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• W2000794339 abstract "This literature review and the recommendations therein were prepared for the AGA Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on March 12, 2007, and by the AGA Institute Governing Board on May 19, 2007. This literature review and the recommendations therein were prepared for the AGA Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on March 12, 2007, and by the AGA Institute Governing Board on May 19, 2007. CME quiz on page 1692. CME quiz on page 1692. The diagnosis and management of patients with obscure gastrointestinal (GI) bleeding was challenging for the gastroenterologist until the development of small bowel capsule endoscopy and double-balloon enteroscopy (DBE). Both of these techniques have revolutionized the management of patients with obscure GI bleeding. Detection of lesions such as small intestinal angioectasia has become possible with the advent of capsule endoscopy, and therapy of such lesions can be accomplished with DBE, without the need for intraoperative enteroscopy. The goal of this review is to shed light on the recent paradigm shift to the use of endoscopy in the diagnosis and management of patients with obscure GI bleeding. Obscure GI bleeding, defined as bleeding from the GI tract that persists or recurs without an obvious etiology after esophagogastroduodenoscopy (EGD), colonoscopy, and radiologic evaluation of the small bowel such as small bowel follow-through or enteroclysis, could be categorized into obscure overt and obscure occult bleeding based on the presence or absence of clinically evident bleeding.1American Gastroenterological Association medical position statementevaluation and management of occult and obscure gastrointestinal bleeding.Gastroenterology. 2000; 118: 197-201Abstract Full Text Full Text PDF PubMed Google Scholar, 2Gralnek I.M. Obscure-overt gastrointestinal bleeding.Gastroenterology. 2005; 128: 1424-1430Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Occult GI bleeding is detected by fecal occult blood testing. There is no recent publication that recommends or has studied the role of fecal occult blood testing beyond the clinical context of colorectal cancer screening. A fecal occult blood test should be performed only in the appropriate context of colorectal cancer screening. If the test result is positive and the findings of a recommended colon cancer screening workup are negative, in the absence of iron deficiency anemia and GI symptoms, no further workup is recommended. If associated (iron deficiency) anemia is present, and if the clinical presentation satisfies the definition of obscure GI bleeding, then only it should be worked up as obscure GI bleeding. Obscure GI bleeding could be due to lesions that are overlooked in the esophagus, stomach, and colon during initial workup or lesions in the small intestine that are difficult to visualize with conventional endoscopy and radiologic imaging. Explanations for overlooking a lesion and missing the diagnosis include lesions that have stopped bleeding during endoscopic examination, lesions that are obscured by blood clots that are unable to be mobilized during endoscopy, hypovolemia and significant anemia causing lesions to look less obvious, and intermittent and slow bleeding leading to negative findings on endoscopic and nuclear scans. Overall, lesions in the small intestine account for approximately 5% of causes of obscure GI bleeding. Medical imaging of the small intestine has been a very difficult and limited undertaking. Several factors account for the difficulty encountered in small bowel visualization. The length of the small intestine, in addition to its free intraperitoneal location, vigorous contractility, and overlying loops, confounds the usual diagnostic techniques. These attributes limit the diagnostic ability of barium studies, endoscopic intubation, and the identification of specific sites by the special imaging techniques of nuclear medicine scans and angiography. In patients with obscure GI bleeding, the bleeding rate may be slow or intermittent, thereby not allowing identification by either angiography or bleeding scan.3Rantis Jr, P.C. Harford F.J. Wagner R.H. Henkin R.E. Technetium-labelled red blood cell scintigraphy: is it useful in acute lower gastrointestinal bleeding?.Int J Colorectal Dis. 1995; 10: 210-215Crossref PubMed Scopus (36) Google Scholar The yield of a small bowel series for diagnosing tumors of the small intestine is quite low and barium studies, even enteroclysis, cannot diagnose angiectasias, which are the most common causes of small intestinal bleeding.4Ott D.J. Chen Y.M. Gelfand D.W. Van Swearingen F. Munitz H.A. Detailed per-oral small bowel examination vs. enteroclysis. Part I: expenditures and radiation exposure.Radiology. 