Untere gastrointestinale Blutung

Abstract

The bleeding source in the gastrointestinal system might be assigned to the upper, mid, and lower intestinal tract. Mid intestinal bleeding comprises lesions in the small bowel and lower intestinal bleeding becomes manifest in the colon. Ileo-colonoscopy is the standard method to detect a bleeding source in the colon, and small bowel endoscopy techniques such as Capsule endoscopy and Balloon enteroscopy enable diagnosis of small bowel bleeding. Scintigrapy and small bowel radiography has rarely been used recently to investigate the small bowel for intestinal blood loss.

Frequent lesions that bleed are diverticula, angiectasias, neoplasias and chronic inflammatory bowel disease in the colon and angiectasias, ulcerations, Crohn’s disease, neoplasia and diverticula in the small bowel. Endoscopic therapy may be offered with injection techniques, electrosurgical cautery, and through-the scope clips, and new endoscopic treatment options include hemostatic powder and the over-the-scope (OTS) clipping device. For selected patients highly specialized centers offer angiography or intraoperative enteroscopy to treat intractable small bowel bleeding.

Kernaussagen

Definition, Klinik und Ursachen

• Bei einer Blutung distal des Treitz-Bandes kann eine mittlere intestinale Blutung mit einer Blutungsquelle im Dünndarm (zwischen Treitz-Band und Bauhin-Klappe) von einer unteren intestinalen Blutung im engeren Sinn (Kolon) aus klinischer Sicht mit entsprechender epidemiologischer, diagnostischer und therapeutischer Relevanz abgegrenzt werden.

• Die mittlere und untere gastrointestinale Blutung manifestiert sich als positiver okkulter Stuhlbluttest, als unerklärte Eisenmangelanämie, sichtbarer Teerstuhl, ein intermittierendes „Blutschmieren“ beim Stuhlgang oder als aktive Hämatochezie.

• Häufige Blutungsquellen im Kolon sind Divertikel, Angiektasien, Neoplasien und entzündliche Darmerkrankungen unterschiedlicher Genese. Im Dünndarm werden Angiektasien, Ulzera bzw. Erosionen bei NSAR-Gebrauch oder ein Morbus Crohn, Tumoren, Metastasen und Divertikel gefunden.

Diagnostik und Therapie

• Die Diagnostik ist eine Domäne der Koloskopie und der neuen Enteroskopieverfahren (Kapselendoskopie, Ballonenteroskopie).

• Selten sind szintigrafische Verfahren und die Röntgenkontrastdarstellung des Dünndarms hilfreich. Für ausgewählte Patienten im spezialisierten Zentrum stehen die Angiografie und die intraoperative Enteroskopie zur Verfügung. In einigen Fällen kann die hochauflösende CT, ggf. mit Angiografie, weiterhelfen.

• Die Therapie richtet sich nach dem Befund und ist ebenfalls eine Domäne der Endoskopie, umfasst aber auch radiologische und operative Verfahren.

