Management Of Small Intestinal Bleed

Management of Small Intestinal Bleed Dr Shamail Zafar Assistant Professor of Medicine Lahore Medical & Dental College Lahore

Bleeding from Small Intestine CLASSIFICATION Bleeding from Small Intestine can be classified as i) Overt Small Intestinal Bleed: in which patient presents with hematochezia or malena. ii) Occult Small Intestinal Bleed: in which patient presents with iron Practice Committee Guideline deficiency anemiaASGE and/or positive on GI Bleed

Bleeding from Small Intestine INCIDENCE About ~5 % of Total GIT Bleed. Angiectasias account for about 50 % of these cases.

Raju GS.Gastroenterology 2007;133(5):1697-1717 Concha R. J Clin Gastroenterol 2007;41(3):242-51

Bleeding from Small Intestine CAUSES Younger than 40 years Tumorsof age

Older than 40 Uncommon years of age Angiectasia

Hemobilia

Meckel’s Diverticulum

NSAID Enteropathy

Hemosuccus Pancreaticus

Dieulafoy’s lesion Celiac Disease

Celiac Disease

Inflammatory Bowel Disease

Tumors

Aortoenteric Fistula Portal Hypertensive Vasculopathy GAVE

Inflammatory Bowel Disease

AGA Institute Technical Review on Obscure GI Bleed

Bleeding from Small Intestine ii) iii) iv) v) vi) vii)

DIAGNOSIS & MANAGEMENT History & Clinical examination Laboratory Analysis Emergency room management Non-Endoscopic management Endoscopic Management Pharmacological Management

Bleeding from Small Intestine NON-ENDOSCOPIC MANAGEMENT i) Barium studies a) Small Bowel follow through b) Enteroclysis

ii) Nuclear Scans a) Tagged Red Blood Cell Scan b) Meckel’s Scan

iii) CT Scan and MRI iv) Angiography

Bleeding from Small Intestine ii)

v) vi)

ENDOSCOPIC MANAGEMENT Enteroscopy a) Push Enteroscopy b) Double Balloon Enteroscopy Wireless Capsule endoscopy Intraoperative enteroscopy

Barium Studies 

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Small Bowel follow through studies have shown a low diagnostic yield (0% to 6%)1 Diagnosis is improved when combined with Enteroclysis which is a Biphasic examination using barium and methylcellulose as double contrast agent (10% to 20%)2 Even Enteroclysis fails to detect flat mucosal lesions like Angiodysplasia, 1.Gastrointest Endosc.2003;57:418thus use is limited to 420 tumor and 2.Med Clin North Am 2002;86:1319-56

Radionuclide Scans 

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Threshold bleeding rate is in the range of 0.1 to 0.4 ml/min. Technitium Tc 99m-lableled RBC’s stay in the vascular space for 24 hours. Aid in localization of bleeding which can later verified endoscopically or angiographically. Advances in Small Intestinal Bleed Surgical yield of earlyRecent positive scan Kovacs TO. Med Clin North (1to 4 hr) is 70 to 80%. Am.2002;86:1319-56

Angiography 

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Threshold bleeding rate is more than 0.5ml/min Can detect both bleeding lesions of tumors and AVM’s. Therapy can be offered in the form of micro-coils, glue or drugs (vasopressin). Diagnostic yield varies between 1270 %. Concha R. Obscure GI Bleed. J Clin Gastroenterol CT Angiography2007;41(3):242-51 is better than

Cross Sectional Imaging Techniques 

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CT SCAN , CT ENTEROCLYSIS, MRE It provides non-superimposed views of all small bowel loops as well as of any mesenteric or extra intestinal lesions. CTE requires distension of bowel lumen with 1200-1500 cc of low density, negative oral contrast agent like water or barium sulphate Horton KM.MDCT of small bowel neoplasms. J CAT suspension. 2004;28:106-116

Cross Sectional Imaging Techniques 

Both CTE and MRE are novel techniques of accurate diagnosis of inflammatory, vascular and neoplastic lesions of small intestine.

Push Enteroscopy 

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Proximal part of small intestine can be directly visualized using extended length enteroscope or pediatric Colonoscope. Accessories like Biopsy forceps or APC probes enable to perform diagnostic and therapeutic procedures. 50 % of small Bowel is accessible Waye JD. Enteroscopy.Gastrointest Endosc 1997;46:247-56 Diagnostic Yield 40-65%.

Double Balloon Enteroscopy 

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It allows complete examination of small intestine Scope has got a balloon at its tip and a soft overtube with another balloon at the distal end are used together.

