Neoplasia sólida pseudopapilar de páncreas: una serie de cinco casos y revisión de la literatura / Solid pseudopapillary neoplasm of the pancreas: A series of five cases and a literature review

Resumen Introducción: las neoplasias sólidas pseudopapilares de páncreas representan alrededor del 3% de los tumores pancreáticos quísticos resecados. Se presentan con mayor frecuencia en mujeres jóvenes entre la segunda y tercera décadas de la vida. Es un tumor con poco potencial maligno que se ubica principalmente en la cola; sin embargo, puede encontrarse en cualquier localización anatómica pancreática. Métodos: se presentan 5 casos de cuatro mujeres y un hombre, entre 16 y 36 años, que consultaron principalmente por dolor abdominal. Resultados: cuatro pacientes fueron llevados a pancreatectomía distal sin esplenectomía por laparoscopia, y una paciente a pancreatoduodenectomía por laparotomía. Se logró extraer por completo y satisfactoriamente el tumor a los cinco pacientes. No se evidenció metástasis. Los tumores se localizaron en la cabeza (1), cuello (1) y predominantemente en cuerpo y cola (3). El reporte histopatológico posoperatorio confirmó el diagnóstico en los cinco casos, en la paciente más joven se había realizado una biopsia percutánea previa a la intervención quirúrgica. Conclusiones: la resección quirúrgica completa del tumor con preservación del bazo es el tratamiento de elección en pacientes con neoplasia sólida pseudopapilar de páncreas.

Abstract Introduction: Solid pseudopapillary neoplasms of the pancreas represent around 3% of resected cystic pancreatic tumors. They occur more frequently in young women between the second and third decades of life. It is a tumor with little malignant potential located mainly in the tail; however, it can be found in any pancreatic anatomical location. Materials and methods: We reported five cases of four women and one man, between 16 and 36 years of age, who consulted mainly for abdominal pain. Results: Four patients underwent distal pancreatectomy without laparoscopic splenectomy, and one underwent laparotomy pancreatoduodenectomy. The tumor was completely and satisfactorily removed from all five patients. No metastasis was found. The tumors were located on the head (1), neck (1), and predominantly on the body and tail (3). The postoperative histopathological report confirmed the diagnosis in all five cases; in the youngest patient, a percutaneous biopsy had been performed before surgical intervention. Conclusions: Complete surgical resection of the tumor with preservation of the spleen is the treatment of choice in patients with solid pseudopapillary neoplasm of the pancreas.

Colestasis en el adulto: enfoque diagnóstico y terapéutico. Revisión de tema / Diagnostic and therapeutic approach for cholestasis in the adult

Resumen La colestasis es uno de los motivos de consulta más frecuentes en hepatología. Se genera por una alteración en la síntesis, la secreción o el flujo de la bilis, a través del tracto biliar. Esta se define por una elevación de enzimas como la fosfatasa alcalina (Alkaline Phosphatase, ALP) y la gamma-glutamil transferasa, y en estadios tardíos con la hiperbilirrubinemia, al igual que con otras manifestaciones clínicas, tales como el prurito y la ictericia. El enfoque diagnóstico implica establecer el origen de dicha elevación, determinando si es intrahepática o extrahepática. Si es intrahepática, se debe esclarecer si proviene de los hepatocitos o de la vía biliar de pequeño y de gran calibre. El tratamiento dependerá de la etiología, por lo cual es importante un diagnóstico preciso. En esta revisión se presenta la fisiopatología y un enfoque diagnóstico y terapéutico.

Abstract Cholestasis is one of the most frequent reasons for hepatology consultation. It is generated by altered synthesis, secretion or flow of bile through the biliary tract and is defined by elevated levels of enzymes such as alkaline phosphatase and gamma glutamyl transferase. In late stages, hyperbilirubinemia and clinical manifestations such as pruritus and jaundice develop. The diagnostic approach involves establishment of the reasons for elevated enzyme levels and determination of whether it is intrahepatic or extrahepatic. If it is intrahepatic, the source must be determined (hepatocytes, small bile ducts, or large caliber bile ducts). Treatment depends on the etiology, so accurate diagnosis is important. This review presents the pathophysiology and a diagnostic and therapeutic approach.

Eosinophilic esophagitis: Current concepts in diagnosis and treatment.

