Small bowel bleeding
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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
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