Abdominal Imaging

, 34:311

The evaluation and management of obscure and occult gastrointestinal bleeding



Gastrointestinal (GI) bleeding is a common clinical presentation increasing in an aging population, frequently requiring hospitalization and emergent intervention, with significant morbidity, mortality, and costs. It may manifest overtly as hematemesis, melena, or hematochezia, or as an asymptomatic occult bleed. Management typically involves an esophagogastroduodenoscopy or a colonoscopy; these in combination sometimes do not identify a source of bleeding, with the source remaining obscure. Further work up to identify an obscure source frequently requires radiologically detecting the leakage of an intravascular tracer (using tagged red blood cells or angiography) with brisk bleeding or in other cases CT enterography (CTE) to detect bowel wall changes consistent with a bleeding source. Recent advances including capsule endoscopy, CTE, and double-balloon endoscopy have helped to identify bleeding sources beyond the reach of conventional endoscopy. Clinical decision-making about their use is complex and evolving. Knowing their relative merits and weaknesses including yield, contraindications, complications, and cost is essential in coming up with an appropriate management plan. This review covers the rationale for clinical management of obscure sources of GI bleeding, mentioning the approach to and the yield of conventional methods, with an emphasis on the recent advances mentioned above.


Gastrointestinal bleeding Occult Obscure Management Review 


  1. 1.
    Raju GS, Gerson L, Das A, et al. (2007) American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 133:1697–717PubMedCrossRefGoogle Scholar
  2. 2.
    Ell C, May A. (2006) Mid-gastrointestinal bleeding: capsule endoscopy and push-and-pull enteroscopy give rise to a new medical term. Endoscopy 38:73–75PubMedCrossRefGoogle Scholar
  3. 3.
    Lin S, Rockey DC (2005) Obscure gastrointestinal bleeding. Gastroenterol Clin North Am 34:679–698PubMedCrossRefGoogle Scholar
  4. 4.
    Chong J, Tagle M, Barkin JS et al (1994) Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology. Am J Gastroenterol 89:2143–6PubMedGoogle Scholar
  5. 5.
    Davies GR, Benson MJ, Gertner DJ et al (1995) Diagnostic and therapeutic push type enteroscopy in clinical use. Gut 37:346–52PubMedCrossRefGoogle Scholar
  6. 6.
    Pennazio M, Arrigoni A, Risio M et al (1995) Clinical evaluation of push-type enteroscopy. Endoscopy 27:164–70PubMedCrossRefGoogle Scholar
  7. 7.
    Szold A, Katz LB, Lewis BS. (1992) Surgical approach to occult gastrointestinal bleeding. Am J Surg 163:90–2; discussion 2–3PubMedCrossRefGoogle Scholar
  8. 8.
    Foutch PG, Sawyer R, Sanowski RA. (1990) Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin. Gastrointest Endosc 36:337–41PubMedCrossRefGoogle Scholar
  9. 9.
    Goldfarb N, Phillips A, Conn M et al (2002) Economic and health outcomes of capsule endoscopy. Disease Management 5:123–35CrossRefGoogle Scholar
  10. 10.
    Maiden L, Thjodleifsson B, Seigal A et al (2007) Long-term effects of nonsteroidal anti-inflammatory drugs and cyclooxygenase–2 selective agents on the small bowel: a cross-sectional capsule enteroscopy study. Clin Gastroenterol Hepatol 5:1040–5PubMedCrossRefGoogle Scholar
  11. 11.
    Goldstein JL, Eisen GM, Lewis B et al (2005) Video capsule endoscopy to prospectively assess small bowel injury with celecoxib, naproxen plus omeprazole, and placebo. Clin Gastroenterol Hepatol 3:133–41PubMedCrossRefGoogle Scholar
  12. 12.
    Graham DY, Opekun AR, Willingham FF et al (2005) Visible small-intestinal mucosal injury in chronic NSAID users. Clin Gastroenterol Hepatol 3:55–9PubMedCrossRefGoogle Scholar
  13. 13.