1985; 155: 29-31Crossref PubMed Google Scholar, 5Ott D.J. Chen Y.M. Gelfand D.W. Van Swearingen F. Munitz H.A. Detailed per-oral small bowel examination vs. enteroclysis. Part II: radiographic accuracy.Radiology. 1985; 155: 31-34Crossref PubMed Google Scholar The distal small intestine has been relatively inaccessible to endoscopic intubation despite the development of various enteroscopes. Because of the inability to localize a bleeding site in the small bowel, patients with obscure GI bleeding typically present with prolonged occult blood loss or recurrent episodes of melena or maroon stool without a specific diagnosis. In this group of patients, an early diagnosis of the bleeding site has been the exception rather than the norm until recently with the development of capsule endoscopy and DBE. A MEDLINE search of English-language publications was performed from 1966 to June 2006 related to obscure GI bleeding by using the following search terms: obscure GI bleeding, occult GI bleeding, video capsule endoscopy, and enteroscopy. Reference lists from relevant manuscripts were also inspected to identify additional applicable articles missed with the above search strategy. The following sections describe recent advances in our understanding of the etiology, diagnosis, and management of obscure GI bleeding since the publication of American Gastroenterological Association medical position statement entitled “Evaluation and Management of Occult and Obscure Gastrointestinal Bleeding” in 2000.1American Gastroenterological Association medical position statementevaluation and management of occult and obscure gastrointestinal bleeding.Gastroenterology. 2000; 118: 197-201Abstract Full Text Full Text PDF PubMed Google Scholar Studies published only as abstracts were excluded. For assessment of procedural outcomes, case series were not included. To calculate yearly probabilities, the formula p = 1 − e(−rt) was used, where p represents probability, r represents rate, and t represents time. Causes of obscure GI bleeding may potentially include any lesion from the oral cavity to the anorectum that may bleed into the GI tract (see Table 1). To date, there are no longitudinal or population-based studies on the frequency and location of specific causes of obscure GI bleeding.Table 1Etiology of Obscure GI BleedingUpper GI and lower GI bleeding overlookedMid GI bleedingUpper GI lesionsYounger than 40 years of age Cameron’s erosions Tumors Fundic varices Meckel’s diverticulum Peptic ulcer Dieulafoy’s lesion Angiectasia Crohn’s disease Dieulafoy’s lesion Celiac disease Gastric antral vascular ectasiaOlder than 40 years of ageLower GI lesions Angiectasia Angiectasia NSAID enteropathy Neoplasms Celiac diseaseUncommon Hemobilia Hemosuccus pancreaticus Aortoenteric fistula Open table in a new tab Commonly overlooked lesions in the upper GI tract include Cameron’s erosions in large hiatal hernias,6Zaman 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: 372-376Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar fundic varices,7Mullan F.J. McKelvey S.T. Pancreatic carcinoma presenting as bleeding from segmental gastric varices: pitfalls in diagnosis.Postgrad Med J. 1990; 66: 401-403Crossref PubMed Google Scholar, 8Kovacs T.O. Jensen D.M. Recent advances in the endoscopic diagnosis and therapy of upper gastrointestinal, small intestinal, and colonic bleeding.Med Clin North Am. 2002; 86: 1319-1356Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar peptic ulcer disease, angioectasias,6Zaman 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: 372-376Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar Dieulafoy’s lesion,9Lee Y.T. Walmsley R.S. Leong R.W. Sung J.J. Dieulafoy’s lesion.Gastrointest Endosc. 