Diagnostic evaluation and management of obscure gastrointestinal bleeding: a changing paradigm

Abstract

Obscure gastrointestinal bleeding (OGIB) is defined as bleeding from the gastrointestinal tract that persists or recurs after a negative initial evaluation using bidirectional endoscopy and radiologic imaging with small-bowel radiograph. The main challenges related to evaluation of OGIB include the high miss rate for lesions on initial evaluation with standard endoscopy and the limited capacity of older diagnostic modalities to effectively examine the small bowel. The introduction of capsule endoscopy, balloon-assisted enteroscopy, spiral enteroscopy, and computed tomography (CT) enterography have served to overcome the limitations of older diagnostic tests. Capsule endoscopy is currently recommended as the third test of choice in the evaluation of patients with OGIB, after a negative bidirectional endoscopy. Balloon-assisted enteroscopy is useful for both the diagnosis and endoscopic management of OGIB. CT enterography is superior to small-bowel radiograph for luminal and extraluminal small-bowel examination. These advances in small-bowel diagnostics and the capacity to successfully perform endoscopic therapeutics have largely replaced surgical procedures and resulted in a trend toward noninvasive evaluation and endoscopic management of OGIB.

Keywords: Obscure gastrointestinal bleeding; balloon-assisted enteroscopy; computed tomography enterography; double-balloon enteroscopy; single-balloon enteroscopy; spiral enteroscopy; video capsule endoscopy.

Figure 2

Dieulafoy lesion in the proximal ileum detected on retrograde double-balloon enteroscopy in a patient with overt obscure gastrointestinal bleeding. The location was tattooed with Spot injection. Segmental resection of the small bowel was performed.

Figure 3

Submucosal tumor with overlying ulceration detected on capsule endoscopy in a 46-year-old man with occult obscure gastrointestinal bleeding (A). Retained capsule seen on abdominal radiograph (B). Gross specimen of resected ileum with carcinoid tumor and retained capsule endoscope (C). Surgical pathology was consistent with nests of neuroendocrine cells, which corresponds to a carcinoid tumor (D).

Figure 4

Angioectasia and mucosal scalloping of the small bowel detected on capsule endoscopy in a patient with overt obscure gastrointestinal bleeding and iron-deficiency anemia. Argon plasma coagulation of multiple angioectasias was performed, and small-bowel biopsies were obtained on double-balloon enteroscopy (A). Small-bowel biopsies were consistent with villous atrophy secondary to celiac sprue (B).

Figure 5

Diaphragm disease related to nonsteroidal anti-inflammatory drug use seen on video capsule endoscopy (A) and confirmed on double-balloon enteroscopy (B) in a patient with occult obscure gastrointestinal bleeding.

Figure 1

Evaluation and management of obscure gastrointestinal bleeding (OGIB). BAE=balloon-assisted enteroscopy; CE=capsule endoscopy; CTE=computed tomography enterography.