Up to 5% of patients with recurrent gastrointestinal (GI) bleeding will remain undiagnosed by standard gastroscopy and colonoscopy. In these patients, the small intestine is often suspected as the potential site of bleeding. During the past two decades push enteroscopy has become an important investigation in the evaluation of patients with obscure GI bleeding, with diagnostic yields varying from 38% to 80%. However, studies on the impact of push enteroscopy on the clinical outcome of these patients are lacking. Two retrospective studies have suggested that push enteroscopy may influence management decisions in 40% of patients.

Well, I had such a patient. He was an elderly gentleman who presented to us with a diagnosis of Upper GI bleed. I proceeded to do an OGDS which did not reveal any source of bleeding. So, I proceeded with colonoscopy and apart from an unhealthy colonic wall, diverticuli and some angiodysplasia, there were no reall source of bleed and no evidence of any recent bleed. As I was about to withdraw the scope, my intuition attracted me to the opening into the terminal ileum (the end of the small bowel). I manouvered my scope into it and wallah — there was a rare diverticula of the terminal ileum and evidence of fresh blood within the small bowel.

I decided to proceed for a push enteroscopy.

These scopes have a working length 210-cm or more and have standard and therapeutic sized biopsy channels that will accommodate a full range of accessories. They are similar to standard upper endoscopes in that they have up/down and right/left angulation along with a field of view of 120° or greater.

To aid in achieving the greatest possible depth of advancement, an overtube is usually placed over the endoscope prior to its insertion. The overtube reduces looping of the scope within the stomach or colon. Gradual insertion and withdrawal movements of the enteroscope help to pleat as much small intestine onto the scope and improve the depth of insertion. Using these techniques it is possible to examine 100 cm of small intestine beyond the ligament of Trietz in the majority of patients. Complications from push enteroscopy appear to be more frequent than for standard upper endoscopy. Perforation, possibly related to the use of an overtube, has been reported.

Using a standard colonoscope to examine the small bowel, a diagnostic yield of 38% has been reported.5,6 Whereas the use of a small bowel enteroscope resulted in diagnostic yield rates of 52% to 80%.

Well, this is what I managed to see about 200cm proximal to the ileocaecal valve(terminal ileum) — multiple large ulcers and one of them had a visible pulsating vessel waiting to rupture.

He was started on treatment and was discharged well yesterday.