Eosinophilic esophagitis is an immune-allergic pathology of multifactorial etiology (genetic and environmental) that affects both pediatric and adult patients. Its symptoms, which include heartburn, regurgitation, and esophageal stenosis (with dysphagia being more frequent in eosinophilic esophagitis in young adults and children), are similar to those of gastroesophageal reflux disease, causing delays in diagnosis and treatment. Although endoscopic findings such as furrows, esophageal mucosa trachealization, and whitish exudates may suggest its presence, this diagnosis should be confirmed histologically based on the presence of more than 15 eosinophils per high-power field and the exclusion of other causes of eosinophilia (parasitic infections, hypereosinophilic syndrome, inflammatory bowel disease, among others) for which treatment could be initiated. Currently, the 3 "D"s ("Drugs, Diet, and Dilation") are considered the fundamental components of treatment. The first 2 components, which involve the use of proton pump inhibitors, corticosteroids, immunosuppressants and empirical diets or guided food elimination based on allergy tests, are more useful in the initial phases, whereas endoscopic dilation is reserved for esophageal strictures. Herein, the most important aspects of eosinophilic esophagitis pathophysiology will be reviewed, in addition to evidence for the various treatments.

Fisiopatología de la hepatitis C y diabetes mellitus. Hacia la cura de dos epidemias en el siglo XXI / Pathophysiology of Hepatitis C and Diabetes Mellitus: Towards the cure of two epidemics in the 21 st century

Resumen La infección crónica por virus de la hepatitis C (VHC) y la diabetes mellitus (DM) son dos problemas de salud pública que impactan los sistemas de salud, con una alta carga económica global. La infección por VHC produce manifestaciones hepáticas tales como hepatitis, cirrosis y carcinoma hepatocelular; asimismo, se ha involucrado en la patogénesis de manifestaciones extrahepáticas, entre las cuales se ha asociado con alteraciones metabólicas como la DM. Estudios longitudinales y transversales han reportado mayor incidencia y prevalencia de DM en pacientes con infección crónica por VHC. La DM acelera la progresión histológica y clínica en pacientes con infección crónica por VHC y las complicaciones cardiovasculares. Recientemente se ha avanzado en el tratamiento y la introducción de nuevos medicamentos como los antivirales de acción directa, que mejoran el control glucémico en estos pacientes.

Abstract Chronic hepatitis C virus (HCV) and diabetes mellitus (DM) are two public health problems that impact health care systems with overall high costs. HCV infections cause liver manifestations such as hepatitis, cirrhosis and hepatocellular carcinoma. They have also been involved in the pathogenesis of extrahepatic manifestations among which are metabolic disorders such as DM. Longitudinal and cross-sectional studies have reported a higher incidence and prevalence of DM in patients with chronic HCV infections. DM accelerates histological and clinical progression of chronic HCV infections and leads to cardiovascular complications. Recently, progress has been made in treatment with the introduction of new medications such as direct-acting antiviral drugs that improve glycemic control in these patients.

[Diagnostic and therapeutic approach to dyspepsia and functional dyspepsia:what's new in 2019?] / Enfoque diagnóstico y terapéutico de dispepsia y dispepsia funcional:¿qué hay nuevo en el 2019?

Dyspepsia encompasses a set of symptoms that originate in the gastroduodenal region. It is characterized by pain or epigastric burning, early satiety and post-prandial fullness. According to the relationship of symptoms with meals, it is divided into epigastric pain syndrome and postprandial distress syndrome. However, in clinical practice, they frequently overlap. In recent years the paradigm of gastric physiological alterations has been changed and evidence supporting duodenal eosinophilia has increased, as a primary alteration that alters gastric physiology and can induce symptomatology. Every day there is more interest in the alteration of the microbiota. The treatment is based on the suppression of acid, neuromodulators, prokinetics, psychotherapy, alternative and complementary therapies. No treatment is effective in all patients.

[Duodenal eosinophilia in functional dyspepsia in a Colombian sample: a case-control study]. / Eosinofilia duodenal en pacientes Colombianos con dispepsia funcional: un estudio de casos y controles.

