Enteroscopy as a tool for diagnosing gastrointestinal bleeding requiring blood transfusion

Iron-deficiency anemia secondary to gastrointestinal blood loss is a common cause of hospitalization. In many cases, the bleeding site cannot be defined despite thorough routine examination of the gastrointestinal tract. The aim of this study was to evaluate push enteroscopy as a diagnostic tool in patients with severe anemia, secondary to recurrent gastrointestinal bleeding, that required management by transfusion. Thirty-five consecutive push enteroscopy investigations were performed in 1998 and 1999 on 25 patients (15 men, 10 women). Mean age was 57 +/- 16 years (range, 33-83). All patients had received blood transfusions because of pronounced anemia secondary to gastrointestinal bleeding. Before push enteroscopy, all patients had been investigated with esophagogastroduodenoscopy, colonoscopy, and small-bowel radiography using the double contrast technique; no bleeding site was found. In addition, 10 of 25 patients had been investigated beforehand with 99mTc-labelled red blood cell scintigraphy, and 5 of 25 with scintigraphy for Meckel diverticulum. Two patients were also investigated with angiography before the push enteroscopy, and in six patients an additional total intraoperative enteroscopy was performed, preceded by a new colonoscopy, esophagogastroduodenoscopy, and push enteroscopy. A bleeding site was disclosed in 15 of 25 (60%) patients. In 7 of 25 patients (28%) the bleeding site was found in the stomach or esophagus. even though the patients had undergone one or two esophagogastroduodenoscopies earlier with normal findings. Total intraoperative enteroscopy identified a bleeding site in four of six (67%) patients studied. Two patients had bleeding hemangiomas that were resected surgically. Two patients had small intestinal adenomas, one with adenocarcinoma in situ. Push enteroscopy performed with an overtube inserted under fluoroscopic guidance is an important diagnostic tool in patients in whom conventional examinations do not disclose bleeding sites. Interestingly, 28% of patients had bleeding within reach of the gastroscope, indicating that a new upper endoscopy should be recommended before push enteroscopy is performed. When no positive findings are seen on push enteroscopy and the patient is affected by severe, recurrent iron-deficiency anemia, total intraoperative enteroscopy should be considered.