Lower And Obscure Gastrointestinal

Luis S. Marsano, MD Professor of University of Louisville and Louisville VAMC June 2012 Acute Lower Gastrointestinal Bleed Magnitude of the Problem

• Incidence: 20/100,000 persons • Mortality: 3.6% (23% if starts in hospital) • Mean Age: 63‐77 • Source of : – 76% colon – 11% above Ligament of Treitz – 9% small bowel – 6 % unknown Etiology of Lower GI Bleeding Zuckerman G et al. Gastrointest Endosc 1999;49:228 • : 33% • Colon Ca or polyps: 19% • (IBD, infectious, ischemic, radiation, vasculitis, etc.): 18% • : 8% • Other intestinal lesions (post‐polypectomy, Ao‐ enteric fistula, stercoral ulcer, etc.): 8% • Ano‐rectal: 4% • Unknown: 16% Heater Probe in (Inject “Pillow” before burn; tattoo after) Lesion Probe Pressure Energy Pulses/ Site Ulcer 10 Fr Moderate 15 J 2

Stalk 10 Fr Moderate 15-20 J 2

Diverticuli 10 Fr Moderate 15 J 2

Cancer 10 Fr Moderate 20 J 2

Angiodys 7-10 Fr Light 10 J 1 plasia BICAP in Colonoscopy (Inject “Pillow” before burn; tattoo after)

Lesion Probe Pressure Energy Time/ Site

Ulcer 10 Fr Moderate 20 W 2 sec

Stalk 10 Fr Moderate 20 W 2 sec

Diverticuli 10 Fr Moderate 20 W 2 sec

Cancer 10 Fr Moderate 20 W 2 sec

Angiodys 7-10 Fr Light 15 W 1 sec plasia Common Causes of Lower Gastrointestinal Bleed Diverticular Bleed

• Frequency: Occurs in 3‐15% of patients with diverticulosis • Causes 30‐50% of massive hematochezia. • Cause: Erosion of artery in dome of diverticulum. • Presentation: Painless maroon or red bleed • Location: Right colon 50‐90% (< 25% of tics are in this region) • Course: – Persistent bleed in 20% – Stops spontaneously in 75‐80% (90% of those needing < 4U PRBC); – 25% rebleed @ 4y • Treatment: – Endoscopic treatment (injection, BICAP, Heater Probe, banding, clip); if fails: – Arteriography + Intra‐arterial vasopressin is successful in 90%. Transcatheter embolization causes intestinal infarction in 20%. – : in 18% of those needing transfusion. Has 10% mortality. Blind segmental resection should not be done. Angiodysplasia of Colon

• Prevalence in screening colonoscopy is 0.8%; – multiple in 40‐60%; – 20% have them in more than 1 portion of GI tract (eg: colon & SB). • Frequency of bleed: – Less than 10% of angioectasia patients bleed; – once they bleed, up to 50% rebleed. • Age: 2/3 are > 70 y old. • Presentation: – acute hemorrhage in 45%; – low grade blood loss in 55%. • Location: May have multiple lesions. – More frequent in (37%) & – Rt. Colon (17%), – Transverse and descending (7% each) – Sigmoid (18%) & – (14%) Angiodysplasia of Colon

• Associations: – CKD (20‐30% of bleeds), – valvular heart dz., specially (Heyde S.); • Ao valve replacement decreases bleeding risk. – von Willebrand, – latent acquired von Willebrand (eg: Aortic Stenosis or LVAD), – CREST, – HHT. • Diagnosis: – : Precautions; May “blanch” with narcotics, tense insufflation, or . Can use Naloxone 0.4‐0.8 mg once in cecum, but has risk. Hemoclip is good choice if anticoagulation will be needed. – Angiography – CT angiography (yield 70‐100% as angiography) • Treatment: only if bleeding or in unexplained Fe deficiency. – Endoscopic; if fails, – Angio + intra‐arterial vasopressin (90% success). – Thalidomide 25 mg QID for refractory, transfusion dependent patients. – 50 mcg SQ BID or Octreotide‐LAR monthly IM. Classification of Angiectasias