    Voderholzer WA, Maiden L, Adler SN. (2007) Interobserver variablility of wireless capsule endoscopy (WCE) in patients with Crohn’s disease and NSAID enteropathy. Gastroenterology 132:A190CrossRefGoogle Scholar
  14. 14.
    Zuckerman GR, Prakash C, Askin MP et al (2000) AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology 118:201–21PubMedCrossRefGoogle Scholar
  15. 15.
    Swaniker F, Soldes O, Hirschl RB. (1999) The utility of technetium 99m pertechnetate scintigraphy in the evaluation of patients with Meckel’s diverticulum. J Pediatr Surg 34:760–4; discussion 5PubMedCrossRefGoogle Scholar
  16. 16.
    Rerksuppaphol S, Hutson JM, Oliver MR. (2004) Ranitidine-enhanced 99mtechnetium pertechnetate imaging in children improves the sensitivity of identifying heterotopic gastric mucosa in Meckel’s diverticulum. Pediatr Surg Int 20:323–5PubMedGoogle Scholar
  17. 17.
    Bailey AA, Debinski HS, Appleyard MN et al (2006) Diagnosis and outcome of small bowel tumors found by capsule endoscopy: a three-center Australian experience. Am J Gastroenterol 101:2237–43PubMedCrossRefGoogle Scholar
  18. 18.
    Cobrin GM, Pittman RH, Lewis BS. (2006) Increased diagnostic yield of small bowel tumors with capsule endoscopy. Cancer 107:22–7PubMedCrossRefGoogle Scholar
  19. 19.
    Veyradier A, Balian A, Wolf M et al (2001) Abnormal von Willebrand factor in bleeding angiodysplasias of the digestive tract. Gastroenterology 120:346–53PubMedCrossRefGoogle Scholar
  20. 20.
    Warkentin TE, Moore JC, Anand SS et al (2003) Gastrointestinal bleeding, angiodysplasia, cardiovascular disease, and acquired von Willebrand syndrome. Transfus Med Rev 17:272–86PubMedCrossRefGoogle Scholar
  21. 21.
    Williams RC Jr. (2003) Aortic stenosis, von Willebrand factor, and bleeding. N Engl J Med 349:1773–4; author reply –4PubMedCrossRefGoogle Scholar
  22. 22.
    Bhutani MS, Gupta SC, Markert RJ et al (1995) A prospective controlled evaluation of endoscopic detection of angiodysplasia and its association with aortic valve disease. Gastrointest Endosc 42:398–402PubMedCrossRefGoogle Scholar
  23. 23.
    Pate GE, Mulligan A. (2004) An epidemiological study of Heyde’s syndrome: an association between aortic stenosis and gastrointestinal bleeding. J Heart Valve Dis 13:713–6PubMedGoogle Scholar
  24. 24.
    Junquera F, Saperas E, Angles A et al (2005) Increased plasma fibrinolytic activity in bleeding gastrointestinal angiodysplasia. Eur J Gastroenterol Hepatol 17:199–205PubMedCrossRefGoogle Scholar
  25. 25.
    Leighton JA, Goldstein J, Hirota W et al (2003) Obscure gastrointestinal bleeding. Gastrointest Endosc 58:650–5PubMedCrossRefGoogle Scholar
  26. 26.
    Mullan FJ, McKelvey ST. (1990) Pancreatic carcinoma presenting as bleeding from segmental gastric varices: pitfalls in diagnosis. Postgrad Med J 66:401–3PubMedCrossRefGoogle Scholar
  27. 27.
    Dube C, Rostom A, Sy R et al (2005) The prevalence of celiac disease in average-risk and at-risk Western European populations: a systematic review. Gastroenterology 128:S57–67PubMedCrossRefGoogle Scholar
  28. 28.
    Triester SL, Leighton JA, Leontiadis GI et al (2005) A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 100:2407–18PubMedCrossRefGoogle Scholar
  29. 29.
    Chak A, Cooper GS, Canto MI et al (1998) Enteroscopy for the initial evaluation of iron deficiency. Gastrointest Endosc 47:144–8PubMedCrossRefGoogle Scholar
  30. 30.