2003; 58: 236-243Abstract Full Text PDF PubMed Scopus (81) Google Scholar and gastric antral vascular ectasia.10Burak K.W. Lee S.S. Beck P.L. Portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE) syndrome.Gut. 2001; 49: 866-872Crossref PubMed Scopus (99) Google Scholar, 11Raju G.S. Morris K. Boening S. Carpenter D. Gomez G. Capillary refilling sign demonstrated by capsule endoscopy.Gastrointest Endosc. 2003; 58: 936-937Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Lesions missed during colonoscopy include angioectasias and neoplasms.12Leighton J.A. Goldstein J. Hirota W. Jacobson B.C. Johanson J.F. Mallery J.S. Peterson K. Waring J.P. Fanelli R.D. Wheeler-Harbaugh J. Baron T.H. Faigel D.O. Obscure gastrointestinal bleeding.Gastrointest Endosc. 2003; 58: 650-655Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar The etiology of small intestinal bleeding is dependent on the age of the patient. Patients younger than 40 years are more likely to have small intestinal tumors (such as lymphomas, carcinoid tumors, and adenocarcinoma, and polyps from hereditary polyposis syndrome), Meckel’s diverticulum, Dieulafoy’s lesion, and Crohn’s disease. Patients who are older than 40 years are more prone to bleeding from vascular lesions, which comprise up to 40% of all causes, and nonsteroidal anti-inflammatory drug (NSAID)-induced small bowel disease. Less common etiologies of bleeding, which originate in the C-loop of duodenum, include hemobilia in patients with liver biopsy, trauma, and hepatocellular cancer, hemosuccus pancreaticus in patients with necrotizing pancreatitis or pancreatic transplantation, and aortoenteric fistula in patients with prior abdominal aortic aneurysm repair. Approximately 5% of patients presenting with GI hemorrhage have no source found by upper endoscopy and colonoscopy.13Szold A. Katz L.B. Lewis B.S. Surgical approach to occult gastrointestinal bleeding.Am J Surg. 1992; 163 (discussion 92–93): 90-92Abstract Full Text PDF PubMed Scopus (103) Google Scholar In approximately 75% of these patients, responsible lesions can be detected in the small bowel.14Pennazio M. Arrigoni A. Risio M. Spandre M. Rossini F.P. Clinical evaluation of push-type enteroscopy.Endoscopy. 1995; 27: 164-170Crossref PubMed Google Scholar, 15Chong J. Tagle M. Barkin J.S. Reiner D.K. Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology.Am J Gastroenterol. 1994; 89: 2143-2146PubMed Google Scholar, 16Davies G.R. Benson M.J. Gertner D.J. Van Someren R.M. Rampton D.S. Swain C.P. Diagnostic and therapeutic push type enteroscopy in clinical use.Gut. 1995; 37: 346-352Crossref PubMed Google Scholar In patients presenting with obscure overt bleeding (defined as the presence of recurrent melena or hematochezia with normal evaluation by upper endoscopy and colonoscopy), small bowel angiectasias are detected in 30%–60% of examinations.17Thompson J.N. Hemingway A.P. McPherson G.A. Rees H.C. Allison D.J. Spencer J. Obscure gastrointestinal haemorrhage of small-bowel origin.Br Med J (Clin Res Ed). 1984; 288: 1663-1665Crossref PubMed Google Scholar Recent advances in endoscopic imaging of the small intestine provide us an opportunity to revisit the traditional definitions of the source of GI bleeding. GI bleeding has been defined as upper or lower GI bleeding based on the location of the bleeding either proximal or distal to the ligament of Treitz. Reclassifying GI bleeding (and obscure GI bleeding) into 3 categories (upper, mid, and lower GI bleeding) instead of adhering to the traditional classification of upper GI and lower GI bleeding may be useful to improve our understanding of the problem. Bleeding above the ampulla of Vater, within the reach of an EGD, is defined as upper GI bleeding; small intestinal bleeding from the ampulla of Vater to the terminal ileum, best investigated by capsule endoscopy and DBE, is defined as mid GI bleeding; and colonic bleeding is defined as lower GI bleeding, which can be evaluated by colonoscopy.18Ell C. May A. Mid-gastrointestinal bleeding: capsule endoscopy and push-and-pull enteroscopy give rise to a new medical term.Endoscopy. 