From the Guidelines
For patients with suspected occult gastrointestinal (GI) bleed that is negative on endoscopy, the next step should be capsule endoscopy to evaluate the small bowel, as it has a higher sensitivity (87%) compared to CT enterography 52, 53. When evaluating a patient with a suspected occult GI bleed, it is essential to consider the most effective diagnostic tools to identify the source of bleeding.
- The patient should fast for 12 hours and may need bowel preparation with 2-4 liters of polyethylene glycol solution before undergoing capsule endoscopy.
- If capsule endoscopy identifies a bleeding source, device-assisted enteroscopy (balloon-assisted or spiral enteroscopy) can be performed for direct visualization and intervention 1.
- If capsule endoscopy is negative, consider CT enterography, as mentioned in the study by 1, which may be helpful in identifying a small bowel source of GI bleed, although its sensitivity is typically lower.
- It is crucial to weigh the advantages and disadvantages of each diagnostic tool, including ease of performance, patient satisfaction, and sensitivity, to determine the best course of action for each patient.
- Iron supplementation, such as ferrous sulfate 325mg three times daily or ferrous gluconate 325mg twice daily, should be initiated to correct anemia while the diagnostic evaluation continues, as iron deficiency anemia can significantly impact the patient's quality of life.
From the Research
Next Steps in Evaluating Occult GI Bleed
If a patient with a suspected occult gastrointestinal (GI) bleed is negative on endoscopy, the next steps in evaluation may include:
- Repeat endoscopy to identify the bleeding source, as the initial endoscopy may have missed the lesion 2
- Capsule endoscopy to evaluate for small bowel bleeding, as this is a common location for occult GI bleeding 3, 2, 4
- Other diagnostic tests, such as:
- CT angiography, which can be used to detect active bleeding in the small bowel 4
- Red cell scintigraphy, which can detect lower bleeding rates and may be advantageous in certain cases 4
- Video capsule endoscopy or double balloon endoscopy, which can be considered in occult GI bleeding following normal upper and lower endoscopy 4, 5
- Evaluation for conditions or treatments that may increase the risk of rebleeding, such as nonsteroidal anti-inflammatory drug use or antiplatelet/anticoagulant therapy 2
Diagnostic Approaches
The diagnostic approach to occult GI bleeding should be guided by the clinical history and physical findings, and may involve a combination of the above tests 3, 6. The choice of investigation may depend on the timing of presentation and accessibility to investigations 4.
Management
Management of identified lesions varies, but they are often amenable to endoscopic intervention or medical management 2. In some cases, surgical intervention may be necessary 2, 4.