Hemostasis of Acute Small Intestinal Bleeding

  • Klaus MönkemüllerEmail author
  • C. Mel Wilcox
  • Shajan Peter


Deep enteroscopy has increased our ability to diagnose, treat, and palliate small intestinal causes of gastrointestinal (GI) bleeding. The therapeutic interventions for small bowel bleeding depend on the etiology, size, and location of the lesions and include primarily injection therapies, thermal coagulation, clip placement, or any combination thereof. Important differences in endoscopic approach exist when treating small bowel bleeding relative to other parts of the GI tract. First, the small bowel is long and tortuous, often making it challenging to obtain a satisfactory endoscopic position to target the lesion of interest. Advanced endoscopic skills are mandatory to maneuver the enteroscope through the small bowel. Second, the wall of the small intestine is thin. Therefore, particular attention is required during injection and/or application of noncontact or contact thermal therapies, such as argon plasma or bipolar coagulation. Third, passage and utilization of available hemostatic tools during deep enteroscopy can be difficult. The proceduralist treating small bowel bleeding disorders should be versed in advanced endoscopic techniques, be familiar with devices available for therapeutic enteroscopy, and be able to improvise and troubleshoot during challenging enteroscopic procedures.


Enteroscopy Therapeutic enteroscopy Deep enteroscopy Obscure gastrointestinal bleeding Hemostasis 

Supplementary material

Video 14.1

Enteroscopic management of a jejunal Dieulafoy lesion (MP4 60827 kb)

Video 14.2

Enteroscopic management of a bleeding jejunal diverticulum (MP4 30656 kb)

Video 14.3

Enteroscopic management of an actively bleeding jejunal vascular ectasia (MP4 32093 kb)


