SMALL BOWEL GASTROINTESTINAL BLEEDING Giovanni DI NARDO giovanni.dinardo@uniroma1.it UOC Gastroenterologia ed Epatologia Pediatrica Dipartimento di Pediatria, Sapienza - Università di Roma (Direttore: prof. Salvatore Cucchiara)
OUTLINE DEFINITIONS DIAGNOSTIC APPROACH TO ADULT PATIENTS WITH OGIB PEDIATRIC EVIDENCE-BASED CONSIDERATIONS PROPOSED APPROACH TO PEDIATRIC PATIENTS WITH OGIB
OUTLINE DEFINITIONS DIAGNOSTIC APPROACH TO ADULT PATIENTS WITH OGIB PEDIATRIC EVIDENCE BASED CONSIDERATIONS PROPOSED APPROACH TO PEDIATRIC PATIENTS WITH OGIB
Definitions Obscure GI bleeding (OGIB) is defined as occult or overt bleeding of unknown origin that persists or recurs after an initial negative endoscopic evaluation including colonoscopy and EGD. Overt OGIB is defined as visible GI bleeding (eg, melena or hematochezia) and can be categorized further as active (ie, evidence of ongoing bleeding) versus inactive Bleeding. Occult OGIB is defined when there is no evidence of gross bleeding (eg, unexplained iron deficiency anemia suspected to be caused by GI blood loss). Fisher L et al. ASGE Standards of Practice. GIE 2010
(5% of GI Bleeding) Pennazio M. Gastrointest Endoscopy Clin N Am 2009
Singh A et al. Curr Opin Gastroenterol 2013
OUTLINE DEFINITIONS DIAGNOSTIC APPROACH TO ADULT PATIENTS WITH OGIB PEDIATRIC EVIDENCE BASED CONSIDERATIONS PROPOSED APPROACH TO PEDIATRIC PATIENTS WITH OGIB
Overt Obscure GI Bleeding Active Bleeding Inactive Bleeding Suspected Upper GI Bleeding Repeat EGDS or PE Negative Other GI Bleeding Capsule Endoscopy Deep Enteroscopy Push Enteroscopy and/or Colonoscopy Consider CT Enterography Or CT Angiography Because these tests are complementary, a combination may be required Consider Deep Enteroscopy Expecially for pts with surgically alter anatomy Consider CT Enterography or CT Angiography Negative Capsule Endoscopy and/or Scintigraphy Because these tests are complementary, a combination may be required Angiography Expecially for pts with massive bleeding and/or Colonoscopy Consider Provocative Testing Recurrent Bleeding Negative Consider Intraoperative Endoscopy No Recurrent Bleeding Occult OGIB Algorithm Fisher L et al. ASGE Standards of Practice. GIE 2010
Occult Obscure GI Bleeding Consider Trial of Empiric Iron Therapy Negative Small Bowel Evaluation Negative Consider Repeat EGDS/Colonoscopy Consider CT Enterography or CT Angiography Capsule Endoscopy Consider Deep Enteroscopy Several authors have suggested initial CE followed by Therapeutic BAE, if positive, as best strategy for increased yeald and improved treatment success Expecially for pts with altered anatomy or increased suspicion of angiectasia Negative Stable Continued Bleeding Observe Trial of Iron, if appropriate Repeat EGDS or PE and Colonoscopy Expecially if not previously repeated Repeat Capsule Endoscopy Expecially if GI Bleeding is now overt or if Hb decrease is 4 g/dl Deep Enteroscopy Fisher L et al. ASGE Standards of Practice. GIE 2010
Italian Club for Capsule Endoscopy and Enteroscopy. DLD 2013
OUTLINE DEFINITIONS DIAGNOSTIC APPROACH TO ADULT PATIENTS WITH OGIB PEDIATRIC EVIDENCE BASED CONSIDERATIONS PROPOSED APPROACH TO PEDIATRIC PATIENTS WITH OGIB
Indication Children vs Adults (%) < 8 yrs vs > 8 yrs Crohn s Disease 50% vs 10,4% 24% vs 40-66% OGIB 17% vs 66% 36% vs 13-24% Abdominal Pain and diarrhoea 13% vs 10,6% 14% vs ----- Polyposis 11% vs ------ ----------- Other (i.e. Malabsorption, Protein losin enteropathies) 5% vs 13% 24% vs ----- 42% confirmed diagnoses in children with OGIB as compared to 60,5% in adults Cohen SA. Clin Gastroenterol Hepatol 2011
Cohen AS. JPGN 2012
Xinias I. Case Reports Gastroenterol 2012
OGIB is the most common indication for BAE in children 104 children with OGIB (age 3-20 yrs, weight > 13,5 Kg), only in 36% CE preceded BAE Diagnostic yield 70-96%
Nishimura N. GIE 2010; Liu W. Can J Gastroenterol 2009; Shen R. Dig Endosc 2012
Nishimura N. GIE 2010
Can J Gastroenterol 2009; Shen R. Dig Endosc 2012
CAPSULE ENDOSCOPY FOLLOWED BY SINGLE BALLOON ENTEROSCOPY IN CHILDREN WITH OBSCURE GASTROINTESTINAL BLEEDING: DIAGNOSTIC YIELD AND OUTCOME OF A COMBINED APPROACH. We prospectively enrolled all pediatric patients referred to our unit for OGIB and who underwent both CE and SBE from January 2009 and July 2012. All patients underwent before the enrolment esophagogastroduodenoscopy and ileocolonoscopy at least twice. MR-enterography was performed before CE in all patients to exclude stricture, to diagnose endoluminal mass/polyps and to direct the SBE insertion route. Meckel s scan was performed before CE in all patients with painful bloody stool and/or who had not performed a previous laparoscopy/laparotomy that excluded Meckel s diverticulum. Angiography has also been performed in patients during ongoing bleeding.
