Review article: the diagnosis and investigation of obscure gastrointestinal bleeding.

BACKGROUND: Obscure gastrointestinal bleeding (OGIB) is a commonly encountered clinical problem in gastroenterology and is associated with significant morbidity and mortality. The investigation and management of OGIB has changed dramatically over the past decade with the advent of newer gastroenterological and radiological technologies. AIM: To review the current evidence on the diagnosis and investigation of OGIB. METHODS: We searched the PubMed database (1985-2010) for full original articles in English-language journals relevant to the investigation of OGIB. The search terms we used were 'gastrointestinal bleeding' or 'gastrointestinal hemorrhage' or 'small bowel bleeding' each in combination with 'obscure', or 'capsule endoscopy', or 'enteroscopy' or 'enterography' or 'enteroclysis'. RESULTS: Capsule endoscopy (CE) or double balloon enteroscopy (DBE) should be first line investigations. They are complimentary procedures with comparable high diagnostic yields. DBE is also able to provide therapeutic intervention. Newer technologies such as single balloon and spiral enteroscopy are currently being evaluated. Radiological and nuclear medicine investigations, such as CT enterography and CT enteroclysis, are alternative diagnostic tools when CE or DBE are contraindicated. Repeating the gastroscopy and/or colonoscopy may be considered in selective situations. An algorithm for investigation of obscure bleeding is proposed. CONCLUSIONS: The development of capsule endoscopy and double balloon enteroscopy has transformed the approach to the evaluation and management of obscure gastrointestinal bleeding over the past decade. Older diagnostic modalities still play a complementary, but increasingly selective role.

Antegrade double balloon enteroscopy for continued obscure gastrointestinal bleeding following push enteroscopy: is there a role?

BACKGROUND: The benefit of double balloon endoscopy (DBE) over push enteroscopy (PE) for the proximal small bowel in patients with obscure gastrointestinal bleeding remains unclear. AIM: To quantify the benefit of DBE if PE fails to benefit patients with obscure gastrointestinal bleeding. METHODS: This retrospective DBE database review between July 2004 and April 2008 was conducted at a tertiary university hospital in Australia. Thirty-three patients with obscure gastrointestinal bleeding who had undergone PE for proximal small bowel lesions were identified from a DBE database of 280 patients. Mean age was 68.6 (range 30-91) years, and 17 were men. In group A (n = 15) the target lesion was not reached by PE, and in group B (n = 18) an abnormality was found by PE (angioectasia in 17 and red spots in 1) but the patient had ongoing bleeding. Mean follow-up for the cohort was 19.2 (range 5-39) months. DBE interventions were performed as appropriate. RESULTS: An abnormality was found at DBE in 28/33 (85%) patients. DBE found an abnormality in 12/15 (80%) in group A and 16/18 (89%) in group B. Endoscopic intervention was performed in 23/33 patients (70%). In 27/33 (82%) patients a clinical benefit was seen following DBE. Six patients (18%) had no clinical benefit from DBE. CONCLUSIONS: In patients with obscure gastrointestinal bleeding and proximal small bowel lesions who fail to benefit from PE, DBE offers a very high benefit in finding and treating lesions with good long-term outcomes.

Complications of double balloon enteroscopy: a multicenter survey.

BACKGROUND AND STUDY AIMS: Double balloon enteroscopy (DBE) is a new technique for the visualization of the small bowel. Although the technique is widely used, little is known about the complications. A few complications have been reported in the literature, mainly in case reports. The aim of this study was to establish the complication rate of both diagnostic and therapeutic DBE. PATIENTS AND METHODS: A total of 10 centers (nine academic centers and one teaching hospital) across four continents participated in the study. Complications were defined according to the literature. A therapeutic DBE was defined as a DBE with use of argon plasma coagulation, a polypectomy snare, injection of fluids (other than ink for marking), removal of foreign body, or balloon dilation. RESULTS: A total 85 adverse events were reported in 2362 DBE procedures. In all, 40 events fulfilled the definition of a complication, 13 in 1728 diagnostic DBE (0.8 %) and 27 during 634 therapeutic procedures (4.3 %). The complications were rated minor in 21 (0.9 %), moderate in 6 (0.3 %) and severe in 13 procedures (0.6 %). No fatal complications were reported. Seven cases of pancreatitis were reported, six after diagnostic (0.3 %) and one after therapeutic (0.2 %) DBE. CONCLUSIONS: Diagnostic DBE is safe with a low complication rate. The complication rate of therapeutic DBE is high compared with therapeutic colonoscopy. The reason for this is unclear. The incidence of pancreatitis after DBE is low (0.3 %), but has to be considered in patients with persistent abdominal complaints after a DBE procedure.

Argon plasma coagulation in the management of symptomatic gastrointestinal vascular lesions: experience in 100 consecutive patients with long-term follow-up.

