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Small Bowel Sources of Gastrointestinal Bleeds

  • Shuyan Wei
  • Lillian S. Kao
Chapter

Abstract

Small bowel gastrointestinal (GI) bleeding accounts for 5–10% of all GI bleeds. Common causes in adults include vascular ectasias, neoplasms, ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs), Crohn’s disease, Dieulafoy’s lesions, and Meckel’s diverticula. Diagnostic tools to evaluate patients with suspected small bowel GI bleeds include video capsule endoscopy, computed tomographic enterography and magnetic resonance enterography, nuclear medicine scans, angiography, and enteroscopy. Treatments vary depending on the source of bleeding, ongoing blood loss, and hemodynamic status. Hemodynamically unstable patients with acute bleeding should undergo conventional angiography. Surgical treatment requires guidance from preoperative source localization and is often used as last resort. Endoscopic therapies include sclerotherapy, coagulation, clipping, and band ligation of bleeding lesions. Medical management of small bowel GI bleeds is focused on treatment of anemia and reducing the risk of recurrent bleeding.

Keywords

Small bowel gastrointestinal bleed Vascular ectasia Dieulafoy’s lesion Meckel’s diverticulum Video capsule endoscopy (VCE) Angiography Enteroscopy 

References

  1. 1.
    Gerson LB, Fidler JL, Cave DR, et al. ACG clinical guideline: diagnosis and management of small bowel bleeding. Am J Gastroenterol. 2015;110(9):1265–87; quiz 1288PubMedCrossRefGoogle Scholar
  2. 2.
    Jackson CS, Strong R. Gastrointestinal angiodysplasia: diagnosis and management. Gastrointest Endosc Clin N Am. 2017;27(1):51–62.PubMedCrossRefGoogle Scholar
  3. 3.
    Clouse RE, Costigan DJ, Mills BA, et al. Angiodysplasia as a cause of upper gastrointestinal bleeding. Arch Intern Med. 1985;145(3):458–61.PubMedCrossRefGoogle Scholar
  4. 4.
    Boley SJ, Sammartano R, Adams A, et al. On the nature and etiology of vascular ectasias of the colon. Degenerative lesions of aging. Gastroenterology. 1977;72(4 Pt 1):650–60.PubMedGoogle Scholar
  5. 5.
    Zajjari Y, Tamzaourte M, Montasser D, et al. Gastrointestinal bleeding due to angiodysplasia in patients on hemodialysis: a single-center study. Saudi J Kidney Dis Transpl. 2016;27(4):748–51.PubMedCrossRefGoogle Scholar
  6. 6.
    Alhumood SA, Devine DV, Lawson L, et al. Idiopathic immune-mediated acquired von Willebrand’s disease in a patient with angiodysplasia: demonstration of an unusual inhibitor causing a functional defect and rapid clearance of von Willebrand factor. Am J Hematol. 1999;60(2):151–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Hudzik B, Wilczek K, Gasior M. Heyde syndrome: gastrointestinal bleeding and aortic stenosis. CMAJ. 2016;188(2):135–8.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Singh G, Albeldawi M, Kalra SS, et al. Features of patients with gastrointestinal bleeding after implantation of ventricular assist devices. Clin Gastroenterol Hepatol. 2015;13(1):107–14.e101.PubMedCrossRefGoogle Scholar
  9. 9.
    Poralla T. Angiodysplasia in the renal patient: how to diagnose and how to treat? Nephrol Dial Transplant. 1998;13(9):2188–91.PubMedCrossRefGoogle Scholar
  10. 10.
    Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017;67(1):7–30.PubMedCrossRefGoogle Scholar
  11. 11.
    Ciresi DL, Scholten DJ. The continuing clinical dilemma of primary tumors of the small intestine. Am Surg. 1995;61(8):698–702; discussion 702–3PubMedGoogle Scholar
  12. 12.
    Kemp CD, Russell RT, Sharp KW. Resection of benign duodenal neoplasms. Am Surg. 2007;73(11):1086–91.PubMedGoogle Scholar
  13. 13.
    Cross AJ, Leitzmann MF, Subar AF, et al. A prospective study of meat and fat intake in relation to small intestinal cancer. Cancer Res. 2008;68(22):9274–9.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Wu AH, Yu MC, Mack TM. Smoking, alcohol use, dietary factors and risk of small intestinal adenocarcinoma. Int J Cancer. 1997;70(5):512–7.PubMedCrossRefGoogle Scholar
  15. 15.
    d’Amore F, Brincker H, Gronbaek K, et al. Non-Hodgkin’s lymphoma of the gastrointestinal tract: a population-based analysis of incidence, geographic distribution, clinicopathologic presentation features, and prognosis. Danish Lymphoma Study Group. J Clin Oncol. 1994;12(8):1673–84.PubMedCrossRefGoogle Scholar
