Bleeding of obscure origin

Bleeding of obscure origin

Obscure gastrointestinal (GI) bleeding is recurrent blood loss without an identified source despite upper endoscopy and colonoscopy.

Patients aged ≤50 years are more likely to have:

• Tumours (leiomyomas, carcinoid tumours, adenocarcinoma, or lymphoma)

• Dieulafoy lesion

• Crohn's disease

Older patients are more likely to have vascular lesions such as angiodysplasia.

Angiodysplasia is the most common cause of obscure GI bleeding, accounting for approximately 40% of all cases.

Clinical presentation

Patients may present with:

• Melena

• Haematochezia

• Positive faecal occult blood test (FOBT)

Initial evaluation

• Repeat upper endoscopy and/or colonoscopy as the first step.

• Repeat endoscopic evaluation is diagnostic in approximately 40% of cases.

Investigations and diagnostic approach

Patients with obscure active GI bleeding

Nuclear imaging

• Technetium-99m labelled erythrocyte scan

OR

• Technetium-99m sulphur colloid nuclear scan

Angiography

• Perform angiography following nuclear imaging when indicated.

Deep small bowel evaluation

If the source remains unidentified:

• Push enteroscopy

OR

• Balloon-assisted enteroscopy (deep enteroscopy)

Surgical evaluation

If all investigations remain unrevealing:

• Surgery with intraoperative enteroscopy may be considered as the final diagnostic option.

Patients with occult GI bleeding

First-line investigation

• Capsule endoscopy (first-choice investigation)

OR

• Deep enteroscopy

Further evaluation

If initial investigations are unrevealing:

• Repeat upper endoscopy

• Repeat colonoscopy

• Repeat capsule endoscopy

• Deep enteroscopy

Non-pharmacological management

• Management depends on identification and treatment of the underlying source of bleeding.