INTRODUCTION: Functional dyspepsia (FD) is a complex symptom. Currently there are multiple therapeutic options that are used for the management of these patients; however, FD therapies are based on symptomatic control and do not address the pathophysiological pathways involved in its development. The duodenum has been proposed as a key site to understand the complex pathophysiology involved in FD. OBJECTIVE: The aim of the study is to determine duodenal eosinophilia in patients with FD and establish the clinical-pathological correlation with the cardinal symptoms of dyspepsia. MATERIAL AND METHODS: Case-control study. Patients older than 18 years with dyspepsia according to the Rome IV criteria, and upper gastrointestinal endoscopy normal (FD group).Patients with iron deficiency anemia and chronic diarrhea (control group). Biopsies were taken in the stomach, duodenal bulb and second portion of duodenum. A sample size of 140 patients (70 patients in the FD group and 70 patients in the control group) was calculated. The collected information was described and analyzed by conventional statistical techniques. RESULTS: 243 patients were recruited. 84 patients were included in the FD group and 84 patients in the control group. 135 patients were women (80.3%). The mean age was 53.6 years (SD 14.9). Duodenal eosinophilia was found with significant difference in patients with early satiety (p=0.01). There was no difference in patients with postprandial fullness (p=0.63), epigastric pain or burning (p=0.26), gastroesophageal reflux symptoms (p=0.13), allergy and food intolerance (p=0.42) and smoking (p=0.28). There was no relationship between duodenal mastocytosis and early satiety (p=0.98), postprandial fullness (p=0.78), and epigastric pain or burning (p=0.82). CONCLUSIONS: Duodenal eosinophilia was similar in FD and controls. In subgroup analysis, duodenal eosinophilia occurs in patients with early satiety.

Enfoque diagnóstico y terapéutico de dispepsia y dispepsia funcional: ¿qué hay nuevo en el 2019? / Diagnostic and therapeutic approach to dyspepsia and functional dyspepsia: what's new in 2019?

La dispepsia abarca un conjunto de síntomas que se originan en la región gastroduodenal. Se caracteriza por dolor o ardor epigástrico, saciedad precoz y llenura pos-prandial. Según la relación de los síntomas con las comidas se divide en síndrome de dolor epigástrico y síndrome de malestar pos-prandial. Sin embargo, en la práctica clínica, frecuentemente se sobreponen. En los últimos años se ha cambiado el paradigma de las alteraciones fisiológicas gástricas y han aumentado las evidencias que apoya a la eosinofilia duodenal, como una alteración primaria que altera la fisiología gástrica y puede inducir la sintomatología. Así mismo, cada día hay mayor interés en la alteración de la microbiota. El tratamiento se basa en la supresión de ácido, procinéticos, neuromoduladores, psicoterapia, terapias alternativas y complementarias. Ningún tratamiento es universalmente eficaz en todos los pacientes.

Dyspepsia encompasses a set of symptoms that originate in the gastroduodenal region. It is characterized by pain or epigastric burning, early satiety and post-prandial fullness. According to the relationship of symptoms with meals, it is divided into epigastric pain syndrome and postprandial distress syndrome. However, in clinical practice, they frequently overlap. In recent years the paradigm of gastric physiological alterations has been changed and evidence supporting duodenal eosinophilia has increased, as a primary alteration that alters gastric physiology and can induce symptomatology. Every day there is more interest in the alteration of the microbiota. The treatment is based on the suppression of acid, neuromodulators, prokinetics, psychotherapy, alternative and complementary therapies. No treatment is effective in all patients.

Eosinofilia duodenal en pacientes Colombianos con dispepsia funcional: un estudio de casos y controles / Duodenal eosinophilia in functional dyspepsia in a Colombian sample: a case-control study

Introducción: La dispepsia funcional (DPF) es una entidad compleja cuya fisiopatología no está claramente definida. Existen alteraciones motoras gastroduodenales y recientemente se ha dado importancia a la eosinofilia duodenal. Objetivo: El objetivo de este estudio fuedeterminar si existe asociación entre eosinofilia duodenal y DPF. Materiales y métodos: Estudio de casos y controles. Pacientes mayores de 18 años con dispepsia según ROMA IV, a quienes se descartó DP orgánica con endoscopia alta (EVDA). Los controles fueron pacientes con anemia ferropénica y diarrea crónica a quienes de rutina se toman biopsias tanto del estómago como del duodeno. Se calcularon 70 pacientes en cada grupo. La información se recolectó en un formulario específico. Resultados: Hubo 243 pacientes elegibles. Se incluyeron 84 pacientes en grupo. El 80% eran mujeres. Edad promedio 53,6 años. Se encontró eosinofilia duodenal con diferencia significativa en los pacientes con saciedad precoz (p=0,01). No hubo diferencia significativa en los pacientes con llenura posprandial (p=0,63), dolor o ardor epigástrico (p=0,26), síntomas de reflujo gastroesofágico (p=0,13), alergia e intolerancia a alimentos (p=0,42) y tabaquismo (p=0,28). Asimismo, no se encontró relación entre mastocitosis duodenal y saciedad precoz (p=0,98), llenura posprandial (p=0,78) y dolor o ardor epigástrico (p=0,82). Conclusiones: La eosinofilia duodenal fue más frecuente en pacientes con DPF que tenían saciedad precoz.

