Management of

Small Intestinal
Bleed
Dr Shamail Zafar
Assistant Professor of Medicine
Lahore Medical & Dental College
Lahore
 Bleeding from Small
Intestine
CLASSIFICATION
Bleeding from Small Intestine can be
classified as
i) Overt Small Intestinal Bleed:
in which patient presents with
hematochezia or malena.
ii) Occult Small Intestinal Bleed:
in which patient presents with iron
deficiency anemiaASGE
and/or positive
Practice Committee Guideline
on GI Bleed
 Bleeding from Small
Intestine
INCIDENCE
About ~5 % of Total GIT Bleed.
Angiectasias account for about 50 % of
these cases.

Raju GS.Gastroenterology
2007;133(5):1697-1717
Concha R. J Clin Gastroenterol
2007;41(3):242-51
Bleeding from Small
Intestine
CAUSES
Younger Older than 40 Uncommon
than 40 years of age
years
Tumorsof Angiectasia Hemobilia
age
Meckel’s NSAID Hemosuccus
Diverticulum Enteropathy Pancreaticus
Dieulafoy’s Celiac Disease Aortoenteric
lesion Fistula
Celiac Inflammatory Portal
Disease Bowel Disease Hypertensive
Inflammatory Tumors Vasculopathy
GAVE
Bowel
Disease AGA Institute Technical Review on Obscure
GI Bleed
 Bleeding from Small
Intestine
DIAGNOSIS & MANAGEMENT
ii) History & Clinical examination
iii) Laboratory Analysis
iv) Emergency room management
v) Non-Endoscopic management
vi) Endoscopic Management
vii) Pharmacological Management
 Bleeding from Small
Intestine
NON-ENDOSCOPIC MANAGEMENT
i) Barium studies
a) Small Bowel follow through
b) Enteroclysis
ii) Nuclear Scans
a) Tagged Red Blood Cell Scan
b) Meckel’s Scan
iii) CT Scan and MRI
iv) Angiography
 Bleeding from Small
Intestine
ENDOSCOPIC MANAGEMENT
ii) Enteroscopy
a) Push Enteroscopy
b) Double Balloon Enteroscopy
v) Wireless Capsule endoscopy
vi) Intraoperative enteroscopy
 Barium Studies
 Small Bowel follow through studies
have shown a low diagnostic yield
(0% to 6%)1
 Diagnosis is improved when
combined with Enteroclysis which is
a Biphasic examination using barium
and methylcellulose as double
contrast agent (10% to 20%)2
 Even Enteroclysis fails to detect flat
mucosal lesions like Angiodysplasia,
1.Gastrointest Endosc.2003;57:418-

thus use is limited to 420

tumor and
2.Med Clin North Am 2002;86:1319-56
 Radionuclide Scans
 Threshold bleeding rate is in the
range of 0.1 to 0.4 ml/min.
 Technitium Tc 99m-lableled RBC’s
stay in the vascular space for 24
hours.
 Aid in localization of bleeding which
can later verified endoscopically or
angiographically.
 Surgical yield of earlyRecent
positive scan
Advances in Small Intestinal Bleed

(1to 4 hr) is 70 to 80%.

Kovacs TO. Med Clin North
Am.2002;86:1319-56
 Angiography
 Threshold bleeding rate is more than
0.5ml/min
 Can detect both bleeding lesions of
tumors and AVM’s.
 Therapy can be offered in the form of
micro-coils, glue or drugs
(vasopressin).
 Diagnostic yield varies between 12-
70 %.
Concha R. Obscure GI Bleed. J Clin Gastroenterol
 CT Angiography2007;41(3):242-51
is better than
 Cross Sectional Imaging
Techniques
CT SCAN , CT ENTEROCLYSIS,
MRE
 It provides non-superimposed views
of all small bowel loops as well as of
any mesenteric or extra intestinal
lesions.
 CTE requires distension of bowel
lumen with 1200-1500 cc of low
density, negative oral contrast agent
like water or barium sulphate
suspension. Horton KM.MDCT of small bowel neoplasms. J CAT
2004;28:106-116
 Cross Sectional Imaging
Techniques
 Both CTE and MRE are novel
techniques of accurate diagnosis of
inflammatory, vascular and
neoplastic lesions of small intestine.
 Push Enteroscopy
 Proximal part of small intestine can
be directly visualized using extended
length enteroscope or pediatric
Colonoscope.
 Accessories like Biopsy forceps or
APC probes enable to perform
diagnostic and therapeutic
procedures.
 50 % of small Bowel is accessible
Waye JD. Enteroscopy.Gastrointest Endosc
 Diagnostic Yield 40-65%.
1997;46:247-56
Double Balloon
Enteroscopy
 It allows complete
examination of
small intestine
 Scope has got a
balloon at its tip
and a soft overtube
with another
balloon at the
distal end are used
together.
 Double Balloon
Enteroscopy
 Accessory channel enables
interventions like biopsies, balloon
dilatation, stent placement,
polypectomy and endoscopic
mucosal resection.
 Overall Diagnostic yield is 43-80 %
 DBE can be performed in antegrade
and /or retrograde fashion; insertion
route is chosen according to the
Nakamura M.Which route to select in DBE.Gastrointest
suspected Endosc2008;687(3)577-8
lesion location.
 Double Balloon
Enteroscopy
Endoscopic Coagulation
 Heated probe or lasers such as Nd:YAG
and argon
 Argon laser treatment is recommended
for mucosal or superficial lesions
because the energy penetrates only 1
mm.
 Nd:YAG lasers are more useful for
deeper lesions because they penetrate
3-4 mm .
 Absolute alcohol, Ethanolamine and
 Capsule Endoscopy
Procedure Consists of three
steps
1. Ingest the video capsule.