2006; 38: 73-75Crossref PubMed Scopus (84) Google Scholar Angiectasias are ectatic blood vessels made of thin wall with or without endothelial lining. Small arteriovenous communications are often present due to incompetence of the precapillary sphincter. Although they are often incidentally identified during endoscopic procedures, they are increasingly recognized as a major cause of GI bleeding, particularly in the elderly. The factors that trigger these common incidentally detected lesions to present with obscure and often clinically overt GI bleeding have not been clearly elucidated. The association of abnormal von Willebrand’s factor (vWF) is receiving increasing attention in the management of patients with bleeding GI angiectasias. Von Willebrand’s disease is a bleeding disorder that results from a qualitative or quantitative defect in vWF. vWF is a complex multimeric glycoprotein present in platelets, plasma, and subendothelium. vWF is essential to platelet adhesion and aggregation at the site of vascular injury. In an elegant study of patients with both bleeding and nonbleeding angiectasias of the GI tract and control patients with colonic diverticular hemorrhage, Veyradier et al showed that most patients with bleeding angiectasias of the GI tract lack the largest multimers of vWF induced by a latent acquired form of von Willebrand’s disease.19Veyradier A. Balian A. Wolf M. Giraud V. Montembault S. Obert B. Dagher I. Chaput J.C. Meyer D. Naveau S. Abnormal von Willebrand factor in bleeding angiodysplasias of the digestive tract.Gastroenterology. 2001; 120: 346-353Abstract Full Text Full Text PDF PubMed Google Scholar Because these specific multimers are the most effective in inducing platelet aggregation in condition of high shear stress that is commonly present in the microcirculation of angioectatic lesions, it was concluded their deficiency contributes to active bleeding. Bleeding from angiectasias in patients with aortic stenosis, called Heyde’s syndrome, has been recently reviewed.20Warkentin T.E. Moore J.C. Anand S.S. Lonn E.M. Morgan D.G. Gastrointestinal bleeding, angiodysplasia, cardiovascular disease, and acquired von Willebrand syndrome.Transfus Med Rev. 2003; 17: 272-286Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar, 21Williams Jr, R.C. Aortic stenosis, von Willebrand factor, and bleeding.N Engl J Med. 2003; 349 (author reply 1773–1774): 1773-1774Crossref PubMed Google Scholar Whether such an association actually exists has been questioned by an earlier prospective study,22Bhutani M.S. Gupta S.C. Markert R.J. Barde C.J. Donese R. Gopalswamy N. A prospective controlled evaluation of endoscopic detection of angiodysplasia and its association with aortic valve disease.Gastrointest Endosc. 1995; 42: 398-402Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar while a more recent larger but retrospective study lent support in its favor.23Pate G.E. Mulligan A. An epidemiological study of Heyde’s syndrome: an association between aortic stenosis and gastrointestinal bleeding.J Heart Valve Dis. 2004; 13: 713-716PubMed Google Scholar In patients with aortic stenosis, the aortic wall shear stress is high. At such high macrovascular shear stress, increased consumption of high-molecular-weight multimers of vWF appears to occur possibly related to the increased activity of the shear-dependent vWF-cleaving metalloprotease. This leads to a relative deficiency of high-molecular-weight multimers of vWF, leading to clinically manifest bleeding from angiodysplastic lesions in the GI tract. Support for this hypothesis comes from the fact that after aortic valve replacement, the severity of bleeding from these lesions decreases along with an increase in the level of the circulating high-molecular-weight multimers of vWF. Presumably other factors such as tissue hypoxemia due to reduced GI mucosal perfusion related to hemodynamically significant aortic stenosis might play a role in this situation. Thus, this may be an urban legend; even if there is an association, it is weak and often exaggerated. It is possible that similar pathophysiology can occur