**2. References**


(Goodman 1964). For the lesions located at colon, colonoscopy may be helpful in defining the source of bleeding (Barbier et al., 1985). Sometimes, multiple endoscopies may be necessary. Endoscopic evaluation reveals tiny ulcer, the protruding vessels, surrounding inflammatory reaction and occasionally a clot on this lesion. Since this lesion is small and the bleeding in stomach might interfere with the endoscopic visualization, the aspiration of intragastric blood and good air insufflation is necessary. If the visualization can not be enhanced with these interventions, endoscopy should be ended and restarted after the hemodynamic stabilization is achieved. Endoscopy is used for both diagnosis and treatment (Fig 1) Successful hemostasis has been reported with many different endoscopic techniques. Endoscopic hemoclip application, endoscopic band ligation, heater probe application, Nd:YAG, with or without epinephrine injection therapy have all been shown to be effective in various studies(Al-mshlab et al., 1999; Ekci et al., 2010). An experienced endoscopist and appropriate therapeutic instruments are essential to achieve a high success rate. Reilly et al. (Reilly & Al-Kawas, 1991) achieved permanent haemostasis in 85% of cases with endoscopic therapy. The authors concluded that of the remaining 15% in whom re-bleeding occurs, 10% can successfully be treated by repeat endoscopic therapy and 5% may ultimately require

If endoscopic therapy fails, angiography with embolization or surgery is indicated (Alva et al., 2006; Garg, 2007; Reilly & Al-Kawas, 1991; Regula et al., 2008). While the bleeding is active, angiography might be helpful with cases in which initial endoscopy failed to show the bleeding source(Katz & Salas., 1993). It should be kept in mind that angiography can not make a diagnose unless there is active bleeding, and therefore, it is of little value. Angiography may also be used therapeutically by gelfoam embolisation (Helliwell & Irving,

In cases where endoscopic therapy is not effective, surgical therapy is necessary. After a gastrotomy and identification of the lesion, the bleeding vessel can be ligated. Furthermore, proximal gastric resection, or a large wedge resection might be performed. Limited wedge resection is most commonly employed surgical procedure (Turan et al., 2008; Ekci et al., 2010 ; Yanar et al., 2007). During surgery, intra-operative endoscopy might be helpful with

In conclusion, for patients with Dieulafoy's disease, early diagnosis through emergency endoscopy and endoscopic therapy might be very effective and life saving. But if these

Al-mshlab T, Amin AM, Ellul JPM. (1999) Dieulafoy's lesion: an obscure cause of GI

Alva. S, Abir F, Tran DD. (2006) Laparoscopic Gastric Wedge Resection for Dieulafoy's

Baettig B, Haecki W, Lammer F, Jost R. (1993) Dieulafoy's disease: endoscopic treatment and

Barbier P, Luder P, Triller J, Ruchti CH, Hassler H, Stafford A. (1985) Colonic haemorrhage from a solitary minute ulcer. Report of three cases. *Gastroenterology* 88: 1065-8 Boix J, Humbert P, Fernandez-Llamazares J, Planas R, Ojanguren I, Salva JA.(1988)

Disease Following Preoperative Endoscopic Localization With India Ink and

the identification of the lesion, thereby unnecessary bowel resection is avoided.

bleeding. *J. R. Coll. Surg. Edinb.* 44, 222-5

Dieulafoy malformation. *Dig Dis Sci* 33: 1496-7

Endoscopic Clips. *JSLS* 10: 244–246

follow up. *Gut* 34: 1418-21

techniques are not successful, surgical management should be the treatment choice.

surgical intervention.

1981).

**2. References** 


**19** 

*Spain* 

Javier Molina-Infante,

*Department of Gastroenterology,* 

*Hospital San Pedro de Alcantara, Caceres,* 

**Pharmacological Therapy for Recurrent** 

Gema Vinagre-Rodriguez and Miguel Fernandez-Bermejo

Obscure gastrointestinal bleeding (OGIB) is defined as occult or overt bleeding of unknown origin that persists or recurs despite negative primary radiological and endoscopic studies. It can be classified into two different clinical forms: obscure-overt OGIB, defined as visible passage of blood (ie, melena or hematochezia) and obscure-occult OGIB, manifested by irondeficiency anemia or positive fecal occult blood test without other evidence of bleeding.1 Since the source of bleeding is not readily identifiable by upper GI endoscopy and colonoscopy, OGIB is therefore, by definition, recurrent. Approximately, 5% of GI bleeding occurs between the ligament of Treitz and the ileocecal valve. Angiodysplasias of the small bowel account for 30% to 40% of OGIB and are the most common source of bleeding in patients over 60 years.1,2 They can be found as a primary disease or a gastrointestinal manifestation of systemic diseases such as hereditary haemorrhagic telangiectasia (HHT), von Willebrand (vW) disease, cardiac valvular disease, radiation enteritis, end-stage renal disease, portal hypertension, connective tissue diseases or vasculitis. Other causes include non-steroidal anti-inflammatory drugs enteropathy, inflammatory bowel disease, small bowel tumors (ie, leiomyomas, carcinoid, lymphomas, adenocarcinomas), Meckel´s

Over the last decade, the diagnostic yield and therapeutic capabilities of small bowel endoscopy have dramatically changed with the development of video capsule endoscopy and deep enteroscopy systems (single balloon, double balloon or spiral). Nonetheless, the diagnostic yield is 75% at best combining both techniques, so a quarter of patients lack a diagnosis of the source of bleeding despite exhaustive evaluation and may be at high risk of rebleeding.1 Additionally, a variable percentage of patients with a diagnosis may not respond to endoscopic therapy or may not be tributary to aggressive endoscopic or surgical management due to severe comorbidities or diffuse distribution of lesions throughout the GI tract. In this particular subset of patients, medical therapy is commonly required to stop, or at least, ameliorate bleeding, which usually leads to high transfusional requirements, exacerbations of medical conditions and subsequent hospital admissions. Indications for medical therapy in OGIB, as approved in the latest American Gastroenterology Association

**1. Introduction** 

diverticulum or Dieulafoy´s lesion.

technical review, are listed in Table 1.2

**Obscure Gastrointestinal Bleeding** 