    Ng DA, Opelka FG, Beck DE et al (1997) Predictive value of technetium Tc 99m-labeled red blood cell scintigraphy for positive angiogram in massive lower gastrointestinal hemorrhage. Dis Colon Rectum 40:471–7PubMedCrossRefGoogle Scholar
  31. 31.
    Ingle S, Alexander J. (2007) Recurrent obscure gastrointestinal bleeding: time for provocative thinking? Gastroenterology & Hepatology 3:571–3Google Scholar
  32. 32.
    Ryan JM, Key SM, Dumbleton SA et al (2001) Nonlocalized lower gastrointestinal bleeding: provocative bleeding studies with intraarterial tPA, heparin, and tolazoline. J Vasc Interv Radiol 12:1273–7PubMedCrossRefGoogle Scholar
  33. 33.
    Koval G, Benner KG, Rosch J et al (1987) Aggressive angiographic diagnosis in acute lower gastrointestinal hemorrhage. Dig Dis Sci 32:248–53PubMedCrossRefGoogle Scholar
  34. 34.
    Bloomfeld RS, Smith TP, Schneider AM et al (2000) Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin. Am J Gastroenterol 95:2807–12PubMedCrossRefGoogle Scholar
  35. 35.
    Lau WY, Fan ST, Wong SH et al (1987) Preoperative and intraoperative localisation of gastrointestinal bleeding of obscure origin. Gut 28:869–77PubMedCrossRefGoogle Scholar
  36. 36.
    Flickinger EG, Stanforth AC, Sinar DR et al (1989) Intraoperative video panendoscopy for diagnosing sites of chronic intestinal bleeding. Am J Surg 157:137–44PubMedCrossRefGoogle Scholar
  37. 37.
    Kendrick ML, Buttar NS, Anderson MA et al (2001) Contribution of intraoperative enteroscopy in the management of obscure gastrointestinal bleeding. J Gastrointest Surg 5:162–7PubMedCrossRefGoogle Scholar
  38. 38.
    Lewis BS, Eisen GM, Friedman S. (2005) A pooled analysis to evaluate results of capsule endoscopy trials. Endoscopy 37:960–5PubMedCrossRefGoogle Scholar
  39. 39.
    Viazis N, Papaxoinis K, Theodoropoulos I et al (2005) Impact of capsule endoscopy in obscure small-bowel bleeding: defining strict diagnostic criteria for a favorable outcome. Gastrointest Endosc 62:717–22PubMedCrossRefGoogle Scholar
  40. 40.
    Viazis N, Sgouros S, Papaxoinis K et al (2004) Bowel preparation increases the diagnostic yield of capsule endoscopy: a prospective, randomized, controlled study. Gastrointest Endosc 60:534–8PubMedCrossRefGoogle Scholar
  41. 41.
    Dai N, Gubler C, Hengstler P et al (2005) Improved capsule endoscopy after bowel preparation. Gastrointest Endosc 61:28–31PubMedCrossRefGoogle Scholar
  42. 42.
    Payeras G, Piqueras J, Moreno VJ et al (2005) Effects of capsule endoscopy on cardiac pacemakers. Endoscopy 37:1181–5PubMedCrossRefGoogle Scholar
  43. 43.
    Leighton JA, Sharma VK, Srivathsan K et al (2004) Safety of capsule endoscopy in patients with pacemakers. Gastrointest Endosc 59:567–9PubMedCrossRefGoogle Scholar
  44. 44.
    Leighton JA, Srivathsan K, Carey EJ et al (2005) Safety of wireless capsule endoscopy in patients with implantable cardiac defibrillators. Am J Gastroenterol 100:1728–31PubMedCrossRefGoogle Scholar
  45. 45.
    Pennazio M, Santucci R, Rondonotti E et al (2004) Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 126:643–53PubMedCrossRefGoogle Scholar
  46. 46.
    Estevez E, Gonzalez-Conde B, Vazquez-Iglesias JL et al (2006) Diagnostic yield and clinical outcomes after capsule endoscopy in 100 consecutive patients with obscure gastrointestinal bleeding. Eur J Gastroenterol Hepatol 18:881–8PubMedCrossRefGoogle Scholar
  47. 47.