LOCATION SIZE (S) NUMBER (N) Gastric (G) Minute (S1) = < 2 mm Unique (N1) = 1 Duodenal (D) Intermediate (S2) = 2 –5 Multiple (N2) = 2 ‐ 10 mm Jejunal (J) Large (S3) = > 5 mm Diffuse (N3) = > 10 Ileal (I) Colonic (C)

Example: D‐ S3‐N3

• Due to: – low flow state, – vasospasm, – small vessel dz., or – Occlusion (arterial or venous). • Types: – 85% non‐gangrenous; – 15% gangrenous. • Middle‐age or elderly patient. • Associations: Atherosclerosis, Ao surgery, DM, critical illness, hypotension, “pressors”, pseudoephedrine, IBS, COPD, . • Symptoms: – abdominal cramps and tenderness over affected bowel (usually left side) followed with hematochezia. (Small bowel ischemia gives mid‐abdomen pain). – Usually bloody dominates over pain, except in Isolated Right Colonic Ischemia (IRCI) where dominant symptom is pain. – Predictive factors: Age > 60, Hemodialysis, Hypertension, Hypoalbuminemia, Diabetes, Constipation induced medication. Spectrum and Pattern of Ischemic Colitis

• Reversible • Right sided: 25.2% – Intramural hemorrhage, – More abdominal pain than colopathy. bloody diarrhea – Transient segmental colitis – More CAD, AF, ESRD – Stricture – Cause found in 22% • Irreversible – Males > females – Gangrenous infarction – Worse prognosis (LOS, – Persistent segmental colitis Surgery, and mortality) – Fulminant universal colitis – Consider CTA or MRA (acute • Other rare situations mesenteric ischemia). – Colitis simulating Cancer • Transverse: 10.2% – Colitis with distal obstruction • Left sided: 32.6% – Protein loosing – Recurrent sepsis • Sigmoid/distal: 24.6% • Pancolitis: 7.3% Ischemic Colitis

• Diagnosis: Clinical features plus: – X‐Ray: “thumbprinting” on colon in 30%; pneumatosis in advanced severe disease. – CT Scan: segmental wall edema; Necrosis if pneumatosis or portal venous air – Flex‐Sigm or colonoscopy; found most frequently on splenic flexure, descending, and sigmoid. Ischemic mucosa +/‐ ulcers. May have pseudomembranes. • Treatment: – IV fluid resuscitation + bowel rest, and antibiotics. – NGT for . – Improve oxygenation and cardiac output. – Surgery (unprep) for intestinal gangrene. – Anticoagulation + hypercoagulability work‐up for acute mesenteric vein thrombosis. • Prognosis: – most improve in 1‐2 days, and resolve in 1‐2 weeks. – 20% develop chronic ischemic colitis with strictures, recurrent bacteremia, protein loosing enteropathy, bloody diarrhea and/or weight loss. May need resection.

Radiation Colitis

• Timing: – Acute: within 6 weeks of radiation, – Chronic: > 6 weeks; often 9‐14 months post‐radiation, up to 30 years. • Presentation: – Diarrhea, tenesmus and/or rectal pain, bleeding. – Less often obstructive symptoms from stricture, or incontinence. – Fistulas are uncommon. • Endoscopy: – friable pale mucosa and . – Biopsy over prostate could cause fistula. • Treatment: – Acute: Butyrate enemas. – Chronic: • Endoscopic: APC, BICAP, H‐P, Laser (65‐90% success). • Formalin Instillation. • Sucralfate enemas 2 gm in 20 mL saline or water BID. • Hyperbaric oxygen. • Mesalamine+Betamethasone Enema + oral Flagyl 400 mg BID Infectious Colitis

• Frequently related to shiga toxin: – Shigella, Enterohemorrhagic E. Coli, Salmonella. – Also C. difficile, Klebsiella oxytoca, and campylobacter jejuni. • Less often: – CMV, Ameba, Mycobacterium avium, Yersinia. • Dx: Stool culture • Endoscopy: spotty colitis; Bx c/w ischemia Inflammatory Bowel Disease

• Diarrhea and bleeding. • Tenesmus is frequent. • DX: Colonoscopy/sigmoidoscopy with compatible Bx and negative stool studies. Rectal Varices

• Massive bleed is infrequent. • Painless hematochezia in patient with . • Need exam after volume resuscitation. • Treatment: – Banding or sclerotherapy. – May need TIPSS or non‐selective surgical shunt. Obscure‐Overt Gastrointestinal Bleeding Initial Evaluation Obscure‐Overt LGI bleed • Repeat EGD and Colonoscopy after – volume resuscitation, – correction of anemia, – perfect colon preparation, – without use of narcotics, (or with Narcan given before endoscope withdrawal). • If work‐up is non‐diagnostic: – Push‐Enteroscopy – – Balloon assisted, or Intra‐operative Enteroscopy Etiology of Mid GI Bleeding (Ampulla of Vater to TI)

• Younger than 40 – Tumors (lymphoma, carcinoid, adenocarcinoma, polyposis) – Meckel’s – Dieulafoy – Crohn – Celiac disease • Older than 40 – Angiectasia (latent acquired von Willebrand, HHT, blue rubber bleb S.): 40% – NSAID enteropathy – Celiac disease • Uncommon – Hemobilia – Hemosuccus pancreaticus – Aortoenteric fistula – Kaposi, Ehlers‐Danlos, neurifibromatosis, Klippel‐Trenaunay‐Weber 1: Push Enteroscopy

• Ideally with “Dedicated Video‐Enteroscope”, using an overtube – Spiral Enteroscopy with pediatric colonoscope as second choice. • Yield is highest when lesion is seen in initial 10% of total SB length as determined by capsule enteroscopy [Tlesion‐pylorus / Tcecum‐pylorus]

• Needs good Small Bowel Prep. • Reeding rate

• Predictors of (+) capsule finding: – Through Hb < 10 g, – more than 1 bleeding episode, or – bleeding persisting > 6 months • Capsule vs Intraop Endoscopy: – yield 74 vs 76.6%, – Capsule: sensitivity = 95%, specificity = 75%, PPV = 95%, NPV = 86% • Management change: 37 to 66%; this led to resolution of bleeding in 65% 3: Intraoperative Enteroscopy (IOE)

• Yield: 58‐88% of small bowel lesions. • IOE: Examination done “anterograde”, with dedicated enteroscope, with dimmed OR light. Lesions are marked when seen in the “way in”. • TI reached in > 90% • Therapy given in 64%. • Recurrent bleed: 12.5‐60% • Mortality: up to 17% • May cause lacerations, perforations, bowel ischemia, , and prolonged ileus. • Should be done only when DBE is limited for adhesions or other anatomic factors. 4: Double‐Balloon Enteroscopy (DBE) or Single‐Balloon Enteroscopy (SBE)

• Yield: 41‐80% of small bowel lesions. • DBE: uses anterograde + retrograde approach • Time: anterograde 72‐95 min, retrograde 75‐102 min. Each exam done in separate days. • Outcomes: – Diagnostic yield 65%, – Diagnostic/treatment success 64%, – Total SB exam 29% (tattoo), – Miss rates 28% (vs 20% for capsule) 4: Double‐Balloon Enteroscopy (DBE) or Single‐Balloon Enteroscopy (SBE)

• Findings: – Angioectasia 31%, – Ulcers (including IBD) 13%, – Malignancies 8%, – Other 6%, – Negative exam 40% • May cause lacerations, perforations, bleeding, and pancreatitis. • Ante‐grade approach recommended when lesion is in initial 11‐70% of SB [Tlesion‐pylorus / Tcecum‐pylorus] >0.1 & < 0.7. Retrograde approach when ratio is > 0.7. Angiography

• Yield: – When actively bleeding: 61‐72%; – Overall: 27‐77% (mean 40%). • Reasonable test in patient with hemodynamic instability, or ongoing need. • Study first the SMA (50‐80% of bleeds), then IMV, and then Celiac axis. • Needs bleed > 0.5 mL/min • Can control bleeding with vasopressin 0.2‐0.6 U/min infusion (90% effective) or coil embolization (riskier; 20% infart) • Provocative angiography (anticoagulation or thrombolytic) can increase yield but may cause uncontrollable bleed (not recommended by me) Dynamic Enhanced Helical CT

• CT scan 0.5 and 5, and 15 minutes after IV contrast bolus. • Looks for pooling of contrast in lumen. • Is better than Nuclear medicine scan but less accurate than angiogram. Tagged RBC Scan

• Tc‐99m‐labeled RBC scan • Yield: 45% (15% for “occult” & 70% for “overt” obscure GI bleed) • Needs bleed of 0.1‐0.4 mL/min • Frequent false (+) and (‐). • Early (within 4 hours) (+) is more reliable than late (+) • Patient can be re‐scanned for up to 24 hours. Meckel’s Scan

• Technetium‐99m pertechnetate; enhanced by

H2‐blocker pre‐treatment. • Yield: 75‐100% in children with bleeding Meckel’s Diverticulum

• Remnant of vitelline duct. At 50‐75 cm proximal from IC valve. • Present in 0.3 –3% of population; – 50% have ectopic gastric mucosa. – In some, acid secretion causes ulcer and bleed; 85% with gastric mucosa are seen with Meckel scan; – May cause obstruction due to intussusception or intraperitoneal bands with , or . • Presentation: Painless bleed (currant jelly, , or hematochezia) • DX:

– Meckel Scan: Technetium scan after H2‐blocker, – Capsule endoscopy, – Enteroclysis – Balloon assisted enteroscopy • Treatment: surgery Dieulafoy

• Definition: Aberrant submucosal artery, without ramification in gastric wall, which erodes the overlying epithelium in the absence of a primary ulcer. – Causes less than 1 percent of cases of severe UGI hemorrhage. – Caliber of the artery is 1 to 3 mm (10‐times the caliber of mucosal capillaries). – Usually located in the upper along the lesser curvature near the gastro‐ esophageal junction. – May be found in all areas of the , including the and . – Bleeding is often self‐limited, although it is usually recurrent and can be profuse • Etiology is unknown, likely congenital. • Causes of bleeding are not well‐understood. – Associations: cardiovascular disease, hypertension, chronic kidney disease, diabetes, or alcohol abuse. – Use of NSAIDs is common; NSAIDS may incite bleeding by causing mucosal atrophy and ischemic injury.. Aorto‐Enteric Fistula

• Rare cause of acute UGI bleeding, but associated with high mortality if undiagnosed and untreated. • Location: The third or fourth portion of the duodenum is the most common site for aortoenteric fistulas, followed by the and . • Presentation: – Repetitive herald bleed with and/or hematochezia; this may be followed by massive bleeding and exsanguination. – Intermittent bleeding can be seen if clot temporarily seals the fistula. – Other signs and symptoms may include abdominal or back pain, fever, and sepsis. Infrequently, an abdominal mass is palpable or an abdominal bruit is heard. • Pathophysiology — Aortoenteric fistulas arise from direct communication between the aorta and the gastrointestinal tract. Aorto‐Enteric Fistula

