Obscure gastrointestinal bleeding: A diagnostic algorithm

Transcription

1 Obscure gastrointestinal bleeding: A diagnostic algorithm Poster No.: R-0112 Congress: RANZCR ASM 2013 Type: Authors: Keywords: DOI: Educational Exhibit C. Werren, B. Kodivlasa, R. M. Mendelson; Perth/AU Abdomen, Gastrointestinal tract, Small bowel, CT, MR, SPECT, Endoscopy, Hemorrhage /ranzcr2013/R-0112 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. Page 1 of 14

2 Learning Objectives 1. To understand the complementary role of imaging and luminal techniques in obscure gastrointestinal bleeding (OGIB) 2. To review current literature and propose a diagnostic algorithm for occult, or currently inactive OGIB. Background Obscure gastrointestinal bleeding (OGIB) is bleeding that remains of uncertain origin after negative upper and lower endoscopy 1. It may have two distinct forms: Obscure occult bleeding, characterised by iron deficiency anaemia with positive faecal occult blood samples. Obscure overt bleeding, characterised by recurrent episodes clinically evident bleeding. OGIB accounts for approximately 5% 2,3 of gastrointestinal bleeding and represents a diagnostic challenge for the treating team. In many cases it resolves spontaneously, however those with recurrent overt blood loss, ongoing iron deficiency anaemia or positive faecal occult blood testing require further investigation. Approximately 80% of OGIB arises from the small bowel and the most common causes include angiodysplasia and tumours 4,5. The investigation of OGIB has evolved significantly in the last 10 years with capsule endoscopy (CE), double balloon enteroscopy and fast, high resolution MDCT improving the visualisation of the small bowel dramatically 5. Imaging Findings OR Procedure Details Investigation of Obscure Gastrointestinal Bleeding In patients presenting with occult, or currently inactive OGIB luminal techniques are initially appropriate. Page 2 of 14

3 Capsule Endoscopy (CE) has a sensitivity and specificity of 95% and 75% respectively, when compared with the far more invasive reference standard of intraoperative enteroscopy 6. CE is able to visualise the whole small bowel consistently and improves patient outcome when compared initial investigation with double balloon endoscopy or intraoperative enteroscopy 7,8,9. In patients with a negative CE or suspected small bowel stenosis and recurrent episodes of bleeding, MRI or CT enterography or enteroclysis play a complementary diagnostic role as they are able to visualise extramucosal lesions not apparent on CE 10,11. This is especially the case in those under 50 where the most common cause for OGIB is tumours 12. A positive CE or MR/CT examination can be followed by a therapeutic double balloon or push enteroscopy for definitive treatment as appropriate 6,13,14 In the cohort of patients where clinical suspicion of a Meckel's Diverticulum is high, a technetium- pertechnetate scan is appropriate for visualisation of ectopic gastric mucosa in the area of the small bowel 15 Computed Tomography Enteroclysis and Enterography CT enterography and enteroclysis are techniques to provide better imaging of the small bowel lumen and wall. CT enterography involves the ingestion of 2L contrast prior to scanning, this may be neutral or dilute positive contrast. Neutral intra-luminal contrast is essential for the detection of OGIB. CT may be performed in several phases (e.g. non-contrast, postcontrast arterial, portal venous phase or delayed phase), or combined with CT angiography when investigating active bleeding. Limitations include inability of some patients to consume a large amount of fluid in a short period of time, achieving appropriate timing of the scan to obtain good bowel distension and radiation dose. CT enteroclysis involves passing a naso-jejunal catheter under fluoroscopic guidance. Neutral or dilute positive contrast is instilled through the tube allowing rapid filling and distension of the intestine. Images are obtained as for CT enterography. Limitations of this technique include more invasive nature (compared to enterography), achieving correct timing of scan (less problematic than enterography) and radiation dose. Page 3 of 14

4 Enteroclysis has been shown to provide superior bowel distension than enterography 18, however it is uncertain whether this translates into better diagnostic outcomes. There are few comparisons in the literature. Two studies found similar accuracy between the two techniques 16,17 CT techniques are unable to detect Angiodysplastic lesions in the bowel, which are usually small and flat and are better visualized with endoscopic techniques like CE or DBE. Cross-sectional imaging can detect non-mucosal lesions such as tumours. One study found multiphase CT enterography to have a higher diagnostic yield than capsule endoscopy, but there was a high prevalence of tumours in the study population 18 A recent study comparing CE and Uniphasic Multidetector CT suggest that the techniques are complementary, since CE may miss extra-mucosal lesions best seen on a CT 10 CT/MR imaging has replaced Small Bowel Follow-Through (SBFT) series in the detection of OGIB. SBFT has a low diagnostic yield for the detection of OGIB, 3% in a recent retrospective series 19 Images for this section: Page 4 of 14

5 Fig. 1: The Diagnostic Algorithm for Obscure Gastrointestinal Bleeding Page 5 of 14

6 Fig. 2: Computed Tomography Angiography: Extravasated contrast in the lumen of the sigmoid colon. Page 6 of 14

7 Fig. 3: Coronal views of the same patient. Extravasated contrast is seen in the lumen of the sigmoid colon. Page 7 of 14