in the setting of other common cardiovascular disorders such as severe peripheral vascular occlusive disease and may help explain why elderly people often develop recurrent GI bleeding or iron deficiency anemia from bleeding angiectasias in the GI tract.20Warkentin T.E. Moore J.C. Anand S.S. Lonn E.M. Morgan D.G. Gastrointestinal bleeding, angiodysplasia, cardiovascular disease, and acquired von Willebrand syndrome.Transfus Med Rev. 2003; 17: 272-286Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar The issue of specific coagulation disorders in patients with bleeding GI angiectasias was also recently studied in a prospective cohort of 21 patients.24Junquera F. Saperas E. Angles A. Abadia C. Monasterio J. Malagelada J.R. Increased plasma fibrinolytic activity in bleeding gastrointestinal angiodysplasia.Eur J Gastroenterol Hepatol. 2005; 17: 199-205Crossref PubMed Scopus (5) Google Scholar Plasma levels of vWF, D-dimer, and tissue plasminogen activator activity were significantly different in patients with GI angiectasia compared with control patients with bleeding duodenal ulcer. The plasminogen activator inhibitor type 1 was shown to be an independent predictor of future bleeding in these patients on multivariate analysis. Angiectasias are usually distinguished from telangiectasias, which, although anatomically similar, are usually referred to in the context of systemic or hereditary diseases. Hereditary hemorrhagic telangiectasia (HHT, Rendu–Osler–Weber syndrome) is one of the most well-known hereditary entities associated with obscure GI bleeding.25Longacre A.V. Gross C.P. Gallitelli M. Henderson K.J. White Jr, R.I. Proctor D.D. Diagnosis and management of gastrointestinal bleeding in patients with hereditary hemorrhagic telangiectasia.Am J Gastroenterol. 2003; 98: 59-65Crossref PubMed Scopus (58) Google Scholar Most patients with HHT will have a history of epistaxis that tends to antedate development of cutaneous or visceral telangiectasias by a decade or more. In a recent report from Denmark, the overall incidence of GI bleeding was 33% in patients with HHT and appeared to develop in the fourth or fifth decade of life.26Kjeldsen A.D. Kjeldsen J. Gastrointestinal bleeding in patients with hereditary hemorrhagic telangiectasia.Am J Gastroenterol. 2000; 95: 415-418Crossref PubMed Google Scholar HHT is an autosomal dominant disease with high penetrance, and prevalence is estimated to range from 1:40,000 to 1:100,000. The gene for HHT has been located on chromosome 9q3, and there are 2 disease types described as HHT1 and HHT2, caused by mutations in the endoglin and ALK1 genes, respectively.27Begbie M.E. Wallace G.M. Shovlin C.L. Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome): a view from the 21st century.Postgrad Med J. 2003; 79: 18-24Crossref PubMed Scopus (173) Google Scholar HHT1 has been associated with a higher frequency of visceral manifestations, including GI bleeding, and HHT2 is believed to be associated with a lower penetrance and milder disease manifestations.28Abdalla S.A. Geisthoff U.W. Bonneau D. Plauchu H. McDonald J. Kennedy S. Faughnan M.E. Letarte M. Visceral manifestations in hereditary haemorrhagic telangiectasia type 2.J Med Genet. 2003; 40: 494-502Crossref PubMed Google Scholar, 29Kjeldsen A.D. Moller T.R. Brusgaard K. Vase P. Andersen P.E. Clinical symptoms according to genotype amongst patients with hereditary haemorrhagic telangiectasia.J Intern Med. 2005; 258: 349-355Crossref PubMed Scopus (44) Google Scholar Blue rubber bleb nevus syndrome is a rare disorder characterized by the development of cavernous hemangiomas,30Echenique-Elizondo M. Chronic digestive bleeding in blue rubber-bleb nevus (Bean syndrome).J Am Coll Surg. 2003; 196: 816Abstract Full Text PDF PubMed Scopus (1) Google Scholar which most commonly involve the skin and the GI tract. The most common presentations of blue rubber bleb nevus syndrome are either the appearance of the skin lesions alone or iron deficiency anemia. Most patients with GI bleeding are asymptomatic and generally respond to a blood transfusion and an iron supplement given orally. The lesions can also cause numerous extraintestinal problems such as orthopedic deformities, central nervous system involvement, spinal cord compression, disseminated intravascular coagulation, thrombocytopenia, hemothorax, and hemopericardium. Blue rubber bleb nevus syndrome is a rare, probably inherited disorder that frequently presents as GI blood loss for which endoscopic therapy and surgery is often of value.31Beck P.L. Aspinall A.I. Kilvert V.M. Dort J. Blue rubber bleb nevus syndrome.Gastrointest Endosc. 