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Gastrointestinal Occult Bleeding
Aka: Gastrointestinal Occult Bleeding, Occult Gastrointestinal Bleeding
- See Also
- Gastrointestinal Bleeding
- Diagnosis
- Fecal Occult Blood positive or
- Iron Deficiency Anemia without other source of iron loss
- Causes
- See Occult Gastrointestinal Bleeding Causes
- More than one bleeding source identified in up to 17% of cases
- Upper Gastrintestinal bleeding source (29-56%)
- Lower Gastrointestinal Bleeding source (20-30%)
- Small Intestinal Bleeding source
- Typically Obscure Gastrointestinal Bleeding in which no source is identified (29-52%)
- A large percentage of Obscure Gastrointestinal Bleeding are likely secondary to small bowel Gastrointestinal Bleeding
- History
- Past History
- Gastrointestinal Bleeding History
- Abdominal Surgery
- Gastric Bypass Surgery
- Risk of Iron Deficiency Anemia
- Liver disease
- Risk of Portal Hypertension and Esophageal Varices
- Extra-intestinal sources of bleeding
- Menorrhagia
- Epistaxis
- Hematuria
- Family History Gastrointestinal Bleeding
- Hereditary Hemorrhagic Telangiectasia
- Vascular lesions on lips, Tongue and palms
- Blue Rubber Bleb Nevus Syndrome
- Venous malformation of gastrointestinal tract, skin and soft tissue
- Red Flags
- Unintentional Weight Loss
- Focal Symptoms
- Abdominal Pain
- Medications
- NSAIDs
- Anticoagulant
- Warfarin
- Pradaxa
- Antiplatelet Agents
- Aspirin
- Plavix
- Exam: Specific findings in syndromes predisposing to Gastrointestinal Bleeding
- Gluten Sensitive Enteropathy
- Dermatitis Herpetiformis
- Crohn's Disease
- Erythema Nodosum
- Plummer-Vinson Syndrome
- Spoon shaped nails
- Ehler-Danlos Syndrome
- Hyperextensible joints
- Peutz-Jeghers Syndrome
- Lips and mouth freckling
- Approach
- Overt or visible bleeding
- See Gastrointestinal Bleeding
- Step 1: Upper and Lower endoscopy
- Upper and lower endoscopy identifies 48 to 71% of sources
- Indications to start with lower endoscopy
- Age over 50 years
- Indications to start with upper endoscopy
- Age under 50 years
- Significant NSAID use
- Alcohol Abuse
- Step 2: Approach to negative endoscopy
- Active, overt bleeding
- Tagged Red Cell Scan (helpful in brisk bleeding) or
- Angiography
- Recurrent intermittent bleeding
- Repeat endoscopy identifies missed lesions in 35% of cases
- Consider CT enterography
- Step 3: Small Bowel evaluation
- Evaluate Small Bowel for source if endoscopy does not reveal source
- Start with Capsule Endoscopy
- Consider push enteroscopy, deep enteroscopy or surgery if Capsule Endoscopy negative
- References
- Rockey in Feldman (2002) Sleisenger GI, p. 232-48
- Bull-Henry (2013) Am Fam Physician 87(6): 430-6 [PubMed]
- Leighton (2003) Gastrointest Endosc 58(5):650-5 [PubMed]
- Mitchell (2004) Am Fam Physician 69(4):875-81 [PubMed]
- Rockey (2010) Nat Rev Gastroenterol Hepatol 7(5): 265-79 [PubMed]