Q&A

• 72 hours after her initial presentation, the patient had ongoing rectal bleeding. She required a further blood transfusion but remained haemodynamically stable.

  1. Of the following options, which is the most common cause of obscure GI bleeding?

  1. Meckel’s diverticulum
  2. Angioectasia
  3. Malignancy
  4. NSAID-induced ulceration

  Answer is B.

  Angioectasias are the most common single cause of obscure GI bleeding. A systematic review and meta-analysis of 227 studies reported that angioectasia was the identified cause in 50% of cases (Liao et al., 2010).

• 72 hours after her initial presentation, the patient had ongoing rectal bleeding. She required a further blood transfusion but remained haemodynamically stable.

  2. What is the most appropriate next investigation?

  1. Repeat ‘second-look’ OGD
  2. CT angiogram
  3. Small-bowel video capsule endoscopy
  4. Double-balloon enteroscopy

  Answer is C.

  Small-bowel VCE is recommended as the first line investigation in obscure gastrointestinal bleeding (Pennazio et al., 2015). This should be performed as soon as possible after the bleeding episode to maximise diagnostic yield. In acutely unwell patients, who are haemodynamically unstable, a CT angiography would be the most appropriate next investigation after a negative upper gastrointestinal endoscopy.

• Small-bowel VCE identified a bleeding lesion located in the first small bowel tertile, identified in the images below. Seven days after the patient’s initial presentation, there was clinical evidence of ongoing GI bleeding, requiring regular blood transfusion.

  3. Which of the following is the most appropriate next step in management?

  1. Double-balloon enteroscopy + argon plasma coagulation
  2. Thalidomide
  3. Selective embolization
  4. Lanreotide

  Answer is A.

  This is a young, healthy patient with evidence of active small bowel bleeding and no contraindication to endoscopic management. DBE is therefore the most appropriate next step.

  A DBE was performed which identified multiple bleeding angioectasia, likely in the jejunum. These were successfully treated with APC and the patient went on to make a good recovery.

  
  

  Image 1: Bleeding angioectasia seen at DBE (top) followed by successful APC (bottom)