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For further information, see CMDT Part 15-07: Gastrointestinal Bleeding

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-fourth 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

  • Multiphasic CT enterography may be considered if capsule endoscopy is unrevealing since it is more sensitive for the detection of small bowel neoplasms and can exclude hepatic or pancreatic sources of bleeding

  • 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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