Diagnostic and therapeutic considerations for obscure gastrointestinal bleeding in patients with chronic kidney disease

Abstract

Recurrent obscure gastrointestinal bleeding amongst patients with chronic kidney disease is a challenging problem gastroenterologists are facing and is associated with an extensive diagnostic workup, limited therapeutic options, and high healthcare costs. Small-bowel angiodysplasia is the most common etiology of obscure and recurrent gastrointestinal bleeding in the general population. Chronic kidney disease is associated with a higher risk of gastrointestinal bleeding and of developing angiodysplasia compared with the general population. As a result, recurrent bleeding in this subgroup of patients is more prevalent and is associated with an increased number of endoscopic and radiographic procedures with uncertain benefit. Alternative medical therapies can reduce re-bleeding; however, more studies are needed to confirm their efficacy in this subgroup of patients.

Angiodysplasia in Renal Disease Patients: Analysis of Risk Factors and Approach to Manage Such Patients

“…Video capsule endoscopy (VCE) is an effective means of diagnosis and has a higher yield when done soon after the onset of bleeding. The characteristics of a lesion on VCE may be used to evaluate the bleeding tendency of that lesion and can be used for an appropriate selection of patients for double-balloon endoscopy (DBE) [15,16].…”

“…Device-assisted enteroscopy (DAE) is a technique that includes DBE, single-balloon enteroscopy, through-the-scope balloon-assisted enteroscopy, and spiral enteroscopy. These techniques are used for a thorough evaluation of the small bowel and also allow for therapeutic intervention [16,17].…”

“…It can be inserted more deeply into the small intestine via either an oral or anal approach. The combination of capsule endoscopy (CE) and DBE can be a complementary approach for renal disease patients with intestinal bleeding [16,18].…”

“…Push enteroscopy is a useful technique with a higher yield than CE, especially in patients with suspected proximal small bowel lesions. It may be a better alternative in patients with recurrent bleeding [16].…”

“…Observation, along with as-needed transfusions and iron replacement, is potentially a viable option for patients for whom sedation is risky or those who have had multiple prior endoscopic interventions with recurrent or persistent bleeding. Iron replacement is done intravenously as oral iron is ineffective in renal disease patients [16].…”