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Key Features

  • Overt small bowel bleeding

    • Refers to patients with melena, maroon stools, or bright red blood per rectum

    • Small bowel bleeding source presumed in up to 5-10% of patients admitted to hospitals with clinically overt gastrointestinal bleeding who do not have a cause identified on upper endoscopy or colonoscopy

    • In up to one-third of cases, a source of bleeding has been overlooked in the upper or lower tract on prior endoscopic studies

  • Occult small bowel bleeding refers to

    • Bleeding that is manifested by recurrent positive fecal occult blood tests (FOBTs) or fecal immunochemical tests (FITs)

    • Recurrent iron deficiency anemia

    • See Gastrointestinal Bleeding, Occult

Clinical Findings

  • The most common causes of small intestinal bleeding in patients under age 40 years are

    • Neoplasms (stromal tumors, lymphomas, adenocarcinomas, carcinoids)

    • Crohn disease

    • Celiac disease

    • Meckel diverticulum

  • While these disorders also occur in patients over age 40, angioectasias and NSAID-induced ulcers are far more common

Diagnosis

  • Evaluation depends on the age and overall health status of the patient, associated symptoms, and severity of the bleeding

  • Upper endoscopy and colonoscopy should be repeated to ascertain that a lesion has not been overlooked

  • If these studies are unrevealing and the patient is hemodynamically stable, capsule endoscopy should be performed to evaluate the small intestine

  • Abdominal CT may be considered to exclude a hepatic or pancreatic source of bleeding

  • CT enterography may be considered if capsule endoscopy is unrevealing since it is more sensitive for the detection of small bowel neoplasms

  • For hemodynamically stable overt bleeding, CT angiography may be useful to localize bleeding site and guide therapeutic interventions (enteroscopy or angiography with embolization)

  • In patients under age 30, a nuclear scan for Meckel diverticulum should be obtained

Treatment

  • Management depends on the capsule endoscopic findings

  • Laparotomy is warranted if a small bowel tumor is identified by capsule endoscopy or radiographic studies

  • With the advent of capsule imaging and advanced endoscopic technologies for evaluating and treating bleeding lesions in the small intestine, intraoperative enteroscopy of the small bowel is seldom required

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