The most appropriate diagnostic test is a repeat upper endoscopy. The underlying cause of obscure gastrointestinal bleeding can often be found by repeating upper endoscopy or colonoscopy. Approximately 30% to 50% of lesions can be detected using this approach. Bleeding sources found by these modalities include Cameron ulcerations in a hiatal hernia, bleeding colonic diverticula, and vascular lesions. This patient had an initial upper endoscopy that showed a hiatal hernia and old blood in the stomach. She also reported dark stools, which suggests an upper gastrointestinal bleeding source. She subsequently had a colonoscopy with normal results. Her large hiatal hernia and old blood in the stomach are clues that she may have chronic bleeding from within the hiatal hernia. Cameron ulcerations are linear gastric erosions found within a hiatal hernia. These erosions have been associated with both iron deficiency anemia and acute and chronic blood loss. Repeating the upper endoscopy will allow re-evaluation of the hiatal hernia and the possible diagnosis of Cameron erosions.
Push enteroscopy and balloon enteroscopy are used for evaluating and treating a small-bowel source of bleeding. The clues of a hiatal hernia and blood in the stomach support upper endoscopy as a higher-yield test to perform next.
Intraoperative endoscopy is generally employed only as a last resort for the evaluation of obscure gastrointestinal bleeding. The patient undergoes laparotomy or laparoscopy, and the bowel is evaluated with a colonoscope following surgical enterotomy. This technique should only be used if other less invasive options have been exhausted or if a patient has unexplained, life-threatening bleeding. In addition, the yield is somewhat low (approximately 25%).
A repeat colonoscopy would not be as helpful as a repeat upper endoscopy because this patient has clues to an upper gastrointestinal bleeding source (hiatal hernia, blood in the stomach, and dark stools).