Demographic and Clinical Characteristics
Capsule Endoscopy (n=22) Positive (n=14) Angiodysplasias (n=9) Polyps (n=1) Ulcers (n=6) Negative (n=3) Colon Capsule Endoscopy-2 (n=3) Suspicious (n=5) Erosions (n=1) Other (n=4) Positive (n=2) Polyps (n=1) Ulcers (n=1) Negative (n=1) Single Balloon Enteroscopy (n=22) CE finding reached (n=13) Biopsy (n=3) Endoscopic Therapy (n=10) CE finding not reached (Ulcers n=2) CE finding Reached (Polyp n=1) Negative uncomplete SBE CE finding reached (n=5) Biopsy (n=5) IOE (Anastomotic ulcers n=2) Resolved with therapy n=12 Not resolved n=1 Resolved with surgical resection n=2 Resolved with polypcetomy Resolved spontaneously Resolved with therapy n=2; Resolved spontaneously n=1; Not resolved n=2
Second-Look with CCE-2 IOE finding (Dr Barabino)
SB-2 finding SBE finding APC Treatment
SB-2 finding SBE finding Polypectomy
A 3 year-old girl with syncope, anemia (3,5 g/dl), negative upper and lower GI endoscopy and FIT +
OUTLINE DEFINITIONS DIAGNOSTIC APPROACH TO ADULT PATIENTS WITH OGIB PEDIATRIC EVIDENCE BASED CONSIDERATIONS PROPOSED APPROACH TO PEDIATRIC PATIENTS WITH OGIB
Overt Obscure GI Bleeding Active Bleeding Inactive Bleeding Suspected Upper GI Bleeding MR Enterography and/or Meckel s scan Negative Positive Repeat EGDS or PE Negative Other GI Bleeding Capsule Endoscopy Positive Deep Enteroscopy or Surgery Consider Deep Enteroscopy Capsule Endoscopy Angiography Expecially for pts with massive bleeding and/or Colonoscopy No Recurrent Bleeding Occult OGIB Algorithm Negative Consider Repeat CE Recurrent Bleeding Lesions not reached Consider IOE or Repeat Deep Enteroscopy Negative
Occult Obscure GI Bleeding Consider Trial of Empiric Iron Therapy Negative Small Bowel Evaluation Negative Consider Repeat EGDS/Colonoscopy MR Enterography Negative or suspicious positive Capsule Endoscopy positive Negative Deep Deep Enteroscopy or Enteroscopy (DE) Surgery Lesions not reached Stable Continued Bleeding Observe Trial of Iron, if appropriate Repeat EGDS or PE and Colonoscopy Expecially if not previously repeated Repeat Capsule Endoscopy Expecially if GI Bleeding is now overt or if Hb decrease is 4 g/dl Consider Repeat DE or IOE* *Expecially if previous DE was uncomplete
RINGRAZIAMENTI Prof. S. Cucchiara IBD Prof.ssa F. Viola Dr.ssa M. Aloi Dr.ssa F. Nuti Ricerca di Base Dr.ssa L. Stronati Dr.ssa M. Costanzo Dr.ssa M Pierdomenico Dr.ssa A. Negroni Celiachia Prof.ssa M. Barbato Dr. F Valitutti Dr.ssa I. Celletti RMN e SICUS Prof. G.F. Gualdi Dr. E. Casciani Dr.ssa F. Maccioni Dr.ssa F. Civitelli Anestesia Dr. M. Passariello, Dr. F. Alessandri Page 39 Allergologia Prof.ssa S. Lucarelli Prof. T. Frediani Dr.ssa T. Federici Dr.ssa G. Lastrucci Motilità Dr. P. Rossi Dr. S. Mallardo Drssa V. Labalestra Endoscopia Dr G. Di Nardo Dr. S. Oliva Chirurgia Prof. D. Cozzi Dr. S. Frediani Epatologia Prof. D. Alvaro Dr.ssa F. Ferrari UOC Diagnostica e Terapia Endoscopica INT di Napoli Fondazione Pascale Prof. AM Tempesta e collaboratori Dipartimento di Medicina Interna e Gastroenterologia Università di Bologna Prof. V. Stanghellini, Dr. G. Barbara, Dr. R. De Giorgio, Dr. C. Cremon UO Endoscopia Digestiva Ospedale Sant Andrea Prof. E. Di Giulio e collaboratori