Introduction: Functional dyspepsia (FD) is a complex symptom. Currently there are multiple therapeutic options that are used for the management of these patients; however, FD therapies are based on symptomatic control and do not address the pathophysiological pathways involved in its development. The duodenum has been proposed as a key site to understand the complex pathophysiology involved in FD. Objective: The aim of the study is to determine duodenal eosinophilia in patients with FD and establish the clinical-pathological correlation with the cardinal symptoms of dyspepsia. Material and methods: Case-control study. Patients older than 18 years with dyspepsia according to the Rome IV criteria, and upper gastrointestinal endoscopy normal (FD group).Patients with iron deficiency anemia and chronic diarrhea (control group). Biopsies were taken in the stomach, duodenal bulb and second portion of duodenum. A sample size of 140 patients (70 patients in the FD group and 70 patients in the control group) was calculated. The collected information was described and analyzed by conventional statistical techniques. Results: 243 patients were recruited. 84 patients were included in the FD group and 84 patients in the control group. 135 patients were women (80.3%). The mean age was 53.6 years (SD 14.9). Duodenal eosinophilia was found with significant difference in patients with early satiety (p=0.01). There was no difference in patients with postprandial fullness (p=0.63), epigastric pain or burning (p=0.26), gastroesophageal reflux symptoms (p=0.13), allergy and food intolerance (p=0.42) and smoking (p=0.28). There was no relationship between duodenal mastocytosis and early satiety (p=0.98), postprandial fullness (p=0.78), and epigastric pain or burning (p=0.82). Conclusions: Duodenal eosinophilia was similar in FD and controls. In subgroup analysis, duodenal eosinophilia occurs in patients with early satiety.

Neurofibromatosis tipo 1 y sangrado de intestino delgado. Reporte de caso / Neurofibromatosis type 1 and small bowel bleeding: Case report and literature review

Resumen La neurofibromatosis tipo 1, o enfermedad de von Recklinghausen, es un desorden neurocutáneo hereditario con compromiso gastrointestinal en el 5-25% de los pacientes, siendo sintomático solo el 5%; se presenta posterior a las manifestaciones cutáneas y afecta en su mayoría el yeyuno. Los síntomas de esta enfermedad son dolor abdominal, obstrucción intestinal, perforación, diarrea, masa palpable y sangrado gastrointestinal alto o bajo. A continuación se reporta el caso de una mujer con sangrado gastrointestinal manifiesto secundario a neurofibromas plexiformes en yeyuno y se realiza una breve revisión de la literatura sobre compromiso gastrointestinal.

Abstract Neurofibromatosis type 1, also known as von Recklinghausen disease, is an inherited neurocutaneous disorder with gastrointestinal involvement in 5-25% of patients, with only 5% being symptomatic; it develops following cutaneous manifestations and mostly affects the jejunum. The symptoms include abdominal pain, intestinal obstruction, perforation, diarrhea, palpable mass and high or low gastrointestinal bleeding. The following report presents the case of a woman with manifest gastrointestinal bleeding secondary to plexiform neurofibromas in the jejunum, as well as a brief review of the literature on gastrointestinal involvement.

