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Occult gastrointestinal bleeding refers to bleeding that is not apparent to the patient Chronic gastrointestinal blood loss of less than 100 mL/d may cause no appreciable change in stool appearance Thus, occult bleeding in an adult is identified by a positive FOBT or iron deficiency anemia in the absence of visible blood loss FOBT may be performed in patients with gastrointestinal symptoms or as a screening test for colorectal neoplasia (see 39) From 1% to 25% of patients in screening programs have a positive FOBT In the United States, 2% of men and 5% of women have iron deficiency anemia (serum ferritin < 30 45 mcg/L) In premenopausal women, iron deficiency anemia is most commonly attributable to menstrual and pregnancy-associated iron loss; however, a gastrointestinal source of chronic blood loss is present in 10% Among men and postmenopausal women, a potential gastrointestinal cause of blood loss can be identified in the colon in 15 30% and in the upper gastrointestinal tract in 35 55%; a malignancy is present in 10% Iron deficiency on rare occasions is caused by malabsorption (especially celiac disease) or malnutrition Obscure gastrointestinal bleeding refers to occult or overt bleeding of unknown origin that persists or recurs after initial endoscopic evaluation with upper endoscopy and colonoscopy Obscure-occult bleeding is manifested by recurrent positive FOBTs or recurrent iron deficiency anemia, or both Obscure-overt bleeding is manifested by persistent or recurrent visible evidence of gastrointestinal bleeding (hematemesis, hematochezia, or melena) Up to 5% of patients admitted to hospitals with clinically overt gastrointestinal bleeding do not have a cause identified on upper endoscopy or colonoscopy

All adults over age 40 45 years with positive FOBTs or iron deficiency anemia should undergo colonoscopy or upper endoscopy Endoscopic evaluation is also recommended in premenopausal women and younger men with gastrointestinal symptoms (abdominal pain, dyspepsia or heartburn, change in bowel habits, weight loss), a positive family history of gastrointestinal cancer, or anemia that is disproportionate to the estimated menstrual blood loss The presence and nature of gastrointestinal symptoms help guide the choice of initial study After evaluation of the upper and lower gastrointestinal tract with upper endoscopy and colonoscopy, the origin of positive FOBT or iron deficiency anemia remains unexplained in 30 50% of patients Patients with occult bleeding who have a negative initial endoscopic evaluation may be given a trial of iron supplementation and closely observed Most require no further evaluation For recurrent or persistent chronic gastrointestinal blood loss or anemia that responds poorly to iron supplementation, further evaluation is pursued for a source of obscure bleeding (as described below) When possible, antiplatelet agents (aspirin, NSAIDs, clopidogrel) should be discontinued

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Unless patients have symptoms referable to the upper gastrointestinal tract, the colon should be evaluated first Colonoscopy detects over 95% of colorectal polyps and cancer and permits polypectomy, tumor biopsy, or endoscopic cautery of vascular ectasias The finding on colonoscopy of a significant lesion clearly consistent with chronic bleeding (mass lesion, large ulceration, bleeding ectasias) obviates the need for upper endoscopy For patients who are unwilling or unable to undergo colonoscopy, CT colography is accurate for the detection of most significant neoplasms Barium enema misses up to 50% of significant neoplasms and is no longer recommended

Occult blood loss may arise from anywhere in the gastrointestinal tract The most common causes are (1) neoplasms; (2) vascular abnormalities (vascular ectasias, portal hypertensive gastropathy); (3) acid-peptic lesions (esophagi-

Upper endoscopy should be performed first in patients with symptoms referable to the upper gastrointestinal tract

May A et al Prospective comparison of push enteroscopy and push-and-pull enteroscopy in patients with suspected smallbowel bleeding Am J Gastroenterol 2006 Sep;101(9):2016 24 [PMID: 16968508] Mishkin D et al ASGE technology status evaluation report: wireless capsule endoscopy Gastrointest Endosc 2006 Apr;63 (4):539 45 [PMID: 16564850] Sun B et al Diagnostic yield and therapeutic impact of doubleballoon enteroscopy in a large cohort of patients with obscure gastrointestinal bleeding Am J Gastroenterol 2006 Sep;101 (9):2011 5 [PMID: 16848814]

(heartburn, dyspepsia, dysphagia, vomiting, weight loss) Upper endoscopy should also be performed in patients with iron deficiency anemia after colonoscopy In asymptomatic patients with a positive FOBT without iron deficiency anemia whose colonoscopic examination is negative, significant abnormalities are found in almost 50% of patients on upper endoscopy Although the cost-effectiveness of evaluation of the upper gastrointestinal tract in this setting is uncertain, upper endoscopy is recommended by many experts Owing to its lower diagnostic accuracy, upper gastrointestinal radiography should be performed only in patients in whom upper endoscopy is contraindicated or where a gastroenterologist is unavailable

If you click the Filter button, shown here, you will see the inactive statuses, as shown in Figure 4-34 Active statuses are always highlighted in blue

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