SMALL INTESTINAL BLEEDING

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The small intestine, beyond the duodenal bulb where inflammatory changes are common, is an uncommon site of hemorrhage.92 It is estimated that in only 3% to 5% of patients with gastrointestinal bleeding has the site been located between the second portion of the duodenum and the ileocecal valve.115 Bleeding within the small bowel beyond the duodenal bulb (from here on referred to simply as small intestinal bleeding), unless massive, is often difficult to diagnose. Several factors are responsible for the inability to find the source of small bowel blood loss. In addition to being an unusual site of bleeding and not routinely considered, the small bowel is relatively inaccessible as compared with the stomach and colon. The length of the small intestine, its free intraperitoneal location, vigorous contractility, and overlying loops confound the usual diagnostic techniques. For example, although classically the ileum is located in the right lower diagonal of the abdomen and the jejunum is located in the left upper diagonal of the abdomen, these locations are variable. All these characteristics limit the diagnostic ability of barium studies, limit endoscopic intubation, and limit the identification of specific sites by the special imaging techniques of nuclear medicine scans and angiography. In addition to these technical problems, the bleeding rate may be slow or intermittent, not allowing identification by angiography or bleeding scan. The yield of a small bowel series for diagnosing tumors of the small intestine is quite low, and all barium studies, including enteroclysis, cannot diagnose angiodysplasias, which are the commonest cause of small intestinal bleeding. The distal small intestine is still relatively inaccessible to endoscopic evaluation despite the development of various enteroscopes. Because of the inability to localize a bleeding site in the small bowel, these patients may present with prolonged chronic occult blood loss or recurrent episodes of melena or maroon stool without a specific diagnosis. Multiple transfusions are often required to support these patients, in whom multiple repeated examinations by colonoscopy, upper intestinal endoscopy, barium enema, upper gastrointestinal series, and bleeding scan are negative. In this group of patients, an early diagnosis of the bleeding site is rarely made.122, 144, 147, 148

Section snippets

Vascular Lesions of the Small Bowel

A variety of causes of small bowel bleeding may be encountered, each with its own bleeding pattern (Table 1). Vascular lesions are the commonest cause of small intestinal bleeding, accounting for 70% to 80%.82 Vascular lesions of the bowel are not all the same. Although most vascular lesions appear endoscopically similar and can be a cause of bleeding, they consist of various pathologic identities, as follows81:

  • Angiodysplasia (vascular ectasia)

    • Sporadic

    • Associated with renal

Radiology

Small bowel series has long been considered the mainstay in the evaluation of the small intestine.83 Data, however, show a relatively low diagnostic yield for patients with occult bleeding or iron deficiency. Although Crohn's disease and large ulcerations of the small intestine are readily diagnosed using this standard examination,21 only approximately 5% of small bowel follow-through examinations detect an intestinal bleeding site. Rabe et al124 reported a diagnostic yield of 5.6% in a series

DIAGNOSTIC AND THERAPEUTIC APPROACH

The extent of evaluation of the patient with obscure bleeding depends on two factors: the extent of the bleeding and the age of the patient. As discussed, the commonest cause of obscure bleeding is angiodysplasia, which accounts for 80% of causes. These patients are typically older than 60 years old. Small bowel tumors are the commonest cause of obscure bleeding in patients younger than age 50. These patients are evaluated differently than older patients. Management decisions in the older group

References (158)

  • P. Dixon et al.

    The small bowel enema: A ten year review

    Clin Radiol

    (1993)
  • P. Duray et al.

    Gastrointestinal angiodysplasia: A possible component of von Willebrand's disease

    Hum Pathol

    (1984)
  • L. Eidus et al.

    Caliber-persistent artery of the stomach (Dieulafoy's vascular malformation)

    Gastroenterology

    (1990)
  • R. Farmer et al.

    Clinical patterns in Crohn's disease: A statistical study of 615 cases

    Gastroenterology

    (1975)
  • P. Fockens et al.

    Dieulafoy's disease

    Gastrointest Endosc Clin N Am

    (1996)
  • L. Golitz

    Heritable cutaneous disorders that affect the gastrointestinal tract

    Med Clin North Am

    (1980)
  • C. Gostout et al.

    Small bowel enteroscopy: An early experience in gastrointestinal bleeding of unknown origin

    Gastrointest Endosc

    (1991)
  • J. Gryboski et al.

    Prognosis in children with Crohn's disease

    Gastroenterology

    (1978)
  • M. Harris et al.

    Systemic diseases affecting the mesenteric circulation

    Surg Clin North Am

    (1992)
  • R. Hull et al.