Double Balloon Enteroscopy 

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Accessory channel enables interventions like biopsies, balloon dilatation, stent placement, polypectomy and endoscopic mucosal resection. Overall Diagnostic yield is 43-80 % DBE can be performed in antegrade and /or retrograde fashion; insertion route is chosen according to the Nakamura M.Which route to select in DBE.Gastrointest suspected Endosc2008;687(3)577-8 lesion location.

Double Balloon Enteroscopy Endoscopic Coagulation  Heated probe or lasers such as Nd:YAG and argon  Argon laser treatment is recommended for mucosal or superficial lesions because the energy penetrates only 1 mm.  Nd:YAG lasers are more useful for deeper lesions because they penetrate 3-4 mm .  Absolute alcohol, Ethanolamine and

Capsule Endoscopy Procedure Consists of three steps 1. Ingest the video capsule. 2. Capsule transmits images to Data Recorder. 3. Images are reviewed using RAPID software, and physician makes diagnosis.

Capsule Endoscopy 

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Capsule includes a miniature color video camera, a light, a battery and transmitter Weighs 3.7 g and measures 11 mm × 26 mm Image features include a 140° field of view, 1:8 magnification, 1 to 30 mm depth of view, and a minimum size of detection of about 0.1 mm The camera takes two pictures every second for eight hours Capsule cost: Pack of 1 for $500 Capsule endoscopy not a substitute for regular endoscopy

AVM

Sprue

Bleeding Lesion

Polyp

Intra-operative Enteroscopy 

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Intra-operative Enteroscopy is the traditional Gold standard in small bowel visualization. If facilities of DBE are not available or it cannot be performed due to abdominal adhesions, IOE still remains the procedure of choice especially in transfusion dependant patients. D.Comparing CE with IOE in OGIB. Diagnostic yieldHartmann is 58-88%. Gastrointest Endosc 2005;61(7):826-32

Diagnostic Yield of IOE

AGA Institute Technical Review on Obscure GI Bleed

Push Enteroscopy vs Capsule Endoscopy

Barium Radiography vs Capsule Endoscopy

Pharmacological Therapy 

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Pharmacotherapy should be considered whenever endoscopic therapy, surgical intervention or angiographic therapy is either not available or effective. It includes supportive therapy with Blood transfusions Epoetin alpha Iron replacement Hormonal therapy Octreotide Avoidance of Anticoagulants, aspirin and NSAID’s

Hormonal Therapy 

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Discordant results have been obtained regarding efficacy of Hormonal therapy for suspected Angiodysplasia bleeding. Combined hormonal therapies with estrogen-progesterone significantly reduces blood transfusions and rebleeding. Van Custem E. Treatment of vascular malformations with estrogen progeterone. Lancet 1990;335:953-5 Hormonal therapy in GI angiodysplasia.Gastroenterology

Octreotide Acetate 

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Potential benefit of reducing Angiodysplastic bleeding. 20% reduction in bleeding can be obtained over a 1-2 year period.

Junquera F. Longterm efficacy of Octreotide in recurrent GI Bleeding Am J Gastroenterol 2007;102(2):254-70 Nardone G. Efficacy of Octreotide in GI Bleeding. Aliment Pharmacol Ther 1999;13(11) 1429-36)

Thalidomide 

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It is proven to have anti inflammatory activity in patients of Crohn’s disease. It also displays anti-angiogenic activity

Perez-Ecinas. Is thalidomide effective for management of GI Bleeding. Haematologica 2002;87:ELT 34

Anti Fibrinolytic Agents 

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Tranexamic acid and EpsilonAminocaproic acid. They inhibit the process of Fibrinolysis in Telangiectasia walls, which enables fibrin deposits to seal the bleeding site. Korzenik JR. Treatment of bleeding in HHT with aminocaproic acid. NEJM 1994;331:1236

Conclusions 

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Push Enteroscopy is better than barium studies. Help should be taken radionuclide scans and mesenteric Angiography to localize the lesions. Intra-operative Enteroscopy still remains the Gold standard.

Thank you

PE vs PPE 

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Insertion depth of push enteroscopy is limited to the proximal jejunum. The diagnostic yield of push enteroscopy can be estimated on approximately 40%. With the new method of push-and-pull enteroscopy in double-balloon technique also deeper parts of the small bowel can be reached. Push-and-pull enteroscopy is superior to push enteroscopy both with regard to the length of small bowel visualized and to the