SANGRADO GASTROINTESTINAL OSCURO MC RONALD NORABUENA HUAMAN MR3 GASTROENTEROLOGIA HAMA

HEMORRAGIA DIGESTIVA DE ORIGEN OSCURO  Obscure GI bleeding (OGIB) : sangrado oculto o manifiesto de origen desconocido que persiste o recurre despues de una evaluación inicial negativa por Endoscopia Alta o Colonoscopia.  Overt OGIB o manifiesta: sangrado GI visible ( melena o hematochezia) a su vez categorizado como activo o inactivo.  Oculta aun sin consenso, sin sangrado grosero evidente, manifestado por anemia por deficit de hierro inexplicada, con sospecha de perdidas GI. The role of endoscopy in the management of obscure GI bleeding. ASGE 2010

 5% : hemorragia entre Lig. Treitz-VIC = ID  30-40% : Angiectasias ID (> edad)  Enteropatia por AINEs, EII  erosiones, ulceras y estenosis  Tumoraciones (< 50añ) : leiomiomas, tumores carcinoide, limphomas y adenocarcinomas.  Ulceración asociado a diverticulo de Meckel (jóvenes), post RT, lesion de Dieulafoy, hemosuccus pancreaticus y varices del intestino delgado.

Sources of small bowel bleeding CURRENT Diagnosis and Treatment. Gastroenterology, Hepatology, and Endoscopy. 3rd Edition. 2016

METODOS DE ESTUDIO  Video capsula endoscopica (VCE)  Enteroscopia profunda (Deep enteroscopy)  Comparado con enfoque convencional (push enteroscopy (PE), enteroscopia intraoperatoria y radiologia, muestran superior rendimiento diagnostico.

CAPSULA ENDOSCOPICA  Miden 11x26 mm  The capsule is propelled throughout the small bowel by peristalsis over an 8- to 12-h period. Images are captured by the camera at the rate of two to six frames per second and transferred by wireless technology to the data recorder, which is strapped to the patient’s waist.  The images are then downloaded and viewed on a computer with the appropriate software. The average physician time for viewing the images ranges from 45 to 120 min, depending on the complexity of the study. PillCam SB2 (Given Imaging Ltd, Yoqneam, Israel) the Endo Capsule (Olympus Medical Systems Group, Center Valley, Pennsylvania)

 Acceptable approaches include either or both a 24-h fast and a clear liquid diet the day before the examination and the ingestion of 2 to 4 liters of a gut lavage solution.  The capsule videos allow visualization of the entire small bowel in 79% to 90% of patients.  The test is FDA-approved for use in patients older than age 2 years for evaluation of OGIB, Crohn’s disease, celiac sprue, polyposis syndromes, small bowel abnormalities on imaging studies, and clinical symptoms. the OMOM capsule (Jinshan Science and Technology Co Ltd, Chongqing, China) MiroCam (IntroMedic Co Ltd, Seoul, Korea)

 Capsule images may be limited by incomplete visualization of the small bowel in 15% to 20% of patients.  Cardiac pacemakers, defibrillators, and other electromechanical devices are a contraindication to the use of VCE.

Small bowel angioectasia Angiectasias seen on capsule endoscopy

Small bowel ulcer (NSAID associated)

ENTEROSCOPIA PROFUNDA Enteroscopio con un / doble Balon

 Enteroscopio en espiral Spiral enteroscope (Endo-Ease Discovery SB, Spirus Medical LLC, Stoughton, Massachusetts).

Small bowel angioectasias Teshima CW. Small bowel endoscopy for obscure GI bleeding. Best Practice & Research Clinical Gastroenterology 26 (2012) 247–261

Small bowel ulcer secondary to NSAIDs

Small bowel ulceration secondary to ulcerative jejunitis developing after long- standing Celiac disease

Severe ulceration and mass-like lesions from enteropathy-associated T-cell lymphoma (EATL) in patient with no prior history of Celiac disease.