• Causes: – Primary A‐E fistula in USA are due to atherosclerotic aortic aneurysm. In other parts of the world are infectious aortitis due to syphilis or tuberculosis. – Secondary A‐E fistula due to prosthetic abdominal aortic vascular graft. May have pressure necrosis or graft infection causing the fistula. Other secondary causes include penetrating ulcers, tumor invasion, trauma, radiation therapy, and foreign body perforation. • Diagnosis: – A high index of suspicion. – Should be considered in all patients with massive or repetitive UGI bleeding and a history of a thoracic or abdominal aortic aneurysm, or prosthetic vascular graft. – Endoscopy is the procedure of choice for diagnosis and exclusion of other causes of acute UGI bleeding. – Endoscopy with an enteroscope or side‐viewing endoscope may reveal a graft, an ulcer or erosion at the adherent clot, or an extrinsic pulsatile mass in the distal duodenum or esophagus. – Abdominal CT scan and aortography can be useful in confirming the diagnosis, but may be unreliable. Aorto‐Enteric Fistula

• Treatment: – Exploratory laparotomy is indicated for patients with suspected aortoenteric fistula and severe ongoing bleeding. – The mortality rate of an untreated aortoenteric fistula that presents with UGI hemorrhage is nearly 100 percent. – Surgical repair of the aortic aneurysm and fistula is the standard treatment regardless of the cause. – Therapy of an aortoenteric fistula due to an infected graft consists of intravenous antibiotics and emergency surgery with removal of the infected graft and extra‐anatomic bypass. Infected graft removal with in situ graft replacement has been proposed as an alternative treatment. Hemobilia

• Bleeding from the hepatobiliary tract; rare cause of acute UGI bleeding. • Should be considered in a patient with acute UGI bleeding and a recent history of: – hepatic parenchymal or injury, – percutaneous and transjugular liver biopsy, – percutaneous transhepatic cholangiogram, – cholecystectomy, – endoscopic biliary biopsies or stenting, – TIPS, – Angioembolization, or – blunt abdominal trauma . – Other causes include , , hepatic or tumors, intrahepatic stents, hepatic artery aneurysms, and hepatic abscesses. Hemobilia

• Signs & Symptoms: – Classic triad is , obstructive jaundice, and occult or acute GI bleeding. – Hemobilia can result in obstructive jaundice with or without biliary sepsis. • Diagnosis: – Often overlooked in the absence of active bleeding. – A side‐viewing duodenoscope is helpful for visualizing the ampulla or for performing diagnostic endoscopic retrograde cholangiography (ERCP). – Technetium‐tagged red blood cell scan or – Selective hepatic artery angiography to reveal the source of hemobilia and for treatment. • Treatment: directed at the primary cause of bleeding; – embolization or surgical resection of a hepatic tumor, or – arterial embolization following liver biopsy or PTC, – laparoscopic cholecystectomy Hemosuccus Pancreaticus

• Definition: Bleeding from the pancreatic duct; rare cause of UGI bleeding. • Causes: , pancreatic pseudocysts, and pancreatic tumors. • Pathogenesis: – Pseudocyst or tumor erodes into a vessel, forming a direct communication between the pancreatic duct and a blood vessel. – May be seen after of the pancreas or pancreatic duct, including pancreatic stone removal, pancreatic duct sphincterotomy, pseudocyst drainage, or pancreatic duct stenting. • Diagnosis: confirmed by abdominal CT scan, ERCP, angiography, or intraoperative exploration. – CT scan is performed first (least invasive). • Treatment: – Mesenteric arteriography with coil embolization can control acute bleeding. – If bleeding persists or is massive: pancreaticoduodenectomy or pseudocyst resection and ligation of the bleeding vessel. Obscure‐Occult Gastrointestinal Bleeding Assessment of occult GI Blood Loss (FOBT)

