Evaluation of suspected small bowel bleeding (formerly obscure gastrointestinal bleeding)
- David Cave, MD, PhD
David Cave, MD, PhD
- Professor of Medicine
- University of Massachusetts Medical Center
Bleeding from the small bowel is uncommon, but it is responsible for the majority of patients with gastrointestinal bleeding that persists or recurs without an obvious etiology after upper endoscopy, colonoscopy, and, possibly, radiologic evaluation of the small bowel . In the past, if no source of bleeding was found after an endoscopic evaluation, the bleeding was referred to as being "obscure." However, more recently, it has been proposed that the term obscure only be used if patients have not had a source of bleeding identified after a thorough examination of the entire gastrointestinal tract, including the small bowel . Most cases of what was previously referred to as obscure bleeding are more correctly categorized as suspected small bowel bleeding.
Small bowel bleeding may either be occult or overt:
●Occult bleeding refers to a positive fecal occult blood test result that may or may not be associated with iron deficiency anemia when there is no evidence of visible blood loss to the patient or clinician.
●Overt bleeding refers to bleeding that is visible to the patient or clinician. Overt bleeding may manifest as hematemesis, melena, or hematochezia.
The evaluation of patients with suspected small bowel bleeding will be reviewed here. The initial evaluation of patients with gastrointestinal bleeding is discussed separately. (See "Evaluation of occult gastrointestinal bleeding" and "Approach to acute upper gastrointestinal bleeding in adults" and "Approach to acute lower gastrointestinal bleeding in adults".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Pasha SF, Leighton JA, Das A, et al. Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis. Clin Gastroenterol Hepatol 2008; 6:671.
- Gerson LB, Fidler JL, Cave DR, Leighton JA. ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol 2015; 110:1265.
- Szold A, Katz LB, Lewis BS. Surgical approach to occult gastrointestinal bleeding. Am J Surg 1992; 163:90.
- Tee HP, Kaffes AJ. Non-small-bowel lesions encountered during double-balloon enteroscopy performed for obscure gastrointestinal bleeding. World J Gastroenterol 2010; 16:1885.
- Pennazio M, Arrigoni A, Risio M, et al. Clinical evaluation of push-type enteroscopy. Endoscopy 1995; 27:164.
- Chong J, Tagle M, Barkin JS, Reiner DK. Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology. Am J Gastroenterol 1994; 89:2143.
- Davies GR, Benson MJ, Gertner DJ, et al. Diagnostic and therapeutic push type enteroscopy in clinical use. Gut 1995; 37:346.
- Raju GS, Gerson L, Das A, et al. American Gastroenterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding. Gastroenterology 2007; 133:1694.
- Spiller RC, Parkins RA. Recurrent gastrointestinal bleeding of obscure origin: report of 17 cases and a guide to logical management. Br J Surg 1983; 70:489.
- Leaper M, Johnston MJ, Barclay M, et al. Reasons for failure to diagnose colorectal carcinoma at colonoscopy. Endoscopy 2004; 36:499.
- Zaman A, Katon RM. Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a standard endoscope. Gastrointest Endosc 1998; 47:372.
- Descamps C, Schmit A, Van Gossum A. "Missed" upper gastrointestinal tract lesions may explain "occult" bleeding. Endoscopy 1999; 31:452.
- Chak A, Cooper GS, Canto MI, et al. Enteroscopy for the initial evaluation of iron deficiency. Gastrointest Endosc 1998; 47:144.
- Lin S, Branch MS, Shetzline M. The importance of indication in the diagnostic value of push enteroscopy. Endoscopy 2003; 35:315.
- Vlachogiannakos J, Papaxoinis K, Viazis N, et al. Bleeding lesions within reach of conventional endoscopy in capsule endoscopy examinations for obscure gastrointestinal bleeding: is repeating endoscopy economically feasible? Dig Dis Sci 2011; 56:1763.
- Ibrahim AM, Hackford AW, Lee YM, Cave DR. Hemorrhoids can be a source of obscure gastrointestinal bleeding that requires transfusion: report of five patients. Dis Colon Rectum 2008; 51:1292.
- Bandorski D, Keuchel M, Brück M, et al. Capsule endoscopy in patients with cardiac pacemakers, implantable cardioverter defibrillators, and left heart devices: a review of the current literature. Diagn Ther Endosc 2011; 2011:376053.
- Stanich PP, Kleinman B, Betkerur K, et al. Video capsule endoscopy is successful and effective in outpatients with implantable cardiac devices. Dig Endosc 2014; 26:726.
- de Leusse A, Vahedi K, Edery J, et al. Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding? Gastroenterology 2007; 132:855.
- Laine L, Sahota A, Shah A. Does capsule endoscopy improve outcomes in obscure gastrointestinal bleeding? Randomized trial versus dedicated small bowel radiography. Gastroenterology 2010; 138:1673.