    Conjugated estrogens reduce endothelial prostacyclin production and fail to reduce postbypass blood loss

    Chest

    (1991)
  • T. Imperiale et al.

    Aortic stenosis, idiopathic gastrointestinal bleeding and angiodysplasia: Is there an association

    Gastroenterology

    (1988)
  • F. Junquera et al.

    Increased expression of angiogenic factors in human colonic angiodysplasia

    Am J Gastroenterol

    (1999)
  • B. Lewis

    Radiology versus endoscopy of the small bowel

    Gastrointest Clin North Am

    (1999)
  • B. Lewis et al.

    Total small bowel enteroscopy

    Gastrointest Endosc

    (1987)
  • B. Lewis et al.

    Gastrointestinal bleeding of obscure origin: The role of small bowel enteroscopy

    Gastroenterology

    (1988)
  • J. MacKenzie

    Push enteroscopy

    Gastrointest Endosc Clin N Am

    (1999)
  • J. Markisz et al.

    An evaluation of 99M-Tc labeled red blood cell scintigraphy for the detection and localization of gastrointestinal bleeding sites

    Gastroenterology

    (1982)
  • R. Akhrass et al.

    Small-bowel diverticulosis: Perceptions and reality

    J Am Coll Surg

    (1997)
  • A. Allen et al.

    Potassium-induced lesions of the small bowel

    JAMA

    (1965)
  • G. Antes et al.

    Gastrointestinal bleeding of obscure origin: Role of enteroclysis

    Eur Radiol

    (1996)
  • C. Anthanasoulis et al.

    Intraoperative localization of small bowel bleeding sites with combined angiographic methods and methylene blue injection

    Surgery

    (1980)
  • K. Apelgren et al.

    Principles for use of intraoperative enteroscopy for hemorrhage from the small bowel

    Am Surg

    (1988)
  • S. Ashley et al.

    Tumors of the small intestine

    Semin Oncol

    (1988)
  • T. Barloon et al.

    Does a normal small-bowel enteroclysis exclude small-bowel disease?

    Abdom Imaging

    (1994)
  • J. Barthel et al.

    Assisted passive enteroscopy and gastrointestinal tract bleeding of obscure origin

    Gastrointest Endosc

    (1990)
  • M. Baum

    Pertechnetate imaging following cimetidine administration in Meckel's diverticulum of the ileum

    Am J Gastroenterol

    (1981)
  • S. Baum et al.

    Angiodysplasia of the right colon: A cause of gastrointestinal bleeding

    AJR Am J Roentgenol

    (1977)
  • J. Berner et al.

    Push and sonde enteroscopy for the diagnosis of obscure gastrointestinal bleeding

    Am J Gastroenterol

    (1994)
  • J. Bessette et al.

    Primary malignant tumors in the small bowel: A comparison of the small-bowel enema and conventional follow-through examination

    AJR Am J Roentgenol

    (1989)
  • A. Biener et al.

    Intraoperative scintigraphy for active small intestinal bleeding

    Surg Gynecol Obstet

    (1990)
  • S. Boley et al.

    The pathophysiologic basis for the angiographic signs of vascular ectasias of the colon

    Radiology

    (1977)
  • T. Bowden et al.

    Intraoperative gastrointestinal endoscopy

    Ann Surg

    (1980)
  • T. Bowden et al.

    Occult gastrointestinal bleeding, locating the cause

    Am Surg

    (1980)
  • M. Bronner et al.

    Estrogen-progesterone therapy for bleeding gastrointestinal telangiectasias in chronic renal failure

    Ann Intern Med

    (1986)
  • W. Browder et al.

    Impact of emergency angiography in massive lower gastrointestinal bleeding

    Ann Surg

    (1986)
  • S. Bunker et al.

    Detection of gastrointestinal bleeding sites: Use of in vitro Tc 99m-labelled RBC's

    JAMA

    (1982)
  • M.S. Cappell

    Spatial clustering of simultaneous nonhereditary gastrointestinal angiodysplasia: The small but significant correlation between nonhereditary colonic and upper gastrointestinal angiodysplasia

    Dig Dis Sci

    (1992)
  • M. Cappell et al.

    Cessation of recurrent bleeding from gastrointestinal angiodysplasias after aortic valve replacement

    Ann Intern Med

    (1986)

  • Case 24-1991: Case records of the Massachusetts General Hospital

    N Engl J Med

    (1991)
  • J. Chong et al.

    Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology

    Am J Gastroenterol

    (1994)

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