• Guaiac (leuco‐dye) Test: (Hemoccult) – Normal blood loss in GI tract: 0.5‐1 mL/d – Loss of 2‐80 ml blood/day needed for (+) – 10 ml blood/day gives (+) in 50% – Water (diarrhea or rehydration of specimen) increases rate of (+) results (false & true positives). – Test should be done while on proper diet and only in soft or formed stool. – False (+): meat, radish, turnip, cantaloupe, bean sprout, cauliflower, broccoli, grapes, toilet bowl sanitizer, cimetidine, halogens, wet stools. – False (‐): ascorbic acid, antacids, heat, acid pH, enterocolic Hb metabolism (fecal storage), dry stools. Assessment of occult GI Blood Loss (FOBT)

• Guaiac (leuco‐dye) Test: (Hemoccult) – Guaiac testing should be done evaluating 2 samples in each of 3 consecutive soft or formed stools. – Waiting 3 days before developing the test allows for diet restriction of red meat only (no effect on the test). – Hemoccult & Hemoccult II are not recommended for CRC screening. – Hemoccult Sensa is OK for CRC Screening and to detect occult blood loss from the small bowel. – Colonoscopy is recommended for all those with a FOBT(+) stool. – One national study has shown that only 1 in 3 patients with a guaiac(+) stool undergoes colonoscopy Assessment of occult GI Blood Loss (FOBT) • High Sensitivity FOBT is indicated for: – Screening for CRC in asymptomatic, average risk person older than 50, with proper diet. – Fe defic. anemia with (‐) Colon & EGD+SB bx (to get approval for capsule enteroscopy) – Best: HemeSelect & Hemoccult ICT – Second choice: Hemoccult II Sensa (good for SB occult blood loss) – Not recommended: Hemoccult & Hemoccult II • FOBT is not indicated for: – Person younger than 50 (45 for African Americans ?) – Person who has not follow proper diet if using guaiac based test (admission or clinic visit) – Nasogastric aspirate or vomit. – Person with Fe deficiency [unless colon & EGD+SB Bx (‐)] – Melena, hematochezia, “coffee ground” emesis, hematemesis. – Person in a “colonoscopy surveillance” program. Assessment of occult GI Blood Loss (FOBT)

• Immunochemical (HemeSelect & Hemoccult ICT) – Anti‐Hb or anti‐albumin (human only); no special diet. – May miss < 100 ml UGI blood; – Very poor for UGI source; only fair for proximal colon. – False (‐) from enterocolic Hb metabolism & long storage (Hb degradation). – Recommended for CRC screening. • Heme‐porphyrin (HemoQuant) – Detects heme‐derived porphyrins (human or animal) (detects 88% of ingested blood). Avoid meat. – Hb‐equivalent /g‐stool > 2 mg/g is abnormal. – Good for upper & lower GI sources. (Best test to detect occult SB bleed) – Can help to guide work‐up in menstruating women, post‐gastrectomy patients, vegeterians, and when unable to differentiate “Fe deficiency” from “chronic disease” or CRF anemia. Utilization of FOBT by Primary Care Ann. Inter. Med 2005;142:81‐94,146‐148

Sensitivity Neoplasia Advanced Carcinoma for: Adenoma • COLONOSCOPY ORDERED AFTER (+) FOBT: Single 4.94.9 6.46.4 9.59.5 Digital FOBT •30 % 3-Card FOBT 2424 3030 4343 Initial Evaluation Obscure‐Occult LGI bleed • Repeat Colonoscopy and do Push‐enteroscopy with dedicated Enteroscope/overtube, or Spiral Enteroscopy with pediatric colonoscope, after – volume resuscitation, – correction of anemia, – perfect colon preparation, – without use of narcotics, (or with Narcan given before endoscope withdrawal). • If work‐up is non‐diagnostic, or dedicated enteroscope with overtube, and Spiral Enteroscopy is not available: – Capsule Endoscopy – Double‐Balloon Enteroscopy, or Single‐Balloon enteroscopy – Meckel scan. – Intra‐operative Enteroscopy (rarely) Questions ?