**4. Clinical evaluation**

A thorough history and physical examination are essential in the evaluation of mid-GI bleeding. Besides the symptoms and signs mentioned above, there are certain clinical clues which may direct us to suspect the underlying etiology of mid-GI bleeding:


**25**

device [24].

**5.2 Push enteroscopy**

*Mid-Gastrointestinal Bleeding*

telangiectasia.

syndrome.

**5. Investigations**

**5.1 VCE**

*DOI: http://dx.doi.org/10.5772/intechopen.89337*

• Cutaneous Kaposi's sarcoma.

with intraoperative enteroscopy [15–18].

• Telangiectasia on the lips and tongue may suggest hereditary hemorrhagic

• Itchy blistering rash on the extensor aspect of the elbows, knees, buttocks,

• Oral aphthous ulcers, genital ulcers, and uveitis may suggest Behcet's syndrome.

• Cutaneous manifestations of pseudoxanthoma elasticum and Ehlers-Danlos

The various investigations used for management of mid-GI bleeding include wireless video capsule endoscopy (VCE), push enteroscopy, device-assisted enteroscopy (DAE), multiphasic CT enterography (CTE), magnetic resonance enterography (MRE), bleeding scan, Meckel's scan, angiography, and rarely laparoscopy

VCE has revolutionized the visualization of the entire mucosa of the small bowel. It was approved by the US Food and Drug Administration (FDA) in 2001. The video capsule (size: 13 × 27.9 mm) takes 2 pictures per second with a total of approximately 57,600 color pictures wirelessly over a period of 8 hours [19]. It can detect subtle mucosal changes which cannot be detected by imaging studies. VCE is very useful not only in patients with chronic or intermittent mid-GI bleeding but also in acute overt mid-GI bleeding. VCE should be done as soon as possible after the bleeding episode ideally within 14 days in the case of chronic or recurrent overt mid-GI bleeding and within 24–72 hours of acute overt mid-GI bleeding for maximal diagnostic yield [20]. The European Society of Gastrointestinal Endoscopy (ESGE) recommends that patients should take 2 L of polyethylene glycol (PEG) and simethicone (80–200 mg) prior to VCE. Prokinetic drugs (metoclopramide or domperidone) should be given if the video capsule stays in the stomach for more than 30–60 minutes as shown by real-time VCE viewer [21, 22]. Ideally video capsule should be placed endoscopically into the small bowel by using a capsule endoscope delivery device in patients with dysphagia or abnormal gastrointestinal anatomy or delayed gastric emptying where there will be increased risk of incomplete VCE study [23]. It is safe to perform VCE in patients with cardiac pacemaker, automatic implantable cardioverter-defibrillator (AICD), and left ventricular assist

Push enteroscopy is a very useful tool in the evaluation of lesion seen in the proximal part of the small bowel by VCE. Push enteroscopy is generally done by a dedicated push enteroscope (250 cm long) or a pediatric or standard colonoscope. Gastric looping and duodenal angulation prevent advancement of the scope. An overtube back-loaded on to the scope or a stiffening wire through the biopsy channel of the scope helps prevent loop formation of the scope allowing deeper

back, and scalp may suggest dermatitis herpetiformis.

