions within Reach of Conventional Upper and
Lower Endoscopes in Patients Undergoing Double-Balloon Enteroscopy for Obscure Gastrointestinal Bleeding. Aliment. Pharmacol. Ther. 2009, 29, 342–349. 9. Chak, A.; Koehler, M. K.; Sundaram, S. N.; et al. Diagnostic and Therapeutic Impact of Push Enteroscopy: Analysis of Factors associated with Positive Findings. Gastrointest. Endosc. 1998, 47, 18–22. 10. Tacheci, I.; Devie`re, J.; Kopacova, M.; et al. The Importance of Upper Gastrointestinal Lesions Detected with Capsule Endoscopy in Patients with Obscure Digestive Bleeding. Acta Gastroenterol. Belg. 2011, 74(3), 395–399.