BACKGROUND: The long-term efficacy of argon plasma coagulation (APC) in the management of gastrointestinal vascular lesions has not been evaluated in a large and well-defined series. The impact of APC on transfusion requirements and hemoglobin, and technical parameters including complications and number of treatment sessions, is assessed in this series. METHODS: Patients who underwent APC for bleeding gastrointestinal vascular lesions were identified via interrogation of an established endoscopic database, excluding patients with radiation proctitis, tumors, residual polypectomy tissue and acute ulcer bleeding. Follow-up data were collected via interview with patients and referring doctors, review of medical records, and follow-up blood tests. RESULTS: One hundred patients were enrolled, males = 46, median age = 74 yr (range: 19-99 yr). Median follow-up time was 16 months (range: 4-47 months). Lesions treated were arteriovenous malformations (n = 74) and gastric antral vascular ectasia (n = 26). Fifty-three patients required transfusion. In this group, median hemoglobin improved from 66 g/L (range: 35-114) to 111 g/L (range: 55-155, p < 0.001). Median transfusion velocity fell from 2 units/month (range: 0.1-6) to 0 units/month (range: 0-4, p < 0.001). Transfusion requirement was abolished in 77%. In non-transfusion-requiring patients, median hemoglobin improved from 105 g/L (range: 58-143) to 123 g/L (range: 79-158, p < 0.001). No complications occurred. CONCLUSIONS: APC is effective and safe in the management of gastrointestinal vascular lesions.

Endoscopic ultrasound-guided drainage of pancreatic pseudocysts complicated by portal hypertension or by intervening vessels.

BACKGROUND AND STUDY AIMS: Portal hypertension often coexists with pancreatic pseudocysts and is potentially dangerous if a collateral vessel is in the vicinity of the needle puncture pathway. Hitherto, there have been no reports of pseudocyst drainage in this setting. PATIENTS AND METHODS: Patients who underwent endoscopic ultrasound (EUS)-guided pancreatic pseudocyst drainage complicated by intervening vessels were assessed for success and outcomes. An Olympus mechanical linear-array video echo endoscope GF-UM 140D was used for the drainage procedure in all patients. Either a "hot" diathermy technique was employed or a "cold" technique using direct aspiration with a 19-G needle, followed by deployment of a nasocystic catheter. RESULTS: Eight patients with a symptomatic pseudocyst and intervening vessels underwent drainage that was guided (n = 6) or assisted (n = 2) by EUS. All were found to have successful resolution of the cyst at follow-up 6 weeks later, while segmental portal hypertension had disappeared in one patient. There were no major complications. One patient had transient hemorrhagic drainage that resolved by itself. CONCLUSIONS: Pseudocysts complicated by portal hypertension or by intervening vessels can be safely drained under EUS guidance, even in the absence of color Doppler imaging.

Upper gastrointestinal endoscopic ultrasound and its impact on patient management: 1990-2000.

BACKGROUND: Endoscopic ultrasound (EUS) is a relatively new method used in the investigation and staging of upper gastrointestinal tract (UGIT) disease. AIMS: To review practice and outcomes of EUS in an Australian university teaching hospital. METHODS: The first part of the study was a retrospective review of indications, safety, referral patterns and technical difficulties of all EUS procedures performed at Concord Hospital, New South Wales, Australia, over a 10-year period from 1990 to 2000. The second part of the study examined the impact of EUS on the management of 225 consecutive cases, as determined by a questionnaire completed by each of the referring doctors. RESULTS: A total of 537 EUS examinations was performed over the 10-year period. Indications for EUS included: (i) assessment of oesophageal lesions (241), (ii) assessment of gastric lesions (184) and (iii) assessment of pancreaticobiliary (112) disease. Cancer staging was performed in 46.7% of oesophageal and 31.4% of gastric cases. Sedation was achieved using intravenous midazolam (5.3+/-1.3 mg; mean +/- SD) and 52% of cases required additional intravenous pethidine (48.5+/-10.0 mg; mean +/- SD). Technical difficulties were encountered in 11% of cases and these were mainly related to nontraversable luminal stricturing. Of the 537 referrals, 48.2% were from within Central Sydney Area Health Services, and the remainder were from other Sydney hospitals, New South Wales regional centres and interstate. Of 225 questionnaires sent to referring doctors, 146 questionnaires were completed and returned for analysis. EUS aided staging of malignant disease, and confirmed or established a diagnosis in 86% of cases. The diagnostic accuracy of EUS was 76% when confirmed histologically. EUS avoided further diagnostic investigations in the majority of cases and in 25% of cases surgery was avoided. Fine-needle aspiration biopsy (FNAB) during EUS would have been useful in 30% of cases. Overall, clinical decision-making and management were changed in one-third of cases. CONCLUSIONS: Endoscopic ultrasound is an accurate, safe and useful imaging method in UGIT disease. The increasing demand for EUS and EUS-guided FNAB suggests an expanding future for EUS in Australia.