  16. 16.
    Gibson GR, Whitacre EB, Ricotti CA. Colitis induced by nonsteroidal anti-inflammatory drugs. Report of four cases and review of the literature. Arch Intern Med. 1992;152(3):625–32.PubMedCrossRefGoogle Scholar
  17. 17.
    Shin SJ, Noh CK, Lim SG, et al. Non-steroidal anti-inflammatory drug-induced enteropathy. Intest Res. 2017;15(4):446–55.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Matsumoto T, Kudo T, Esaki M, et al. Prevalence of non-steroidal anti-inflammatory drug-induced enteropathy determined by double-balloon endoscopy: a Japanese multicenter study. Scand J Gastroenterol. 2008;43(4):490–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Reuter BK, Davies NM, Wallace JL. Nonsteroidal anti-inflammatory drug enteropathy in rats: role of permeability, bacteria, and enterohepatic circulation. Gastroenterology. 1997;112(1):109–17.PubMedCrossRefGoogle Scholar
  20. 20.
    Bjarnason I, Hayllar J, MacPherson AJ, et al. Side effects of nonsteroidal anti-inflammatory drugs on the small and large intestine in humans. Gastroenterology. 1993;104(6):1832–47.PubMedCrossRefGoogle Scholar
  21. 21.
    Uejima M, Kinouchi T, Kataoka K, et al. Role of intestinal bacteria in ileal ulcer formation in rats treated with a nonsteroidal antiinflammatory drug. Microbiol Immunol. 1996;40(8):553–60.PubMedCrossRefGoogle Scholar
  22. 22.
    Koga H, Aoyagi K, Matsumoto T, et al. Experimental enteropathy in athymic and euthymic rats: synergistic role of lipopolysaccharide and indomethacin. Am J Phys. 1999;276(3 Pt 1):G576–82.Google Scholar
  23. 23.
    Ullah S, Ajab S, Rao R, et al. Diaphragm disease of the small intestine: an interesting case report. Int J Surg Pathol. 2015;23(4):322–4.PubMedCrossRefGoogle Scholar
  24. 24.
    Mehdizadeh S, Lo SK. Treatment of small-bowel diaphragm disease by using double-balloon enteroscopy. Gastrointest Endosc. 2006;64(6):1014–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Slesser AA, Wharton R, Smith GV, et al. Systematic review of small bowel diaphragm disease requiring surgery. Color Dis. 2012;14(7):804–13.CrossRefGoogle Scholar
  26. 26.
    Gajendran M, Loganathan P, Catinella AP, et al. A comprehensive review and update on Crohn’s disease. Dis Mon. 2018;64(2):20–57.PubMedCrossRefGoogle Scholar
  27. 27.
    Matake H, Matsui T, Yao T. Inflammatory bowel disease – Crohn’s diseaseNihon Rinsho. 1998;56(9):2349–53.PubMedGoogle Scholar
  28. 28.
    Cirocco WC, Reilly JC, Rusin LC. Life-threatening hemorrhage and exsanguination from Crohn’s disease. Report of four cases. Dis Colon Rectum. 1995;38(1):85–95.PubMedCrossRefGoogle Scholar
  29. 29.
    Michelassi F, Sultan S. Surgical treatment of complex small bowel Crohn disease. Ann Surg. 2014;260(2):230–5.PubMedCrossRefGoogle Scholar
  30. 30.
    St-Vil D, Brandt ML, Panic S, et al. Meckel’s diverticulum in children: a 20-year review. J Pediatr Surg. 1991;26(11):1289–92.PubMedCrossRefGoogle Scholar
  31. 31.
    Close LN, Kumar NC, Glazer ES, Ong ES. A dieulafoy lesion as the cause of massive upper gastrointestinal bleeding after a distal pancreatectomy and splenectomy: case report and literature review. J Surg. 2013;1(2):3.Google Scholar
  32. 32.
    Lee YT, Walmsley RS, Leong RW, et al. Dieulafoy’s lesion. Gastrointest Endosc. 2003;58(2):236–43.PubMedCrossRefGoogle Scholar
  33. 33.
    Gerson LB. Small bowel bleeding: updated algorithm and outcomes. Gastrointest Endosc Clin N Am. 2017;27(1):171–80.PubMedCrossRefGoogle Scholar
  34. 34.
    Delvaux M, Fassler I, Gay G. Clinical usefulness of the endoscopic video capsule as the initial intestinal investigation in patients with obscure digestive bleeding: validation of a diagnostic strategy based on the patient outcome after 12 months. Endoscopy. 2004;36(12):1067–73.PubMedCrossRefGoogle Scholar
  35. 35.
    Yamada A, Watabe H, Kobayashi Y, et al. Timing of capsule endoscopy influences the diagnosis and outcome in obscure-overt gastrointestinal bleeding. Hepato-Gastroenterology. 2012;59(115):676–9.PubMedGoogle Scholar
  36. 36.
    Kong H, Kim YS, Hyun JJ, et al. Limited ability of capsule endoscopy to detect normally positioned duodenal papilla. Gastrointest Endosc. 2006;64(4):538–41.PubMedCrossRefGoogle Scholar
