GenSurg.nz

Small bowel bleeding

Section: Small bowel Curriculum: Curriculum, page 60

General

  • Obscure/occult GI bleeding
    • No overt sx but can have positive faecal occult blood test
    • Normal OGD and colonoscopy → likely SB origin
  • Overt GI bleeding
    • Symptomatic and visible bleeding

Aetiology

  • Vascular
  • Inflammatory/infectious
    • Crohn’s
  • Neoplasia
    • Benign and malignant SB polyps/tumours (GIST, carcinoid, met, lymphoma, carcinoma)
  • Drugs
    • NSAID induced (PUD)
  • Iatrogenic
    • Anastomotic
  • Congenital

Pathology

Dieulafoy’s lesion

  • Dilated submucosal vessel usually accompanied by mucosal thinning leading to bleeding
  • Aetiology and pathophys not well understood
  • Often bleeds then settles intermittently
  • Common locations include stomach and duodenal
  • Amenable to OGD therapeutic procedures

Angiodysplasia

  • Vascular anomalies
  • More common in patients with aortic stenosis
  • Amenable to endoscopic APC application

GAVE

  • GAVE = watermelon stomach (gastric antral vascular ectasia)
  • Pathology
    • Red stripes represent ectatic and sacculated mucosal vessels
    • Vascular ectasia, spindle cell proliferation, fibrohylalinosis
  • Endoscopy
    • Longitudinal rows of flat red stripes radiating from pylorus
      • The red streaks represent dilated blood vessels, while the pale areas are less affected mucosa.
  • Cause
    • Unclear
    • GΑVE is usually an isolated problem but has been associated with ϲirrhοsiѕ and systemic sclerosis
    • Typically in older women
  • Clinical
    • IDA
  • Treatment
    • APC, RFA, bipolar, heater probe, laser

Clinical

  • Asymptomatic in context of obscure GI bleeding
  • Symptomatic - haematemesis, malaena, Fe def anaemia

Investigations

Stable patient

Options

  • Bloods - Hb, renal function, coags
  • Imaging
    • CTA (1ml/minute bleeding rate required)
    • CTE
    • MRE
    • Meckel’s scan
    • Red cell scan
  • Endoscopic
    • OGD
    • Colonoscopy
    • Push enteroscopy = past ligament of Treitz
    • Video capsule endoscopy
      • Pros - evaluate entire SB, non invasive
      • Cons - can’t biopsy or treat, doesn’t visualise entire mucosa
      • Contraindications
        • Partial/complete obstruction
        • Pregnant
        • Can’t swallow

Algorithm

  1. Gastroscopy + colonoscopy (consider repeating as can have missed lesions)
  2. Capsule endoscopy + CT or MRE
  3. Push enteroscopy
  4. Options
    • Meckel’s scan (Tc99 pertechtenate)
      • Taken up by native and ectopic gastric mucous producing cells
      • Gamma camera imaging
    • Red cell scan (0.1-0.5mL/minute)
      • Blood taken from patient
      • RBC separated and labelled with Tc99 radionuclide
      • Reinjected
      • Gamma camera imaging to identify bleeding point
    • On table enteroscopy

Management

  • Resus
    • CRISP protocol
    • 2 large bore lines
    • MTP
  • General
    • Want gastroenterology input early
  • Medical
    • Interventional
      • Selective angioembolization
      • Likely in an unwell patient
      • Likely needs post procedure resection if ischaemia ensues
    • Endoscopic
      • APC
      • Clips
      • Adrenaline 1 in 10,000
  • Surgical
    • Resection
    • On table enteroscopy guided

Algorithm for an unstable GI bleed of unclear cause

  • Assess and resuscitate etc
  • Massive transfusion protocol, IV omeprazole, IV abx
    • ?Hx suggestive of possible cause
      • Cirrhosis - varices
      • AA repair - fistula
      • Place an NGT - ?blood comes back → UGIB
      • Always look for Hemorrhoidal bleeding
  • IR at my hospital
    • Gastroscopy in theatre (intubated)
      • Instability is much more likely to be due to a UGIB than a LGIB
      • Consent for +/- laparotomy if unable to control UGIB endoscopically
      • Reasonable to go to IR first if you don’t think it is UGI
    • If normal keep patient intubated and transfer for CTA or IR
      • All the time MTP is going - if LGIB the patient should be stabilising
      • Localise bleed
        • Embolise
        • Or surgery and resect localised segment
  • No IR at my hospital
    • On table gastroscopy + colonoscopy
    • Subtotal colectomy + ileostomy
    • If still bleeding ileostomy (from SB)
      • Enteroscopy - push enteroscopy + through ileostomy
      • Segmental clamping and enterotomy/enteroscopy

Missed lesions

OGD

  • Cameron ulcers
  • Peptic ulcers on the medial aspect of the junction between D1 and D2.
  • Dieulafoy lesions (single enlarged submucosal vessel/arteriole which can bleed)
  • Angioectasia
  • Oesophageal varices

Colonoscopy

  • Carcinoma
  • Angioectasia
  • Diverticular
  • IBD.

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