The role of endoscopy in the management of obscure GI bleeding. ASGE 2010

RECOMENDACIONES ASGE  1. After appropriate resuscitation, we recommend emergent endoscopy or angiography in patients with massive OGIB. ++  2. We recommend urgent EGD in patients with active overt OGIB and a clinical presentation suggestive of upper GI bleeding. +++  For those with signs or symptoms of lower GI bleeding, we suggest repeating colonoscopy. ++  Otherwise, recommended diagnostic options include PE, VCE, and tagged red blood cell scintigraphy.  3. For those patients with inactive overt OGIB, we suggest VCE, deep enteroscopy, PE, and/or colonoscopy. ++

 4. In patients with occult OGIB and a high clinical suspicion for an upper GI lesion, we suggest repeating EGD before small-bowel evaluation. ++  For those with a suspected lower GI lesion, we suggest repeating colonoscopy prior to small-bowel evaluation. ++  In the absence of localizing signs or symptoms, we recommend small-bowel evaluation. +++

 5. We recommend VCE as the first-line diagnostic tool for evaluation of the small bowel in patients with OGIB. +++  6. We recommend that patients with occult OGIB and a negative VCE evaluation who remain clinically stable be treated with iron therapy if evidence of iron deficiency is present. +++  7. We suggest that, in patients with negative VCE and continued bleeding, repeat VCE be considered, particularly if the clinical state changes from obscure to overt bleeding or if the hemoglobin level drops by 4 g/dL. ++

Suggested diagnostic approach to overt obscure GI bleeding.

Suggested diagnostic approach to occult obscure GI bleeding

 The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB).  The term OGIB would then be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract and may represent a source of bleeding outside of the small bowel.  A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination.  The term “obscure GI bleeding” should be reserved for patients not found to have a source of bleeding after performance of standard upper and lower endoscopic examinations, small bowel evaluation with VCE and/or enteroscopy, and radiographic testing. Am J Gastroenterol 2015; 110:1265–1287; doi: /ajg ; published online 25 August 2015

Endoscopy 2015; 47: 352–376

PRINCIPALES RECOMENDACIONES  ESGE recomienda la video cápsula endoscopica del intestino delgado como la primera línea de investigación en pacientes con sangrado gastrointestinal oscuro (recomendación fuerte, evidencia de calidad moderada).  En pacientes con sangrado gastrointestinal oscuro manifiesto, ESGE recomienda realizar VCE del intestino delgado tan pronto como sea posible después del episodio de hemorragia, óptimamente dentro de 14 días, para maximizar el rendimiento diagnóstico (recomendación fuerte, evidencia de calidad moderada).  ESGE no recomienda endoscopia second look de rutina antes de VCE del intestino delgado; considerar realizarlo en pacientes con hemorragia gastrointestinal oscura o anemia ferropénica según caso por caso (recomendación fuerte, evidencia de baja calidad).

 En pacientes con hallazgos positivos en VCE del intestino delgado, ESGE recomienda la enteroscopia asistido con dispositivo para confirmar y posiblemente tratar lesiones identificadas por VCE (recomendación fuerte, evidencia de alta calidad).  ESGE recomienda la ileocolonoscopia como el primer examen endoscópico para investigar a pacientes con sospecha de enfermedad de Crohn (recomendación fuerte, evidencia de alta calidad). Ante hallazgos negativos, recomienda VCE del intestino delgado como modalidad diagnóstica inicial, en ausencia de síntomas obstructivos o estenosis conocida (recomendación fuerte, evidencia de calidad moderada).  En presencia de síntomas obstructivos o conocida estenosis, ESGE recomienda que primero se realicen estudios de imágenes del ID como enterografía / enteroclisis por RM o TEM (recomendación fuerte, evidencia de baja calidad)

 En pacientes con resultados no determinantes o no diagnósticos en imágenes del intestino delgado, ESGE recomienda VCE del intestino delgado, si se considera que influye en el manejo del paciente (recomendación fuerte, evidencia de baja calidad).  Cuando la VCE está indicada, ESGE recomienda el uso de la cápsula PillCam patency para confirmar la permeabilidad funcional del intestino delgado (recomendación fuerte, evidencia de baja calidad).  ESGE no recomienda el uso VCE del ID ante sospecha de enfermedad celíaca, pero sugiere que podría utilizarse en pacientes poco dispuestos o incapaces de someterse a una endoscopia convencional (recomendación fuerte, evidencia de baja calidad).

Yamamoto et al. Clinical Practice Guideline for Enteroscopy. Japanese Gastroenterological Endoscopy Society (JGES) 2017

GRACIAS