Diagnosis and Management of Small Bowel Bleeding

Publication Date: September 1, 2015
Last Updated: March 14, 2022

Recommendations

Diagnosis

Second-look upper endoscopy should be considered in cases of recurrent hematemesis, melena, or a previously incomplete exam. (Strong  “We recommend”Low)
317609
Second-look colonoscopy should be considered in the setting of recurrent hematochezia or if a lower source is suspected. (Conditional (weak)  “We suggest”Very low)
317609
If the second-look examinations are normal, the next step should be a small bowel evaluation. (Strong  “We recommend”Moderate)
317609
Push enteroscopy can be performed as a second-look examination in the evaluation of suspected small bowel bleeding. (Conditional (weak)  “We suggest”Moderate)
317609
VCE should be considered a first-line procedure for small bowel (SB) evaluation after upper and lower GI sources have been excluded, including second-look endoscopy when indicated. (Strong  “We recommend”Moderate)
317609
Owing to the lower detection rate of lesions in the duodenum and proximal jejunum with VCE, push enteroscopy should be performed if proximal lesions are suspected. (Strong  “We recommend”Very low)
317609
Total deep enteroscopy should be attempted if there is a strong suspicion of a small bowel lesion based on clinical presentation or abnormal VCE study. (Strong  “We recommend”Moderate)
317609
Any method of deep enteroscopy can be used when endoscopic evaluation and therapy is required based on similar diagnostic yields. (Strong  “We recommend”High)
317609
Intraoperative enteroscopy (IOE) is a highly sensitive but invasive diagnostic and effective therapeutic procedure. Its usage should be limited to scenarios where enteroscopy cannot be performed, such as patients with prior surgeries and intestinal adhesions. (Strong  “We recommend”Low)
317609
VCE should be performed before deep enteroscopy to increase diagnostic yield. Initial deep enteroscopy can be considered in cases of massive hemorrhage or when VCE is contraindicated. (Strong  “We recommend”High)
317609

Diagnosis using radiographic techniques

Barium studies should not be performed in the evaluation of small bowel bleeding. (Strong  “We recommend”, High)
317609
CTE should be performed in patients with suspected small bowel bleeding and negative capsule endoscopy because of higher sensitivity for the detection of mural-based small bowel masses, superior capability to locate small bowel masses, and ability to guide subsequent deep enteroscopy. (Strong  “We recommend”Low)
317609
CT is preferred over MR imaging for the evaluation of suspected small bowel bleeding. MR can be considered in patients with contraindications for CT or to avoid radiation exposure in younger patients. (Conditional (weak)  “We suggest”Very low)
317609
CTE could be considered before VCE in the setting of established inflammatory bowel disease, prior radiation therapy, previous small bowel surgery, and/or suspected small bowel stenosis. (Strong  “We recommend”Very low)
317609
In patients with suspected small bowel bleeding and negative VCE examination, CTE should be performed if there is high clinical suspicion for a small bowel source despite the performance of a prior standard CT of the abdomen. (Conditional (weak)  “We suggest”Very low)
317609

Overt acute GI bleeding

In acute overt massive GI bleeding, conventional angiography should be performed emergently for hemodynamically unstable patients. (Strong  “We recommend”Low)
317609
In hemodynamically stable patients with evidence of active bleeding, multiphasic CT (CTA) can be performed to identify the site of bleeding and guide further management. (Strong  “We recommend”Low)
317609
In patients with acute overt GI bleeding and slower rates of bleeding (0.1–0.2 ml/min), or uncertainty if actively bleeding, tagged red blood cell (RBC) scintigraphy should be performed if deep enteroscopy or VCE are not performed to guide timing of angiography. (Strong  “We recommend”Moderate)
317609
In brisk active overt bleeding, CTA is preferred over CTE. (Conditional (weak)  “We suggest”Very low)
317609
Conventional angiography should not be performed as a diagnostic test in patients without overt bleeding. (Conditional (weak)  “We suggest”Very low)
317609
Provocative angiography can be considered in the setting of ongoing overt bleeding and negative VCE, deep enteroscopy, and/or CT examination. (Conditional (weak)  “We suggest”Very low)
317609
In younger patients with ongoing overt bleeding and normal testing with VCE and enterography examinations, a Meckel’s scan should be performed. (Conditional (weak)  “We suggest”Very low)
317609

Treatment and outcomes

If a source of bleeding is found by VCE and/or deep enteroscopy in the small intestine that is associated with significant ongoing anemia or active bleeding, then the patient should be managed with endoscopic therapy. (Strong  “We recommend”Low)
317609
If after appropriate small bowel investigation no source of bleeding is found, the patient should be managed conservatively with oral iron or by intravenous infusion as is dictated by the severity and persistence of the associated iron-deficiency anemia. In this context, a small vascular lesion found on capsule endoscopy does not always need treatment. (Strong  “We recommend”Very low)
317609
If bleeding persists in either of the above situations with worsening anemia, a further diagnostic workup should include a repeated upper and lower endoscopy, VCE, deep enteroscopy, CT, or MRI enterography as is appropriate for the clinical situation and availability of investigative devices. (Strong  “We recommend”Low)
317609
If bleeding persists or recurs or a lesion cannot be localized consideration may be given to medical treatment with iron, somostatin analogs, or antiangiogenic therapy. (Strong  “We recommend”Moderate)
317609
Anticoagulation and/or antiplatelet therapy should be discontinued if possible in patients with small bowel hemorrhage. (Conditional (weak)  “We suggest”Very low)
317609
Surgical intervention in massive small bowel bleeding may be useful, but is greatly aided with presurgical localization of the bleeding site by marking the lesion with a tattoo. (Strong  “We recommend”Low)
317609
IOE should be available at the time of the surgical procedure to provide assistance to localize the source of bleeding and to perform endoscopic therapy. (Conditional (weak)  “We suggest”Low)
317609
Patients with Heyde’s syndrome (aortic stenosis and angioectasia) and ongoing bleeding should undergo aortic valve replacement. (Conditional (weak)  “We suggest”Moderate)
317609
For patients with recurrence of small bowel bleeding, endoscopic management can be considered depending on the patient’s clinical course and response to prior therapy. (Conditional (weak)  “We suggest”Moderate)
317609

Recommendation Grading

Overview

Title

Diagnosis and Management of Small Bowel Bleeding

Authoring Organization

Publication Month/Year

September 1, 2015

Last Updated Month/Year

January 10, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The purpose of this guideline will be to review the definition, epidemiology, causes of small bowel bleeding, and therapeutic options. 

Target Patient Population

Patients with small bowel bleeding

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D013502 - General Surgery, D006471 - Gastrointestinal Hemorrhage, D007421 - Intestine, Small

Keywords

computed tomographic imaging (CT), Overt small-bowel bleeding, Occult small-bowel bleeding, small-bowel bleeding, bleeding, small intestine

Source Citation

Gerson, Lauren B MD, MSc, FACG; Fidler, Jeff L MD; Cave, David R MD, PhD, FACG; Leighton, Jonathan A MD, FACG. ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding, American Journal of Gastroenterology: September 2015 - Volume 110 - Issue 9 - p 1265-1287 doi: 10.1038/ajg.2015.246

Supplemental Methodology Resources

Data Supplement