  1. 1.
    Raju GS, Gerson L, Das A, Lewis B, American Gastroenterological Association. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology. 2007;133:1697–717.CrossRefPubMedGoogle Scholar
  2. 2.
    Fry LC, Bellutti M, Neumann H, Malfertheiner P, Mönkemüller K. 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;29:342–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Mönkemüller K, Weigt J, Treiber G, et al. Diagnostic and therapeutic impact of double-balloon enteroscopy. Endoscopy. 2006;38:67–72.CrossRefPubMedGoogle Scholar
  4. 4.
    Xin L, Liao Z, Jiang YP, Li ZS. 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;74:563–70.CrossRefPubMedGoogle Scholar
  5. 5.
    Mönkemüller K, Bellutti M, Fry LC, Malfertheiner P. Enteroscopy. Best Pract Res Clin Gastroenterol. 2008;22:789–811.CrossRefPubMedGoogle Scholar
  6. 6.
    Mönkemüller K, Neumann H, Meyer F, Kuhn R, Malfertheiner P, Fry LC. A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding. Endoscopy. 2009;41:715–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Buscaglia JM, Okolo 3rd PI. Deep enteroscopy: training, indications, and the endoscopic technique. Gastrointest Endosc. 2011;73:1023–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Mönkemüller K, Neumann H, Fry LC. Middle-gastrointestinal bleeding (MGIB). In: Mönkemüller K, Wilcox CM, Munoz-Navas M, editors. Interventional and therapeutic gatsrointestinal endoscopy, Frontiers of gastrointestinal research, vol. 27. Basel: Karger; 2010. p. 221–39.CrossRefGoogle Scholar
  9. 9.
    Mönkemüller K, Fry LC, Bellutti M, Malfertheiner P. Balloon-assisted enteroscopy: unifying double-balloon and single-balloon enteroscopy. Endoscopy. 2008;40:537.CrossRefPubMedGoogle Scholar
  10. 10.
    Samaha E, Rahmi G, Landi B, et al. Long-term outcome of patients treated with double balloon enteroscopy for small bowel vascular lesions. Am J Gastroenterol. 2012;107:240–6.CrossRefPubMedGoogle Scholar
  11. 11.
    May A, Friesing-Sosnik T, Manner H, Pohl J, Ell C. Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding. Endoscopy. 2011;43:759–65.CrossRefPubMedGoogle Scholar
  12. 12.
    Fujita M, Manabe N, Honda K, et al. Long-term outcome after double-balloon endoscopy in patients with obscure gastrointestinal bleeding. Digestion. 2010;82:173–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Shinozaki S, Yamamoto H, Yano T, et al. Long-term outcome of patients with obscure gastrointestinal bleeding investigated by double-balloon endoscopy. Clin Gastroenterol Hepatol. 2010;8:151–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Gerson LB, Batenic MA, Newsom SL, Ross A, Semrad CE. Long-term outcomes after double-balloon enteroscopy for obscure gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2009;7:664–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Arakawa D, Ohmiya N, Nakamura M, et al. Outcome after enteroscopy for patients with obscure GI bleeding: diagnostic comparison between double-balloon endoscopy and video capsule endoscopy. Gastrointest Endosc. 2009;69:866–74.CrossRefPubMedGoogle Scholar
  16. 16.
    Hindryckx P, Botelberge T, De Vos M, De Looze D. Clinical impact of capsule endoscopy on further strategy and long-term clinical outcome in patients with obscure bleeding. Gastrointest Endosc. 2008;68:98–104.CrossRefPubMedGoogle Scholar
  17. 17.
    Albert JG, Schulbe R, Hahn L, et al. Impact of capsule endoscopy on outcome in mid-intestinal bleeding: a multicentre cohort study in 285 patients. Eur J Gastroenterol Hepatol. 2008;20:971–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Madisch A, Schmolders J, Bruckner S, Aust D, Miehlke S. Less favorable clinical outcome after diagnostic and interventional double balloon enteroscopy in patients with suspected small-bowel bleeding? Endoscopy. 2008;40:731–4.CrossRefPubMedGoogle Scholar
  19. 19.
    Zhong J, Ma T, Zhang C, Sun B, Chen S, Cao Y, Wu Y. A retrospective study of the application on double-balloon enteroscopy in 378 patients with suspected small-bowel diseases. Endoscopy. 2007;39:208–15.CrossRefPubMedGoogle Scholar
  20. 20.
    Ohmiya N, Yano T, Yamamoto H, et al. Diagnosis and treatment of obscure GI bleeding at double balloon endoscopy. Gastrointest Endosc. 2007;66:S72–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Hsu CM, Chiu CT, Su MY, Lin WP, Chen PC, Chen CH. The outcome assessment of double-balloon enteroscopy for diagnosing and managing patients with obscure gastrointestinal bleeding. Dig Dis Sci. 2007;52:162–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Sun B, Rajan E, Cheng S, et al. Diagnostic yield and therapeutic impact of double-balloon enteroscopy in a large cohort of patients with obscure gastrointestinal bleeding. Am J Gastroenterol. 2006;101:2011–5.CrossRefPubMedGoogle Scholar
  23. 23.
    Fry LC, Neumann H, Jovanovic I, Malfertheiner P, Mönkemüller K. Capsule endoscopy increases the diagnostic yield of double balloon enteroscopy in patients being investigated for obscure gastrointestinal bleeding. Arch Gastroenterol Hepatol. 2012;29:9–15.Google Scholar
  24. 24.
    Jovanovic I, Vormbrock K, Zimmermann DS, Ugljesic M, Malfertheiner P, Fry LC, Mönkemüller K. Therapeutic small bowel endoscopy: a binational, three-center experience. Dig Dis. 2011;29:27–31.CrossRefPubMedGoogle Scholar
  25. 25.
    Schäfer C, Stange EF. Therapeutic possibilities with DBE: a focus on accessories. Tech Gastrointest Endosc. 2008;10:70–6.CrossRefGoogle Scholar
  26. 26.
    Yen HH, Chen YY, Su WW, Soon MS, Lin YM. Intestinal necrosis as a complication of epinephrine injection therapy during double-balloon enteroscopy. Endoscopy. 2006;38:542.CrossRefPubMedGoogle Scholar
  27. 27.
    Gubler C, Glenck M, Pfammatter T, Bauerfeind P. Successful treatment of anastomotic jejunal varices with N-butyl-2-cyanoacrylate (Histoacryl): single-center experience. Endoscopy. 2012;44:776–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Mensink PB, Haringsma J, Kucharzik T, Cellier C, Pérez-Cuadrado E, Mönkemüller K, Gasbarrini A, Kaffes AJ, Nakamura K, Yen HH, Yamamoto H. Complications of double balloon enteroscopy: a multicenter survey. Endoscopy. 2007;39:613–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Klaus Mönkemüller
    • 1
    Email author
  • C. Mel Wilcox
    • 1
  • Shajan Peter
    • 1
  1. 1.Division of Gastroenterology and HepatologyBasil Hirschowitz Endoscopic Center of Excellence, University of Alabama at BirminghamBirminghamUSA

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