- Hartmann D, Schmidt H, Bolz G, et al. A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc 2005; 61:826.
- Pennazio M, Santucci R, Rondonotti E, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004; 126:643.
- Goenka MK, Majumder S, Kumar S, et al. Single center experience of capsule endoscopy in patients with obscure gastrointestinal bleeding. World J Gastroenterol 2011; 17:774.
- Yamada A, Watabe H, Kobayashi Y, et al. Timing of capsule endoscopy influences the diagnosis and outcome in obscure-overt gastrointestinal bleeding. Hepatogastroenterology 2012; 59:676.
- Singh A, Marshall C, Chaudhuri B, et al. Timing of video capsule endoscopy relative to overt obscure GI bleeding: implications from a retrospective study. Gastrointest Endosc 2013; 77:761.
- Kobayashi Y, Watabe H, Yamada A, et al. Impact of fecal occult blood on obscure gastrointestinal bleeding: observational study. World J Gastroenterol 2015; 21:326.
- Min YW, Kim JS, Jeon SW, et al. Long-term outcome of capsule endoscopy in obscure gastrointestinal bleeding: a nationwide analysis. Endoscopy 2014; 46:59.
- Svarta S, Segal B, Law J, et al. Diagnostic yield of repeat capsule endoscopy and the effect on subsequent patient management. Can J Gastroenterol 2010; 24:441.
- Cave DR, Fleischer DE, Leighton JA, et al. A multicenter randomized comparison of the Endocapsule and the Pillcam SB. Gastrointest Endosc 2008; 68:487.
- ASGE TECHNOLOGY COMMITTEE, DiSario JA, Petersen BT, et al. Enteroscopes. Gastrointest Endosc 2007; 66:872.
- Benz C, Jakobs R, Riemann JF. Do we need the overtube for push-enteroscopy? Endoscopy 2001; 33:658.
- Taylor AC, Chen RY, Desmond PV. Use of an overtube for enteroscopy--does it increase depth of insertion? A prospective study of enteroscopy with and without an overtube. Endoscopy 2001; 33:227.
- Foutch PG, Sawyer R, Sanowski RA. Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin. Gastrointest Endosc 1990; 36:337.
- Lewis BS, Wenger JS, Waye JD. Small bowel enteroscopy and intraoperative enteroscopy for obscure gastrointestinal bleeding. Am J Gastroenterol 1991; 86:171.
- Shinozaki S, Yamamoto H, Yano T, et al. Long-term outcome of patients with obscure gastrointestinal bleeding investigated by double-balloon endoscopy. Clin Gastroenterol Hepatol 2010; 8:151.
- Gerson L, Kamal A. Cost-effectiveness analysis of management strategies for obscure GI bleeding. Gastrointest Endosc 2008; 68:920.
- Jackson CS, Gerson LB. Management of gastrointestinal angiodysplastic lesions (GIADs): a systematic review and meta-analysis. Am J Gastroenterol 2014; 109:474.
- Zaman A, Sheppard B, Katon RM. Total peroral intraoperative enteroscopy for obscure GI bleeding using a dedicated push enteroscope: diagnostic yield and patient outcome. Gastrointest Endosc 1999; 50:506.
- Ress AM, Benacci JC, Sarr MG. Efficacy of intraoperative enteroscopy in diagnosis and prevention of recurrent, occult gastrointestinal bleeding. Am J Surg 1992; 163:94.
- Wang Z, Chen JQ, Liu JL, et al. CT enterography in obscure gastrointestinal bleeding: a systematic review and meta-analysis. J Med Imaging Radiat Oncol 2013; 57:263.
- Lee SS, Oh TS, Kim HJ, et al. Obscure gastrointestinal bleeding: diagnostic performance of multidetector CT enterography. Radiology 2011; 259:739.
- Lin S, Suhocki PV, Ludwig KA, Shetzline MA. Gastrointestinal bleeding in adult patients with Meckel's diverticulum: the role of technetium 99m pertechnetate scan. South Med J 2002; 95:1338.
- Leung WK, Ho SS, Suen BY, et al. Capsule endoscopy or angiography in patients with acute overt obscure gastrointestinal bleeding: a prospective randomized study with long-term follow-up. Am J Gastroenterol 2012; 107:1370.
- General approach
- - Hemodynamically stable patients
- - Hemodynamically unstable patients
- DIAGNOSTIC TESTS
- Repeat upper endoscopy and colonoscopy
- Wireless video capsule endoscopy
- - Push enteroscopy
- - Deep small bowel enteroscopy
- - Intraoperative enteroscopy
- Radiographic imaging
- - Enterography
- - Radionuclide scanning
- - Angiography
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS