A young male is admitted with hemetemesis and malena. On UGI endoscopy there was no significant finding. Patient rebleeds in hospital 2 days later.
What will be the next best line of investigation
|B||Repeat endoscopy during re bleed|
GIS OF OBSCURE ORIGIN
a. Obscure GIS is defined as recurrent acute or chronic bleeding for which no source has been identified by routine endoscopic and contrast x ray studies.
b. Push enteroscopy, with a specially designed enteroscope or a pediatric colonoscope to inspect the entire duodenum and part of the jejunum, is generally the next step.
c. Push enteroscopy may identify probable bleeding sites in 20 to 40% of patients with obscure GIS.
d. Video capsule endoscopy, which allows endoscopic examination of the entire small intestine, increases diagnostic yield in obscure GIS: bleeding sites are identified in approximately 30 to 65% of cases in the initial published reports.
e. However, lack of control of the capsule prevents its manipulation and full visualization of the intestine; in addition, tissue cannot be sampled and therapy cannot be applied.
f. If enteroscopy and video capsule endoscopy are negative or unavailable, a specialized radiographic examination of the small bowel (e.g., enteroclysis) should be performed.
g. Patients with continued obscure GIS who require transfusions or repeated hospitalizations warrant further investigation.
h. 99MTc labeled red blood cell scintigraphy should be employed.
i. Angiography is useful even if bleeding has subsided, since it may disclose 99MTc- pertechnetate scintingraphy for diagnosis of Meckel's diverticulum should be done, especially in the evaluation of young patients.
j. When all tests are unrevealing intraoperative endoscopy is indicated in patients with severe recurrent or persistent bleeding requiring repeated transfusions.