    Sachdev MS, Leighton JA, Fleischer DE et al (2007) A prospective study of the utility of abdominal radiographs after capsule endoscopy for the diagnosis of capsule retention. Gastrointest Endosc 66:894–900PubMedCrossRefGoogle Scholar
  48. 48.
    Appleyard M, Fireman Z, Glukhovsky A et al (2000) A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small-bowel lesions. Gastroenterology 119:1431–8PubMedCrossRefGoogle Scholar
  49. 49.
    Lai LH, Wong GL, Chow DK et al (2006) Long-term follow-up of patients with obscure gastrointestinal bleeding after negative capsule endoscopy. Am J Gastroenterol 101:1224–8PubMedCrossRefGoogle Scholar
  50. 50.
    Kovacs M, Nemeth A, Pak P et al (2006) [Evaluation of diagnostic yield and clinical impact of capsule endoscopy in patients with obscure gastrointestinal bleeding]. Orv Hetil 147:1827–33PubMedGoogle Scholar
  51. 51.
    Bar-Meir S, Eliakim R, Nadler M et al (2004) Second capsule endoscopy for patients with severe iron deficiency anemia. Gastrointest Endosc 60:711–3PubMedCrossRefGoogle Scholar
  52. 52.
    Jones BH, Fleischer DE, Sharma VK et al (2005) Yield of repeat wireless video capsule endoscopy in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 100:1058–64PubMedCrossRefGoogle Scholar
  53. 53.
    Bresci G, Parisi G, Bertoni M et al (2005) The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: usefulness of early use. J Gastroenterol 40:256–9PubMedCrossRefGoogle Scholar
  54. 54.
    Yamamoto H, Sekine Y, Sato Y et al (2001) Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 53:216–20PubMedCrossRefGoogle Scholar
  55. 55.
    May A. (2007) Current status of double balloon enteroscopy with focus on the Wiesbaden results. Gastrointest Endosc 66:S12–4PubMedCrossRefGoogle Scholar
  56. 56.
    Mehdizadeh S, Ross A, Gerson L et al (2006) What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers. Gastrointest Endosc 64:740–50PubMedCrossRefGoogle Scholar
  57. 57.
    Ohmiya N, Yano T, Yamamoto H et al (2007) Diagnosis and treatment of obscure GI bleeding at double balloon endoscopy. Gastrointest Endosc 66:S72–7PubMedCrossRefGoogle Scholar
  58. 58.
    Honda K, Itaba S, Mizutani T et al (2006) An increase in the serum amylase level in patients after peroral double-balloon enteroscopy: an association with the development of pancreatitis. Endoscopy 38:1040–3PubMedCrossRefGoogle Scholar
  59. 59.
    Kopacova M, Rejchrt S, Tacheci I et al (2007) Hyperamylasemia of uncertain significance associated with oral double-balloon enteroscopy. Gastrointest Endosc 66:1133–8PubMedCrossRefGoogle Scholar
  60. 60.
    May A, Nachbar L, Pohl J et al (2007) Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations. Am J Gastroenterol 102:527–35PubMedCrossRefGoogle Scholar
  61. 61.
    Nakamura M, Niwa Y, Ohmiya N et al (2006) Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding. Endoscopy 38:59–66PubMedCrossRefGoogle Scholar
  62. 62.
    Matsumoto T, Esaki M, Moriyama T et al (2005) Comparison of capsule endoscopy and enteroscopy with the double-balloon method in patients with obscure bleeding and polyposis. Endoscopy 37:827–32PubMedCrossRefGoogle Scholar
  63. 63.
    Hadithi M, Heine GD, Jacobs MA et al (2006) A prospective study comparing video capsule endoscopy with double-balloon enteroscopy in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 101:52–7PubMedCrossRefGoogle Scholar
  64. 64.
    May A, Nachbar L, Ell C. (2005) Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease. Gastrointest Endosc 62:62–70PubMedCrossRefGoogle Scholar
  65. 65.
