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Obscure gastrointestinal bleeding — ESEGH MCQ

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ModerateEndoscopyObscure gastrointestinal bleedingESEGH

A 63-year-old man has recurrent iron deficiency anaemia despite iron replacement and requires red-cell transfusion approximately every 3 months. He reports intermittent melaena but is currently haemodynamically stable without ongoing bleeding. Two complete OGDs and two ileocolonoscopies have been performed with adequate views and have not identified a source. A conventional contrast-enhanced CT of the abdomen is unremarkable. He has no obstructive symptoms, previous small-bowel surgery or known intestinal stricture. What is the most appropriate next investigation?

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Correct answer: B — Small-bowel capsule endoscopy

The correct answer is B, small-bowel capsule endoscopy. Recurrent, transfusion-dependent iron deficiency anaemia with melaena after repeated high-quality negative upper and lower endoscopy indicates suspected small-bowel bleeding. Capsule endoscopy is the preferred first-line small-bowel investigation because of its high sensitivity for mucosal lesions; angioectasias are a common finding in older patients. CT angiography is primarily used to localise active, clinically significant bleeding and is less appropriate when bleeding is intermittent and not ongoing. CT enterography is complementary and is particularly useful when a mass, stricture or capsule-retention risk is suspected. Device-assisted enteroscopy is invasive and is usually directed by a capsule finding to permit biopsy or treatment. Routine repeat OGD is not indicated after two adequate examinations without a specific concern that pathology was missed.

Reference: British Society of Gastroenterology. British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults, section 'Further evaluation of the small bowel', statements 13–14. 2021. https://www.bsg.org.uk/getmedia/3e13dd5c-8e7b-4110-87c5-dcc1feee495d/Iron-Deficiency-Aneamia-in-Adults.pdf