Review Article

The Diagnosis and Investigation of Obscure Gastrointestinal Bleeding

K. Liu; A. J. Kaffes

Aliment Pharmacol Ther. 2011;34(14):416-423.

History and Examination

History taking and examination can help predict the aetiology and localise the site of bleeding. It is important to take into account the age of the patient. Small bowel tumours such as leiomyomas, carcinoid tumours, adenocarcinomas and lymphomas are the most common cause of OGIB in patients <50 years old.^[4] Other common lesions in younger patients include Meckel's diverticulum Dieulafoy's lesion and Crohn's disease. By contrast, angiodysplasias are the most common cause of small bowel bleeding in older patients.^[5] Presentations with haematemesis, melaena, bloody nasogastric lavage fluid or isolated elevations in urea are typically (but not exclusively) associated with lesions in the upper gastrointestinal tracts, while haematochezia suggests lower GI bleeding.^[3] Patients should be asked about non-steroidal anti-inflammatory drug (NSAID) use for the possibility of NSAID-induced small bowel disease. A prior history of abdominal aortic aneurysm repair, necrotising pancreatitis or liver injury (trauma, biopsy and hepatocellular carcinoma) should alert the clinician to search for an aortoenteric fistula, haemosuccus pancreaticus and haemobilia respectively. A thorough physical examination can detect skin signs associated with diagnoses responsible for OGIB such as hereditary haemorrhagic telangiectasia or coeliac disease.

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Cite this: The Diagnosis and Investigation of Obscure Gastrointestinal Bleeding - Medscape - Aug 01, 2011.

Table 1. Causes of obscure gastrointestinal bleeding
Upper GI lesions
Cameron erosions	5–15
Angioectasia	5–10
Varices	1–5
Dieulafoy lesion	2–3
Gastric antral vascular ectasia (GAVE)	1–2
Portal hypertensive gastropathy	1–2
Small bowel lesions
Angioectasia	20–55
Small bowel tumours	10–20
Crohn's disease	2–10
Coeliac disease	2–5
Meckel's diverticulum	2–5
NSAID enteropathy	5
Dieulafoy lesion	1–2
Ectopic varices	1–2
Portal hypertensive enteropathy	1–2 (but 60–70in those with portal hypertension)
Radiation enteritis	<1
Lower GI lesions
Angioectasias	2
Neoplasms	1
Dieulafoy lesion	<1
Rare lesions
Haemobilia	<1
Haemosuccus pancreaticus	<1

Values are expressed as percentages.^{27,40,65–69}

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