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    Diagnosis and Management of Small Bowel Bleeding (beta)

    Official guideline from the American College of Gastroenterology.

    Summary by Vineet Rolston, MD & Shannon Chang, MD
    Strong recommendation
    Moderate recommendation
    Conditional recommendation
    Weak recommendation
    High quality evidence
    Moderate-high quality evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence

    Diagnosis: Endoscopy

    Second Look
    1. Consider 2nd look upper endoscopy if recurrent hematemesis, melena, or previously incomplete exam.
    2. Consider 2nd look colonoscopy in recurrent hematochezia or if lower source suspected.
    3. If 2nd-look exams are normal, next step should be small bowel evaluation.
    Push Enteroscopy
    1. Can be performed as 2nd-look exam.
    2. Should be performed if proximal lesions suspected, as VCE has lower detection rates of lesions in duodenum and proximal jejunum.
    Video Capsule Endoscopy (VCE)
    1. VCE should be considered as first-line evaluation of SB once upper and lower GI sources are excluded.
    2. VCE should be performed before deep enteroscopy to increase yield. Deep enteroscopy can be considered for initial evaluation in massive hemorrhage or when VCE is contraindicated.
    Total Deep Enteroscopy, Intraoperative Enteroscopy
    1. Should attempt deep enteroscopy if strong clinical suspicion of small bowel lesions.
    2. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required.
    3. Intraoperative enteroscopy is highly sensitive but invasive. Should limit usage to scenarios where enteroscopy cannot be performed (e.g. prior surgeries with intestinal adhesions).

    Diagnosis: Imaging

    CT Enterography
    1. Should be performed if VCE is negative. CTE has higher sensitivity for mural-based masses and superior capability to locate mass and guide subsequent deep enteroscopy.
    2. CT is preferred over MR for evaluation. Can consider MR in younger patients or those with contraindications to CT.
    3. Could consider CTE prior to VCE in established IBD, previous bowel surgery, and/or suspected small bowel stenosis.
    4. CTE should be performed if high suspicion for small bowel source despite prior standard CT abdomen.
    CT Angiography
    1. In hemodynamically stable patients with active bleeding, multiphasic CT can be performed to guide management.
    2. In brisk, active, overt bleeding, CTA is preferred over CTE.
    Conventional Angiography
    1. If hemodynamically unstable and acute overt massive GI bleed, conventional angiography should be performed emergently.
    2. Conventional angiography should not be performed in patients without overt bleeding.
    3. Provocative angiography should be considered if all other diagnostic techniques inconclusive.
    Tagged RBC
    1. In overt slow bleeding rates (0.1-0.2 mL/min) or uncertainty if actively bleeding, tagged RBC scintigraphy should be performed if deep enteroscopy or VCE not performed.
    Meckel’s Scan
    1. In younger patients with overt bleeding normal VCE and enterography, a Meckel’s scan should be performed.
    1. Barium studies should not be performed in the evaluation of small bowel bleeding.


    Endoscopic Therapy
    1. If bleeding source is found by VCE or enteroscopy and associated with significant ongoing anemia or active bleeding, patient should be managed with endoscopic therapy.
    Medical Therapy
    1. If no source of bleeding found, patient should be managed conservatively with oral iron or IV infusion as dictated by severity of iron-deficiency anemia.
    2. If bleeding persists or recurs, or if the lesion cannot be localized, consider medical treatment with iron, somatostatin analogs, or antiangiogenic therapy.
    Persistent Bleeding, Recurrence
    1. If bleeding persists with worsening anemia, further diagnostic workup should include repeat upper and lower endoscopy, VCE, deep enteroscopy, CTE or MRE as appropriate.
    2. In recurrent small bowel bleeding, endoscopic management can be considered depending clinical course and response to prior therapy.
    1. Surgical intervention in massive bleeding may be useful and is greatly helped by presurgical localization (tattooing lesion).
    2. Intraoperative enteroscopy should be available at time of surgical procedure to assist localization and perform endoscopic therapy.
    1. Should discontinue anticoagulation and/or antiplatelet therapy in patients with small bowel bleeding, in a shared decision among the patient, cardiologist, and gastroenterologist.
    Heyde’s Syndrome
    1. Patients with Heyde’s syndrome (aortic stenosis + angioectasia) and bleeding should be considered for aortic valve replacement.
    What do the icons mean?  
    Research PaperGerson LB, Fidler JL, Cave DR, Leighton JA. ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol. 2015;110(9):1265-87.