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Approach to Suspected Small Intestinal Bleeding

  • Lauren B. GersonEmail author

Abstract

Small intestinal bleeding is uncommon and can present as overt or occult hemorrhage. Video capsule endoscopy (VCE) is recommended as the third diagnostic test after a repeat negative upper and lower endoscopic examination in a patient presenting with overt hemorrhage. Given miss rates of 20–30 % for standard endoscopic examinations, consideration should be made for repeating these procedures, particularly in the setting of suboptimal visualization. In patients who undergo VCE and have abnormal findings detected, deep enteroscopy can be performed with the intent to provide therapy. However, the rebleeding rate for small bowel vascular lesions is significant. In the scenario where the VCE examination is normal, options include repeating the VCE study if the patient rebleeds or consideration for a radiologic examination, such as CT enterography with bleeding protocol. Angiography is generally reserved for patients with suspected small intestinal massive acute bleeding and hemodynamic instability.

This chapter includes supplementary videos.

Keywords

Obscure gastrointestinal bleeding Capsule endoscopy Deep enteroscopy Angiography Computed tomographic enterography 

Supplementary material

Video 5.1

Obscure GI bleeding diagnosed by angiography. A 42-year-old man presented with hematochezia with past medical history notable for protein S deficiency complicated by pulmonary embolism on warfarin therapy, deep venous thrombosis status post inferior venous cava filter placement, and prior diverticular bleed status post partial colectomy. Upper endoscopy was normal and colonoscopy demonstrated fresh blood throughout the colon without a discrete source. Due to ongoing bleeding and hemodynamic instability, an urgent evaluation in interventional radiology was requested. Mesenteric angiography demonstrated a 2.5 × 2.5 cm hypervascular lesion in the mid-distal jejunum (Video clip 5.1), which demonstrated temporary bleeding cessation post-embolization (Video clip 5.2). Despite therapy, the patient remained hemodynamically unstable in the intensive care unit. Subsequent exploratory laparotomy was performed with resection of a transmural mass at 100 cm distal to the ligament of Treitz. Pathologic examination confirmed the presence of a gastrointestinal stromal tumor (MP4 1583 kb)

Video 5.2

Obscure GI bleeding diagnosed by angiography. A 42-year-old man presented with hematochezia with past medical history notable for protein S deficiency complicated by pulmonary embolism on warfarin therapy, deep venous thrombosis status post inferior venous cava filter placement, and prior diverticular bleed status post partial colectomy. Upper endoscopy was normal and colonoscopy demonstrated fresh blood throughout the colon without a discrete source. Due to ongoing bleeding and hemodynamic instability, an urgent evaluation in interventional radiology was requested. Mesenteric angiography demonstrated a 2.5 × 2.5 cm hypervascular lesion in the mid-distal jejunum (Video clip 5.1), which demonstrated temporary bleeding cessation post-embolization (Video clip 5.2). Despite therapy, the patient remained hemodynamically unstable in the intensive care unit. Subsequent exploratory laparotomy was performed with resection of a transmural mass at 100 cm distal to the ligament of Treitz. Pathologic examination confirmed the presence of a gastrointestinal stromal tumor (MP4 563 kb)

Video 5.3

Diffuse angiodysplastic lesions on VCE study. A 67-year-old woman with transfusion-dependent anemia and a history of GI bleeding presented with a 2-day history of melena and crampy abdominal pain. Her past medical history was notable for CREST syndrome, coronary artery disease, factor V Leiden thrombophilia with multiple deep venous thromboses on warfarin therapy, peripheral vascular disease, chronic obstructive pulmonary disease, and congestive heart failure. On physical examination, telangiectasias were apparent on the lips, chest, and mucous membranes. Laboratory data included hemoglobin of 4.4 g/dl with an MCV of 76, INR of 6.0, and BUN of 37. Prior upper endoscopy and colonoscopy demonstrated small vascular ectasias in the gastric fundus and body, as well as in the colon, which were treated with argon plasma coagulation therapy. However, there were no changes in transfusion requirements after endoscopic therapy. A capsule endoscopy study was performed demonstrating multiple confluent angiodysplastic lesions throughout the small bowel that were not actively bleeding. Since the number of angiodysplastic lesions in the small bowel was too numerous for endoscopic therapy, treatment was initiated with intravenous octreotide, with transition to subcutaneous injection. The patient’s transfusion requirements improved following initiation of subcutaneous octreotide administration (MP4 3948 kb)

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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.Division of GastroenterologyCalifornia Pacific Medical CenterSan FranciscoUSA

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