El costo de ignorar el signo de Carnett: Reporte de caso y revisión de la literatura / The Cost Of Ignoring Carnett’s Sign: A Case Report and Literature Review

El dolor abdominal crónico es un motivo frecuente de consulta externa y de urgencias. Los médicos tradicionalmente consideran que el origen del mismo son las estructuras intraabdominales, incluido el tracto gastrointestinal. Rara vez tienen en cuenta la pared abdominal como la causa de la molestia y someten a los pacientes a numerosos e interminables procedimientos diagnósticos, como laparoscopias y cirugías, entre otros. Por lo menos el 50% de estos pacientes tiene dolor de la pared abdominal por lesión del nervio cutáneo anterior y el diagnóstico se hace identificando el signo de Carnett. Se presenta un caso típico con esta patología, cuyo enfoque inicial ilustra los errores y altos costos en el abordaje de esta patología

Chronic abdominal pain is a frequent cause of outpatient and emergency visits. Doctors traditionally consider that its origin is in intra-abdominal structures, including the gastrointestinal tract. They rarely take into account the abdominal wall as a cause of discomfort and subject patients to numerous and endless diagnostic procedures, including laparoscopy and surgery. At least 50% of these patients have abdominal wall pain due to injuries to the anterior cutaneous vein the diagnosis of which is made by identifying Carnett’s sign. A typical case of this pathology is here. The initial approach illustrates the errors and high costs that can be involved in the approach to this pathology

Drenaje de pseudoquiste pancreático guiado por ecoendoscopia sin fluoroscopia: serie de casos / Case Series of Drainage of Pancreatic Pseudocysts Guided by Echoendoscopy without Fluoroscopy

Resumen Introducción: los pseudoquistes pancreáticos pueden ser drenados por métodos quirúrgicos, laparoscópicos, percutáneos y endoscópicos. Este último es el más aceptado en la actualidad dado que es más simple y genera menos morbimortalidad; sin embargo, siempre se ha descrito asociado con el uso de la fluoroscopia, lo cual le suma complejidad. En este trabajo presentamos nuestra técnica de drenaje sin fluoroscopia guiado por ecoendoscopia. Materiales y métodos: el objetivo de este trabajo es describir una técnica de drenaje de pseudoquistes pancreáticos sin el uso de fluoroscopia y con la guía del ecoendoscopio. Se reporta una serie de casos de 10 pacientes a quienes se les realizó drenaje transgástrico, en los que se describen la técnica, complicaciones y resultados en el seguimiento. Resultados: se incluyeron 10 pacientes consecutivos, 5 pacientes eran mujeres y 5 hombres. El 90% de los casos comprometía el cuerpo del páncreas. Se implantó exitosamente 1 stent (metálico) transmural (cistogastrostomía) solo con guía ecoendoscópica en 9 pacientes; en 1 paciente no se logró liberar el stent, por lo cual se realizó el drenaje por aspiración. Los 9 pacientes a quienes se les implantó stent no presentaron recidiva; la paciente a quien se realizó drenaje por aspiración presentó recidiva a nivel del cuerpo de páncreas. La principal complicación fue la migración del stent hacia la cavidad del pseudoquiste en 1 paciente, el cual requirió segundo tiempo endoscópico para retirarlo. Conclusiones: el drenaje transmural del pseudoquiste pancreático con implante de stent es una técnica mínimamente invasiva, segura y efectiva para el tratamiento del pseudoquiste pancreático.

Abstract Introduction: Pancreatic pseudocysts can be drained by surgical, laparoscopic, percutaneous, and endoscopic methods. Endoscopic methods have become the most widely accepted nowadays since they are simpler and generate less morbidity and mortality. They have always been associated with the use of fluoroscopy, which adds complexity. This study presents our drainage technique which is guided by echoendoscopy rather than fluoroscopy. Materials and methods: The objective of this study is to describe a technique for drainage of pancreatic pseudocysts which does not use fluoroscopy to guide the endoscope. Instead, echoendoscopy guides the instrument. We report a case series of 10 patients who underwent transgastric drainage and describe the technique, complications and results during follow-up. Results: Ten consecutive patients, five women and five men, were included in this study. Ninety percent were cases in which the body of the pancreas had been compromised. Cystogastrostomy was successfully performed in nine patients. It consisted of implantation of a transmural metallic stent under single endoscopic guidance. In one patient the stent was not released and aspiration drainage was performed. The nine patients who had stents implanted have presented no recurrences, but the patient who underwent aspiration drainage presented recurrence in the body of the pancreas. The main complication was migration of the stent into the pseudocyst cavity which occurred in one patient and which required a second endoscopic procedure to remove the stent. Conclusions: Transmural drainage of pancreatic pseudocysts through placement of stents is a safe, effective and minimally invasive technique for the treatment of pancreatic pseudocysts.