    Kamal A, Gerson LB. (2006) Cost-Benefit Analysis of Double Balloon Enteroscopy Compared to Other Diagnostic Modalities for Obscure Gastrointestinal Hemorrhage. Gastrointestinal Endoscopy 63:AB90CrossRefGoogle Scholar
  66. 66.
    Huprich JE, Fletcher JG, Alexander JA et al (2008) Obscure gastrointestinal bleeding: evaluation with 64–section multiphase CT enterography–initial experience. Radiology 246:562–71PubMedCrossRefGoogle Scholar
  67. 67.
    Huprich J, Fletcher J, Alexander J (2008) Triphasic CT enterography; an initial experience. Society of Gastrointestinal Radiologists (abstract)Google Scholar
  68. 68.
    Yoon W, Jeong YY, Shin SS et al (2006) Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology 239:160–7PubMedCrossRefGoogle Scholar
  69. 69.
    Rimon E, Kagansky N, Kagansky M et al (2005) Are we giving too much iron? Low-dose iron therapy is effective in octogenarians. Am J Med 118:1142–7PubMedCrossRefGoogle Scholar
  70. 70.
    Silverstein SB, Rodgers GM. (2004) Parenteral iron therapy options. Am J Hematol 76:74–8PubMedCrossRefGoogle Scholar
  71. 71.
    Junquera F, Saperas E, Videla S et al (2007) Long-term efficacy of octreotide in the prevention of recurrent bleeding from gastrointestinal angiodysplasia. Am J Gastroenterol 102:254–60PubMedCrossRefGoogle Scholar
  72. 72.
    Grant EC. (2002) Avoid hormones in gastrointestinal angiodysplasia. Lancet 360:1254PubMedCrossRefGoogle Scholar
  73. 73.
    Hodgson H. (2002) Hormonal therapy for gastrointestinal angiodysplasia. Lancet 359:1630–1PubMedCrossRefGoogle Scholar
  74. 74.
    Madanick RD, Barkin JS. (2002) Hormonal therapy in angiodysplasia: should we completely abandon its use? Gastroenterology 123:2156; author reply -7PubMedCrossRefGoogle Scholar
  75. 75.
    Perez-Encinas M, Rabunal Martinez MJ, Bello Lopez JL. (2002) Is thalidomide effective for the treatment of gastrointestinal bleeding in hereditary hemorrhagic telangiectasia? Haematologica 87:ELT34PubMedGoogle Scholar
  76. 76.
    Shurafa M, Kamboj G. (2003) Thalidomide for the treatment of bleeding angiodysplasias. Am J Gastroenterol 98:221–2PubMedCrossRefGoogle Scholar
  77. 77.
    Zaharia-Czeizler V. (2001) Erythropoietin stops chronic diffuse transfusion-dependent gastrointestinal bleeding. Ann Intern Med 135:933PubMedGoogle Scholar
  78. 78.
    Haq AU, Glass J, Netchvolodoff CV et al (1988) Hereditary hemorrhagic telangiectasia and danazol. Ann Intern Med 109:171PubMedGoogle Scholar
  79. 79.
    Quitt M, Froom P, Veisler A et al (1990) The effect of desmopressin on massive gastrointestinal bleeding in hereditary telangiectasia unresponsive to treatment with cryoprecipitate. Arch Intern Med 150:1744–6PubMedCrossRefGoogle Scholar
  80. 80.
    Saba HI, Morelli GA, Logrono LA. (1994) Brief report: treatment of bleeding in hereditary hemorrhagic telangiectasia with aminocaproic acid. N Engl J Med 330:1789–90PubMedCrossRefGoogle Scholar
  81. 81.
    Morris ES, Hampton KK, Nesbitt IM et al (2001) The management of von Willebrand’s disease-associated gastrointestinal angiodysplasia. Blood Coagul Fibrinolysis 12:143–8PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Department of Internal Medicine, Division of Gastroenterology, Miles and Shirley Fiterman Center for Digestive Diseases19 East Mayo ClinicRochesterUSA

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