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Small bowel bleeding

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Opinion statement

  • Most patients with small bowel bleeding present with chronic, recurrent, transfusion-dependent, debilitating disease. Less commonly, an acute gastrointestinal bleeding episode with negative upper and lower endoscopic exams may be the initial presentation. Lesions responsible for small bowel bleeding, on the other hand, include arterio-venous malformations, tumors, and ulcers. The treatment options must therefore be directed to the specific cause of bleeding and its mode of presentation (acute versus chronic; intermittent).

  • Treatment before a specific diagnosis has been reached includes blood transfusions as needed, and chronic iron supplementation. Once the diagnosis of arterio-venous malformations has been made, thermal endoscopic therapy (heater probe, bipolar electrocoagulation, argon plasma coagulation, or laser) with or without injection (epinephrine) is the mainstay treatment option. The same option is available for small bowel ulcers that show stigmata of recent bleeding, eg, a non-bleeding visible vessel or adherent clot, or are actively bleeding at the time of enteroscopy. For the patient with a small bowel tumor thought to be responsible for the bleeding, surgical excision or resection is the treatment of choice. The surgical option is also reserved for those patients with diffuse and multiple lesions, and those with lesions beyond the reach of the push enteroscope, which preclude endoscopic therapy. Invasive radiological methods via selective catheterization and vasopressin injection or embolization are reserved for patients with a demonstrable actively bleeding lesion found at the time of the diagnostic work-up, and those who may not be candidates for surgery.

  • For those patients in whom endoscopic therapy or surgery is not amenable (ie, anatomical location, multiple lesions involving several segments of the small bowel), those who are not surgical candidates and those who have recurrent bleeding after repeat endoscopic or surgical therapies, medical therapy with continuous iron supplementation, avoidance of ulcerogenic drugs (eg, NSAIDs) and hormonal therapy (for those with arteriovenous malformations) should be considered.

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References and Recommended Reading

  1. Netaville R, Nardy J, Marton R: Small bowel hemorrhage. Ann Surg 1968, 167:949–991.

    Article  Google Scholar 

  2. Richardson J, McInnis W, Ramos, R, Aust JB: Occult gastrointestinal bleeding. Arch Surg 1975, 110:661–665.

    PubMed  CAS  Google Scholar 

  3. Meyers R: Diagnosis and management of occult gastrointestinal bleeding. Am Surgeon 1976, 42:92–95.

    Google Scholar 

  4. Bowden T, Koohs V, Mansberger A: Intraoperative gastrointestinal endoscopy in the management of occult gastrointestinal bleeding. South Med J 1979, 72:1532–1534.

    PubMed  Google Scholar 

  5. Spiller RC, Parkins RA: Recurrent gastrointestinal bleeding of obscure origin. Report of 17 cases and a guide to logical management. Br J Surg 1983, 70:489–493.

    Article  PubMed  CAS  Google Scholar 

  6. Thompson JN, Slaeim RR, Hemingway AP, et al.: Specialist investigation of obscure gastrointestinal bleeding. Gut 1987, 28:47–51.

    PubMed  CAS  Google Scholar 

  7. Rockey DC, Cello JP: Evaluation of the gastrointestinal tract in patients with iron deficiency anemia. N Engl J Med 1993, 329:1691–1695.

    Article  PubMed  CAS  Google Scholar 

  8. Ramirez FC: Small bowel bleeding. In Gastroenterology and Hepatology-The comprehensive visual reference, vol VII: Small Intestine. Edited by Schiller, L. Philadelphia: Current Medicine; 1997: 9.3–9.18. This is a comprehensive review of small bowel bleeding, which includes natural history, etiology, diagnostic methods, and treatment options for this condition.

    Google Scholar 

  9. Lewis B, Salomon P, Rivera Mac Murray S, et al.: Does hormonal therapy have any benefit for bleeding angiodysplasia? J Clin Gastroenterol 1992, 15:99–103. Available reported data on the effects of malformations as a cause of small bowel bleeding.

    Article  PubMed  CAS  Google Scholar 

  10. Van Custem E, Rutgeert P, Vantrappen G: Treatment of gastrointestinal vascular malformations with oestrogen-progesterone. Lancet 1990, 335:953–955. Available reported data on the effects of malformations as a cause of small bowel bleeding.

    Article  Google Scholar 

  11. Bronner MH, Pate MB, Cunningham JT, et al.: Estrogenprogesterone therapy for bleeding gastrointestinal telangiectasias in chronic renal failure. Ann Intern Med 1986, 105:371–374. Available reported data on the effects of malformations as a cause of small bowel bleeding.

    PubMed  CAS  Google Scholar 

  12. Barkin JS, Ross BS: Medical therapy for chronic gastrointestinal bleeding of obscure origin. Am J Gastroenterol 1998, 93:1250–1254. Available reported data on the effects of malformations as a cause of small bowel bleeding.

    Article  PubMed  CAS  Google Scholar 

  13. Torsoli A, Annibale B, Viscardi A, et al.: Treatment of bleeding due to diffuse angiodysplasia of the small intestine with somatostatin analogue. Eur J Gastroenterol Hepatol 1991, 3:785–787. Describes the reported effects of octreotide upon small bowel bleeding arising from arteriovenous malformations.

    Google Scholar 

  14. Rossini FP, Arrigoni A, Pennazio M: Octreotide in the treatment of bleeding due to angiodysplasia of the small intestine. Am J Gastroenterol 1993, 8:1424–1427.

    Google Scholar 

  15. Piesseroux M, Conemans G, Rutgeert P, Van Cutsem E: Octreotide in the treatment of bleeding gastrointestinal vascular malformations. Gastroenterology 1995, 110:353. Describes the reported effects of octreotide upon small bowel bleeding arising from arteriovenous malformations.

    Google Scholar 

  16. Woltering E, Barrie R, O’Dorisio T, et al.: Somatostatin analogues inhibit angiogenesis in the chick chorioallantoic membrane. J Surg Res 1991, 50:245–251.

    Article  PubMed  CAS  Google Scholar 

  17. Barrie R, Woltering E, Hajarizadeh H, et al.: Inhibition of angiogenesis by somatostatin and somatostatinlike compounds is structurally dependent. J Surg Res 1993, 55:446–450.

    Article  PubMed  CAS  Google Scholar 

  18. Reubi J, Horisberger U, Laissue J: High density of somatostatin receptors in veins surrounding human cancer tissue: role in tumor-host interaction? Int J Cancer 1994, 56:681–688.

    Article  PubMed  CAS  Google Scholar 

  19. Korzenik J, Topazian M, Burdge C, et al.: Danazol in the treatment of GI hemorrhage secondary to hereditary hemorrhagic telangiectasia (Abstract). Gastroenterology 1995, 108:297. Available reports on the treatment of small bowel arteriovenous malformations with danazol.

    Article  Google Scholar 

  20. Van Cutsem E, Piessevaux H: Pharmacologic therapy of arteriovenous malformations. Gastrointest Endosc Clin N Am 1996, 6:819–832. Available reports on the treatment of small bowel arteriovenous malformations with danazol.

    PubMed  Google Scholar 

  21. Sorbi D, Conio M, Gostout CJ: Vascular disorders of the small bowel. Gastrointest Endosc Clin N Am 1999, 9:71–92. Excellent review of vascular disorders of the small bowel, including arteriovenous malformations. Includes a discussion of the different therapeutic modalities available, endoscopic in particular.

    PubMed  CAS  Google Scholar 

  22. Adrian AL, Krevsky B: Enteroscopy in patients with gastrointestinal bleeding of obscure origin. Dig Dis 1996, 14:345–355.

    Google Scholar 

  23. Foutch PG, Sawyer R, Sanowski RA: Push enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin. Gastrointest Endosc 1990, 36:337–341.

    Article  PubMed  CAS  Google Scholar 

  24. Gostout CJ: Gastrointestinal laser endoscopy-future horizons. Mayo Clin Proc 1990, 65:509–517.

    PubMed  CAS  Google Scholar 

  25. Morris AJ, Mokhashi M, Straiton M, et al.: Push enteroscopy and heater probe therapy for small bowel bleeding. Gastrointest Endosc 1996, 44:394–397.

    Article  PubMed  CAS  Google Scholar 

  26. Askin M, Lewis B: Long-term success of endoscopic cauterization of small intestinal angiodysplasia. Gastrointest Endosc 1996, 43:450.

    Article  Google Scholar 

  27. Swain CP: Therapeutic small bowel endoscopy (Abstract). Gut 1997, 40:A40.

    Google Scholar 

  28. Swain CP: The role of enteroscopy in clinical practice. Gastrointest Endosc Clin N Am 1999, 9:135–144.

    PubMed  CAS  Google Scholar 

  29. Van Gossum A, Schmit A: Enteroscopy and cautery for small intestinal angiodysplasia (letter, comment). Gastrointest Endosc 1997, 45:216–217.

    PubMed  Google Scholar 

  30. Gostout CJ: Enteroscopy for unexplained iron-deficiency anemia: identifying the patient with sprue. Gastrointest Endosc 1993, 39:76–79.

    PubMed  CAS  Google Scholar 

  31. Huilgol V, Harris MS, Vakil N: Enteroscopy: Outcomes. Gastrointest Endosc Clin N Am 1996, 6:811–817. A very important review of the outcome studies pertinent to the role of enteroscopy in the management of patients with small bowel bleeding.

    PubMed  CAS  Google Scholar 

  32. Vakil N, Huilgol V, Khan I: Effect of push enteroscopy on transfusion requirements and quality of life in patients with unexplained gastrointestinal bleeding. Am J Gastroenterol 1997, 92:425–428.

    PubMed  CAS  Google Scholar 

  33. Adrian AL, Dabezies MA, Krevsky B: Enteroscopy improves the clinical outcome in patients with obscure gastrointestinal bleeding. J Laparoendosc Advanc Surg Tech (Part A) 1998, 8:279–284.

    Google Scholar 

  34. Chak A, Cooper GS, Canto MI, et al.: Enteroscopy for the initial evaluation of iron deficiency anemia. Gastrointest Endosc 1998, 47:144–148.

    Article  PubMed  CAS  Google Scholar 

  35. Ress A, Benacci J, Sarr M: Efficacy of intraoperative enteroscopy in diagnosis and prevention of recurrent occult gastrointestinal bleeding. Am J Surg 1992, 163:94–98. Very good paper outlining not only the utility of intraoperative enteroscoppy in the management of small bowel bleeding, but also describing the outcomes of surgical options.

    Article  PubMed  CAS  Google Scholar 

  36. Browder W, Cerise E, Litwin M: Impact of emergency arteriography in massive lower gastrointestinal bleeding. Ann Surg 1986, 204:530–536.

    Article  PubMed  CAS  Google Scholar 

  37. Richter JM, Christensen MR, Colditz GA, et al.: Angiodysplasia: Natural history and efficacy of therapeutic interventions. Dig Dis Sci 1989, 34:1542–1546.

    Article  PubMed  CAS  Google Scholar 

  38. Johnsrude IS, Jackson DC: The role of the radiologist in acute gastrointestinal bleeding. Gastrointest Radiol 1978, 3:357–368. Paper describes the role of invasive radiology in the diagnosis and management of small bowel bleeding. It describes the radiographic techniques for the treatment of bleeding.

    Article  PubMed  CAS  Google Scholar 

  39. Briley Jr., CA, Jackson DC, Johnsrude IS, et al.: Acute gastrointestinal hemorrhage of small bowel origin. Radiology 1980, 136:317–319.

    PubMed  Google Scholar 

  40. Tillotson CL, Geller SC, Kantrowitz L, et al.: Small bowel hemorrhage: angiographic localization and intervention. Gastrointest Radiol 1988, 13:207–211.

    Article  PubMed  CAS  Google Scholar 

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  1. Carl T. Hayden VA Medical Center, 650 E. Indian School Rd., 85012, Phoenix, AZ

    Francisco C. Ramirez MD

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  1. Francisco C. Ramirez MD
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Ramirez, F.C. Small bowel bleeding. Curr Treat Options Gastro 2, 355–362 (1999). https://doi.org/10.1007/s11938-999-0025-2

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  • DOI: https://doi.org/10.1007/s11938-999-0025-2

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