Small Intestinal Bleeding

Aka: Small Intestinal Bleeding, Small Intestine Bleeding, Small Bowel Bleeding, Obscure Gastrointestinal Bleeding

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II. Epidemiology

  1. May represent 5-10% of GI Bleeding sources

III. Causes: General

  1. See Occult Gastrointestinal Bleeding Causes
  2. Angiodysplasia (most common cause)
    1. Associated conditions
      1. Chronic Renal Failure
      2. Aortic Stenosis
      3. Cirrhosis
      4. Von Willebrand's Disease
  3. Neoplasms (usually cause chronic intermittent bleeding)
  4. Ulcers
  5. Crohn's Disease
  6. Diverticula
  7. Meckel's Diverticulum

IV. Causes: Common By Age

  1. Age <30 years old
    1. Meckel's Diverticulum
    2. Inflammatory Bowel Disease
    3. Long Distance Running
  2. Age 30-60 years old
    1. Vascular tumor (GIST, Carcinoid)
    2. Inflammatory Bowel Disease
    3. Celiac Disease
    4. NSAID-Induced Ulcer
  3. Age >60 years old
    1. Vascular tumor (GIST, Carcinoid)
    2. Arteriovenous Malformation
    3. NSAID-Induced Ulcer
  4. References
    1. Loftus (2012) Mayo POIM Conference, Rochester

V. Diagnosis

  1. First-line evaluation of Small Intestinal Bleeding
    1. Video Capsule Endoscopy
      1. Identifies Arteriovenous Malformations with Clinically Significant recurrent bleeding
      2. Costamagna (2002) Gastroenterology 123:999-1005 [PubMed]
    2. CT Enterography or CT with IV Contrast
      1. Best detects vascular tumors and should be a first-line study
      2. Loftus (2012) Mayo POIM Conference, Rochester
  2. Second-line evaluation of Small Intestinal Bleeding
    1. Endoscopy
      1. Deep enteroscopy can reach the distal Small Bowel
      2. Push enteroscopy (longer upper endoscope) reaches proximal jejunum
      3. Sonde enteroscopy (small caliber tube via nose)
      4. Intraoperative enteroscopy (during laparotomy)
  3. Third-line evaluation of Small Intestinal Bleeding
    1. Surgical exploration
    2. Mesenteric angiography (celiac and mesenterics)
      1. Helpful in brisk Gastrointestinal Bleeding
  4. Low yield tests in identifying bleeding site
    1. Small Bowel follow through with enteroclysis
      1. Does not identify mucosal lesions
    2. Double-contrast Barium Enema
      1. Indicated only in suboptimal Colonoscopy
    3. Tagged Red Blood Cell Scan
      1. Requires brisk bleeding (high False Negative Rate)
      2. May inaccurately localize lesion

VI. References

  1. Fallah (2000) Med Clin North Am 84(5):1183-208 [PubMed]
  2. Leighton (2003) Gastrointest Endosc 58(5):650-5 [PubMed]

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