2002; 56: 598-600Abstract Full Text Full Text PDF PubMed Google Scholar, 32Fishman S.J. Smithers C.J. Folkman J. Lund D.P. Burrows P.E. Mulliken J.B. Fox V.L. Blue rubber bleb nevus syndrome: surgical eradication of gastrointestinal bleeding.Ann Surg. 2005; 241: 523-528Crossref PubMed Scopus (78) Google Scholar The importance of a thorough history and physical examination cannot be overemphasized in the evaluation of a patient with obscure GI bleeding. The nature of the exact presenting symptom is important in deciding a practical, efficient, and cost-effective evaluation plan. For example, recurrent hematemesis from an unknown source usually signifies a bleeding lesion above the ligament of Treitz, and lower GI evaluations are generally not warranted in such a scenario. Severity and temporal pattern of the associated anemia should have a significant impact on subsequent management decisions. For example, in a patient with mild anemia and a very slow decrease in hematocrit who has multiple severe comorbidities, a conservative workup may be prudent, although little information is available on the safety and efficacy of such a strategy. Also, the degree of severity of anemia has a bearing on planning endoscopic evaluation in terms of potential complications related to sedation. Although abdominal symptoms may sometimes help in targeting focused evaluation, conclusions from few available studies are too divergent to recommend targeted evaluation based on abdominal symptoms.1American Gastroenterological Association medical position statementevaluation and management of occult and obscure gastrointestinal bleeding.Gastroenterology. 2000; 118: 197-201Abstract Full Text Full Text PDF PubMed Google Scholar A thorough history of consumption of prescription and over-the-counter medications is very important to exclude medication-related mucosal lesions that may precipitate or exacerbate bleeding. A recent review stresses the importance of skin signs that may enable a clinician to make a diagnosis of the etiology of obscure GI bleeding.33Braverman I.M. Skin signs of gastrointestinal disease.Gastroenterology. 2003; 124: 1595-1614Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar In HHT, the vascular lesions develop primarily on the lips, nasal mucosa, tongue, palms, and palate, but they also can be found under the nails, on the soles of the feet, and even on the tympanic membrane. They appear as dark red, slightly elevated lesions with an ill-defined border and one or more legs radiating from an eccentrically placed punctum. The lesions are often more prominent after blood transfusion and may be missed in an anemic patient.33Braverman I.M. Skin signs of gastrointestinal disease.Gastroenterology. 2003; 124: 1595-1614Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar In patients with blue rubber bleb nevus syndrome, classically the skin lesions present in childhood but can develop later in life. They are usually blue in color and easily compressible with light palpation. Complete compression classically results in an empty, slowly refilling sac.33Braverman I.M. Skin signs of gastrointestinal disease.Gastroenterology. 2003; 124: 1595-1614Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Other rare causes of obscure GI bleeding with cutaneous stigma are celiac disease (dermatitis herpetiformis), acquired immunodeficiency syndrome (Kaposi’s sarcoma), Plummer–Vinson syndrome, tylosis, pseudoxanthoma elasticum (brittle spoon nails), Ehlers–Danlos syndrome (chicken skin appearance, angioid streaks in retina), Schoenlein–Henoch purpura, neurofibromatosis, malignant atrophic papulosis (painless papules), and inherited polyposis syndromes. Reports of severe GI bleeding in patients with Klippel–Trénaunay–Weber syndrome exist34Sato T. Ohta K. Ohyama S. Suenaga M. Ueno M. Oya M. Yamamoto J. Yamaguchi T. Muto T. Kato Y. Klippel-Trenaunay-Weber syndrome and duodenal hemorrhage.Gastrointest Endosc. 