OCTREOTIDE-LAR IN OVERT OBSCURE GI BLEED (OOGIB)

OCTREOTIDE-LAR IN OVERT OBSCURE GI BLEED (OOGIB)
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Overt Obscure gastrointestinal bleeding (OOGIB) is defined as bleeding from the gastrointestinal tract that persists or recurs after a initial evaluation using bidirectional endoscopy and radiologic imaging with small-bowel radiograph. Diagnosis of OOGIB may include angiography (a procedure that involves injecting contrast dye into blood vessels to identify the source of bleeding), capsule endoscopy (a procedure that involves swallowing a camera capsule that takes pictures of the digestive tract) or double balloon endoscopy. Treatment options depends on the location and severity of the bleeding and may include medications, endoscopic procedures and surgeries.

Etiology:

The most common causes of OOGIB:

  1. Angiodysplasia: The blood vessels become fragile and prone to bleeding.
  2. Inflammatory bowel disease (IBD): Crohn’s disease and ulcerative colitis are types of IBD that can cause inflammation and ulcers in the digestive tract, which can lead to bleeding.
  3. Tumors: Cancerous or noncancerous tumors in the digestive tract can cause bleeding.
  4. Meckel’s diverticulum: A pouch that protrudes from the wall of the small intestine.
  5. Radiation enteritis: This is a condition in which radiation therapy for cancer damages the lining of the digestive tract, leading to bleeding.
  6. Polyps: Small growths on the lining of the colon or rectum can sometimes bleed.
  7. Medications: Certain medications, such as blood thinners and nonsteroidal anti-inflammatory drugs (NSAIDs), can increase the risk of GI bleeding.
  8. Others vascular malformations, ischemic colitis, and diverticulitis.

In the elderly age group, small bowel bleeds are usually attributed to vascular lesions, like angioectasia, with vascular lesions making up 30-40% of bleeding in the small bowel in all age groups.

OCTREOTIDE – LAR

Octreotide LAR (Long Acting Release) belongs to a class of drugs called somatostatin analogs. It works by suppresses the secretion of growth hormones, thyrotropin from the anterior pituitary gland, in addition to decreasing the release of certain pancreatic islet cell hormones such as insulin, glucagon and vasoactive peptide(VIP). It is used to treat a variety of medical conditions, including acromegaly (a condition in which the body produces too much growth hormone), severe diarrhea and flushing caused by certain types of tumors (e.g.carcinoid tumors), and certain types of pancreatic tumors.

Current studies says that Octreotide LAR is an effective therapy in the management of overt obscure gastrointestinal bleeding (OGIB) in certain cases. It works by reducing the blood flow to the digestive tract, which can help to stop or slow down bleeding. It can also decrease the secretion of acid and digestive enzymes, which can help to reduce irritation and inflammation in the digestive tract. This plays a role in gastrointestinal bleeding by augmenting platelet aggregation, decreasing splanchnic blood flow, and antagonizing angiogenesis by suppressing VEGF production.

Octreotide lar is usually given by injection into a muscle every 2 to 4 weeks, depending on the condition being treated and the patient’s response to the medication. Common side effects of octreotide lar include injection site reactions, gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea), and changes in blood glucose levels.

Studies have shown that octreotide LAR may be effective in reducing the frequency and severity of bleeding episodes in patients with OGIB. However, it is not always effective and may not be appropriate for all patients. Recently, octreotide has been shown to be an effective therapy in treating GI bleeding in patients with poor responses to endoscopic interventions or surgeries.

bP value for reduction of transfusions.

cP value for reduction of hemoglobin levels.

1{Loyaga-Rendon, 2015 #34}: 17 patients (70%) did not require blood transfusions while on treatment. However, 7 patients still required blood transfusions.

N/A: Not applicable; SD: Standard deviation.

This paper aims to elucidate the role of Octreotide – LAR in treating small bowel bleeding with different diseases and presentations.

