Clin Endosc.  2023 May;56(3):283-289. 10.5946/ce.2022.302.

A practical approach for small bowel bleeding

• Kim SE
• Kim HJ
• Koh M
• Kim MC
• Kim JS
• Nam JH
• Cho YK
• Choe AR
• The Research Group for Capsule Endoscopy and Enteroscopy of the Korean Society of Gastrointestinal Endoscopy

• KMID: 2542453
• DOI: http://doi.org/10.5946/ce.2022.302

Abstract

Gastrointestinal (GI) bleeding is one of the most common conditions among patients visiting emergency departments in Korea. GI bleeding is divided into upper and lower GI bleeding, according to the bleeding site. GI bleeding is also divided into overt and occult GI bleeding based on bleeding characteristics. In addition, obscure GI bleeding refers to recurrent or persistent GI bleeding from a source that cannot be identified after esophagogastroduodenoscopy or colonoscopy. The small intestine is the largest part of the alimentary tract. It extends from the pylorus to the cecum. The small intestine is difficult to access owing to its long length. Moreover, it is not fixed to the abdominal cavity. When hemorrhage occurs in the small intestine, the source cannot be found in many cases because of the characteristics of the small intestine. In practice, small-intestinal bleeding accounts for most of the obscure GI bleeding. Therefore, in this review, we introduce and describe systemic approaches and examination methods, including video capsule endoscopy and balloon enteroscopy, that can be performed in patients with suspected small bowel bleeding in clinical practice.

Keyword

Balloon enteroscopy; Capsule endoscopy; Hemorrhage; Intestine, small

Figure

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  Fig. 1. Management algorithm for suspected small bowel bleeding. EGD, esophagogastroduodenoscopy; CT, computed tomography; VCE, video capsule endoscopy; DAE, device-assisted enteroscopy.

Reference

1. Saltzman JR. Burden and costs of gastrointestinal disease in the U.S. [Internet]. US: NEJM Journal Watch;2018. [cited 2022 Aug 26]. Available from: https://www.jwatch.org/na47723/2018/10/23/burden-and-costs-gastrointestinal-disease-us/.

2. Raju GS, Gerson L, Das A, et al. American Gastroenterological Association (AGA) institute technical review on obscure gastrointestinal bleeding. Gastroenterology. 2007; 133:1697–1717.

3. Gerson LB, Fidler JL, Cave DR, et al. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol. 2015; 110:1265–1287.

4. Pasha SF, Leighton JA, Das A, et al. Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis. Clin Gastroenterol Hepatol. 2008; 6:671–676.

5. Havlichek DH, Kamboj AK, Leggett CL. A practical guide to the evaluation of small bowel bleeding. Mayo Clin Proc. 2022; 97:146–153.

6. Lee YK, Oh TK, Choi A, et al. A case of Henoch Schoenlein purpura with gastrointestinal bleeding due to jejunal ulcer by capsule endoscopy. Kosin Med J. 2012; 27:45–49.

7. Yoo AY, Lee BJ, Kim WS, et al. Clinicopathological features of small bowel tumors diagnosed by video capsule endoscopy and balloon-assisted enteroscopy: a single center experience. Clin Endosc. 2021; 54:85–91.

8. Zhu CN, Friedland J, Yan B, et al. Presence of melena in obscure gastrointestinal bleeding predicts bleeding in the proximal small intestine. Dig Dis Sci. 2018; 63:1280–1285.

9. Descamps C, Schmit A, Van Gossum A. "Missed" upper gastrointestinal tract lesions may explain "occult" bleeding. Endoscopy. 1999; 31:452–455.

10. Fry LC, Bellutti M, Neumann H, et al. Incidence of bleeding lesions within reach of conventional upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding. Aliment Pharmacol Ther. 2009; 29:342–349.

11. Lara LF, Bloomfeld RS, Pineau BC. The rate of lesions found within reach of esophagogastroduodenoscopy during push enteroscopy depends on the type of obscure gastrointestinal bleeding. Endoscopy. 2005; 37:745–750.

12. Innocenti T, Dragoni G, Roselli J, et al. Non-small-bowel lesions identification by capsule endoscopy: a single centre retrospective study. Clin Res Hepatol Gastroenterol. 2021; 45:101409.

13. Ilangovan R, Burling D, George A, et al. CT enterography: review of technique and practical tips. Br J Radiol. 2012; 85:876–886.

14. Deepak P, Pundi KN, Bruining DH, et al. Multiphase computed tomographic enterography: diagnostic yield and efficacy in patients with suspected small bowel bleeding. Mayo Clin Proc Innov Qual Outcomes. 2019; 3:438–447.

15. Wang Z, Chen JQ, Liu JL, et al. CT enterography in obscure gastrointestinal bleeding: a systematic review and meta-analysis. J Med Imaging Radiat Oncol. 2013; 57:263–273.

16. ASGE Technology Committee, Wang A, Banerjee S, et al. Wireless capsule endoscopy. Gastrointest Endosc. 2013; 78:805–815.

17. Abutalib H, Yano T, Shinozaki S, et al. Roles of capsule endoscopy and balloon-assisted enteroscopy in the optimal management of small bowel bleeding. Clin Endosc. 2020; 53:402–409.

18. Elli L, Centorrino E, Costantino A, et al. Capsule enteroscopy versus small-bowel ultrasonography for the detection and differential diagnosis of intestinal diseases. Clin Endosc. 2022; 55:532–539.

19. Cortegoso Valdivia P, Skonieczna-Żydecka K, Elosua A, et al. Indications, detection, completion and retention rates of capsule endoscopy in two decades of use: a systematic review and meta-analysis. Diagnostics (Basel). 2022; 12:1105.

20. Lai LH, Wong GL, Chow DK, et al. Long-term follow-up of patients with obscure gastrointestinal bleeding after negative capsule endoscopy. Am J Gastroenterol. 2006; 101:1224–1228.

21. Estévez E, González-Conde B, Vázquez-Iglesias JL, et al. Diagnostic yield and clinical outcomes after capsule endoscopy in 100 consecutive patients with obscure gastrointestinal bleeding. Eur J Gastroenterol Hepatol. 2006; 18:881–888.

22. Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol. 2005; 100:2407–2418.

23. Teshima CW, Kuipers EJ, van Zanten SV, et al. Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis. J Gastroenterol Hepatol. 2011; 26:796–801.

24. Rezapour M, Amadi C, Gerson LB. Retention associated with video capsule endoscopy: systematic review and meta-analysis. Gastrointest Endosc. 2017; 85:1157–1168.

25. ASGE Technology Committee, DiSario JA, Petersen BT, et al. Enteroscopes. Gastrointest Endosc. 2007; 66:872–880.

26. Linder J, Cheruvattath R, Truss C, et al. Diagnostic yield and clinical implications of push enteroscopy: results from a nonspecialized center. J Clin Gastroenterol. 2002; 35:383–386.

27. Yamamoto H, Kita H, Sunada K, et al. Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol. 2004; 2:1010–1016.

28. May A, Nachbar L, Ell C. Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease. Gastrointest Endosc. 2005; 62:62–70.

29. Brito HP, Ribeiro IB, de Moura DT, et al. Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding: a systematic review and meta-analysis. World J Gastrointest Endosc. 2018; 10:400–421.

30. Xin L, Liao Z, Jiang YP, et al. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use. Gastrointest Endosc. 2011; 74:563–570.