Small Intestinal Bleeding

Small Intestinal Bleeding, Small Intestine Bleeding, Small Bowel Bleeding, Obscure Gastrointestinal Bleeding

Age <30 years old
1. Meckel's Diverticulum
2. Inflammatory Bowel Disease
3. Long Distance Running
Age 30-60 years old
1. Vascular tumor (GIST, Carcinoid)
2. Inflammatory Bowel Disease
3. Celiac Disease
4. NSAID-Induced Ulcer
Age >60 years old
1. Vascular tumor (GIST, Carcinoid)
2. Arteriovenous Malformation
3. NSAID-Induced Ulcer
References
1. Loftus (2012) Mayo POIM Conference, Rochester

First-line evaluation of Small Intestinal Bleeding
1. Video Capsule Endoscopy
  1. Identifies Arteriovenous Malformations with Clinically Significant recurrent bleeding
  2. Costamagna (2002) Gastroenterology 123:999-1005 [PubMed]
2. CT Enterography or CT with IV Contrast
  1. Best detects vascular tumors and should be a first-line study
  2. Loftus (2012) Mayo POIM Conference, Rochester
Second-line evaluation of Small Intestinal Bleeding
1. Endoscopy
  1. Deep enteroscopy can reach the distal Small Bowel
  2. Push enteroscopy (longer upper endoscope) reaches proximal jejunum
  3. Sonde enteroscopy (small caliber tube via nose)
  4. Intraoperative enteroscopy (during laparotomy)
Third-line evaluation of Small Intestinal Bleeding
1. Surgical exploration
2. Mesenteric angiography (celiac and mesenterics)
  1. Helpful in brisk Gastrointestinal Bleeding
Low yield tests in identifying bleeding site
1. Small Bowel follow through with enteroclysis
  1. Does not identify mucosal lesions
2. Double-contrast Barium Enema
  1. Indicated only in suboptimal Colonoscopy
3. Tagged Red Blood Cell Scan
  1. Requires brisk bleeding (high False Negative Rate)
  2. May inaccurately localize lesion