Diagnosis and Management of Small Bowel Bleeding

Second-look upper endoscopy should be considered in cases of recurrent hematemesis, melena, or a previously incomplete exam. (Strong  “We recommend”Low)

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)

If the second-look examinations are normal, the next step should be a small bowel evaluation. (Strong  “We recommend”Moderate)

Push enteroscopy can be performed as a second-look examination in the evaluation of suspected small bowel bleeding. (Conditional (weak)  “We suggest”Moderate)

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)

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)

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)

Any method of deep enteroscopy can be used when endoscopic evaluation and therapy is required based on similar diagnostic yields. (Strong  “We recommend”High)

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)

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)