Question

A 50-year-old female patient presents with obscure gastro-intestinal bleeding:
Discuss the evaluation and investigation of this patient.

Hint:

In patients with obscure GI bleeding, capsule endoscopy and double-balloon enteroscopy are valuable tools for identifying sources in the small bowel.

Answer 1

Obscure gastrointestinal (GI) bleeding refers to cases of GI bleeding where the source cannot be identified despite initial endoscopic examination. This is a challenging clinical scenario, requiring a systematic approach to diagnosis and investigation.
Step 1: Initial Assessment and History:
- Detailed History: Obtain a thorough history, including the onset, frequency, and nature of the bleeding (e.g., hematemesis, melena, or hematochezia). Ask about risk factors such as NSAID use, alcohol consumption, previous GI diseases (e.g., peptic ulcers, diverticular disease), and family history of GI cancers.
- Physical Examination: A full examination should include checking vital signs for signs of anemia or shock, abdominal examination for signs of tenderness, masses, or organomegaly, and a rectal examination to identify any blood per rectum.
Step 2: Laboratory Investigations:
1. Complete Blood Count (CBC): Check for anemia, which is a common finding in GI bleeding.
2. Coagulation Profile: Ensure normal clotting function.
3. Stool Occult Blood Test: This test is helpful to confirm the presence of blood in the stool.
4. Liver Function Tests and Renal Function Tests: Assess for any underlying hepatic or renal dysfunction that could be contributing to the bleeding.
Step 3: Endoscopic Evaluation:
1. Upper Endoscopy (Esophagogastroduodenoscopy - EGD): Perform to evaluate the upper GI tract for ulcers, varices, or tumors. This is the first-line investigation in cases of upper GI bleeding.
2. Colonoscopy: If the source of bleeding is suspected to be in the colon or rectum, a colonoscopy should be performed to identify causes such as diverticular disease, colorectal cancer, or colitis.
Step 4: Further Investigations:
1. Capsule Endoscopy: This is a useful tool for investigating small bowel bleeding, particularly in cases where upper endoscopy and colonoscopy are unremarkable.
2. CT Angiography or Arteriography: In cases of active bleeding, angiography may be helpful for detecting vascular malformations or arterial sources of bleeding that are not visible on conventional endoscopy.
3. Double-Balloon Enteroscopy: This can be used if there is suspicion of a small bowel lesion after negative capsule endoscopy.