AGA Technical Review on the Evaluation and management of Occult ...
Transcript of AGA Technical Review on the Evaluation and management of Occult ...
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AGA Technical Review on the Evaluation and management of Occult and Obscure Gastrointestinal Bleeding
Gastroenterology 2000;118:201-221
Reporter :Intern 陳美舒2002/10/28
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Bleeding Definitions ( )Ⅰ
Overt or visible bleeding: GI bleeding manifest as visible bright red or altered blood in emesis or feces
Occult bleeding: initial present of IDA and/or positive FOBT; no visible blood in feces
Obscure bleeding: Recurrent or persistent IDA, positive FOBT ,or visible bleeding with no bleeding source found at original endoscopy
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Bleeding Definitions ( )Ⅱ
Obscure-occult bleeding: subcategory of obscure characterized by recurrent or persistent IDA and/or positive FOBT with no source found at original endoscopy; no visible blood in feces
Obscure-overt bleeding: subcategory of obscure characterized by recurrent or persistent overt/visible bleeding with no source found at original endoscopy; bleeding manifest as visible blood in emesis or feces
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Bedside Examination
History: especially drug history( NSAID, Aspirin, KCl, anticoagulation) and family history.
Physical Examination: cutaneous manifestations VS. GI bleeding
It has been proposed that information on either upper or lower intestinal symptoms can direct the initial endoscopic approach to patients with occult bleeding.
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Evaluation of Occult Bleeding( )Ⅰ
Study design factors: The method of stool collection ( digital collection or spontaneously passed stool); dietary modification; Guaiac-based tests or immunochemical test for hemoglobin
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Evaluation of Occult Bleeding( )Ⅱ
Endoscopic evaluation: colonoscopy and upper endoscopy remain the cornerstones for investigation of occult blood loss.
Colon cancer screening trial: 78%-86% FOBT (+) p’ts performed colonoscopy:
2.2%-17% colon cancer; 16.7%-40% adenomatous polyps annual FOBT reduced mortality from colorectal cancer
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Evaluation of Occult Bleeding( )Ⅲ
Bidirectional Endoscopy
-IDA and positive FOBT results are unaccounted for in up to 52% of cases
-a lesion identified as responsible for occult blood loss was located in the upper GI tract (29%-56%) more than in the lower GI tract(20%-30%)
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Evaluation of Occult Bleeding( )Ⅳ
Radiographic Evaluation - Single-column barium enemas: discontinued, 20% miss rate
of colon cancer - double-contrast enemas have been used primarily when
results of colonoscopy are suboptimal -air-contrast barium enemas preferably with flexible
sigmoidoscopy: sensitivity of 98% for carcinoma and 99% for adenoma VS. ACBE alone missed 25% cancer and polyps in the rectosigmoid region
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Evaluation of Obscure Bleeding( )Ⅰ
Small bowel Repeat upper endoscopy and colonoscopy : 35% bleeding source identified (29% upper, 6%
colonoscopy) Upper GI tract: erosion of hiatal hernias, peptic ulcer,
vascular ectasia Colon: angiodysplasia and neoplasia Enteroscopy in place of repeat upper endoscopy
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Evaluation of Obscure Bleeding( )Ⅱ
Small bowel biopsy: celiac sprue
Peroral and transnasal enteroscopy:
-push enteroscopy: standard approach to exam the proximal small bowel
-Sonde enteroscopy : potential for direct exam of the entire small bowel mucosa,but less popular.
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Evaluation of Obscure Bleeding( )Ⅲ
Retrograde enteroscopy: examination of the distal ileum at colonoscopy
-low diagnostic rate (2.7%) and should be reserved for instances in which other evidence indicates a potential source of blood loss in the terminal ileum
Intraoperative enteroscopy (IOE): apply in cases of transfusion dependent bleeding that is not localized in spite of extensive diagnostic evaluation.
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Evaluation of Obscure Bleeding( )Ⅳ
-IOE: the ability to identify potential bleeding lesions ranging from 70%-93%
-Laparotomy has been coupled with the passage of an endoscope orally, per rectum, transnasally, or through enterotomy
-IOE through an enterotomy: decreased intestinal dead space and decreased trauma to the bowel.
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Evaluation of Obscure Bleeding( )Ⅴ
Small bowel x-ray series and enteroclysis
-enteroclysis: higher radiation exposure and discomfort; higher diagnostic yield, sensitivity, shorter procedure time.
-enteroclysis: the radiological study of choice for the investigation of suspected gross disorder of the small bowel. (diagnostic rate of neoplasia of 95%)
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Evaluation of Obscure Bleeding( )Ⅵ
Nuclear scans: technetium 99m-labeled red blood cell (TRBC)scan
-long half-life , bleeding rate:0.1-0.4 mL/min
-significant false localization and miss rate →alternate test: angiography or endoscopy before an invasive therapeutic procedure
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Evaluation of Obscure Bleeding( )Ⅶ
Angiography
-active bleeding rate >=0.5 mL/min → extravasation of contrast may be found
- diagnostic rate:27%-77% in acute lower intestine bleeding
-repeat angiography: increased diagnostic rate from 43% to 54% in patient with no initial diagnosis.
Exploratory laparotomy
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Etiology( )Ⅰ
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Etiology ( )Ⅱ
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Management
Endoscopic therapy Angiographic therapy Pharmacotherapy Surgery Nonspecific therapy
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Endoscopic Therapy
Thermal contact probes, injection sclerotherapy, argon plasma coagulation,Nd:YAG laser
decrease the requirement for blood transfusion requirement
slightly higher rebleeding rates( up to 34%) have been reported with the use of thermal contact devices
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Angiotherapy
The number of patients successfully treated with vasopressin infusion or embolization for obscure-overt small bowel bleeding is limited.
Vessopressin- cardiovascular complications rate up to 9%-21%
embolization-complication rate: 17% Embolozation may have utility in patients with coronary
disease or other disorders wherein vasopressin infusion is relatively contraindicated or as an alternative to surgery.
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Pharmacotherapy
Reserved for diffuse disease, lesion in area inaccessible endoscopic therapy, rebleeding with unknown source
estrogen-progesteron combination therapy octreotide danazol and desmopressin
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Surgery
Bleeding tumor, bleeding with high transfusion requirement,
angiographic localization of the bleeding source assisted resection: the lowest rebleeding rates after bowel resection for bleeding angiodysplasia
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Nonspecific Measures
Iron supplymentation: IDA with unknown bleeding source--anemia resolved in 83% with no recurrence over a mean F/U period of 20 months
obs. and intermittent transfusion :54%had no rebleeding episodes during a 3-year follow-up period
elderly patient, slowly blood loss rate,risk for further diagnostic evaluation
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Outcomes
The overall prognosis in occult bleeding is generally good , with no early mortality noted in prospective studies.
There appears to be no single efficient diagnostic approach or therapeutic panacea in the management of obscure bleeding.