Diagnosis and Management of Small Bowel Bleeding(beta)
Consider 2nd look upper endoscopy if recurrent hematemesis, melena, or previously incomplete exam.
Consider 2nd look colonoscopy in recurrent hematochezia or if lower source suspected.
VCE should be considered as first-line evaluation of SB once upper and lower GI sources are excluded.
Should attempt deep enteroscopy if strong clinical suspicion of small bowel lesions.
Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required.
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.
CT is preferred over MR for evaluation. Can consider MR in younger patients or those with contraindications to CT.
Could consider CTE prior to VCE in established IBD, previous bowel surgery, and/or suspected small bowel stenosis.
In hemodynamically stable patients with active bleeding, multiphasic CT can be performed to guide management.
If hemodynamically unstable and acute overt massive GI bleed, conventional angiography should be performed emergently.
Conventional angiography should not be performed in patients without overt bleeding.
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.
If bleeding persists with worsening anemia, further diagnostic workup should include repeat upper and lower endoscopy, VCE, deep enteroscopy, CTE or MRE as appropriate.
Surgical intervention in massive bleeding may be useful and is greatly helped by presurgical localization (tattooing lesion).
How strong is the ACG's recommendation?