ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding

Abstract

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

Neurofibromatosis tipo 1 y sangrado de intestino delgado. Reporte de caso

“…Con el advenimiento de técnicas endoscópicas y radiológicas que evalúan el intestino delgado, en los último años se ha propuesto la definición de sangrado probable de intestino delgado o sangrado gastrointestinal intermedio para los pacientes a quienes se realiza endoscopia digestiva alta y colonoscopia negativas, reservando el término sangrado de origen oscuro para los pacientes en quienes el origen de la hemorragia no se ha identificado posterior a realizar endoscopia digestiva alta, colonoscopia y estudios de intestino delgado como videocápsula endoscópica, enterografía por tomografía o resonancia magnética, angiografía, gammagrafía, enteroscopia de empuje, enteroscopia profunda con balón o en espiral, o enteroscopia intraoperatoria (9). Dado que en el caso presentado se evidencia un sangrado probable de intestino delgado, se decidió realizar enteroscopia intraoperatoria por disponibilidad institucional.…”

Hemobilia secundaria a aneurisma de la artera hepática

“…Su incidencia exacta se desconoce, pero se ha descrito una mortalidad muy alta, de hasta el 25% (10). En este caso, se resalta la importancia de sospechar esta patología en aquellos pacientes que se presentan con sangrado digestivo oscuro manifiesto (11).…”

What is the clinical yield of capsule endoscopy in the management of obscure bleeding in emergency service?

“…[14] Guidelines have begun to emerge with widespread use of CE in patients with GI bleeds and no obvious etiology. Guidelines developed by Gerson et al are presented here as an example.…”

“…Guidelines developed by Gerson et al are presented here as an example. [8][9][10][11][12][13][14][15][16][17][18] Our algorithm is shown in Figure 5.…”