Gastrointestinal Bleeding, Small Bowel

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