8 Fig. 4: Mesenteric Embolisation: Bleeding has ceased with coils deployed in the bleeding artery. Page 8 of 14

9 Page 9 of 14

10 Fig. 5: Radionuclide RBC Scan: Extravasation of tracer in ascending colon (arrow, AC) with extension over time in the transverse colon (arrow, TC). Page 10 of 14

11 Conclusion The availability of capsule endoscopy, double balloon endoscopy and significant improvements in both CT and MR enterography/enteroclysis techniques in recent times has allowed for more rapid, less invasive diagnosis of the bleeding lesion in patients with OGIB. Current evidence indicates that CE is the most appropriate investigation in those with obscure occult gastrointestinal bleeding. If CE is unsuccessful in locating the offending lesion, CTE or MRE are likely to provide additional information which may lead to a diagnosis. Once the lesion has been found double balloon endoscopy or surgical intervention can provide targeted definitive management. This poster provides a diagnostic algorithm for the investigation of Obscure gastrointestinal bleeding. Personal Information Dr Balaji Kodivalasa Radiology Registrar Royal Perth Hospital Perth, WA Dr Charles Werren Resident Royal Perth Hospital Perth, WA Clinical Professor Richard Mendelson Chief Editor of Diagnostic Imaging Pathways Gastro-intestinal Radiologist Page 11 of 14

12 Royal Perth Hospital Perth, WA References 1.Zuckerman G, Prakash C, Askin M, Lewis B. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. [Review] [226 refs]. Gastroenterology Jan;118(1): Spiller RC, Parkins RA. Recurrent gastrointestinal bleeding of obscure origin: report of 17 cases and a guide to logical management. Br J Surg Aug;70(8): Myers RT. Diagnosis and management of occult gastrointestinal bleeding: visualization of the small bowel lumen by fiberoptic colonoscope. Am Surg Feb;42(2): Lin S, Rockey DC. Obscure Gastrointestinal Bleeding. Gastroenterology Clinics of North America Dec;34(4): Liu K, Kaffes AJ. Review article: the diagnosis and investigation of obscure gastrointestinal bleeding. Alimentary Pharmacology & Therapeutics Aug;34(4): Hartmann D, Schmidt H, Bolz G, Schilling D, Kinzel F, Eickhoff A, et al. A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding. Gastrointestinal endoscopy. 2005;61(7): Marmo R, Rotondano G, Piscopo R, Bianco MA, Cipolletta L. Meta-analysis: capsule enteroscopy vs. conventional modalities in diagnosis of small bowel diseases. Alimentary Pharmacology and Therapeutics Oct;22(7): Saurin JC, Delvaux M, Vahedi K, Gaudin JL, Villarejo J, Florent C, et al. Clinical impact of capsule endoscopy compared to push enteroscopy: 1-year follow-up study. Endoscopy Apr;37(4): Triester SL, Leighton JA, Leontiadis GI, Fleischer DE, Hara AK, Heigh RI, et al. A Meta-Analysis of the Yield of Capsule Endoscopy Compared to Other Diagnostic Page 12 of 14

13 Modalities in Patients with Obscure Gastrointestinal Bleeding. The American Journal of Gastroenterology Nov;100(11): Khalife S, Soyer P, Alatawi A, Vahedi K, Hamzi L, Dray X, et al. Obscure gastrointestinal bleeding: preliminary comparison of 64-section CT enteroclysis with video capsule endoscopy. European Radiology Jul 24;21(1): Wiarda B, Heine D, Mensink P, Stolk M, Dees J, Hazenberg H, et al. Comparison of magnetic resonance enteroclysis and capsule endoscopy with balloon-assisted enteroscopy in patients with obscure gastrointestinal bleeding. Endoscopy Apr 23;44(07): Filippone A, Cianci R, Milano A, Pace E, Neri M, Cotroneo AR. Obscure and occult gastrointestinal bleeding: comparison of different imaging modalities. Abdominal Imaging Sep 13;37(1): Keum B, Chun HJ. Capsule endoscopy and double balloon enteroscopy for obscure gastrointestinal bleeding: Which is better? Journal of gastroenterology and hepatology. 2011;26(5): Nakamura M, Niwa Y, Ohmiya N, Miyahara R, Ohashi A, Itoh A, et al. Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding. Endoscopy Jan;38(1): Van Weyenberg SJB, Van Waesberghe JHTM, Ell C, Pohl J. Enteroscopy and its Relationship to Radiological Small Bowel Imaging. Gastrointestinal Endoscopy Clinics of North America Jul;19(3): Minordi LM, Vecchioli A, Mirk P, Bonomo L. CT enterography with polyethylene glycol solution vs. CT enteroclysis in small bowel disease. Br J Radiol. 2011;84: Wold PB, Fletcher JG, Johnson CD, Sandborn WJ. Assessment of small bowel Crohn disease: noninvasive peroral CT enterography compared with other imaging methods and endoscopy-feasibility study. Radiology. 2003;229: Huprich JE, Fletcher JG, Fidler JL et al. Prospective blinded comparison of wireless capsule endoscopy and multiphase CT enterography in obscure gastrointestinal bleeding. Radiology. 2011;260: Page 13 of 14

14 19.Hara A, Leighton J, Sharma V et al. Small Bowel: Preliminary comparison of Capsule Endoscopy with Barium Study and CT. Radiol 2004;230: Page 14 of 14