SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 22 Table 1. Figure 5. Algorithm for overt obscure GI bleeding CASE SERIES case series. It requires rapid diagnosis and intervention in order to stabilize the patient and prevent mortality from exsanguination. Overt obscure bleeding generally follows the same clinical picture in their presenting features as the classical acute upper and lower GI bleeds. Identifying key elements in the history may help localize the source of bleeding. A history of haematemesis is usually as a result of bleeding proximal to the ligament of Treitz. Dark tarry stools will have their origin in the upper GI tract, jejunum or ileum. Bright red or dark red blood stools usually indicates an ileal or lower GI tract origin. 15,16 At presentation it is equally important to establish a medical history to rule out potential syndromes and pre disposing conditions associated with bleeding and angiodysplasia formation. 9,16 Diagnostic modalities in overt obscure bleeding: visualising the unseen in the distraught circumstances To manage the bleeding, it must first be seen. To shed light on the endoscopically inaccessible small bowel, several modalities are available. Needless to say, the order depends on the clinical clues, the stability of the patient, the logistics and availability of investigations. Repeat endoscopy When entertaining the prospect of an OGIB, one must first confirm that the most probable has indeed been excluded. Gralnek reported a wide variation (range 0 – 75%) in the detection rate on missed or overlooked pathologies that were in reach of a standard endoscopic evaluation. 17 Repeat endoscopy, especially in the patient with the overt bleeding, allows for easily accessible lesions that may have initially been overlooked, to be diagnosed and managed. 18 Therefore repeat endoscopy should be standard practice. One of the described approach for the repeat gastroscopy is to perform a push enteroscopy by using an enteroscope or if unavailable a colonoscope to evaluate the upper GI tract and inspect the proximal jejunum at the same intervention. 17,19 An argument can be made for deferring a repeat colonoscopy if haematemesis or melaena was the clinical presentation 17 as these as typical features of proximal gut bleeding. The yield from repeat lower endoscopy identifying missed lesions has been reported to be between 3 - 7%. 14,17 Small bowel enteroscopy When OGIB originates in the small bowel, enteroscopy allows for identification and possible therapeutic interventions in the acutely bleeding patient. Techniques include using a dedicated enteroscope, where available, or using an adult or paediatric colonoscopy to evaluate the upper GI tract and small bowel. 14,17,19 Device assisted enteroscopy: single balloon enteroscopy, double balloon enteroscopy and spiral enteroscopy allow inspection of a greater length of the small bowel. 19 In expert hand inspection of all the small bowel in occult OGIB is possible with bi-directional enteroscopy. 19,20 Intraoperative assisted endoscopy Intraoperative assisted endoscopy (IOE) is performed by creating an enterotomy in the small bowel and introducing a standard endoscope to visualize otherwise inaccessible segments of bowel. 21 A variant of this was performed on our third case: intraoperative hand assisted push enteroscopy. A standard gastroscopy was performed and then advanced past the duodenum. The team performing the laparotomy then telescoped the jejunum over the advancing scope in order to progress distally (Figures 3a, b and c). Alternatively the appendiceal orifice can potentially be used with closure of the stump after endoscopy. Further as highlighted in our second case, the innovative use of IOE allowed for accurate location of the bleeding source and hence a safe segmental resection and anastomosis (Figure 2b). CT Abdomen and angiograms The CT of the abdomen can provide information on mass lesions as well identify haemorrhaging vessels aiding localization during intervention via conventional angiography or open surgery. A catheter directed angiography allows for diagnostic and therapeutic interventions. In patients active bleeding the positive identification rate ranges from 50 – 86% and 25 – 50% in patients whom bleeding has slowed or ceased. 18 Potential complications include renal impairment, bowel infarction and can occur in up to 10% of patients. With super selective angioembolization fewer complications have been reported. 19 Approach An approach to overt OGIB is outlined in Figure 5 and involves, given the incidence of missed upper GI pathology, starting with *Dependant on degree of instability and availability of resources. IR: Interventional Radiology, VCE: Video Capsule Endoscopy, SBE: Small Bowel Endoscopy, IOE: Intra Operative Endoscopy a repeat gastroscopy especially with a suspected upper GI bleed. Opting for a push endoscopy strategy would allow for examination of the small bowel and exclude proximal lesions. The decision to proceed in such a fashion would be dependent