This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. Hi, this is Gerard Eisenberg bringing you part three of the 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 healthcare costs associated with additional endoscopic procedures, including deep small bowel neuroscopy, it is 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 three. Tip number seven, think about MR enterography or CT enterography. Oftentimes a lesion is identified on these studies that may be a potential source for GI bleeding. It actually allows improved interventional planning when the lesion is identified either from a proximal or a distal standpoint from the small bowel. MR enterography is radiation-free, it often has findings consistent of lesions that have wall thickening, wall enhancement, ulcerations, masses, and perianteric inflammation. CT enterography has similar findings, although the risk is associated with radiation exposure compared to MRE. Here's an example of a stricture that was actually identified within the distal small bowel with wall enhancement and thickening. This is an instance in which a area of Crohn's disease was identified. This is a retrograde deep small bowel neuroscopy that identified ulcerations within the mucosa of the distal small bowel as well as a stricture that was identified and subsequently balloon dilated. Tip number eight, attempt to localize the site of bleeding using age and clinical history as clues for potential additional diagnostic studies. Some examples include in patients under the age of 40, inflammatory bowel disease, meccal diverticulum, neoplasms, or de la foie lesions. Patients that are over the age of 40, entities include angioictasia, NSAID andropathy, neoplasms, and de la foie lesions. Uncommon causes can include small bowel varices, portal hypertensive enteropathy, amyloidosis, tuberculosis in certain high-risk patients, small bowel ulcerations. Think about Bichette's syndrome, cytomegalovirus medications, including those that are used for chemotherapy. Bichette's syndrome can cause small bowel ulcers, and an entity called cryptogenic multifocal ulcerous denosing enteritis may be seen on CT or MR enterography. Blue rubber bleb nevus syndrome or Asa Weber-Rondu syndrome are important entities to consider. Common small bowel sources, including hemobilia, hemosuxus pancreaticus, and aortic enteric fistulas can also be considered in the appropriate clinical setting. Many times using clinical history, you may be able to identify possible etiologies. For example, patients with Lynch syndrome, familial adenomatous polyposis syndrome, Putz-Jaeger syndrome, Crohn's disease, and celiac disease have a higher risk for adenocarcinoma. So in these patients, you might want to consider doing a CT or MR enterography to identify possible small bowel tumors. Patients with advanced age, aortic stenosis, and an entity called Hady's syndrome, left ventricular assist devices, or in stage renal disease, these patients tend to have a higher likelihood of having angioictasias. So considering small bowel capsule endoscopy in these patients might help you to identify these angioictasias. Interestingly, many of these patients have angioictasias more proximally as opposed to distally throughout the small bowel. A herald bleed, or a massive GI bleed that is associated with significant hypotension, those are patients that you might want to consider the possibility of an aortic enteric fistula. These are seen in patients who've had prior history of aortic aneurysm repairs, radiation damage, tumor invasion, or foreign body perforation. Vascular surgeons nowadays are modifying their techniques with aortic grafts, and they often place mesentery in between the graft itself and the small bowel. So aortic enteric fistulas are becoming more rare because of the changes associated with the surgical operations with these particular patients. A large hiatal hernia, of course, you need to consider Cameron's erosions, as pointed out in part one of this series. Hemobilia, think about patients who have just recently undergone a liver biopsy or have liver or bile duct tumors. Sponic artery pseudaneadenorism should be considered in the setting of chronic pancreatitis, pancreatic necrosis, pseudocysts, or neoplasms. Lymphomas should be considered in patients with celiac disease, Crohn's disease, chronic immunosuppression, radiation therapy, and said use, of course, with NSAID enteropathy. MEN type 1 or neurofibromatosis type 1, consider neuroendocrine tumors. History of gastric surgeries or alterations in gastric anatomy, consider post-surgical and asthmatic bleeding. Radiation therapy, consider radiation enteritis. And chronic liver disease, consider varices or hypertensive enteropathy. Attempt to localize a source of bleeding by using additional diagnostic studies based on clinical history. Also includes things like a patient who presents with bright red blood on multiple occasions. Think about using an anuscope. CT angiogram in instances of active hemodynamically unstable bleeding. Tumors or masses, consider CT or MR anoragraphy. If you think about the possibility of a doulefoil lesion, particularly in the stomach or rectum, think about using an endoscopic ultrasound. Varices can also be picked up with EUS. MEKL scan can be done in patients young age who have recurrent GI bleeding. Although some MEKLs diverticula do not have gastric metaplasia, so sometimes there could be a false negative MEKL scan. Using a side-viewing duodenoscope to identify ulcers in the duodenal sweep in order to evaluate the ampulla. Using a tagged red blood cell scan to detect lesions that have a slower rate of bleeding compared to CTA. For further information, subscribe to GI Now. Consider using these resources. And thank you for your attention.

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