Déficit de vitamina B 12 asociado con el consumo de inhibidores de la bomba de protones / Vitamin B 12 Deficiency Associated with Consumption of Proton Pump Inhibitors

Resumen Introducción: la deficiencia de vitamina B12 se ha relacionado con el consumo crónico de inhibidores de la bomba de protones (IBP). El objetivo del estudio es determinar los niveles séricos de vitamina B12 en pacientes en tratamiento con un inhibidor de la bomba de protones y describir los niveles de vitamina B12 de acuerdo con el tipo de IBP, el tiempo de uso, la dosis, la edad y el sexo. Materiales y métodos: se incluyeron pacientes mayores de 18 años que acudieron a la consulta externa del servicio de gastroenterología de la Clínica Fundadores, institución de tercer nivel, con diagnóstico de enfermedad gastrointestinal y consumo de IBP. Se determinaron los niveles de vitamina B12. La información recolectada fue descrita y analizada mediante técnicas estadísticas convencionales, con análisis estratificado según variables. Resultados: se reclutaron 109 pacientes, el 78,9% de ellos eran mujeres. La edad promedio fue de 58,9 años. Los pacientes en tratamiento con IBP durante >3 años tuvieron niveles de vitamina B12 significativamente más bajos comparados con el grupo ≤3 años (p = 0,022). No se encontró diferencia estadísticamente significativa de acuerdo con el tipo de IBP (p = 0,881; p = 0,098 y p = 0,131 para esomeprazol, omeprazol y lansoprazol, respectivamente), la edad (p = 0,937) y el sexo (p = 0,519). Conclusiones: el consumo de IBP durante >3 años se relaciona con una disminución en los niveles séricos de vitamina B12. La edad, el sexo, el tipo de IBP y la dosis utilizada no son factores independientes relacionados con esta disminución.

Abstract Introduction: Vitamin B12 deficiencies have been linked to chronic consumption of proton pump inhibitors (PPIs). The aim of the study is to determine serum levels of vitamin B12 in patients receiving proton pump inhibitors and to describe vitamin B12 levels according to type of PPI, time of use, dosage, patient age and patient gender. Materials and methods: Patients older than 18 years of age at the outpatient clinic of the gastroenterology department of Clínica Fundadores (a third-level institution) who had been diagnosed with gastrointestinal disease and who took PPIs were included. Vitamin B12 levels were determined. The collected information was described and analyzed using conventional statistical techniques with analysis stratified according to variables. Results: One hundred nine patients were recruited, 78.9% were women, and the average age was 58.9 years. Patients who had been treated with PPIs for more than three years had significantly lower vitamin B12 levels than did patients who had been treated for less than three years (p = 0.022). No statistically significant differences were found according to the type of PPI (p = 0.881 for Esomeprazole, p = 0.098 for Omeprazole, and p = 0.131 for Lansoprazole), age (p = 0.937) or gender (p = 0.519). Conclusions: Using PPIs for more than three years is related to decreased serum levels of vitamin B12. The age, gender, type of PPI and dosage used are not independent factors related to these decreases.

Sangrado del intestino delgado: enfoque y tratamiento / Small Bowel Bleeding: Approach and Treatment

Resumen Actualmente, se pueden identificar lesiones del intestino delgado que antes eran inaccesibles. La principal herramienta diagnóstica es la videocápsula endoscópica por el alto valor predictivo negativo. Con los avances en los métodos endoscópicos, la clasificación del sangrado gastrointestinal ha cambiado. Es así como la definición del sangrado oscuro, que antes incluía al originado en el intestino delgado, se ha relegado cuando su origen no se puede identificar tras la realización de una esofagogastroduodenoscopia, colonoscopia y estudios del tracto digestivo medio, tales como videocápsula endoscópica, enteroscopia de empuje, enteroscopia profunda, enteroscopia intraoperatoria, enterorresonancia, enterotomografía, angiografía y gammagrafía.

Abstract Intestinal lesions that were previously inaccessible can now be identified. The most important new diagnostic tool is the endoscopic videocapsule because of its high negative predictive value. With advances in endoscopic methods, the classification of gastrointestinal bleeding has changed so that definition of occult and obscure bleeding that previously included bleeding originating in the small intestine has been relegated to cases for which the origin cannot be identified after performing esophagogastroduodenoscopy, colonoscopy and studies of the middle digestive tract such as endoscopic videocapsule, push enteroscopy, deep enteroscopy , intraoperative enteroscopy, MRI enterography, CT enterography, angiography and scintigraphy.