Review Article

The Diagnosis and Investigation of Obscure Gastrointestinal Bleeding

K. Liu; A. J. Kaffes

Disclosures

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

In This Article

Repeat Upper or Lower Endoscopy

Bleeding lesions within the reach of oesophagogastroduodenoscopy are identified in 10–64% of patients with OGIB on PE[40–43] and 24–25% on DBE.[44,45] These lesions were often overlooked or difficult to visualise on initial endoscopy and include erosions in large hiatus hernias (Cameron lesions), peptic ulcers, vascular ectasias, watermelon stomach and portal hypertensive gastropathy.[40–43,46] Missed lesions on colonoscopy are less common but can occur in up to 7% of patients,[45] especially when bowel preparation on initial evaluation was poor or incomplete. Commonly overlooked lesions in the lower GI tract include angiodysplasia and neoplasia. A recent Australian study demonstrated that repeat upper and lower endoscopies after initial (negative) endoscopic evaluations in 50 patients with OGIB detected a missed lesion in only 2/50 (4%) patients. This approach was less cost effective than progressing onto capsule endoscopy without repeating conventional endoscopies (A$148 364 vs. A$123 199 for 50 patients respectively).[47] Conversely, in another Australian study, patients with OGIB and a lesion seen on CE still had a missed lesion within reach of standard scopes in up to 15% of patients.[45] One should therefore proceed straight to capsule endoscopy as the next test in evaluating patients with OGIB with a close review of capsule images of the stomach and colon for potential missed lesions. Repeat endoscopic examinations should be considered in patients with ongoing overt bleeding or poor visualisation of the fundus or colon on initial examination. A side viewing endoscope should be used to examine the ampulla if haemobilia or haemosuccus pancreaticus (wirsungorrhagia) is suspected.

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