2003; 58: 756-757Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 35Wilson C.L. Song L.M. Chua H. Ferrara M. Devine R.M. Dozois R.R. Nehra V. Bleeding from cavernous angiomatosis of the rectum in Klippel-Trenaunay syndrome: report of three cases and literature review.Am J Gastroenterol. 2001; 96: 2783-2788PubMed Google Scholar; these patients can be identified during physical examination because of the presence of hemihypertrophy involving the extremities and external genitalia. A number of investigations can be undertaken to define the etiology of obscure GI bleeding, and the choice depends on the clinical presentation. Repeat EGD and colonoscopy should be undertaken if there is a suspicion of an overlooked lesion, particularly if the fundus has not been well visualized on the initial EGD. Detailed examination of the C-loop of the duodenum should be considered in patients with clinical suspicion of pancreaticobiliary pathology or previous aortic aneurysm repair. Small bowel examination can be performed with a number of radiologic and endoscopic modalities. Radiographic techniques include barium studies, such as small bowel follow-through and enteroclysis; nuclear studies, such as tagged red blood cell scans and Meckel’s scan; computed tomography (CT) and magnetic resonance imaging with enteroclysis; and angiography. Endoscopic techniques include cable endoscopy techniques such as repetition of standard endoscopy (EGD and colonoscopy), push enteroscopy, DBE, and cableless (wireless) capsule endoscopy. Surgical procedures include exploratory laparotomy with and without intraoperative enteroscopy. Lesions overlooked during prior EGD, such as Cameron’s lesions, Dieulafoy’s lesions, vascular ectasias, peptic ulcers, and gastric antral vascular ectasias, account for up to half of the cases.6Zaman 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: 372-376Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar, 36Chak A. Cooper G.S. Canto M.I. Pollack B.J. Sivak Jr, M.V. Enteroscopy for the initial evaluation of iron deficiency.Gastrointest Endosc. 1998; 47: 144-148Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 37Descamps C. Schmit A. Van Gossum A. “Missed” upper gastrointestinal tract lesions may explain “occult” bleeding.Endoscopy. 1999; 31: 452-455Crossref PubMed Scopus (100) Google Scholar, 38Lin S. Branch M.S. Shetzline M. The importance of indication in the diagnostic value of push enteroscopy.Endoscopy. 2003; 35: 315-321Crossref PubMed Scopus (32) Google Scholar Repeat EGD should be considered in patients with hematemesis and in those taking NSAIDs and the fundus should be carefully examined, with special attention to the site of diaphragmatic hiatus for Cameron’s lesion, which remains an underrecognized etiology of obscure GI bleeding. In addition, a transparent cap (band-ligator cap after deploying the bands) fitted to the end of the endoscope may serve as a retractor to examine the blind areas of the upper GI tract, such as the posterior and inferior wall of the duodenum, antrum, high lesser curve, and anastomotic sites, for ulcers and is helpful in uncovering hidden ulcers.39Yap C.K. Ng H.S. Cap-fitted gastroscopy improves visualization and targeting of lesions.Gastrointest Endosc. 2001; 53: 93-95Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar If a capsule endoscopy is performed, instead of repeating the EGD, careful review of the capsule endoscopic images of the stomach and colon might be useful in the detection of lesions missed on prior EGD, such as gastric antral vascular ectasias and inflamed pyloric canal polyps,40Kitiyakara T. Selby W. Non-small-bowel lesions detected by capsule endoscopy in patients with obscure GI bleeding.Gastrointest Endosc. 2005; 62: 234-238Abstract Full Text F" @default.
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• W2000794339 title "American Gastroenterological Association (AGA) Institute Technical Review on Obscure Gastrointestinal Bleeding" @default.
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