• Literatur

• 1 Ell C, May A. Mid-gastrointestinal bleeding: capsule endoscopy and push-and-pull enteroscopy give rise to a new medical term. Endoscopy 2006; 38: 73-75
• 2 Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1997; 92: 419-424
• 3 Lanas A, Garcia-Rodriguez LA, Polo-Tomas M et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol 2009; 104: 1633-1641
• 4 Strate LL, Ayanian JZ, Kotler G et al. Risk factors for mortality in lower intestinal bleeding. Clin Gastroenterol Hepatol 2008; 6: 1004-1010
• 5 Rockey DC. Occult gastrointestinal bleeding. N Engl J Med 1999; 341: 38-46
• 6 Rockey DC, Koch J, Cello JP et al. Relative frequency of upper gastrointestinal and colonic lesions in patients with positive fecal occult-blood tests. N Engl J Med 1998; 339: 153-159
• 7 Pohl J, Blancas JM, Cave D et al. Consensus report of the 2nd International Conference on double balloon endoscopy. Endoscopy 2008; 40: 156-160
• 8 Albert JG, Schülbe R, Hahn L et al. Impact of capsule endoscopy on outcome in mid-intestinal bleeding: a multicentre cohort study in 285 patients. Eur J Gastroenterol Hepatol 2008; 20: 971-977
• 9 Fry LC, Bellutti M, Neumann H et al. Incidence of bleeding lesions within reach of conventional upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding. Aliment Pharmacol Ther 2009; 29: 342-349
• 10 Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc 1999; 49: 228-238
• 11 Albert JG, Lübbert C, Surow A et al. Die Divertikelkrankheit des Dünndarms im Zeitalter der Dünndarmendoskopie. Z Gastroenterol 2009; 47: 674-681
• 12 Strate LL, Liu YL, Aldoori WH et al. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology 2009; 136: 115-122.e1
• 13 Polese L, D’Inca R, Angriman I et al. Gastrointestinal telangiectasia: a study by EGD, colonoscopy, and capsule endoscopy in 75 patients. Endoscopy 2008; 40: 23-29
• 14 Brown C, Subramanian V, Wilcox CM et al. Somatostatin analogues in the treatment of recurrent bleeding from gastrointestinal vascular malformations: an overview and systematic review of prospective observational studies. Dig Dis Sci 2010; 55: 2129-2134
• 15 Junquera F, Feu F, Papo M et al. A multicenter, randomized, clinical trial of hormonal therapy in the prevention of rebleeding from gastrointestinal angiodysplasia. Gastroenterology 2001; 121: 1073-1079
• 16 Davila RE, Rajan E, Adler DG et al. ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest Endosc 2005; 62: 656-660
• 17 Hartmann D, Schmidt H, Bolz G et al. A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc 2005; 61: 826-832
• 18 Carey EJ, Leighton JA, Heigh RI et al. A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding. Am J Gastroenterol 2007; 102: 89-95
• 19 Pennazio M, Santucci R, Rondonotti E et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004; 126: 643-653
• 20 Redondo-Cerezo E, Perez-Vigara G, Perez-Sola A et al. Diagnostic yield and impact of capsule endoscopy on management of patients with gastrointestinal bleeding of obscure origin. Dig Dis Sci 2007; 52: 1376-1381
• 21 Fujimori S, Seo T, Gudis K et al. Diagnosis and treatment of obscure gastrointestinal bleeding using combined capsule endoscopy and double balloon endoscopy: 1-year follow-up study. Endoscopy 2007; 39: 1053-1058
• 22 Kaffes AJ, Siah C, Koo JH. Clinical outcomes after double-balloon enteroscopy in patients with obscure GI bleeding and a positive capsule endoscopy. Gastrointest Endosc 2007; 66: 304-309
• 23 Hadithi M, Heine GDN, Jacobs MAJM et al. A prospective study comparing video capsule endoscopy with double-balloon enteroscopy in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2006; 101: 52-57
• 24 Gay G, Delvaux M, Fassler I. Outcome of capsule endoscopy in determining indication and route for push-and-pull enteroscopy. Endoscopy 2006; 38: 49-58
• 25 Nakamura M, Niwa Y, Ohmiya N et al. Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding. Endoscopy 2006; 38: 59-66
• 26 Looker AC, Dallman PR, Carroll MD et al. Prevalence of iron deficiency in the United States. JAMA 1997; 277: 973-976
• 27 Rockey DC, Cello JP. Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia. N Engl J Med 1993; 329: 1691-1695
• 28 Kepczyk T, Kadakia SC. Prospective evaluation of gastrointestinal tract in patients with iron-deficiency anemia. Dig Dis Sci 1995; 40: 1283-1289
• 29 Zuckerman G, Benitez J. A prospective study of bidirectional endoscopy (colonoscopy and upper endoscopy) in the evaluation of patients with occult gastrointestinal bleeding. Am J Gastroenterol 1992; 87: 62-66
• 30 Riccioni ME, Urgesi R, Spada C et al. Unexplained iron deficiency anaemia: Is it worthwhile to perform capsule endoscopy?. Dig Liver Dis 2010; 42: 560-566
• 31 Albert JG, Friedrich-Rust M, Woeste G et al. Benefit of a clipping device in use in intestinal bleeding and intestinal leakage. Gastrointest Endosc 2011; 74: 389-397
• 32 Niikura R, Nagata N, Yamada A et al. Recurrence of colonic diverticular bleeding and associated risk factors. Colorectal Dis 2012; 14: 302-305