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 giving you the top 10 tips for obscure GI bleeding, part two. 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 enteroscopy, 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 10 top tips for obscure GI bleeding. Tip number two, repeat the small bowel capsule endoscopy. In a study that was published almost 16 years ago, 41 patients underwent back-to-back small bowel capsule endoscopy within four days of the first study. This was a double-blinded study. The third reader confirmed the findings and reviewed the discordant cases. 11 out of the 41 patients had new lesions that weren't detected on the other capsule endoscopy that was performed. Seven of these were minor erosions, but four, importantly, had clinically significant lesions. One patient had four angioictasias, one had a distal duodenal polyp, one had a bleeding ileal ulcer, and one had bleeding angioictasia. Here's an example from one of the studies in which a patient had a bleeding distal ileal ulcer. Reasons for previously negative small bowel capsule endoscopies are that the capsule does not travel axially but tumbles unpredictably, so lesions may be missed. This was pointed out by Dr. Cave in one of his studies in which he administered two capsules at once and showed that the images of one capsule showing another capsule in terms of its view were related to the camera and how it was pointed throughout the small bowel. So a lesion that is behind the camera may have been missed. Tip number three, do an inpatient small bowel capsule endoscopy. It is important to consider doing an inpatient capsule endoscopy in patients with obscure GI bleeding because the odds ratio of finding a particular lesion is as high as 4.8 if it's done within the first two days as compared to subsequent days. This was a study that was done in the emergency room in terms of presentation to the emergency room and how many hours after onset to bleeding and doing an early capsule endoscopy increased the yield of finding a particular bleeding lesion. Diagnostic yield of inpatient small bowel capsule endoscopies is more than 90% when administered within the 48 hours of bleeding onset and timely performance decreases morbidity, mortality, readmission rates, and length of stay. Tip number four, use a longer time small bowel capsule endoscopy device. An incomplete exam or lack of passage into the cecum before the battery expires occurs in 16 to 20% of patients. It's more common in inpatients and it's thought to be related to slow transit time through the small bowel. There are a variety of companies that make longer length or longer time small bowel capsule endoscopies. These are listed here. Here's an example of a lesion that was found after eight hours. So you can see that the timer on the top left, 11 hours, 29 minutes, etc. into the study And you can see that there was an ulcer or small bowel ulcer found in the distal ileum. This would not have been seen if an eight hour capsule was used. Tip number five, consider doing a device assisted endoscopy early if available. This is a meta-analysis of 15 studies showing that the diagnostic yield and therapeutic yield is higher within the first three days of an event of GEI bleeding. Unfortunately, these studies did not show that deep small bowel endoscopy or device assisted endoscopy affected the re-bleeding rates in these patients. Here's an example of an early device assisted endoscopy that was performed showing a stricture in the foreground as well as a stricture in the background. You can see an ulceration associated with the one in the distal area, whereas blood is associated or seen in the proximal area. This is due to NSAIDs. Tip number six, talk to your interventional radiologist. So CT angiogram obviously is part of the algorithm in detecting obscure GEI bleeding, particularly when somebody presents with hemodynamic instability. The sensitivity is based on a bleeding rate of at least 0.3 cc per minute. CT angiogram can show things like a extravasation of blood within the lumen. This is associated with somebody who had a bleeding gist. But you may also want to talk to your interventional radiologist about performing a provoked angiogram. So this is oftentimes a situation in which bleeding recurs and source or localization of the bleeding is not identified. And typically, a radiologist will use these various agents that are listed here on the left as a way to try to identify the possibility of a particular lesion that they might be able to angioembolize or consider a surgical backup term for surgical options to treat the bleeding lesion. So here's an example of a provoked angiogram showing a large angiotasia that was bleeding in the distal small bowel. So for further information, subscribe to GI Now. This is the ASGE's premier subscription service that allows you access to a comprehensive collection of educational resources at a great value. It's relevant for both general and advanced endoscopists. And then here are two references that you can use to further educate yourself on small bowel capsule endoscopy.

obscure GI bleeding

small bowel capsule endoscopy

diagnostic challenges

management challenges

bleeding lesions