Thread by @HELPatologist

Just scoped a patients with GI bleed 🩸 BUT no pathology identified❓

Following the @ScopingSundays GI bleed theme and inspired by @ebtapper let me try and share some practical tips / thought process as a #tweetorial #GItwitter #MedTwitter

1/

GI bleed 🩸- ‘Normal endoscopy’

▶️ No endoscopic Dx
(10% no source established)
Dagradi et al. Am.J.Gastroent

Or

▶️ Wrong endoscopic Dx

2/

No Endoscopix Dx

➕ Blood 🩸 but NO lesion

➖ No blood 🩸 & NO lesion

3/

No endoscopic Dx
⬇️
Blood 🩸 BUT no lesion
⬇️
Obscured by blood - suck, 🧼 wash, clean, roll or elevate the head end as @dr_zaidi @JacquelineChuMD
had earlier suggested

4/

Uncleared Fundal Blood Pool

▪️12% Bleeders blood pool can’t be cleared
(51% Varices. 20% Gastric ulcer)

▪️More morbidity & Greater mortality
(Length of stay, blood transfusion, rebleeding)

Stollman et al. Gastrointest.Endosc.

5/

Going back to ...
No endoscopic Dx
⬇️
Blood 🩸 BUT no lesion
⬇️
Consider ‘small lesion with big potential’ i.e. Dieulafoy lesion

6/

Paul Georges (1839-1911)was French Physician & Surgeon - Classic description of appendicitis & Dieulafoy lesion (source - #Wikipedia)

7/

Dieulafoy lesion:

▪️Recurrent often massive bleeds

▪️Large submucosal artery
(80% within 6 cm of GOJ)

▪️Bleed from superficial erosion, infiltration & rupture

▪️Control with adrenaline then clip/ablate (avoid haemopray)

8/

Recap:

No endoscopic Dx
⬇️
Blood but no lesion
⬇️
Suck/wash/clean/roll/elevate the head end
⬇️
If it’s not a dieulafoy lesion
⬇️
Don’t forget the lesion which VANISHES with Anaemia

🔻🔻🔻

Focal MVA

9/

Focal Mucosal Vascular Anomaly

🔸 Less apparent when anaemic

🔸 present with anaemia & minor bleeds

🔸 Anywhere in the gut (Mucosal / submucosal)

🔸 Asso with
- skin telangiectasiae
- blue rubber bleb nevus synd
- coagulopathies
- aortic VD or not ‘Heyde’s syndrome’?

10/

No endoscopic Dx
⬇️
Blood but no lesion
⬇️
Suck/wash/clean/roll/elevate the head end
⬇️
If it’s not a dieulafoy lesion
⬇️
If Its not a Focal MVA
⬇️
Lesion beyond reach of the scope⁉️

What comes to your mind❓

11/

We owe this gent a lot of lives‼️

Johann Friedrich Meckel 1781 – 1833

German anatomist and embryologist who described the vestigial omphalomesenteric duct
Present in 2% of population

12/

Lesions beyond reach of scope

🔹 Meckel’s diverticulum

🔹 Ulcerative jejunitis (h/o Coeliac dis❓)

🔹 Aorto-enteric fistula - EXSANGUINATE - Think CT‼️

🔹 Haemobilia - Numerous causes - Bleed then jaundice (ERCP vs IR)

13/

No endoscopic Dx
⬇️
🩸 but no lesion
⬇️
⛔️ dieulafoy lesion
⛔️ Focal MVA
⛔️Lesion beyond reach of the scope
⬇️
❓ hidden in deformity
🔻Look for pyloric canal / asymmetry
🔻Duodenal (oedema / flask ulcers)
🔻Stomal ‼️ retriever in jejunum‼️

14/

Let’s SHIFT the focus like my patient

No Endoscopic diagnosis

⬇️

No blood

⬇️

❓Not actually bleeding – anaemic on iron + diarrhoea

❓Not UGIB – Burgundy stool

❓Healed lesion

Rarely: sudden massive bleed with none left

Or as we discussed Bleeding beyond reach❓

15/

▶️ ‘Lesions are seen but not believed to be cause’

e.g.

♦️GAVE & Prolapse Gastropathy reported as Gastritis‼️

♦️Dieulafoy lesion reported as small gastric erosions ‼️

16/

Prolapse Gastropathy is not as innocent as it may seem & can present with haematemesis❗️

🔹Caused by retching
🔹Described by Tony Axon (ex Pres. BSG) @BritSocGastro
🔹Leaves sharply demarcated area of erythema/oozing
🔹Looks like focal gastritis

17/

Lesion appears to be cause but is not ⁉️

♦️ Mallory Weiss tear

‘Tear is often a marker of another significant bleeding source’

MacCulloch S & Rose JDR 1999

18/

So how to deal with MW tear❓

▪️Not bleeding
▪️No “visible vessel”
▪️Mild bleed
⬇️
No treatment

▪️Big bleed
▪️“visible vessel”
▪️Continued bleeding
⬇️
Injection or mechanical

19/

20/ The End @ScopingSundays #MedTwitter #GItwitter
@UHS_LiverTeam

▶️ ‘Lesions are seen but not believed to be cause’

e.g.

♦️GAVE & Prolapse Gastropathy reported as Gastritis‼️

♦️Dieulafoy lesion reported as small gastric erosions ‼️

16/

Prolapse Gastropathy is not as innocent as it may seem & can present with haematemesis❗️

🔹Caused by retching
🔹Described by Tony Axon (ex Pres. BSG) @BritSocGastro
🔹Leaves sharply demarcated area of erythema/oozing
🔹Looks like focal gastritis

17/

Lesion appears to be cause but is not ⁉️

♦️ Mallory Weiss tear

‘Tear is often a marker of another significant bleeding source’

MacCulloch S & Rose JDR 1999

18/

So how to deal with MW tear❓

▪️Not bleeding
▪️No “visible vessel”
▪️Mild bleed
⬇️
No treatment

▪️Big bleed
▪️“visible vessel”
▪️Continued bleeding
⬇️
Injection or mechanical

19/

20/ The End @ScopingSundays #MedTwitter #GItwitter
@UHS_LiverTeam

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