Small bowel bleeding: a comprehensive review

Small bowel bleeding: cause and the role of endoscopy and medical therapy

PURPOSE OF REVIEW

The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias.

SUMMARY

SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.

Etiology of gastrointestinal bleeding in children referred to pediatric wards of Mashhad hospitals, Iran

Background

Gastrointestinal (GI) bleeding, which has several clinical manifestation and origins, is known as one of the most life-threatening events in children. Several etiologies have been suggested for GI bleeding.

Objective

To determine the most important causes of GI bleeding in children referred to Ghaem Hospital and Dr. Sheikh Hospital, Mashhad, Iran.

Methods

In this cross-sectional study, after obtaining written informed consent of their parents, 113 patients aging from newborn infants to 18-year-old children with GI bleeding admitted to Ghaem Hospital and Dr. Sheikh hospital were enrolled in this study from June 2012 to June 2014. After performing routine diagnostic and therapeutic procedures, a checklist containing all necessary information including demographic data, clinical history of patients, endoscopy and pathology findings, clinical and preclinical information were collected. The data were then analyzed using Statistical Package for the Social Sciences (SPSS) version 16.

Results

Of a total 113 study children, 61 (54%) were male and 52 (46%) were female. The results of this study showed that the most important causes of bleeding in upper GI among all admitted patients were prolapse gastropathy (18.6%), esophagitis (15.9%) and esophageal varices, gastritis, and coagulopathy (7.1% for each). The main causes of lower GI bleeding were polyp (32.5%), chronic nonspecific colitis (20.7%), and proctitis (18.2%).

Conclusion

Findings of this study indicated that prolapse gastropathy and esophagitis are more prevalent causes of upper GI bleeding. Furthermore, esophageal varices were more common in children older than 13 years. Polyp, chronic nonspecific colitis and proctitis are the most prevalent causes of lower GI bleeding.

Ileal angiodysplasia presentation as a bowel obstruction: A case report

•

Angiodysplasia is an important cause of both overt and occult gastrointestinal bleeding.

•

However, angiodysplasia should also be kept in mind while dealing with an acute abdomen due to a bowel obstruction, especially in elderly patients with occult gastrointestinal bleeding.

•

Such exceptional presentation of angiodysplasia can be explained by the development, in the digestive submucosa, of acquired arteriovenous malformation with multiple shunts and rapid blood flow. This results in an inadequate oxygenation of a segment of intestine, chronic ischemia, wall thickness and stenosis and bowel obstruction.

Introduction

Angiodysplasia is a common vascular abnormality of the gastrointestinal tract, found in the elderly and most frequently revealed by gastrointestinal bleeding. We report an original case of ileal angiodysplasia in an 83-year-old woman presenting as a bowel obstruction.

Case presentation

An 83-year-old woman with a medical history of chronic untreated anemia, presented with cardinal symptoms of bowel obstruction. Computed tomography revealed diffuse ileal wall thickening with multiple zones of stenosis, which were aggravated by an ileal perforation and associated with vascular abnormalities compatible with angiodysplasia. Surgery confirmed the imaging findings. A large resection importing one meter of ileum was performed. The pathology report of the resected specimen revealed ischemic lesions of ileum associated with ileal angiodysplasia. The postoperative period was marked by an acute dehydration in the patient who died 3 weeks after surgery.

Discussion

Angiodysplastic lesions develop with aging due to chronic low-grade intermittent obstruction of submucosal veins. These lesions are the result of increased contractility at the level of muscularis propria, leading to congestion of the capillaries and failure of pre-capillary sphincters, resulting in the formation of small arteriovenous collaterals. The acquired arteriovenous malformation consisting of multiple shunts with rapid blood flow may result in inadequate oxygenation of a segment of the intestine and lead to ischemia and eventually wall thickening, stenosis and even perforation of the small bowel.

Conclusion

Angiodysplasia should be kept in the back of one’s mind as one of the causes of acute abdomen and bowel obstruction, especially in elderly people suffering from occult gastrointestinal bleeding.

Laparotomy-Assisted Endoscopic Injection of Jejunal Varices for Overt Small Bowel Bleeding

A 54-year old male liver transplant recipient with Roux-en-Y choledochojejunostomy was admitted for symptomatic anemia. Despite endoscopies and a bleeding scan, active bleeding was not visualized. Angiography and abdominal computed tomography demonstrated possible jejunal varices at the choledochojejunal anastomosis. Double-balloon enteroscopy demonstrated varices with overlying clots in the Roux limb at the anastomosis. Due to the extensive loop formation and unstable position of the endoscope, therapeutic intervention could not be performed. Operative enterotomy and intraoperative endoscopy were subsequently required. A varix in the jejunum with venous flow on Doppler was injected twice with cyanoacrylate and successfully obturated.

