Long-Term Outcome of Patients With Gastrointestinal Bleeding of Obscure Origin Explored by Push Enteroscopy

Background and Study Aims: Little is known of the long-term outcome in patients with gastrointestinal bleeding of obscure origin, who undergo investigation by means of push enteroscopy. The aim of this study was to assess the rate of recurrent bleeding and its predictive factors in patients with gastrointestinal bleeding of obscure origin, after exploration by push enteroscopy.
Patients and Methods: 105 patients with gastrointestinal bleeding of obscure origin (iron-deficiency anemia: n = 56; overt bleeding: n = 49) underwent exploration by push enteroscopy from December 1994 to December 1998. They were classified into three groups according to enteroscopy findings: no lesion found (group A; 56 patients), arteriovenous malformations (group B; 18 patients), and other gastrointestinal lesions (group C; 31 patients). Actuarial rates of rebleeding during follow-up were calculated and factors associated with rebleeding were assessed by means of univariate and multivariate analysis.
Results: Follow-up data were obtained for 101 patients (96 %). The mean follow-up was 29 months (6 - 54 months). The 2-year actuarial rate of rebleeding was 31 % in the overall population, and 27.6 %, 56 % and 24 % in groups A, B, and C, respectively (P = 0.13). The number of previous bleeding episodes and the number of packed red cell units transfused were two independent factors predictive of recurrent bleeding. The modality of recurrent bleeding (anemia or overt bleeding) was similar to that of the initial episode in 94 % of cases. In group A, a gastrointestinal lesion was found after rebleeding in one of the 12 patients with iron-deficiency anemia, and in four of the five patients with overt bleeding.
Conclusion: Recurrent bleeding occurs in about one-third of patients who undergo investigation by push enteroscopy for gastrointestinal bleeding of obscure origin, with a trend towards more frequent rebleeding in patients with arteriovenous malformations. Frequent previous bleeding episodes and transfusion requirements are predictive of recurrent bleeding.

References

• 1 Sayer J M, Long R G. A perspective on iron-deficiency anemia.  Gut. 1993;  34 1297-1299
• 2 Rockey D C. Occult gastrointestinal bleeding.  N Engl J Med. 1999;  341 38-46
• 3 Landi B, Tkoub M, Gaudric M, Guimbaud R, Cervoni J P, Chaussade S, Couturier D, Barbier J Ph, Cellier C. Diagnostic yield of push-type enteroscopy in relation to the indication.  Gut. 1998;  42 421-425
• 4 Rossini F P, Arrigoni A, Pennazio M. Clinical enteroscopy.  J Clin Gastroenterol. 1996;  22 231-235
• 5 Waye J D. Enteroscopy.  Gastrointest Endosc. 1997;  46 247-256
• 6 Chak A, Koehler M K, Sundaram S N, Cooper G S, Canto M I, Sivak M V. Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings.  Gastrointest Endosc. 1998;  47 18-22
• 7 Askin M P, Lewis B S. Push enteroscopic cauterization: long term follow-up of 83 patients with bleeding small intestinal angiodysplasia.  Gastrointest Endosc. 1996;  43 580-583
• 8 Morris A J, Mokhashi M, Straiton M, Murray L, Mackenzie J F. Push enteroscopy and heater probe therapy for small bowel bleeding.  Gastrointest Endosc. 1996;  44 394-397
• 9 Vakil N, Huilgol V, Khan I. Effect of push enteroscopy on transfusion requirements and quality of life in patients with unexplained gastrointestinal bleeding.  Am J Gastroenterol. 1997;  92 425-428
• 10 Waye J D. Small bowel endoscopy.  Endoscopy. 1999;  31 56-59
• 11 Mujica V, Barkin J S. Outcome of enteroscopic treatment for patients with occult gastrointestinal bleeding (abstract).  Gastroenterology. 1996;  110 348
• 12 Villagomez S, Young H S. Impact of small-bowel endoscopy on the long term outcome of patients with chronic occult gastrointestinal bleeding (abstract).  Gastrointest Endosc. 1996;  43 360
• 13 Zaman A, Katon R M. Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within the reach of a standard endoscope.  Gastrointest Endosc. 1998;  47 372-376
• 14 Rockey D C, Cello J P. Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia.  N Engl J Med. 1993;  329 1691-1695
• 15 Sahay R, Scott B B. Iron-deficiency anemia - how far to investigate?.  Gut. 1993;  34 1427-1428
• 16 Gordon S R, Smith R E, Power G C. The role of endoscopy in the evaluation of iron-deficiency anemia in patients over the age of 50.  Am J Gastroenterol. 1994;  89 1963-1967
• 17 Schmit A, Gay F, Adler M, Cremer M, van Gossum A. Diagnostic efficacy of push enteroscopy and long term follow-up of patients with small intestinal angiodysplasias.  Dig Dis Sci. 1996;  41 2348-2352
• 18 Barkin J S, Ross B S. Medical therapy for chronic gastrointestinal bleeding of obscure origin.  Am J Gastroenterol. 1998;  93 1250-1254
• 19 Marshall J K, Hunt R H. Hormonal therapy for bleeding gastrointestinal mucosal vascular abnormalities: a promising alternative.  Eur J Gastroenterol Hepatol. 1997;  9 521-525
• 20 Lewis B, Salomon P, Rivera-MacMurray S, Kornbluth A, Wenger J, Waye J. Does hormonal therapy have any benefit for bleeding angiodysplasia.  J Clin Gastroenterol. 1992;  15 99-103