American Gastroenterological AssociationAmerican Gastroenterological Association medical position statement: Evaluation and management of occult and obscure gastrointestinal bleeding☆
Section snippets
Occult bleeding
A review of occult bleeding studies finds similarities between cases that are predominantly FOBT positive2, 3 and those that are predominantly anemic with iron deficiency.4, 5, 6 Therefore, these two presentations probably represent a continuum of the same clinical spectrum—intermittent or chronic slow bleeding occurring from various gastrointestinal (GI) lesions, benign or malignant. The FOBT may detect this bleeding at any point in a longitudinal course that can culminate in IDA. Colonoscopy
Obscure bleeding
Data are sparse on the frequency and natural history of the two forms of obscure bleeding, obscure-occult and obscure-overt bleeding. Repeating routine upper and lower endoscopy before investigation of the small bowel will frequently identify lesions overlooked at the initial endoscopy, most commonly erosions within large hiatal hernias (Cameron's erosions), peptic ulcer disease and vascular ectasia in the upper GI tract, and angiodysplasia and neoplasia in the lower GI tract.1 Thus, the
Management
Although management of the primary disorder leading to occult and obscure GI bleeding can vary depending on the nature of the disorder, management of blood loss generally falls into the following categories: endoscopic therapy, angiographic therapy, pharmacotherapy, surgery, and nonspecific measures.
Intestinal vascular lesions have been successfully obliterated using thermal contact probes, injection sclerotherapy, argon plasma coagulation, or neodymium:yttrium-aluminium-garnet (Nd:YAG) laser.1
Conclusion
There appears to be no single efficient diagnostic approach or therapeutic panacea in the management of occult and obscure bleeding. Most patients will benefit from a meticulous investigative routine that attempts to visualize as much of the bowel as necessary. However, when the risks of further diagnostic procedures are significant, nonspecific measures and empiric therapy may be effective in controlling blood loss and improving quality of life.
This Medical Position Statement has been endorsed
Acknowledgements
The Clinical Practice and Practice Economics Committee acknowledges the following individuals, whose critiques of this review paper provided valuable guidance to the authors: David Alquist, M.D., Brian Fennerty, M.D., David Fleischer, M.D., W. Michael McDonnell, M.D., Douglas B. McGill, M.D., J. Patrick Waring, M.D., C. Mel Wilcox, M.D., and Sidney Winawer, M.D.
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2013, American Family PhysicianCitation Excerpt :In one prospective study, 15 of 16 patients receiving anticoagulants with a positive FOBT had significant lesions, and 20 percent of the lesions were malignant.24 Figure 7 illustrates a recommended approach to the evaluation of patients who have iron deficiency anemia with or without a positive FOBT.25 Until proven otherwise, men and postmenopausal women with iron deficiency anemia are assumed to have GI blood loss.
Chinese consensus on endoscopic diagnosis and managment of small bowel bleeding (version 2023)
2023, Chinese Journal of Digestive Endoscopy
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