2. Capsule transmits images to

Data Recorder.
3. Images are reviewed using
RAPID software, and
physician makes diagnosis.
 Capsule Endoscopy
 Capsule includes a miniature color video
camera, a light, a battery and transmitter
 Weighs 3.7 g and measures 11 mm × 26 mm
 Image features include a 140° field of view, 1:8
magnification, 1 to 30 mm depth of view, and a
minimum size of detection of about 0.1 mm
 The camera takes two pictures every second
for eight hours
 Capsule cost: Pack of 1 for $500
Capsule endoscopy not a substitute for regular
endoscopy
 AVM Sprue

Bleeding Lesion Polyp

 Intra-operative
Enteroscopy
 Intra-operative Enteroscopy is the
traditional Gold standard in small
bowel visualization.
 If facilities of DBE are not available or
it cannot be performed due to
abdominal adhesions, IOE still
remains the procedure of choice
especially in transfusion dependant
patients.
 Diagnostic yieldHartmann
is 58-88%.
D.Comparing CE with IOE in OGIB.
Gastrointest Endosc 2005;61(7):826-32
Diagnostic Yield of IOE

AGA Institute Technical Review on Obscure

GI Bleed
Push Enteroscopy vs Capsule
Endoscopy
Barium Radiography vs Capsule
Endoscopy
Pharmacological Therapy
 Pharmacotherapy should be considered
whenever endoscopic therapy, surgical
intervention or angiographic therapy is
either not available or effective.
 It includes supportive therapy with
3. Blood transfusions
4. Epoetin alpha
5. Iron replacement
6. Hormonal therapy
7. Octreotide
8. Avoidance of Anticoagulants, aspirin and
NSAID’s
 Hormonal Therapy
 Discordant results have been
obtained regarding efficacy of
Hormonal therapy for suspected
Angiodysplasia bleeding.
 Combined hormonal therapies with
estrogen-progesterone significantly
reduces blood transfusions and
rebleeding.
Van Custem E. Treatment of vascular malformations with
estrogen progeterone. Lancet 1990;335:953-5
Hormonal therapy in GI angiodysplasia.Gastroenterology
 Octreotide Acetate
 Potential benefit of reducing
Angiodysplastic bleeding.
 20% reduction in bleeding can be
obtained over a 1-2 year period.

Junquera F. Longterm efficacy of Octreotide in recurrent GI Bleeding

Am J Gastroenterol 2007;102(2):254-70
Nardone G. Efficacy of Octreotide in GI Bleeding. Aliment Pharmacol Ther
1999;13(11) 1429-36)
 Thalidomide
 It is proven to have anti
inflammatory activity in patients of
Crohn’s disease.
 It also displays anti-angiogenic
activity

Perez-Ecinas. Is thalidomide effective for management

of GI Bleeding. Haematologica 2002;87:ELT 34
 Anti Fibrinolytic Agents
 Tranexamic acid and Epsilon-
Aminocaproic acid.
 They inhibit the process of
Fibrinolysis in Telangiectasia walls,
which enables fibrin deposits to seal
the bleeding site.

Korzenik JR. Treatment of bleeding in HHT with

aminocaproic acid. NEJM 1994;331:1236
 Conclusions
 Push Enteroscopy is better than
barium studies.
 Help should be taken radionuclide
scans and mesenteric Angiography
to localize the lesions.
 Intra-operative Enteroscopy still
remains the Gold standard.
Thank you
 PE vs PPE
 Insertion depth of push enteroscopy is
limited to the
 proximal jejunum. The diagnostic yield of
push enteroscopy can be estimated on
approximately 40%. With the new method
of push-and-pull enteroscopy in
double-balloon technique also deeper
parts of the small bowel can be reached.
 Push-and-pull enteroscopy is superior to
push enteroscopy both with regard to the
length of small bowel visualized and to the