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Recurrent obscure gastrointestinal bleeding: time for provocative thinking?

Obscure gastrointestinal bleeding (OGIB) is defined as bleeding of unclear origin after a complete evaluation by standard endoscopic techniques, usually esophagogastro-duodenoscopy (EGD) and ileocolonoscopy. Among the more than 300,000 patients hospitalized annually for gastrointestinal bleeding (GIB), approximately 5% have recurrent OGIB.1 After initial evaluation, a repeat lower endoscopy has a yield of 5–10% and is performed on a selective basis. Push enteroscopy is routinely performed in the evaluation of OGIB and has a yield of over 30%.2 Although many lesions are located within reach of standard upper endoscopes, push enteroscopy has been shown to be a more cost-effective approach than EGD in patients with iron deficiency anemia and OGIB.3