[Surgical Removal of Migrated Coil after Embolization of Jejunal Variceal Bleeding: A Case Report]

Jejunal variceal bleeding is less common compared with esophagogastric varices in patients with portal hypertension. However, jejunal variceal bleeding can be fatal without treatment. Treatments include surgery, transjugular intrahepatic porto-systemic shunt (TIPS), endoscopic sclerotherapy, percutaneous coil embolization, and balloon-occluded retrograde transvenous obliteration (BRTO). Percutaneous coil embolization can be considered as an alternative treatment option for those where endoscopic sclerotherapy, surgery, TIPS or BRTO are not possible. Complications of percutaneous coil embolization have been reported, including coil migration. Herein, we report a case of migration of the coil into the jejunal lumen after percutaneous coil embolization for jejunal variceal bleeding. The migrated coil was successfully removed using surgery.

The Approach to Occult Gastrointestinal Bleed

Occult gastrointestinal bleeding is not visible and may present with a positive fecal occult blood test or iron deficiency anemia. Obscure bleeding can be overt or occult, with no source identified despite an appropriate diagnostic workup. A stepwise approach to this evaluation after negative upper and lower endoscopy has been shown to be cost effective. This includes repeat endoscopies if warranted, followed by video capsule endoscopy (VCE) if no obstruction is present. If the VCE is positive then specific endoscopic intervention may be possible. If negative, patients may undergo either repeat testing or watchful waiting with iron supplements.

Obscure gastrointestinal bleeding caused by small intestinal lipoma: a case report

BACKGROUND

Small intestinal lipomas are rare, usually asymptomatic, and most commonly encountered incidentally during investigation of the gastrointestinal tract for another reason. However, they may cause obscure gastrointestinal bleeding.

CASE PRESENTATION

We report a case of obscure gastrointestinal bleeding due to a small intestinal lipoma. A 69-year-old Japanese man on antiplatelet therapy presented to our department with tarry stools and anemic symptoms. A small intestinal tumor was detected by capsule endoscopy and double-balloon endoscopy. After laparoscopic resection, the tumor was confirmed to be a lipoma.

CONCLUSIONS

Small intestinal lipomas are difficult to detect by conventional modalities, but capsule endoscopy and double-balloon endoscopy are good modalities for the diagnosis of small intestinal lipomas. Treatment of small intestinal lipomas should be selected carefully, considering the tumor size, size of stalk, administration of antithrombotic therapy, and endoscopic operability.

Gastrointestinal bleeding in the tropics: Look for the hookworm

Hookworms are recognised as a cause of iron-deficiency anaemia in endemic areas. They are, however, often not considered in the differential diagnosis of overt gastrointestinal bleeding. We report the endoscopic diagnosis of hookworms as the cause of gastrointestinal bleeding in three patients, two of whom had frank haemorrhage with one presenting in hypovolemic shock. Hookworm infestation is an important treatable cause of gastrointestinal bleeding in tropical countries.

Real-time fluorescence angiography by intra-arterial indocyanine green injection to identify obscure gastrointestinal bleeding territory: proof of concept in the porcine model

BACKGROUND

Despite intensive preoperative localization workouts, intraoperative localization of the bleeding source in case of obscure gastrointestinal bleeding (OGIB) can be cumbersome and time-consuming. Our aim was to assess the feasibility of image-guided laparoscopic identification of the small bowel loop containing the bleeding source with and without near-infrared angiographic enhancement.

MATERIALS AND METHODS

Angiography of superior mesenteric artery (SMA) branches was performed in 11 pigs using a right femoral artery approach, followed by a three-port laparoscopy, using a near-infrared-equipped laparoscope. Two pigs were used to identify the optimal intra-arterial indocyanine green (ICG) dose. Eight pigs were divided into two groups: ICG near-infrared angiography-assisted laparoscopy (n = 4) and fluoroscopic-assisted laparoscopy (n = 4). Finally, in one pig, a novel OGIB model was created and used to evaluate the ICG enhancement pattern in the presence of active bleeding.

RESULTS

Mean time to identify the fluorescence signal from the small bowel segment fed by the catheterized SMA branch was 13.75 ± 7.8 s, which was statistically significantly shorter than the time required to identify the tip of the catheter by fluoroscopic guidance, i.e., 243.25 ± 107 s (p = 0.02).

CONCLUSIONS

Near-infrared fluorescence angiography using intra-arterial ICG injection provides a fast image-guided intraoperative localization of the small bowel loop fed by the arterial territory identified as bleeding by digital subtraction angiography and could help target the bleeding source during OGIB surgery.