Push enteroscopy for obscure GI bleeding yields a high incidence of proximal lesions within the reach of standard endoscopy

The use of push enteroscopy to evaluate obscure GI bleeding has increased in recent years and diagnostic yield has ranged from 20 to 65%. This yield may be an overestimate, as some lesions are within reach of a standard endoscope. Aim: Assess the diagnostic yield of a push enteroscope (Olympus SIF 100) in a large group of patients referred to a tertiary medical center for obscure GI bleeding. Methods: 85 consecutive enteroscopies in 84 patients were performed. Each patient had at least one EGD/colonoscopy as prior work up. There were 51 males and 33 females with a mean age of 69 (range 42-93) There were 53 patients with melena/hematochezia, 15 with occult bleeding and 16 with chronic iron deficiency anemia. Results: A presumed source of bleeding was found in 34/84(40%). Location of Lesions (N=84)(Figure Presented) Proximal lesions (above the ampulla of Vater) accounted for 26/34 (76%) and included 2 esophageal sources (ulceration 1, erosion 1), 17 gastric sources (Cameron's ulcers 8, AVM's 5, portal gastropathy 2, Dieulafoy lesion 1, Mallory Weiss tear 1, and bleeding erosions 1) and 6 proximal duodenal sources (Dieulafoy lesion 2, AVM's 2, duodenal ulcer 1, duodenal erosions 1). Distal lesions accounted for only 8/34 (24%) and included AVM's in distal duodenum 4, jejunal AVM 1,Dieulafoy lesion in distal duodenum 1, jejunal melanoma 1, and jejunal anastomotic bleed 1. Endoscopic treatment (Bicap, Heater Probe) was performed in 13 of 34 patients(AVM's 10, Dieulafoy lesions 3). Conclusions: Push enteroscopy identified a presumed bleeding source in 40% of patients with obscure GI bleeding However, only 24% were distal to the ampulla of Vater, while 76% were proximal and within reach of a standard endoscope. Only 3 lesions(9%) were beyond the ligament of Treitz. Common proximal lesions were Cameron's ulcers 8, AVM's of the stomach/proximal duodenum 7, and Dieulafoy lesions of the stomach/proximal duodenum 3. Repeat standard endoscopy should be considered prior to push enteroscopy for obscure GI bleeding, and during enteroscopy meticulous attention should be given to the proximal GI tract in addition to the distal duodenum and jejunum.