A patient comes with hematemesis and malena. On the upper GI endoscopy there was no significant finding. 2-days later the patient rebleeds. Next line of investigation is
**Core Concept**
Upper GI bleeding can be due to several causes, including peptic ulcer disease, varices, and Dieulafoff's lesions. However, in cases where initial endoscopy is negative, but rebleeding occurs, a more sensitive investigation is required to identify the source of bleeding.
**Why the Correct Answer is Right**
The next line of investigation in such cases is a **mesenteric angiogram**. This is because angiography is more sensitive than endoscopy in detecting active bleeding, especially in cases of Dieulafoff's lesions or other non-visualized lesions. The angiogram can also be used to selectively embolize the bleeding vessel, thereby controlling the bleeding.
**Why Each Wrong Option is Incorrect**
**Option A:** **CT angiogram** can be used in some cases, but it is not as sensitive as conventional angiogram in detecting active bleeding. It is also not suitable for therapeutic embolization.
**Option B:** **Repeat endoscopy** may not be helpful if the initial endoscopy was negative, as the source of bleeding may not be visualized even with repeated attempts.
**Option C:** **Capsule endoscopy** is not suitable for detecting acute bleeding, as it relies on the capsule passing through the GI tract and does not provide real-time imaging.
**Option D:** **MRI** is not typically used in the acute management of GI bleeding.
**Clinical Pearl / High-Yield Fact**
Remember that the sensitivity of endoscopy is limited in detecting active bleeding, and a negative endoscopy does not rule out the possibility of a bleeding lesion. In such cases, a more sensitive investigation like angiography is required to identify the source of bleeding.
**Correct Answer:** C. Capsule endoscopy is not suitable for detecting acute bleeding, as it relies on the capsule passing through the GI tract and does not provide real-time imaging.