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Anemia due to blood loss in obscure intestinal bleeding

Short summary

43 years old patient without any notable pathologies in anamnesis. After two episodes of severe hematochezia the patient underwent EGD, Colonoscopy, digestive system X-rays with contrast medium and capsule endoscopy camera (digestive system micro camera) without any pathological evidences

Patient's questions

1. What are the diagnostic hypothesis you suggest?

2. Any further diagnostic strategies?

3. Do you share the indication of arteriography?

4. Other suggestions?

Medical Background

43 years old patient without any notable pathologies in anamnesis.
Two episodes of severe hematochezia occurred after 3-4 months from one another with total loss of 4-5 grams of hemoglobin.
The following medical tests were carried out with the motivation of hematochezia due to obscure intestinal bleeding:
-EGD (esophagogastroduodenoscopy): within normal limits.
-Colonscopy: within normal limits.

Besides those examinations, we have the medical report of which, the patient tells he underwent also digestive system X-rays with contrast medium and capsule endoscopy camera (digestive system micro camera) without any pathological evidences.
Therefore, at any next episodes, it was deemed it necessary to proceed with carrying out an arteriography with contrast medium during the bleeding episode.

Medical opinion

The patient is presented for consideration of diagnostic strategies for his anemia. This 43 year old male has had two episodes of hematochezia in a 4 month period and lost 4-5 grams of hemoglobin. He has undergone EDG, colonoscopy and video endoscopy. No site of bleeding was found. He apparently also had conventional GI tract X-rays (UGI Series and Barium enema?) which were unrevealing.

I have summarized all the information I have about this patient. One crucial detail I don't know is how long after the hematochezia were the various studies performed: obviously if they were not done at the time of the bleeding the tests might well not reveal anything. Unfortunately this problem is common here in our Hematology Clinic and we don't have any novel diagnostic approaches. We carry a number of patients along in the clinic who simply submit to regular checks of their hemoglobin and ferritin and they are periodically given intravenous iron if they can't keep up their ferritin using oral iron supplements.
Diverticular disease would probably be the most common cause for hematochezia in our clinic. Internal hemorrhoids would be second (especially if the imaging was done after the bleeding stopped).

We tend to think these chronic bleeders who don't have one of the above causes for hemotchezia have a small area of angioectasia somewhere along the GI tract that could be missed by the above studies. As you probably know, angioectasia is sometimes associated with aortic stenosis; does he have a murmur? One variant of that would he hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome).

There is always the worry that they have some malignancy in the small bowel (sarcoma, lymphoma or adenocarcinoma) that cannot be appreciated by any of the above tests. Weight loss and pain might be clues and if these symptoms are present, the next step would be a CT scan with oral and iv contrast.
If the above studies were not done while he was actively bleeding, I would first repeat them when he has his next bleed. If he really has hematochezia, I'd start with the colonoscopy. There has to be blood mixed with stool that is visible, not just a guaiac-positive stool that is dark, before redoing these studies
Arteriography isn't going to be helpful unless he is bleeding briskly--your radiologists/angiographers can tell you, based on their experience, how fast the bleeding must be to see on angiogram.

Questions (In summary)-
1. Diagnostic hypotheses: diverticular disease, occult hemorrhoids, angioectasia, hereditary hemorrhagic telangiectasias.
2. Further studies would include a CT scan with oral and IV contrast
3. I would agree with arteriography as a last resort, but only if he's bleeding fast enough.
4. At least up until now at this clinic, we have been content to simply support these patients with blood and iron and not resort to exploratory laparotomies, unless a case can be made for the presence of a tumor.