Case Series:

Mr. X, 80 years old male admitted with complaints of melena and anemia. Medical history included aortic stenosis, treated by aortic valve replacement. He had past history of caecal angioectasia for which hemoclipping & argon plasma coagulation was done, hence the condition is associated with Heyde’s syndrome. In the current admission, his endoscopy and colonoscopy was normal without any obvious bleed lesions. Capsule endoscopy showed diffuse angioectasia in mid jejunum. Then he was advised for spiral enteroscopy with further intervention. Because of the medical co-morbidities and recurrent bleeding, rescue treatment was started with octreotide – LAR 30mg intramuscularly once a month. He was under followup. His blood transfusion requirement was nill after starting therapy. His stool occult blood became negative after 3rd dose. He was conservatively managed with parentral iron supplements along with octreotide – LAR, in order to avoid oral iron related discoloration of stool.

Mr. X, 75 years old male, presented with history of hematochezia for 3 days. Medical history included coronary artery disease for which he is on antiplatelets for several years. He is known case of carcinoma of right breast – S/P left modified radical mastectomy and on oral chemotherapy. He has pancytopenia which is induced by chemotherapy. Endoscopy and colonoscopy showed no obvious bleed lesions. Capsule endoscopy showed bleed from ampulla intermittently after prolonged stay of capsule at D2 and diagnosed as ampullary bleed. CT abdomen angiogram done showed no obvious lesion in liver or pancreas & bile duct or contrast extravasation at the time of study. Then, he was started with octreotide – LAR 30mg intramuscularly once a month. After 2 week, on OPD basis he was on followup with no complaints of hematechezia  and his hemoglobin remained stable(….).

A  67 years old female is case of Left Carcinoma of breast stage IV – on chemotherapy – Denosumab – came with complaints of melena for 20 days. Her hemoglobin was 5.9 gms/dl and stool occult blood was positive. History showed that her hemoglobin was grossly dropped from 11.1 gms/dl to 9.3 gms/dl within one month. And further dropped to 5.9 gms/dl within 20 days. She was planned for endoscopy which showed severe Gastric Antral Vascular Angioectasia (GAVE) and planned for Argon Plasma Coagulation (APC). As a complete of the study, her colonoscopy was normal upto terminal ileum. After 1 unit of PRBC transfusion, APC was done along the GAVE and Adrenaline therapy was done along multiple superficial ulcers in D2. After the endoscopic interventions, she was conservatively managed with octreotide- LAR 30 mg intramuscularly once a month. Portal venous doppler  showed normal portal venous flow, no thrombus seen in IVC. After 2 weeks, her stool occult blood was negative and hemoglobin remains stable(…).

A 54 years years old male is known case of carcinoma in head of pancreas with metastases – on chemotherapy for 6 months. Medical history included Diabetes mellitus and Systemic hypertension on medications. Surgical history included posterior Gastro- Jejunostomy status. He has presented with complaints of melena on & off for 3 months. History of progressive anemia for 3 months which was conservatively managed with blood transfusion and iron therapies. Endoscopy showed severe Portal hypertensive duodenopathy and gastropathy, Tumor infiltration into duodenal bulb for which APC was done. Incidentally, esophageal varices were noted with no RCS which can be a complication of liver metastases. Then, he was conservatively managed with Octreotide – LAR 30 mg intramuscularly stat. After 2 weeks, his stool color were changed and occult blood was not detected.

A 63 Years old male is case of Hepatic flexure growth – S/P right hemicolectomy status. Medical history included Systemic Hypertension, coronary artery disease – post  PTCA status. Patient has to be in anti-platelets mandatory. After 3 months from hemicolectomy status, he has complaints of melena with hemoglobin drop. Colonoscopy showed Ileo-colic anastamosis site was erythematous. Scope negotiated beyond easily. Using 23G-EST needle, adrenaline (1:10,000) injected submucosally around the anastamotic site to raise a wheal. Using IT- knife,

stricturotomy done at 12, 5 & 7’O clock position and hemoclips were placed at the stricturotomy region. He kept under followup for 1 week, but his stool for occult blood was positive and hemoglobin was dropped (7.8 gms%). Then he was treated with octreotide- LAR 30 mg intramuscularly stat once a month. After 2 weeks, his stool occult blood was negative and Hemoglobin is 7.4 gms%. Then, He was conservatively managed with parentral iron supplements along with octreotide – LAR, in order to avoid oral iron related discoloration of stool.

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Dr. S. Vadivel Kumaran
Senior Consultant Gastroenterologist
Kauvery Hospital Chennai

Miss.Kiruba Nandhini

Miss. Kiruba Nandhini
Physician Assistant
Kauvery Hospital Chennai