  37. 37.
    Pennazio M. Capsule endoscopy: where are we after 6 years of clinical use? Dig Liver Dis. 2006;38(12):867–78.PubMedCrossRefGoogle Scholar
  38. 38.
    Leighton JA, Sharma VK, Srivathsan K, et al. Safety of capsule endoscopy in patients with pacemakers. Gastrointest Endosc. 2004;59(4):567–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Leighton JA, Srivathsan K, Carey EJ, et al. Safety of wireless capsule endoscopy in patients with implantable cardiac defibrillators. Am J Gastroenterol. 2005;100(8):1728–31.PubMedCrossRefGoogle Scholar
  40. 40.
    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(3):263–73.PubMedCrossRefGoogle Scholar
  41. 41.
    Heo HM, Park CH, Lim JS, et al. The role of capsule endoscopy after negative CT enterography in patients with obscure gastrointestinal bleeding. Eur Radiol. 2012;22(6):1159–66.PubMedCrossRefGoogle Scholar
  42. 42.
    Howarth DM. The role of nuclear medicine in the detection of acute gastrointestinal bleeding. Semin Nucl Med. 2006;36(2):133–46.PubMedCrossRefGoogle Scholar
  43. 43.
    Rollins ES, Picus D, Hicks ME, et al. Angiography is useful in detecting the source of chronic gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol. 1991;156(2):385–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Charbonnet P, Toman J, Buhler L, et al. Treatment of gastrointestinal hemorrhage. Abdom Imaging. 2005;30(6):719–26.PubMedCrossRefGoogle Scholar
  45. 45.
    Wu LM, Xu JR, Yin Y, et al. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis. World J Gastroenterol. 2010;16(31):3957–63.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    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(1):62–70.PubMedCrossRefGoogle Scholar
  47. 47.
    Mensink PB, Haringsma J, Kucharzik T, et al. Complications of double balloon enteroscopy: a multicenter survey. Endoscopy. 2007;39(7):613–5.PubMedCrossRefGoogle Scholar
  48. 48.
    Manno M, Riccioni ME, Cannizzaro R, et al. Diagnostic and therapeutic yield of single balloon enteroscopy in patients with suspected small-bowel disease: results of the Italian multicentre study. Dig Liver Dis. 2013;45(3):211–5.PubMedCrossRefGoogle Scholar
  49. 49.
    Domagk D, Mensink P, Aktas H, et al. Single- vs. double-balloon enteroscopy in small-bowel diagnostics: a randomized multicenter trial. Endoscopy. 2011;43(6):472–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Hartmann D, Schmidt H, Bolz G, et al. A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc. 2005;61(7):826–32.PubMedCrossRefGoogle Scholar
  51. 51.
    Leighton JA, Goldstein J, Hirota W, et al. Obscure gastrointestinal bleeding. Gastrointest Endosc. 2003;58(5):650–5.PubMedCrossRefGoogle Scholar
  52. 52.
    Mejaddam AY, Cropano CM, Kalva S, et al. Outcomes following “rescue” superselective angioembolization for gastrointestinal hemorrhage in hemodynamically unstable patients. J Trauma Acute Care Surg. 2013;75(3):398–403.PubMedCrossRefGoogle Scholar
  53. 53.
    Fernandez de Sevilla Gomez E, Vallribera Valls F, Espin Basany E, et al. Postoperative small bowel and colonic anastomotic bleeding. Therapeutic management and complications. Cir Esp. 2014;92(7):463–7.PubMedCrossRefGoogle Scholar
  54. 54.
    Frydman J, Bahouth H, Leiderman M, et al. Methylene blue injection via superior mesenteric artery microcatheter for focused enterectomy in the treatment of a bleeding small intestinal arteriovenous malformation. World J Emerg Surg. 2014;9(1):17.PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    Szilagyi A, Ghali MP. Pharmacological therapy of vascular malformations of the gastrointestinal tract. Can J Gastroenterol. 2006;20(3):171–8.PubMedPubMedCentralCrossRefGoogle Scholar
  56. 56.
    Jackson CS, Gerson LB. Management of gastrointestinal angiodysplastic lesions (GIADs): a systematic review and meta-analysis. Am J Gastroenterol. 2014;109(4):474–83; quiz 484PubMedCrossRefGoogle Scholar
  57. 57.
    Garrido A, Sayago M, Lopez J, et al. Thalidomide in refractory bleeding due to gastrointestinal angiodysplasias. Rev Esp Enferm Dig. 2012;104(2):69–71.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryMcGovern Medical School at the University of Texas Health Science Center at HoustonHoustonUSA

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