Approach to Suspected Small Intestinal Bleeding

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.