Guidelines recommend narrower use of term 'obscure GI bleeding'

Last Updated: 2015-09-04

By Anne Harding

NEW YORK (Reuters Health) - "Small bowel bleeding" should replace the classification of "obscure gastrointestinal bleeding," because advances in imaging the small intestine mean it's usually possible to identify the source of bleeding, according to new practice guidelines.

The new American College of Gastroenterology guidelines, on the diagnosis and management of small bowel bleeding, were published online August 25 in the American Journal of Gastroenterology.

"Traditionally, when patients with GI bleeding underwent an upper and lower endoscopy without identification of a bleeding source, they were labeled as having obscure GI bleeding," Dr. Lauren Gerson of California Pacific Medical Center in San Francisco, who helped draft the new guidelines, told Reuters Health.

But thanks to capsule endoscopy, enteroscopy and advances in computed tomography (CT) imaging, she added, it's possible to find the source of bleeding in about 75% of cases.

Other key points in the new ACG guidelines include:

- When patients have negative upper and lower endoscopy, second-look tests may be warranted. "About 10-20% of the time you can find a lesion that was missed, more commonly in the upper digestive tract," Dr. Gerson said.

- If repeated tests do not reveal a bleeding source, capsule endoscopy should be the next step. CT enterography is recommended as the next test, however, for patients with symptoms suggestive of potential obstruction or at risk of capsule retention, for example those with suspected stricture.

- CT enterography, performed with administration of neutral volume contrast, is also useful for identifying tumors and vascular lesions below the small bowel surface. This test is recommended as the next step in patients following a normal capsule endoscopy test.

- Centers with expertise in MRI enterography can consider it as an alternative to CT enterography, especially in patients younger than 40 in order to limit radiation exposure.

- Relatively stable patients with active bleeding should undergo multiphasic CT angiography, which is more accurate than angiography and able to detect sources when bleeding is occurring at rates of approximately 0.3 ml/min compared to 0.5-1 ml/min for angiography.

- Most small bowel bleeding is due to angiodysplastic lesions, which can be treated very effectively with argon plasma coagulation, Dr. Gerson said. However, she added, recurrence rates range from 30% to 40%, so re-treatment may be necessary.

- An increasing number of patients with small bowel bleeding have advanced comorbidities that make them poor candidates for endoscopic treatment, and meta-analyses suggest that medical treatment with somatostatin analogs such as octreotide can be an effective approach for these patients.

- The guidelines also strongly recommend against performance of small bowel barium studies, given their poor diagnostic yield of less than 10%.

Dr. Gerson and other study authors have served as consultants for Covidien, Given Imaging, and other companies that make imaging equipment.

SOURCE: http://bit.ly/1QdlsKP

Am J Gastroenterol 2015.