This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. This is Gerard Eisenberg giving you the top 10 tips for obscure GI bleeding, part four in this series. GI bleeding is challenging for physicians in diagnosing and managing cases in which patients have ongoing or recurrent GI bleeding in which the etiology is not readily identified. Because of healthcare costs associated with additional endoscopic procedures, including deep small bowel and neuroscopy, it's important that physicians consider a systematic logical approach for these challenging patients. This multi-part video tip series will provide you with 10 top tips for obscure GI bleeding. This is part four in this series. Tip number eight, attempt to localize the site of bleeding. Oftentimes small bowel capsule endoscopy and small bowel transit time is used to determine whether an antigrade or retrograde route is used. Often lesions identified in the first 60% of the small bowel transit time is considered accessible by the antigrade route, whereas if it's more than 60% of the small bowel transit time, the recommendation is to consider a retrograde device-assisted route. There is a caveat associated with this. You really need to look at the capsule endoscopy video to determine whether or not there is a delay in transit time. This can occur on occasion, either when the capsule device enters the duodenum, and oftentimes there can be a delay in the transit time when the capsule is within the bulb. Here is an instance in which the transit time here with a two-hour and 50-minute image, when the capsule entered the small bowel at one minute and 50 seconds, this could have been interpreted as being a lesion either in the mid-to-distal small bowel. However, this turned out that the lesion was actually in the distal duodenum. This is because the capsule device had delayed transit in the duodenal bulb. So be careful of small bowel capsule endoscopy transit times. Also be aware that blood on capsule endoscopy may not necessarily be from the small bowel, but have actually transited from the stomach. So be careful of interpreting studies without realizing what the transit time is and whether or not there was any blood within the stomach. So usually, once you've identified a potential site of bleeding, this oftentimes leads to consideration of what particular endoscope to use. And if it's in the proximal small bowel, such as the duodenum or proximal jejunum, standard enteroscopy is often used. I don't like to use the word push enteroscopy because that refers to an older technique involving an overtube. However, most people use a pediatric colonoscope to access this area. And the word push is a rather archaic term in that endoscopy is often performed by using a push technique. So for example, we don't use push colonoscopy as a term. If it's in the proximal to mid-small bowel, antigrade deep small bowel enteroscopy is the preferred choice. If it's in the distal small bowel, retrograde deep small bowel enteroscopy using the colon to reach the distal small bowel is the chosen route. So whenever you've identified a potential area of bleeding, so this is an example of a patient who had an extraordinary amount of active bleeding during deep small bowel enteroscopy, the tip is to use hemoclips and or tattoos to mark the areas for localization for either angiography or surgery. In this instance, this was due to an ulcer within the small bowel. It was actually eventually treated endoscopically with a combination use of epinephrine and clips, but this had the high potential for re-bleeding and so tattoo and hemoclips were used in this instance. So depending on the studies that were done, you want to consider whether to repeat the small bowel capsule endoscopy, repeat a device-assisted enteroscopy, repeat radiologic evaluation including CT angiogram or tagged red blood cell scans, and consider surgical evaluation for the possibility of an interoperative enteroscopy. This is done in conjunction with surgical consultation as doing interoperative enteroscopy is often frowned upon these days due to the concern for morbidity associated with these operations. Tip number nine, give patients a prescription to give to the ER physician for an urgent CT angiogram if the patient has recurrent bleeding after discharge. This is one of those tricks that, you know, if the patient has had recurrent bleeding and then suddenly stops and you've not identified a source and they eventually go home after and they're no longer transfusion dependent, this is something to give patients in the event that they do have recurrent bleeding at home, this expedites the workup and potentially increases the diagnostic yield for CTA in these situations. And finally, tip number 10, phone a friend with expertise in obscure GI bleeding and device-assisted enteroscopy skills. It's sometimes useful to discuss your cases with an experienced enteroscopist who has a lot of experience with obscure GI bleeding because sometimes there are things that you may not have thought about or they may provide some assistance in guiding you along many of these algorithms that I've shown you in these series. So thank you again for viewing our video tip series. I encourage you to subscribe to GI Now, which is the ASGE's premier subscription service. At a fraction of the cost, it allows you to attend many different courses virtually. And here are some reference sources for capsule endoscopy that I think you'll find useful. Thank you again.

obscure GI bleeding

GI bleeding management

localize site of bleeding

capsule endoscopy

endoscopes for bleeding location