This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. This is Dr. Gerard Eisenberg talking about top 10 tips for obscure GI bleeding. It's sometimes challenging for physicians in diagnosing and managing cases in which patients have ongoing or recurrent GI bleeding in which an etiology is not readily identified. Because of higher health care costs associated with obscure GI bleeding, it is important that physicians consider a systematic, logical approach for these challenging patients. This multi-part video tip series will provide you with the top 10 tips for obscure GI bleeding. Tip number one, repeat upper endoscopy and or colonoscopy due to potential mislesions. Up to 45% of patients who have lesions that can cause obscure GI bleeding on repeat upper endoscopy and or colonoscopy. This is an example of a patient who had a large hiatal hernia. You can see that there are several erosions noted in the hernia sac. These are called Cameron's erosions. These can cause iron deficiency anemia in patients with large hiatal hernias. Here's an upper endoscopy that was repeated in a patient who had upper GI bleeding. And this was a douletois lesion, which is a aberrant mucosal or submucosal vessel that intermittently bleeds. Sometimes it's challenging to identify whether somebody has portal hypertensive gastropathy as on the left or gastroenteral vascular ectasia as noted on the right. Here is a upper endoscopy that was done here showing in retroflex view, the portal hypertensive gastropathy picture. It is consistent with a mosaic form or snake skin like erythema with some red dots noted there. Under narrow band imaging, these vascular patterns can be more appreciated with, again, the snake skin appearance. Here is a classic example of gastroenteral vascular ectasia or so-called watermelon stomach. You can see the red stripes that are consistent with what's colloquially known as watermelon stomach. But sometimes it can be a little bit challenging to identify gastroenteral vascular ectasia. Sometimes this is mischaracterized as just gastritis. If biopsies aren't performed to actually differentiate or use narrow band imaging to identify the vascular lesions, this can be missed. Here's an example under narrow band imaging of what these lesions look like. Sometimes ulcers can be missed. Ulcers that are located in the incisura, fundus, or cardia can be missed. Here's an example of a ulcer that was noted on the incisura on repeat endoscopy. Here the endoscopist is using a cold snare to guillotine the clot off in order to better visualize whether or not there's any underlying vessel. Doing a repeat upper endoscopy in somebody who has significant duodenal edema may also be helpful. Putting a cap on the scope can sometimes identify an area of ulceration in the edematous folds. And in this particular instance, bleeding is noted at the periphery. Using a duodenoscope can also be useful. Duodenoscopes have that side-viewing way of evaluating the duodenal sweep. Sometimes ulcers are missed in this area. Doing a cap-assisted colonoscopy is also very important in determining the detection of diverticular bleeding, as in this case. In this instance, hemoclips are applied for treatment. With cap-assisted colonoscopies, sometimes it is useful to use water to identify a particular lesion under better visualization. In this instance, a vessel is seen in a diverticulum, and a hemoclip is being applied underwater to stop the bleeding. In this particular case, if the colonoscopy had a poor prep, this particular lesion may not have been seen. This is a large angioictasia that was actually noted in the cecum. This can also be seen in the ascending colon and other areas of the colon. These lesions could have been missed on prior colonoscopy. Similar to what is seen on upper endoscopy, doulefoil lesions can also be seen in colonoscopy procedures. Here, in this instance, hemoclips are applied. It is important to actually look inside the terminaoleum, particularly if areas or suspicion for small bowel bleeding is considered. In this particular instance, it was worthwhile to look in the terminaoleum, as a diverticulum was noted. In this instance, it was bleeding. In this particular case, a hemoclip was applied. Here's another example of peeking into the terminaoleum. This is known as a Meckel's diverticulum. Sometimes these can be seen during colonoscopy. These lesions can be seen on the rectum. Sometimes may have been missed by stool. These are ulcerations that occur in the rectum, and they're known as stercoral ulcers, or solitary rectal ulcer syndrome, often seen in patients who are constipated or have had rectal prolapse. Sometimes it's important to consider the possibility of radiation proctitis, say, for example, in a man who has had radiation treatment for prostate cancer. Sometimes this could be misinterpreted as erythema related to PrEP artifact. Here's a patient who actually underwent small bowel capsule endoscopy, and this is towards the terminaoleum and went into the colon. And obviously, you can see that there is actually a mass within the cecum. This particular patient had a colon cancer that was actually missed at the time of colonoscopy. So take-home points. Part one, repeat upper endoscopy and or colonoscopy due to potential mislesions. If there's doubt regarding the quality of the previous upper endoscopy and or colonoscopy, or if the clinical presentation is highly suggestive of either an upper GI bleed or lower GI bleed, consider repeating the endoscopy and or colonoscopy. For further information, subscribe to GI Now or use these resources on GILeap.

obscure GI bleeding

missed lesions

cap-assisted colonoscopy

duodenoscopes

repeat endoscopy